Kaplan and Sadock's Comprehensive textbook of Psychiatry 8th edition

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 1 - Neural S ciences > 1.1: Neural S ciences : Introduction and

1.1: Neural S c ienc es : Introduc tion and Overview J ac k A. Grebb M.D. P art of "1 - Neural S ciences " A paradox in the ongoing effort to unders tand the brain is that it is wis e to know everything there is to in the area of neural s ciences, but nothing should be believed. Much like Maurits C . E scher's enigmatic illus tration of a hand drawing itself, it is up to our own brains to discover and diagram how they are put T his paradox should not be s een as nihilis tic, but rather reflecting the tremendous excitement regarding neural sciences in the 21st century, which was us hered in by awarding of the 2000 Nobel P rize in Medicine to three neuros cientists : Arvid C arlss on, P aul G reengard, and K andel. It is the human brain, after all, that is the subs trate for emotions , cognitive abilities, and behaviors that is , everything that humans feel, think, do. E very week, the s cientific journals publish new into the neural sciences, many of which conflict with or least modify previous obs ervations, hypotheses, or theoretical models. Obvious overs implifications from past include the abs olute demarcation between neurological and ps ychiatric dis orders, the absolute categorization of brain regions as devoted to only or emotional activities , and the absolute dogma that 1 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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only release neurotransmitters and dendrites only to neurotrans mitters . Although the sections in this first chapter on neural s ciences do not include everything is to know, they do provide a framework that outlines much of what is currently known. Moreover, each of the sections provides an ins ight into the directions in which that particular field is evolving.

NE UR OA NA TOMY A ND NE UR ODE VE L OP ME NT F unctional neuroanatomy (dis cuss ed in S ection 1.2) is study of interacting and interdependent neurons, glia, groups of neurons and glia (e.g., nuclei), and brain T he three neural systems of most interest in psychiatry the thalamocortical system, the basal ganglia, and the limbic s ys tem. Although previous generations of neuroanatomis ts have ass igned functions, such as sens ation, movement, emotion, cognition, and specific neuroanatomical structures, a general trend in neuroanatomy is to des cribe how networks of brain regions interact to produce what is eventually or obs erved as feelings , thoughts, or behaviors . In as another example of a change to previous dogma, it increasingly becoming accepted that new neurons can form and function in the adult human brain, es pecially regions of the limbic s ys tem, such as the hippocampus. T his area of neural science is covered in S ection 1.3, Development and Neurogenes is , which discus ses embryonic neurogenesis , the migration of neurons, and the outgrowth and formation of neuronal axons and dendrites. T hese developmental proces ses are of to psychiatrists because pathology in neural might later res ult in clinical symptoms , or, conversely, 2 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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clinical pathological states (e.g., excess ive s tres s) affect thes e very same neural development and neurogenes is proces ses in an adverse manner.

INTE R NE UR ONA L MOL E C UL A R S IG NA L S T he two methods for communication among neurons glia are molecular (or chemical) and electrical. T he four most widely recognized class es of molecular signals the monoamines , amino acids , peptides, and the more recently dis covered neurotrophic factors. Although it is reasonable to dis cuss each of thes e clas ses done in this textbook, there are a number of common themes relevant to all four clas ses of molecular signals. F irst, new molecular s ignals are being discovered, both within thes e exis ting clas ses (e.g., previous ly amino acid or peptide neurotransmitters), as well as in novel class es of molecular signals (e.g., nitric oxide, monoxide, adenosine, adenosine triphosphate [AT P ]). S econd, there are hundreds of so-called orphan that have been discovered through examining the sequence of the human genome. T hes e proteins have the characteristics of receptor proteins, but the endogenous ligands for them have not been and, in most cas es , chemicals that activate or inhibit receptor function have not yet been s ynthes ized. T hird, general theme among both known and unknown receptors is heterogeneity, s uch that there are multiple subtypes of receptors for a particular neurotrans mitter, such as the α-adrenergic and β-adrenergic receptors norepinephrine. S imilar to heterogeneity in receptors is heterogeneity in the deactivation of neurotransmitter molecules via multiple s ubtypes of deactivating 3 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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(e.g., monoamine oxidas e, peptidas es ) as well as subtypes of trans porter proteins (e.g., reuptake F ourth, any s ingle neuron can releas e multiple different types of molecular signals (e.g., two different peptides a monoamine) and als o have receptors and receptor subtypes for multiple different molecular signals, thus making each individual neuron capable of exquisite integration and modulation of incoming and outgoing signals . T here are s ix class ic monoamine neurotransmitters: serotonin, the three catecholamines (epinephrine, norepinephrine, and dopamine), acetylcholine, and histamine (S ection 1.4). T he monoamine neurotransmitters, although present in only a small percentage of neurons localized in s mall nuclei in the brain, have enormous impact on total brain function because the diffuse projections of axons from these monoaminergic neurons can affect virtually every brain region. In contras t to the monoamine the amino acid neurotrans mitters are widely dis tributed the brain, and it is poss ible to conceptualize the brain reflecting the balance between the excitatory amino glutamate and the inhibitory amino acid γ-aminobutyric acid (G AB A) (S ection 1.5). In P.2 contrast to the relatively s mall number of different monoamine neurotrans mitters and amino acid neurotransmitters, more than 100 different putative neuropeptide neurotrans mitters have been identified (S ection 1.6). T he neurotrophic factors (S ection 1.7) clas s of protein molecular signals that were more 4 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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discovered than the other molecular signals. T hes e proteins are involved in the growth, differentiation, maintenance, and death of neuronal and glial cells and have been demonstrated to be involved in process es as learning, memory, and complex behaviors .

INTR A NE UR ONA L S IG NA L S T he integrative work of an individual neuron is accomplis hed via intraneuronal molecular signaling pathways, the modulation of the balance between external and internal concentrations of ions , and the conversion of these signals within each individual into the s timulation of axon potentials, the trans cription deoxyribonucleic acid (DNA) into ribonucleic acid and the translation of R NA into proteins . W hen a signal binds to its specific cell surface receptor, a of intraneuronal signals is initiated (S ection 1.8). T here multiple interacting s ignaling pathways within each neuron, and these intraneuronal events s hould actually cons idered the es sential s ites of action for drugs rather than merely the cell surface receptors. T hes e complex intraneuronal s ignaling pathways are additional sites of interest for understanding the pathophysiology neurops ychiatric disorders . T he balance between external and internal of ions is achieved by a wide array of ion channels, which are regulated by neurotrans mitters and others by voltage gradients directly (S ection 1.9). Many of the of interes t in psychiatry act directly on ion channels. benzodiazepines act on G AB A type A receptors that chloride ion channels. P hencyclidine (P C P , or angel acts on a subtype of glutamate receptors that are 5 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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ion channels . Nicotine, the active ingredient in tobacco, acts on nicotinic acetylcholine receptors that are and potas sium ion channels. A more recently property of certain neurons and ion channels is the role of pacemaker, or oscillatory, activity in normal maintenance of wakefulness , attention, and mood. Driving the development of the brain as well as the maintenance and regulation of brain function is the proces s of genetic express ion (S ection 1.10). T he proces s of genetics involves the trans cription of DNA R NA and the translation of R NA into a protein. A system of regulation exis ts for transcription and translation, and the newly dis covered molecules and pathways for this regulation are sites of investigation discoveries in the etiology, pathophysiology, and treatment of mental disorders . Alterations in gene expres sion occur both during development and in adulthood and may be the bas is of abnormal and development and of abnormal and normal adaptation stress .

E NDOC R INOL OG Y, A ND C HR ONOB IOL OG Y In addition to the central nervous system (C NS ), the body contains two other systems that have a complex, internal communicative network: the endocrine system and the immune s ys tem. Mostly becaus e of the of the involved molecular s ignals , it is now known that these three systems are integrated with each other, has given birth to the sciences of ps ychoneuroendocrinology (S ection 1.11) and ps ychoneuroimmunology (S ection 1.12). T he 6 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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between the neuroendocrine s ys tem and C NS can easily be s een in the ps ychiatric s ymptoms that can accompany some hormonal disorders (e.g., depres sion C us hing's s yndrome) and also in the identification of disorders of neuroendocrine regulation as potential markers for state or trait variables in ps ychiatric S imilarly, the immune s ys tem is linked with both the and endocrine system through s hared molecular T he other property s hared by the C NS , endocrine and immune s ys tem is that they undergo regular with time. T he s tudy of these changes with time and disorders of time regulation are included in the field of chronobiology (S ection 1.13).

B R A IN IMA G ING C urrent technology allows brain imaging to detect and display electrical brain activity and physical brain as well as functional brain activity. Hans B erger firs t recorded the human electroencephalogram (E E G ) in and s ubs equent advances in this area have resulted in as sess ment of evoked potentials (vis ual, auditory, somatos ens ory, and cognitive), as well as quantitative, computerized as sess ments of topographic E E G s ignals (S ection 1.14). In addition to the standard X -ray techniques, including computed tomography (C T ), a of brain imaging techniques relies on nuclear magnetic res onance imaging (MR I) to as ses s both the structure function of the brain (S ection 1.15). T hes e techniques externally induced manipulations in the magnetic fields nuclei to image brain s tructure (sMR I) and brain (fMR I and magnetic res onance spectroscopy [MR S ]). other major technique for brain imaging uses very amounts of radioactive compounds introduced into the 7 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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brain and then vis ualized by the use of specific imaging cameras (S ection 1.16). T he two major techniques of type are positron emiss ion tomography (P E T ) and photon emis sion C T (S P E C T ). T hese techniques are particularly well suited for the s tudy of receptors, and metabolis m. T hes e techniques can and visualize brain function during increasingly s horter time periods, allowing res earchers to as k s pecific about brain regions and neural networks and their relations hips to emotional, cognitive, and behavioral states and activities .

G E NE TIC S S ince the las t edition of this textbook, the human, the mous e, and other animal genomes have been and, in a s ense, the ans wers are now there, but the questions must be asked with regard to the genetic of mental disorders . B y studying the genetics of both populations and individuals, investigators are to break the code regarding the etiology of mental disorders (S ections 1.17 and 1.18). Increasingly, inves tigators conceptualize mos t complex neurops ychiatric disorders as res ulting from the interaction of multiple s us ceptibility genes rather than a single caus al gene or a small number of causal genes. eventual identification of the key genes, however, potentially allow an entirely different approach to the diagnosis, prevention, and treatment of mental by us ing targeted genetic and pharmacological approaches. One of the key experimental approaches this path of unders tanding human ps ychopathology is us e of transgenic animal models of behavior (S ection T he mous e genome is remarkably s imilar to the human 8 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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genome, and investigators are now able to make manipulations in the mous e genome to produce transgenic mous e models that may evidence behavior treatment res ponses that are relevant to unders tanding and treating human disorders .

C OMP L E X HUMA N B E HA VIOR S T his textbook contains many chapters describing and abnormal complex human behaviors . T hree of such complex P.3 behaviors are sleep (S ection 1.20), appetite (S ection and s ubs tance abus e and dependence (S ection 1.22). the beginning of this s ection, it was mentioned that it is neces sary to know everything and believe nothing and also to be wary of overs implifications from past models the brain and behavior. S leep, appetite, and substance abuse are all examples of thes e less ons , as all three now conceptualized as involving complex systems the brain responding to bodily functions outside of the C NS and changing in res ponse to external influences of biological, psychological, and s ocial

FUTUR E DIR E C TIONS R es earchers in neural s cience will continue to the s equencing of the human genome and advances in brain imaging techniques, as well as other advances in experimental neuroscience. Although the ultimate goal all these efforts is to prevent the development of disorders , the immediate goals are to alter dis ease progres sion and promote recovery. T he pace of 9 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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in neural s cience is, unfortunately, well matched by the complexity of the brain. Nevertheles s, neuroscientis ts finding ways to challenge their own beliefs in the light new data, and it may indeed be one of the readers of textbook that breaks through the current relative ignorance and leads psychiatry into a new paradigm for unders tanding mental illness in the 21s t century.

S UG G E S TE D C R OS S Neurops ychiatry and behavioral neurology are in C hapter 2; the neuropsychological and psychiatric as pects of AIDS are discuss ed in S ection 2.8; the neurochemical, viral, and immunological studies of schizophrenia are discus sed in S ection 12.4; the biochemical as pects of mood disorders are discus sed S ection 13.3; biological therapies are discus sed in 31; and Alzheimer's disease is discus sed in S ection T he future of ps ychiatry is discus sed in S ection 55.3.

R E F E R E NC E S *B urke W : G enomics as a probe for dis eas e biology. E ngl J Me d. 2003;349:969. *Dolan R J : E motion, cognition, and behavior. 2002;298:1191. G ingrich J A, ed. G enetically altered mice in the neurops ychiatry. C NS S pe ctrums . 2003;8:551. McK hann G M: Neurology: then, now, and in the Arch Neurol. 2002;59:1369. 10 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/1.1.htm

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*R utter M: T he interplay of nature, nurture, and developmental influences . Arch G e n P s ychiatry. 2002;59:996. *S nyder S H: F orty years of neurotrans mitters . A personal account. Arch G e n P s ychiatry. *Zonta M, Angulo MC , G obbo S , R osengarten B , Hos smann K -A, P oss an T , C armignoto G : Neuronas trocyte signaling is central to the dynamic control brain microcirculation. Nat N euros ci. 2003;6:43.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 2 - Neurops ychiatry and B eha vioral Neurology > 2.1: Approach to the P a tient

2.1: Neurops yc hiatric Approac h to the Patient Fred Ovs iew M.D. P art of "2 - Neurops ychiatry and B ehavioral Neurology"

INTR ODUC TION Neurops ychiatry is the ps ychiatric s ubs pecialty that with the psychological and behavioral manifestations of brain dis eas e. Neurops ychiatry is closely allied with the neurological s ubs pecialty that interes ts itself in ps ychological phenomena in patients with brain namely cognitive and behavioral neurology. T he care patients with identifiable, acquired brain dis eas e—such those with epileps y, movement disorders , and brain injury—requires the phys ician to have a base and a familiarity with ass ess ment and treatment methods not usually required for patients with primary ps ychiatric disorders. P atients with organic mental syndromes are common in clinical practice and often difficult to manage for the generalist or for the general ps ychiatris t in consultation with s pecialis ts in other In addition to expert management of patients with mental disorders , from its clinical vantage point, neurops ychiatry can offer a dis tinctive pers pective on idiopathic psychiatric disorders . Moreover, neurops ychiatry draws on a knowledge bas e in the 12 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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cognitive neuros ciences that has the potential to sharpen, and modernize ass ess ment and nosology in general ps ychiatry. T his chapter provides information about as ses sment by history, examination, and paraclinical investigations in neurops ychiatry and des cribes neuropsychiatric ps ychopathology from three pers pectives : anatomy, symptom or s yndrome, and disease. C overage from vantage point is panoramic in the hope that the three perspectives , by triangulation, produce an image of neurops ychiatris t thinks when ass ess ing a patient—the cerebral s ubs trate of behavior, the plausible of dis eas e process es, the clinical phenomena, and elucidation at the bedside. S ome of the points made in description of clinical techniques are illustrated in vignettes in the final s ection of the chapter that focus as sess ment is sues. T he seemingly obvious view that neuropsychiatry is the offspring of ps ychiatry and neurology is his torically mistaken. P s ychiatry differentiated itself as a medical specialty in the early part of the 19th century and neurology somewhat later. Ample evidence s hows that early asylum phys icians, the precursors of cons idered their patients to have brain dis eas es and, moreover, that a large proportion of their patients organic disease, even as it could be identified with the tools of that time. G eneral pares is of the insane (neuros yphilis, as it was later discovered to be), mental retardation, and the complications of alcohol abuse were all common in the 19th-century asylum. On this evidence, one might s ay that general ps ychiatry, was understood for the larger part of the 20th century, 13 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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derived from an earlier neurops ychiatry. E arly neurology, on the other hand, took little part in care of patients with major ps ychiatric disorders, at those requiring hospitalization; but what would later become outpatient ps ychiatry—the care of patients milder mood and anxiety disorders not requiring management, for example—fell into the province of the early neurologis ts. T he theories by virtue of which they unders tood their patients have, fortunately, been cons igned to the dus tbin of his tory. T he mains tream of Anglo-American neurology was ill equipped to give ris e a s cientific neurops ychiatry, and it was not until (as a convenient and meaningful landmark) Norman in 1965 awakened interest in the continental tradition of behavioral neurology avant la le ttre that the of J ohn Hughlings J ackson, Ludwig Lichtheim, Hugo Liepmann, K arl W ernicke, and others could provide impetus for the development of a clinical specialty devoted to scientific understanding of the cerebral mental and behavioral disorder. T o say that neuropsychiatry is devoted to the care of patients with brain dis eas e is not to depreciate the role ps ychological and social factors in the unders tanding of the genes is of s ymptoms or in the formulation of interventions to ass is t patients. T o the contrary, with brain disease are often inordinately reactive to or dependent on influences from the outside world, the social world. Neurops ychiatric case formulation into account both the vulnerability and the setting. T o extent that patients s uffer from brain-based in proces sing information from their environment, their need for as sistance in dealing with ins trumental and 14 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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interpersonal tas ks increas es . Much of the brain, after devoted to process ing social information and devising ways of meeting internal needs in a s ocial context. T he neurops ychiatris t requires a detailed ass ess ment of the patient's functional deficits and the contexts in which arise. T o say that the neuropsychiatris t regards deficits , or for that matter intact behavior, as the manifes tation of based proces ses is not to imply that idiopathic disorders occur in people with normal brains nor that general ps ychiatris ts are unaware of the cerebral origin these disorders . T o the contrary, the evidence for abnormal brain structure and function in the major ps ychiatric disorders is unmis takable, and general ps ychiatris ts often as sert the neurobiological nature of these illnes ses. However, evidence for s uch as sertions often not demonstrable in the individual cas e, all laboratory inves tigations characteris tically falling within the broad range of normal. Moreover, the abnormalities P.324 in question are believed to be, at least in large part and least in mos t illness es , genetic in nature and developmental in pathogenes is . T he recognition and unders tanding of the mental cons equences of acquired diseases of the brain—which form the bulk of the neurops ychiatris t's concern—are likely to require tools from those required by the general ps ychiatris t treating idiopathic disorders . Although a bright line between the two situations is not poss ible, and many neuropsychiatrists maintain a lively interest in 15 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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disorders as schizophrenia and autis m, the dis tinction supports the continued use of the term organic to refer these acquired disorders with pathology identifiable at bedside and by the clinical laboratory, as much as want to see the term interred. T o define neuropsychiatry by how the clinician thinks, however, may be less telling than to define it by what clinician does . Neurops ychiatris ts perform phys ical examinations, not just a focus ed screen for signs , s uch as is within the ambit of mos t general ps ychiatris ts, but a broad as sess ment of cerebral us ing the tools available. Neuropsychiatrists not only neuroimaging and electroencephalographic studies but also review them pers onally, not just to “rule out disease” but to see which organic disease is pres ent where.

NE UR OA NA TOMIC A L B A S IS OF NE UR OP S YC HIA TR IC T he neurops ychiatric brain is more complex than the general ps ychiatric brain. T he latter is a s oup of neurotransmitters, perhaps in “chemical imbalance” (as patients are wont to say), with cons iderable pharmacological, but little anatomical, specificity. Although the benefits of ps ychopharmacological intervention are indis putable, the locus of these effects rarely of concern to clinicians . A neuropsychiatric relies on greater differentiation among brain circuits systems . T he chapter cons iders s everal major brain systems of key importance to neurops ychiatric case formulation.

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L ateralization T he two hemispheres differentially s ubs erve many functions , although in many instances, both participate in naturally occurring behavior, albeit contributing differently to the complex outcome. B rain as ymmetries arise early in vertebrate evolution, and two hemispheres display regional lateral as ymmetries size and differentially innervate viscera and peripheral endocrine tis sues. F or example, the pars opercularis of third frontal gyrus (B roca's area) and the planum temporale (infolded cortex in the pos terior portion of sylvian fis sure) are typically larger on the left, with dendritic branching of the neurons therein (for sake, “left” and “right” here refer to the situation in the average dextral patient). T hes e cortical regions are the substrate of language process ing. Ins ular cortex of right hemisphere regulates cardiac sympathetic drive of the left hemis phere, parasympathetic drive. In cons equence, left hemisphere s troke involving ins ula produces more cardiac destabilization and morbidity right, and lateralization of s eizure dis charges may have implications for autonomic function and unexplained sudden death in patients with epilepsy. Lateral in limbic (hypothalamic and amygdalar) regulation of sexual function als o have clinical implications; for polycys tic ovary syndrome in females may be more commonly ass ociated with left-sided limbic epileps y. Hemispheric s ide of les ion als o affects the cons equences of brain injury. Whether a s ingle tag can accurately contras t the proces sing “styles ” of the hemispheres —“local versus global” or “linear versus context dependent,” for 17 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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example—acros s multiple functions is doubtful. left lateralization of language and right lateralization of visuospatial function are widely recognized, lateral specialization in the prefrontal regions is less obvious of clinical significance. F rontal lobe degeneration the right, more than the left, frontal lobe is particularly as sociated with disinhibition. T raumatic injury to the hemis phere is more ass ociated with depres sion and anxiety, to the left with anger and hos tility. W omen and sinis trals tend to s how less lateralization of language perhaps of other functions ), s o that left hemisphere are les s likely to produce severe impairment. Of cons iderable importance for neurops ychiatric is the ques tion of lateralization of emotional An array of evidence s upports the notion of differential emotional valences in the two hemispheres . On this account, the left hemis phere is specialized for pos itive emotions , the right for negative emotions. T hus left hemis phere destructive les ions are as sociated with pathological crying and right hemisphere ones with pathological laughing; contrariwise, left hemisphere discharging les ions produce gelastic (laughing) and right hemisphere ones , dacrystic (crying) epilepsy. this context, the reported ass ociation of left anterior with depress ion makes s ense. However, much evidence favors as signing a prepotent in emotional process ing in general to the right hemis phere. P atients with right hemisphere damage appear to be more impaired at perceiving emotion regardless of the valence or input medium. Lesions of right hemisphere are ass ociated with impairments in proces sing emotion in speech, a defect known as 18 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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apros odia. P atients may lack the capacity to modulate prosody, so as to encode emotional information into speech, or the capacity to recognize emotional produced by others . S ubtler clinically may be deficits in recognizing emotion in faces or visual scenes . S uch may be part of the bas is for a finding that may s eem counterintuitive, namely that patients with right hemis phere injury have a poorer rehabilitation outcome than their left hemisphere counterparts .

Frontos ubc ortic al C irc uits T he projection of prefrontal cortex to s ubcortical structures in multiple clos ed loops is a crucial feature of behavioral neuroanatomy. T he key concept is that, in loop, a distinct region of prefrontal cortex projects to a distinct portion of the s triatum, then to an output of the bas al ganglia, then, in turn, to a specific nucleus the thalamus , which itself projects to the given area of cortex. T hus, a s et of parallel clos ed loops of frontos ubcortical connections proces ses information in separate domains . In the motor system, premotor and s upplementary motor area project primarily to putamen, the output of which projects via ventrolateral globus pallidus and caudolateral substantia nigra pars reticulata (S Nr) to ventrolateral-ventroanterior and centromedian nuclei of thalamus and then back to the originating cortical structures. Of particular interest to neurops ychiatris ts are the loops involving dors olateral prefrontal, medial and lateral orbitofrontal, and anterior cingulate cortex: Dors olateral prefrontal cortex projects to caudate; projections from caudate go to 19 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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globus pallidus and S Nr. T he output from basal flows primarily to ventrolateral and ventroanterior nuclei of thalamus (but als o to dors omedial nucleus thalamus ), whence it projects to areas 9 and 46 of dorsolateral prefrontal cortex. Lateral orbitofrontal cortex projects to ventromedial caudate, thence to the caudomedial aspect of S Nr. thalamic level of this loop is repres ented in ventral anterior and dors omedial P.325 nuclei, whence projections aris e back to the lateral as pect of area 12 in orbitofrontal cortex. T he medial orbitofrontal cortex loop features projections from gyrus rectus and medial orbital to ventromedial caudate; output from the basal ganglia arises in S Nr and flows to dorsomedial of thalamus, as well as ventrolateral and nuclei, thence back to medial orbitofrontal cortex. Anterior cingulate cortex, in the dorsomedial as pect the hemis phere, projects to ventral striatum, nucleus accumbens and olfactory tubercle (termini the mesolimbic dopamine system), with output from S Nr flowing through ventroanterior thalamus on its way back to anterior cingulate cortex. Dis ruption of each of thes e loops produces a distinctive clinical s yndrome. As is implied by the concept of a deficits similar to those produced by cortical damage also occur with damage to the subcortical connections the cortical region. B efore a sketch of each of these syndromes, note mus t be made that mos t naturally 20 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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occurring les ions do not res pect the anatomic so that clinical presentations are commonly mixed. Nonetheles s, for analytical purposes , the anatomical specificity is of interes t and importance. Interference with the loop involving dorsolateral cortex prominently produces executive cognitive impairment, with decrements in working memory, problem s olving, and related capacities. Damage to loop commonly arises from traumatic brain injury, and basal ganglion degenerative diseases s uch as P arkins on's dis ease. Involvement of the white matter of frontal lobes by small-vess el dis eas e commonly leads interruption of corticos ubcortical connections in this circuit and the picture of subcortical dementia. Damage to orbitofrontal cortex and its connections produces impulsivity, dis inhibition, dampening of the experience of emotion, irritability and lability of affect, poor judgment and decis ion making (es pecially in to social behavior), and ins ightless nes s about thes e impairments . T hese impairments are generally s een bilateral damage, although unilateral right-sided injury may als o produce them. As a neighborhood s ign, often involves the olfactory nerve (which runs along the orbital surface of the brain) with cons equent anos mia— times the only neurological s ign. C ognitive function, as tes ted by the usual beds ide or neuropsychological may be unaffected even in the presence of devastating personality change. T rauma is a common etiology. Damage to dorsomedial prefrontal s tructures may aris e from tumor or s troke. Abulia and apathy, disorders of initiation of action and the experience of motivation, are the res ult. Abnormalities of initiation of movement, with 21 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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akinetic mutis m as the mos t extreme s tate, may occur. C ingulate cortex is a structure of particular interest. E vidence from animal and imaging s tudies its importance in orienting attention under conflicting stimulus demands , modulating focus ed problem and monitoring performance to optimize reward. A cell type s een only in cingulate cortex, the s pindle cell, in evolution only with the great apes and in ontogeny at 4 months of age, concomitant with the infant's increasing capacity to focus attention. Interference with the output of cingulate gyrus , namely by interrupting cingulum—the procedure of cingulotomy—appears to beneficial in a dis order of excess ive attention, namely obses sive-compuls ive disorder (OC D).

L imbic S ys tem L e grand lobe limbique was delineated in the mid-19th century (by P aul B roca of aphas ia fame) as a ring of and s ubcortical structures on the medial aspect of the hemis pheres . J ames P apez drew attention to the formed by projections from hippocampus via fornix to mamillary bodies of hypothalamus, thence to anterior nucleus of thalamus , thence via the anterior limb of internal caps ule to cingulate gyrus , thence back to hippocampus via presubiculum, entorhinal cortex, and perforant pathway. In addition to this “P apez circuit,” amygdala and its reciprocally connected orbitofrontal cortex are taken to form part of a limbic s ys tem, a term us ed by P aul MacLean one-half century ago. Although some anatomists bristle at its inclusivenes s, the nearly universally us ed, probably because it focuses attention on the “emotional brain.” 22 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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T he core limbic structures are characterized by rich reciprocal monosynaptic connections with these are Hippocampus Amygdala P iriform cortex anterior to amygdala on the medial surface of the temporal lobe S eptal nuclei in the medial wall of the hemispheres , immediately ros tral to lamina terminalis S ubstantia innominata in the bas al forebrain P aralimbic cortices res ide in temporopolar, insular, and orbitofrontal regions, which have primary affiliations amygdala, and in parahippocampal, cingulate, and s ubcallosal regions, with primary with hippocampus . In the limbic s ys tem, broad and direct input from cortices into amygdala and hippocampus is extensively proces sed on its way to effector neurons in regulating autonomic and endocrine activity. In addition to this mediation of the regulation of the internal milieu, the limbic s ys tem gates the activity of the motor in the bas al ganglia, regulating action in the external milieu. T his occurs by prefrontal cortical integration of information in the limbic frontosubcortical circuit, which reaches the cortex via projections from ventral pallidum mediodors al nucleus of thalamus . One reas on for the central importance of the limbic in neuropsychiatry is that the threshold for production 23 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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epileptic discharges is lowest in amygdala and hippocampus . T hus, most epileps y in adults is limbic epilepsy. One consequence is the “voluminous mental state,” first identified by Hughlings J ackson. T his refers the range of experiential phenomena encountered as auras in limbic epilepsy: dé jà vu, depers onalization/derealization, microps ia, and and s o forth. S uch s ymptoms are s een not only in but also in mood dis orders and as putative pointers to limbic involvement in paroxys mal disorders not of clear epileptic nature, including those ass ociated with borderline pers onality disorder and with childhood T heir presence, therefore, does not unequivocally mark organic diagnosis. Another reas on for the centrality of the limbic system is that hippocampus, in particular, has a crucial role in explicit memory, further discus sed below. P ers is ting subs tantial amnestic deficits in multiple modalities limbic s ys tem damage.

C erebellum Agains t the prevailing notion that the cerebellum is a motor s tructure, anatomical evidence s hows that cerebellar inputs acces s areas of prefrontal cortex, with relay in thalamus. T hes e areas of cortex project to cerebellum, creating, as with the prefrontal-basal ganglia circuits previously dis cus sed, a set of parallel (relatively) clos ed loops, or channels . T hes e cross ed connections from the cerebellar hemis pheres and the further cros sing of des cending cerebrofugal long tracts mean that motor deficits are manifest ips ilateral to lateralized cerebellar injuries . Additional 24 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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P.326 reciprocal connections link cerebellum with monos ynaptically and with other areas of the limbic via a relay in the bas is pontis. T he phylogenetically vermis and fastigial nucleus can be differentiated from neocerebellum of the cerebellar hemispheres and cons idered a “limbic cerebellum.” G rowing evidence of cerebellar contributions to and affect comes from clinical data and studies. T he data are fraught with uncertainty, however, because many cerebellar patients have disorders that not be limited to cerebellum; for example, cerebellar degenerations may include cortical degeneration, and tumors (and their treatment with radiation and chemotherapy) may have remote effects . Moreover, the phenomenon of cross ed cerebellar dias chisis —the reduction in blood flow to connected neocortical areas after cerebellar damage—means that interpretation of deficits as due to abnormal ce rebe llar process ing, as compared to s hutdown of cerebral cortical proces sing, treacherous . Nonetheles s, patients with stroke les ions clinically and by neuroimaging limited to cerebellum have deficits in executive cognitive function, memory, language, and visuospatial function. T he data sugges t lateralized cerebellar damage is as sociated with the predicted lateralized cognitive phenomena (right damage with language impairment, left with visuos patial impairment). R eports of an affective s yndrome after cerebellar injury are les s systematic. Defects in affect regulation, with irritability and lability, are propos ed to as sociated with damage to the limbic cerebellum, 25 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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the vermis.

White Matter and C erebral C onnec tivity Whereas the volume of neocortex has increased over cours e of phylogenetic history, the volume of white has increased disproportionately. In humans, the white matter tracts occupy some 42 percent of the volume of hemis pheres . T he great majority of thes e fibers serve corticocortical connectivity rather than projections between cortical regions and s ubcortical sites ; for example, thalamic input is estimated to represent only percent of the total input into primary sensory cortex, remainder being from other cortical areas. T he fibers in white matter are of several types . F irst are longer intrahemis pheric fiber tracts : Arcuate fas ciculus, which connects s uperior and middle frontal gyri to the temporal lobe and (via a superior portion of the fas ciculus called s upe rior longitudinal fas ciculus ) the parietal and occipital Uncinate fasciculus , which connects orbitofrontal cortex to temporal cortex and (via an inferior of the fasciculus called inferior occipitofrontal fas ciculus ) the occipital lobe C ingulum, which lies medially beneath cingulate cortex in cingulate gyrus and connects frontal and parietal lobes with parahippocampal gyrus and adjacent structures S econd are the long projection systems linking cortex, 26 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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subcortical nuclei, and lower portions of the neuraxis . Medial forebrain bundle is the primary connection between limbic s tructures and the brains tem and projections from the monoaminergic cells in the and pons. Others are the thalamic peduncle with reciprocal fibers between thalamus and parietal lobe the corticopontine and corticos pinal tracts descending through corona radiata and internal caps ule. F ibers prefrontal cortex descend in the anterior limb of internal caps ule, so that les ions there may have predominant behavioral and a paucity of elementary sensorimotor effects. Lacunes and degeneration of the white matter due to hypertens ive s mall-vess el dis eas e (B inswanger's interrupt these corticocortical fibers and projections. T he result of progres sive los s of communication among cortical regions and between cortex and subcortical gray matter is the clinical state subcortical dementia, which is prominently by slowing of mental proces sing and failure of control process es. T he latter may be explained in part the preferential occurrence of lacunes in frontal but also by the impairment of connectivity. T hird, U fibers are the short, juxtacortical fibers adjacent cortical regions. T hes e fibers are spared in B ins wanger's disease, cerebral autos omal dominant arteriopathy with s ubcortical infarction and lacunes (C ADAS IL), and certain other dis eas e F ourth are the many specific projection systems linking delimited regions s uch as mammillothalamic tract, connects mammillary bodies with anterior nucleus of thalamus , and fornix, which connects mammillary 27 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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with hippocampus. Interesting neurobehavioral syndromes have been described related to rare cas es focal interruption of s uch pathways. F or example, interruption of mammillothalamic tract or of fornix is implicated in amnesia. F ifth, s everal pathways connect the two hemis pheres , notably corpus callosum but also anterior and pos terior commis sures and mas sa intermedia of thalamus . S yndromes due to interruption of the smaller have not s o far been described, although abs ence of mass a intermedia is reported to be as sociated with schizophrenia in women, and anterior commiss ure and mass a intermedia are larger in women than in men. C orpus callos um is congenitally absent in numerous neurodevelopmental syndromes , and its absence has as sociated with s chizophrenia. C ongenital abs ence is however, as sociated with the interes ting disconnection symptoms s een in les ional interruption of the callosum such as by anterior or posterior cerebral artery s troke surgical callosotomy for control of epileps y. T wo callos al dis connection s yndromes are worthy of specific mention. After anterior cerebral artery with anterior callos al infarction, the right hemisphere is deprived of verbal information; a left-hand apraxia is and the patient cannot name uns een objects placed in left hand. R eciprocally, the right hand shows cons tructional apraxia. T his is the anterior s yndrome . After occlus ion of the left posterior cerebral artery with infarction of the left occipital lobe and the splenium (posterior portion) of corpus callosum, the language cortices of the left hemis phere lose acces s to visual information: T he left visual cortex is damaged, 28 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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the projections from the right visual cortex, which cros s the splenium. T hus, reading becomes imposs ible, other language functions are unaffected—the of ale xia without agraphia.

C erebral C ortex T he cerebral cortex develops through complex but increasingly well-unders tood proces ses of cell and migration, axonal projection, and dendritic proliferation and pruning. Abnormalities in these proces ses lead to cortical dysplas ia with clinical cons equences, including mental retardation and S ome 10 percent of intractable epilepsy may be due to such dis orders, and increas ingly, migration are recognizable by imaging before neuropathological examination. F ailure of normal pruning of synapses by elimination of dendrites is now known to be crucial in pathogenes is of the fragile X syndrome and has been speculatively linked to s chizophrenia. R arely, cortical dysplas ia may be pres ent without epileps y or mental retardation; the neurobehavioral cons equences of this abnormality are just coming under investigation. T he organization of s ens ory cortices follows a regular E ach primary s ens ory cortical area projects to as sociation cortices s pecialized for the extraction of features in that particular modality; the unimodal as sociation cortices are dens ely and reciprocally interconnected. F or example, visual ass ociation cortex specialized regions for color, motion, and s hape. T his creates an intricate P.327 29 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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web of s ens ory proces sing; the vis ual cortex in the cat, example, is believed to have 19 process ing regions . Unimodal as sociation cortices project, in turn, to heteromodal cortices , which receive inputs from more than a single sensory modality. Heteromodal cortices located in prefrontal, pos terior parietal, lateral temporal, and parahippocampal regions. Unimodal cortices do project to unimodal cortices in other modalities , only to the higher-level heteromodal cortices . F urther, hippocampal projections to cortex arrive only at as sociation cortices , not primary s ens ory cortices. structural features amount to the isolation of s ens ory proces sing from top-down influences over the first synaptic s tages and presumably increase its fidelity to external phenomena. Lesions of cortical as sociation areas produce an array behavioral and cognitive disorders of intriguing T he specificity can be demonstrated by the occurrence double diss ociations : A lesion in area A produces a in function x but not y; a lesion in area B produces a in function y but not x. T his pattern of findings provides crucial confirmation that the deficits aris e not from task difficulty (if y were s imply more difficult than x, then y would always be dis turbed when x was dis turbed), but from s eparable proces sing components . F or example, some patients s how a greater impairment for naming living things than for naming artifacts after a brain However, occasionally, patients show the opposite greater impairment in naming living things: a double diss ociation. T he explanation of the discrepancy thus cannot depend on ins ufficient process ing res ources but must reveal a property of the organization of the 30 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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system. C ognitive dis orders of the visual s ys tem can s erve as a paradigm of the s yndromes s een with damage to the as sociation cortex. Lesions of primary visual cortex B rodmann's area [B A] 17) produce cortical blindnes s in quadrant, hemifield, or the entire vis ual field. Despite genuine blindnes s, accuracy above chance in visual s timuli can be achieved without awarenes s of the phenomenon of blinds ight, which tes tifies to subcortical visual proces sing inaccess ible to cons ciousnes s. V 1 projects to adjacent cortical regions (B A18 and B A19), which contain neurons that respond specific features of visual s timuli such as color, or s hape. Lesions in thes e cortices produce deficits in identification of these features. T hus arise syndromes as central achromatopsia, demons trated by inability to (as well as to name) colors. T he s tream of information transfer divides into dors al and ventral streams, the specialized for localization of visual s timuli (“where”) the latter for identification of the s timuli (“what”). Dors al lesions involving s uperior parietal lobule can produce impaired reaching under vis ual guidance (optic ataxia), part of B alint's syndrome; the deficit testifies to the integration of vis ual information with motor output in as sociation cortex. V entral les ions, involving inferotemporal cortex, produce defects in recognition (agnos ia). Agnos ic patients are not only unable to elements within the domain of agnos ia but also are to demons trate their us e or show recognition of the in other nonverbal ways. C entral auditory dis orders include cortical (or central) deafness ; pure word deafnes s, the inability to 31 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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words presented in the auditory modality despite preserved vis ual–verbal function; and auditory agnos ia, the inability to recognize words or complex s ounds the meaning of the ringing of a telephone). C entral deafness requires bilateral les ions involving primary auditory cortex in s uperior temporal gyrus or auditory radiations in white matter. P atients with pure word deafness generally have bilateral les ions of as sociation cortex more anteriorly in superior temporal gyrus , although unilateral left lesions , presumably left from right cortices by s ubcortical damage, also are reported. P rimary auditory cortex is partially s pared in these cas es . In agnosia for nonverbal environmental sounds, right hemisphere damage is sufficient to the deficit. Amus ia, the incapacity to recognize musical sounds, is ass ociated with cortical damage, but the laterality is complex, dependent in part on the preinjury level of mus ical s kills . F ull evaluation of these dis orders requires techniques go well beyond beds ide examination or routine paraclinical tools . At iss ue in the agnos ic dis orders is extent to which a deficit is apperceptive—that is , due to impairment in analysis of subtle perceptual elements presumably dependent on more ups tream cortical regions —and as sociative—that is , occurring in the absence of definable perceptual abnormalities and presumably due to dysfunction of more downstream cortical analyzers . T his dis tinction requires detailed neurops ychological and often psychophysical

Modulators of B rain S tates T his account of cognitive proces sing in cortex seems to 32 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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many ps ychiatris ts to leave out of consideration the matters with which they are mos t concerned: pervasive states of altered mood, drive, and behavior. T hat such states are behaviorally pervas ive does not argue that are anatomically global. Limbic structures dis cuss ed provide in part the anatomical s ubs trate for emotional states . F urther, several s ys tems with diffus e cortical projections have the capacity to modulate process ing widespread brain regions. T hes e originate in Intralaminar thalamic nuclei, which project to cortex (es pecially prefrontal and cingulate cortex) and to striatum His taminergic cells in pos terior hypothalamus S erotonergic cells in pontine raphe nuclei Noradrenergic cells in locus ceruleus Dopaminergic cells in the midbrain ventral area giving rise to the mesocortical and mes olimbic systems C holinergic cells in bas al forebrain nuclei s uch as nucleus basalis of Meynert T he last of these is of relevance to cholines teras e treatment of dementia, the preceding three of to treatment of mood, anxiety, and ps ychotic dis orders . T he hypothalamic histaminergic projections are in arousal. “Nons pecific” thalamic projections may have important role in executive dys function s een after lesions . S o as not to become complacent about current unders tanding of s uch pathways, recall that only within the pas t few years were a previously unknown 33 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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neurotransmitter and its pathways recognized, and the discovery of orexin/hypocretin and its hypothalamic anatomy exposed the secrets of narcoleps y. Neurops ychiatric anatomy is not a closed book.

MODUL A R ITY A ND NE UR OP S YC HIA TR Y T hese focal behavioral syndromes , and many others, compel attention to local proces sing in the brain and almos t irresistibly s uggest a particular model of brain organization. One imagines a box-and-arrow diagram, which each box—representing an elementary cognitive function—maps on to a specialized region of cortex. area of cortex has its job to do, and a lesion of any produces a distinctive, delimited, and predictable T his model rais es the iss ue of modular organization of brain. T he general topic of modularity in cognitive proces sing des erves further cons ideration because it is crucial to the theoretical perspective of neuropsychiatry and, in particular, becaus e it bears on the value of neurops ychiatric data for the understanding of ps ychiatric disorders. Modularity in cognitive refers to a brain organization P.328 characterized by multiple computational devices , each which operates on characteris tically encapsulated input with prewired (perhaps innate) rules, thus being rapid, efficient, and reliable. F or example, elementary visual proces sing can be considered modular, inasmuch as it res tricted input with hard-wired feature extraction (e.g., motion, color, s hape). In another domain, consider that 34 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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easier to teach an animal to as sociate a tas te than a stimulus with the aversive effects of an inges ted toxin. finding implies domain-specific, innate learning cons traints. T he class ic cognitive example of domainspecific prewiring is language—for example, observation that children generate language errors that they have never heard: “He bringed me here,” the child might s ay, although he or s he has never heard an adult say “bringed.” T he implication is that a languageproces sing module pos sess es innate grammatical that have generated a grammatical form without experiential foundation. E volutionary psychologis ts have forcefully argued the for modular process ing, as oppos ed to domain-general problem-solving devices. T he core of the evolutionary argument is that cerebral organization is the res ult of natural selection operating on the adaptational fitness humans' P leistocene hunter-gatherer ances tors . specific proces sing has advantages of speed and that neces sarily lead to an advantage in fitness . T he availability of preexperiential information about the content of domain-specific process ing carries a large advantage over the “combinatorial explosion” of informational pos sibilities requiring evaluation by a domain-general proces sor. F or example, detection of cheating in s ocial exchanges is an es sential element of adaptation in a population group featuring cooperative behavior. Is it a function of a domain-general logical problem-solving device, or is there a “cheatermodule? C ross -cultural evidence s hows that people better at detecting violation of s ocial exchange rules at solving problems of equivalent logical complexity 35 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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posed in other terms, and focal les ions can affect cheater detection. T he implication is that mechanisms, presumably located in a particular brain are “tuned” to recognize and reason about this adaptationally crucial behavior, jus t as innate subs erve language learning and toxin recognition. One the s trengths of the evolutionary approach is to direct attention to proces sing domains the modularity of is plaus ible on adaptational grounds. However, many of the “modules ” that have attracted clinical interest are not plaus ibly directly the objects of natural selection. R eading and writing are clear T hese have arisen too recently in evolutionary time to been the product of natural selection and, thus, must depend on the workings of process ors that are, at leas t this extent, domain general. Moreover, much of the literature on modularity is from a cognitive-ps ychological or philosophical perspective, with les s attention to the “wetware” (i.e., actual brain s ubs tance) implementation of the devices . A foundation in cognitive neuros cience and evolutionary biology can enrich clinical theories, but it creates the potential for mis understanding by clinicians interes ted in the functioning of patients with brain T he modules of the evolutionary biologis ts and philosophically inclined cognitivis ts do not map directly onto brain areas . One of the s triking res ults of neuroimaging experiments is that, however the function under s tudy is delimited, multiple areas of brain are found. A metaanalysis of reports of positron tomography (P E T ) s tudies of cognition found that the mean number of activation peaks per experiment was 36 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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10.24! E ach tas k engaged a mean of 3.3 B rodmann's contrariwis e, each B rodmann's area was engaged by a mean of 3.42 perceptual or cognitive tasks. E ven that s eem ps ychologically fundamental are not implemented in a s imple way, and local process ing components may be recruited into networks s ubs erving variety of tas ks . T his seems to be the case in respect limited number of frontal sites involved in a wide range executive tasks. T he specialization of regions is on input from other regions ; specialization is not dependent on intrinsic properties but partially on topdown influences. T he is sue is not whether different cerebral regions out different modes of information process ing. T his is unques tionably so, and neither unreconstructed holists who believe in the equipotentiality of cortex nor strict localizationis ts who believe only in fully autonomous proces sing devices figure on the current neuros cientific scene. T he question is how regions are linked in out tas ks . F unctions are implemented by networks , or all of the nodes of which participate in multiple functional networks . T his pattern of cerebral has been termed s e le ctively dis tribute d proce s s ing or s pars e ly dis tribute d ne tworks . Although cortical regions have specialized capacities for information process ing, functions cannot be localized to regions (as Hughlings J ackson explicitly warned a century and a half ago). It erroneous, for example, to believe that an area crucial face recognition contains all of the neurons, and only neurons , that respond to faces . Moreover, normal individuals may differ in how they recruit regions into networks. T he methods us ed in 37 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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studying groups of s ubjects in functional imaging experiments may obscure s uch individual differences . example, robust individual differences in patterns of activation emerged in a memory tas k, differences putatively reflecting different s trategies in performing tas k. T he differences were stable within individuals time, yet analys is of group data revealed activations in regions activated in only some of the subjects and disclos e activations in regions cons istently activated in others . Individual differences in organization of cortex are evident clinically in the unusual, but not negligible, occurrence of cross ed aphasia (aphas ia due right hemisphere injury in a dextral), cross ed (lack of aphasia with a left hemisphere injury that to cause aphasia in a dextral), and aphas ic deficits anomalous in res pect to the predicted effects of lesions both dextrals and sinis trals. Another crucial critique for neurops ychiatry of the modularity hypothes is derives from developmental ps ychology. T renchant arguments contradict the as sumption that a mapping of deficits to specific brain structures could be s tatic over developmental time. T o contrary, how the brain performs cognitive tasks with development. Development entails changing patterns of interaction among brain components , and localization may alter as neurons and regions become “tuned” in res pons iveness bas ed on their initial characteristic process ing biases and their patterns of inputs and connectivity. T his reorganization of cortical function could mean that the same behavior has subs trates at different developmental epochs. F or example, in adult s ubjects with Williams s yndrome, 38 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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number proces sing and good language s kills are characteristic; however, in infancy, the opposite pattern seen. W hatever the fundamental process ing disorder genetic origin may be, it cannot be seen as having “knocked out” a module. A large expanse of nonlinear brain development lies between the gene and the phenomena, an expanse that can be unders tood only a better theory than neophrenology (F ig. 2.1-1). T he development of modularity can be anomalous . Indeed, the Williams syndrome cases , magnetic res onance (MR I) data disclos e an anomalous, diffuse pattern of activation for music perception, an area of preserved or enhanced ability in these patients . F ocal syndromes in adults provide an appropriate place to s tart in hypothes es, but a deficit s een in an idiopathic dis order cannot be as sumed to have its bas is in dysfunction in same simple locus as a phenomenologically similar seen after a focal brain lesion occurring in an adult.

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FIGUR E 2.1-1 A phrenological head as pictured in (A) and 1957 (B ). Des pite the interval of 67 years, are s uspicious ly alike. (F rom F owler OS , F owler LN. S elf-Ins tructor in P hre nology and P hys iology. New F owler & W ells ; 1890:iii; and P olyak S . T he V is ual S ys te m. C hicago: T he University of C hicago 1957:456, with permis sion.) P.329 Nothing in this line of argument diminis hes the interes t focal neurobehavioral s yndromes , which are clinical and have a s ubs tantial heuris tic value for the cognitive neuros ciences. Neuropsychiatry, along with other brain specialties , has the task of importing into clinical theory the unders tanding of the mind and brain that is developing in cognitive neuros cience. T he s earch for ps ychopathological unders tanding based on of deficits in cognitive modules that are relatively well unders tood in normal subjects has been termed ne urops ychiatry. T his purs uit inevitably results in deconstruction of the ps ychiatric diagnoses of the fourth edition of Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ) or the International Dis eas es P.330 (IC D) into s ymptoms or s yndromes becaus e the diagnostic categories are generally based on folkps ychological notions (s uch as the divis ion between 41 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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“thought” and “affective” disorders ). Much of this chapter is devoted to the anatomical mode thought practiced by neurops ychiatris ts . However, clinicians appear to hope that neuropsychiatry will a localizing taxonomy of behavioral syndromes, s o that particular psychiatric dis orders will carry the same localizing power as, s ay, the B abinski s ign for the corticos pinal tract—the nuclear s yndrome of schizophrenia to the left temporal lobe, for example. the contemporary cognitive neuros cience perspective reviewed, this seems likely to be fals e hope. T he sign is a limiting, not a paradigmatic, cas e of brain– behavior relations hips. F or the fullest understanding of complex mental s yndromes, notably those traditionally the realm of ps ychiatry, a more adequate theory of function is needed than can be offered by the localizationis t tradition.

C L INIC A L E VA L UA TION T he neurops ychiatric perspective places great reliance information that can be gathered at the bedside. No practical inquiry and examination can include all items ; rather, the clinician selects from a toolbox of of the his tory and of the patient's functioning in the examination room to confirm or refute hypotheses generated by the emerging clinical picture. S creening items should have high s ens itivity but not necess arily specificity. B eyond s creening, elements of the his tory examination that might potentially elucidate the nature the disease process under consideration form the corpus of medical ass ess ment and cannot be dealt comprehensively in this chapter. F or example, the 42 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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neurops ychiatris t cons idering liver dis eas e as the explanation for delirium wants to estimate the liver during the physical examination, but techniques for so are not discus sed below. T he discus sion here is on both common iss ues and techniques dis tinctive to neurops ychiatry.

Neurops yc hiatric His tory T he initial s teps in screening for the presence of disease in patients with mental s ymptoms are eas ily T he phys ician s hould obtain a general medical his tory, including a his tory of dis eas es pos sibly relevant to the neurops ychiatric s ymptoms under consideration, and a review of s ys tems in potentially relevant areas. W ith a cognitively impaired or ps ychotic patient, s uch history taking may be unreliable. C ollateral his tory from a member or other informant and review of medical are almos t always es sential. With virtually every patient, the clinician s hould inquire to a history of Heart, lung, liver, kidney, skin, joint, and eye Hypertension Diabetes T raumatic brain injury S eizures, including febrile convulsions in childhood Unexplained medical symptoms S ubstance misus e C urrent medication 43 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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F amily history of neuropsychiatric disorder T he inquiry about thes e disorders in some settings can quite general. F or example, the question “have you had heart problems ? ” along with a few questions in the review of s ys tems may suffice to screen for heart a young, apparently healthy patient. In other settings, more detailed information mus t be gathered. T he review of systems as well s hould vary according to setting. P os itive res pons es should of course lead to inquiry. T he clinician s hould be practiced in inquiring about C ons titutional symptoms: fever, malaise, weight pain complaints Neurological s ymptoms : headache, blurred or vision, impairment of balance, impairments of auditory acuity, swallowing disturbance, focal or transient weakness or sensory loss , clumsines s, disturbance, alteration of urinary or defecatory function, altered s exual function P aroxysmal limbic phenomena: micropsia, metamorphops ia, dé jà vu and jamais vu, dé jà and jamais é couté, forced thoughts or emotions , depers onalization/derealization, autos copy, paranormal experiences such as clairvoyance or telepathy T hyroid s ymptoms: heat or cold sens itivity, cons tipation or diarrhea, rapid heart rate, alopecia change in texture of hair R heumatic dis eas e s ymptoms : joint pain or 44 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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mouth ulcers , dry mouth or eyes , rash, pas t spontaneous abortions

B irth His tory and E arly Development B ecaus e brain development s tarts before birth, s o does neurops ychiatric history. T he clinician should note Maternal s ubs tance mis us e, bleeding, and during the pregnancy C ours e of labor F etal dis tres s at birth, including Apgar s cores, if available P erinatal infection or jaundice Motor and cognitive miles tones s uch as the age the child crawled, walked, s poke words , s poke T he infant's temperament T he child's s chool performance (including special education and anomalous profiles of intellectual strengths and weaknes ses ), usually the best guide (absent ps ychometrical data) to premorbid function T he role of perinatal injury in cerebral palsy and mental retardation has commonly been overestimated; in instances, developmental disorder is present in before the perinatal misadventure, which may in fact from the preexisting abnormality. However, perinatal injury, in particular hypoxic injury, is probably with later s chizophrenia. 45 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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Head Injury and Its S equelae Head injury is common and potentially a factor in later mood and ps ychotic dis orders as well as cognitive impairment, epileps y, and pos ttraumatic s tres s disorder (P T S D). T he clinician should inquire about a his tory of injury in virtually every patient. T he nature of the injury should be clarified by eliciting the circums tances , including ris k-taking behaviors that may have to injury and others who were injured in the s ame often an emotionally powerful aspect of the event. T he loss of cons cious nes s is not a prerequisite to important sequelae; even a period of being stunned, “seeing can presage later neurops ychiatric symptoms . T he of los s of cons cious nes s, or coma, should be ideally with the ass istance of contemporaneous records . T he period of retrograde amnesia—from last memory before the injury to the injury itself—and of anterograde amnes ia—from injury to recovery of the capacity for consecutive memory—should be noted.

A ttac k Dis orders P aroxysmal dis orders of neurops ychiatric interes t epilepsy, migraine, panic attacks, and epis odic P.331 of aggress ion. T aking a his tory of an attack has features irrespective of the nature of the dis order. T he clinician should track through the chronology of the attack. T his starts with the poss ible presence of a prodrome, a warning of an impending attack in the or days before one. T he attack its elf may be presaged an aura, lasting s econds to minutes . In the cas e of an 46 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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epileptic seizure, this represents the core of the s eizure its elf and may carry important localizing information the side and s ite of the focus . T he pace of buildup, onset to peak of the ictus, is of differential diagnos tic importance. F or example, epileptic seizures begin abruptly; panic attacks may have a more gradual development to peak intens ity. T he mental and features of the ictus its elf should be elicited in detail collateral informants as well as from the patient, if T he duration of the spell and the mode of its should be elicited. Inquiring whether the patient has one s ort of spell or more than one is an es sential to establishing the frequency of episodes , both at and at maximum and minimum in the pas t. B y interviewing the patient and collateral informants , information necess ary to make a differential diagnos is us ually be elicited. T he differential diagnos is between epilepsy and ps eudoseizures can be difficult, but at if asked properly, the patient makes the diagnosis for clinician by reporting “two kinds of s eizures ,” one of is clearly epileptic and the other of which is clearly dependent on emotional s tates.

C ognitive S ymptoms R ecognizing cognitive symptoms in patients without es tablis hed dementia is a crucial element of neurops ychiatric history taking. S uch symptoms may outweighed by more dramatic behavior or mood but identification of cognitive impairment can reorient diagnostic evaluation of a late-life depres sion, for No doubt the mos t common complaint along cognitive lines is of memory problems. In the s etting of 47 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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the more intense the complaint of memory impairment, the less likely it is to have an organic bas is and the likely to testify to depres sive ideation and attentional failure. T he clinician s hould establish whether forgotten material (for example, an acquaintance's name or a meant to be performed) comes to the patient later, as a matter of absentmindedness rather than amnestic C ertain other complaints are highly characteristic of organic disease. T hese include a los s of the capacity divided attention or for the automatic performance of familiar tasks. A patient might report, for example, no longer being able to read and listen to the radio at the same time. G etting los t or beginning to us e aids for such as a notebook, are sugges tive of organic failure.

A ppetitive S ymptoms and C hange Alterations of s leep, appetite, and energy are common idiopathic ps ychiatric disorders , as well as transiently in healthy population, and cannot be interpreted as brain dis eas e. C ertain patterns of altered s leeping and eating behavior and personality, however, are pointers organic disease. E xces sive daytime s leepiness or attacks rais e the question of s leep apnea or narcoleps y in a different temporal pattern, K leine-Levin s yndrome. Abnormal behavior during s leep raises the ques tion of parasomnia. Of particular interes t is rapid eye (R E M) behavior disorder, which may be due to a lesion but, when a focal lesion is abs ent, strongly ingraves cent Lewy body dis eas e. Much more rarely, nocturnal oneiric behavior repres ents a prion dis ease, notably fatal familial ins omnia. Los s of dreaming occurs 48 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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with parietal or bifrontal damage; loss of vis ual imagery dreams occurs with ventral occipitotemporal damage, of the C harcot-Wilbrandt s yndrome (loss of vis ual with brain damage). In medial hypothalamic disease, eating behavior is marked by lack of satiety and obesity. In the K lüver-B ucy s yndrome of bilateral temporal damage (involving amygdala), patients mouth nonfood items . W ith frontal damage, patients may s tuff food into the mouth, a form of utilization behavior, sometimes with alarming or even fatal cons equences. “gourmand” syndrome of exces sive concern with fine eating has been ass ociated with right anterior injury. C hanges in sexual behavior are common brain disease. Hyposexuality is common in epileps y, poss ibly as a consequence of limbic dis charges . A in habitual s exual interests, quantitative or qualitative, developing in midlife sugges ts organic dis eas e. It is poss ible, although understudied, that relevant organic disease, such as the s equelae of traumatic brain injury, common in s exual offenders. Other changes in such as the development of shallownes s of affect, irritability, loss of sense of humor, or a coarsening of sens ibilities , may indicate ingraves cent organic example, frontotemporal dementia.

Handednes s Approximately 90 percent of people designate as dextral, almost all the rest as sinis tral, and a very ambidextrous . T he true state of affairs is somewhat complicated, in that handednes s may be considered dimensionally—that is , as a matter of degrees rather categories . A patient may call hims elf or herself right49 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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handed but us e the left hand preferentially for certain tas ks . Inquiring about a few s pecific tasks —writing, throwing, drawing, using s ciss ors or a toothbrus h— helpful information. A family his tory of s inistrality may be relevant.

Neurops yc hiatric Phys ic al T o the neurops ychiatrist, the physical examination is a central feature of clinical evaluation. In principle, any as pect of the general physical or neurological may be relevant to neuropsychiatric diagnos is, if only in revealing an incidental clinical problem in a neurops ychiatric patient. Here, the focus is on the physical examination with specific relevance to detection and identification of organic dis ease in with mental presentations . T he mental examination, including the cognitive examination, is discuss ed below as sociation with syndromes of behavioral disorder and insofar as it can elicit or elucidate thes e s yndromes in cons ultation room.

G eneral P hys ic al E xamination GE NE R AL APPE AR ANC E Dys morphic fe ature s include so-called minor physical anomalies, s ome of which are captured in the widely Waldrop s cale. T hes e are as sociated with disorders , including s chizophrenia. S ome of thes e are lis ted in T able 2.1-1. T hes e features center on the hands , and feet. No single minor anomaly is diagnos tic pathological development, but the coincidence of anomalies argues that development has gone awry. specific developmental dis ability s yndromes can be 50 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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diagnosed by the constellation of dysmorphic features presented. C le ft lip or palate is as sociated with brain malformations and frontal cognitive impairment. As ymme try of the extremities, often bes t s een in the thumbnails, or of the cranial vault points to a developmental abnormality. Occas ionally, a patient reports wearing s hoes of different s izes on the two feet. T he larger extremity and the s maller side of the head ipsilateral to the abnormal cerebral hemis phere. S hort s tature is an important feature of many developmental syndromes, both common, s uch as fetal alcohol and Down s yndrome, and uncommon, such as mitochondrial cytopathies . Abnormal habitus , s uch as marfanoid habitus of homocys tinuria, may be a clue to diagnosis. W e ight los s is an important P.332 clue to s ys temic dis eas e, s uch as neoplasia; it should be dis miss ed, even in a patient with depres sion, which may—but may not—account for the weight los s. gain equally may point to limbic or systemic disease, es pecially an endocrinopathy, or may reflect toxicity of ps ychotropic drugs .

Table 2.1-1 S elec ted Minor Anomalies Head and face

Mouth 51

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   Head circumference a

   High arch of palate a

   Hair whorls a

   F urrowed tongue a

   F ine electric hair that will not comb downa

   G eographical tongue a

   Abnormal philtrum    F rontal boss ing

   C left uvula

E yes

E xtremities

   W ide-spaced eyes a

   C linodactyly a

   E picanthus a

   Abnormal palm creas e a

   S hort palpebral fis sures

   T oe 3 longer than toe 2 a

   Iris dis coloration or

   P artial

E ars

   G ap between 1 and 2 a

   Adherent lobes a

   S mall nails

   Malformationa

   S ingle creas e 52

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5    As ymmetrya

   

   S oft and pliable a

 

   Low s eateda

 

   P reauricular s kin tag

 

aAnomaly

is part of W aldrop s cale.

VITAL S IG NS E le vate d te mpe rature or he art or res piratory rate never be ignored, even in a patient whose agitation or anxiety might s eem to explain the abnormality. Doing ris ks miss ing infection, neuroleptic malignant connective tis sue disease, or other important caus es of morbidity. Abnormal re s piratory patterns occur in hyperkinetic movement disorders (including tardive dyskinesia). Y awning is a feature of opiate withdrawal serotonergic toxicity.

S K IN Alopecia or ras h may point to systemic connective disease. Alopecia is als o a feature of drug toxicity and hypothyroidism (where thinning of the lateral part of the eyebrow is characteris tic). T he malar ras h of s ys temic 53 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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erythematosus is typically slightly rais ed and tender extends to both cheeks in a “butterfly” pattern while sparing the nasolabial folds. Dis coid rashes in lupus characterized by hyperkeratosis, atrophy, and los s of pigment; the s trong tendency to scarring means that presence of a dis coid ras h does not neces sarily active disease. A pink periungual rash is also of lupus. A vasculitic ras h is clas sically palpable and may be s een in lupus or other connective tis sue diseases . Livedo reticularis, a net-like violaceous the trunk and lower extremities , is not s pecific but the question of S neddon's s yndrome, in which s troke or dementia is a clinical accompaniment. T he neurocutaneous s yndromes have typical skin manifestations: adenoma s ebaceum (facial as h-leaf macules , depigmented nevi, and s hagreen patches (thickened, yellowish skin over the area) in tuberous s cleros is; a port-wine stain (typically involving both upper and lower eyelids) in S turgesyndrome; neurofibromas , café au lait spots, and freckling in neurofibromatos is .

HE AD Head circumfe re nce s hould be meas ured in patients question of developmental dis order. Most reference give normal ranges for head circumference in children but not for adults , and extrapolation is F ortunately, adequate data to establis h normal ranges exis t. Although height and weight need to be taken into account along with gender, the normal range for adult men is approximately 54 to 60 cm (21.25 to 23.50 in.), women, 52 to 58 cm (20.50 to 22.75 in.). O ld s kull 54 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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intracranial s urge ry us ually leaves palpable evidence.

E YE S E xophthalmos us ually indicates G raves' disease, may reveal a space-occupying les ion, es pecially if unilateral. Dry e ye s , along with dry mouth, rais e the question of S jögren's s yndrome, although drug toxicity the aging process is a common confound. Inflammation the anterior portion of the eye, uveitis , can be at the beds ide by the pres ence of pain, rednes s, and a cons tricted pupil; this is commonly ass ociated with connective tis sue dis ease. T he K ays e r-F le is che r ring is brownis h-green discoloration at the limbus of the it sensitively and s pecifically indicates Wilson's pupils, optic disks, vis ual fields, and eye movements discuss ed below.

MOUTH O ral ulce rs can be s een in lupus, B ehçet's s yndrome, other connective tis sue disease. Dry mouth is a part of sicca s yndrome along with dry eyes, dis cus sed above. V itamin B 12 deficiency produces atrophic glos s itis , a smooth, painful, red tongue.

HE AR T AND VE S S E L S A carotid bruit indicates turbulent flow in the vess el but poor predictor of the degree or potential ris k of the vascular lesion. A thickened, tender te mporal artery to giant cell arteritis ; here, the phys ical examination is excellent guide to clinical significance. C ardiac valvular disease, marked by cardiac murmurs , is important in as sess ing the cause of s troke, and congestive failure 55 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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be relevant in delirium. In a schizophrenic patient, a murmur may imply the velocardiofacial syndrome. with developmental dis abilities may have multiple anomalies, including structural heart dis eas e.

E XTR E MITIE S J oint inflammation as an indication of s ys temic disease is dis tinguis hed from noninflammatory degenerative joint dis eas e (osteoarthritis) by the of swelling, warmth, and erythema and is seen in wrists , ankles, and metacarpophalangeal joints, compared with the involvement of the bas e of the distal interphalangeal joints, and spine in degenerative joint dis eas e. R aynaud's phe nome non and signs of connective tiss ue disease.

Neurologic al E xamination OL FAC TION Hypos mia is common in neurological disease but even more common in local dis eas e of the nas al mucos a, must be excluded before a defect is taken to be of neurops ychiatric s ignificance. As ses sment of olfaction often ignored (cranial nerves II through XII normal), but easily performed and gives clues to the integrity of otherwis e hard to as ses s, notably orbitofrontal cortex. olfactory nerve lies underneath orbitofrontal cortex; projections go to olfactory tubercle, entorhinal and piriform cortex in the temporal lobes , amygdala, and orbitofrontal cortex. T esting of olfaction is bes t us ing a floral odorant such as scented lip balms, which inexpens ive and s imple to carry. Although a dis tinction be made between the threshold for odor detection and 56 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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that for identification of the s timulus with differing anatomies , at the bedside without special equipment, best one can achieve is recognition of a decrement in sens itivity—that is , whether the patient s mells anything, even without being able to identify it.

E YE S P upillary dilation may indicate anticholinergic toxicity; pupillary constriction is a characteristic feature of toxicity. Argyll R obertson pupils are bilateral, small, irregular, and reactive to accommodation but not to the finding is characteristic of paretic P.333 neuros yphilis but also is present in other conditions. P apille de ma indicates elevated intracranial pres sure; earliest and mos t s ens itive feature is loss of venous pulsations at the optic dis k. A homonymous upper quadrantic fie ld defe ct is present when temporal lobe disease affects Meyer's loop, the portion of the optic radiation that dips into the temporal lobe. A field defect a delirious patient may point to an etiology in focal vascular disease (as dis cus sed below). T he normal spontaneous blink rate is 16 ± 8 per minute. Hypodopaminergia is as sociated with a reduction in rate. Impairment of voluntary eye opening is s een in as sociation with extrapyramidal s igns , making the common denomination of “apraxia” of eye opening a misnomer. Impairment of voluntary eye closure is s een after frontal or basal ganglia damage. B oth saccadic and pursuit eye move me nts s hould be examined. T he former are ass ess ed by asking the 57 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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to look to the left and the right, up and down, and at the examiner's finger on the left, right, up, and down. eye movements are examined by asking the patient to follow a moving s timulus in both the horizontal and vertical planes . T hese maneuvers test supranuclear of eye movements; the oculocephalic maneuver (doll's head eyes )—that is , moving the patient's head—tes ts brains tem pathways and may be added to the if saccades or purs uit is abnormal. Limitation of upgaze is common in the normal elderly. A limitation of voluntary downgaze, however, in a patient with extrapyramidal s igns or frontal cognitive impairment suggest progress ive supranuclear pals y. S lowed are characteris tic of Huntington's diseas e. Impairment initiation of voluntary s accades, requiring a head thrus t head turning, amounts to apraxia of gaze and is s een developmental disorders as well as Huntington's and parietal damage. C ontrariwise, impairment of inhibition of saccades repres ents a vis ual gras p, with forced gaze at environmental stimuli. T his can be tes ted by placing s timuli (a finger and a fist) in the left right vis ual fields of the patient and asking the patient look at the fist when the finger moves and vice vers a. patient's inability to perform horizontal pursuit or movements without turning the head may represent the same impairment of inhibition.

FAC IAL MOVE ME NT B oth spontaneous movements of emotional expres sion and movement to command s hould be tes ted. In pyramidal disorders , spontaneous movements may be relatively s pared when the face is hemiparetic for voluntary movements. C ontrariwise, in nonpyramidal 58 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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motor dis orders , voluntary movement may be poss ible despite a hemipares is of s pontaneous movement. T he latter s ituation is s een inter alia in temporal lobe including temporal lobe epilepsy, for which it has lateralizing value. V ertical furrowing between the eyebrows is known as V eraguth folds and is as sociated depres sion.

S PE E C H A variety of s peech abnormalities is tabulated in T able 2. A s ys tematic examination of speech may include the patient to produce a s ustained vowel (“ahhh…”), performance being as sess ed for voice quality, and loudness ; then s trings of cons onants (“puh-puhand alternating cons onants (“puh-tuh-kuh-puh-tuhthe performance being as sess ed for rate, rhythm, and clarity.

Table 2.1-2 S peec h S yndromes S yndrome

Output

C harac teris tic Les ion Loc ation or As s oc iations

Aphemia

Initial mutis m, recovery

B roca's area (B A44), foot of

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without agrammatism

left third gyrus

Apraxia of speech

Inconsis tent and s lowed articulation, flattened volume, abnormal prosody

Left insula

Ataxic dysarthria

S lowed, equalization of or erratic (s canning), imprecis e articulation

C erebellum, es pecially superior anterior left > right

P yramidal dysarthria

S lowed, strained, slurred

Anterior hemis pheres , us ually bilateral; may be accompanied by ps eudobulbar palsy (dysphagia, drooling, pathological

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laughing and crying) E xtrapyramidal dysarthria

Hypophonia, monotony of intonation, trailing off with longer

B as al ganglia

B ulbar dysarthria

Nas ality, breathines s, slurred articulation

B rainstem

F oreign syndrome

P honetic and prosodic alterations like those of dysarthria cortical damage but giving listener feeling of foreign accent

Motor or premotor cortex or subjacent white matter of left

Developmental stuttering

R epetition, prolongation, arrest of sounds; if overcome in

?

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childhood, reemerge stroke, onset P arkins on's disease Acquired stuttering

No dys tonic facial movements as are seen in developmental stuttering

V arious hemis phere sites

C es sation of stuttering

Not an abnormality but the of an abnormality

V arious hemis phere sites

E cholalia

Automatic repetition of interlocutor's speech or words heard environment, sometimes with reversal pronouns, correction of grammar,

V arious anatomies , but seen in frontotemporal dementia, transcortical aphas ias , settings

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completion of well-known phrases P alilalia

Automatic repetition of own final word or phras e, increasing rapidity and decreasing volume

Usually extrapyramidal system

“B lurting,” “echoing approval”

Automatic utterance of stereotyped or simple res ponses “yes, yes ”)

F rontal system

T he mute patie nt poses a special problem in neurops ychiatric as sess ment. Mutism may occur at the onset of aphemia or transcortical aphas ia due to lesions , and it commonly develops late in the cours e of patients with frontotemporal dementia or primary progres sive aphas ia. T he examiner s hould ass es s nonspeech movements of the relevant musculature, for example, tongue movements , s wallowing, and Other means of communication should be attempted 63 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as gesture, writing, or pointing on a letter board or word board.

AB NOR MALITIE S OF MOVE ME NT T he neurops ychiatric examiner should pay attention to weaknes s, abnormality of mus cle tone, abnormal gait, involuntary movements . W e akne s s due to muscle, peripheral nerve, or lower motor neuron dis eas e is as sociated with atrophy, fas ciculations, characteris tic distributions , loss of reflexes , and tendernes s in the muscle dis eas e. Of greater relevance to P.334 cerebral mechanisms, pyramidal weaknes s, greatest in distal musculature, is accompanied by increased tone in a s pas tic pattern (flexors in the upper extremity, extensors in the lower extremity, with the sudden loss increased tone during pas sive movement, the “clas pphenomenon), los s of control of fine movements, bris k tendon jerks , and the presence of abnormal reflexes as the B abins ki sign (discus sed below). Less well recognized is the nonpyramidal motor syndrome s uch seen in caudate or premotor cortical les ions: decreased s pontaneous us e of effected limbs , weaknes s but production of full s trength with coaxing. Mild degrees of impairment can be elicited with the pronator tes t by s eeking pronation of the outs tretched supinated arms; the forearm rolling tes t, by asking the patient to roll the forearms around each other first in direction then in the other, looking for one s ide that less , thus, appearing to be an axis with the other around; or fine finger movements, with the hands 64 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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facing up on the thighs, the patient touching each to the thumb in turn and repeatedly. Mus cle tone can be increased not only in the pyramidal fas hion just des cribed but als o as a manifestation of extrapyramidal or diffus e brain diseas e. In the latter paratonic rigidity, or G egenhalten, is manifes ted by an erratic, “ps eudoactive” increase in res is tance to movement. T he fluctuating quality of the resis tance reflects the presence of both oppositional and facilitory as pects of the patient's respons e to pas sive T he facilitory as pect can be evoked by repeatedly and extending the patient's arm at the elbow, then abruptly ceas ing and letting go when the arm is the abnormal respons e, facilitory paratonia, is for the patient to continue the s equence by flexion. In the case extrapyramidal diseas e, tone is increas ed in both and flexors and throughout the range of movement, s ocalled lead-pipe rigidity. T he “cogwheel” or ratchety feel the rigidity is imparted by a coexis ting tremor and is not intrins ic to the hypertonus; when paratonic rigidity cooccurs with a metabolic tremor, a delirious patient may mistakenly be believed to have P arkinson's disease. G ait s hould always be tes ted, if only by focus ed to the patient's entering or leaving the room. Attention should be paid to the patient's station, postural stride length and base, and turning. P os tural re flexe s as sess ed by as king the patient to stand in a fas hion, then pus hing gently on the ches t or back, with care taken to avoid a fall. G ait should be stress ed by the patient to walk in tandem fashion and on the outer as pects of the feet. T his may reveal not only mild (representing cerebellar vermis dysfunction), but also 65 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as ymmetric pos turing of the upper extremity (in nonpyramidal motor dys function). Akine s ia is manifes ted by delay in initiation, s lowness execution, and difficulty with complex or simultaneous movements. Mild akines ia may be obs erved in the patient's lack of spontaneous movements of the body while s itting or of the face or elicited by as king the to make repeated large amplitude taps of the forefinger the thumb (looking for decay of the amplitude). characteristically accompanied by rigidity. T hes e s igns, plus rest tremor and postural ins tability, repres ent the features of the parkins onian syndrome, seen not only idiopathic P arkinson's disease (IP D), but in several degenerative, “P arkins on-plus” disorders , such as progres sive s upranuclear palsy and multiple system atrophy, as well as in vascular white matter dis eas e. tremor is les s common in thes e other dis orders than in Dys tonia is s ustained mus cle contraction with twis ting movements or abnormal pos tures . T ypically, dystonia in the upper extremity is manifes ted as hyperpronation, in the lower extremity as inversion of foot with plantar flexion. Dystonia may occur only with certain actions , such as writer's cramp; focally, s uch as blepharos pas m or oculogyric cris is; or in a generalized pattern, such as torsion dys tonia ass ociated with mutations in the DY T 1 gene. T he symptoms and s igns often do not comport with a naäve idea of how things ought to be in organic disease; only expert knowledge suffices for recognition. F or example, a patient with tors ion dystonia may be able to run but not walk the latter action elicits leg dystonia. Or a patient with intens e neck muscle contraction may be able to bring 66 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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head to the midline by a light touch on the chin, a antagonis te ” diagnostic for dystonia. T re mor is a regular oscillating movement around a re s t tre mor, the movement occurs in a relaxed, extremity and is reduced by action. Often an upper extremity res t tremor is exaggerated by ambulation. frequency is us ually 4 to 8 Hz. T his is the distinctive of P arkins on's dis eas e. In pos tural tre mor, s us tained posture elicits tremor. It may be amplified if obs cured placing a sheet of paper over the outs tretched hand. Hereditary es sential tremor pres ents as postural predominantly in upper extremities but als o at times involving head, jaw, and voice. A coars e, irregular, postural tremor is often s een in metabolic encephalopathy. In intention tremor, the active limb os cillates more prominently when approaching its such as touching the examiner's finger with the index finger. Maximizing the range of movement increas es sens itivity of the tes t. Intention tremor is one form of kine tic tremor—that is , tremor elicited by movement; another s ort of kinetic tremor is that elicited by a action, s uch as writing tremor or orthos tatic tremor on standing upright. T he examiner can characterize observing the patient with arms s upported and fully at res t, then with arms outs tretched and pronated, then arms abducted to 90 degrees at the s houlders and the elbows while the hands are held palms down with fingers pointing at each other in front of the ches t. T he patient should also be observed during ambulation. Anxiety exaggerates tremor; this normal phenomenon, example, when the patient is conscious of being should not be mis taken for ps ychogenes is . A good test 67 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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ps ychogenic tremor relies on the fact that, although organic tremor may vary in amplitude, it varies little in frequency. A patient can be as ked to tap a hand at a frequency different from the tremor frequency; if tremulous body part entrains to the tapped frequency, ps ychogenic tremor is likely. C hore ic movements are random and arrhythmic movements of s mall amplitude that dance over the patient's body. T hey may be more evident when the patient is engaged in an activity such as ambulation. the movements are of large amplitude and forceful, the disorder is called ballis m. B allistic movements are unilateral. Myoclonus is a sudden, jerky, shock-like movement. It more discontinuous than chorea or tremor. T he of myoclonus is as terixis , a sudden lapse of muscle contraction in the context of attempted maintenance of posture. B oth phenomena, but more s ens itively are common in toxic-metabolic encephalopathy (not hepatic encephalopathy). Asterixis should be carefully sought by observation of the patient's attempt to extension of the hands with the arms outs tretched because it is pathognomonic for organic diseas e and is never seen in acute idiopathic psychosis or other nonorganic disorders . Myoclonus is additionally an important feature of nonconvulsive generalized s tatus epilepticus , Has himoto's encephalopathy, and J akob disease. Unilateral as terixis rarely may be seen parietal, frontal, or (most often) thalamic structural T ics are sudden, jerky movements as well, but they more complex than myoclonic jerks and are characterized by 68 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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P.335 an impulse to perform the act and a s ens e of relief for having done s o (or mounting tens ion if restrained from doing so). C ompulsions are not eas y to differentiate complex tics; the tiqueur may, like the patient with compuls ions, report deliberately performing the act. R epetitive behavior s uperficially s imilar to compulsions may occur in organic disease but represents driven behavior and does not have the s ame s ubjective structure as compulsive behavior. F or example, a with frontal disease may repeatedly touch an alluring object without an elicitable subjective impulse and without anxiety if separated from the object. Organic obses sions and compuls ions occur as well and have as sociated with globus pallidus les ions , among others . Akathis ia is defined by both its s ubjective and its features. T he patient exhibits motor restles sness , for example, by shifting weight from foot to foot while standing, and expres ses an urge to move. At times , ps ychotic or cognitively impaired patients cannot the subjective experience clearly, and the examiner be alert for the objective s igns to differentiate akathis ia from agitation due to anxiety or ps ychosis . T he and the signs in akathisia are referable to the lower, the upper, extremities ; the anxious patient may wring or her hands , the akathis ic patient shuffles his or her Myoclonic jerks of the legs may be evident in the recumbent patient. T he phenomenon occurs in IP D with drug-induced dopamine blockade but also rarely extensive frontal or temporal structural lesions . Ataxia is a dis order of coordinating the rate, range, and 69 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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force of movement and is characteristic of disease of cerebellum and its connections. In the limbs, dys metria represents dis ordered determination of the dis tance to moved, s o that the patient overs hoots or unders hoots target; if the reaching limb oscillates in the proces s, the clinician observes intention tremor. As king the patient touch the examiner's finger and then his or her own tes ts this s ys tem. Accurately touching one's own nos e eyes closed requires both cerebellar and function. E ye movements als o may be hypermetric or hypometric. T he patient's difficulty in performing rapid alternating movements, such as s upination/pronation of the hand or tapping of the foot, is called dys diadochokines ia. T he failure of coordination of movement is also demons trated by loss of check, should not be elicited by arranging for the patient to hit hims elf or herself when the examiner's hand is the normal situation, if the outstretched arms are only a s light waver is produced; the ataxic patient does damp the movement. G ait may be affected by midline cerebellar (vermis) dis eas e in the abs ence of limb which is related to cerebellar hemisphere dis eas e. G ait unsteady, with irregular stride length and a widened (In the normal s ubject, the feet nearly touch at their neares t point; even a few inches of s eparation widening of the bas e.) G ait and limb ataxia may be complemented by cerebellar dysarthria (des cribed in 2.1-2) and by eye movement dis orders , including nystagmus (us ually gaze paretic), slowed s accades , saccadic pursuit, and gaze apraxia. T he catatonic s yndrome has been various ly defined. core of the syndrome is a mute motionles s s tate; 70 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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added are abnormal movements, including grimacing, stereotypy, echopraxia, and catalepsy. T he latter, also as fle xibilitas ce rea (waxy flexibility), refers to of a limb in the position in which it is placed by the examiner or in some other unnatural position. It is not in all or even mos t cases of catatonia, and it can be apart from the catatonic s yndrome in patients with contralateral parietal les ions (as described below as avoidance s ign of parietal dis eas e). C atatonic refers to the sudden eruption into overactivity of a catatonic patient; this probably usually represents ps ychotic mania. T he catatonic s yndrome occurs in the cours e of schizophrenia or mood disorder, or without other psychopathology as idiopathic catatonia, or in the setting of acute cerebral metabolic or s tructural derangements . In the latter case, it is best thought of nonspecific reaction pattern, s uch as is delirium, a comprehensive clinical and laboratory evaluation to the cause of the behavioral disturbance. An important instance is catatonia as part of the neuroleptic syndrome, the diagnosis of which requires exclus ion of other metabolic encephalopathy, notably s ys temic infection. C atatonia is thus a medical emergency, prompt attention to diagnostic evaluation as well as supportive care (fluids, nutrition, meas ures to avoid complications of immobility, including venous thrombosis). Motor s equencing tests as say function of premotor areas and striatum and are related to deficits in cognitive function seen with dysfunction of the dorsolateral prefrontal loop. T he ring/fist test involves as king the patient to alternate between making a ring 71 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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his thumb and first finger and making a fis t with the hand: “ring, fist, ring, fist…” T he abnormal respons e is perseveration of one or the other posture or disorganization of the s equence. At times, patients are unable to perform the correct s eries even when the verbal cues aloud. A more complex alternation is between striking the table gently with the fist, then the edge of the hand, then the palm: “fis t, edge, palm, fis t, edge, palm…” A different approach is to ask the patient extend the arms, make a fis t with one hand while the other hand flat, then switch hands. T he abnormal res ponse has the patient ending up with two fis ts or palms outstretched. Much can be accomplished in the neurological examination by asking the patient to stretch out his or arms. W ith a few additional maneuvers (tapping the outstretched pronated hands, s upinating them and the patient to close his or her eyes , then asking the to touch his or her nos e with the eyes still closed, then as king the patient to perform the alternating fists test), of the following can be as ses sed in a matter of a so: postural and intention tremor, los s of check, and myoclonus , a pronator sign, dysmetria, and motor sequencing. Doing this, plus testing mus cle tone, plus observing the patient's natural and stress ed gait, plus checking tendon jerks and abnormal reflexes , takes few minutes and does not elucidate disorders of nerve, and spinal cord but repres ents a rather as sess ment of the central organization of the motor system.

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Dis orders of sensation are sometimes difficult to reliably in patients with cognitive and behavior Nonetheles s, s everal points s hould be familiar to the neurops ychiatris t. Distal loss of s ens ation, often accompanied by loss of ankle jerks , is characteristic of peripheral neuropathy. Often, all modalities of are dis turbed. If proprioception is s ufficiently s everely reduced, R omberg's s ign is pres ent. R omberg's s ign that clos ing the eyes produces s ubs tantial impairment balance; it is elicited by as king the patient to s tand, allowing the patient to seek a comfortably balanced position, then as king the patient to close the eyes (ensuring against a fall). Loss of s ens ation from sensory cortex injury is limited to complex dis criminations such as (recognizing numbers written on the palm), (identifying uns een objects in the hand), and two-point discrimination (telling whether the examiner is touching with one or two points , as these come closer together space). However, patients with parietal s troke may ps eudothalamic sensory s yndrome (with impairments elementary s ens ory modalities and s ubs equent dysesthesia) or other anomalous patterns of s ens ory At times, thes e patients pres ent with P.336 ps eudomotor deficits : ataxia, fluctuating muscle tone strength (dependent in part on vis ual cueing), and “levitation” and awkward positioning of the arm contralateral (or at times ips ilateral) to the lesion. In the acute phase, the combination of deficits can amount to “motor helpless ness .” T hese deficits result from the 73 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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sens ory input to regions in which motor programs T he less ons are that “cortical” sens ory deficits s hould sought if there is a ques tion of cortical involvement and that more dramatic or unus ual sensory abnormalities also occur with cortical lesions .

S OFT S IG NS An extensive literature about “soft s igns ” of dysfunction is difficult to comprehend becaus e of the varied definitions and batteries used in the various Most of the s igns s ought in these batteries are this chapter under their more s pecific headings , s uch graphes thesia under Abnormalities of S ens ation and alternating fis t (Oserets ky) tes t in the paragraph on sequencing. F rom the corpus of test batteries , a few maneuvers can be extracted that may make a to the neurological examination of the patient with a mental presentation. While the patient is touching each finger to the thumb, examiner can watch the oppos ite hand for mirror movements. Obligatory bimanual s ynkinesias are s een specifically in disorders of the pyramidal pathways , the K lippel-F eil s yndrome, and in agenesis of the callosum but also in putative neurodevelopmental disorders such as s chizophrenia. Asking the patient, eyes closed, to report whether the examiner is touching one or the other hand (with the patient's hands on the lap), or one or the other s ides of the face, or a is called the face–hand test. T he examiner touches the hand and right face s imultaneously. If the patient only the touch on the face—that is , extinguishes the peripheral stimulus —then the examiner can prompt 74 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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(once): “Anywhere els e? ” T hen the examiner touches right hand and left cheek, left hand and left cheek, right hand and right cheek, both hands , and both cheeks . E xtinction of the peripheral s timulus is the pathological res ponse and has been ass ociated with schizophrenia dementia.

AB NOR MAL R E FL E XE S T he B abins ki sign is the s hibboleth of the neurological examination. It s hould be elicited by stroking the lateral as pect of the foot from back to front, with the leg extended at the knee, us ing a pointed object s uch as orange stick or a key. T he response of extens ion of the great toe with or without fanning of the other toes indicates corticos pinal tract dis eas e. T wo confounding factors in as ses sment of the B abinski s ign are the toe and the plantar grasp. T he striatal toe is extens ion the hallux without fanning of the other toes or a flexion synergy in the other mus cles of flexion of the leg. It occur spontaneously or on elicitation in patients with P arkins on's dis ease in the absence of evidence of pyramidal dysfunction. T he plantar grasp, the of the familiar palmar gras p, may mask an extens or res ponse to lateral foot s timulation when stimulation in the midfoot brings about flexion of the toes . Other important reflexes for the neuropsychiatrist are Myers on's sign, a failure to habituate to regular, per-second taps on the glabella (with the tapping hand outs ide of the patient's vis ual field), present in parkinsonis m and diffuse brain disease Hoffmann's s ign, flexion of the thumb with s napping 75 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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of the dis tal phalanx of the patient's middle finger, upper extremity s ign of pyramidal dysfunction, although s ometimes present bilaterally in normal subjects G rasp, flexion of the fingers with stroking of the patient's palm toward the fingers during dis traction and despite instructions to relax, as sociated with disease of the contralateral supplementary motor Avoidance, extension of the wrist and fingers to the same s timulus as the grasp, a less well-known s ign points to contralateral parietal cortex abnormality S everal other “primitive reflexes” are les s specific in they are commonly present in the normal subject and, thus, are less us eful for diagnostic purposes. T hes e the suck, s nout, and palmomental reflexes .

FOC A L NE UR OB E HA VIOR A L S YNDR OME S T he idea that the brain is regionally specialized had a difficult gestation in the 19th century, and the key to its acceptance lay in recognition of the effects of focal lesions . At the end of the 18th century and early in the 19th century, phrenology drew adherents to the claim personality traits could be inferred by inspection of the cranium. T his claim was faulty, but phrenology had an underlying theory that was an important step forward the brain s ciences; in particular, the beliefs that the was the organ of the mind and that the mind could be fractionated into functions gave impetus to the development of neuros cience in a modern form. In the middle of the 19th century, the gradual realization that 76 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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aphas ia occurred with damage to s pecific areas of the hemis phere was another crucial s tep. T he subsequent identification of numerous s yndromes of localized damage—such as apraxia, agnos ia, visuospatial impairment in its various forms, and s o forth—is a fas cinating story of as tute and painstaking clinicopathological, and later clinicoradiological, correlation. P atients' introspective access to their deficits may be limited. Much of cognitive proces sing is unconscious, in the sense of being excluded from awareness by motivated defens e, but in the s ens e that it is not even principle open to introspection. J onathan Miller, in his television s how T he B ody in Q ues tion, displayed this by as king pass ers by in a pers on-in-the-street interview, “S ir, where is your spleen? ” No one can s ay from intros pection where the spleen is . T he same is true of much of cognitive process ing. E xplanations provided patients may be confabulations that fill in s uch intros pective gaps in a situation in which the brain is functioning abnormally in a way not fores een in its In neurops ychiatry, s ubjective experience and behavior separate explicanda. F or instance, in the realm of the networks s ubs erving conscious experience— “feelings”—and those underlying the emotional forces influencing behavior are dis tinct, although overlapping, with the amygdala notably absent from the former. T he patient's appraisal of his or her own situation is always relevant to collaboration with treatment and its outcome and s hould be explored in every clinical encounter.

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Although dementia is characteris tically considered a syndrome of “global” cognitive impairment, implying global or diffuse brain dysfunction, each dementing disorder produces a distinct pattern of brain pathology and corres ponding pattern of cognitive dys function. F or this reas on, and against tradition, dementia is under the rubric of focal neurobehavioral s yndromes. In Alzheimer's dis eas e, the earliest neuropathological abnormality is characteristically medial temporal accumulation of plaques and tangles, initially in cortex and subiculum (the input and output zones of hippocampus ). T he disease progres sively involves as sociation cortices in temporoparietal and prefrontal regions. T his burden of pathology determines the characteristic early memory P.337 impairment with ensuing anomia, failure of grasp, and coars ening of pers onality. On occas ion, Alzheimer's disease pathology is predominantly posterior, with concomitant predominance of vis uos patial impairment the clinical cours e. B y contras t, in frontotemporal dementia, the earliest dis eas e manifes tations are pathologically in frontal or temporal cortex, clinically presenting as primary progres sive aphasia, s emantic dementia, or a frontal apathy or disinhibition syndrome. none of these situations is a view of dementia as a impairment of brain function jus tified by the clinical or pathological facts; rather, s elective dis ruption of anatomical networks corres ponds to s ymptomatic features. E xtens ive s ubcortical white and gray matter damage 78 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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to s mall-vess el dis eas e is a common caus e of and, in this s ituation, the clinical picture is dominated slowed mental proces sing, forgetfulness with relative preservation of recognition memory (as opposed to recall), and executive cognitive dys function. located s ingle infarctions can also produce dementia. T hese strokes can involve left angular gyrus , genu of internal caps ule, and (perhaps most commonly) medial thalamus . T he thalamic and internal caps ule strokes produce cognitive impairment by interfering with frontal networks .

Delirium C las sically a s yndrome of “global” brain dys function toxic-metabolic infectious encephalopathy, delirium also point to focal brain dis eas e. Delirium may be due infarction in the right pos terior s uperior temporal gyrus caus ed by occlus ion of the inferior division of the right middle cerebral artery or to infarction in the inferior temporo-occipital cortex on the left or bilaterally due to posterior cerebral artery occlusion. In both instances, neurological signs may be limited to a vis ual field cut or absent entirely. F inding bilateral asterixis or multifocal myoclonus strongly indicates a toxic-metabolic brain derangement, and the history and physical examination should provide pointers for the ess ential laboratory confirmation of the abnormality. F eatures of the mental state are of little us e in determining the caus e of the syndrome except that agitation is far more common in certain disorders such as substance withdrawal, and the syndromes of left posterior cerebral artery or of right middle cerebral artery territory s troke with 79 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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involvement of the temporal lobe.

Aphas ia Acquired impairment of lexical or s yntactical is termed aphas ia. Lexicon and s yntax do not exhaust domain of language, and attention is devoted below to prosody and discourse pragmatics . At the beds ide, the clinician s hould be able to distinguis h language impairment from other sources of abnormal discours e (s uch as ps ychos is), delineate the features of in the patient's linguistic function, and tentatively the locus of brain injury. A s imple dis tinction between “expres sive” and defects has s ome power to dis tinguis h between and posterior les ion sites, but it is not in current use in aphas iology because mos t aphas iogenic lesions some impairment in both production and of language, and these impairments are of multiple A widely accepted approach to examination and clas sification in aphas ia identifies six domains for elucidation: s pontane ous s pee ch, naming, re pe tition, reading, and writing. Attention to speech reveals dys fluency and word-finding difficulties . T he dysfluent speaker produces shorter phrases and utterances without a natural “flow.” S ubstantives and verbs ) may be preserved at the expense of words (s uch as prepositions) and grammatical (s uch as tens e endings ), leading to agrammatical utterances that are nonetheles s relatively information Lesions dis rupting fluency are characteris tically the left hemis phere or involve putamen. Naming performance requires the adequate functioning of a 80 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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network, including posterior temporal, temporoparietal, and inferior frontal sites. T his is ordinarily tes ted by confrontation (“What do you call this? ”), which can be conveniently done using body parts or common items the bedside. Naming from description (“What do you the vehicle that travels under water? ”) is an alternative mode of testing, particularly us eful for visually impaired agnos ic patients . C omprehens ion is tes ted bes t using probes with minimal demand on output, so “yes/no” questions (“Does a stone s ink in water? ”) are better motor commands , which may be impaired by apraxia. Impairment of comprehension results from posterior temporal les ions. Disordered repetition is disclos ed by asking the patient to produce longer utterances, reiterating the examiner: “airplane, and s he are here…” R epetition may be s urprisingly (the so-called transcortical aphas ias ) or affected (conduction aphasia). T he latter depends on lesions of insula or external capsule. R eading comprehension (not reading aloud, a different skill) comprehension with a different input modality from comprehension, and s ome patients s how significant diss ociations . S imilarly, writing tests output in a modality from s peech. W riting is a particularly s ens itive probe for the anomia s een in early Alzheimer's disease the disorganization s een in delirium. A clas sification of the aphasias using the data from an examination as just outlined is s hown in T able 2.1-3. C linicians recognize, however, that many patients do fit well into the categories created by this scheme.

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Table 2 Aphas ic S yndrome

S pontaneous R epetition S peech

Naming

G lobal

Impaired

Impaired

Impaired

B roca's

Dys fluent, effortful, agrammatic

Impaired

Impaired

Wernicke's

F luent, paraphasic, absence of subs tantive words

Impaired

Impaired

C onduction

F luent, paraphasic

Impaired

Impaired

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with phonemic errors T ranscortical Dys fluent motor

S pared

Impaired

T ranscortical F luent, sens ory paraphasic

S pared

Impaired

Mixed transcortical

Dys fluent

R elatively spared

Impaired

Anomical

F luent, paraphasic

S pared

Impaired

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Ide omotor apraxia commonly occurs together with aphas ia. T his is a dis order of performance of s killed movements to command in the abs ence of explanatory elementary s ens ory and motor disturbances . Oral is revealed by the patient's incapacity to show, for example, how to blow out a match or lick a pos tage Limb apraxia is shown by the patient's incapacity to for example, how to wave good-bye or us e a hammer screwdriver. P atients with these deficits may, be able to follow whole body commands: “S how me boxer stands ,” for example. P atients rarely complain of apraxic deficits , in part because they are artifacts of the examination in the s ense that they may not be present the us e of real-world items .

Attention S everal related phenomena cluster under the clinical description of attentional disorders . At the mos t fundamental level, alertnes s repres ents a continuum ranging from coma to normal wakefulness . T he faced with a patient who is les s than fully alert should quantify the dis order by ass es sing the patient's to a graded series of probes: Does the patient orient to examiner's pres ence in the room; what does the patient when his or her name is called or when touched or shaken or when a (harmless ) painful s timulus is and s o forth. T hese res ponses s hould be recorded in rather than s ummarized by ambiguous terms s uch as “lethargic.” Alert patients may show deficits in sus tained attention external s timuli (vigilance) or internal stimuli (concentration). Attentional deficits of these sorts are 84 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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characteristic of delirium. V igilance can be ass es sed bedside adaptation of a continuous performance tas k, example, by as king the patient to lift a hand each time examiner says the letter “A” or, to increase the each time P.338 the examiner says the letter “A” after the letter “D.” T he examiner then produces a series of random letters at a deliberate and steady rate over an extended period. error of omiss ion or commis sion repres ents a failure. as king the patient to count from 20 to 1 or give the the week or the months of the year in revers e, the examiner can appraise concentration. Digit span— the patient to repeat a lis t of numbers spoken at a slow, steady rate without separation into chunks —is a clas sic tes t of attention; the lower limit of normal for digit span five. A “higher” level of attentional function is the capacity to manipulate information kept in consciousness over a period—a test of working memory. An excellent is alphanumeric sequencing. T he patient is as ked to alternate between numbers and letters; the examiner provides “1-A-2-B -3-C ” as a model, then allows 30 for the patient to s tart at 1 and give as many as poss ible. If only the number of correct alternations is counted (ignoring errors ), the lower limit of normal is comparable, s imple tas k is alphabetizing the letters of word “world” (or any s imilar word). W orking memory is known to require intact process ing in dorsolateral prefrontal cortex. Hemine gle ct is a focal disorder of attention almos t 85 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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of left hemis pace in a patient with acute right disease. Most characteris tically, the lesion is parietal, distinguishable patterns of hemineglect occur with and cingulate lesions . G ros s neglect can be recognized the patient's ignoring, or even denying the owners hip the left limbs or not attending to objects and people in hemis pace. S ubtler degrees of neglect can be elicited presenting an array in which the patient mus t s earch both hemifields to point to items, for example, all the yellow dots in a s timulus card with dots of varied colors both left and right. In the phenomenon of hypermetamorphosis, part of the K lüver-B ucy s yndrome of bilateral anterior temporal damage, animals or patients exhibit an increased level attention to individual items in the environment.

Amnes ia T he term me mory is us ed in s everal ways by clinicians ps ychologists . T he amnes tic s yndrome features impairment of learning of new material (anterograde amnes ia) and a variable period of impaired recall the ons et of the s yndrome (retrograde amnesia). It is to damage to hippocampus or to anterior thalamus P.339 (including mammillothalamic tract). Memory proper is distinguished from retention in consciousness of over the cours e of a few seconds, which may be called “working” or “iconic” or “short-term” memory. T his function is s pared in the amnes tic s yndrome because it depends on frontoparietal mechanis ms dis tinct from hippocampal and thalamic pathways damaged in 86 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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Deficits due to hippocampal and thalamic les ions are dependent on the lateralization of the damage, leftdamage producing verbal and right-sided damage producing figural memory impairments . A distinction between free recall and recognition is of neuropsychological s ignificance and generally can made adequately, if imperfectly, at the beds ide. Hippocampal and thalamic patients show accelerated forgetting, so that cues (s uch as providing the semantic category) are relatively ineffective in aiding recall. R ecognition memory is always better than free recall absolute scale; exaggeration of the dis parity—that is , sparing of recognition memory—is characteristic of memory impairment due to dysfunction of frontal mechanisms of effortful search. In addition, frontal patients s how impairments of for the temporal context or s ource of information. T his deficit is probably relevant to the occurrence of confabulation. S pontaneous confabulation occurs in minority of amnestic patients and depends on ventromedial frontal damage. Memory is s o commonly impaired in brain dis orders should be tested in all patients undergoing neurops ychiatric evaluation. R ecall of a test phras e (for example, a name and addres s) over a several-minute distraction is a valid and s imple screening test. more detailed analys is of memory is necess ary in with dis orders likely to affect memory mechanis ms , including (among many others) head injury, epilepsy, dementing disorders. T esting s hould include both and nonverbal material. F or example, tes ting recall of words and three s hapes or three words and three 87 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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directions over s everal minutes' delay is easily F urther, the examiner should be prepared with cues, including appropriate (incorrect) foils, to as ses s sparing the capacity to make use of cues in frontal memory impairment. F or example, if one of the words provided “piano,” the examiner could cue, “One was a mus ical instrument,” and further provide “guitar, piano, violin” multiple-choice options . Only rough inferences can be drawn from this beds ide ass es sment, as compared formal neurops ychological evaluation. Apart from patients with persisting amnestic the neuropsychiatrist may be pres ented with patients experienced an amnestic s tate trans iently or rarely may one during a transient amnes tic state. T he s yndromes transient global amnesia and transient epileptic and their differentiation have been fully des cribed and require thorough his tory taking, neuropsychological evaluation, and electroencephalography (E E G ) T he neuropsychiatrist s hould als o know that amnesia criminal offenses is common; certainly it is not confined those who committed a crime while in a delirious , ictal, postictal s tate, as is sometimes claimed for legal

Vis uos patial Dys func tion T he requirement to test visual, as well as verbal, has just been mentioned. Drawing and copying tasks further the ass ess ment. C opying inters ecting (as in the Mini-Mental S tate E xamination [MMS E ]) or incidental performance) the s hapes used in the tas k begins the as sess ment. W ith more complex failures with a slavish element-by-element s trategy are characteristic of patients with right hemisphere 88 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as is neglect of the left side of the stimulus . T he variety of dis orders of higher visual function has already been mentioned in des cribing the complex structure of visual ass ociation cortices . P ros opagnos ia defect in recognition of faces. S uch a defect may be obvious from the his tory or may be a more s ubtle abnormality; it can be s potted at the bedside, albeit insensitively, with the us e of a few pictures of famous people. Defe cts of topographical s kill, although rarely presenting in an isolated form, als o occur with right hemis phere dys function. T he patient can be as ked to describe a route between familiar places or a question believed to be within premorbid capacities (“If you're going from New Y ork to Los Angeles , is the Ocean in front of you, behind you, to your left, to your right? ”). T he incapacity to grasp in attention multiple visual at once is known as s imultanagnos ia. T he patient may in des cribing a complex vis ual scene by virtue of only a s ingle, perhaps peripheral, element. T ogether ps ychic paralysis of gaze (inability to direct gaze voluntarily, or ocular apraxia) and optic ataxia (a of mis reaching under vis ual guidance), it makes up syndrome, the archetypal disorder of the dorsal visual pathway. T he patient with impairment of reaching visual guidance s hould be examined without vis ual guidance (e.g., pointing to parts of his or her own body with eyes closed) to confirm the defect.

E xec utive C ognitive Dys func tion E xe cutive cognitive dys function refers to initiation of cognition and action, their maintenance in the face of 89 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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distraction, organized but flexible purs uit of goals, and self-monitoring with error correction. E xecutive are crucial in adaptive function, and performance in this realm is better correlated with real-world outcomes of brain-injured patients than are many other domains traditionally analyzed in neuropsychology or many ps ychos ocial variables . B edside exploration of function is of central importance in the neurops ychiatric examination. Analys is of behavioral dis turbance and neurops ychological deficits in patients with cerebral suggests that multiple dis sociable proces ses compos e executive cognitive function, and certainly these are ins tantiated by anatomically dis tributed systems . C urious ly, however, many different tasks recruit a identical set of regions in the middors olateral prefrontal cortex, midventrolateral prefrontal cortex, and anterior cingulate. Nonetheles s, the clinical examiner must that no single probe can screen for all dysfunctions. Many as pects of executive function are illuminated by attention to the patient's performance of elements of history taking and examination. Dis inhibition may be in abnormalities of comportment during s ocial Motor impe rs is te nce , the failure to sustain actions that be undertaken properly, may be noted in the patient's “peeking” when as ked to keep the eyes clos ed, looking back at the examiner's face when lateral gaze (es pecially to the left) is attempted, or not keeping the arms extended or the tongue protruded when to do s o. P ers eve ration is the continuation of elements past actions into present activity. P ers everative may be noted when tes ting naming or attention. E chopraxia, for example, the patient cross ing his or her 90 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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arms when the examiner (spontaneously) does s o, when some other behavior has been reques ted, can be observed during the interview and examination. be havior is an automatic tendency to make use of in the environment, for example, picking up a pen and starting to write des pite this behavior's being inappropriate to the setting. More focused efforts to as sess executive function are almos t always indicated in the neurops ychiatric examination. P ers everation may be specifically s ought the motor s equencing tas ks described above or with a sample of s pontaneous writing. A tapping tas k with conflicting ins tructions may illuminate the inflexibility of goal-directed P.340 behavior that gives rise to pers everative res ponding. patient is instructed to tap once if the examiner taps and twice if the examiner taps once. T he examiner taps on the table in a random s eries of one or two taps . T his can be directly followed by a go/no-go tapping in which the patient is instructed to tap once if the examiner taps once, not at all if the examiner taps Intrusions from the previous task's instructions perseverative res ponding; echopraxic respons es just like the examiner) represent failures of inhibition. Inhibition of reflexive gaze can be tes ted during the examination of eye movements . Looking at the moving stimulus rather than in the oppos ite direction as amounts to a vis ual gras p response and represents of inhibition. S pontaneous word-list generation (“T ell all the animals you can think of” or “T ell me all the 91 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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that s tart with ‘s ’”) depends on the capacity for effortful search of s emantic s tores . A greater decrement in to semantic cues (“animals ”) than to phonemic cues (“words with ‘s ’”) is seen in Alzheimer's disease the degradation of semantic stores due to damage. W orking memory can be ass es sed with the alphanumeric sequencing task described above. Anatomical inferences from dis sociations in on thes e tasks are limited. G o/no-go tas ks depend on integrity of orbitofrontal cortex, other tasks on the dorsolateral prefrontal cortex and its circuit. is as sociated with right hemis phere dysfunction. A diss ociation is between executive cognitive and personality change in frontal injury. E specially with orbitofrontal lesions , executive function can be spared even in the face of grave alterations in emotion and comportment; the two domains cannot s imply be cons idered two sides of the s ame coin. Nonetheless , it bears repeating that neuropsychiatric examiners should cons ider executive cognitive function in their formulation of cases .

Dis ordered Mood and E motion S everal syndromes of dis ordered emotion in organic disease can be delineated. Dis turbance s of re cognition expre s s ion of e motion with right hemisphere les ions already been mentioned. P atients and their familiars rarely aware of these deficits and do not complain of rather, the examiner must recognize the deficit and it into a formulation of the patient's social and functional decline. Impairment of prosodic expres sion s hould not mistaken for depress ed affect. T esting of affective 92 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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can be undertaken at the beds ide without s pecial equipment. T he examiner should as k the patient to say emotionally loaded sentences in a emotional manner, expres sing s urprise, fear, pleas ure, and anger. P eople cons iderably in their native acting talents, and the normal performance is wide. T he examiner als o can neutral sentences in various emotional tones : “I am to the store,” stated with surpris e, and s o forth, with the examiner's face turned away from the patient to avoid providing a s econd input channel. P atients should be to recognize the affect. S eparately, if tes ting materials available, the examiner can as sess the patient's identify emotions in visual scenes and facial Lesions that involve both limbic and heteromodal in the right hemis phere especially impair performance recognizing emotional facial expres sions. P athological laughing and crying also are mentioned as lateralized behavioral dis turbances. T he phenomena displays of affect incongruent with inner experience elicited by inappropriate, nonemotional, or inadequate stimuli. T he examiner may, in the extreme, be able to full displays of affect by waving a hand in front of the patient's face. T he patient is often embarrass ed by the pathological expres sion of affect. T he traditional explanation is that a lesion of des cending frontopontine pathways releases from inhibition a “laughing center” “crying center” in the brains tem. Indeed, features of ps eudobulbar palsy are often pres ent in thes e patients. However, the relevant centers have never been and the poss ibility that the phenomena res ult from cerebellar dis connection has been raised. A broader of affe ctive dys re gulation, which may be called 93 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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“emotionalis m,” is commonly s een, us ually in the of tearfulness . P atients report that they are more emotional than previous ly and that the tears are unexpected, and uncontrollable. However, they are generally congruent with the patient's s ubjective state. S uch patients are often cognitively impaired; les ions the left frontotemporal region. T he rare phenomenon of fou rire prodromique (mad prodromal laughter) acute vas cular les ions of the brains tem or thalamus . Apathy is an emotional dis turbance marked by of affect and motivation. G oal-directed behavior is reduced, and emotional res ponses are lacking. T he distinction from depress ion is crucial: P atients do not report negative emotional states or ideational content. Although they may meet criteria for depres sion the loss of interest in activities , they are mentally empty rather than full of distress . R ecognizing apathy rather mistaking it for depress ion may imply treatment with different pharmacological agents, for example, us e of dopamine agonis ts. E uphoria refers to a pers is tent and unrealistic sense of well-being without the increased mental or motor rate of mania. Although often in connection with multiple sclerosis , it is unusual and almos t always as sociated with extens ive dis ease and subs tantial cognitive impairment. T he K lüve r-B ucy s yndrome , as described in the captive monkey, includes reduction in aggres sion (tamenes s), excess ive and indis criminate sexual behavior, hypermetamorphos is (forced attention to environmental stimuli), and hyperorality (mouthing nonfood items ). mixture of emotional, perceptual, and motivational changes is dependent on bilateral damage to 94 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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human patients, pathologies including trauma, herpes simplex encephalitis , and frontotemporal dementia can produce the s yndrome, us ually in partial form. Depre s s ion is common in patients with brain dis eas es , including s troke, multiple sclerosis, traumatic brain and P arkins on's dis ease. C ertainly, this is in part a to altered circums tances and distress ing dis ability. Nonetheles s, the s yndromal nature of the depres sed and its imperfect correlation with measures of disability have prompted extens ive efforts to seek anatomical correlations. C onverging evidence leads to a model of alterations in a distributed network involving neocortical and limbic elements. In particular, a dors al involving dorsolateral prefrontal cortex, inferior parietal cortex, and the dorsal and posterior portions of gyrus shows underactivity in the depres sed s tate; regions are believed to mediate the cognitive and impairments of depress ion. Invers ely, a ventral compartment containing anterior insula, subgenual cingulate, hippocampus , and hypothalamus is these elements are believed to mediate somatic (“vegetative”) features of the depres sed s tate. between the two compartments are mediated through thalamus , basal ganglia, and, especially, rostral Mania is s ubs tantially les s common than depres sion brain injury. Mania is ass ociated with right-sided involving paralimbic cortices in orbitofrontal or basotemporal regions or s ubcortical sites in caudate or thalamus . S ome evidence s uggests that s ubcortical are more likely to produce a bipolar picture, cortical unipolar mania. As with depress ion, the abnormal state does not necess arily appear in close temporal 95 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as sociation with the injury, so determining whether the mood dis order is organic or idiopathic is not always straightforward. T he absence of a pers onal history of disorder is an obvious criterion, but the presence of a family history of mood dis order may mark a factor not operative in the P.341 absence of the brain les ion. Age of onset is relevant, es pecially for mania: T he ons et of idiopathic mania years of age is rare. A particularly common iss ue in neuropsychiatric as sess ment is the patient with late-onset depress ion in whom evaluation reveals executive cognitive and s ubcortical white matter dis eas e. T his state of “vascular depres sion” is marked by the presence of vascular ris k factors, notably hypertension, a tendency ps ychomotor retardation and anhedonia and not ps ychos is or guilty ideation, and poor outcome with treatments . S ome, but not all, of these patients have apathy rather than depress ion.

Abnormalities in Agenc y Ordinarily, the person performing an action has the of being the one performing it. T he prototype of this normal subjective sense is the “alien hand” phenomenon. P atients with parietal les ions may report sens e of strangenes s of the hand, and the limb may levitation or avoidance reactions. More dramatically, medial frontal or callos al les ions , the hand may engage unwilled behavior (representing unilateral utilization behavior), or intermanual conflict may occur. 96 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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Abnormal S oc ial B ehavior T he multitude of behaviors exhibited in s ocial has, of cours e, multiple underpinnings . S everal complexes , the neurobiology of which has come under scrutiny, can be obs erved in their abnormal form in patients and, at times, understood from an anatomical phys iological point of view. T he intens ity of social interaction manifes ted by with temporal lobe epilepsy may be due to deficits in social cognition or to a limbic lesion reinforcing s ocial cohes iveness . F ailures of empathic understanding are common in patients with frontal injury. T hes e res ult both from cognitive inflexibility in ass es sing complex social s ituations, es pecially in patients with dorsolateral prefrontal les ions, and from emotional impoverishment, es pecially in patients with orbitofrontal lesions . T he capacity of humans to understand the mental others —and thus to recognize not just another's goals intentions but also the other's deceptions or pretense— has been termed me ntalization or the ory of mind. and lesion data s ugges t that this capacity depends critically on prefrontal cortex (particularly right medial prefrontal cortex adjacent to anterior cingulate gyrus ), right temporoparietal cortices , and amygdala. P atients with is olated les ions of amygdala are rare, but deficits theory of mind are seen in patients with frontal dis ease and may contribute to their s ocial failure. P atients with right hemisphere les ions have a range of deficits in interaction that may be characterized as a dis order of pragmatics. Although they may grasp the propositional 97 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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content of language correctly, they mis take as pects of communication that require apprais al of the intent, for example, whether an utterance was intended a joke. P ragmatic disorders due to frontal and right hemis phere damage may impair narrative coherence through verbos ity, vaguenes s, and dis regard for the listener's informational needs . T hus, for example, us e may be s yntactically correct but the referents of pronouns obscure to the listener. Although language is normal, the way language is embedded in social interaction is not.

Abnormal B eliefs and E xperienc es Hallucinations are a common feature of diseas es of the brain. V is ual hallucinations in the abs ence of auditory hallucinations are s ugges tive of organic dis ease. V isual hallucinations may occur in a hemifield blind from disease, so-called releas e hallucinations . V is ual hallucinations in the s etting of vis ual impairment due to ocular disease, usually in the elderly, are known as the C harles B onne t s yndrome . T he hallucinations are characteristically vivid images of living figures, and the patient is aware of their unreality. Other is absent, but treatment aimed at the hallucinations is us ually ineffective. E laborate-formed visual may occur with lesions of thalamus or upper brains tem, called peduncular hallucinos is. T he symptoms are the evening (crepuscular), and again, the patient is of the unreality of the visual experiences . P rominent, visual hallucinations in the context of progress ive dementia may s uggest dementia with Lewy bodies . Auditory hallucinations occur rarely with pontine 98 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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More common are mus ical hallucinations in the setting hearing impairment, akin to the C harles B onnet Unilateral hallucinations are characteris tically ips ilateral the deaf ear. Olfactory hallucinations occur as a limbic in partial epilepsy, but they also occur in idiopathic ps ychiatric illnes s. P alinops ia and palinacous is refer to pers is ting or perceptual experiences after the object is gone in the visual and auditory domains, res pectively. Les ions in as sociation cortex—parieto-occipital and temporal, res pectively—are res pons ible, although (for the vis ual sphere more than the auditory) drug toxicity is often the explanation. T he content of de lus ions may yield clues to causative organic disease and its nature. Most notably, misidentification delus ions have been ass ociated with dysfunction of face proces sing and clearly linked—in but not all cases —to right hemis phere dysfunction. Misidentification of place is regularly ass ociated with visuospatial and executive cognitive dys function. Misidentification delusions have been of s pecial cognitive neuropsychiatry, with a focus on face recognition impairment in s uch patients. P erceptual recognition without a s ens e of familiarity (as in syndrome and perhaps the nihilistic delusions of syndrome) may reflect a dis ruption of vis ual–limbic connections . In a s ens e, it is the revers e of dé jà vu, amounts to familiarity without perceptual recognition. However, many patients with mis identification have no evidence of organic disease. Although such patients may have dys function of similar underlying mechanisms to patients with as certainable organic 99 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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disease, the similarity of clinical phenomena cannot be taken to prove an identity of mechanis m. P articular delusional themes may mark delirious such as a focus on danger or harm to others, as the more s elf-centered cons tructions in idiopathic ps ychotic dis orders. However, most delusions in with brain disease are of more banal nature, often with persecutory elements that bespeak cognitive failure theft of one's purse, for example, repres enting a failure memory as to its location). C omplexity or delus ional ideation is as sociated with preservation of intellect, and delus ions tend to become les s complex progres sion of dementia.

L A B OR A TOR Y INVE S TIG A TIONS S pecialized laboratory investigation forms a major part the neuropsychiatrist's arsenal. S ometimes patients are referred for neuropsychiatric cons ultation when a inves tigation—such as a s creening MR I or E E G —gives unexpected abnormal res ult; the neurops ychiatris t is called on to ass es s the meaning of the finding in the ps ychiatric context.

Neuroimaging S tructural neuroimaging with computed tomography and later with MR I revolutionized practice in the clinical neuros ciences. No longer was the organ of interes t invis ible within the carapace of the skull. C T relies on differential absorption P.342 of X-rays by brain tis sues and on the power of 100 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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computerized methods to integrate data from multiple perspectives . T he s trengths of C T are its speed and its sens itivity to blood and bone. T hus, for purpos es, situations in which a patient cannot tolerate prolonged imaging procedure may mandate C T . T his problem often aris es with an agitated demented or ps ychotic patient. B ony abnormalities , parenchymal depos ition of calcium, and intracranial hemorrhage are particularly well as sess ed by C T . S uch questions arise acute aftermath of trauma in particular. T he advent of MR I was an advance over C T in several res pects . T he anatomical resolution is substantially and the discrimination of white matter abnormalities exceptionally so. T he capacity to display data from a acquisition in multiple views —sagittal, axial, and coronal—allows improved anatomical understanding. (or s hort relaxation time [T R ]) images give maximal anatomical resolution. T 2 (or long T R ) images and intermediate-weighted (proton dens ity) images give maximum s alience to areas of abnormality, characteristically bright against a darker parenchyma. attenuation invers ion recovery (F LAIR ) images mark the lesions even better, with dark cerebrospinal fluid providing better contrast with regions of abnormality the bright C S F of T 2 images. G radient echo images sens itively reveal the sequelae of hemorrhage and may us eful in as ses sing the damage from trauma. Infusion gadolinium for contrast enhancement is not neces sary delineation of nonvascular anatomical s tructures , s uch is the goal in the case of atrophy or old s troke or but can identify areas of breakdown of the blood–brain barrier s uch as in the meninges in meningitis or in 101 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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parenchymal lesions of active multiple s cleros is , tumor, acute stroke. S pecial imaging s equences should be for the identification of cortical dysplas ia or mesial temporal s cleros is . V olumetric MR I allows diagnos is by quantitative ass es sment of delineated brain s tructures such as hippocampus in the cas e of temporal epilepsy potentially Alzheimer's diseas e. One imagines the day the near future when the s cans come (as electrocardiograms now do) with quantitative routinely accompanying the analog image. Magnetic res onance angiography (MR A) allows the delineation medium and large vess els without the adminis tration of contrast material, as is required for conventional angiography. S tenos is of thes e ves sels, such as the of the neck, or the presence of vas cular malformations aneurysms is reliably as certained. However, resolution not sufficient to allow as sess ment of small vess els ; some forms of vasculitis cannot be excluded with MR A require contras t angiography. Additional MR I s equences include diffusion-weighted imaging, which captures acute vas cular injury; diffusion tensor imaging, which dis clos es patterns of white matter; and magnetization transfer imaging, promis es even greater sens itivity to brain lesions than F LAIR imaging. E xcept for diffusion-weighted imaging acute stroke, none has an es tablis hed clinical use. Magnetic res onance spectroscopy is a method for analyzing the regional chemical composition of the T he benefits of its ability to identify neuronal loss and proliferation are s till under investigation, although in certain circums tances , s uch as dis tinguishing radiation necros is from recurrent brain tumor, it is of proven 102 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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us efulnes s.

Func tional Neuroimaging F our methods of functional neuroimaging are available: single photon emis sion computed tomography P E T , functional MR I, and brain mapping by quantitative E E G . All are exciting research avenues, but the clinical role for functional imaging is limited. All the techniques have a place in the pres urgical evaluation epileptic patients. S P E C T or P E T in the patient with frontotemporal dementia typically dis closes the lobar nature of the dys function, although their value diagnostically over and above neuropsychological demonstration of the s ame phenomenon is S imilarly, in exactly which circums tances bilateral temporoparietal hypoperfusion advances the diagnosis of Alzheimer's dis ease is not yet clear. T he demonstration of occipital hypoperfus ion strongly supports a diagnosis of dementia with Lewy bodies . evidence for other clinical us es of functional imaging is present limited or anecdotal.

E lec troenc ephalography T he expectation of the originators of E E G was that it allow tracking of mental process es . T his hope has not realized. E E G does have the advantage over other available brain imaging tools that it reflects function at high temporal res olution, res olution corresponding to time cours e of mental proces sing. T hus , at least from a res earch perspective, meas urement of brain potentials relation to stimuli—the technique of evoked has the capacity to identify anomalous modes of 103 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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proces sing. R ecordings from electrode placements in subdural or cortical sites provide irreplaceable about the origin and s pread of epileptic dis charges , but this invasive technique is jus tified only under circums tances . F rom today's practical point of view, E E G has s everal uses : Inves tigation of epileps y to confirm the diagnos is clarify the type of epilepsy Differentiation of delirium from acute nonorganic ps ychos is R ecognition of C reutzfeldt-J akob disease Dis tinction of frontotemporal dementia Only 30 to 50 percent of patients with epilepsy show an epileptic abnormality on a single interictal waking E E G . With s leep deprivation, s leep during the recording, and repeated recordings , s ens itivity improves to 70 to 80 percent. Anterior temporal electrodes add to the sens itivity and localizing power of the E E G , but nasopharyngeal electrodes, which are quite uncomfortable for the patient, do not provide additional sens itivity, and are not recommended. A reasonable protocol s tarts with a routine E E G , including anterior temporal leads ; if this is negative but suspicion remains high, a second E E G with sleep deprivation can be undertaken. A third and fourth E E G may be us eful, but rate of dis covery of abnormalities decreas es after that. E ven then, some epileptic patients will not have been shown to have interictal abnormalities. At times , ambulatory E E G is of use to ascertain the epileptic of undiagnosed events, but the restricted montage of 104 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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ambulatory equipment limits its us efulness . Hos pitalization for video-E E G recording may be for clarifying the nature of puzzling s pells . Delirium is characterized by s lowing of the E E G , a never s een in acute idiopathic psychosis. T his point can be decisive in a confusing clinical s etting. However, E E G is not indicated as a routine in the of psychotic patients. Among the dementing disorders , frontotemporal dementia is dis tinctive in having a E E G even as the clinical s tate becomes moderately In C reutzfeldt-J akob disease, the E E G is always s low may ultimately (not neces sarily immediately) show the diagnostic feature of ps eudoperiodic complexes. E E G s at weekly intervals may clinch this diagnosis in a puzzling case. E voked potentials can identify abnormalities in neural transmis sion along myelinated pathways such as the pathway or the s ens ory pathways of the s pinal cord brains tem. T his can help in the diagnosis of dis orders as multiple sclerosis or vitamin B 12 deficiency. P.343

L aboratory Inves tigations In general, empirical evidence for the usefulness of laboratory s tudies supports only a limited role for or s creening investigations; for the most part, tes ts should be performed as guided by the his tory and examination. A full discus sion of laboratory strategies all neuropsychiatric s ituations is beyond the scope of chapter. In regard to dementia, a complete blood cell count (C B C ), chemistry panel, vitamin B 12 as say, and 105 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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thyrotropin (T S H) as say are indicated as screening addition to a test for s yphilis (the fluorescent antibody test [F T A]) in those areas of the United S tates which the prevalence of s yphilis jus tifies the testing. region of high incidence is a broad belt acros s the addition to s ome urban areas in the North; 30 U.S . contribute more than one-half of the national total of cases.) T he reason the F T A is the tes t of choice is that reagin tes ts (the V enereal Dis ease R esearch [V DR L] or R apid P lasma R eagin [R P R ]) revert to intercurrent antibiotic treatment or with the pas sage of time and, thus , are insufficiently sensitive to serve as screening tes ts for neurosyphilis . Appropriate s creening tests for mental pres entations than dementia, for example, first episode psychosis , less well es tablished. Unfortunately, no cohort studies applying a cons is tent laboratory diagnos tic approach available to provide guidance as to the s ens itivity and specificity of tes ting or even as to the prevalence of organic disease in this s ituation. T he first s tep should neurops ychiatric history and examination. A laboratory screen might include C B C , chemistry panel, urinalys is, and urine toxicology. If it is cons idered to screen for rheumatic disease, an antinuclear tes t (ANA) is adequate for this purpos e, being almos t all cas es of lupus , although not sufficient to that diagnosis. (F als e positives from ps ychotropic induced ANA tests are an important confound.) E xces sive laboratory testing is to be deplored; on the hand, limiting laboratory tes ting to generally familiar diseases is inexpert. C onsideration of rare metabolic diseases s hould be within the neuropsychiatrist's 106 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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R uling out aminoacidurias or organic acidurias in with adoles cent or young-adult ons et of ps ychos is be considered, es pecially if unexplained fluctuations poss ibly due to dietary factors , unexplained physical or unexplained cognitive impairment is pres ent. A reasonable broad s creen includes ammonia, plas ma amino acids , and urine for organic acids, although this to detect s uch conditions (known to be as sociated with ps ychiatric pres entations ) as G M 2 ganglios idosis (hexos aminidas e A deficiency) and F urther testing with s pecific metabolic or genetic should be performed as circums tances indicate.

E xamination of the C erebros pinal E xamination of C S F obtained through lumbar puncture sometimes a crucial element of the diagnos tic proces s, particular to diagnos e infection or inflammation, more rarely in neuropsychiatric practice to seek evidence of neoplasia (s uch as meningeal carcinomatos is ). as says are available for the diagnosis of neurops ychiatrically relevant infectious agents s uch as polymerase chain reaction (P C R ) for the herpes virus (HS V ) genome to diagnose herpes encephalitis or cryptococcal antigen ass ay to diagnos e this fungal meningitis. In rheumatic diseases involving the brain, white cell count may not be elevated, but elevated and evidence of intrathecal elaboration of antibodies give evidence of inflammatory activity. T he latter is by the ratio of immunoglobulin G (IgG ) to albumin or, better, by the IgG index, which requires meas urement serum IgG by immunoelectrophores is . C S F antibodies are uncommon but s pecific for cerebral In the future, ass ay of C S F cytokines may provide 107 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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as sistance in the difficult diagnos is of these diseases . Meas urement of the neuron-derived 14-3-3 protein has adequate s pecificity and s ens itivity to as sist in the diagnosis of C reutzfeldt-J akob disease as long as the pretes t probability of this rare disease is sufficiently In practice, this means that us e of the tes t should be confined to patients with a progres sive dementia of than 2 years' duration. Meas urement of tau and peptides is not yet of s atisfactory validity for general the diagnosis of Alzheimer's dis eas e. R emoval of C S F by lumbar puncture or external also plays an important role in the evaluation of suspected of shunt-revers ible normal press ure hydrocephalus.

Neurops yc hologic al As s es s ment Neurops ychological evaluation has an important role to play in neuropsychiatric care, both for diagnos is and for management. S ound us e of the clinical as a cons ultant requires , as a first step, formulation of cogent cons ultative question. T he more s pecific the cons ultant's ques tion, the more able the neurops ychologist is to integrate the ps ychometric data with the res t of the clinical picture. Much of the early literature on neuropsychological as sess ment focus ed identifying and localizing organic brain dis eas e. W ith advent of neuroimaging, neuropsychological testing is seldom the mos t powerful means of addres sing this although it certainly continues to play s uch a role, for example, in lateralizing cognitive deficits as a tool in epileptic patients. Nor is the role of the 108 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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neurops ychologist to make a dis eas e diagnosis, at times the psychometric picture is strongly s ugges tive a particular diagnosis. In several areas of as sess ment, the neuropsychiatrist particular reas on to turn to the neurops ychologis t. If subs tantial confounds make bedside diagnos is difficult, neurops ychological data may be of cons iderable as sistance. F or example, identifying supervening impairment in a mentally retarded or poorly educated patient or s ubtle impairment in a highly intelligent may be imposs ible for the clinician to do with whereas quantitative ass ess ment may allow these diagnoses. Another example of us ing as sess ment as a probe of brain function is disclos ing a pattern of cognitive s trengths and weakness es to right hemis phere learning dis abilities in a patient with clinical picture s uggestive of pervasive developmental disorder or a clus ter A pers onality disorder. Obtaining neurops ychological data about a dementing patient allows more precis e targeting of behavioral more s pecific education of families , and more confident as sess ment of decline or of benefit from treatments . One common us e of neurops ychological as ses sment requires a word of caution: identifying cognitive impairment in an older patient presenting with mood disorder or psychos is. No neurops ychological findings should deter the clinician from aggress ive treatment of ps ychiatric symptoms, and nons pecific, s tateattentional and motivational factors may confound the neurops ychological res ults. R ather than devoting res ources of time and energy to pinpointing a moving 109 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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target in the acute phase, deferring the as sess ment symptoms are reduced is often the wiser course. Another caution about neuropsychological ass ess ment falls under the rubric of ecological validity. T his term to the extrapolation P.344 of results obtained in the neuropsychological laboratory by artificial “paper-and-pencil” methods to real-world performance. T he concern aris es in particular with orbitofrontal lesions , which may produce a paucity of cognitive findings but devas tating personality change. Deriving clinical meas ures from the developing realm affective neuros cience suitable to characterize such patients is a current challenge to neurops ychology.

B rain B iops y B iopsy of the brain has a limited role in evaluation. T he morbidity and mortality of the as performed by an experienced neurosurgeon, are but the sensitivity of the procedure is lower than one might expect. F or example, the sensitivity of biops y for primary angiitis of the central nervous system (C NS ) be only 75 percent. In some circums tances , biops y of a peripheral tis sue can s ubs titute for brain biops y in a patient with primarily cerebral symptoms at lower ris k. example, lung or muscle biopsy may make a diagnosis sarcoid, skin biopsy a diagnosis of vasculitis if a rash is present or of C ADAS IL, temporal artery biops y of giant arteritis. In neuropsychiatric s ituations, the major indication for biops y of the brain is cons ideration of inflammatory disease when the nature and 110 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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of treatment depend on a tiss ue-proven diagnosis . Although of course it cannot be cons idered a clinical diagnostic test, autopsy s hould not be overlooked by neurops ychiatris t as a learning tool.

C OMMON NE UR OP S YC HIA TR IC C ONDITIONS T his s ection provides a s urvey of s ome is sues brought to the attention of neuropsychiatrists . T he emphasis is on the priorities for clinical and laboratory as sess ment for a variety of presentations . T he is by disease and syndrome, as a complement to the anatomical and s ymptom-oriented discus sion provided far. T his perspective is distinctive for neuropsychiatry within psychiatry; the disease proces ses underlying symptoms in the idiopathic disorders are unknown. F or neurops ychiatric patients, one can hope and work to uncover the disease causing the s ymptoms and, on fortunate occasions , to provide dis eas e-specific

Dementia An extensive lis t of dis eases produces the clinical state dementia. A shotgun laboratory approach to “ruling out treatable disease” is unwise, if only because finding revers ibility is s o unusual. Moreover, clinical clues to revers ible disease are available in the history and examination: us e of ps ychotoxic medicines , rapid mildnes s of cognitive impairment (even s hort of fully meeting criteria for dementia), subcortical features of cognitive disorder, and pres ence of motor s igns. T able 4 provides specific guidance to be gained from clinical clues . T he differential diagnos is of dementia needs to 111 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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include differential diagnos is among the degenerative disorders , an exercise that depends very largely on findings rather than imaging or laboratory data. In particular, apolipoprotein E testing is by cons ens us not recommended for routine diagnos tic purposes at the present time.

Table 2.1-4 C lues to the Diagnos is of Dementia in the Neurologic al E xamination Abnormal eye findings    C eliac disease    G aucher's disease type 3    Mitochondrial cytopathy    Multiple s cleros is    Niemann-P ick dis eas e type C    P rogres sive supranuclear pals y    S yphilis    V ascular dementia 112 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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   W ernicke-K ors akoff s yndrome    W hipple's dis ease    W ils on's dis eas e Ataxia    C eliac disease    C erebellar degenerations    G M 2 ganglios idosis    Hypothyroidism    Multiple s cleros is    Niemann-P ick dis eas e type C    P rion dis eas e    P rogres sive multifocal leukoencephalopathy    T oxic-metabolic encephalopathy    W ernicke-K ors akoff s yndrome    W ils on's dis eas e

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Dys arthria    C erebellar degenerations    Dementia pugilistica    Dialysis dementia    Motor neuron dis eas e    Multiple s cleros is    Niemann-P ick dis eas e type C    Neuroacanthocytosis    P antothenate kinase–as sociated neurodegeneration    P rogres sive multifocal leukoencephalopathy    P rogres sive supranuclear pals y    W ils on's dis eas e E xtrapyramidal signs    Alzheimer's dis eas e    C erebellar degenerations 114 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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   Dementia pugilistica    Dementia with Lewy bodies    F ahr's syndrome    G M 1 ganglios idosis, type III    Huntington's disease    Multiple s ys tem atrophy    Neuroacanthocytosis    Niemann-P ick dis eas e type C    Normal press ure hydrocephalus    P antothenate kinase–as sociated neurodegeneration    P arkinson's diseas e    P rogres sive supranuclear pals y    P ostencephalitic parkins onism    S ubacute sclerosing panencephalitis    T oxic-metabolic encephalopathy 115 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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   V ascular dementia    W ils on's dis eas e G ait dis order    Adrenomyeloneuropathy    C erebellar degenerations    Dementia pugilistica    HIV encephalopathy    Multiple s cleros is    Normal press ure hydrocephalus    P arkinson's diseas e    P rogres sive supranuclear pals y    S yphilis    V ascular dementia    W ernicke-K ors akoff s yndrome Myoclonus

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   Alzheimer's dis eas e    C eliac disease    Dialysis dementia    K ufs' disease    Lafora's body dis eas e    Mitochondrial cytopathy    P rion dis eas e    S ubacute sclerosing panencephalitis P eripheral neuropathy    Adrenomyeloneuropathy    B 12 deficiency    HIV encephalopathy    Metachromatic leukodys trophy    P orphyria    T oxic-metabolic encephalopathy

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P yramidal signs    Adrenomyeloneuropathy    B 12 deficiency    C erebellar degenerations    G M 2 ganglios idosis    HIV encephalopathy    K ufs' disease    Metachromatic leukodys trophy    Motor neuron dis eas e    Multiple s cleros is    P antothenate kinase–as sociated neurodegeneration    P olyglucos an body disease    P rogres sive multifocal leukoencephalopathy    S yphilis    V ascular dementia 118 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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HIV , human immunodeficiency virus . Modified from S andson T A, P rice B H: Diagnos tic tes ting and dementia. Neurol C lin. 1996;14:45–

T he clinician needs to gather data relevant to management iss ues other than purported reversibility, such as safety of living arrangements , driving ability, preparation of a will and advance directives . patients often develop psychiatric s ymptoms, which res pond to pharmacological and behavioral treatment. these considerations s hould prompt the clinician to cast wide net in data gathering regarding the demented patient. P.345

E pileps y Major concerns in patients with epileps y include differential diagnosis, psychosis, pers onality change, depres sion, violence and other epis odic behaviors , and ps eudoseizures . T he last will be dealt with below along with other conversion dis orders. A 67-year-old woman pres ented with at leas t 1 year of progres sive memory impairment, confus ion, then irritability and s us piciousness . T he mental s tate was 119 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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of Alzheimer's dis eas e, and the phys ical examination disclos ed only bris k tendon jerks . An E E G , done earlier because of a spell of uncertain nature, had shown left temporal s pikes . Neurops ychological as ses sment had shown a pattern typical for Alzheimer's dis eas e, with memory impairment characterized by rapid forgetting, semantic–phonemic verbal fluency deficits , and MR I, however, demonstrated extens ive white matter disease, with bilateral confluent hyperintensities, which extended into the gyri and involved U fibers . C S F examination was entirely normal. S kin biops y for and s creening genetic as say for C ADAS IL were R epeat E E G s howed bilateral temporal spikes, and carbamazepine (T egretol) was begun. T he clinical diagnosis was leukoencephalopathy due to cerebral amyloid angiopathy, poss ibly with Alzheimer's disease. T he patient's mother had died at 86 years of age, suffered from “the same thing” as the patient. F our of mother's five s iblings demented in the 8th or 9th of life, none earlier, in most cases with a diagnos is of Alzheimer's disease. T he patient was an only child. patient's two daughters, both young adults, were very concerned that they might inherit the same dis eas e as their mother, and they ins is ted the patient undergo the brain biopsy that a geriatrician had recommended. T his disclos ed pronounced congophilic angiopathy. Immunos taining for A-beta confirmed the vess el abnormality and showed neuropil plaques ; immunos taining for tau did not reveal neuritic plaques . Nonetheles s, Alzheimer's diseas e could not be No inflammation was seen. However, s everal days biops y, she developed s tatus epilepticus . 120 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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P atients with attack disorders can be misdiagnosed as having epilepsy when they do not or as having a disorder when epilepsy is the correct diagnosis. P aroxysmal s ymptoms from panics, cardiac disease syncope or near syncope, endocrine dis orders (pheochromocytoma, carcinoid, systemic conversion dis order can be mistakenly labeled contrariwis e, epileps y can be mis sed when a diagnosis panic dis order, in particular, is accepted. A 59-year-old man was evaluated for 7 years of problems and s pells refractory to treatment on a of panic dis order. T hese spells characteristically lasted 10 seconds and recurred as often as hourly; he was sometimes amnestic for the s pells afterward. During an attack, he had goos eflesh, and his s peech became once at church, he was believed to be s peaking in E xtens ive treatment trials with benzodiazepines and serotonergic drugs had given no consistent benefit. from hyperlipidemia, he had no significant medical E E G had been negative on three occas ions, MR I on Holter monitoring and S P E C T on one each. T he neurological and mental s tate examinations were An attack was witnes sed during the examination: He showed 10 s econds of facial flushing and stereotyped hand movements . T he attacks were s ubs equently abolished by a trial of an antiepileptic drug. T he case illus trates that epileps y is primarily a clinical, not an diagnosis. A 52-year-old woman was referred for the evaluation of spells. In her 30s s he had been hos pitalized for and was subsequently treated intermittently as an 121 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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outpatient. T he family history included s everal with depress ion or bipolar dis order. T wo years before evaluation, s he pres ented with headache and proved have an unruptured aneurys m, which was clipped a craniotomy. S everal months later, s he had a convuls ion. S he went on to have s pells at a rate of up a day. T hey were stereotyped and abrupt in ons et and termination; s he could not identify provocative factors social contexts. During a s pell, s he felt cold and had goosefles h for approximately 3 minutes. T hen she rigid and unable to s peak or interact, although she hear others ' s peech. T his las ted s everal minutes. T hen began to cry. T he whole sequence las ted 6 to 10 S he was on phenytoin with a therapeutic s erum level. P revious trials of divalproex (Depakote) and topiramate (T opamax) were not tolerated. E E G s had shown only frontal s lowing with no epileptic features on several tracings. T he neurological and cognitive examinations were normal, and she was not depress ed at the time of evaluation. T he clinical picture was inconclus ive: In epilepsy were the abrupt ons et and termination, stereotyped nature of the s pells , and background of craniotomy; agains t epilepsy were the weeping, length the ictus (if all the phenomena were taken to be ictal), of respons e to treatment, relatively inactive E E G , and background of depress ion. V ideo E E G done after medication withdrawal recorded three complex partial seizures with right anterior inferior temporal ons et with her typical s emiology and no ps eudos eizures . In exploring the psychiatric concomitants of epilepsy, clinician needs to be aware of the nature of the Most adult epilepsy is focal (“localization-related 122 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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epilepsy”), with the ictal ons et in the temporal lobe. However, other forms of epilepsy, including frontal epilepsy and primary generalized epileps y, are T hese dis tinctions , and the laterality of the focus , can be inferred from the semiology of the seizures as or as observed clinically. A history of febrile childhood and age of onset of epileps y are relevant to likelihood of mesial temporal sclerosis as the pathology. B ody asymmetry and dis sociated facial should be sought as indicators of laterality. T he MR I E E G provide crucial information on pathology and type. Almost all the findings relating ps ychiatric epilepsy are concerned with partial epileps y of onset; linking psychiatric s ymptoms to epileptic syndromes other than temporal lobe, or limbic, epilepsy generally goes beyond the evidence. F urther, to what extent ps ychopathology is as sociated with the epileps y per se and to what extent with the underlying brain disease remain controversial. W ithout ques tion, impairments are related to the lateralization of the temporal focus . P sychotic s tates in epileptic patients are usually into those occurring during the epileptic ictus , often epile ptic twilight s tate s ; thos e occurring for a delimited period in the aftermath of a seizure or, more flurry of s eizures , s o-called pos tictal ps ychos is ; and that are chronic, called interictal ps ychos is . Us ually, chronology can be ascertained by inquiry, but at times, E E G monitoring is necess ary to identify the occurrence seizures in relation to ps ychopathological phenomena, es pecially becaus e patients can be amnes tic for partial seizures . A further iss ue to be elucidated from 123 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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history is of a relations hip between s eizure treatment control and the level of ps ychopathology, especially ps ychos is . An inverse relationship is s ometimes P.346 noted, better s eizure control being as sociated with occurrence of ps ychos is, a phenomenon known as normalization. On the other hand, frequent seizures certainly can caus e an increase in confusion and failure in functional capacity. A 35-year-old woman with lupus and intractable was admitted several times with pers ecutory and delus ions (“I'm dead”) and depres sive s ymptoms . Inves tigations to identify active cerebral lupus were unrevealing, even when she had evidence of peripheral activity of the dis eas e. In fact, MR I disclos ed the hippocampal sclerosis, s ugges ting that the epilepsy idiopathic and not due to old cerebral lupus . W ithout specific treatment, the psychotic s ymptoms diminished over the cours e of several days ; this als o was believed make a diagnosis of cerebral lupus unlikely. B etween episodes , s he s howed no ps ychotic phenomena. T he interictal pers onality s yndrome of temporal lobe epilepsy (the G as taut-G eschwind s yndrome) is characterized by hypergraphia; religios ity or deepened metaphys ical interest; intens ified emotionality with a tendency to holding grudges and aggress ion; hypos exuality; and an alteration of social behavior with intens ity of interaction, an inability to end interactions , circums tantiality of discourse (phenomena confus ingly denominated as “viscos ity”). T he syndrome remains 124 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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controvers ial; what is of importance for as sess ment is that inquiry be directed to phenomena, as hypergraphia, that are not included in the review of symptoms of idiopathic ps ychiatric disorder. E pisodic aggress ion is often s us pected of being ictal very rarely is . Aggress ion occurring during s eizures is almos t always disorganized, not carefully directed. A threshold is jus tified in attributing a violent act to in the abs ence of typical epileptic features. Amnesia for serious violence is common and not a s trong pointer to epileptic origin. A s pecial is sue in neurops ychiatric as ses sment of the epileptic patient is the presurgical evaluation. S urgical treatment, especially of temporal lobe epilepsy due to mesial temporal sclerosis, is underused; ideally, more more patients with medically refractory epileps y will be evaluated for their s uitability for surgery. Along with intens ive electroencephalographic evaluation, MR I, and neurops ychological as sess ment, the patient's ps ychiatric state s hould be s ys tematically evaluated. patient's ability to cons ent and is sues s uch as the capacity to cope with the stress of monitoring and as well as the expectations held for surgery should be addres sed. Neither depress ion nor psychosis is an contraindication to s urgery, although a chronic probably will not be alleviated by s urgery. Indeed, few, any, psychiatric findings contraindicate s urgery, but ps ychiatric evaluation may well reveal deficits that be taken into account in developing a treatment plan.

Traumatic B rain Injury T raumatic brain injury is epidemic in society, with 125 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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advances in emergency medical care leading to growth the prevalence of survivors of s evere injury. Is sues commonly facing the neuropsychiatrist include aggres sion, depres sion and anxiety, and the deficits (sometimes for legal purpos es ) in patients with mild traumatic injury. T he features of the head injury should be as certained, ideally with confirmation from medical records. T he altered behavior and personality common after traumatic brain injury are more burdensome for families than are the physical disabilities. Dis inhibition and aggres sion are particularly uncomfortable and often to treat. A complicating factor is that preinjury and s ubs tance abus e are common, as they predis pos e head injury. A 24-year-old woman was s een 19 months after an automobile collision in which she was an unres trained pass enger. S he was comatose for 3 months and underwent surgical evacuation of a left-sided hematoma. S he had a few weeks of rehabilitation after regaining consciousness and returned home after spending most of a year in a nursing home. T he family at wits' end over epis odes of aggres sion, which to be directed angry behavior elicited by frus tration. did not have depress ive symptoms. On examination, showed severe bilateral s pas ticity, including s pas tic dysarthria, drooling, and a bris k jaw jerk. S he was able recall dates and other details of her illness accurately, she disclaimed behavioral or emotional alterations . Her language comprehens ion was adequate, but output telegraphic. Affect was labile. B ehavior during the 126 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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cons ultation was initially appropriate, with an obvious effort to cooperate with the evaluation, although she greeted the examiner with, “I love you.” At the end of examination, however, she urgently requested the examiner's bus iness card and rammed him with her wheelchair while cutting off his access to the door. C hronic-phase C T s howed atrophy and left temporal encephalomalacia. A 59-year-old man was referred by a court for of his ability to take part in proceedings related to his divorce. T hree months before evaluation, he was several times by an unknown as sailant during an altercation regarding who was to get the us e of a taxi. suffered contusions of the left periorbital area but no overt injury. He was able to recount the events in s ome detail, but he explained that this was because, over by comparing notes with others, he had “put it all back together”; of his own recollection, he could remember first punch that s truck him but not the s econd or subs equent events of the altercation. Although he not be certain of the duration of the gap in his it was clearly a matter of some s econds , conceivably a minute or two, and at no time was he uncons cious . In aftermath, he was “confused” and had a headache. He found that he could not come up with names , dates, or numbers, although this information generally came to him later or with considerable unaccus tomed effort. also noticed that he “couldn't visualize” geographical scenes, so that in planning to go to a familiar place, he unable to picture it in his mind. Although he did not get lost, he found that he turned the wrong way or mis sed turn because of inattention and had to correct himself. 127 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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noted that his memory, previous ly highly trustworthy, could not be counted on: “I had to write everything He found that he had to “take time to think,” “strain my brain to focus .” He distanced hims elf from busines s decis ions and relied on trus ted subordinates to counsel him. He acknowledged s ens itivity to light, noting that had begun to wear sunglass es even when the weather cloudy and to turn off the room lights when he was watching televis ion. T o a less er extent, he was noise. He noted that he was more readily irritated than characteristic of him. He did not have depress ive symptoms, intrusive recall of the altercation, or nightmares . T he s ymptoms had gotten gradually less severe. T he history included s everal head injuries in adoles cence, two of which resulted in los s of cons ciousnes s of a few hours without recognized sequelae. T he noncognitive mental s tate and P.347 examinations were normal. He s cored 21 on the Mental Alternation T es t, a clearly normal performance on a mental s peed and working memory. He s cored 16 out 18 on the F rontal As ses sment B attery, a collection of as sess ing executive cognitive function. T he two lost were on the go/no-go tas k, on which he made perseverative errors. He was mildly dis organized on performing the ring/fis t tes t of motor s equencing. MR I E E G had been normal. T he picture was believed to be cons istent with organic s equelae of traumatic brain T he case underlines the importance of prior traumatic brain injury in determining the effects of s eemingly mild trauma and that los s of cons cious nes s is not a 128 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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for significant s equelae.

Movement Dis orders C ognitive impairment due to involvement of subcortical structures is a common neuropsychiatric feature of the movement disorders . T his applies to cerebellar, as well basal ganglia, diseas es for the anatomical reas ons described above. T he anatomy of the clos e relation between emotion and movement was als o described above. C linically, mood disorders are common in IP D other movement disorders . Anxiety disorders , although less emphas ized in the literature than depres sion, are common. T he evaluator s hould take into account that mood and anxiety can fluctuate according to the timing doses of dopaminergic drugs . A mood dis order can occasionally pres ent in advance of overt movement abnormalities , s o IP D mus t be considered in the differential diagnosis of late-onset mood disorders . A 43-year-old woman with no personal or family history ps ychiatric illnes s developed a ps ychotic depress ion. had a s evere extrapyramidal reaction to risperidone (R is perdal). T wo years later, when euthymic and unmedicated, she developed progres sive shuffling gait, upper-extremity tremor, and micrographia. S he then suffered another episode of depres sion. T hree years she had s evere anxiety, no cognitive impairment, and motor features of IP D. P sychotic reactions to dopaminergic drugs are an important feature of movement dis orders. S ometimes is the res ult of overuse of prescribed dopaminergic in an effort to increas e time in the “on” state. 129 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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A 63-year-old man with long-standing IP D developed delus ions while being treated with high-dose levodopa (S inemet) on a five-times -a-day s chedule, pramipexole (Mirapex), tolcapone, and amantadine (S ymmetrel). Under inpatient obs ervation for several on the pres cribed dos es, he remained ps ychotic. He res ponded well to quetiapine (S eroquel).

Developmental Dis abilities Adult patients with developmental dis abilities are enormously unders erved by the medical and s ocial communities and are frequently referred for neurops ychiatric attention. F ew of thes e patients have adequate diagnostic evaluation for the caus e of the disability. B eyond clinical as sess ment, with particular attention to dysmorphology becaus e features of the mental s tate and neurological examination are nonspecific, the most us eful diagnostic tes ts are MR I karyotyping. S pecific genetic probes can confirm clinical recognition of syndromes of mental retardation. P atients with developmental disabilities are indeed, es pecially vulnerable—to the mood, anxiety, ps ychotic dis orders that can afflict anyone and can be treated effectively for these; diagnostic overs hadowing (attributing all psychological and behavioral to “retardation” tout court) is to be avoided. T hese syndromes may pres ent atypically in the disabled population, and the clinician mus t be alert to indirect indicators of mood dis turbance or psychotic experience. F or example, although the patient may not report depres sed mood verbally, the caregivers may the loss of interest in favorite activities and the other 130 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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features of a depres sive syndrome. Of particular neurops ychiatric interes t is the question of behavioral phenotypes, specific psychological developmental s yndromes. S yndromes recognized to behavioral phenotypes (and their correlates ) include Lesch-Nyhan s yndrome (s elf-injury) P rader-Willi syndrome (exces sive eating) Williams s yndrome (anomalous cognitive profile, elevated s ociability) V elocardiofacial syndrome (schizophrenia)

Infec tious and Inflammatory Infectious and inflammatory diseases of the brain need always to be cons idered in acutely or s ubacutely mental disorders . Among the infectious dis eas es, HS V encephalitis has a particular claim on attention delay in diagnos is , even by hours , can lead to increased morbidity and mortality. Definitive diagnosis poss ible without biopsy by as saying for HS V in the with the P C R , but treatment may be indicated if is high in advance of firm diagnos is . C hronic example, from infection with fungi, is a rare in subacutely evolving dementia; the definitive tes ts are C S F ass ays or serological tes ts (e.g., for toxoplas mos is ). In the acquired immunodeficiency syndrome (AIDS ) era, infection with opportunis tic and with the human immunodeficiency virus itself to be kept in mind, even in circumstances not suggestive of AIDS . 131 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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Noninfectious inflammatory dis eas es include the rheumatic dis eases , of which the prototype is systemic lupus . A rheumatic disease review of systems is importance in exploring the differential diagnosis of a puzzling case, es pecially in a young woman. Although ps ychos is is often cons idered the ps ychiatric hallmark lupus , in fact, psychotic states (other than delirium) are unusual, and a variety of other ps ychiatric pictures be included in the clinician's consideration. F ew clinical features of lupus are risk factors for cerebral disease, even dis eas e activity, which may be misleading in positive or a negative direction. One feature that is a factor for neuropsychiatric s ymptoms , including impairment, is the presence of antiphos pholipid antibodies; the primary antiphos pholipid syndrome similarly carries mental risk. A 40-year-old woman pres ented with the typical of a ps ychotic depress ion. T here was a family history depres sion, and s he had s uffered two episodes of depres sion earlier in her adult life, both of which were brief, nonpsychotic, and res ponsive to treatment. F or previous year, however, her depress ion had been res ponsive to pharmacological and electroconvuls ive therapy (E C T ) treatment P.348 E xamination dis closed no definite cognitive abnormality and brisker reflexes on the left. R eview of MR I her previous treatment venue, presumably performed routine before the adminis tration of E C T , evinced areas of white matter abnormality in the right 132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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E xtens ive laboratory inves tigation, s hort of and biops y, revealed only high-titer IgA anti-β2glycoprotein-1 antibodies . Neurops ychological performed after partial remis sion of the depres sion showed deficits in attention and mental proces sing T he working diagnostic formulation was that an ordinary idiopathic depress ive disorder had been treatment resistant and gravely s evere by a wave of cerebral injury due to the antiphospholipid syndrome. less on of the case is to always look at the imaging. Other rheumatic dis eas es, such as S jögren's s yndrome the vasculitides, are als o of neurops ychiatric Has himoto's encephalopathy—subacutely developing cognitive impairment and myoclonus or s eizures with high-titer antithyroid antibodies—is important in the differential diagnosis of C reutzfeldt-J akob disease and subacute confus ional s tates. P rominent among nonrheumatic inflammatory dis eas es is paraneoplas tic limbic encephalitis, an autoimmune complication of several tumors, notably small cell carcinoma of the A 60-year-old woman was admitted for confusion. S he been drinking more heavily than us ual after a forced retirement several months earlier. T he family noted that she had been forgetful and behaviorally erratic for 1 to months. S he s moked cigarettes and had hypertension. examination, s he had mild gait instability but no other phys ical s igns. T hought was disorganized, but no ps ychotic ideas were present. P s ychomotor rate and were normal. S he s howed verbal memory impairment disinhibition, with many errors of commis sion on a go tas k and inability to inhibit reflexive gaze. C S F 133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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examination revealed a mild lymphocytic pleocytos is no other abnormalities. E E G s howed intermittent slowing. T he following were negative or normal: serological studies, thyroid function and antibody tests, anti-Hu, MR I, MR A, ches t and abdominal C T (except a benign adrenal tumor), and cerebral angiogram. T he patient's family refus ed brain biops y. On a differential diagnosis of primary angiitis and paraneoplas tic encephalitis , the patient received a puls e of (IV ) methylprednisolone, without benefit, then a cours e oral cyclos phosphamide and prednis one, again without benefit. S ome months after dis charge, she died Autops y revealed pulmonary embolus to be the cause death. P erivas cular T -cell infiltrates and activated were seen in the medial temporal lobes and to a less er degree wides pread in the cortex. No tumor was found the lungs or elsewhere. Nonetheless , the pathology supported the clinical consideration of “paraneoplastic” encephalitis , which has been reported to occur in otherwis e typical form but without a dis coverable Often, extens ive evaluation is necess ary for patients suspected of inflammatory brain dis eas e; at times , extensive evaluation does not s uffice.

C onvers ion Dis order Neurops ychiatrists often see patients whose symptoms appear to arise from brain diseas e but do not. T hes e patients' conditions have been described under various names : hys teria, functional disorder, psychogenic conversion dis order, and medically unexplained symptoms. None of the designations is entirely satis factory. F or example, the DS M-IV -T R 134 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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conve rs ion dis orde r is based on an outmoded notion of conversion of emotions into phys ical form. W hatever designation, such patients are not uncommon. C omplicating matters is the common coexis tence of organic disease and conversion s ymptoms . F or sizable minority of patients with pseudos eizures have epilepsy as well. B rain disease may, in s ome of these patients, have produced organic pers onality change reduction in the maturity of defens es and the too-easy res ort to s omatization. V arious techniques have been advocated for of nonorganic disease by the physical examination. have several shortcomings . F irst, they easily lend thems elves to a countertherapeutic alliance in which examiner is trying to trick the patient—not a good start the treatment, whatever the findings. S econd, they fail distinguish deliberate fals ification on the patient's that is , malingering—from convers ion dis order. T hird, most s uch findings are commonly pres ent in patients organic disease who are trying to help the examiner the diagnosis. T hat is, they may mark a patient as or s ugges tible but fail to rule out organic disease. T hus, example, reporting a difference in vibratory sensation between the two sides of the s ternum is by no means confined to patients with convers ion disorder. to this caution occur in cases in which the nonphysiological finding is precisely the phenomenon the complaint. E ven then, however, the phenomena of brain dis eas e are sufficiently odd that the examiner maintain an attitude of humility about achieving diagnostic certainty by recognizing the at a glance. Of the described “signs of hys teria,” 135 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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the best is Hoover's s ign. T he examiner places a hand underneath the heel of the affected leg of a supine who complains of leg weaknes s. Asked to press down the heel, the patient does not generate power with the Asked to raise the opposing leg, however, the patient produces an automatic s ynergistic downward of the affected leg. R ecent systematic findings of progress ively greater methodological s ophistication confirm the belief that experiences of abus e in childhood are common in the background of patients with conversion dis order. T his indirectly account for another progres sively more subs tantiated finding, namely, that the prognos is of conversion dis order is poor. Although a given s ymptom may wax and wane or dis appear, patients commonly a chronic course of dis ability, interpers onal difficulties , ps ychiatric symptoms, and fruitles s s eeking after help. Although hys terical symptoms have often been taken to represent s ymbolically a psychological conflict, the fundamental difficulty is that patients who make prominent use of somatization have a dis order of the symbolic function its elf. T he goal of the examiner not be to catch the patient out but to establish an that allows exploration of areas of the patient's life the presenting symptoms and cons truction of a plan to reduce dis tres s (including focused treatment of coexisting depress ive disorder) and to develop ways of seeking attention and as sistance for dis tres s.

NE UR OP S YC HIA TR IC T he neurops ychiatris t thinks anatomically about mental state disorders , even as cognitive neuroscientis ts 136 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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to construct a sufficiently s ophisticated model of largescale brain function to do justice to the complex mental states of neurops ychiatric interes t. T he relies on rich data gathered at the bedside and on laboratory methods of inves tigating brain s tructure and function and of P.349 diagnosing diseas e. T he effort is to identify not jus t behavioral s yndromes as found in DS M-IV -T R or IC D, the pathological proces ses underlying them in two F irst, neurops ychiatry s eeks medical diagnoses of or brain dis eases to account for the patient's illness . S econd, neurops ychiatry seeks to understand clinical phenomena in terms of the disruption of elementary mental proces ses, the nature of which is beginning to elucidated by the cognitive neuros ciences . T he res ult is highly differentiated diagnostic enterprise. With refreshment from a multidisciplinary bas e—ranging cognitive neuros cience to general medicine—the neurops ychiatric approach to the patient is certain to remain exciting.

S UG G E S TE D C R OS S S ection 1.2 provides a review of neuroanatomy. 1.15 discus ses nuclear MR I and S ection 1.16 covers radiotracer imaging. T he other s ections in this chapter in detail with neuropsychiatric aspects of various proces ses. T he s ections inC hapter 7 deal with the diagnostic process in general ps ychiatry, including the examination of the mental s tate (see S ections 7.1 and neurops ychological evaluation (s ee S ection 7.5), and 137 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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laboratory tes ting (see S ection 7.8).

R E F E R E NC E S *B ogouss lavs ky J , C ummings J L, eds. B ehavior and Dis orde rs in F ocal B rain L e s ions . C ambridge: Univers ity P res s; 2000. D'E s posito M, ed. Neurological F oundations of Neuros cie nce . C ambridge, MA: MIT P ress ; 2003. Dolan R J : E motion, cognition, and behavior. 2002;298:1191. Duchaine B , C osmides L, T ooby J : E volutionary ps ychology and the brain. C urr O pin N eurobiol. 2001;11:225. Duncan J , Owen AM: C ommon regions of the frontal lobe recruited by divers e cognitive demands . T re nds N euros ci. 2000;23:475. Duus P . T opical Diagnos is in N eurology. 3rd ed. Y ork: T hieme; 1998. F riston K J , P rice C J : Dynamic repres entations and generative models of brain function. B rain R es B ull. 2001;54:275. G eschwind N: Dis connexion s yndromes in animals man. I. B rain. 1965;88:237. G eschwind N: Dis connexion s yndromes in animals 138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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man. II. B rain. 1965;88:585. G olomb M: P s ychiatric symptoms in metabolic and other genetic dis orders: Is our “organic” workup complete? Harv R e v P s ychiatry. 2002;10:242. Halligan P W , David AS : C ognitive neurops ychiatry: T owards a s cientific psychopathology. Nat R e v 2001;2:209. J ohns on MH, Halit H, G rice S J , K armiloff-S mith A: Neuroimaging of typical and atypical development: A perspective from multiple levels of analysis. Dev P s ychopathol. 2002;14:521. K opelman MD: Dis orders of memory. B rain. 2002;125:2152. Levitin DJ , Menon V , S chmitt J E , E liez S , White C D, G lover G H, K adis J , K orenberg J R , B ellugi U, R eiss Neural correlates of auditory perception in W illiams syndrome: An F MR I s tudy. Neuroimage . Liddle P F . Dis orde re d B rain and Mind: T he N eural Me ntal S ymptoms . London: G as kell; 2001. *Lis hman W A. O rganic P s ychiatry: T he C ons equences of C e re bral Dis orde rs . Oxford: S cience; 1998. Lloyd D: T erra cognita: F rom functional to the map of the mind. B rain Mind. 2000;1:93. 139 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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*Mesulam MM. B ehavioral neuroanatomy: Largenetworks , as sociation cortex, frontal syndromes, the limbic s ys tem, and hemispheric s pecializations. In: Mesulam MM, ed. P rinciple s of B e havioral and Neurology. London: Oxford University P ress ; 2000. Mesulam MM: F rom s ensation to cognition. B rain. 1998;121:1013. Middleton F A, S trick P L: B asal ganglia and loops : motor and cognitive circuits. B rain R es B rain R ev. 2000;31:236. Miller MB , V an Horn J D, Wolford G L, Handy T C , V alsangkar-S myth M, Inati S , G rafton S , G azzaniga E xtens ive individual differences in brain activations as sociated with epis odic retrieval are reliable over J C ogn Ne uros ci. 2002;14:1200. *Ovsiew F . B eds ide neurops ychiatry: E liciting the phenomena of neurops ychiatric illnes s. In: Y udofsky Hales R E , eds . Ame rican P s ychiatric P ublis hing of Ne urops ychiatry and C linical Ne uros cie nces . Was hington, DC : American P sychiatric P ublis hing; Ovs iew F : S eeking revers ibility and treatability in dementia. S emin C lin Ne urops ychiatry. 2003;8:3. Ovs iew F , B ylsma F W : T he three cognitive S emin C lin Ne urops ychiatry. 2002;7:54. Ovs iew F , J obe T . Neuropsychiatry in the his tory of 140 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/2.1.htm

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mental health s ervices. In: Ovs iew F , ed. and Me ntal H ealth S e rvices . W ashington, DC : P sychiatric P ress ; 1999. P aterson S J , B rown J H, G sodl MK , J ohns on MH, K armiloff-S mith A: C ognitive modularity and genetic disorders . S cience . 1999;286:2355. S chmahmann J D, S herman J C : T he cerebellar affective syndrome. B rain. 1998;121:561. *S hallice T . F rom Ne urops ychology to Mental C ambridge: C ambridge Univers ity P res s; 1988. S ilver J M, McAllister T W : F orensic iss ues in the neurops ychiatric evaluation of the patient with mild traumatic brain injury. J Ne urops ychiatry C lin 1997;9:102. S tone V E , C osmides L, T ooby J , K roll N, K night R T : S elective impairment of reas oning about social exchange in a patient with bilateral limbic s ys tem damage. P roc Natl Acad S ci U S A . 2002;99:11531. S ugiyama LS , T ooby J , C osmides L: C ros s-cultural evidence of cognitive adaptations for social among the S hiwiar of E cuadorian Amazonia. P roc Acad S ci U S A. 2002;99:11537.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 3 - C ontributions of the P s ychological S ciences > 3.1: S ens atio P erception, and C ognition

3.1: S ens ation, Perc eption, and C ognition Louis J . C ozolino Ph.D. Daniel J . S iegel M.D. P art of "3 - C ontributions of the P sychological S ens ation, pe rce ption, and cognition refer to three broadening tiers of human information proces sing. S ens ation is us ually defined as the immediate res ult of stimulation of s ens ory neurons , whereas pe rce ption involves the organization and evaluation of thes e sens ations to obtain information about the inner or environments . C ognition refers to a set of vas tly proces ses, such as language, problem solving, and thinking, that apply plans and strategies to s ens ations perceptions. Although dis tinguis hing between perception, and cognition has a long history, the and value of s eparating them are increasingly unclear light of growing knowledge of nervous system functioning. Most information proces sing depends on the brain. B ecaus e the brain is built and maintained through the interaction of biological, psychological, and s ocial the study of s ens ation, perception, and cognition is neces sarily broad and far reaching. T he rapid increase knowledge of neuroanatomy and the development of 142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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hypothetical models to unders tand its functioning this an exciting time in the cognitive s ciences . T his reflects the juxtapos ition of many new and old models , containing much of the excitement and uncertainty that emerge as res earchers strive to understand how perceive and understand the world.

C OG NITIVE S C IE NC E T he fields relevant to this overview are a part of the interdisciplinary s tudies of cognitive science, which includes cognitive ps ychology, developmental ps ychology, ps ycholinguis tics, computational science, the emerging field of interpers onal neurobiology. E ach these dis ciplines provides an important and unique perspective on the human ps yche. B iological, ps ychodynamic, and s ocial ps ychiatry find a common home within cognitive s cience in which the usual of nature versus nurture and biology vers us ps ychology disappear in an examination of the building of the brain and the origins of mental proces ses. In recent years , discoveries in the neuros ciences have revealed a wide range of findings relevant to One of the major dis coveries was that the brain's and function are a res ult of the transaction of s everal factors , including genetic, physiological, and variables . In particular, brain development requires forms of experience to foster the growth of neural involved in a wide array of mental proces ses, including attention, memory, emotion, attachment, and selfreflection. T hus, experiences shape the unfolding of genetically programmed development of the central nervous s ys tem (C NS ). G enes function as a template 143 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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information and as a mediator of trans cription of the proteins that determine neural structure. E xperience directly shapes the selection and timing of how the of genes influences the structure of the brain. T he human brain, especially the cerebral cortex, is immature at birth. T his immaturity requires that the brain use the caregiver's brain to grow and to organize. F indings from developmental neuros cience point to the centrality of interpers onal relations hips in the development of the brain. T he cooperative communication of infant–caregiver attachments is thought to provide the infras tructure not only for emotional development, but als o for abstract reasoning and cognitive abilities. T he patterns of interaction child and caregiver have a direct impact on the way the brain develops and the mind of the child functions. T hus, cognitive proces ses need to be considered as way in which the mind emerges from within the genetic, phys iological, and experiential factors that shape the development and maintenance of mental function.

Hot and C old C ognition T raditionally, cognition was studied by experimental ps ychologists in university laboratories, whereas were explored by ps ychoanalys ts in cons ulting rooms. C ognitive psychologis ts, striving to avoid the subjective and imprecis e nature of emotions, devised flowcharts algorithms s imilar to thos e us ed to describe proces ses within organizations or, later, in programming Input was calibrated, output was measured, and were generated des cribing what happened within the “black box” of the brain. T he increasing complexity of 144 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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these models did not s eem to improve their power, and words s uch as motivation and emotion invariably aris e. As knowledge of brain functioning has increased, it is becoming increasingly clear that neural networks in sensation, perception, and cognition are inextricably interwoven with other networks process ing survival emotion, motivation, and s omatic states . T he myth of cognition, that is, cognitive proces ses devoid of influence, is gradually fading. F low charts and other diagrams depicting linear input-output proces ses are being replaced with more s ophisticated models to the complex neural s ys tems that psychologists are attempting to des cribe. Not all cognition is “hot,” such traumatic memories or scanning the environment for dangerous or s exually attractive others . S ome may be cool, such as adding rows of figures or checkbook. T hese s ame tasks, for s omeone with math anxiety, during an P.513 examination, or before an Internal R evenue S ervice may become warm or even hot. T he fundamental principle, however, is that s ens ation, perception, and cognition occur in the context of feed-forward and feedback networks , interwoven with and guided by complex (and largely uncons cious) emotional determinants.

E motion What is an emotion? T he answer to this question is as complex as the mind its elf. Although the lack of clear 145 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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definitions and good animal models has hindered empirical res earch, it is clear that emotions play a role in perceptual and cognitive proces ses. One view considers emotion as a primary value s ys tem the brain, allowing activations to be s electively F or example, emotionally charged experiences may be more readily recalled than uneventful ones . According this view, the mos t fundamental aspect of emotion is arousal-appraisal s ys tem in which the brain responds given stimulus with the signal of “this is important— note and pay attention now!” E motion thus gives value a repres entation by arousing attentional mechanisms by focus ing a s potlight of attention on the s timulus. T he second s tage would then appraise the meaning of s uch emotional arousal by as sess ing its hedonic tone: “Is good or is this bad? S hould this be approached or avoided? ” E motion thus directs the flow of energy—the activations within s pecific circuits of the brain—as the arousal-appraisal system focuses cognitive process es elements of the internal and external environment. A level of emotional process ing is the elaboration of this appraisal into a more specific form, called a categorical emotion, s uch as joy, interest, surpris e, fear, anger, or s hame. T hes e categorical emotions have universal expres sions of affect found in all cultures, which may distinct ps ychophysiological manifes tations . An additional view examines the way in which the in the body's state are repres ented in the brain in the of what Antonio Damas io has called a s omatic marke r. According to this view, the energizing or deenergizing bodily responses let the brain know how the individual feels about an experience. S uch a s omatic marker can 146 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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be us ed in future emotional ass es sments , or gut to an experience. A part of the brain called the orbitofrontal corte x has implicated as the s ite of s omatic marker proces sing or what is called intuition. Allan S chore has als o noted the importance of early experiences with caregivers in the maturation of this region and als o its central role in coordinating self-regulatory functions early in development with bas ic emotional reactions and s ocial functioning. T he orbitofrontal cortex has been not only in monitoring, but also in regulating bodily and may pos sibly be involved in psychiatric ranging from autis m to mood dis orders. Disorders in organization and social functioning may be better unders tood by examining the central role of emotion perhaps , the orbitofrontal cortex and related regions in development and maintenance of dysfunctional mental states . S tudies also sugges t that this region is for the capacity for s elf-knowledge and the s ubjective experience enabling the mind to reflect on the s elf in past, pres ent, and the potential future. Inborn and experiential factors may play important roles in allowing this region to develop the capacity to integrate a wide range of important functions of the mind, including the appraisal of meaning, emotional regulation, social cognition, and autobiographical consciousness .

NE UR A L NE TWOR K G R OWTH INTE G R A TION T he growth and s elective connectivity of neurons is the basic mechanism of all learning and adaptation. can be reflected in neural changes in a number of 147 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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including (1) the growth of new neurons , (2) the of existing neurons, and (3) the changes in the between exis ting neurons . All of thes e changes are expres sions of plas ticity, or the ability of the nervous system to change. T he birth of new neurons , or neurogenes is , is a controversial field of study. S ome res earch s ugges ts that new neurons are generated in different areas of primate and human brains, es pecially regions involved with new learning, s uch as the hippocampus , the amygdala, and the frontal and lobes . E xisting neurons grow through the expansion and branching of the dendrites they project to other T here is now sufficient evidence for the fact that demonstrate growth and changes in reaction to new experiences and learning. Although neurons to form neural networks, neural networks , in turn, integrate with one another to perform increas ingly complex tas ks . T he brain is modular, that is , different networks have evolved to perform divers e tasks. networks converge and coordinate to perform higher level tas ks . F or example, networks that in language, emotion, and memory interact and for humans to recall and to tell an emotionally story with the proper affect, correct details , and appropriate words . Ass ociation areas within the brain serve the role of bridging, coordinating, and directing the multiple neural circuits to which they are connected. E xecutive within ass ociation areas , like a s witchboard operator, the capability to interconnect different neural networks. Although the actual mechanisms of this integration are 148 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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not yet known, they are likely to include some combination of changes in (1) the biochemical within neurons, (2) the s ynaptic connections between neurons , (3) the relations hips between local neuronal circuits , and (4) the interactions between functional systems . C hanges in the synchrony of activation of multiple neural networks may also play a role in the coordination of their activity. If everything humans experience is repres ented within neural networks, then psychopathology of all kinds, the mildest neurotic symptoms to the mos t s evere ps ychos is , must be repres ented within and between neural networks. Healthy functioning requires proper development and functioning of neural networks organizing cons cious awarenes s, behavior, emotion, sens ation. P s ychopathology correlates with the suboptimal integration and coordination of neural networks . P atterns of dys regulation of brain activation specific disorders support the theory of a brain-based explanation for the s ymptoms of psychopathology. In general, ps ychological integration sugges ts that the cognitive functions of the executive brain have access to information across networks of sensation, behavior, and emotion. Dis sociation among these proces ses can occur when biochemical changes high levels of s tres s inhibit or disrupt the brain's integrative abilities. P hys ical trauma, disease genetic predispositions that disrupt the development functioning of neural networks can all result in neural dysregulation and ps ychiatric s ymptomatology. Applying this model to treatment, ps ychotherapy, ps ychopharmacology, and psychosurgery can be s een 149 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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ways of creating or res toring integration and between various neural networks . F or example, has demonstrated that success ful ps ychotherapy correlates with changes in activation in areas of the hypothes ized to be involved in disorders , s uch as obses sive-compuls ive disorder (OC D) and depress ion. return to normal levels of activation res ults in reestablishing positive reciprocal control between neural structures and networks.

MIND A ND B R A IN A generally accepted view of the mind is that it from a portion of the activity of the brain. W hat is this activity of the brain, P.514 and how does it give rise to s uch mental process es as perception and cognition? How do the human of s ens ation, thought, emotion, attention, selfand memory emerge from neural proces ses? T he brain is compos ed of approximately 10 to 20 billion neurons . An average neuron is connected to approximately 10,000 other neurons at s ynaptic With hundreds of trillions of connections within and among thousands of web-like neural networks, there countles s combinations of poss ible activation profiles . term ne ural net profile is us ed to describe a certain of activation of the complex layers of neural circuits . neural net profile is the fundamental way in which proces ses are created. T hes e activations can lead to neural proces ses in a cas cade of dynamic interactions produce a range of internal events and external 150 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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T he es sential components of the mind come directly how these neural events create the flow of energy and information.

E NE R G Y A ND INF OR MA TION T he mind is a proces sor of patterns in the flow of and information within the brain (T able 3.1-1). of individual neurons , groups of neurons, circuits, or networks of neurons all involve the flow of energy the complex system of the brain. T his energy reflects flow of ions acros s membranes, the consumption of oxygen and nutrients by neural cells, and the active transport of molecules into and out of nervous tis sue. However, the mind is much more than s ome outcome energy flow—the function and purpose of this flow of energy are to process information.

Table 3.1-1 B as ic Ideas of the T he mind is a proces sor of energy and E nergy is contained within the activations of circuits . Information is contained within the patterns of activation, termed a ne ural net profile or me ntal re pre s e ntation.

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T hese representations serve as symbols that further effects in the mind, leading to the of information.

Information is created within the brain by a proces s of representation. F or example, when an individual s ees E iffel T ower, the brain res ponds in particular regions of visual s ys tem with the activation of a neural net profile. When the E iffel T ower is recalled at a later time, the cortex activates a similar neural net pattern, and the T ower is visualized. T he activation of a particular neural firing thus contains within it information about something (the E iffel T ower). E xamples of forms include perceptual, s ens ory, linguistic, and more abstract repres entations of concepts and categories.

INF OR MA TION P R OC E S S ING S everal elements of the brain's function as an proces sor can be des cribed (F ig. 3.1-1). At the mos t level (F ig. 3.1-1A), energy leads to neural respons es. energy can be in the external form of light on the retina sound waves vibrating the tympanic membrane. It may also take an internal form in which the flow of energy within neural activations thems elves produces neural res ponses.

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FIGUR E 3.1-1 Information-proces sing models. A s econd level of unders tanding information (F ig. 3.1-1B ) is in the idea that an input (internal or external) leads to a repres entational respons e (a profile of activation), which, in turn, produces a downstream effect or output. T his output can be such as the generation of other repres entations, or external, in the form of observable behavior. proces sing becomes even more complex when the thems elves carry information. W ithin cognitive ps ychology, these information-proces sing events can seen as the contrasting, comparing, generalizing, chunking, clus tering, differentiating, and extracting proces ses that lead to interwoven sets of increasingly complex mental repres entations. A third level of viewing information process ing in the (F ig. 3.1-1C ) is the conceptualization of forms of perception, attention, and memory. According to this external energy is s ens ed by the peripheral nervous system and is registered as s ens ation within the brain. 153 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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selective process ing of aspects of thes e s ensations , filtering, leads to the production of perception. T hes e perceptions are thems elves s ubject to further filtering in which only a s elect few are placed within working memory. T his is sometimes called the “chalkboard of mind.” It is within working memory that representations can be cons cious ly manipulated, contrasted, clustered, and reass embled. T hus, cons cious nes s may be related to this as pect of mental functioning. S ens ation refers to the initial s tages of the basic information-proces sing model (F ig. 3.1-1). In traditional experimental paradigms , sens ory memory is conceptualized as las ting for approximately 0.25 Items in sensory memory are then filtered into working short-term memory, where they last for approximately minutes. W hen humans attempt to cons cious ly learn information, working memory is able to handle approximately s even items, unless further process ing creates linkages to other items within longer-term memory. R ehears al allows thes e repres entations to for longer periods of time. C ognitive process es that can group bits of information into large chunks (chunking) increase the capacity of working memory by making unit more information rich. R epresentations are then proces sed and placed within long-term memory from which they can be retrieved for future us e.

A TTE NTION Attention is the proces s that controls the focus and flow information process ing. T hereare many aspects to attention that may derive from P.515 154 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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their neuroanatomical localization. T hree components attention (s electivity, capacity, and sustained concentration) have traditionally been us ed to describe cognitive deficits in psychiatric disorders such as schizophrenia and attention-deficit/hyperactivity (ADHD). All aspects of attention in normal and patient populations are influenced by the emotional or motivational value of the s timulus. E arly conceptualizations of attention were based on Donald B roadbent's idea of a filter that s elects a limited amount of incoming stimuli to be further proces sed. Limited capacity of attention was thus attributable to inability to proces s the overwhelming amount of stimuli. An attention bottleneck was des cribed as occurring early in the sens ory process (automatic) or the perceptual proces sing s tage (identification and clas sification).

S elec tive Attention One aspect of attention is that it focuses a spotlight on external s timuli or internal mental representations. In B roadbent's conceptualization, selectivity has three dimens ions: (1) filtering, focusing specific attributes (e.g., large s quares vs . s mall categorizing, based on stimulus class (e.g., attending letters in whatever script they are written); and (3) pigeonholing, reducing perceptual information needed place a stimulus into a s pecified category (e.g., using long hair to clas sify individuals as female). E ach of as pects of attention acts on incoming s timuli to make a determination of fit for the sought-after characteristic. 155 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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S chizophrenic patients, for example, s how greater difficulty with pigeonholing than with filtering when they are symptomatic. Another conceptualization of selective attention distinguishes between two interactive ways of sens ory input. P reattentive proce s s ing (a parallel as sess es global, holistic patterns and appears to be an early component of the perceptual process . F ocal (a s erial process ) follows preattentive process ing and involves a detailed analysis of stimuli characteristics . attention can be directed at one s timulus form only and thus limited in its capacity. In contras t, parallel (preattentive) attention process es do not appear to limited capacity and can detect ges talt as pects of environmental s timuli from numerous sources . T he to hear one's name called out by a nonattended voice crowded, noisy room is an example of an ongoing proces s with the ability to detect gestalt features and extremely familiar (and thus automatically process ed) stimuli.

Attention C apac ity T he concept of proces sing capacity involves the idea given task makes a demand on a limited pool of A task with a high process ing load draws more from the finite pool than does a task with a low load, thus inhibiting the access ibility of resources for simultaneous functions drawing from the same pool. attention requires cognitive effort and thus has a high– proces sing load demand. C ognitive models describing several resource pools sugges t an executive process distributes res ources to various cognitive functions. 156 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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proces ses that demand process ing capacity inhibit the simultaneous action of other s erial high-load contrast, parallel proces ses have low or no process ing capacity demands and can function simultaneous ly numerous other functions without inhibiting them. Optimal performance is attained with moderate levels arousal that allow for the es tablis hment of task goals feedback from the performance of the tas k, leading to appropriate res ource allocation. Low levels of arous al impair those proces ses and lead to inadequate allocation. High levels of arousal may be detrimental to performance because of poor dis crimination of stimuli diminis hed efficiency of allocation, resulting in poor attention functioning.

S us tained Attention T he ability to sustain attention is called vigilance and be tes ted with task demands for alertness and concentration over a period of a few minutes to an T he tes ts usually involve detection requirements for stimuli that occur infrequently at random intervals . An example of s uch a test is the C ontinuous P erformance which has been us ed to s tudy various psychiatric disorders . Important aspects of the tests are derived signal detection theory and include the factors of sens itivity and res ponse criterion. S ensitivity is the distinguishing of target s timuli from nontarget s timuli. res ponse criterion is the amount of perceptual required to support the decision regarding a target item versus a nontarget item.

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T he es sential feature of information process ing in the is that the patterns of activation of neural circuits (the neural net profile) contain information. T hese mental representations, in turn, produce further neural events . T he location and pattern of neural activations the nature of what the neural net profile repres ents. F or example, activity in the optic nerve in response to light leads to a cascade of neural res ponses within the cortex generating a visual s ensation. F uture activation those layers in the visual cortex in that general pattern the experience or recollection of the vis ual image. and localization determine the kind of repres entation the information that it specifically contains .

S E NS A TION A ND P E R C E P TION F orms of repres entations include sens ory and ones that derive from input from the external world via peripheral sensory nervous s ys tem. T he initial s tage of encoding a vis ual representation is called an iconic and is held within sensory memory for a brief period. F eatures of the initial stimulus , s uch as its s ize, and color, are the information held within this sens ory representation. S ens ory repres entations are the least proces sed of mental representations and are thought be as close as the brain can get to representing the as it is. T his is a form of proces sing termed bottom-up proce s s ing and is in contrast to more elaborately representations that are directly influenced by more abstract aspects of prior experience, called top-down proce s s ing. As the initial s ens ory activations are (clas sified, compared, and linked to repres entations prior experience) they become influenced by higherproces ses and become organized as perceptual 158 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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representations. Attentional proces ses at the level of s ens ory memory on the initial image with higher cognitive functions , as clas sifications and chunking. In their es sence, these down proces ses compare, contras t, and transform the initial repres entation to create new perceptual images within working memory. S tudies of patients with schizophrenia reveal s pecific deficits at this early stage perceptual proces sing. P erception is created by the top-down transformations sens ory images but does not neces sarily involve the experience of consciousness . T his has important implications in that patients may be influenced by and s timuli that they cannot cons cious ly recall. cons cious, focal attention is involved in perception, the representations are proces sed differently. T he involvement of focal attention appears to be necess ary the activation of the hippocampus in memory which allows for the encoding of explicit, consciously access ible, autobiographical memory. P os ttraumatic diss ociative s tates may involve the blockage of focal proces sing P.516 of perceptual repres entations , thereby leading to a disconnection among cons cious and nonconscious elements of experience. Imagery involves the activation of brain circuits res ponsible for perceptual proces sing. R epres entations (neural net profile activation patterns ) can thus be by external or internal means . Mental imagery can 159 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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the generation, ins pection, retention, and of perceptual images . T his proces sing involves s imilar effort and timing as when the object is perceived from external s ource. T hus , complex visual images require effort and time to rotate in internal and external reality. T he ability of the mind to generate mental images is in various forms of psychotherapy and may also be an important mechanis m in the pathological production of hallucinations and illus ions seen in several disorders .

ME MOR Y S YS TE MS T he neural networks of the brain are capable of res ponding to experience by the activation of particular patterns of dis tributed activation. Donald Hebb a bas ic principle of memory that has been repeatedly supported by research: “Neurons that fire together, together.” Neurons that are activated in a particular pattern at one time tend to fire together in a s imilar pattern in the future—this is the ess ence of memory. T he brain has various forms of circuits res ponsible for different s ys tems of memory (T able 3.1-2). T he form of memory mos t commonly thought of as me mory is explicit or de clarative memory. T his form involves the cons cious sensation of s omething being recalled at the time of retrieval and allows for the awarenes s of the autobiographical or factual knowledge to be s hared, verbally, with others and the s elf. T his explicit memory system requires the involvement of focal attention and activation of the hippocampus for encoding and Items focally attended to are placed in working proces sed further, and then placed in long-term After a period of weeks to months , items are thought to 160 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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undergo a process called cortical cons olidation that them in permanent memory, where their retrieval no longer requires the hippocampus . C ortical helps to explain the phenomenon of retrograde after head trauma.

Table 3.1-2 Memory S ys tems Implicit    A behavioral, emotional, and perceptual form of memory devoid of the subjective internal of recalling of s elf, or of pas t. C an include mental models that are s ummations of representations from numerous experiences .    Also known as early, procedural, me mory. C annot be express ed in words.    P resent from birth. Does not involve the hippocampus or require focal, cons cious P robably involves various circuits, including those the bas al ganglia, limbic s ys tem (amygdala, cingulate, and orbitofrontal cortex), and cortices . E xplicit

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   A form of memory requiring cons cious and involving the s ubjective sense of recollection and, if autobiographical, of s elf and pas t.    Also known as late , epis odic or s e mantic, or de clarative memory. C an be express ed in words drawings .    T he autobiographical component of explicit memory does not fully develop until pas t the firs t years of life, as the hippocampus and cortex on which it depends are maturing.

B efore explicit autobiographical memory process ing becomes available after the first years of life (during time the hippocampus and cerebral cortex are form of memory called implicit or nonde clarative already in place and remains active throughout the life span. Implicit memory involves a wide range of including behavioral, emotional, and perceptual When these circuits are activated in retrieval, they do include the cons cious s ens ation of something being recalled. F or example, when riding a bicycle, a pers on not recall having learned to ride and may not even feel that anything is being recalled. S imilarly, a pers on with fear of dogs may be unable to explicitly recall any event that may explain s uch an emotional T he exis tence of intact implicit recollection in the of explicit memory is found in various conditions , 162 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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including s urgical anes thes ia; the advers e effects of benzodiazepines; neurological conditions, such as K ors akoff's syndrome and bilateral hippocampal and childhood amnesia. S uch diss ociation may also in res pons e to trauma. T hus, patients with stress disorder (P T S D) may have an inability to recall a traumatic event and yet may avoid contextual stimuli similar to the initial trauma, may evidence s tartle res ponse and anxiety, and may have intrus ive images for the event. T hese latter symptoms may the cons cious awarenes s of implicit memory retrieval lacks the s ubjective s ens ation that s omething is being recalled.

C ONS C IOUS NE S S T he vast majority of mental proces ses are outside of cons cious awarenes s. C ons cious awarenes s is a as pect of some cognitive process es. In general, many authors ' views converge on the idea that there exis t fundamental forms of consciousness : a he re -and-now a pas t-pre s e nt-future form of awarenes s. T hes e two proces ses are likely mediated via the integration of different neural circuits in the brain. T wo hypotheses focus on the way in which representational process es are linked or bound during the flow of informational transformations within the mind. One hypothes is sugges ts that a 60-cycle-persecond s weeping process extends from the thalamus the neocortex. T his s weep may s erve to bind representational process es together in the internal experience of consciousness . P roces ses that are the time of the sweep thus become linked within 163 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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cons ciousnes s. Another view implicates the role of the lateral prefrontal cortex and its role in working memory. Working memory s erves as the chalkboard of the mind, and representational process es that become linked to activity in this region are then a part of the attentional spotlight of conscious awarenes s. B as ed on a biological as sess ment of brain function, E delman's theory describes two forms of that derive from the res onant interactions between of neurons . In his model, primary cons cious nes s s tems from the interaction between perceptual and conceptual categorizations. T his form of cons ciousnes s, called the re membere d pre s e nt, is also found in higher animals and is unable to trans cend momentary awarenes s. It is embedded in the pres ent is influenced by categorizations from the past. In beings , the capacity for lexical or language proces sing enables a secondary or higher-order cons cious nes s to and s tems from the resonance between thos e and conceptual categories. Higher-order frees inner experience from the prison of the present allows for views of the pas t and plans for the future. Included in these forms of consciousness is a scene of present s ituation in which the s elf is placed in a temporospatial context. C ortically blind patients state that they cannot see stimuli, but they res pond behaviorally as if they were sighted. T hey describe being unaware of vis ual but they make eye and P.517 hand movements that reflect the proces sing of 164 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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information about stimulus location, shape, orientation, and direction of motion. In information-proces sing behavioral tests reveal that blind-sighted patients do sens e and perceive visual s timuli but do not have cons cious awareness of the perceptual process , an example of a dis sociation of the normally as sociated proces ses of perception and consciousness or of phenomena. Misidentification syndromes are other examples of subjective, cons cious experience disturbances . In prosopagnosia, patients are unable to cons cious ly memories regarding persons familiar to them. C apgras syndrome patients are able to recognize a familiar face but feel that it is not really that person. B eing as in recognition, is one as pect of cons cious nes s as a cognitive process . T he pathological uncertainty of with OC D theoretically can be viewed as a disturbance that as pect of cons cious functioning. C ons cious nes s provides a sense of continuity. Many ps ychiatric patients experience a profound s ense of discontinuity and confusion that may be related to a dysfunction in the s ense-making, continuity-creating proces s of cons cious nes s. S ome ps ychiatric including derealization and depers onalization, may be unders tood in terms of alterations in conscious functioning (as s een in some patients with mood dis orders, anxiety dis orders, dis sociative P T S D, and s ome personality disorders ), distorted body image (as in eating dis orders or mood disorders ), memories and flashback phenomena (as in P T S D), hallucinations (as in ps ychotic s tates). 165 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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Mental Models and S c hemata S tudies of perception and memory support the view the mind has organizational s tructures that influence interpretation of s ens ory data, s hape the encoding of information into long-term memory, bias the retrieval of items stored in memory, and help determine the behavioral res ponse. T hose organizing cognitive are called me ntal mode ls or s che mata. Mental models are unconscious, highly organized, structural process es derived from pas t experiences guide in interpreting present s timuli and influence the direction of behavior. Mental models exis t for various situations. W hen a s ituation activates a given mental model, that model, in turn, guides s ubs equent proces sing and behavior. T he adaptational value of a mental model depends on an accurate reading of the survival demands of the s ituation. T he downside of models is s een when their unconscious and automatic activation occurs in s ituations in which they are inappropriate. Aaron B eck's theory of depress ion is on the idea that mental models or s chemata can depres sive thinking and depres sed moods . J ohn us ed the concept of internal working models to the development of early forms of s chemata for attachment relations hips. Difficulties in intimate relations hips and related behavioral dysregulation can seen as derivatives of models of inadequate early attachment and the presence of multiple, conflictual models. T he inner obje cts of ps ychodynamic theory are examples of mental models. Mardi Horowitz's view of certain personality dis orders and maladaptive interpersonal behavior also includes the role of mental 166 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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models or pers on schemata. S ome ps ychiatric s igns symptoms can be s een as derivatives of conflicted schemata and s ituations. C lass ic des criptions of interpersonal patterns in some patients with pers onality disorders , such as idealization and devaluation, can be seen as maladaptive s chema functions .

Thought, L anguage, and C ognition T here is no universally accepted definition of thought. S ugges ted bas ic elements include propos itions containing meaning), images, and lexical and s emantic symbols . C ognitive proces ses can be carried out in simultaneously, and without cons cious nes s. C ognitive proces ses, such as thoughts, are often directly known through translation into cons cious nes s and language. in the study of mental models, clinical obs ervation and experimental paradigms can infer the nature of thought proces ses only through indirect meas ures . T hese are important in defining the term thought dis orde r. T hinking involves the mental representation of s ome as pect of the world or of the s elf and the manipulation those representations . T hinking depends on explicit implicit memory of prior experiences . In addition, proces ses are influenced by a pers on's emotional mental models, and other uncons cious determinants. basic components of the cons cious components of thinking include categorization, judgment, decision making, and general problem s olving. T he as signment representations of events or objects to categories is important to s ubs equent thought process ing, because thoughts can act on the general clas s to which an item belongs rather than on individual repres entations; this 167 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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another example of top-down proces sing influences. R ational thought contributes to the ability to judge the probability of uncertain events and the decis ion to among various options. T hes e process es contribute to problem s olving in which data are as sess ed, class ified, transformed, and compared on the bas is of logical produce a choice that s olves a problem. F ailures in steps can res ult in limitations and distortions in normal thought proces ses. P s ycholinguis tics focus es on the cognitive process of language formation and s emantic analysis. C ognitive science has traditionally viewed language as a dominant influence on s ubjective experience. It is the medium that dominates human communication and is one of the major features distinguishing Homo s apie ns from other species. shapes the ways in which the world is perceived, the manner in which desires are communicated and and the way in which society responds.

Modes of Proc es s ing and L aterality T he mind is capable of dis tinct modes of proces sing mental repres entations. A serial mode us es sequential proces sing in a linear fashion, which is said to be slow energy-cons uming, becaus e only a few items can be proces sed s erially at a time. F ocal, conscious attention believed to occur in s erial fashion. A parallel mode the simultaneous manipulation of large numbers of representations in a nonlinear fas hion. P attern is an example of s uch a rapid, low-energy consuming proces s that can deal with a wide array of s timuli at the same time. Another dis tinction in contras ting modes of proces sing 168 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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has been identified in the type of mental proces ses primarily attributed to the right or left cerebral hemis phere. S tudies drawing on the findings in patients whos e corpus callosum has been surgically severed, have unilateral neurological lesions , or in s ubjects undergoing brain-imaging protocols have found a remarkable cons istency in trends of left-hemis phere functioning vers us right-hemis phere functioning. S ome general principles from this array of studies s uggest many proces ses involve both hemis pheres ; however, are distinct patterns primarily originating from each side the brain. T he following generalizations relate to right-handed individuals and to most left-handed people as well. In right hemisphere are fast-acting, parallel, holistic proces ses, including vis uospatial perception. T he right specializes in repres entations, s uch as images and sens ations, and the nonverbal meaning of words, sometimes referred to as analogic re pres e ntations . T he right hemisphere is thought to work as a pattern recognition center, capable of as sess ing the ges talt context of a s cene and providing a s ynthetic interpretation. P.518 On the left s ide are primarily more slowly acting, linear, time-dependent, serial proces ses . Left-hemis pheric proces ses manipulate the verbal meaning of words in a logical analytical mode of process ing. A generalization from a number of s tudies is that the right hemisphere tends to note the patterns in the world and creates contextual meaning; the left hemis phere can only make 169 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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rationalization of the details of what it perceives to sens e of meaning from a logical view that lacks context and thus may actually seem like a dis continuous and irrational set of data. T he proces sing of emotion also appears to have a lateralized distribution. T he expres sion of emotion to be mediated primarily by the right hemisphere. recognition of the affective expres sion of others als o appears to be a specialty of the right hemisphere. Of is that the right hemisphere appears to have a more integrated repres entation of the body's s tatus, that may be ess ential for individuals to know how they feel. J erome B runer has described the distinction between earlier mode of thought, called narrative cognition, the later mode, called s cie ntific, logical, or paradigmatic cognition. Narrative thinking is a context-dependent of proces sing that incorporates the internal the teller and the perceived expectations of the lis tener the production of a story. S tories als o involve the subjective experiences of the characters involved in the unfolding sequence of events . Logicos cientific paradigmatic proces sing is s aid to occur in a contextindependent manner that focus es on abs tract concepts and their logical, caus e-and-effect relationships . develop narrative thinking by 2 years of age, and the cons truction of s tories between parent and child is a primary mode of communication in all cultures throughout the world.

Metac ognition and S elf-R eflec tive C apac ity 170 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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Metacognition concerns cons cious proces ses that act cognitive process es—thinking about thinking. of cognition appears to develop by approximately 6 of age; this knowledge takes various forms , including is known as the appearance -re ality dis tinction (things not be as they appear). T wo components of this are repres entational diversity (the s ame object may to be different to different people) and repres entational change (thoughts today are different from those of yesterday and may be different again tomorrow). T his of knowledge about the pers on-specific meaning of cognitive repres entation requires s ome s ens e of the person's awarenes s of the s eparateness of minds, a theoretical domain in developmental cognitive ps ychology called the the ory of mind. T he regulation of cognition, als o called me tacognitive monitoring, includes s uch proces ses as planning monitoring activities, and checking outcomes . Metacognitive monitoring may involve the ass ess ment thinking sequences for fallacious logic, factual errors , contradictions in the content of speech. P eter F onagy colleagues explored the development of reflective function, or an internal obs e rve r of mental life. P arents teach children how to be self-reflective by including own internal state in interactions and by encouraging children to s hare their own. C hildren who have been taught to tell s tories that include mental s tates demonstrate a greater frequency of s ecure attachment. B eing able to unders tand and to consider the mental states of s elf and others has als o been s hown to dependency on defensive s trategies. R es earch that what is created in parent–child narratives about 171 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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experience is not just a s tory. E mbedded within the storytelling is the s election of information to be how it is process ed and understood, and if it is or has multiple s ubjective centers (empathic capacity).

S oc ial C ognition B ridging the fields of social ps ychology and cognitive ps ychology, the s tudy of social cognition focus es on mental proces ses involved in s ocial interactions . T he domains include the s tudy of empathy, interpersonal communication (verbal and nonverbal), pers on perception, relations hip scripts , and group process es . Other related areas include s tudies of attribution bias , memory for social interactions , s tereotyping, mental control of social cognitive process es, and cognitive of a s ens e of self. S ocial cognition can be s een as a of social ps ychology that us es information-proces sing theory to as sess the components of attention, encoding, memory, retrieval, and s chemata. A theme in social cognition res earch has been that topdown, theory-driven proces sing influences of social s ituations and actions in s uch s ituations. Developmental ps ychologis ts have focused on the of social cognitive functioning and its deviations. F or example, children with autistic disorder have significant deficits in empathic capacity and in the ability to social cues . S ocial cognitive deficits may be present in different domains in other ps ychiatric dis orders.

Dis c ours e and Narrative Dis course is communication from one pers on to is thought to involve a sense of intention or plan. 172 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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discours e follows a set of rules that ens ures the and effectivenes s of communication: W hat is intended be stated by the s ender is unders tood by the listener or receiver. S ome researchers support the idea that is a cognitive function that follows the basic principles information process ing, including a s chema for communication, and of social cognition, s uch as taking into account the listener's pers pective. Incoherent discours e can be noted by analyzing unlicens ed of the primary maxims of discours e. Another technique that of dis course analysis , which examines the ways in which dis course deviates from an as sumed discours e T he exact method to quantify abnormalities in remains controversial, but clinical impres sions of incoherence remain important for ass ess ing deficits in social communication. T he deficits may res ult from behavior, inherent cognitive abnormalities in thought or language, or deviations in s ocial cognitive functioning. Deviations from normal discours e can be a general in need of further as sess ment. Abnormal discours e is clinically evident in ps ychos is , s pecifically in Narrative is a broad domain ranging from the literary of fiction to the developmental psychology of the origin of autobiographical accounts . F rom a cognitive point of view, narrative is important in unders tanding the relations of language, memory, cons ciousnes s, mental models, self-schemata, and cognition. Narrative can be generally defined as the which a person creates a verbal account of a s equence events in the world and the internal s ubjective of the characters of the s tory. Autobiographical narrative begins early in life as the 173 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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capacity for language develops. S tudies of early monologues find that young children interpret and meaning to events in their world from an early age. Narrative helps record and make s ens e of the pas t, interpret the present, and anticipate the future. T he has been called an “anticipation machine,” and mental models, pros pective memory, and narrative are the ways in which top-down proces sing attempts to for the pos sible future. T he enactment of narrative directly affects the way in which individuals live out the story of their lives. Anthropologists who study psycholinguistic acros s cultures have described a phenomenon called cons truction, in which family members collaboratively create a s tory of daily events P.519 in their lives. How thos e family behaviors influence the child's emerging capacity to organize experiences and encode them into long-term memory to be retrieved in the production of autobiographical narrative is a fundamental ques tion for many dis ciplines in cognitive science as well as a primary focus of ps ychodynamic of ps ychotherapy. S pecific deficits in early family experiences and in innate cognitive capacities may theoretically impact the child's narrative capacity. differences can be s een in how different individuals tell stories of their lives and the way that they make in life.

C ognitive Development Developmental theories and research can be divided 174 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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several views . S tage theories (J ean P iaget, and the sociocultural s chool of Alexander Luria and V ygots ky) des cribe dis continuous periods of with times of s tability and consolidation alternating with instability and trans ition. Information-proces sing have not been explored in as much detail with regard child development, but the models postulate a theory, in which the emergence of cognitive capacity is continuous process that does not require a s et of sequences. S tage and nonstage views embrace the that a hierarchical integration and an ongoing differentiation are fundamental as pects of cognitive development. Another dis tinguis hing feature is the degree to which theories view the contributing role of innate, biological factors and the role of culturally determined s ocial experiences . Do cognitive capacities emerge from a genetically determined plan, as in the P iagetian view, they develop in respons e to experience, as in the sociocultural view? Developmental ps ychologists have found features of both views , s upporting the idea of a transaction between innate factors and environmental experiences . More recent conceptualizations have on the functioning of complex systems to conceptualize development as the continual emergence of ever more complex capacities . P sychiatric dis turbances in cognition may reflect patterns of normal cognition (as in mental retardation), deviant developmental pathways (e.g., s ocial cognitive functioning in persons with autis tic disorder), and cognitive impairments (e.g., s chizophrenia) that may been present early on or only became evident as life 175 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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requirements, such as s chool, became demanding cases of ADHD). Investigations into the developmental features of these dis orders is a major focus of the field developmental ps ychopathology.

S elf-Organizational Proc es s es An understanding of the development and s ubjective experience of cognitive process es has been greatly informed by the insights from the fields of evolutionary neurobiology and the nonlinear dynamics of complex systems , otherwis e known as chaos the ory. W ith neurons , each with an average of 10,000 synaptic connections with other neurons , the brain is capable of organizing an incomprehens ible number of pos sible activation patterns. In s electionist theory, the billions of neurons become clus tered into groups that have functions and, when activated, become reinforced. Neuronal groups that are not activated die off; thos e are activated s urvive. In other words , the brain divers ity of activity that can then be s elected by interaction with the environment. In addition, the brain has value s ys tems that s electively reinforce the activity neuronal groups that enhance s urvival. In this way the brain's neuronal groups compete and differentiate the brain and create an ongoing and evolving system. C haos theory s uggests that complex s ys tems adhere specific s et of principles . T hree principles — self-organizational process es, and movement toward complexity—are es pecially relevant to psychiatry. Nonline ar refers to the finding that s mall changes in (or initial conditions) can lead to large and 176 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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changes in output. C omplex s ys tems function on the of probability, which predict that certain combinations activity within the s ys tem are more likely than others tend to move the s ys tem toward s elf-organization. T his probability also predicts that the s ys tem moves its elf toward increasingly complex s tates of functioning. T he state of activation of the various parts of the can clus ter into repeated patterns called s tate s . In the brain, a s tate of mind or me ntal s tate describes the way which various neuronal groups may become activated given time. R epeated patterns of neuronal group activation, a neural net profile, can become reinforced they occur frequently or if the value s ys tem of the brain ingrains their profile. T hese ingrained patterns of activation are called attractor s tate s ; thos e s tates that least likely to occur are called re pe llor s tate s . T he states are determined by the constraints on the Modification of constraints allows the nature of attractor and repellor s tates to be altered. C onstraints are and internal. T hus , features of the external such as the way other people behave and relate to an individual, can directly affect which mental state is likely to be activated within the pers on. Internal cons traints include the synaptic strengths of as determined by constitutional features and genetics, those learned from experience, as encoded within proces ses. Daniel J . S iegel has propos ed that complexity theory offer a us eful working definition of mental health applicable to individuals , families , and larger social systems . In complex systems , s elf-organizational that move the system's states toward maximal 177 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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are mathematically shown to be the mos t s table, and flexible. T hese features may be us eful in defining he althy s ys tems. T he movement toward complexity is between the extremes of samenes s, with rigidity and on the one s ide and change, randomnes s, and chaos the other. C omplexity is achieved when the of the system achieve a balance in the two proces ses of differentiation (specialization in function) integration (coming together as a functional whole). F or single individual, such a balance can be achieved as genetically and experientially influenced growth of circuits combines differentiation of s pecialized regions with their functional integration via neural fibers that connect widely distributed areas into a functional similar balance would be seen in larger systems as Dis order can be seen in this view as occurring when a system is stress ed in its flow toward complexity, as revealed in movement toward either extreme: rigidity or chaos . T rauma may impair integration in an individual, revealed in the finding of negative effects on the integrative regions of the corpus callosum and hippocampus in abused and neglected individuals . A dysfunctional family s ys tem would be conceptualized occurring when the individuals are excess ively differentiated (without emotional connections ) or integrated (enmeshing that inhibits individuality from being expres sed). S uch s tres sed s ys tems are limited in their movement toward complexity and, hence, their stability, flexibility, and adaptability. P sychiatric dis turbances may be conceptualized as disturbances in s elf-organizational process es. Inherited and experiential internal determinants and ongoing 178 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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external, environmental, and social influences on the cons traints of the s ys tem can thus directly affect the development and effective use of s elf-regulatory mechanisms. C linical interventions may function at the level of external constraints (ps ychotherapy) or internal cons traints (pharmacological treatments ) that alter the ways in which the individual's mind is able to achieve healthy forms of self-organization. V iewing psychiatric disturbances P.520 in this way allows for a synthesis of the views of ps ychodynamic, biological, and s ocial psychiatry.

S tates of Mind One way of des cribing the brain's self-organizational proces s is in the concept of s tates of mind. R epeatedly reinforced patterns of neuronal group firing link the cognitive process es of attention, perceptual bias, mental models, behavioral res pons e patterns, and emotional tone and regulation. T hese states of mind in the patterns of cognitive, emotional, and behavioral symptoms s een in various ps ychiatric disorders . F or example, in a depres sed s tate of mind, one may pay cons cious attention to negative aspects of experience, may interpret incoming stimuli in a pess imis tic manner, may have greater acces s to depres sing past may have the activation or instantiation of a mental of the self and others as bad or guilty, may have the behavioral pattern of withdrawal, and may have a depres sed mood with difficulty regulating intense Healthy mental functioning may depend on a flow of 179 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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states of mind through time, allowing for flexible adaptation to an ever-changing environment. C haos theory sugges ts that nonlinear complex s ys tems mus t move continually toward maximizing complexity. Achieving such a goal requires a balance between predictability and novelty. Dys functional mental s tates may be conceptualized as a dis ruption toward either of this balance: with exces sive rigidity, as in the case of character pathology, or excess ive fluidity, as in the disorders of thought or of mood.

S E NS A TION, P E R C E P TION, A ND C OG NITION IN P S YC HIA TR IC DIS OR DE R S S ince the time of E mil K raepelin and E ugen B leuler, ps ychiatris ts have known that certain disorders include profound disturbances in cognitive functioning. S ince 1950s , res earchers have attempted to determine the nature of s uch deficits. W ith advances in computer technology and an increasing technical ability to stimulus presentation and respons e times on the order tens of milliseconds , cognitive ps ychologists have been able to devis e res earch paradigms capable of tes ting presence of increasingly s ubtle as pects of cognitive proces sing. P roces sing res earch has focused on all three domains sens ation, perception, and cognition. S ensorystudies focus on posts timulus events for as long as a maximum of 1 s econd, using simple stimuli. P erceptual studies examine process ing after a period of as long as approximately 5 seconds after a slightly more complex stimulus . C ognitive proces sing experiments can 180 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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the early aspects of proces sing (e.g., phenomena within the first 30 s econds ) of complex, as well as longterm, process es that occur over hours , days, or years . R ecent attempts have been made to correlate complex cognitive findings with clinical pres entations. A general problem correlating cognitive process es with clinical populations is the divers ity of patients falling the same syndrome clas sification. S chizophrenia, major depress ive disorder, and P T S D are all by symptomatic heterogeneity. T hus, the array of dysfunctions identified for certain syndromes mus t be interpreted in light of the diversity of patient A related problem is the distinction between general specific deficits . C are mus t be taken in interpreting experimental data that s how differences among normal controls and patient groups. Do ps ychiatrically ill perform les s well on a given paradigm because they or becaus e of a deficit s pecific to the disorder? F or example, ps ychomotor slowing, as meas ured by time and respons e rate, is s een in schizophrenia, depres sion, and other psychiatric and neurobehavioral disorders . T he side effects of medications can also influence proces sing and respons e s peed. on the creative design of experimental tas ks to help distinguish between general and s pecific deficits. A comparis on of target patient populations with matched healthy persons and other ps ychiatric patients can help determine dis order-specific cognitive dys function. Another general iss ue is that of s tate markers versus markers. F or example, a patient with s chizophrenia have a cognitive deficit when actively ps ychotic (state) also when asymptomatic (trait). T hes e abnormal 181 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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have been found in certain cognitive tests of attention correlate with improvement on medications; some abnormal results are als o found in the non-ill firstrelatives of schizophrenic patients. Is the marker of vulnerability a coincidental finding or part of the core deficit in s chizophrenia? An exploration of the of thes e cognitive abnormalities for the daily life of the patient is an important application of the res earch to clinical psychiatry.

S c hizophrenia In the late 1890s, K raepelin described a primary deficit in his elaborate clinical des cription of patients schizophrenia. Numerous investigators have since attempted to define the nature of the cognitive deficits schizophrenia. A general approach is that an early perceptual process ing deficit leads to problems in perceptual organization and cognition. In general, information-proces sing models note that two things are proces sed: energy (in the form of external stimuli impinging on the senses) and information (a stimulus carries a signal value bas ed on s ignificance derived the prior process ing of s imilar energy configurations ). S chizophrenia patients appear to have deficits in the proces sing of energy as well as information. S ome cognitive tasks have been identified as traitmarkers of schizophrenia: reaction time cross over, backward masking, dichotic listening, s erial recall vigilance (s us tained attention) tas ks requiring high proces sing loads, and span-of-apprehens ion tes ts with large vis ual arrays. Deficits in those areas have been explored through many s tudies examining various 182 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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of proces sing.

R eac tion Time C ros s over and S hift E ffec ts T hese paradigms examine the general finding that schizophrenic patients have a slower than usual on tas ks that require rapid reaction times . A s timulus is presented with varied combinations of warning signals and preparatory intervals . S chizophrenic patients s how advantage only with s hort preparatory intervals and res ponse times with regularly spaced s timuli, a pattern distinct from that of normal controls (cross over effect). related paradigm, when the modality of the stimulus is varied (e.g., light is inters pers ed with tone), the latency (delay) of the respons e in schizophrenic patients, when compared with controls , is longer if the preceding was of a different modality. T hat is termed the modality s hift e ffect, revealing a greater degree of cros s-modal retardation in s chizophrenic patients than in controls . A number of theories have been proposed to explain effects. T hey may be quantitative rather than distinctions from normal control groups . However, the cross over and modality shift effects support the idea schizophrenic patients are overly influenced by s timuli that occurred immediately before the effect. T he information-proces sing s tages that explain the of prior stimulus effects are under investigation.

Vis ual B ac kward Mas king, G ating, and Habituation In vis ual backward mas king, a stimulus is followed by interval of time, and then a s ubs equent s timulus is 183 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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presented. P.521 F igure 3.1-2 s hows a typical masking experiment. T he presentation of the secondary s timulus leads the schizophrenic patient not to report (or mask) the initial stimulus . Lengthening of the interstimulus interval 500 milliseconds can lead to normalization, with no masking pres ent. T hus, the rapidity of pres entation of secondary s timulus is the factor determining whether it influences the perception or at leas t the reporting of the initial s timulus. S ome studies find that the impairment improves with treatment by medication and can be induced in normal patients given catecholaminergic agents . Other studies find that the impairment may be marker of increas ed vulnerability to s chizophrenia.

FIGUR E 3.1-2 Diagram showing the difference in the reports of normal vers us schizophrenic s ubjects with a s ingle backward mas king trial with a 100inters timulus interval (IS I). T he T repres ents the target stimulus , and the Xs represent the masking stimulus . 184 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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B raff DL, S accuzzo DT , G eyer MA. Information dysfunctions in s chizophrenia: S tudies of visual masking, s ens ory motor gating and habituation. In: S teinhauer S R , G ruzelier J H, Zubin J , eds . Handbook S chizophre nia. V ol 5. Neurops ychology and Information P roces s ing. New Y ork: E lsevier S cience; 1991, with permis sion.) S ensorimotor gating and habituation are the proces ses which the reaction to s timuli decreas es with repeated presentation. S ens ory gating and habituation are to involve automatic preattentive process ing, whereas visual mas king requires higher cognitive functions. S chizophrenic patients show a markedly diminished capacity to habituate. One common s tudy examines persis tent acous tic s tartle reflex as the pers on blink with repetitive tones . Lysergic acid diethylamide (LS D) adminis tration and the intracerebral injection of dopaminergic agents in rats lead to similar findings , supporting the idea that excess ive dopamine activity, thought to be central in s chizophrenia, can induce deficits . In general, deficits in habituation and vis ual backward masking lend support to the idea that s chizophrenic patients have a diminished capacity to regulate the flow rapidly presented information. T hey experience being inundated by stimuli that are filtered out in the brain of normal person. Deficits in process ing externally derived stimuli, as demons trated in experimental paradigms , also occur with internally generated s timuli. 185 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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S elec tive A ttention In general, selective attention paradigms pres ent the person with a target stimulus and dis tracters . In listening tas ks , the s ubject is as ked to attend to presented to one ear and to ignore mes sages the other ear. S tudies of schizophrenic patients have revealed cons is tent deficits in their ability to repeat the mess age they were as ked to focus on. Analys is of findings sugges ts that schizophrenic patients have an impairment in their ability to avoid distracting stimuli (to filter) and to pigeonhole (to us e category features to reduce stimulus qualities needed to res pond). T he suggest that dis tractibility is a core cognitive deficit, supported by its high incidence in genetically persons, its worsening in acutely psychotic s tates , and improvement with medications. T hese findings were explained by us ing the framework an impaired filtering structure and pigeonholing but recent conceptualizations have examined a generalized impairment of the information-proces sing capacity in s chizophrenia. T he capacity model the way in which a pool or pools of attention capacity be allocated across mental activities. T wo components quantity of res ources available (capacity) and allocation policy. Other areas of deficit may involve an impaired respons e s election process , leading to res ults on tas ks . S everal pos sibilities have been proposed to explain attention deficits in schizophrenic patients on the basis the capacity model: (1) deautomatization of normally automatic preattentive process es, (2) disproportionate 186 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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allocation of attention to schema-relevant but task-irrelevant information, (3) inability to s ustain controlled proces ses needed to maintain attention allocation without shifting, (4) inability to shift allocation biases to correct wandering attention, and (5) res ponse s election because of heightened arous al distracting conditions . S tudies of s elective attention begin to examine these pos sibilities in a capacity rather than in the previous ly explored s tructural framework.

S us tained A ttention S us tained attention, or vigilance , is required to proces s stimuli of long duration. T he most common res earch paradigm us ed to examine sustained attention is the C ontinuous P e rformance T e s t. T he test consis ts of a presented set of tasks with varied spacing and timing target and nontarget stimuli. T he process ing load for a C ontinuous P erformance T es t can be varied by blurring the stimuli presented or by changing the pace of presentation. V igilance tes ts, such as the C ontinuous P erformance require analysis of res ponse features on the basis of signal detection theory. T he two elements are sensitivity and the res pons e criterion. Diminished sens itivity is a sign of decreas ed vigilance and res ults high mis s rate (errors of omis sion). T he respons e can be diminis hed, leading to a high false-positive rate (error of commiss ion). T he analysis is important in the interpretation of res ults. T he vigilance studies using the C ontinuous P erformance T es t reveal that patients have a deficit in their ability to dis tinguis h 187 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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stimuli from nontarget s timuli when the s timuli are presented as brief signals at a rapid pace. S chizophrenic patients als o appear to have a s pecific diminis hment in sens itivity but not a lowering of the res ponse criterion for verbal and s patial stimuli. T he impaired respons es were s ignificantly as sociated with specific clinical features in patients and their firs trelatives . T est abnormalities, although pres ent in other disorders , appear to be most robus t in s chizophrenia. P os itron emis sion tomography (P E T ) in s chizophrenic patients performing a C ontinuous P erformance T es t lower metabolic activity than in normal persons in the prefrontal cortex bilaterally but normal or elevated activation in the occipital region. T hat finding is with other findings supporting the idea of impaired functioning in s chizophrenia. P.522

L anguage and Dis c ours e Ass es sments of language dys function in schizophrenia have focused on the bas ic question of whether the abnormalities in speech are reflections of a core thought or an abnormality in s peech production. T he search for a s chizophrenic language has yielded conclus ions. Discours e analyses of conversations with schizophrenic patients s uggest that they may have significant difficulties in the maintenance of a specific topic (derailment) and in the lack of a dis course plan directing speech (disorganization). Other inves tigators have argued that schizophrenic patients have impaired capacities to perceive the 188 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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others and may be schema driven in the direction of speech, rather than intending to communicate One s tudy s howed that delus ion-cons istent material presented in the nonattended channel in a dichotic listening tas k leads to diminis hed attention to the target channel. A clinical implication of this experimental is the pos sibility that s chema-driven proces sing during speech production may be diverting attention to stimuli and away from the potentially confusing s ocial demands of convers ation.

S pan of A pprehens ion In the span-of-apprehens ion tes t, an array of letters is displayed for a brief period (from 50 to 100 most studies). One of the letters is a T or an F , and the person must detect which letter is present. T he number nontarget letters is increased, and s ignificant detection are found for dis plays of ten or more letters . F igure 3.1-3 provides an example of a vis ual dis play for span-of-apprehens ion tes t.

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FIGUR E 3.1-3 S ample arryas us ed in the wideangle vers ion of the partial report span-ofapprehens ion task.(C ourtesy of R obert T he serial scanning proces s is an element of focal attention. P arallel process ing in the s earch involves increased as pects of ass ess ment of figure-ground and textual s egregation and is thought to be an automatic proces s. S tudies have shown that the s equential of the attention spotlight is directly affected by the complexity of certain dis play characteristics , increased errors in detection. T his is logical, because iconic image has a limited dis play time, and the of the image may be incomplete by the time it decays such an ultrabrief form of memory. 190 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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S chizophrenic patients show significantly increased in the s pan-of-apprehens ion tes t under conditions of increased complexity of dis play. T heir s cores are als o wors e in ps ychotic conditions and are improved with symptomatic improvement while taking medications. Increased errors are als o found in nons chizophrenic mothers of children with s chizophrenia. T hus the s panapprehens ion tes t is a meas ure of s tate and trait in cases of s chizophrenia. Only approximately one-half of the patients with the diagnosis of s chizophrenia have abnormal results on of-apprehens ion tes ts. T hos e who do have abnormal res ults also have the clinical s ymptom of anergia. ps ychiatric disorders studied did not reveal these T hus, the abnormal res ults on the test appear to be to some forms of schizophrenia. S hort-term and longoutcome studies have found that those patients with abnormal test res ults whos e s cores improve after antips ychotic medication have a good clinical res ponse pharmacotherapy. T he span-of-apprehens ion tes t taps into some aspect cognitive function specific to s ome patients with schizophrenia, their nonschizophrenic relatives , and persons at ris k for developing the s ymptoms of schizophrenia. T o s can the iconic image, the person (1) engage attention to the iconic regis ter, (2) move the focus of attention, and (3) dis engage the focus of attention. Impairments in performing any one of thos e tas ks can explain the test-res ult abnormalities . Another caus e of the deficiency may be that, with each fixation attention, les s information is process ed. T hus, although individual s teps of iconic s canning may be intact, les s 191 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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visual information is process ed, and more errors occur. third poss ibility is that the initiation of the attention proces s is delayed; this pos sibility is consistent with the increased reaction times revealed on numerous other tas ks . T he delay in the face of a rapid decay rate of memory places the patients at a disadvantage when res ponses are required; this pos sibility is als o with the other forms of attention deficit described previous ly. S chizophrenic patients may have a number structural and capacity deficiencies , and thes e are not mutually exclus ive. F urther studies are needed elucidate the nature of the cognitive state-trait marker schizophrenic patients and persons vulnerable to the disorder.

Attention-Defic it/Hyperac tivity Dis order In the revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ), integrates two categories from the revised third edition the Diagnos tic and S tatis tical Manual of Me ntal (DS M-III-T R ): ADHD and undifferentiated attentiondisorder. Diagnostic criteria embrace a number of the syndrome, and res earch into the cognitive deficits outlined a wide array of tas ks in which attention abnormal. T he pervasive findings of cognitive in the s etting of numerous intact cognitive functions left the res earch field with no clearly accepted view of a core deficit in the disorder. C linically, child and patients pres ent with problems in school, with peers, at home that reflect academic and behavioral dysfunctions. Many s tudies sugges t that the cognitive behavioral dysfunctions in the disorder may be 192 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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independent process es with different bases . F or example, the finding that children with are impulsive may be true behaviorally but cannot be stated as a generalization about their cognitive functioning. R es earchers have attempted to find clear-cut criteria to help clarify the dis order, but individuals clas sified as meeting diagnostic criteria at this point appear be quite heterogeneous. T here is no definitive for the dis order nor is a positive res ponse to ps ychopharmacological intervention pathognomonic. B iochemical studies have found abnormal urinary catecholamine metabolites that normalize as the behavior improves when taking ps ychostimulants . findings and P E T scan data suggest abnormal brain functions in patients with ADHD. P.523 Data from numerous studies s how that the patients ADHD have dysfunctions on a variety of tasks ranging those involving monitoring, perception, memory, and motor control. Intact performance has been found on a number of memory tas ks requiring verbal process es digit span, word tes ts, and s tory recall) and nonverbal proces ses (e.g., recall, visual arrays , and block s eries). A number of theories have been elaborated to explain those differences between patients with the disorder normal persons. E ach theory has s trengths , and varied support from the data, but each highlights complexity of the cognitive dimens ions of the disorder. general, patients with the dis order evidence behavior 193 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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has been compared to that of patients with frontal lobe damage: deficits in the control of motor res ponses , in execution of fine-motor movements , and in the of ongoing res ponse patterns. Memory tas ks and basic as pects of information process ing are intact, but the patients have impaired performance across modalities (auditory, vis ual, motor, and perceptual-motor), suggesting s ome global deficit. T he patients also be unusually s usceptible to boredom when the required tas ks are long and repetitive. Another view examines two propos ed systems —an underactive behavioral inhibition s ys tem and an behavioral reward s ys tem—to explain the behavioral problems that children with the disorder often have. A related view is that the rule-governed behavioral not intact; patients with the disorder appear to do es pecially poorly in a system with delayed or rewards, as in tasks that require s ustained attention, accuracy, or task-directed activity governed by another person's direction or rules . Under those conditions, the patient's poor regulation and inability to meet functional demands are revealed. A related is sue is a diminished motivational drive and, poss ibly, a diminis hed arousal regulation system. Y et another approach supported by research data is the patients have metacognitive deficits. According to perspective, metacognitive process es that help plan, monitor, and regulate performance are impaired. T he patient's ability to as sess the tas k and to determine strategies also has deficits . T hat is an example of topas pects of attention, with impairment of the higher cognitive process es that regulate information flow. 194 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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Additional bottom-up deficiencies involve bas ic as pects attention focus because of abnormalities in arous al, selectivity, and capacity. T he finding that numerous factors can influence the appearance of deficits led V irginia Douglas to the hypothes is that ADHD is a self-regulatory disorder with pervas ive effects. T he impairments affect each of four domains —attention, inhibition, reinforcement, and arousal—res ulting in deficits in several aspects of selfregulation: (1) the organization of information including planning, metacognition, executive functions, adapting appropriate cognitive s ets for a given tas k, regulating arousal levels and alertness , and s elfmonitoring and s elf-correction; (2) the mobilization of attention, including the deployment and the of adequate attention; and (3) the inhibition of inappropriate respons es, such as withholding extraneous s timuli and reinforcers. T hese deficits in regulation imply that increased process ing demands would lead to a diffusion of attention process es and to subs equent impairment of the in-depth, coherent acquisition of knowledge and understanding. One line of research has been based on the additive method, in which experimenters attempt to is olate the stage of the deficit. T he model for that approach entails four stages : encoding (the identification of a s timulus), serial comparis on (of the stimulus with elements the category in long-term memory), decis ion (pertaining the category into which the s timulus is s tored), and translation and res ponse organization. S tudies us ing evoked potentials s ugges t that deficits are found after search and decision s tages (the first three stages ). T he 195 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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res ponse preparation and execution process es appear be impaired. F eatures that increas e the process ing such as s peed demands, complexity of s timuli, leading to divided attention, and increased duration of tas k—reveal different areas of deficit. T his fact may the divers ity of methods and res earch data supporting various theories . T he variables affecting outcome information-proces sing demands , the availability of alternate s timuli to which to attend, and the presence of an external regulator. T he divers ity of research findings and theoretical explanations is paralleled by the clinical finding that children who are severely impaired in the clas sroom have no attention problems in the confined, one-on-one setting of the psychiatrist's or psychoeducational examiner's office. S uch children may also be able to for indefinite periods to video games and yet be unable follow complex conceptual information. T he important principle is that cognitive dys function in ps ychopathological conditions may be tas k s pecific as function of the nature of the cognitive impairment. T he patient's clinical history and evaluation mus t cons ider potentially hidden domains of abnormal cognition.

Autis tic Dis order E arly descriptions of autism delineated the s ocialfunctioning deficits that impair normal functioning. Autistic children were seen as having difficulties in emotional contact. C ognitive dysfunctions in autis tic disorder were des cribed later and were found to number of areas , including abstraction, sequencing, language, and comprehens ion. R es earchers are now 196 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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focus ing on the nature of the core deficit in the Is sues of s pecificity and universality of areas of in the dis order are important. How the cognitive relate to the s ocial-affective deficits is of particular S eventy-five percent of patients with autis tic disorder also mentally retarded. Mental retardation involves cognitive and language impairments that may make it difficult to distinguis h autis tic dis order features. G eneral cognitive impairments may be es pecially difficult to if language functioning is s everely limited. S tudies of functioning patients with autis tic dis order have various deficits to be determined. S tudies of the cognitive deficits in autis tic disorder have distinguished an array of dysfunctional areas , including numerous language problems , excess ive or impaired res ponsiveness to stimuli of various modalities , encoding of auditory stimuli, and impairment in the to extract important features from incoming information. T his range of deficits is thought to require the transformation of s ymbolic representations . In contras t, some patients with autistic disorder have relatively visuospatial and gestalt functions , mus ical abilities, and rote memory. P erformances on s tandardized tests relatively good results in object ass embly and block but poor results in comprehens ion. Language deficits vary and include s yntactic and phonological domains . T hese findings initially left-hemis phere deficit, but other findings , including deficits in pros odic and pragmatic language functions, suggested right-hemis phere involvement as well. T he findings can be interpreted as deviations from normal language functioning as well as delays in language 197 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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functioning. T he wide array of dys functions in autis tic disorder may be due to a number of subtypes, with characteristic deficits and poss ibly different brain loci of dysfunction. Other studies have focused on the social cognition of patients with autis tic disorder. T hey have examined the nature of the patient's emotional P.524 behavior and understanding to as ses s the earliest descriptions of an abnormal emotional connection between autis tic children and their parents . R ecent neurobiology sugges ts a role of the orbitofrontal cortex and the cerebellum in mediating s ome of thes e deficits . T wo findings s upport the initial impress ions: Autis tic children are much less likely than usual to imitate adult vocalizations and ges tures, and they show much les s sophisticated repres entational play with objects than do normal children. T hes e findings led to the sugges tion a core deficit in autis tic disorder is the representation of representations (metarepres entations), leading to in symbolic play and the inability to unders tand the mental s tates of others. T he inability to transfer representations into language symbols may als o be a related metarepres entation deficit. A s eries of studies explored the relation of thes e cognitive impairments to s ocioemotional behavior. In contrast to clinical lore, children with autistic disorder found to look at their parents; they had eye contact with their parents when s ocial interactions were parentally elicited, and they revealed normal behavioral patterns attachment. T he s tudies found a marked lack of s ocial 198 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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referencing (looking to parents for emotional cues in ambiguous s ituations) and protodeclarative gestures (pointing to objects and s howing objects to familiar adults ). T hree domains have been propos ed to explain these findings: (1) Autistic children may not have the capacity to have a representation of another pers on as having ideas , perspectives, or emotions that can be T his proposal is cons istent with a theory-of-mind hypothes is, in which the core deficit is believed to be inability to have a sense of another's mind. (2) Autis tic patients may have an impaired ability to perceive or to comprehend the emotional (us ually facial) s ignals of others . (3) T he core deficit may involve a lack of others or an avers ion to responding to others . S tudies found that although children with autistic disorder do expres s emotions, they have les s positive affects in res ponse to their (relatively infrequent) periods of joint attention. F urthermore, they have an impairment in res ponsivity to the dis play of s trong emotion by whether of distress or of pleas ure. T es ts of high-functioning autis m patients reveal poor performance on emotion-recognition tasks, little comprehension of and empathy with depictions of situations, and difficulty in talking about s ocially derived emotions , s uch as pride and embarrass ment. Autis tic patients with relatively high intelligence use adaptive cognitive s trategies to interpret s ocial stimuli to compens ate for impaired emotion-proces sing abilities. development of s ocial cognition and socioemotional unders tanding requires complex interactions among cognitive, perceptual, and emotional process es . A interactive elements es sential to the development of 199 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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unders tanding has been proposed (F ig. 3.1-4). T his describes the basic precursors of emotional res ponsiveness : the ability to attend to, to encode, and interpret verbal and nonverbal social s timuli; the awarenes s of one's own and others' emotional and the ability to contrast ones elf with others. Out of matrix develops the ability to unders tand others ' views , desires, and beliefs . Accordingly, a deficit in any of basic elements may explain the characteris tic deficits observed in the s ocial understanding of persons with autis tic dis order.

FIGUR E 3.1-4 S igman's model for the development of socioemotional unders tanding.(C ourtesy of M.S igman.)

Mood Dis orders In contras t to schizophrenia, ADHD, and autis tic the mood disorders do not appear to have core deficits that are diagnos is s pecific. Instead, cognitive abnormalities appear to be related to the degree of ps ychopathology and to the severity of the mood 200 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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disturbance. Mos t s tudies have examined patients with depres sion; only a few studies have as sess ed functioning in patients with bipolar I dis order in a manic state. In depress ed patients, the severity of the has ranged from mild depress ion in s tudents to s evere illness in hos pitalized patients with major depress ive disorders . T he studies have primarily examined and memory for neutral and emotionally toned s timuli. the majority of these studies, the concept of s elforganizational process es and state regulation has not the primary focus of attention. T hes e recent conceptualizations of the brain's functioning as a nonlinear complex s ys tem capable of s elf-organization may aid in the future investigation of the primary deregulatory aspect of disorders of mood.

Depres s ive Dis orders Depress ed patients often complain of difficulties with concentrating, learning, and remembering. S tudies documented that s uch patients perform poorly on tas ks that require sustained attention or effortful and rehears al. T hus , controlled limited-capacity proces ses appear to be impaired in major depres sive disorder. limitation on access to capacity-demanding res ources appears to be directly related to the s everity of the depres sion and normalizes with remiss ion from a depres sive epis ode. Depress ed patients have als o been found to have an increased res ponse criterion; they require increas ed supportive data from the presented s timuli to respond tes t s ituation. W hether this need to be certain before res ponding is a psychological respons e to being 201 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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depres sed or a specific feature of the depress ion its elf not yet been determined. T he reluctance to res pond to be cons idered in interpreting research data and interview findings . T he attention and memory findings have suggested several theoretical frameworks that are clinically useful. schema theory of depres sion outlines a positive loop in which negative s elf-schemata prime pers ons to have negative thoughts, to recall negative events in lives , and to interpret present events with a negative Whether as a caus e or as a maintaining influence, depres sogenic s chemata are thought to create a s eries cognitive functions that produce and maintain a depres sed mood. A network theory of memory and emotion has been supported by res earch on depres sed and persons in which mood P.525 leads to a spreading activation of items in memory that congruent with the mood. T hus, emotion directly influences retrieval by a proces s of s tate-dependent learning and memory. While depress ed, patients are to encode items in a form that makes them readily access ible when retrieved in a depress ed state; mood thus becomes an internal context cue that depres sion-related memories . T he network and schemata theories of depress ion are cons onant with res earch findings but do not explain all cognitive and clinical findings in depres sion. T hey a framework for unders tanding how emotions and 202 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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influence cognitive proces sing, such as memory and mental models. T he conceptualization may be applicable to transient mood s tates and s evere mood episodes . T hus, emotions in health and illness can the mental state instantiated at a given time and thus as a context cue, leading to the activation of previous ly formed schemata for ones elf and others. T he activated schemata, in turn, can produce retrieval biasing and behavioral res ponses, fundamental to a mental state, can further elicit a negative emotional res ponse. A reinforcing loop is established to support the of the depres sed mood and depress ive cognition. S ome patients may be es pecially prone to marked cognitive alterations because of an emotional s tate that may be a fundamental part of a clinical presentation. rapid s hifts in s tate of mind may be a learned or cons titutional feature of the individual. F rom the dynamics view, these rapid s hifts in mental s tate can conceptualized as sudden and intens e changes in the cons traints on the s ys tem, which determine the flow of states of mind across time. Activating a s et of that es tablis h and maintain a depres sed s tate can then lead to the pers is tence of the factors that created the in probabilities of that s tate being active. T he state becomes a deeply ingrained attractor state that becomes difficult to alter. P harmacological may directly alter the s ynaptic cons traints maintaining such a s tate. P sychotherapeutic interventions , s uch as cognitive-behavioral and interpersonal therapy, can be propos ed to produce changes in the internal cons traints and in external social cons traints ,

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B ipolar I Dis order P atients with manic episodes present with a s pectrum cognitive dysfunctions that appear to be related to the severity of their mood epis ode and that normalize with remis sion. T he disturbances have been described as rapidly paced thinking and speech, quick self-generated or other-generated s timuli, grandiosity, increased distractibility. F ormal studies of patients with bipolar I dis order are technically difficult to carry out because of the patient's lack of cooperation and res tless nes s, and becaus e patients are few in number. T he s tudies have high rate of combinatory thinking, the inclus ion of as sociated but related intrus ions, and increas ed distractibility. T he clinical impress ion of humor (even in face of an underlying dysphoria) in some patients with bipolar I disorder is corroborated by playful, or flippant elaborations and intrus ions in s peech. T hes e findings seem to indicate primarily state-dependent symptoms that improve on recovery. T hus , forcedspan-of-apprehens ion and backward masking tas ks impairments similar to those seen in actively patients but unlike thos e s een in s chizophrenic patients who have persistent deficits in the remitted state. disorder patients who are not actively ill reveal normal information process ing. T hus, bipolar dis orders can viewed as a disorder of s elf-organization in which the system fluctuates between the extremes of highly activated manic and highly deactivated depres sed of mind.

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Pos ttraumatic S tres s Dis order S tudies of P T S D have extended the findings of information-proces sing abnormalities in anxiety attention bias es toward fear-related and threat-related stimuli. Many of the s tudies were hampered by poorly defined clinical populations and control groups. some general trends, noted es pecially in the wellcontrolled paradigms , are promising and provide important ins ights into the psychopathological cognitive mechanisms in P T S D. C ognitive s tudies of patients with anxiety dis orders focus ed primarily on attention or memory. V arious res earch paradigms have been applied to as ses s bias and memory retrieval for neutral and emotionally activating s timuli. S tudies find that anxious patients an increas ed tendency to attend to fear-related and related words . One research approach includes a listening tas k in which an anxious patient is more easily distracted than are controls by fear-related stimuli in nonattended channel. T his finding s ugges ts that the patients have automatic, parallel attention process es are primed to detect certain types of stimuli. Another approach uses the S troop paradigm, in which words presented in different-colored inks , and the person's to look at the word and s tate the color of the ink. patients have a s ignificant delay in their res ponse times fear-related words , a finding that sugges ts that attention capacity or cognitive proces sing is necess ary when those words are perceived and the color of the determined. One theory that explains these findings is the idea of a 205 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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network that encodes fear-related information in a memory s tructure that is readily access ible and able to influence cognitive, motor, and ps ychophysiological res ponses . T he theoretical fear networks, which may similar to mental models, are thought to contain three related forms of information: fear-eliciting s timulus specific res ponse patterns , and the meaning of the and the res ponses for that particular pers on. According this theory, patients with anxiety disorders are believed have fear networks that are es pecially coherent and and that require few environmental cues to become activated. P atients with P T S D have been found to have attention biases toward threat-related stimuli s pecific to the experienced traumatic event. Many of the patients were combat veterans, and further work is needed to es tablis h the generalization of those findings to other forms of P T S D. T he dis order is clinically characterized intrus ive proces ses (memories, images , emotions , and thoughts) and avoidance elements (psychic and numbing, amnes ia, behavioral avoidance of cues res embling the initial trauma). T he patients are thought to have a unique configuration of fear networks with s timulus cues (environmental s timuli), res ponse components (cognitive, motoric, and ps ychophys iological), and meaning elements (e.g., the moral implications of the trauma, survivor guilt, and the meaning of intentional trauma vs. accidental trauma). S ome theories argue that states of exces sive arous al during trauma impair attention capacity and memory encoding during the event. E motional process ing and after the traumatic experience may als o be 206 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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by the s tates of ps ychophys iological arousal and memory s torage. T he part of the brain necess ary for explicit memory process ing, the hippocampus , has shown to be abnormal in individuals experiencing P T S D. T he s ubs equent clinical s yndrome may have as pects that are adaptive: C ognitive attention bias es are primed to detect fear-related stimuli may permit the early detection of threatening s ituations that, if not avoided, would produce incapacitating ps ychophys iological arousal. Automatic, noncons cious behavioral avoidance respons e patterns, embedded in propos ed fear networks or mental models, allow the patients to minimize excess ive arous al by avoiding trauma-related situations . P atients who us ed mechanisms during P.526 and after a traumatic experience appear to be at far greater risk for developing P T S D. Diss ociation is a proces s that ess entially involves the disass ociation of us ually ass ociated process es, such as attention, perception, memory, consciousness , and sens e of self. T he ps ychopathological as pects of P T S D can be cognitively exemplified as follows : A combat veteran chronic P T S D may have no direct recall (impaired memory) of a helicopter cras h in which his bes t friend, was seated next to him, was killed. Y ears later, avoidance of airports , amnes ia for combat, general and s ocial withdrawal (avoidance elements) combined with startle res pons e, panic attacks , intrus ive images, nightmares (intrus ive components) all sugges t intact implicit memory for the combat trauma. T he veteran is 207 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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emotionally, behaviorally, and cognitively impaired.

S peec hles s Terror S cott L. R auch and colleagues explored the of intense fear us ing patients with P T S D. T hey took patients with P T S D and exposed them to two One was emotionally neutral, and the other was a a traumatic experience. W hile they were listening to tapes , measures of their heart rate and regional blood flow (rC B F ) were meas ured via P E T s cans. rC B F greater during traumatic audio tapes in right-sided structures , including the amygdala; the posterior orbitofrontal, insular, anterior, and medial temporal and the anterior cingulate cortex. T hese are the areas thought to be involved with intens e emotion. An extremely interesting and potentially important finding was a decreas e in rC B F in B roca's area (left frontal and middle temporal cortex). T hes e findings suggest a potential active inhibition of language during trauma. B ased on these results , speechless often reported by victims of trauma, may have neurobiological correlates consis tent with what is about brain architecture and brain–behavior T his inhibitory effect on B roca's area impairs the of conscious memory for traumatic events at the time they occur. It then naturally interferes with the development of narratives that s erve to proces s the experience and lead to neural network integration and ps ychological healing. Activating B roca's area and left cortical networks of explicit epis odic memory may be es sential in ps ychotherapy with patients experiencing P T S D and other anxiety-based disorders . 208 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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T he evaluation and treatment of patients can be greatly enhanced by an unders tanding of development, diss ociation, and cognitive proces ses (including and its careful application to the ass ess ment of symptoms and s igns. S everal areas that have clinicians for decades have become of great societal concern. T wo topics that inspire intense controversy the delayed recall of repress ed memories of traumatic events and the s uggestibility of patients influenced by clinicians , s ociety, or friends to believe that they are the victims of childhood trauma.

Delayed R ec all Many scientis ts and clinicians believe in the cognitive capacity of patients to be unaware for years or severely traumatic experiences that took place in their childhoods. Other researchers dis agree and paucity of s tudies of corroborated cases of childhood trauma that have been followed prospectively into adulthood with documentation of impaired acces s of cons ciousnes s to events presumably stored in cognitive s cience view of delayed recall can examine role of memory proces ses and development and the of trauma on the proces sing of information to des cribe theoretically coherent but yet-to-be-proved set of mechanisms. A repres sed memory can be thought of as originating the active, intentional suppres sion of memory from cons ciousnes s. T he mechanisms underlying the then may become automatic, and the contents of may be inhibited from retrieval into conscious ness . T he blockage may exist to avoid flooding the pers on's 209 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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awarenes s with information that is ass ociated with excess ive anxiety or fear that would impair normal functioning. T his is an example of knowledge is olation which information may be layered in the nervous and certain as pects may be kept from conscious awarenes s. In contras t, a traumatic event may be s o overwhelming that normal process ing may be impaired. If focal is divided, the nonfocally attended (traumatic) material only process ed implicitly. T hus , to adapt to a traumatic event, some pers ons may have the capacity to focus attention on a nonthreatening aspect of the or on their imagination during the trauma; this may be underlying mechanism in a proces s called dis s ociation. T raumatic memory that has been only implicitly affects behavior and emotions and pos sibly contains intrus ive images and bodily s ens ations that are devoid sens e of pas t, of self, or of something being recalled. may partly explain the findings of P T S D with amnes ia (blocked conscious access to a memory or its origin) in setting of avoidance behaviors , hyperarousal, intrus ive images, and flas hbacks. T hus, two distinct mechanis ms that may explain recall of childhood trauma are the concepts of memories and diss ociated memories . A pers on may both mechanisms for different as pects of a traumatic event. R ecollection of the traumatic memory may take different forms . R epress ed memories may have been proces sed to some degree in narrative form, whereas diss ociated memories probably lack that more proces sing. T he latter form thus may be experienced nonpas t and nons elf, making the intrus ive retrieval of 210 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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diss ociated memories a confusing and frightening experience. S tudies of the development of memory in children that the s hared cons truction of narratives about experienced events is often crucial in making the access ible to long-term retrieval. T he establishment of personal memory system appears to be a function of memory talk in which parents discus s with children the contents of their memory. In children who have been forced to keep traumatic events a s ecret, as may occur childhood abus e, the normal developmental process of narration may be blocked. T his may be an additional cognitive mechanism underlying the inacces sibility of some forms of childhood trauma to cons cious nes s in patients.

S ugges tibility K nowledge is olation, s uch as in dis sociation and repress ion, provides a theoretical s cientific explanation the underlying mechanisms that may lead to delayed recall of childhood trauma, but clinicians mus t also be aware of other cognitive proces ses that influence Numerous s tudies have demonstrated that the human mind is eas ily influenced. Human sugges tibility can be us ed to the benefit or detriment of others. S uggestibility adaptive for a s ocial being that relies on the others to inform its knowledge of the world and thus to increase its chance for survival. T hus, lis tening to the stories of others, reading a textbook, and being athletics all require the receiver to accept data from the sender. T he learner (lis tener) needs to trus t the the teacher (teller) to accept the incoming information. 211 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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C ritical analysis of the data received is an important component of learning. T he metacognitive function of as sess ing the accuracy or us efulness of newly information may be s us pended under certain including hypnosis, drug-altered states , and conditions severe threat. S tudies of human s ugges tibility indicate that postevent questioning can bias the metamemory process es that determine the P.527 source and accuracy of a retrieved memory. T he verbal nonverbal cues given by the interviewer may influence person to believe that as pects of an event or an entire event that may have never happened actually took A person can be convinced of the accuracy of an event despite its lack of corres pondence with actual F actors that may influence the biasing of interviewees include a belief in the trustworthines s and authority of interviewer, not being aware that “I don't know” is a permis sible res ponse, repetition of a ques tion that has been ans wered, and the interviewer's beliefs as communicated through emotional tone and nonverbal gestures. It is crucial for clinicians to be aware of human suggestibility to avoid iatrogenic distortions. S imilarly, it important for persons who experienced severe trauma early in life to receive informed and empathetic evaluations and treatment. T here is a delicate balance between supportive neutrality and active advocacy in as sess ment and intervention. Awareness of these fundamental cognitive process es may help guide the 212 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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clinician toward achieving that goal. Approaches to the treatment of patients with P T S D careful evaluation but generally include the view that impaired emotional process ing of the traumatic event requires the active recollection, in explicit terms , of the details of the experience. T he process of effectively treating unresolved trauma us ually involves the active cognitive process ing of s pecific memories, including emotional res ponses , derived belief s ys tems, and the ps ychophys iological arousal at the time of the event. T he provis ion of new cognitive information in the cours e of psychotherapy can, in theory, alter the configuration of the fear networks and can allow previous ly inaccess ible information to be explicitly proces sed and made available to conscious ness for incorporation into an ongoing autobiographical S pecific techniques , s uch as those which facilitate such cognitive process ing of previous ly diss ociated or in ways isolated cognitions, such as beliefs, images , and sens ations, may be us eful in alleviating the s ymptoms dysfunction after acute or chronic trauma. S uch and changes in mental process ing may diminis h the avoidant and intrusive components of the clinical syndrome of P T S D and may improve s ocial, emotional, cognitive functioning.

C omplex P TS D C omplex P T S D occurs in the context of prolonged and inescapable s tres s and trauma. It is complex becaus e extensive phys iological effects and its impact on all of development and functioning, es pecially if it occurs during early childhood. E nduring pers onality traits and 213 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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coping s trategies evolving from traumatic s tates tend to increase the individual's vulnerability to future trauma. T his manifes ts in a traumatic resonance through engagement in abus ive relationships , poor judgment, a lack of self protection. Long-term P T S D has been to correlate with the pres ence of what are called ne urological s oft s igns , pointing to s ubtle neurological impairments . T hese neurological s igns could s uggest a vulnerability to the development of P T S D or reflect the impact of the long-term phys iological dysregulation caus ed by P T S D. When confronted with threat under normal the process es related to arousal and the fight-or-flight res ponse become activated; the threat is dealt with and soon pas ses . F or obvious reas ons , children are not equipped to cope with threat in this way. F ighting and fleeing may actually decrease their chances for because their survival depends on dependency. When child firs t cries for help, but no help arrives, or when trauma is being inflicted by a caretaker, he or she may from hyperarous al to dis sociation. T raumatized who are agitated may be misdiagnosed as having attention-deficit disorder, whereas the numbing in infants can be misinterpreted as a lack of sensitivity pain. T his may als o be true for women who are often unable to outrun or outfight male attackers . Until recently, surgery was performed on infants anesthes ia, becaus e their gradual lack of protest was mistakenly interpreted as insensitivity to pain, as to a traumatic reaction to it. R ecent s urvey res earch suggests that less than 25 percent of phys icians performing circumcis ion on newborns use any form of 214 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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analgesia, despite physiological indications that are experiencing stress and pain during and after the procedure. T hes e practices appear to be a holdover of beliefs that newborns do not experience or do not remember pain. It makes sense that an appreciation for poss ibility of P T S D reactions in neonates and young children has lagged behind other areas . Dis sociation allows the traumatized individual to the trauma via a number of biological and proces ses. Increas ed levels of endogenous opioids sens e of well-being, pain reduction, and a decreas e in explicit proces sing of the overwhelming traumatic situation. P sychological process es, such as and depers onalization, allow the victim to avoid the of his or her s ituation or to watch it as an obs erver. proces ses provide the experience of leaving the body, traveling to other worlds , or immers ing oneself into objects in the environment. Hyperarousal and in childhood es tablis h an inner biops ychological environment primed to es tablish boundaries between different emotional s tates and experiences for a it is too painful to experience the world from ins ide body, s elf-identity can become organized outside the phys ical s elf. E arly traumatic experiences determine biochemical and neuroanatomical networking, impacting experience and adaptation throughout development. T he tendency diss ociate and dis connect various tracks of process ing creates a bias toward unintegrated information acros s cons cious awarenes s, s ensation, affect, and behavior. G eneral diss ociative defens es res ulting in an aberrant organization of networks of memory, fear, and 215 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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the social brain contribute to deficits of affect attachment, and executive functioning. T he of thes e interdependent s ys tems res ults in many res ulting from extreme early stress . C ompulsive related to eating or gambling and somatization in which emotions are converted into phys ical can all be unders tood in this way. P T S D, borderline personality dis order, and self-harm can all reflect adaptation to early trauma.

FUTUR E DIR E C TIONS C ognitive s cience offers a breadth of for unders tanding the way in which the mind functions health and dis ease. T he broad interdis ciplinary field provides numerous research paradigms that are helpful further elucidating the nature of ps ychopathology techniques from the neuros ciences to computer brain functioning and biological applications of chaos theory. T he cognitive unders tanding of emotions and cons ciousnes s may als o expand psychiatry's knowing about human s ubjective experience. C linical tools , from medications to in-depth ps ychotherapy, may also find wider application as the process es of s elforganization and psychological change are better unders tood. P sychiatry, in turn, has much to offer the field of science. T he long history of descriptive and the attempt to s ynthes ize views of the mind and brain can provide nonclinical cognitive s cientists with unique data and relevant ques tions. P sychiatry is join in the s earch for understanding the cognitive proces ses of the human mind. 216 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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P.528

S UG G E S TE D C R OS S P iaget and emotional development are discuss ed in 3.2, memory is dis cuss ed in S ection 3.4, cognitive are dis cuss ed in C hapter 10, s chizophrenia is C hapter 12, mood disorders are dis cuss ed in C hapter and anxiety disorders are dis cuss ed in C hapter 14. Dis sociative disorders are dis cuss ed in C hapter 17, and personality disorders are dis cuss ed in C hapter 23. therapy is discus sed in S ection 30.2, hypnosis is S ection 30.3, and cognitive therapy is dis cus sed in 30.6. Mental retardation is discuss ed in C hapter 34, disorders are dis cus sed in C hapter 35, pervasive developmental disorders are dis cuss ed in C hapter 38, ADHD is dis cuss ed in C hapter 39.

R E F E R E NC E S Andreas en NC : Linking mind and brain in the study mental illness es: A project for a s cientific ps ychopathology. S cience. 1997;275:1586. B addeley A: W orking memory: Looking back and forward. Nature . 2003;4:829. *C ozolino LC . T he Neuros cience of P s ychothe rapy: and R ebuilding the Human B rain. New Y ork: W .W . 2002. Damasio AR . Des carte s ' E rror: E motion, R eas on and Human B rain. New Y ork: P utnam; 1994. 217 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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Douglas V I. C ognitive deficits in children with deficit disorder with hyperactivity. In: B loomingdale S ergeant J A, eds . Atte ntion Deficit Dis orde r: C ognition, Interve ntion. Oxford, UK : P ergamon 1988. F onagy P , S teele M, S teele H, Moran G S , Higgitt capacity to understand mental states: T he reflective in parent and child and its s ignificance for s ecurity of attachment. Infant Me nt He alth J . 1991;12:201–218. J ohns on MH, Magaro P A: E ffects of mood and on memory process es in depress ion and mania. B ull. 1987;101:28. J ohns on-Laird P N. Me ntal Mode ls : T owards a S cience of L anguage, Infe re nce and C ambridge, MA: Harvard University P ress ; 1983. K andel E R : A new intellectual framework for Am J P s ychiatry. 1998;155:457. K os slyn S M. Image and B rain: T he R es olution of the Image ry De bate . C ambridge, MA: MIT P ress ; 1994. Le Doux J . T he S ynaptic S e lf. New Y ork: V iking 2002. Lewis MD: S elf-organizing cognitive appraisals. E motion. 1996;10:1. MacLeod C . Mood disorders and cognition. In: 218 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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MW , ed. C ognitive P s ychology: An Inte rnational C hichester, E ngland: W iley; 1990. Main M. Metacognitive knowledge, metacognitive monitoring, and s ingular (coherent) vs. multiple (incoherent) models of attachment: F indings and directions for future research. In: Marris P , Hinde J , P arkes C , eds. Attachment acros s the L ife New Y ork: R outledge & K egan P aul; 1991. Mesulam MM: R eview article: F rom sens ation to cognition. B rain. 1998;121:1013. *Metcalfe J , S himamura AP . Me tacognition: about K nowing. C ambridge, MA: MIT P ress ; 1994. Milner B , S quire LR , K andel E R : C ognitive and the study of memory. Neuron. 1998;20:445. Morris R G M, ed. P aralle l Dis tributed P roce s s ing: Implications for P s ychology and Ne urobiology. UK : C larendon; 1989. Osherson DN, S mith E E , eds . T hinking: An C ognitive S cie nce . V ol 3. C ambridge, MA: MIT 1990. *P os ner MI, ed. F oundations of C ognitive S cience . C ambridge, MA: MIT P ress ; 1989. R auch S L, van der K olk B A, F is ler R E , Alpert NM, S avage C R , F is chman AJ , J enike MA, P itman R K : A 219 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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symptom provocation s tudy of P T S D using P E T and script driven imagery. Arch G e n P s ychiatry. 387. *S chore AN. Affe ct Dys re gulation and the Damage S elf. New Y ork: Norton; 2002. S iegel DJ : T oward an interpersonal neurobiology of developing mind: Attachment, “minds ight” and integration. Infant Me nt Health J . 22:67–96. S iegel DJ . An interpers onal neurobiology of ps ychotherapy: T he developing mind and the res olution of trauma. In: S olomon M, S iegel DJ , eds . Healing T rauma. New Y ork: Norton; 2003:1–55. *S iegel DJ . T he Deve loping Mind: T oward a of Inte rpers onal E xperie nce . New Y ork: G uilford; S igman M. W hat are the core deficits in autis m? In: B roman S H, G rafman J , eds. Atypical C ognitive Deve lopme ntal Dis orde rs : Implications for B rain Hillsdale, NJ : E rlbaum; 1994. S pringer S P , Deutsch G . L e ft B rain, R ight B rain. 5th New Y ork: W H F reeman; 1998. S teinhauer S R , G ruzelier J H, Zubin J , eds . S chizophre nia. V ol 5. Neurops ychology and P roces s ing. New Y ork: E lsevier S cience; 1991. T aber K , R ausch S , Lanius R , Hurley R : F unctional 220 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/3.1.htm

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magnetic res onance imaging: Application to posttraumatic stress disorder. J Ne urops ychiatry Neuros ci. 2003;15:125. van der K olk B A: T he neurobiology of childhood and abuse. C hild Adole s c P s ychiatr C lin N Am. 2003;12:293. Watts F N, ed. Neurops ychological P e rs pe ctive s on E motion. V ol 7. C ognition and E motion. Hills dale, E rlbaum; 1993. Wheeler MA, S tus s DT , T ulving E : T oward a theory episodic memory: T he frontal lobes and autonoetic cons ciousnes s. P s ychol B ull. 1997;121:331.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 4 - C ontributions of the S ociocultural S ciences > 4.1 T he S cientist and the P s ychoa nalys t

4.1 The Ps yc hiatric and the Ps yc hoanalys t Armando Favazza M.D. M.P.H. P art of "4 - C ontributions of the S ociocultural S ciences " B ehavior is determined by the interplay among a environment, life experiences, and biological C ulture is the matrix within which these psychological, social, and biological forces operate and become meaningful to humans; it is important for ps ychiatry, because it affects not only patients ' experiences of illness , but als o lay and profess ional theories of diagnostic procedures, and therapeutic approaches . C ulture is not a thing that a pers on has, but rather is an ongoing process created by s hared interpersonal experiences that reverberate throughout a s ociety and affect its institutions and the daily life of its members. Matter is neutral; molecules and energies are until they are pers onally interpreted, explained, and accepted as reality through the cultural proces s. Health and illness are cultural categories bas ed on universal biological events and culturally diverse bodily experiences that may be interpreted and acted on differently. S uppos e, for example, that a woman somewhere in the world experiences an enduring and difficult-to-control s ens e of apprehens ive expectations , 222 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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tense muscles , irritability, and difficulty falling as leep. reaction to this complex of experiences depends on her culture. Does her culture provide a word or a cons truct to identify and to explain what s he is experiencing? S hould her experiences be cons trued as normal s uffering or as evidence of a moral flaw, a disharmony of inner energies , an exis tential crisis, deflected rage, nerves , or generalized anxiety What is the culturally accepted limit that she must before dis closing her experiences ? W hom does her sanction to receive her dis closures? G od, perhaps, or a priest, a congregation, a local healer, a televangelis t, a help group, a friend, a family member, a counselor, a phys ician, or a psychiatrist? T he remedies she may be offered—prayer, acts of contrition, increased group participation, change of diet, exercise, interes ting changing jobs, going on a vacation, family or marital couns eling, individual therapy, meditation, are culturally determined, as are the criteria us ed to the efficacy of the remedy.

C UL TUR E C ulture is a vast, complex concept that is us ed to encompas s the behavior patterns and lifestyle of a society—a group of pers ons sharing a s elf-sufficient system of action that is capable of existing longer than life s pan of an individual and whos e adherents are recruited, at leas t in part, by the s exual reproduction of group members . C ulture consis ts of s hared s ymbols, artifacts, beliefs , values, and attitudes. It is manifes ted rituals , customs , and laws and is perpetuated and in shared sayings, legends , literature, art, diet, religion, mating preferences , child rearing practices, 223 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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entertainment, recreation, philos ophical thought, and government. C ulture serves many purposes. It overall cons is tency to a society's patterns and over the generations. It helps organize diversity and mediate between the forces of s tability and conformity and those of new ideas and actions . B y class ifying phenomena into good and bad, right and wrong, and s ick, desirable and undes irable, people are with behavioral guidelines and an interpretation of life's events. B ecause cultural components change at speed (for example, technological advances may a s ociety's capacity to deal with new ethical is sues), cultural s ys tems attempt to minimize s tres s. C ulture is learned through contact with family, friends, teachers, significant persons, and the media; the term this process is enculturation. It res ults in a personal belonging to one's own s ociety and in a native identity. E xcept, perhaps, for a few totally is olated, small s ocial groups , there are no pure cultures. S ocieties are not Acces s to printed media, radio, telephone, televis ion, easy travel, as well as geopolitical changes , has a great deal of cultural blending. Adults s uch as or refugees who only in part adopt the culture of a hos t society are said to be as s imilate d, whereas those who as sume a new cultural identity consonant with that of host culture are s aid to be acculturated. P ersons who, voluntarily or by force, abandon their native culture but to be ass imilated or acculturated usually lose their identity or purpos e in life and are at high ris k for subs tance abus e, and alcoholism. T he holis tic and functional concept of culture also for the exis tence of s maller subcultural groups and 224 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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patterns within the larger society. Native Americans, for example, have distinct cultures, es pecially in tribal that live on reservations . On a smaller, les s scale, there are many subcultural groups and units in which there are s hared feelings , ideas , and behaviors , example, cults , neighborhood ass ociations , institutional inmates, athletic teams, s tudents and teachers at a and unions. Many s ubcultural patterns serve to and to integrate the general society, but s ome may be socially disruptive (organized criminal groups ) or truly destructive (terroris t organizations). E ach family may said to have its own microculture. Although the term culture is a grand abstraction that implies stability, homogeneity, and coherence, social life is often replete with change, heterogeneity, and inconsistencies . Anthropologists traditionally have been the major profes sional group to s tudy culture, whereas have studied P.599 social class . A culture is not the same as a s ocial class . Within every society, one may find the five levels described for social s tratification ranging from clas s I, characterized by high financial income, pres tigious occupations , and poss ess ion of des iderata, to clas s V , characterized by just the oppos ite. In a geographical one or more differing cultural systems may be present, each containing members of the five s ocial class es. such as the culture of pove rty and me ntal he alth of the are misleading, becaus e they imply that all members of lowest social clas s s hare a common culture. It may be that impoverished areas outwardly appear similar and 225 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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slum dwellers s hare some common attitudes and patterns, but these s ocioeconomic phenomena s hould be confus ed with culture. Anthropologists and s ociologis ts have s eparate methodologies, and points of view. Anthropologis ts, for example, study acculturation, whereas sociologis ts migration. B oth of thes e proces ses s hare identical referents in many ins tances . Acculturation studies emphasize s mall-scale, non-Wes tern populations, contact between investigators and their subjects, and a focus on behavior itself; however, migration studies typically emphas ize sociodemographic variables, ps ychiatric us e rates , large W estern populations , and or no direct contact between investigators and their subjects . S ociologists do not have mus eums; anthropologis ts do—this reflects the anthropological concern for biology and artifacts , as well as for B oth sciences are pertinent to medicine, in general, ps ychiatry, in particular. Medical anthropologists s tudy the impact of proces ses on health and on people's experiences of es pecially by us ing cross -cultural comparisons. T heir studies on the lives of patients in mental hospitals and then, after deinstitutionalization, in the community have had direct clinical impact. More than any other medical specialist, ps ychiatris ts have developed expertise in unders tanding sociocultural proces ses and in using this unders tanding clinically. American psychiatric interest culture began in the mid-1800s when mental hos pitals admitted a large number of Iris h and G erman T oward the end of that century, E uropean ps ychiatris ts African, As ian, and C aribbean colonies described a 226 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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of unus ual s yndromes s uch as latah, amok, and koro. R . R ivers , a B ritis h psychiatris t renowned for the field of s ocial anthropology, did research on healing and on the perception of pain in S outh P acific Is landers that he then us ed in treating mentally traumatized s oldiers in World W ar I. At the turn of the century, E mil K raeplin traveled from E urope to Asia, des cribed differences in s ymptomatology among patients, and developed the field of comparative ps ychiatry. S igmund F reud's psychoanalytic office was filled with archeological relics, and, as he dug through the layers his patients ' neurotic minds , he believed that he could recons truct past epochs of human behavior and Among the conclusions of his widely read books written between 1913 and 1938, T ote m and T aboo, T he Illus ion, C ivilization and its Dis contents , and Mos e s Monotheis m, are that culture and repres sion are reciprocally related and that the superego was socially created to control the dangerous human des tructive instinct. Many psychoanalysts , including Otto R ank, T heodor R eik, and C arl J ung, publis hed studies of and myth. G eza R oheim, E rik E rikson, and G eorge Devereux were ps ychoanalyst anthropologists with field experience. R oheim founded the series known as P s ychoanalytic S tudy of S ocie ty. He used his vas t of arcane cultural details to support his extreme ps ychoanalytical theories and then to twit his anthropological colleagues , whom he accused of obvious proof of the oedipal complex becaus e of their own repres sed conflicts. E riks on wrote psychocultural studies of Mahatma G andhi and Martin Luther. His 227 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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experiences with Dakota and Y urok Indians ins pired C hildhood and S ocie ty, written in 1950, in which he the intrins ic wis dom and uncons cious “planfulness ” of cultural conditioning with the ongoing process es of individual psychosocial development. Devereux, with American P lains Indians, believed that s hamans caus ed a social remis sion in patients by repatterning ethnopsychologically s uitable defens e mechanis ms. In treating Mohawk Indian patients, he explicated such as dream interpretation and trans ferencecountertransference, which are encountered in clinical work with ethnically diverse populations . B ecause ps ychoanalys is developed from the s tudy of the its application to cultural phenomena is at least one removed and is open to ques tion. Als o, the concepts of mind and mental process es may not be applicable or meaningful when applied to non-Wes tern groups . T he trend among some ethnopsychoanalysts attend to informants' explanations of their behavior and synthes ize ps ychological and sociocultural exemplified in R obert LeV ine's work and in articles published in the J ournal of P s ychoanalytic and in P s ychiatry, a journal founded by Harry S tack with the as sistance of E dward S apir, a cultural anthropologis t. Modern cultural psychiatry began in 1955, when a T ranscultural P s ychiatry Divis ion was started at McG ill Univers ity in Montreal with the leadership of E rick Wittkower and H. B . M. Murphy. R aymond P rince and, recently, Laurence K irmayer have continued leading Divis ion, including publication of the journal P s ychiatry. In 1971, a T rans cultural P s ychiatry section 228 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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es tablis hed in the W orld P s ychiatric Ass ociation; recent directors include W en-S hing T seng, a C hines ewho wrote the first truly comprehensive Handbook of C ultural P s ychiatry in 2001; W olfgang J ilek, an C anadian with extens ive experience in working with refugees in S outheast Asia and Africa; and G offredo B artocci, an Italian who has vitalized E uropean cultural ps ychiatry and who has published in the area of the United S tates , the journal C ulture, Me dicine and P s ychiatry was es tablis hed in 1976 by Arthur prominent cultural psychiatric researcher, and B yron a medical anthropologis t. T he S ociety for the S tudy of P sychiatry and C ulture was founded in 1979 by F avazza, E dward F oulks , J ohn S piegel, J oseph Wes termeyer, and R onald Wintrob. S imilar exis t in C hina, G ermany, Italy, J apan, and the United K ingdom.

C UL TUR E A ND THE HUMA N Wes tern science now locates the construct of mind in brain; in past times, it was linked with the heart, the and other organs . J us t as s ome body parts can be through us e patterns —for example, physical exercis e affects mus cle strength and s ize—so too can the neural network be modified. R epetitive thoughts , sounds, s mells , tastes, and touches tend to increase specific neuronal dendritic connections and to intensify neurotransmitters, so that certain sensations and become phys ically patterned in the brain. T he ability to speak a particular language, for example, depends on culture-specific neural organization that influences cognitive process ing and creation of cognitive schema as to structure a pers on's perception and experience of 229 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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world. C ulture exerts a great influence on the birth, development, and death of the human body. T wo New G uinean tribes, the E nga and the F ore, provide an of how culture may affect fertility. T he E nga, who live in state of chronic overpopulation and have reached the upper limits of s urvival for their territory, have cultural patterns that s erve P.600 to limit population growth. P remarital s ex is forbidden, celibacy is highly valued, and inces t taboos are broad; woman cannot marry any man related through men to paternal grandfather. Men cannot marry until they are years of age; on the death of a man, his widow is or s trangled to death. Infanticide is practiced, and not a caus e for anguis h. In contrast, the F ore live in an underpopulated area, and their cultural practices serve increase population growth. S exual experimentation early marriage are encouraged, widows are inherited the dead hus band's male relatives, tribal ceremonies erotic elements, and death caus es great communal anguis h. In large, complex societies , fertility rates are affected by monetary incentives, for example, taxation encourage or to discourage large families . In C hina, government policies to lower population growth reportedly have included forced abortion and even infanticide. In Italy, the exceedingly low birth rate secular culture s hift away from the C atholic church's traditional stance that birth control is sinful. C ulture als o affects the ways in which the body is Hunger could be eliminated if all food s ources were but the people of W estern nations are unwilling to eat 230 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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cats, dogs, rats, beetles , and grubs . Dietary and food process ing may affect mental status ; pellagra its as sociated dementia are caus ed by a niacindiet. In 1912, J os eph G oldberger discovered that in the American S outh was caus ed by the removal of from corn during the milling proces s. C orn is currently the center of a great s ocial debate over genetically modified foods; proponents argue that genetically modified corn is safe to eat and produces prodigious yields, whereas opponents refer to it as F ranke ncorn call for more tes ting before it is allowed into the marketplace. B eyond its s cientific merit, this debate reflects the cultural conflict between traditionalis m and progres sivis m and mirrors other contemporary cultural clas hes over s uch disparate topics as homos exuality, abortion, global warming, and creationism. P roblems ass ociated with the drinking of alcohol greatly on culture. T he C hines e have a low rate of alcoholism, whereas the J apanese have a high rate of alcoholism. B oth groups contain many pers ons who an unpleasant “flush” reaction to alcohol, but the low alcoholism rate in C hina appears to be the res ult of a cultural emphas is on moderation and s elf-control, low res pect for problem drinkers, the ass ociation of and eating, and a traditional belief in the medicinal of alcohol. Deviant and culturally s anctioned behaviors that alter destroy body tis sue are found in all s ocial groups. Mos t body modification practices are performed to promote beauty and to enhance s exuality, to s ignify a particular group, or to express rebellious ness and individuality; examples of these behaviors are earlobe 231 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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piercing to affix jewelry, ins ertion of nipple rings , tattoos identify gang members, and a s imple tattoo on the T he widespread fad of body piercing and tattooing in Wes tern nations has no particularly significant meaning other than, perhaps , a diss atisfaction with an bureaucratic and computer-driven society in which are identified by numbers and in which artificial are replacing “the real thing,” for example, chemical organic s ubs titutes and vitamins in pill form. Although a group of persons who have modified their bodies (excluding s ingle earlobe piercing) probably would more psychopathology than a control group, a diagnosis cannot be inferred simply by the presence of tattoos or piercings. B ody modification rituals, unlike fads and practices , are socially functional, integrative, adaptive, and enduring cultural components . P articipants believe that the promote health, heal pathological conditions, maintain social s tability, enhance s pirituality, and provide for religious salvation. B ody modification rituals for promoting health and illness often focus on the importance of blood. Many native tribes in P apua New G uinea, for example, womb blood to be a pathological s ubs tance that in the circulatory s ys tem of adults . Mens truation allows women to purify thems elves naturally, but men must res ort to periodic penis cutting, tongue abras ion, or hemorrhages. T hrus ting sharp, stiff grass into the once a month induces copious nas al bleeding, thus supposedly eliminating womb blood. Members of the Hamads ha, a Moroccan S ufi healing s ect, believe that healers poss es s a s acred force known as baraka that 232 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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promote health and cure mental and physical illnes ses caus ed by jinn s pirits. Afflicted patients gather in a and the healers enter into an ecstatic trance induced rhythmic music and wild dancing. T he healers then open their heads. P atients acquire the healer's baraka eating sugar cubes or bread bits dipped into the flowing blood or by s mearing thems elves with the blood. B ody modification rituals frequently also serve to social s tability; they may help to define group and adult status, to control gender-linked behaviors, to solidify social bonds . E laborate patterns are carved the flesh of T iv (Nigeria) females on reaching puberty. scars repres ent the T iv family, heritage, land, genealogy, and myth, and they duplicate the on sacred objects. T his scarification ritual transforms girl into a woman and into a sacred object on whom the group's fertility depends . In some cultures in which sexuality is cons idered problematic, body modification rituals have been es tablis hed to control women's In an analogy to a ps ychodynamic formulation in which morbid symptom s erves to bind conflict-caus ed anxiety an individual, thes e rituals with their consequent ps ychological, and s ocial morbidity s erve to bind communal anxiety in societies in which s exual conflicts have the potential to disrupt the male–female T hrough the practice of foot-binding, for example, men literally prevented their women from “running around” by crippling them. G irls' feet were tightly bound with bandages to keep them from growing; the flesh became infected, and, s ometimes , one or more toes sloughed off. T he pain lasted for almos t 1 year and diminis hed when the feet became numb. Men extolled 233 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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beauty of the “lotus foot” and cons idered it erotic. women with bound feet could not walk any distance without the help of attendants , men could be s ure of whereabouts . T he practice exis ted for a millennium and ended in the 1920s . A more direct approach to the of female sexuality involves genital modification of girls in S udan and S omalia and parts of E thiopia, K enya, and Nigeria. S imple circumcis ion involves off the clitoral prepuce; excis ion involves als o removing the tip of the clitoris. Infibulation involves removal of the clitoris, the labia, and mon veneris ; the vagina is then shut except for a small opening. Immediate or early medical complications include infection, urinary urethral and anal damage, and hemorrhagic shock or death. Long-term morbidity includes chronic pelvic urinary tract infections, dermoid cysts and absces ses , dyspareunia, and complicated childbirth. An infibulated woman is marriageable, becaus e s he is a guaranteed virgin. E xcis ion of the sensitive clitoral area is done to attenuate the woman's sexual desires and to free her personal lus t. Uncircumcis ed women are regarded as unclean and not worthy of being a wife and a mother; Arabic word tahur refers to purity, cleanlines s, and circumcis ion. T he rituals are perpetuated, in part, becaus e marriage motherhood are often the only s ocial roles available to women; attempts to ban them have been modestly succes sful. C ircumcised women who move to cultural settings in which the experience of pleasure in females cons idered desirable may become clinically depres sed P.601 234 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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when they realize that an important part of their has been cut away. In many cultures , es pecially ones, dis comfort with female sexuality is evident; a rationalization for this discomfort is that untamed sexuality caus es men to act irrationally. T he path to enhanced s pirituality and religious often involves body modification. In the index ritual of P lains (American Midwest) Indians, the stronges t of the braves , while tethered to a rope affixed to s kewers in ches ts, danced, gazed at the s un, and ripped through muscles in a s truggle to be free from the s nares of the flesh. S evere s elf-flagellation occurs in S hia Islam and C hris tianity. T he C atholic church has canonized many saints who zealously mortified their flesh; s ome “holy” anorectics. In the E as tern Orthodox mys tical tradition, the beardles s, corpulent 18th and 19th castrated themselves to achieve the purity of the firs t Adam, before he ate the forbidden fruit, which G od supposedly grafted onto his body as testicles. In R ome and the Middle E ast, the s elf-emas culation of who was unfaithful to the G reat Mother G oddess , was memorialized annually in the ritual of the Day of when cult pries ts flagellated themselves and cut off genitals; the emperor J ulian called it “a holy harves t.” In Hindu T haipusum festival, many persons pierce their bodies with replicas of Lord Murugan's magic trident. An appreciation of the purposes s erved by culturally sanctioned body modification rituals helps demys tify seeming senseles s deviant s elf-mutilation of the ill. As stated by E dward P odvoll: T he self-mutilator can incorporate into his actions which, to a greater or less er degree, remain 235 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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in most of us . T hat is, s uch patterns already exist in intens ities within the patient's s ocial field.… S till the patterns involved are those which elicit s ilent levels of admiration and envy. T he history of these images as far back as the pass ion of the cross and has among some of the most res pected members of our culture. B ody modification rituals and deviant self-mutilation are not alien to the human condition; rather, they are culturally and psychologically embedded in the elemental experiences of healing, social s tability, and religion. T hes e acts acknowledge disruptions within the individual and the collective social body and provide a mechanism for the reestablishment, however brief, of harmony and equilibrium. T he self-inflicted cuts of Wes tern adolescents are not so different from those experienced during the rite of pass age by aboriginal initiates , blood brothers des perate to achieve social acceptance and integration into the adult world.

C UL TUR A L IDE NTITIE S T his s ection deals with three types of identity that as sume or have thrust on them, namely, race, and charis matic group members hip. Among the many other identities that are greatly influenced by culture those ass ociated with age and gender.

R ac e and R ac is m In standard medical cas e presentations, psychiatrists identify patients by age, gender, marital status , occupation, race, and, s ometimes , ethnicity. R ecipients such information immediately proces s it, cons cious ly 236 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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unconsciously, and make certain as sumptions. Of concern to cultural ps ychiatry are ass umptions bas ed race or ethnicity, because both of thes e cons tructs are emotionally evocative that they may distort the and therapeutic process . A characteristic of human beings is to compare to other persons for reasons of enhancing s elf-es teem for setting behavioral boundaries. T he comparative is us ually found lacking in one regard or another. T he ability of a group to perceive flaws in a different group so prodigious as to encompas s every aspect of such as political systems , s kin color, religious beliefs , practices , and gender. R elationships between so-called superior and inferior groups range from friendly rivalry enslavement, from covert hostility to mass murder. Depending on the place and time, men have women, whites have dis paraged blacks, free persons disparaged s laves, the rich have dis paraged the poor, heteros exuals have dis paraged homos exuals ; the complete list of superior-inferior polarities is discouragingly long. W hen cultural patterns based on perceived superiority and inferiority continue over generations, their pers is tence may be thought to reflect natural order that culture then s erves to protect. rationalizations , as well as political expediency, are us ed to perpetuate polarities , for example, men have denied suffrage to women in the belief that they s hould tend to cooking, children, and church activities rather deal with political iss ues that are far too complicated for them to unders tand. T he F ounding F athers of the S tates wrote a C ons titution and B ill of R ights that all men are created equal and have a right to 237 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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happines s, yet slavery was common at the time in the northern and s outhern s tates. Healthy cultures have capacity to change their s ocial patterns in res ponse to ideas , desires, and technologies; change may come gradually, es pecially when many of the perceived group members come to believe that they are truly inferior, or it may come rapidly with forceful rebellion civil war. T he notion that pers ons can be categorized by race has been abandoned by mos t scholars but universally in the general public. P hysical traits , skin color, are the mos t common lay markers of bas ic divis ions into white, black, red, and yellow races . the 1950s , some anthropologis ts class ified the races C aucas ian with Nordic, Alpine, and Mediterranean Mongoloids with Mongolian, C hinese, J apanese, V ietnames e, and T ibetan groups ; Malays ian and Indonesian; Native Americans ; Negroids with Negro, Melanes ian, Negrito, B ushman, and Hottentot groups; Aus traloids . Deoxyribonucleic acid (DNA) tes ting demonstrates the fallacy of racial divisions, becaus e great majority of human alleles are pres ent in all population groups , although their frequencies vary; genetic variability within populations is greater than the variability between them. Moreover, s kin color, hair nose shape, and other physical traits are independently inherited and are not linked one to another. T he saving grace of ancient beliefs about different was the provision of methods for overcoming alleged faults . B arbarians could gain acceptance from G reeks learning to speak and to write the G reek language. B y religious conversion, R omans and J ews could join the 238 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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C hris tian community. Modern forms of differentiation, es pecially those bas ed on the flawed biological of race, however, rarely permit the inferior group to ris e the s tatus of the superior one. Modern racis m began in 15th century S pain, where C hris tians were divided into old and new groups. Old C hris tians had “purity of blood,” whereas the new converted J ews —was hounded by the Inquis ition. On biological grounds, J ews , and later Mus lims, were incorrigibly inferior and therefore were excluded from mains tream S panish society. In the New W orld, conquerors brutalized and enslaved the local to mine for gold; their justification came from s ome theologians who declared that Indians lacked rationality and morality and therefore were, in Aristotelian terms , “natural slaves.” Als o, the famous physician, determined that Indians were s oulles s, inferior beings because they P.602 had not descended from the biblical Adam. A great ensued, and, in 1537, P ope P aul III ruled that “the are truly men.” However, economic interests prevailed, papal declaration was ignored, and harsh slavery continued for several hundred years. B efore the 17th century, there was no tradition of whitenes s among E uropeans or of blacknes s among Africans. Distinctions among groups of people in the in G reek and R oman histories , and in the writings of P olo who traveled from Italy to C hina were made on basis of food preference, cos tume, political s ys tems, rituals ; s kin color was not mentioned. W hite and black 239 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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became cultural categories in the 17th century when transatlantic slave trade was developed to stock colonies in the New World. E uropeans and Americans exploited local populations participated in the s lave trade for economic profit. R ationalizations for thes e practices came from philosophical, and then-current scientific theories. (many B ritish referred to all nonwhite pers ons as supposedly were curs ed by G od as des cendents of an Old T estament biblical figure who s aw his father T he S cottis h utilitarian philosopher, Dave Hume, wrote that only white pers ons were capable of creating nations and of producing ingenious manufacture, art, science. During the E nlightenment, the E nglis h philosopher J ohn Locke s upported the degeneracy namely, that the normal natural s tate of human beings typified by the white E uropean and that other races of men developed through biological and psychological degeneration. S cientis ts noted that white was the true color of nature and that the degenerative process persons of different colors might be reversed through expos ure to E uropean culture. Nonwhites were be ps ychologically flawed and unable to rule as demonstrated by the ease with which E uropean colonialis ts s ubjugated vas t areas of the world. E ven as 1963, a noted B ritis h historian took the position that, although black Africans have darkness , only have a history in Africa. In the United S tates, a 19th century profes sor of named S amuel Morton measured the cranial capacity various s kulls by filling them with peppercorns. He that the cranial capacity was unchanged for at leas t 240 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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years and was largest for whites , followed by Asians , Americans , and Africans. T his finding was confirmed in 1906 by R obert B ean, P rofess or of Anatomy at T he Hopkins Univers ity in B altimore; bas ed on brain size, reported that Negroes have well-developed lower faculties , s uch as smell and melody, whereas whites well-developed higher faculties, s uch as s elf-control reason. In 1856, a S outhern psychiatrist coined the diagnostic term drapetomania, which was applicable to slaves and cats who had an irres trainable propensity to away from their mas ters . Another diagnos is given to slaves was dys oe s thes ia oe thiopica; s ymptoms idleness , s loth, careless nes s when driven to work by compuls ive power of white mas ters , breaking tools, not paying attention to the rights of others . A 19th scientific theory that became ins titutionalized in the of southern states was based on the trans miss ion of heredity in blood from parents to offs pring. P arental supposedly blended in the offs pring; thus , children received one-half of their nature from each parent, onefourth from each grandparent, and s o on. T his belief ris e to such words as half-bre e ds , quadroons , and octoroons . B lack blood was considered to be more than white blood; a pers on with even one drop of black blood was class ified as negro. T he blood theory is scientifically baseles s. G enes undergo neither blending contamination. At the turn of the 20th century, American psychiatrists published articles in pres tigious journals suppos edly demonstrating that the lower rate of mental illness slaves, as compared to blacks in the free s tates, that s lavery protected the mental health of blacks 241 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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of the supervision they received. One study in 1914 concluded that the negro mind is irrespons ible, unthinking, easily aroused to happiness , and rarely experiences depres sion. A W orld Health Organization (W HO) monograph in 1953 perpetuated the myth that black pers ons rarely experience depres sion; the same author noted that Africans are like leukotomized E uropeans, thereby “proving” that Africans did not use the frontal lobes of their brains . In his writings on the collective C arl J ung noted that the brains of blacks probably have whole historical layer less than E uropeans; he also that “racial infection” exercised a tremendous pull on white persons who are expos ed to blacks . S ome educational psychologis ts, namely Lewis T erman, in and Arthur J ens en, in 1969, claimed that racial genetic factors accounted for low s cores by blacks on tes ts . F rantz F anon, a black ps ychiatrist from who studied in F rance and then actively participated in 1950s ' Algerian revolution against F rance, angrily concluded that the color black symbolizes evil, sin, wretchednes s, death, war, and famine in the collective unconscious of Western thought. A trend in many Wes tern societies is the replacement biologically based racis m by s ocial theories and policies that often are meant to attenuate racism but actually may wors en it. A psychodynamic s tudy of 25 American blacks in 1951 cons idered the legacy of to be family dis organization, low self-es teem, pass ivity, and a wretched internal life. Other s tudies negatively out the matriarchal s tructure of black families in the S tates and B ritain, as well as the ps ychological 242 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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emas culation of black males . S uman F ernando, a B ritish cultural ps ychiatris t, notes : T he arguments are bas ed on a naive view of human development where negative experiences are ass umed lead to personality defects . T he lack of cohesion of family life and the pas sivity of black people are clearly deductions made by whites. B lack experience is looked from the outside; the fact that oppress ion may uplift as well as depres s s elf-worth and may promote as well as destroy communal cohesion is not cons idered. After all, this argument is applied to the J ewish people, of pros ecution s hould have left them incapable of any leadership quite apart from being able to establish a political s tate. In studying American immigrants, F ranz B oas , the of modern anthropology, found that the head shapes of second-generation children were more like those of dominant, es tablished Anglo-S axon Americans. F or this proof of the plasticity of physical traits clearly contradicted biological theories that claimed that racial groups had fixed physical and, by extrapolation, fixed ps ychological and personality characteris tics. Despite and other evidence debunking the s cientific validity of race, racial prejudice exis ts throughout the world. In the Wes t, it is us ually directed against pers ons of color. P igmentation s uppos edly indicates deficiencies ranging from intellectual capacity to morality to the capability for experiencing normal emotions. R acism is s o culturally embedded in s ocial structures that even rational, wellmeaning persons are not only affected by it, but als o often amazed and taken aback when the racial undercurrents of their behaviors are pointed out to 243 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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P sychiatrists are probably les s racis t than mos t groups , but they are not immune from bias es . S tudies show that white ps ychiatris ts dealing with black are more apt to diagnos e s chizophrenia, to prescribe higher dos es of tranquilizing medications, to fail to recognize depres sion, to us e involuntary commitment more frequently, to extend hospital stays , and to ps ychotherapeutic treatment. T he S urgeon G eneral's supplemental report, Me ntal H ealth: C ulture , R ace and E thnicity, concluded that the rates of mental illnes s are similar for African Americans and whites who live in a community; rates are much higher in vulnerable populations in which African Americans are P.603 overrepres ented, s uch as the homeless , prisoners , and children placed in foster care. Mentally ill African Americans are less likely than whites to receive treatment. T hey tend to seek help in primary care and, because they often delay s eeking treatment until their symptoms are more severe, in emergency rooms and ps ychiatric hos pitals . E ven African Americans with adequate insurance coverage are les s inclined to seek ps ychiatric treatment. T he report notes that the legacy slavery, racism, and discrimination continues to African Americans' s ocial status , economic s tanding, health-related behavior; additionally, there is a lack of African-American mental health s pecialis ts. In practice, patients are customarily identified as black or white; with other s kin colors typically are identified by In E uropean-American s ocieties , the revelation that a patient is white is relatively meaningles s and, in fact, 244 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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us ually is proces sed as meaning that the patient is not black. On learning that a patient is black, ps ychiatris ts infer that the patient has been victimized to s ome by institutional and personal racism. However, the emergence of a s ubs tantial black middle class , as well high-profile leaders in the pas t s everal decades , along sociopolitical changes, has challenged the concept of a typical black cultural experience. White psychiatrists , in dealing with black patients, must confront their own countertransference and must be attuned to the actual perceived, and unperceived, impact of racial prejudice patients' lives, s ymptomatology, and prognosis.

E thnic Identity E very pers on ass umes multiple roles in the cours e of a lifetime. Infants, for example, mature through adulthood, and old age. P eople also develop personal, family, and group identities that change with circums tances , s uch as remarriage, relocation to a region, religious convers ion, or s witching vocations. E thnicity is a type of group identity based on cultural heritage, including place of origin, cuisine, cos tume, language, and rituals. Unlike the ps eudos cientific biological concept of race, ethnicity is a purely cultural identification that denotes connectednes s to other persons who claim the same identification. T he feelings of connectedness may fluctuate widely as and their s ocial context change. In times of extreme duress , for example, people may deny a certain or they may embrace it fervently, depending on is more psychologically and s ocially advantageous. G overnmental and other programs may reward or persons who select a certain ethnicity. E thnicity is a 245 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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phenomenon. It may be a caus e of great s tres s in immigrant families , es pecially when parents cling to the “old ways ” while their children come to identify more host cultural groups . B arriers to interethnic marriages decreasing, especially in W estern countries ; a pers on marry into an ethnic group and adopt its identity. T he children of parents who are Mexican and American decide to identify thems elves initially as Mexican, American, Mes tizo, C hicano, Latino, or Mexican these self-identifications may change over time. T he concepts of race and ethnicity may be Adolf Hitler combined G erman ethnicity with a Aryan race to promote a Nazi s ociety. He s elected two ethnic groups , J ews and gyps ies, for extermination. history of the world is filled with examples of who have exploited ethnic pass ions, even to the point genocide. S ome persons, becaus e of their s kin color phys iognomy, may be stuck with a racial designation makes it difficult, if not impos sible, to change their ethnicity. J oseph Westermeyer studied American Indian mental patients reared in non–American Indian foster, and group homes in Minnesota. As children they developed ethnic identities, s uch as rural, NorwegianAmerican, Lutheran, s mall-town G erman-American C atholic, or urban S cotch-American P res byterian. T hey referred to American Indian people as the y instead of P roblems arose during adoles cence when society to accept their non–American Indian ethnicity. rejections by the s ame ethnic groups with whom they shared values, attitudes, and behaviors gave ris e to and attempts to reject their ethnicity. T hey were red on 246 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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outside and white on the inside. T he psychiatric they developed—the apple s yndrome —included alcoholism, drug abuse, s uicide attempts, chronic panic attacks, depres sion, and legal and behavioral problems . All thes e s ymptoms were far in excess of might be expected in persons reared in fos ter, group homes. Mos t of the syndromic patients tried to as sume an American Indian ethnic identity by wearing traditional clothes, adopting American Indian drinking behaviors , and marrying American Indian spous es. attempts usually resulted in failure, and their symptoms became chronic. S ensitivity to ethnicity facilitates accuracy in evaluation and s ucces s in treatment. However, it is pos sible to be overly s ens itive and to mis interpret psychopathology as some sort of ethnic quirk. In uncertain s ituations, the as sistance of pers ons familiar with the patient's sociocultural s tatus s hould be obtained.

C ulture and P ers onality T he culture and personality s chool of anthropology, influenced by ps ychoanalys is and influential in the mid-20th century, attempted to link individual with various identifications , es pecially ethnicity. R uth B enedict's popular book, P atte rns of C ulture , written in 1934, held that cultures were really the summation of individual psychologies over a long time span. S he thought that persons with normal personality types are those who conform to a s ociety's dominant cultural configuration, whereas de viants do not, although s ome deviants might be cons idered normal in a different, congenial cultural s etting. T his formulation is applicable 247 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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homos exuals who can lead normal lives in many large American cities but who might be tormented and cons idered deviant in rural towns . In the mid-20th century, anthropologists and s ome ps ychiatris ts developed the concept of national T he personality of R us sian peas ants was supposedly characterized by depres sive and manic traits that from the practice of fairly s evere s waddling of infants farm-worker mothers; the arms were tied close to the with tight cris scross lashing, and the infant was a blanket, so that only its face was visible. Depress ion linked to the impotence experienced in s truggling the swaddling bandages ; mania was linked to orgiastic R us sian feasts and drinking bouts that exemplified the feeding and love that accompanied the removal of bonds . T he rage caus ed by s waddling led to later guilt feelings, such as thos e express ed in Dos toevsky's T he celebrated expres sivity of R uss ian eyes was the of restricted infant mobility that perforce emphasized vision as a means of contact with the world. S uch in the nurs ery” studies were criticized for their reductionism. It als o became apparent that findings were biased, as is evident when the American military commis sioned national character studies of enemies in World W ar II. J apanese brutality was said to res ult from severe toilet training practices , G erman culture was described as paranoid and neurotic, and the hars hsounding G erman language was s een as the of a crude mentality. A 1997 s tudy grouped the of the American national character into six clus ters : reliance, autonomy, and independence; communal volunteerism, and neighborly cooperation; confidence 248 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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the trus tworthiness of others ; openness to new experiences ; antiauthoritarianism; and the equality of justice for everyone. T he American national character doubtless ly would be delineated differently from a E as tern or As ian pers pective. Although national stereotypes may contain a kernel of truth, there is more pers onality variability within a group than there is among different groups. T raits perceived to be peculiarly P.604 G erman, F rench, or Italian turn out, in reality, to be generally human, Occidental, or continental E uropean. current cons ens us is that a clinically meaningful about an individual's personality cannot be made on basis of nationality alone.

C haris matic G roups T he proces s of conversion—the des truction of the old and the cons truction of a new self with new cognitive frameworks and behaviors—can take many pathways. naturalis tic settings, the process us ually involves incubation, s teps forward, and backs liding. Artis ts , and others have written about their convers ion after enduring “a dark night of the soul.” In 1934, B ill W ils on, an alcoholic stockbroker and a cofounder of Alcoholics Anonymous (AA), was for depress ion. He was not a s piritual pers on but cried in des pair for G od to show himself. S uddenly, the room up with a great white light, and he was caught up in an indes cribable ecstasy. He pictured hims elf on a in a s piritual windstorm and realized that he had 249 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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free man. As the ecstasy subsided, he experienced a world or cons cious nes s. All about him and through him there was a wonderful feeling of the pres ence of G od. great peace came over him, and he thought that, no matter how wrong things s eem to be, they are all right. was reass ured by his ps ychiatris t, W illiam S ilkworth, his experience was not the res ult of a brain damaged alcohol. Wilson's life changed for good when he dis covered J ames' book, T he V arie tie s of R eligious E xpe rience . In learned about the ecs tas y that accompanies religious conversion and the hopeless ness that often precedes change. T he book pres ented many case histories , including that of a homeles s, friendless , dying drunkard who became an active and us eful rescuer of alcoholics after his convers ion. J ames described the s pecial of the state of ass urance that accompany convers ion; a sens e that all is ultimately well, a s ens e of perceiving not known before, and an internal and external s ens e clear and beautiful newnes s. W ils on talked about the hopeless nes s of his condition and his subsequent conversion with a friend. F rom thes e talks, he imagined chain reaction among alcoholics in which the mess age about the poss ibility of change would be s pread. Of special concern to society, in general, and to ps ychiatris ts, in particular, are those convers ions of that occur when young adults, us ually between the 15 and 30, are indoctrinated into charismatic groups us e duplicitous methods, have a totalis tic philos ophy, are as sociated with ps ychological and social morbidity. What distinguishes charis matic groups from other clubs , and ass ociations is their strict control over 250 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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behavior and the belief that their leaders or mis sion poss ess es a trans cendent power. C lass ification of groups is problematic, becaus e they may overlap with benign, fringe groups, and becaus e they may be as progres sive in certain cultural settings. Mark includes among these groups cults, zealous religious some highly cohes ive s elf-improvement groups, some political action movements, and terrorist groups. C harismatic groups may be s mall (the S ymbionese Liberation Army of the 1960s had less than a dozen members) or large (R everend S un Myung Moon's neoC hris tian Unification church has thous ands of R ecruiters for these groups cas t a wide net in the hope gaining a few new members. T here is no way of personality type who responds to the bait, although a study of recruits to the Divine Light Mis sion (Hare cult found that 30 percent had previously s ought ps ychiatric help. Many recruits s eem to be quite normal albeit naively idealistic and trusting. S ome may be disillusioned with life, frustrated by romantic failures, and unhappy with s chool. Other vulnerabilities include loneliness and a sense of disorientation that be apparent in newly arrived college s tudents , and runaways. T hey often feel flattered when by a recruiter, often of the oppos ite sex, who offers friends hip, convers ation about s ocial injustices and meaning, and an invitation to attend a meeting or s tudy group. P ersons usually do not know that they are being recruited or the name and purposes of the group. T hey greeted warmly by the group and only hear vague generalities. T hey are then invited to intens e retreats that may las t s everal days, during which they 251 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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overwhelmed with attention, exposure to nons pecific laudable generalities on the need for more s elfand s elf-improvement in the world, and joyful of the love and acceptance that group members have one another. T he emotionality of those few days may powerful that the recruits may experience a convers ion, although they are still unclear about to what they are converting; may accept new beliefs ; express high commitment; and develop a sense of well-being that follows a brief dis sociative epis ode. F as cination turns to reliance as recruits continue their indoctrination and s lowly learn the nature and purpos es the group to which they now belong. Any potential res is tance is prevented by a number of techniques, including decreased and eventual total lack of contact with family and friends, participation in many group activities so as to leave no free time and to create the confes sion of doubts to the group in “struggle sess ions,” and the induction of altered cons cious nes s through meditation, chanting prayer s es sions , or drugs . Louis J . W es t described a cult indoctrination s yndrome includes the following features: 



Dras tic alteration of the victim's value hierarchy, including abandonment of previous academic or career goals. T he changes are often s udden and catas trophic, rather than the gradual changes that might res ult from maturation or education. R edirection of cognitive flexibility and adaptability. V ictims answer ques tions mechanically, cult-specific res ponses for what their own reasoned answers might have been. 252

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







Narrowing, blunting, or artificiality of affect. T he may appear emotionally flat and lifeles s or almost frantically cheerful and ebullient. R egress ion. V ictims become childishly dependent the cult leaders, who are expected to make for them. S ometimes there are phys ical changes , s uch as or weight loss , with deterioration in the victim's phys ical appearance, s trange or mask-like faces, stares , or darting, evasive eyes. C lear-cut ps ychopathological changes may appear, including depres sion, dis sociative phenomena, states , obsess ional ruminations , delus ional hallucinations , and various other psychiatric s igns symptoms.

T he disconnection between the “everything's fine” selfperceptions of group members and the perceptions of them by their family members and friends is s triking tes tament to the power of the group. Members their autonomy and their worldly poss ess ions in for a s ens e of being protected. T hey abandon their independence and conform to the group's behavioral norms in return for a sense of well-being and G alanter has described the relief effect that motivates persons to remain with the group: T he relief of neurotic distress depends on the affiliated commitment of the group members . Attempts to leave the group res ult in increased distress . T his can even be seen in members of AA who P.605 253 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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become irritable and uncomfortable when they mis s meetings . T he group fosters dependency and group identity, becaus e it then becomes the agent of relief. effect can be seen in what is called the S tockholm s yndrome : Hos tages whos e lives are in deadly peril for period of time become s o dependent on their captors they then may identify with them, come to support their caus e, and even attempt to thwart res cue attempts . T he leaders of charis matic groups often lie to members maintain group morale and to negate unfavorable comments made by outs iders. T hey s olidify the group's boundaries when they feel threatened; techniques staring vacantly as a respons e to outsiders ' ques tions aggres sively counterattacking perceived enemies . the xenophobia of a leader turns to full-blown paranoia, the group members may s hare the leader's delusions ; res ult may be catas trophic. In the 1970s, J im J ones , the charismatic, Africanleader of a neo-C hris tian apocalyptic s ect, moved with followers from S an F rancisco to the remote jungles of G uyana, S outh America. In this captive society, he was called Dad by the members. He demanded total and cons tant vigilance, preaching about persecution by enemies and the extermination of all blacks. He members who committed crimes , such as s moking, even forced a celibate woman to have intercours e with man whom s he dis liked in front of the entire As J ones ' persecutory and grandiose delus ions he repeatedly drilled his followers in preparation for the final battle by arming them with rifles and giving them a red, supposedly fatal liquid to drink. In 1978, he 254 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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announced that anarchy was rampant in the United that drought had forced the evacuation of Los Angeles, and that the K u K lux K lan was marching through the former city, S an F rancisco. A month later, a U.S . C ongres sman violated the borders of J onestown by coming to inspect it. W hen four group members to leave with the C ongres sman, J ones attacked him then drilled his group for the true final battle; this time, however, the liquid that they drank was real poison. He succeeded in encouraging more than 900 persons, including 216 children, to die by telling them that they were committing a revolutionary act and not s uicide. Noxious charismatic groups appeal to various human interes ts , such as religion (Universal C hurch of C hrist), outer s pace (the Heaven's G ate group practiced all of its small membership committed suicide in 1997 the expectation of being trans ported to a spaces hip the Hale-B opp comet), and s cience (the C hurch of S cientology is violently antipsychiatry, antimedication, litigious ). P ers ons who eventually leave charis matic groups do because of disgust at the group's behavior and strong ties to family and friends. S ome ex–cult are hired as exit counselors by desperate families to persuade their children to leave the group; elaborate may be used to achieve this goal. T he proces s is difficult and protracted. P s ychiatris ts called on to treat res cued cult members s hould collaborate with reentry couns elors who have knowledge of, and often firsthand experience with, the s pecific groups . V ictims typically display symptoms of what the West terms a disorder characterized by doubts about their “true” 255 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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identity, along with depres sion and feelings of and ambivalence about the entire process of indoctrination, group members hip, and res cue. Among therapeutic is sues that need to be address ed are guilt over abandoning their family at the onset and their group at the end, the reestablishment of independent behaviors , and the forging of a new s ens e of self and direction in life. T he prognos is depends on a victim's premorbid pers onality, the s everity of symptoms, family s upport, the use of reentry and, if neces sary, psychiatric care.

C UL TUR E C HA NG E In the broadest sense, persons experience culture when moving into a different culture or by staying put while their own culture changes around them. Acute wide-sweeping change may overwhelm the adaptive mechanisms of individuals and of their social s upport systems . Dis tortions in parenting and in life may occur, and cultural landmarks may become and difficult to interpret; the result may be individual sociocultural disintegration. T he four categories for situations that necess itate coping with marked culture change are (1) s ojourning, (2) s ettling, (3) segregation, (4) changes in society. In a more narrow s ens e, the changes that result from events such as retirement, into a profess ion, marriage, and adoption may be cons idered s ubcultural mobility; these changes require coping s kills that, when deficient, may result in disorders , as well as more enduring psychopathology.

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S ojourners are persons who have a brief, usually expos ure to a new culture; examples include touris ts; business repres entatives; s cientific field workers ; cons ultants and aid workers, such as P eace C orps volunteers ; military personnel; and limited contract workers. S wiss mercenaries in the 16th century were described as having the prototypical s ojourner's syndrome; phys icians referred to it as nos talgia and recorded its s ymptoms as fever, diarrhea, delus ions, convuls ions. Later, nos talgia was des cribed as a ps ychos omatic condition. Napoleon's troops reportedly were devastated by nos talgia, and it was cons idered to a mild form of insanity among troops in the American War. T he name was changed to home s ickne s s and diagnostic entity in military ps ychiatry during W orld W ar it was the mos t common maladjus tment reaction experienced by American soldiers. Adjustment can be prevented in s ojourners by a proces s of about the new culture before arrival, by providing to telephone and e-mail communication with supportive persons back home, and by shortening the lengths of in the new culture. E xposure to intense trauma or to unanticipated environmental toxins in the new culture, es pecially during wartime, may res ult in delayed and ps ychiatric symptoms.

S ettling S ettling involves a more permanent, forced, or move to a new culture, for example, a change made by refugees and international or internal immigrants . can be a relatively eas y process or a dramatically one. In general, the stress of settling may be with adjus tment dis orders , panic, anxiety, depres sion, 257 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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alcohol and substance abuse, s uicidal behaviors, the triggering of mania, and transient psychotic epis odes . 1932, Odegaard concluded that a higher rate of s tate hospital admis sion for s chizophrenia in Norwegian immigrants to Minnesota than in the native-born Minnesotans or in the population of Norway was bes t explained by s elective migration. S ome s ubs equent studies have s upported this explanation, but others not. E arly African and As ian immigrants to the new of Israel were far more likely to be admitted to a mental hospital than were E uropean immigrants whos e hospitalization rate paralleled that of the local S elective migration may play a minor role, but current evidence demonstrates that enduring psychotic may be exacerbated, but not caused, by s ettling. the factors that affect ps ychopathology in settlers are premorbid mental and physical health status , characteristics of the host society and locale of and conditions necess itating the move. In an ideal immigration scenario, a mentally P.606 and phys ically healthy, intact, multigenerational family voluntarily resettles in a new area in which all the members are welcomed warmly, in which decent and jobs are readily available, in which the language is same as the country of origin, in which an es tablis hed of settlers from the s ame region already lives , and in public and private programs are in place to provide legal, and financial aid. R efugees are typically involuntarily dis placed becaus e warfare and natural disas ters . T hos e who have 258 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and have been the victims of horrific atrocities are at ris k for posttraumatic s tres s disorder (P T S D), panic, depres sion. E ven after real danger is over, refugees are placed in camps often project their fear of their persecutors onto neutral personnel and continue to experience anxiety. T he struggle for self-preservation access to food and shelter may lead to a deterioration moral behaviors; recognition of this deterioration and of the inability to adhere to the values of their lost may result in demoralization and depress ion. R efugees who are res ettled to a foreign land may initially their country of as ylum and may develop s avior about pers ons of authority. However, symptoms may emerge among refugees after the realizations that they may never return to their country origin and that they had been forced to decide among unattractive alternatives in their new place of res ettlement. Most international migration stems from a des ire for upward economic mobility. P remigration mental illnes s tends to wors en with the s tres s of moving to a new culture; this situation may be encountered when healthy immigrants bring mentally ill family members them. C hildren usually adapt better to immigration than do elderly persons who may be fixed in their ways and unable to learn a new language or to find in new customs . Middle-clas s persons with ordinary occupations us ually handle the migration experience better than upper– and lower–social class pers ons , because employment may be easier to find. Women are confined to their homes may become socially and depres sed. E lderly family members may los e the 259 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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prestige they once had in their country of origin as their children adopt the mentality of the hos t culture, thus creating intergenerational stress es . Acces s to s upport s ys tems depends on personal family preferences , traditional patterns, and hos t country practices and programs, such as welfare and legal aid. Immigrants often do better when they live in areas populated by others from the same country of origin. a s ituation can provide comfort and ease of trans ition first but, in the long run, may delay acculturation and even foster res entment in some segments of the host society. Marital conflicts among immigrants often on differences between gender-appropriate behaviors their old and new countries . Intergenerational conflicts may aris e over communications, becaus e children the language of their new culture more rapidly than parents and tend to los e interest in their original in addition, children are more rapidly acculturated than their parents because of the knowledge gained through socialization experiences in school. It is not uncommon immigrants, especially thos e from third world countries, develop acute ps ychotic episodes with persecutory delus ions (the s o-called aliens' paranoid reaction syndrome). T hese episodes us ually have clear-cut precipitants, may recur several times , and do not neces sarily progres s to chronic mental illnes s. In a 1998 major s tudy of 3,012 adult Mexican living in F resno C ounty, C alifornia, those born in had a prevalence rate for any mental disorder of 24.9 percent, compared to a rate of 48.1 percent among born in the United S tates. S ubs tance abus e and dependency rates were s even times higher in native260 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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women than in immigrant women; the ratio for men 2:1. Another C alifornia study of 1,500 us ers of primary medical services found that immigrants , one-half of were born in Mexico and C entral America, had a significantly lower prevalence of depres sion and P T S D, despite their lower s ocioeconomic s tatus, than Latinos born in the United S tates. Other s tudies indicate that immigrant Mexican women, in comparis on to Mexican women born and living in the United S tates , have lower infant mortality rates , much better nutritional intake, are significantly less likely to test positive for drugs at of delivery. T hes e s omewhat shocking findings may, in part, be due to the migration of the fittes t, healthiest, most resilient Mexicans ; a more powerful explanation is that the immigrants are buffered by their clos eness to a traditional culture characterized by clos e-knit, extended families that offer s ocial support, low rates of divorce, healthier eating habits. T he generalization and sustainability of thes e negative findings on the effects acculturation to other cultural s ituations remain to be seen. A typical pattern is that each succeeding of immigrants over time more clos ely approximates the behavioral patterns and phys ical characteris tics of the majority of persons in the host country.

S egregation P ers ons may be removed from the community and in more-or-less total care ins titutions. E rving G offman five types of s egregated institutions : (1) thos e that care incapable harmless persons (orphanages and old-age homes ), (2) thos e that care for ill pers ons who pos e an unintended threat to society (mental hos pitals and lepros aria), (3) thos e that protect the community from 261 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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persons who pos e intentional threats (pris ons and concentration camps ), (4) those established to purs ue work-like tas ks (boarding s chools and military and (5) thos e designed as retreats from the world (monas teries and convents ). Ins titutional inmates all their activities in the s ame place and are regulated the same authority. T his s ituation, incompatible with family life and the bas ic work-payment structure of is reinforced by a s trongly enforced split between and s taff with res trictions agains t social mobility the two. Until the 1950s , large s tate mental hospitals were cons idered to be a static setting within which treated patients . T hes e neatly lands caped, tightly and tranquil hospitals were thought to ins till a beneficial sens e of neatnes s, order, and tranquility to the T he impact of these hos pitals' s ociocultural on patient care became evident in 1954, when Alfred S tanton and Morris S chwartz published their study on C hes tnut Lodge, demonstrating that patients usually improved during periods of effective collaboration personnel and deteriorated during periods when s taff disagreements were not dis cuss ed openly. T his link between a hospital's adminis trative process and patient–staff therapeutic process was also by William C andill, an anthropologis t influenced by Maxwell J ones' work in establishing therapeutic communities on mental hospital wards , who admitted hims elf as a patient to the Y ale P sychiatric Institute to make around-the-clock observations about life on a T hese and other studies, combined with the growth of community mental health movement in the 1960s and 262 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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development of effective medications , have led to the demis e of large s tate hos pitals and to the placement of patients in the leas t res trictive environment, that is , the community. T he deinstitutionalization process has fraught with difficulties, but there now exis ts a number res idential facilities, supervised apartments, day and other placements for patients with s evere and persis tent mental illness es. Unfortunately, because of shortage and inadequacy of facilities , a major P.607 of thos e patients who have been unable to live succes sfully in the community now res ide in jails and prisons.

C hanges in S oc iety Human beings have always had to deal with social induced by natural disas ters , warfare, colonization, revolutions, and new technology. However, in the past centuries , the rapidity and extent of change have been more vas t than the total previous accumulative of human existence. Many benefits, such as improved public health, better communications , and ease of transportation, have resulted, but some of the costs include degradation of the environment, homeless nes s, and the increased lethality of weapons. C hange the number of s tres sful events in people's lives; thes e events range from annoying traffic jams to disastrous loss es of jobs . P ers ons whos e mental health is already marginal may decompensate when confronted by rapid change. E ugene B rody examined rural to urban res ulting from indus trialization in B razil. He identified 263 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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many pers ons , “the lost ones ,” who needed psychiatric care. T hey had feelings of rootless nes s from the loss of familiar cultural guidepos ts, from sadness and due to alienation from work and s eparation from and from s uspicion and dis trus t of the unknown. was a major factor in determining the mental health of “the lost ones ,” because it decisively limited their to understand and to manipulate s ymbols, to receive to integrate information, and to form relations hips with the more dominant members of s ociety. C ultural adaptation always lags behind rapid s ocial change; the more resilient the culture, the briefer the S ocieties whos e culture is unprepared for rapid change may dis integrate. S ome overwhelmed Native American tribes , for example, have died off. T he native Alaskan population in newly discovered oil-rich areas rapid s ocial upheaval. A report on the Inupiat in B arrow found that (1) 72 percent of an adult sample s cored in definite or sugges tive alcoholic range on the Michigan Alcoholis m S creening T est; (2) 42 percent had been detained or arres ted for alcoholis m at least once; (3) that had been almost free of s uicide and homicide marked increase; and (4) when the only liquor store clos ed, wides pread bootlegging ensued as an the social relations hips among family and friends. problematic behaviors have diminis hed somewhat over generation as Inupiat culture has adjusted to the on its traditional way of life.

R E L IG ION A ND S P IR ITUA L ITY T he practice of medicine, including psychiatry, is experiencing major changes as a res ult of rapid 264 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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biotechnological advances. Diagnostic machines are replacing hands-on examinations , robots are already performing some s urgical procedures , computerized ps ychotherapy programs are being perfected, are replacing dialogue, and doctor–patient are giving way to provider–client interactions that are overs een by economically driven and faceles s organizations . One reaction to the impersonality by these changes has been the newfound alternative medicine, an approach that emphas izes traditional, folks y remedies and encourages pers ons to take a more active role in their health care. Another reaction is increas ing interest in the importance of personal religion and spirituality in medicine. In 1995, instruction in religious and s piritual is sues was made mandatory for accredited psychiatric res idency in the United S tates. T his s ection focus es on religion and spirituality. It information on religious and spiritual problems and on objective unders tanding of the human experience of B as ic material about sacred texts, es pecially the B ible the Qur'an, is pres ented because they are at the core two mos t widespread religions, C hris tianity and Is lam. reconfiguration of sin, once a central force in W estern into mental illness and criminality is dis cuss ed, as is influence of religion on problematic behaviors related to sexuality, gender, the drinking of alcohol, and healing. relations hip between religion and mental health is examined, as are differences between religion and spirituality and the psychiatrist's role in dealing with is sues.

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R eligion T hroughout his tory, human beings have held religious beliefs and have engaged in religious practices. the divers ity of thes e beliefs and practices is s o vast is impos sible to define the word re ligion s uccinctly. It generally refers to belief in a s upernatural, creative and in the practice of rituals meant to appease, to to obey, or to relate better with this G od. F or some persons, religion is an ongoing, s elf-actualizing quest holiness , whereas , for others, it is an achievable destination. R eligions s erve the mythopoetic yearnings humankind and provide a stable orientation and moral compass . R eligious systems have greatly influenced human behavior for millennia and often underlie a society's political, legal, medical, and educational T he three great monotheistic religions —J udaism, C hris tianity, and Islam—believe in a single omnipotent G od and in a book, the B ible or the Qur'an, that reveals G od's plan for believers . B uddhis m, a religion prevalent C hina, J apan, K orea, S ri Lanka, and S outh As ia, has traditions ; T herovada B uddhis m emphasizes a s piritual quest for wisdom, whereas Mahayana B uddhis m compass ion, the divine power of the S avior B uddha, spiritual rituals . Hinduis m, prevalent on the Indian subcontinent, emphasizes the many manifestations of G od, reincarnation, a divine power that sus tains life, a dazzling array of religious s ymbols, yoga, and T he revis ed fourth edition of the Diagnos tic and Manual of Me ntal Dis orde rs (DS M-IV -T R ) now includes re ligious or s piritual proble m as an Axis I condition that be a focus of clinical attention. E xamples include over the loss or ques tioning of faith, problems 266 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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with converting to a different faith and ques tioning of spiritual values , and the s ens e of damnation that may experienced by pers ons with P T S D. Modern times seen jolting crises of faith; many C hristians, especially C atholics , are shocked by the revelation of pederasty among clergy, whereas many Mus lims feel that have replaced traditional Is lamic values with and militaris m. DS M-IV -T R has als o reduced the us e of religious examples to illustrate psychopathology. R eligious problems have long been part of the human experience. S ome problems are due to the fact that the faith required for a belief in the s upernatural can be In the face of horrific individual tragedies , such as the death of a child or the accidental disfigurement of a guiltles s person, as well as large-scale disas ters , s uch world wars , concentration camps , ethnic cleansing, and famine, s ome people rely on their faith for s trength and turn to G od and to religion for consolation, whereas may abandon their faith and adopt the belief that beings are res ponsible for their own fate. None of the major religions is monolithic, but rather are compris ed of numerous subdivis ions that may some core beliefs but disagree dramatically in their interpretation of s acred texts and in their rituals and practices . C hristianity alone has hundreds of examples include R oman and E astern R ite C atholic, Orthodox, B aptist, P entecostal, P res byterian, C optic, Maronite, C hristian S cience, J ehovah's and C hurch of P.608 J esus C hrist of Latter-Day S aints. Among C hristians 267 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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claim to be “born again in the Holy S pirit” and to be in C hrist,” E vangelicals recognize the authority of the and a duty to s hare their faith with others in addition to having a pers onal experience with G od; are like E vangelicals but ins ist on the absolute every word in the B ible; P entecos tals are like but place a major emphasis on an immediate with the Holy S pirit and on an exuberant s tyle of C harismatics are pers ons in mains tream C atholic and protes tant churches who practice a P entecos tal form of wors hip. A growing number of C hristians belong to nondenominational churches in which the ministers congregation as a group agree on their beliefs and practices ; extension of this trend is the formation of groups in which members do not attend any church but rather meet in individual homes to study the B ible and attempt to relate it to their lives. T he subdivis ions of the major religions often have other subdivisions bas ed on the degree of orthodoxy and the adoption of local customs . Orthodox J ews , for conform their behavior to a s trict interpretation of laws , whereas “cultural” J ews may practice their predominantly by taking part in selected rituals . In the injunction that women mus t dress modes tly in may have differing interpretations; Orthodox women fully cover their bodies except for eye s lits , whereas may s imply wear a head s carf, and s till other women disregard any special dres s code. R eligious problems believers may aris e out of dis cord between major groups , s uch as Hindus and Mus lims in India, and subdivisions, s uch as conservative and liberal B aptis ts the United S tates . E ven among groups that s hare the 268 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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beliefs and practices, there is a uniqueness to every church, temple, mos que, and synagogue, based on the characteristics of the clergy and the congregation. R eligious problems may aris e when there is dis cord members of a congregation or when the institutional leaders behave inappropriately. Neither religious institutions nor religious leaders, like their secular counterparts, are immune from petty politics and from sexual, financial, and other scandals . R eligion may stir feelings of altruism, forgiveness , tolerance, charity, creativity, and, mos t of all, hope. However, it may be problematic when used to rationalize hatred, irrespons ible behavior, and bodily mortification: include anti-S emitism becaus e J ews were implicated in crucifixion of C hrist, prejudice agains t blacks becaus e are suppos edly cursed in the B ible, indulging in compuls ive behaviors because of s upposed demonic oppres sion, and s evere fasting. T he intens ity of feelings arous ed by religion is so prodigious as to produce a wide variety of reactions . A well-known quote from E dward G ibbon's T he Decline F all of the R oman E mpire s tates that “the various wors hip which prevailed in the R oman W orld were all cons idered by the people as equally true; by the philosopher as equally false; and by the magis trate as equally useful.” T he 16th century conflict in which was forced by church authorities to recant his that the earth moved around the sun set the s tage for modern conflict between naturalis tic and explanations of events and behavior that began with Age of R eason in 18th century E urope. Most anthropologists regard religion, or s acred culture, 269 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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a projection of human wishes that serve to cope with anxieties . W estin La B arre, for example, des cribes as a group dream that originates in the visionary state of the s haman-originator, for example, in dreams , trances, epis odes of spirit pos sess ion, epileptic and periods of s ens ory deprivation. In another theory, sound is a link to religion; infras onic s ound waves in low hertz range can produce a high-intens ity s ound press ure in the abs ence of audible s ound. S ound perceived and proces sed in the brain, but, becaus e cannot be heard or their source identified (commonly distant thunder), they have a mystifying, uncanny, provoking effect on a person who then labels the experience as religious . Drumbeats and chants religious experience not by what can be heard but by what cannot be heard, namely subauditory, sound waves. T his theory involves process ing of the in the temporal lobe, a portion of the brain in which lesions are ass ociated with symptoms s uch as hallucinations , delus ions , illus ions, déjà vu hyperreligios ity, feelings of ecs tas y, intense and cosmological concerns, pos tseizure psychosis with religious content, and mystical states . T here is a long W estern medical tradition of conflict cooperation and religion. Once Hippocrates declared epilepsy to be a biological and not a divine illnes s, phys icians have continued to provide naturalis tic explanations for illnes ses once thought to be caus ed or influenced by the s upernatural. T he s truggle to rescue mental illness from demonology, although s till ongoing many third world countries and some W es tern groups, generally has been success ful. P erhaps this s truggle 270 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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played a role in antipathy toward religion sometimes expres sed by ps ychiatris ts. S tudies have s hown cons istently that psychiatris ts are not as religious as general public; in s urveys done in 1975 to 1976, belief G od was endors ed by 90 percent of Americans but 43 percent of psychiatrists and 5 percent of only 27 percent of ps ychiatris ts s urveyed in London in 1993 reported a belief in G od. A study of articles in ps ychiatric journals from 1977 to 1982 found that only out of 2,348 articles contained a religious variable, a s imple listing of a patient's denomination. F reud regarded religion as an infantalizing, neurosis producing, tyrannical force, and most psychoanalysts followed his critique with the prominent exception of J ung. E ven when they s aid something pos itive about religion, they often managed to find a rankling counterbalance. E rnes t J ones , for example, wrote the “enormous civilizing influence of C hristianity” and “sublimated homosexuality” in the same s entence. Henry Mauds ley, the mos t influential E nglish of his time and certainly not a F reudian, wrote in 1918 “the corporeal or the material is the fundamental fact— mental or the spiritual only its effect.” In 1975, the outspoken ps ychologist, Albert E llis , declared that its elf is a s elf-depreciating, dehumanizing mental However, at approximately that time, ps ychiatris ts turnaround in their thinking about religion. More and more, psychiatrists are treating patients with s evere mental illness es by using new and better medications spending les s time talking with patients. In s uch an environment, psychiatrists have come to realize the importance of programs and personnel such as cas e 271 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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managers, sheltered works hops , s upervised apartment living, and s elf-help groups in helping patients survive occasionally, pros per in the community. Ministers, and rabbis are now regarded as allies in dealing with mentally ill, and church congregations are s een as a potentially healing res ource. E zra G riffith, for example, demonstrated the psychological benefits of rituals in African-American churches. Mos t clergy now accept us efulnes s of psychiatric treatment, although a minority fundamentalists s till regard psychiatrists as agents of devil and mental illness as a moral flaw.

God and the S ac red T hroughout his tory, people have s ought an about the purpos e and meaning of life, the world, and cosmos . T his ques t invariably has led to a belief in sort of divine power or process that is called G od, the or P.609 the S acred. In 1917, the theologian, R udolph Otto, published an influential s tudy in which he cons idered Holy to be s o s pecial a category that neither it nor the human experience of it can be denied. In the pres ence the Holy, a pers on is filled with emotions that Otto in Latin mys te rium tre me ndum e t fas cinos um, that is, sublime, numinous , as tounding feelings of wonder and dread. He regarded these feelings as primary, unique, underived from anything els e, and the basic factor and impulse underlying the entire process of human P aul T illich, one of the mos t influential 20th century theologians, as serted that the sense of the numinous 272 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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presence of the Holy is really an awarenes s of the reality of G od who is being itself and not a being. He claimed that it is jus t as atheis tic to affirm the exis tence G od as to deny it. Apart from being and exis tence, nothing and nonexis tence; psychiatrists can treat anxiety, but exis tential anxiety can be dealt with only by encountering G od, the ground of being. F or T illich, true wis dom demands a religious experience that is a transformation and an illuminating revelation not of a personal god but rather of a G od on whom everything dependent. A leading C atholic theologian, K arl R ahner, as serts G od and s elf come together in the mys ticism of life, the discovery of G od in all things, and the s ober intoxication of the Holy S pirit. In addition to everyday mys ticis m, persons may experience mys tical states which cons cious nes s is briefly altered and all things experienced as interrelated. In religious conversions or illuminations, the mystical state may be perceived as extraordinarily meaningful and coherent; the pers onal expands to a close contact with G od. Inner peace and may give ris e to a vision or s pecial mess age. B ehavioral scientis ts have offered mundane of religion and mys tical states. In 1923, F reud wrote individuals form the idea of G od by merging the image an exalted childhood father with the inherited memory traces of the primal father; thus, G od is a type of father subs titute. R omain R olland, the F rench humanist, then chided F reud for not appreciating the eternal, richly energetic, beneficent, real core of religion that an oceanic-like experience. In C ivilization and Its Dis contents , written in 1930, F reud cons idered the 273 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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experience as the es sence of mystical states and it as an adult regress ion to the earliest undifferentiated state of infantile life in which there is a communal unity between infant and mother. T his unity recedes as the emerges, but many persons retain a connection to this primal unity, which may be experienced more as awe, wonderment, and creative insight. T he of the earliest stages of being, when infants record first experience of mother as a “proces s ” rather than an “object,” is found in the ps ychoanalytic work of C hris topher B ollas. He theorizes that thes e primal experiences are not process ed through language or mental representation but rather as bodily s ens ations emotions . An infant first knows mother existentially as recurrent experience of being. T he infant eventually transforms into a self, and mother is experienced as a proces s of this trans formation. Adults carry the memory this process as evidenced by their s earch for a person, place, event, or ideology that promises to transform the self. Humans revere objects that may transform us and may consider them to be sacred. Humans are religious beings because they carry with them the potential to be transformed and recreated. F rom this perspective, the experience of G od is ultimately bas ed on the transformative potential of creating the self, but this act creation depends on a relations hip with another human being. Although B ollas ' configuration is wholly human, poss ible to imagine a broader dependency and relations hip on what T illich called the ground of be ing namely G od. P sychiatrists W illiam Meiss ner and Ana-Maria R izzuto each propos ed a nontheological understanding of the 274 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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human experience of G od through the life cycle. A initial image of G od is based primarily on the image of parents . T he child's G od may be loving and protective, well as fearsome, cruel, and not always available to the child's wis hes . A positive mother–child experience this s tage res ults in a bas ic sense of trust that, in later years , may lead to a trus ting faith in G od, whereas a negative, insecure experience may dis tort the of G od. As the child begins the process of s eparation of becoming an individual with some independence, it hears about s omething called G od but lacks the to understand what a s pirit or trans cendent force is. child hears that G od has made the world and, thus , G od to the most powerful person that is known, namely both parents but es pecially father, who tends to be the more forceful or aggres sive parent. Over the next few years , as the child comes to recognize that its parents neither know everything nor are all powerful, a view of a perfect, heavenly father may emerge, as well distorted view of the family. G od and parents may be idealized as totally protecting, or there may be a split a good G od and mean parents or into good parents mean G od. B etween 6 and 11 years of age, the child to appreciate symbols. T he concept of G od s hifts from of a flesh and blood pers on to a s till imperfectly unders tood s pirit whos e power mus t be revered and feared, becaus e G od exacts punis hment for every In this s tage, an immature obsess ional religios ity may emerge in conjunction with ritualis tic behaviors . During adolescence, G od becomes more personalized “my S avior” or “my F ather” and is more connected to emotions and to s ubjective attitudes , such as love, 275 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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obedience, trust, and fear. G od is experienced as the leader and advisor who patiently and kindly lis tens to one's innermos t problems and desires. When not tempered by s ome maturity of judgment, this of G od may lead to fanatical tendencies . As become moralis ts, the burden of s infulness emerges, they may engage in the extremes of loose or behavior. R ebellion against parental authority may over to the parent's religion as well as to the G od the parents symbolically represent. As adoles cents step into adulthood, they mus t decide follow the religion of their parents, to s eek a different religion, or to avoid religion altogether. A true religious faith that is bas ed less on conflict and more on mature unders tanding probably is not acquired until 30 years age. F or some, the inner repres entation of G od solid; for others, it may change; and for still others, it be rejected or replaced. T houghts about and the of G od us ually return in old age, es pecially when death nears. A pers on may decide to embrace G od gracefully grudgingly, for reas ons that include mature acceptance the cycle of life, hope of entering a heavenly afterlife, avoidance of eternal damnation, and neurotic fear, or spurn G od's ultimate encroachment; a pers on's las t may be an inspiration or an expiration. F reud regarded belief in G od to be an illusion that fears about the dangers of life; the moral world order G od promises instills hope that justice will be served, belief in an afterlife creates an ultimate s etting for the fulfillment of wis hes . F or F reud, this illusion was because it distorted reality and promoted a state of ps ychic infantilism. However, in s ome modern thought, 276 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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G od is a benevolent illus ion neces sary for the growth nouris hment of mental and s piritual health. G od is like baby blanket or teddy bear that is special to the infant endows it with a unique quality, cuddles it lovingly, and sometimes hates it. As the child matures , these objects are neither mourned nor forgotten but rather simply lose meaning. T hey are the s tuff of illusion and P.610 mentally somewhere between subjective and objective reality. In this formulation, G od is a s pecial transitional object who does not los e meaning totally and who is always available in religion. R izzuto concludes that a person's humanity depends on illus ion; the type of selected, be it s cience, religion, or s omething els e, our pers onal history and the trans itional space each of has created between his objects and hims elf to find a res ting place to live in.”

S ac red Texts S ome, especially tribal, religions have only an oral and tradition, whereas others have books considered authoritative; examples include the four Hindu V edas , T ibetan B uddhis t G re at L ibe ration through H earing in B ardo, and the T aois t T ao T e C hing (T he W ay and its T his s ection dis cuss es the two most globally influential sacred texts , the J udeo-C hris tian B ible and the Mus lim Qur'an.

The B ible T he B ible is a compilation of papyrus or parchment into two books: Hebrew S cripture (relabeled as the Old 277 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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T es tament by C hris tians) and the New T estament. S cripture, written in a language that belonged to Israel never really s pread geographically, presents the s tories creation; the s election of the J ews by the one, true G od the chosen people; and the s uffering of the J ews in quest for holines s. It contains a lengthy catalogue of rituals , and commandments for the faithful to obey, as as a variety of historical recollections , ps alms, wise and prayers . T he book of the prophet Is aiah refers to as a s uffering servant, a man of s orrow who was and rejected yet who “carried our sorrows, was for our trans gres sions , was bruised for our iniquities … his wounds we are healed” (53:3–5). C hris tians claim that their New T estament completes fulfills the Old T estament. T he s uffering servant, for example, is identified as J esus C hrist, the S on of G od allowed himself to be crucified to s ave humankind. T he New T estament also speaks of the problems with starting a new religion, of healing miracles, of the res urrection of J esus , of the power of the Holy S pirit, an impending apocalypse. It was written in koiné language known throughout the cultures of the Mediterranean area and of the ancient Near E as t. J esus C hrist was born and reared as a J ew and many early followers were converted J ews , but the religion founded in his name spread to include converts from many religions. A J ew named P aul, who was a of C hristians , had a profound religious experience on road to Damascus, claimed that he directly came to J esus and G od the F ather as a result of this equated hims elf with the 12 apostles who had known C hrist. His genius and hard work were greatly 278 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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res ponsible for the development and growth of the new religion, C hris tianity, which s uperseded the Levitical of Hebrew S cripture and promised believers and eventual res urrection. Hebrew S cripture was written from approximately 900 to 165 B C ; all the s crolls were edited over the centuries and, in approximately 150 AD, reached a form that approximates what appears in modern B ibles. T here many s crolls , each somewhat different, s o that there was a unique s et of original scrolls. Hebrew S cripture is divided into the 22 B ooks of Law (also known as the of Mos es , the P entateuch, and the T orah), the and the W ritings. B etween 150 B C and 50 AD, no religious material was written that entered into the B ible. T he C hris tian began to compile revered written documents in the second century. In 367 AD, Athanasius, the bis hop of Alexandria, elected 27 books that he considered and large, this list, which contained four G os pels, 13 of P aul's letters , and other writings, was accepted by the C hris tian community and came to be known as the T e s tament. In 50 AD, the firs t entry was written, P aul's Letter to the G alatians; the las t entry, II P eter, written in approximately 150 AD None of the G ospel writers, with the poss ible exception of J ohn, knew personally. Modern versions of Hebrew S cripture are of an idealized text and are based on an uns atisfactory century translation of the text into G reek (the B ible), S t. J erome's 4th century updated translation of S eptuagint into Latin (the V ulgate B ible), and portions from s crolls found in the 20th century in the Dead S ea 279 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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area. T he oldes t exis ting complete copy of Hebrew S cripture was written in 1009 AD (the Masoretic B ible). K nowledge about the New T es tament text comes from few ins cribed pottery remnants ; fewer than 100 fragmentary 2nd, 3rd, and 4th century E gyptian manus cripts ; 250 incomplete 4th to 9th century parchments called uncials ; 2,500 manus cripts , called minis cule s , written from the 9th to 18th centuries; quotations from the early C hurch F athers ; nearly 5,000 G reek manus cripts , each one different than the other; translations, such as the V ulgate, from the G reek no existing trans lations of a manuscript before the 4th century). V ariants in every New T estament sentence found in the manuscript tradition. In 1966, the United B iblical S ocieties iss ued a “standard” text but noted more than 2,000 choices had to be made concerning significant alternative readings of manus cripts ; in 1975 new, improved, “standard” edition was publis hed. problems have been compounded by the difficulty of translations into nearly all the languages of the world. Hundreds of E nglis h language trans lations of the B ible available; thes e range from the magisterial K ing J ames version to a B asic E nglis h vers ion that limits its to 1,000 words to a politically correct inclusive vers ion which, for example, the opening line of the Lord's translated as “Our Mother-F ather in heaven.” In addition to varying and s ometimes confus ing of events presented in the B ible, textual and differences have influenced the interpretations and practices of believers , some of whom hold that in the B ible is literally true. S uch fundamentalists for example, that Adam and E ve were actual pers ons 280 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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whom all human beings have descended, that the s un moves around the earth, that Noah's ark really pair of every animal, and that the earth itself was at 9 AM on October 23, 4004 B C However, most hold that the B ible was ins pired by G od but written by men who compiled their narratives in their own style; the B ible is truthful on significant s piritual matters, s uch faith and s alvation, but is not neces sarily accurate in scientific matters , such as astronomy, animal and botany; and that many biblical accounts are bes t unders tood as meaningful allegories. Although there always been s keptics about s upernatural events in the B ible, s uch as the res urrection of J es us , the truth about fundamental facts is being ques tioned by many s cholars . T here is no good evidence outs ide of B ible itself, for example, that Mos es and J es us were persons or, if they did exis t, that their lives were accurately. T he effects of thes e reports on believers undoubtedly played some role in the marked decline of religious attendance and influence in E urope; the Archdioces e of Dublin, Ireland's larges t archdiocese, example, ordained only one priest in 2001. T he United S tates presents a mixed picture in that, although mos t people profess a belief in G od, church attendance is sporadic, and the number of persons adopting a vocation has fallen dramatically. However, C hris tianity bloss oming in third world countries .

A l-Qur'an Al-Qur'an is a compilation of poetical verses divided 114 chapters ; it is the s acred text of Is lam. Mus lims that, in 610 AD, the angel G abriel confronted in a cave atop a mountain near Mecca, proclaimed him 281 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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mess enger P.611 of the one true G od, Allah, and ordered him to read the verses from written S criptures that exis ted in heaven. experiencing doubts about this experience, cons ulted a man familiar with J ewish and C hris tian S cripture who convinced him that Mos es had seen the same angel. W hen Mohammed realized that he was , indeed, a prophet, he followed the angel's instructions and, over the next 23 years, while in trance-like s tates in many geographic locations , read and spoke aloud heavenly verses (Al-Qur'an means the R eading). His utterances were written down by various scribes. varying collections of the vers es were collected that included material from persons who claimed to have memorized s ome of Mohammed's words that had not been written down. W ithin a generation, the C aliph Uthman iss ued a s tandard vers ion that is s till us ed although there are s ome variations because the Arabic s cript neither noted vowels nor contained dots, thus complicating the parsing of a verb as active pass ive. T he Qur'an has no s tory line; the chapters with the longes t pass ages and end with the shortes t pass ages . T ranslations have been pedestrian and invariably fail to convey its augus t and lofty language. T he content of the book focus es on the necess ity of profes sing faith in the unity of one G od who was known the J ews and C hristians . T hey were the original protoMuslims, but then they suppos edly turned from the true path. T hey must become Muslims again by now Is lam (submiss ion to G od). Abraham, Is hmael, and 282 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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were true prophets , and Muslims anticipate the return J esus in an apocalyptic time. T he book es tablis hes the of Mus lims to pray s everal times daily, to give alms to poor, to fas t during the month of R amadan, to make a pilgrimage to Mecca, and to obey certain seven of which are similar to the T en C ommandments found in the B ible. In the 8th century, Muslims solidified a belief that their behaviors and laws s hould parallel thos e of his C ompanions, and followers. T hus , collections of were gathered into books of tradition called hadith. T he literature on hadith is enormous; out of several hundred thous and hadith that have been propos ed, only s everal hundred are generally regarded as absolutely whereas the others are clas sified into numerous based on the s trength of the evidence that they can be traced back to Mohammed's time. T wo other forces have influenced Mus lim behaviors and laws are reasoning applied to similar cases and consensus by learned persons. C onsideration of all thes e factors has res ulted in a class ification of behaviors into five obligatory, recommended, indifferent, disapproved but not forbidden, and prohibited. A combined s ys tem of secular and religious law emerged, the s haría. In not covered by the s haría, highly esteemed judges may is sue an opinion called a fatwa. S hi'ite Mus lims , only to the S unnis in number, have replaced the of consensus by a belief that G od selects an infallible, authoritative leader, or Imam, who is descended from Mohammed to lead the faithful of each generation. T here are many S unni, S hi'ite, and other Muslim and s ubdivisions with differing interpretations of his tory, 283 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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sacred texts , and s haría. Local customs , the of political states based on Islamic principles , the among fundamentalis ts , moderates , and liberals , and encroachment of W es tern ideas and attitudes have influenced behaviors and caus ed religious problems . homicide-suicide bomb attacks on Is raeli civilians have been both denounced by a majority and prais ed by a minority of differing interpreters of Is lamic principles s haría. T urkey exemplifies a Muslim nation that has adopted a secular, democratic constitution. S audi exemplifies a kingdom caught up in the battle between modernization and adherence to fundamentalist principles: Non-Muslims are not allowed to enter the of Mecca, nor are they allowed to display their own religious symbols or to be buried in S audi soil, yet clothes, fas t food, and televis ion shows are widely available.

S in One of the most profound accomplishments of the was the moral delineation of s in as a rebellion against one true G od and its characterization as wicked, evil, guilt evoking. Hebrew S cripture notes that wicked are es tranged from the womb and go astray as s oon as they are born, following the dictates of an evil heart. century B C J ewis h theologians believed that, from the moment of his creation, Adam, the firs t human, had a of evil s eed that all subs equent humans pos sess . T he penalties for trans gres sing G od's laws included death stoning, horrible diseases, financial failure, severe humiliation, and chronic s adness . However, most J ews are not Orthodox and, rather than referring to notions of innate badnes s or goodness , teach about 284 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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personal respons ibility for one's actions . C hris tianity claims that Adam's mis us e of free will—he forbidden fruit—is the original s in that affects and that it can be removed only by baptis m in the Holy S pirit and belief in J esus C hrist, the R edemptor. rejected a majority of J ewish laws and teaches that, through confes sion and repentance, it is poss ible for to be forgiven and unrighteousness to be cleans ed. A of seven capital s ins bas ed on the T en J esus' S ermon on the Mount, and S t. P aul's writings completed by P ope G regory (1540 to 1604) and the present: pride (from which all the others derive), avarice, envy, wrath, lus t, gluttony, and sloth. elevated the role of S atan, a rebellious evil spirit, and a host of less er demons who enticed humans to s in. It perfected a concept of heaven and hell after death and predicted a cosmic apocalyptic conflict in which G od vanquish S atan and then usher in a new bless ed age the faithful. Although apocalyptic s eminars and “fire and brims tone” sermons persist, in modern times, the notions of s in, and hell have gradually withdrawn into the recess es of Wes tern cons ciousness . In 1973, W illiam Menninger in the popular pres s that s in had dropped out of daily conversation and debate. No longer were people of being s inners, nor were they expected to dis play remors e for their s ins . Indeed, attempts by s ome high profile politicians , as well as common pris oners, to their problematic behaviors as s inful are nowadays met with cynicis m and derision. C urrent s ocial morality reconfigured s in into criminal behavior, defective character, or a s ymptom of mental dis order, and mind 285 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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replaced s oul in ps ychiatry. F ree will, a necess ary ingredient of s in, has become les s meaningful as accumulates demonstrating that much of human is determined by genetic factors, neuronal functioning, learned res ponses , peer press ure, childhood and a hos t of other naturalistic forces.

S exuality and Gender T he major monotheis tic religions reflect the patriarchal cultures in which they were founded. G od and his are masculine. W omen traditionally were valued for roles as mothers and house keepers and were duty to obey their husbands and to remain silent on mos t matters . J ewis h S cripture contains many references to prostitutes and adulteres ses ; the phras e “to play the harlot” is us ed to describe the act of abandoning one's faith. Dis trus t and fear of women's s exuality are T he book of P roverbs s tates that “the mouth of an woman is a deep pit; he who is abhorred by the Lord fall there.” Mens truating women were shunned as P.612 J esus elevated the status of women somewhat when healed a woman with chronic vaginal bleeding who had touched his robe, talked with women on the s treet, allowed women to accompany him and his male and absolutely forbade divorce (s cholars believe that, later addition to the B ible, J esus s upposedly made an exception in the case of an adulterous wife). Despite several New T estament letters encouraging husbands love their wives, S t. P aul and many of the C hurch tolerated marriage only if a person could not exercis e 286 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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sexual s elf-control. W ith E ve as a model, women were perceived as s educers who stimulated men's lustful appetites ; to S t. B ernard (1109 to 1153) was attributed sentiment that “a beautiful woman is like a temple built over a sewer.” F emale virginity became a pathway to heaven, and, in 649, P ope Martin I officially declared perpetual virginity of Mary, the mother of J esus , a belief of the C hurch. Devotion to Mary has remained a hallmark of C atholicism, es pecially among women for whom s he is a model of comportment. T he between virginity and motherhood has been a cause of sexual confusion for some believers who dichotomize women into two types , the s o-called Madonna-whore complex, in which “good” women are like the asexual V irgin Mary, whereas “bad” women are like the biblical prostitute, Mary Magdalen. T he church's recent rehabilitation of Mary Magdalen, who is no longer cons idered a harlot but rather is revered as the firs t to see the res urrected J es us , reflects a s lowly attitude toward women. C atholicis m holds that all acts should not limit the pos sibility of achieving pregnancy, therefore prohibiting the us e of birth control devices . T he defiance of the prohibition by C atholics represents the growing challenge to ecclesiastical authority seen among many C hris tian groups ; in a survey, 75 percent of sexually active C atholic women contraceptives. B y reference to their sacred texts, J ews , C hristians , Muslims traditionally have cited the s ocial superiority of men over women. However, from a his torical the 20th century may be bes t remembered as the era which W estern women achieved a great meas ure of 287 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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equality with men. T his revolution in gender began in earnest in 1878, when the American National Women S uffrage As sociation pass ed resolutions that religion had been used to subjugate women, that female s elf-sacrifice and obedience were s elfand that women s hould claim the right of individual cons cience and judgment that men alone claimed. E lizabeth C ady S tanton gathered together 20 learned women in the 1890s to publis h the firs t real document the revolution, T he W omen's B ible . F eminis t biblical scholars hip has blos somed since the social ferment of 1960s in an attempt to liberate the B ible from its orientation and its us e by political religious groups to women's rights and freedoms . F eminis t scholars that they are continuing the tradition of the biblical prophets who expres sed G od's will by pass ing on injustices and on the perversion of religion. Is lamic societies generally limit the freedoms of women comparis on to W estern s ocieties, although change is slowly becoming apparent. Men are s till legally allowed four wives, although each mus t be treated like the in fact, mos t Muslims today have only one wife. S ome S hi'ite Mus lims recognize mut'a marriages in which a pays a woman for her sexual services for a day or so, which the marriage automatically is diss olved. In a few areas, Muslim women can get a divorce somewhat than in the pas t, whereas men cannot get a divorce without incurring the same s ort of civil liabilities as in Wes t. In areas under F undamentalist control, women not travel alone without getting a permit, and adulterers may be s toned to death (it is eas ier to convict a es pecially if s he becomes pregnant, than a man). 288 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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little, if any, feminist quranic scholars hip. R es is tance to change in gender relationships stems from the of patriarchal attitudes in Islamic s ocieties with high of poverty and low levels of education, from the inward looking nature of Islamic intellectual life over the past centuries , and from a strong belief in a literal and unchanging interpretation of the Qur'an. C ondemnation of homos exuality, a s ocially divis ive is often based on several biblical citations . T he B ook of Leviticus contains myriad laws, s uch as prohibitions agains t trimming one's beard, eating s hellfish or pork, wearing garments made of a mixture of linen and wool; addition, crops mus t not be planted every seventh and adulterers , fortune tellers, and male homosexuals should be put to death. Although C hristians are not obligated to follow the Levitical laws , most groups have selectively chos en to uphold the prohibition again homos exual behavior. T he book of G enesis tells the story of two angels as men who came to the city of S odom, where a man named Lot allowed them to stay in his home. A group townsmen s urrounded the home and asked about the men, s aying “bring them out to us that we may know them.” F rightened, Lot told them to leave his guests and offered his virginal daughters in their place. T he townsmen failed to break down the door and left. T he day, G od rained fire and brims tone on the city, killing inhabitants, although Lot and his children escaped. T he earliest interpretations of this s tory focus ed on the S odomites ' arrogance and rudenes s to s trangers ; G od killed them for incivility to his angels. T he theme of sexuality emerged full force in the 1s t century B C in the 289 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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writings of P hilo of Alexandria, a J ewish his torian. R abbinical writings about S odom in the T almud and the Midras him (commentaries) generally did not mention homos exuality. Although some C hurch fathers agreed with P hilo, others did not, pointing to a parallel s tory in C hapter 19 of the B ook of J udges in which was not implicated. T he S odomite towns men wanted know” the men; the verb “to know” is us ed 943 times in J ewish S cripture, and in only 10 places does it clearly to sexual intercours e. However, over time, the interpretation won out: the K ing J ames B ible translates townsmen's request, “that we may know them whereas the New E nglish B ible says , “so that we can sexual intercourse with them.” S ome s cholars refute translations and note that Lot was not a full citizen of S odom. T he towns men were sus picious becaus e he allowed two s trangers to s tay in the city at night without as king permiss ion of the proper officials and, thus, they wanted “to know” who the two men were. J esus does not mention homos exuality. However, he link S odom with the inhos pitality that his dis ciples might encounter when preaching (Matthew 10:14–15). S t. who barely tolerated marital sexuality, s eems to have disapproved of homosexual behavior, but the exact meaning of the specific words he us ed is unclear. In I C orinthians 5:11, for example, he includes in his list of unrighteous who will not go to heaven people who are malakoi and ars enokoitai. T he translations of thes e vary widely and include effeminate, child moles ters , homos exual, masturbators, immoral, s exually immoral, depraved, and male prostitutes. In fact, sacred, cultic and female prostitution ass ociated with the god B aal 290 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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the goddes s Ishtar are condemned in J ewish S cripture. Although homos exual behavior was practiced the ancient world, the designation of a pers on as a homos exual did not become prevalent until the 11th century AD when S t. P eter Damian coined the word s odomia, thus es tablishing an abs tract es sence: who indulged in s odomia were thereafter sodomites (homos exuals).

Alc ohol Des pite the Qur'an's clear prohibition of alcohol, many cultural Muslims drink. Although the total quantity cons umed in Muslim countries is s mall, problem is prevalent, becaus e alcohol is feared and is not integrated into daily life. J ews have drunk alcohol for thous ands of years with minimal disruptive P.613 T he basis of J ewish sobriety was es tablis hed during 200-year period after the return to Israel in 537 B C of J ews who were held captive in B abylon. B efore this, B ible contained many references to drunkennes s, but afterwards , even though J ews continued to make wine, drink it ritually and for pleasure, and to pour sacrificial libations . In addition to the banis hment of pagan gods whos e rituals demanded heavy drinking, alcohol was positively integrated into religiously oriented in the home and synagogue. Drunkennes s a s ocial problem once wine came to be regarded as a subs tance that s hould be drunk in moderation and only conjunction with food and holy rituals. E ven the fear of drunkenness vanis hed, as evidenced by a scientifically 291 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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unsound medieval rabbinical ruling that E uropean wine was not as potent as the wine produced in biblical and therefore could be drunk undiluted. Drunkennes s alcoholism became alien to J ewis h identity; the Y iddish expres sion s kikke r vi a goy means “drunk as a However, with the increasing los s of Orthodoxy, J ewis h alcoholism rates are ris ing. No C hristian religious group condones drunkennes s, there are variations in attitudes to alcohol. T he official stance of C atholicis m, reflecting the view of S t. Aquinas , is that drinking wine is lawful, except if a takes a vow not to drink, if a pers on gets drunk easily, drinking scandalizes others. P rotes tants leave about drinking to individual dis cretion, but groups such the Lutherans and Methodists preach moderation, whereas P entecos tals and B aptists preach abs tinence regard alcohol as an invariably des tructive s ubs tance. T hese variations stem from conflicting biblical T he clearest negative comments on drinking are found the book of P roverbs 23:29–33: “Who has woe? W ho sorrow? Who has complaining? Who has rednes s of Do not look at wine when it is red, when it s parkles in cup, and goes down smoothly. At the last it bites like a serpent and s tings like an adder. Y ou will s ee s trange things , and your mind utter perverse things.” Among the Hebrew prophets, Isaiah des cribed E gypt akin to a drunken man who s taggers in his vomit and Is rael's leaders as irrespons ible, because they devote thems elves to intoxicating drinks. Hosea warned that harlotry and wine enslave the heart. J esus warned being drunk at the time of his second coming. S everal in the New T es tament cite drunkenness among the 292 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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of thos e persons who do not walk with C hris t, who will inherit the kingdom of G od, and who live doing the of the G entiles ins tead of G od. Other biblical pas sages consider wine as a staple of a bles sing from G od. Is aac as ked G od to give his son, J acob, the dew of heaven, the fatnes s of the land, and plenty of grain and wine. In the book of Amos, G od promis ed to return the J ewis h captives to Is rael, where they s hall plant vineyards and drink their wine. notes that when the people of J udea and Is rael are res tored, then their hearts will rejoice as if with wine. J udges 9:13 refers to wine “which cheers both G od and men.” P roverbs advocates giving wine to pers ons who bitter of heart, s o that they can forget their misery and poverty. I T imothy 5:23 encourages the use of wine “for sake of your s tomach and your frequent ailments .” In the United S tates, alcohol and religion have a linked history. T he consumption of alcohol was quite after the R evolutionary W ar. Americans felt patriotic drinking liquor distilled from healthful, native corn and regarded intoxication as a freedom cons onant with hard-won independence. B enjamin R ush, one of the founders of the American P s ychiatric As sociation, cons idered whiskey and rum as the ruination of the nation, although wine and beer in moderation were the 1780s , Methodis ts and Quakers were like-minded forbidding the drinking of hard liquor, the former it interfered with religious practices and the latter it interfered with s elf-control. In 1826, a P res byterian minis ter in C onnecticut delivered six s ermons on the of liquor that became a basic text of the American T emperance S ociety. Local temperance s ocieties grew 293 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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from 222 in 1827 to 8,500 in 1834, and antidrinking became popular. New towns were established to temperance values, the bes t known being P alo Alto, C alifornia, the s ite of S tanford Univers ity. In 1874, the Women's C hris tian T emperance Union was founded demanded the worldwide prohibition of alcohol, prostitution, child marriages , foot binding in C hina, the J apanese geisha s ys tem, and the sale of opium. frontier churches held that temperance was not enough claim s alvation; only total abs tinence would do so. In 1893, a minis ter from Ohio founded the Anti-S aloon League and s ucces sfully delivered votes for politicians supported prohibition. J ames C annon, a Methodis t from V irginia, pushed through the prohibition to the U.S . C ons titution in 1917 by demonizing alcohol the major caus e of the nation's ills. Although alcoholis m rates declined, prohibition res ulted in wides pread lawles sness and the creation of a vast criminal Ins tead of pros perity, the nation experienced a great economic depres sion. B ishop C annon was dis graced charges of war profiteering, illegal s tock deals , and corrupt political practices . T ired of austerity and nays ayers, Americans repealed prohibition in 1933.

Healing In the earlies t days of humankind, spiritually powerful and women known as s hamans healed disease and revers ed mis ery by retrieving lost souls , by pacifying exorcising malign spirits , and by providing counterT heir legacy continues today in “faith healers ” that exis t all cultures , although, especially in W estern nations, are impostors. 294 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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Hebrew S cripture attributes mos t disease to G od's retribution against dis obedient believers ; E xodus 15:17 the definitive s tatement on G od the healer: “If you diligently heed the voice of the Lord your G od and do what is right in his sight, give ear to his and keep all his statutes, I will put none of the diseases you which I have brought on the E gyptians . F or I am Lord who heals you.” T he early Hebrews dis dained medical practice, because it diminis hed G od's position. However, by 180 B C , the book of E cclesiastes noted sick persons s hould pray to the Lord for healing but also consult phys icians who can provide medicines that heal and take away pain. T he approach of J esus to the sick, many of whom had disenfranchised from full participation in temple was revolutionary. He welcomed the sick and did not blame them for their illness es . Almos t 20 percent of the G ospels are devoted to J es us ' 41 healing encounters individuals and groups . He healed medical and spiritual and ps ychological disorders ; his mos t common was to s ay a few words and to touch the s ick person. A disproportionate number of his healings involved the exorcism of demons, and he pas sed on this power to disciples and all of his followers. T he class ic healing found in the book of J ames 5:13–16 in which sick were enjoined to call the C hurch elders to their be anointed with oil in the name of the Lord, to confes s their s ins , and to pray for one another, and “they will be healed.” In approximately 400 AD, S t. J erome the B ible into Latin; instead of “they will be healed,” J erome wrote, “they will be s aved.” B y this alteration, spiritual salvation displaced the healing of illness as the 295 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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central focus of the text and res ulted in a neglect of phys ical healing for almost 1,500 years. In fact, suffering became a C hristian avocation that allowed a person to s hare in J esus ' suffering on the cross . W hen refused to cure P aul (he may have been epileptic) on occasions, the B ible notes that G od's grace was and that his power was made perfect in weakness . defects were no longer liabilities but rather were opportunities to receive the power of J esus. T his formulation enhanced the self-worth P.614 of dis abled and ill pers ons , but it als o contained the potential for persons to accept their infirmities with pass ivity or even to mortify thems elves in purs uit of a higher, spiritual goal. Medicine was devalued, physicians ridiculed, and healing forgotten (except for occasional exorcisms), so people turned to dead s aints for help. A cult of relics , namely, the pres erved body parts of saints who supposedly had performed miracles , prospered for millennium from the 4th century. T he church ass igned saints to specific diseases ; S t. V itus was the patron of persons with chorea, S t. Lucy was the patron of with eye disease, and S t. Dympna was the patron of mentally ill. T he many shrines that held the healing faded into obs curity when medical practice became effective. A major exception is the relatively new shrine Lourdes in F rance, where S t. B ernadette had her vis ion “the lady” in 1858. Local enthus iasts identified “the the V irgin Mary. Although S t. B ernadette died of tuberculos is at 35 years of age and never s tated that 296 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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lady” would cure anything, the s hrine at Lourdes was promoted by merchants as a place for healing. S everal million vis itors from around the world travel there including many des perate pers ons whos e illness es not res ponded to medical treatment. Lourdes has an official medical bureau for the certification of healing; les s than 100 have been iss ued. T he Lourdes are emotionally charged and spiritually so that temporary functional improvement in some does occur despite the lack of organic changes . Interes t in religious healing in the form of “mind cures ” emerged at the end of the 19th century in New Mary B aker E ddy, for example, wrote S cience and 1875; s he declared that s ickness is a fearful belief manifest on the human body and that it can be by the divine mind. T he real rebirth of C hristian healing occurred in T opeka, K ansas , when a preacher gloss olalia, linked it to healing, and started a revival that relied on the verses found in the G os pel of Mark 16:16–18: “He who believes and is baptized will saved; but he who does not believe will be condemned. And thes e s igns will follow those who believe: In my they will cas t out demons; they will speak with tongues ; they will take up serpents ; and if they drink anything deadly, it will by no means hurt them; they will lay on the sick, and they will recover.” T he American Midwest proved to be a congenial setting for P entecostal faith healing. F rom its humble beginnings in s mall churches , faith healing ceremonies have progress ed to radio and large scale television presentations that raise millions of dollars throughout North and S outh America, E urope, and Africa. T he 297 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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presentations us ually are s pectacular extravaganzas replete with extremely large and expectant crowds, tech lighting, fast-paced music, and continual choruses praise. T he healers have celebrity s tatus and are performers. T he healings often consist of the dramatic exorcism of illnes s—demons who have s uppos edly poss ess ed the sick pers on. S ome s ophisticated speak more about demonic oppress ion rather than poss ess ion, es pecially in pers ons with impulsivity problems , such as compulsive gamblers , alcoholics , subs tance abus ers, and self-cutters . E ven mainstream C hris tian churches have turned to healing, although in a les s s pectacular and calmer in a charismatic renewal that includes s peaking in uttering prophecies, and prayers for healing. After a of 1,600 years , the C atholic C hurch redis covered during the V atican C ouncil II in the 1960s. T he of E xtreme Unction, for example, was renamed of the S ick and is no longer reserved for the dying in private but is given publicly as soon as any of the begins to be in danger of dying from s ickness or old Many flamboyant faith healers have been exposed as charlatans , whereas others probably believe they are doing G od's work. F ollow-up studies have consistently found no evidence of cures, although many pers ons feel better briefly. A study of 71 P entecostal C hristians experienced hands -on faith healing for conditions from leukemia to peptic ulcer to warts found that all the subjects reported an ins tantaneous or gradual healing, despite the fact that the original symptoms were unchanged. T hey proclaimed thems elves to be healed because their belief in G od increased, as did their 298 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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conviction that they were leading a proper, righteous S tudies of attempts to heal persons by prayers offered distant s ite, so that subjects have no knowledge of the prayer attempts , have shown no great advantage to prayed-for vers us control groups . An often-cited study coronary care patients did s how a slightly better cours e among prayed-for patients , but a flawed methodology cas ts doubts on the results : No was provided about the psychological characteris tics of the subjects or the treatment practices of the various health care plans ; the coordinator of the s tudy not only knew which patients were in the prayed-for and control groups , but also was responsible for record keeping on subjects ; and, when the s tudy was returned by a editor with a revision request, the author reconstructed the criteria about what establis hed a good or bad cours e after he knew which group each patient was in. E specially in times of crisis, prayers offer hope. may point to the New T estament, which states , things you ask in prayer, believing, you will receive” (Matthew 21:22), and, “whatever you as k the F ather in My name, He will give you” (J ohn 16:23). However, when a petitioner's prayers are not is us ually the cas e, theologians turn to the biblical of J es us in the garden of G eths emane before his and capture when he prayed to G od the F ather, “not will, but what Y ou will” (Matthew 31:39). Any interpretation of a s upernatural intervention, s uch as intercess ory prayer for a sick pers on, depends on the mind-set of the participants. If a prayed-for pers on is cured, the skeptical scientis t may pos it a natural, but yet unders tood, mechanism; if the pers on is not cured, 299 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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skeptical theologian may contend that the wrong prayer or not enough prayer was offered, that G od was angry being tes ted, or that the res ult was G od's will.

R eligion and Mental Health T he complicated relationship between religion and health is due, in part, to definitions. Is mental health, for example, merely the abs ence of ps ychopathological symptoms or does it imply happines s, contentment, tranquility, s pontaneity, the capacity to love and to the maintenance of a right relations hip with G od, and fulfillment of one's intellectual potential? Is it mentally healthier to criticize or to s ubmit to authority, to be independent or to be dependent on family and friends ? it religiously healthier to focus on self-realization or to accept dogma that demands obedience? G ood data on relations hip between religion and mental health are to come by, especially in non-Wes tern countries in so-called official s tatistics are often misleading P sychiatry has a formal lis t of ps ychopathological s igns and s ymptoms, but there is no such lis t for religion. because at leas t 21 variables have been identified as components of religios ity, the selection of appropriate variables to include in scientific s tudies is problematic. most us eful delineation of religios ity is probably G ordon Allport's and J . Michael R os s' intrinsic and extrinsic T he former implies a sincere commitment to one's which are internalized and serve as a guiding behavior, whereas the latter implies the use of religion obtain status , s ecurity, s elf-justification, and s ociability. P sychiatric studies on the relationship between religion and mental health have generally treated religiosity 300 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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superficially. R eligious P.615 studies, although numerous , tend to rely on s elfoverrepres ent churchgoers and college s tudents , exclude nonbelievers , emphasize church attendance variable, and lack longitudinal data. Mos t s tudies are correlated: A cons istent finding that elderly pers ons attend church demons trate better mental health than those who do not, for example, may s imply mean that elderly churchgoers are in good enough physical health make the trip to church. B ecause there is a pos itive relations hip between physical and mental health, attendance in this group may s ignify good physical and may have little to do with mental health. No meaningful general conclusions can be made at time about the impact of religion on mental health. A conceptually s ound s tudy of 1,902 female twins over a year period found that, except for a lower us e of and alcohol and a poss ibly lower level of depress ion, was little evidence overall for a relations hip between current ps ychiatric symptoms , lifetime and religiosity. A survey of 14,000 youths found that sort of religious commitment was related to a likelihood of s ubs tance abus e. S tudies of religious meas ures in pers ons who had experienced s tres sful events within the pas t year found that religious rituals times of crisis were helpful in 40 percent of cases and harmful in 23 percent. T hese coping meas ures were helpful to religious pers ons who had les s access to material resources and power, s uch as the elderly, the poor, the less educated, African Americans , the 301 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and women. R eligious beliefs may affect the express ion of ps ychopathology. S ome psychotic and manic patients proclaim thems elves to be a god, a prophet, a a s aint. P aranoia may focus on s atanic plots . may be interpreted as supernatural events. Depres sion special cas e in that its psychological torments have, recently, often been cons idered an authentic part of the religious experience; for C hris tians, it is a sharing of sufferings of the martyrs and of J es us on the cros s, whereas many S hi'ite Muslims, during the ritual remembrance of the martyrdoms of religious heroes , flagellate thems elves frenetically and recall the words Hus ain: “T rial, affliction and pains, the thicker they fall man, the better do they prepare him of his journey heavenward.” T he tribulations of Moses are an component of J ewish identity. B uddhism acknowledges the Noble T ruth that s uffering is univers al and that aging, and death are s uffering produced by a craving and repuls ion of s ense pleasure, for existence and nonexistence, and for becoming and s elf-annihilation. Indeed, the calmnes s and s eeming pas sivity of s ome B uddhis ts in dealing with their suffering may tes t the patience of W estern ps ychiatris ts who are accustomed patients s eeking rapid s ymptomatic relief with G uilt, another component of depress ion, and s in are reported by fewer patients nowadays. E ven though obses sive-compuls ive disorder (OC D) mimics the calculated rituals of s ome religions , fewer patients ruminate about right and wrong and good and evil. shifts indicate a decrease in religiosity and an increase naturalis tic, scientific beliefs and modes of express ion. 302 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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Although conversion dis orders are s till prevalent in world countries , their decline in W es tern nations has attributed to the transparency of the s ymptoms in the of wides pread, public understanding of ps ychological principles. In fact, pers ons with conversion disorders be overrepres ented in the throngs of uns ophisticated attendees at faith healing revivals and crusades , s ome which may attract 100,000 participants, as well as a television audience. Attraction to thes e s pectacles represents a disappointment that modern medicine, despite its technological advances , s till cannot cure all diseases . T he rapid growth of C hristian groups that emphasize unabashed emotionality, mus ic, singing, gloss olalia, and a ques t to attain s piritual joy may res ponse to what seems to be a worldwide increas e in depres sion. G loss olalia or s peaking in tongues is a unders tood, nonpathological phenomenon in which a person utters a series of words that are totally unintelligible to the speaker and to listeners . It can quiet or in highly emotional s ettings , in groups or in solitary privacy, in children as well as adults , and in and lower–social class pers ons . It usually is not with an altered s tate of consciousness . It rarely is a negative experience; mos t of the time, it is mildly and s ometimes very positive. It pos sibly benefits depres sed and anxious pers ons a little bit. T he practice mentioned in the New T es tament as a minor gift of the Holy S pirit, ranking below wis dom, faith, healing, and prophecy.

S pirituality S pirituality is a somewhat nebulous concept. In 1990, David E lkins, a psychologis t, outlined the values of 303 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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persons as belief in a “greater s elf” or pers onal G od, a sens e of purpose in life and quest for meaning, of the sacredness of nature and of all human knowledge that ultimate fulfillment is found in and not in material things , altruism, idealism, suffering and death, and leading a life that has a effect on people, nature, and whatever they consider to ultimate, trans cendent reality. S piritual and religious values overlap, but a person with extrins ic religiosity be lacking in s pirituality, whereas a nonchurchgoer who volunteers at a homeles s s helter and is active in environmental caus es may be spiritual but lacking in religiosity. T he spectrum of s pirituality is exceedingly broad. At end is religious s pirituality as exemplified by the quiet prayerful practices of monks and nuns and by the enthus ias tic, highly motoric practices of S ufi Mus lims P entecostal C hristians . At the other end is New Age spirituality, which includes ethereal mus ic, cosmic vibrations, abductions by aliens from outer space, readings, pas t-life regres sions , being touched by and near-death experiences that occur when persons in a s tate of what appears to be death but then are S ome persons later report that they were out of their bodies during the near-death period, looked down at thems elves , and felt thems elves moving through a dark tunnel peacefully. T hey reviewed their lives as in a panorama. T hey s aw a glowing light with a human cities of lights , and a border from which there is no T hey met deceased relatives and friends . T hey heard doctors or spectators who pronounced them dead, but they were res cued from death by a s pirit. R emarkable 304 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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similarities exis t between the reports of near-death survivors and by us ers of hallucinogenic or other drugs. is likely that, when a person approaches death, there is decrease in respons e to external s timuli, a turning of attention, the releas e of old memories , and a fear of death that triggers hallucinations , dreams , and fantas ies of G od, heaven, and rescue. S hould the person survive, then the near-death experience may be interpreted as a valued s piritual phenomenon, various s tudies , as much as 22 percent of s uch have been des cribed as hellis h and terrifying. It is not s urprising that the therapeutic approach of AA centers on s pirituality because of the nature of alcohol. T he V arietie s of R eligious E xpe rie nce , written in 1902, commented on alcohol's power to s timulate the faculties of human nature, to bring drinkers to the core of life, and to make them, for the moment, one truth. Dis tilled spirits were originally called aqua vitae — water of life. T he ancient G reeks worshiped the god Dionys us , who suppos edly invented wine. At his chaste orgies , women were intoxicated with wine, danced ecstatically in the darkness of the mountains, and then ripped apart wild animals and devoured them in the P.616 that each mors el contained a bit of Dionysus hims elf. was als o revered as the Lord of S ouls, his likeness , drunken revelers to a happy afterlife, painted on sarcophagi. T he B ible calls wine “the blood of the and, in C hris tian thought, J es us ins tituted the sacrifice at the Las t S upper, when he offered his bread and wine that he declared to be his body and 305 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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B y eating the bread-flesh and drinking the wine-blood, disciples ingested their G od, and his immortality theirs , an immortality available forevermore to believers who partake of this s acrament of Holy C ommunion. J ellinek, one of the greates t alcohol researchers , that alcoholics us ed drunkenness as a type of s hortcut higher life and higher mental state without an emotional or intellectual effort. T o be “high” is to be clos er to AA is not a religion, although s ome critics have as a religion in denial. Its roots are C hris tian; its steps and traditions unconsciously recall the 12 tribes Is rael and the 12 dis ciples of J es us . T o fulfill the s teps , members mus t believe in a power greater than thems elves , turn their lives over to G od as they him, improve their cons cious contact with G od through prayer and meditation, and experience a spiritual awakening. T he most detailed s tudy of AA dynamics is E rnest K urtz's book, Not G od: A H is tory of Alcoholics Anonymous . T he curious title refers to the fundamental mess age of AA, namely, that each alcoholic mus t claim to be more than human. R eligion's aspiration for perfection and absolute truths was too grandiose for founders of AA, who broke away from the C hristian G roup and es tablished AA's miss ion of s aving “drunks ” not the world. One of the founders noted that, before he was trying to find G od in a bottle. F or many the spiritual approach of AA is undoubtedly effective, although the organization's commitment to remain forever nonprofes sional has hampered impartial

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of religion and spirituality in their lives, the frequency intens ity of their participation in religious and spiritual practices , and the leadership s tyle and members ' behaviors of the religious and s piritual groups in which they are involved. G eneral familiarity with the beliefs behaviors of certain groups in which patients are must be joined with knowledge about s pecific local groups . S ome patients may es chew participation in congregational life—they may lack trans portation, have health problems, feel embarrass ed by their shabby or get panic attacks in crowded churches —and watch televangelis ts in the comfort of their homes . Many pray, put their trust in guardian angels , and read s acred texts daily; although their level of unders tanding may be unsophis ticated, the mere presence of the s acred text their reading of it s uffice to provide a sense of s ecurity purpos e, feelings of hope and solace, and reaffirmation a G od who pers onally cares for them. P sychiatrists s hould ass ess patients' religious and involvement in terms of mental health and social and must be alert to the misuse of religion; an example the citation of s acred texts by some C hristians , J ews, Muslims to jus tify the humiliation and physical abuse of wives. B y using pass ionately pious appeals , abusers gain the s upport of their in-laws and local groups . P sychiatrists who treat the wives of s uch persons may portrayed as evil doers who s ubvert the will of G od, they endors e the s tatus quo. However, if therapeutic efforts to ameliorate the abus ive situation fail, then must be cons idered, even though the patient may find herself es tranged from her family, her congregation, maybe even her religion. 307 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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It is improper for a ps ychiatris t to pros elytize or to dispense s pecific s piritual advice or to pray with other than to remain res pectfully s ilent if a patient does pray. It is proper to suggest to appropriate patients that participation in religious and s piritual activities may some ps ychos ocial benefits and to respect and to encourage thos e religious and s piritual beliefs and practices being used by patients to cope with their However, it is important to know that religious organizations are not mental health providers, although the promotion of mental health may be provided such activities as caring human contacts , forums for open discus sion of values and behaviors, and material help, prayers, and moral support in times of cris is. T he ultimate purposes of religion are not mental health and euthymia but rather salvation and the quest for P sychiatrists s hould warn patients about membership cultic groups and s hould refer patients to mental health chaplains when is sues such as s alvation and dogma “B orn-again” C hris tians us ually s eek out ps ychiatris ts therapists who belong to their congregation or who publicly identify themselves as C hristians , may pray their patients , may use biblical examples in treatment, regard homosexuality as a sin, and may be loathe to cons ider divorce as an option. However, mos t C hristian ps ychiatris ts are aware of the tendency of some disguis e ps ychological problems by a religious presentation. In a study of C hristian-oriented cognitivebehavior psychotherapy, religious and nonreligious therapists were equally effective.

C UL TUR E A ND ME NTA L IL L NE S S Mental illness is the res ult of a complicated chain of 308 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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that implicate flawed biological, psychological, s ocial, cultural process es . S ometimes, the proximal caus es of ps ychopathology are clear cut; examples include storm, drug intoxication, and the experience of a event. However, in most cas es , ps ychopathology slowly in ways not fully unders tood over the cours e of a lifetime. S cientific explanations of ps ychopathology are based on naturalistic, material findings, although the observation, determination, and interpretation of thes e findings may be incorrect and bas ed on cultural biases ; various times, psychiatrists have believed that female masturbation may res ult in mania and epileps y, that mothering may caus e children to be s chizophrenic, that homos exuality in its elf is pathological, and that one or expos ures to heroin invariably res ult in addiction. C ulture influences mental illnes s in many ways. T he content of people's delus ions, auditory hallucinations , obses sional thoughts, and phobias often reflects what significant in their culture; examples include the delus ion of being J esus, Mohammed, or B uddha; the delus ion of being persecuted by terroris ts , the C entral Intelligence Agency (C IA), or space aliens; and contamination by germs , nuclear was te, and environmental toxins. S ocial phobia, as it is known in Wes t, may be shaped by J apanese culture into a known as taijin-kyofu-s hio, an exces sive concern about interpersonal relations, body odor, and eye contact, with flushing. T he J apanes e psychiatrist, S homa developed a s pecial therapy rooted in Zen B uddhism this condition in which patients undergo res t and followed by participation in s imple tas ks , make entries diary for written comments by the therapis t, learn to 309 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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appreciate and to accept things as they are, and their attitudes toward life. C ulture can elaborate normal behaviors , s uch as the reflex and s leep paralysis. In Malaysia and Indonesia, hypers tartling persons, called latahs , may be gleefully goaded by onlookers until they are s o flus tered that utter obscene words , obey forceful commands , and the onlookers ' behaviors. In Newfoundland, C anada, experience of s leep paralysis, which occurs when as leep or awakening P.617 and may be ass ociated with hallucinations, has been elaborated into an “old hag” syndrome. C ulture can facilitate the prevalence of disorders such as abuse and suicide, whos e rates differ depending on attitudes. T he cultural acceptance of technological advances has contributed to global obesity; the replacement of bicycles by motorized vehicles and of shovels and saws by mechanized tools has res ulted in sedentary lifes tyles . In some areas of Africa, obesity come to be valued as an indicator that a person is not infected with human immunodeficiency virus (HIV ). C ultural mating patterns may influence the prevalence ps ychopathological genes ; intermarriage on the s mall is land of B elau, Micronesia, has resulted in a high schizophrenia rate, whereas the effects of female infanticide in C hina, which has caused a surplus of 50 million single men and the ris e of cous in-marriages in “inces t villages,” remain to be s een. C ultural attitudes res ulting in s tigmatization affect the prognos is of disorders ; a positive effect of the current, albeit 310 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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overs implified, notion that major mental illness is the res ult of a “chemical imbalance” has led to greater acceptance of the mentally ill by family, friends , and society and greater access to treatment res ources .

C ulture-R elated S yndromes T here is extreme diversity among the peoples of the concerning the recognition, class ification, and unders tanding of mental behavior s ymptoms. W es tern ps ychiatris ts class ify mental diseases according to the DS M-IV -T R and the International C lass ification of (IC D), which are thought to reflect scientific categories. P eople living in W es tern countries, in part because of economic might and military prowes s, have ass umed their world view is basic and true, whereas the world of others are variations on what is natural. However, lack of biological markers and the differing of behavior contribute to the ethnocentricity of thes e clas sifications. T he DS M-IV -T R and IC D are not applicable; ps ychopathological s yndromes exist, in non-Wes tern cultures that do not fit the scientific nomenclature unless they are placed into the “atypical” category. T hes e s yndromes are perceived to be more influenced by culture than are most W es tern and, therefore, have been labeled culture -bound, culture -re late d is a better term. S ome syndromes are in dis tinct cultural groups , whereas others are found in large cultural regions . Malgri, or intruder sicknes s, is a syndrome of s ome Aus tralian aborigines in which an offended s pirit attacks pers ons who enter the s ea or a foreign territory without performing a proper ceremony and caus es fatigue, headaches, and painful dis tended abdomens . F amily s uicide is a J apanese behavior 311 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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which dis graced parents kill thems elves rather than live with shame; they als o may kill their children for fear their orphans would be s ocial outcas ts. K oro in and s uoyang in C hina are disorders in which men panicked and fearful of death, because they believe their penis is s hrinking into their abdomen. W estern patients with koro-like symptoms tend to be schizophrenic, brain damaged, or intoxicated with or drugs , s uch as amphetamines . Amok runners are Malaysian men who, after a period of brooding, erupt a s tate of frenzied violence and indis criminate attacks that end with exhaus tion and amnes ia. Often runners are killed by the police, although attempts are made to s ubdue them. Most s urviving amok runners been diagnos ed as s chizophrenic. Indis criminate mas s homicidal behaviors have been increasing in W estern cultures, es pecially in the United S tates , in schools and workplaces , s uch as factories and pos t offices. T hes e behaviors differ from terrorist attacks in that they are driven by political and religious motivations . P s ychiatric diagnoses have rarely been made in Wes tern cases , although, on autopsy, a s mall pineal tumor was found man who climbed a tower at the Univers ity of T exas shot at a pas sers by. F ear-of-becoming-fat anorexia appears to be a culture-related syndrome in Wes tern countries , as is diss ociative identity disorder, which to derive from a lingering notion of demon pos ses sion; well-publicized cas e in F rance in 1611 involved a girl, after being seduced by a priest, was s ent to convent at which s he and a young nun were found to be by more than 6,000 demons after developing visions of demons , and lewd behaviors with a crucifix. 312 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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FOL K B E L IE F S A B OUT ME NTA L IL L NE S S T he distinction between cultural explanations of symptoms and true s yndromes is often problematic. beliefs about mental illnes s are rarely found in written form, fall outs ide of the s cientific tradition, and are often magical, integrative, and definitive. Although irrational, they offer explanations for life's vagaries and make the seeming capricious nes s of pathology more acceptable. S cientific and folk beliefs are ritualistic and, regard to mental illness , have s uccess es and failures . systems may function s imultaneously within a culture within a pers on. A mentally disturbed pers on may seek ps ychiatric help and, at the same time, indulge in folk therapies. F olk beliefs about the caus ation of mental illness may to naturalis tic and supernatural forces . E xamples of caus ation include heart dis tress in Iran and renal and nervous s ys tem exhaustion (neuras thenia) in Mys tical theories include fate, astronomical influences, predes tination, bad luck, ominous sensations, contact with mens trual blood or a corps e, violation of taboos , s peaking forbidden words, trespass ing, and improper conduct toward kinsmen, strangers, social superiors , or spirits . Animistic theories include s oul los s and aggres sive acts by s pirits. Magical theories ascribe illness to the use of s orcery or witchcraft; s orcerers their power by s uch means as apprenticeship, theft, whereas witches poss es s inherent powers . techniques include spells; hexes; prayers; curs es ; the supposed intrusion of objects into a pers on's body; performed over portions of a person's body (e.g., nail 313 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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clippings and hair), excreta, or poss ess ions; of poisons that are us ually inert pharmacologically; capture of a victim's soul; sending alien spirits to victim; and rites performed over pictures and dolls thought to resemble the victim. S cientific beliefs hold that dis harmonies in the environment and in s ociety may be linked with mental phys ical disorders in individuals, whereas folk beliefs include s piritual and s upernatural dis harmonies. In traditional C hines e medicine, pathology of the human body and of emotional express ion reflects imbalances cosmic forces ; epilepsy and koro res ult from excess ive a female negative force, whereas mania res ults from yang, a masculine, pos itive force. In this system, emotions are linked to five visceral organs that are to five elements and that are affected by humidity, heat, dryness , and cold. V itality and health in this also depend on jing (vital energy) and qi (vital air). ps ychological concepts have little place in C hines e medicine in which the focus is on a holis tic balance of internal and external forces and on the prescription of herbal remedies, medications, diet, and acupuncture. T raditional Indian medicine, Ayurveda, has s ome similarities with C hinese medicine, although it pays attention to mental disorders , is somewhat more ps ychologically minded, allows for sorcery, and has a broader pharmacopeia. W es tern alternative medicine practitioners, es pecially thos e who practice in luxurious health-spa s ettings , often claim to us e traditional and Indian practices ; patients are us ually told to s top smoking, to eat a nutritious diet, to drink green tea, to relax, to meditate, to get mas sages , to practice yoga, 314 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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to take s ome herbal “medications ” (one well-known phys ician has sold an expensive herbal mix that he described as “pure knowledge compress ed into herbal form”). P.618 F olk beliefs about mental illness are too numerous to report; however, three examples—nerves , hexing, and spirit pos sess ion—are presented.

Nerves T he E nglis h-language terms ne rvous , a cas e of the and ne rvous bre akdown are us ed commonly to mental disturbances ranging from mild anxiety to a ps ychotic epis ode. Among Latinos , the word ne rvios similar general meaning but is more frequently us ed has been elevated by cultural psychiatrists to an idiom distress . It is us ually as sociated with feeling frustrated stress ful situation. Ataque de ne rvios (nervous attack), prevalent among P uerto R icans , is characterized by sudden, dramatic, loss -of-control, anger-discharging behaviors , s uch as falling on the floor, flailing limbs , grinding teeth, and clinching fists. It may involve aggres sion toward others , in which cas e, it often is as sociated with amnesia. Attacks have been likened to adult temper tantrums and epileptic seizures. S ome persons may appear to be in a diss ociative s tate during attack but are not uncons cious . Attacks always occur in the presence of observers, and, unlike true seizures, there is no incontinence or tongue biting. T hey are attention getting and may be used for secondary gain, such as family control; persons may instill fear and guilt 315 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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family members by threatening to have an attack if they are angered.

Hexing: The E vil E ye More than one-third of world cultures hold a belief in evil eye hex. It is widespread throughout E urope, the E as t, His panic America, the Indian subcontinent, and Africa. It is called mal occhio (Italian) and mal de ojo (S panis h). T he evil eye is generally considered to be a sudden, destructive power—sometimes unknown even to the persons who pos sess it—from the eye of a human an animal. T he victim who is hexed may develop headaches, s leepiness or fitful s leep, exhaustion, depres sion, hypochondrias is, spirit poss es sion, failure to thrive, anorexia, listles sness , diarrhea, disrupted social relations hips , and s udden death. T he supposedly can caus e the death of animals , the food, and the wilting of crops; in centuries pas t, J ews in G ermany were forbidden to look at crops for fear that glance (J ude nblick) would be damaging. P ers ons who thought most likely to pos sess the evil eye are those phys ical deformity (es pecially a hunchback), strangers, jealous kin or neighbors , marginal members of society, barren women, the poor and hungry, persons with their lot in life, children who return to their mother's breast after weaning (seen among S lovak-Americans ), most importantly, anyone who utters a word of prais e compliment. T he evil eye can strike anyone, but mos t susceptible are wealthy, handsome, and weak children; and women, es pecially when pregnant. A has been reported of a 27-year-old Italian-American 316 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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living in P hiladelphia, who thought hims elf hexed in his community agreed with him) and s ubsequently murdered s ix people whom he believed were sorcerers res ponsible for s triking him with the evil eye. Diagnos is of the mal occhio in southern Italy reflects practices found in other cultures . A female s pecialis t three drops of oil into a bowl of water, cros ses herself, recites ritual words , calling on G od to remove the evil If the oil and water mix, the patient's s ickness is to be organic. C oagulation of the mixture is evidence of the evil eye. S ymbolically, the water repres ents and the oil repres ents evil. T he force of the Holy T rinity counterbalances the evil eye, thought, and desire. techniques are us ed to ward off evil eye attacks ; include building high, solid fences or walls around home, avoiding the dis play of one's wealth, smudging face of an infant with dirt to make it appear invoking G od's name immediately after one receives a compliment, and pos sess ing amulets in the s hape of horn or of a hunchback holding a horseshoe.

R oot Work P robably derived from hoodoo, root work is a hexing found among s ome African Americans, especially with lower social clas s, rural, S outhern backgrounds. hex is adminis tered by tampering with a victim's food or drink or by a touch or an evil glance. Other techniques include s prinkling s and, salt, or pepper on a victim's step; burying a knife with its point towards a victim's house; and magically manipulating various items — household goods , blood, excreta, and hair—in with special times, such as s unrise or the dark of the 317 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and s pecial days, such as F ridays, and the 13th day of month. P ers ons who believe thems elves to be hexed may emergency rooms with symptoms s uch as chest and abdominal pain, unresponsivenes s, fainting s pells, lip smacking, and epileptic seizures or ps eudoseizures . P sychiatrists may encounter s uch patients becaus e of severe anxiety, hallucinations, and persecutory or grandiose delusions . B ecause they think that might be ignorant about or disparaging of the notion of hexes , victims rarely report their belief that they have hexed. It is important to ask s pecifically about the poss ibility of root work or hoodoo.

S pirit Pos s es s ion Altered states of cons cious nes s can be induced pharmacologically, ps ychologically, and phys iologically and are experienced in many ways, s uch as s leep, concuss ion, a reaction to drugs , delirium, depers onalization and other diss ociative states , and meditation. Depers onalization is a fairly common experience and becomes pathological only when as sociated with marked dis tres s and impaired S ome of the features seen in diss ociative dis orders, in general, and depers onalization, in particular, may be interpreted in various cultures as pathological include the frenetic excitement and s eizures known as pibloktoq among Arctic native peoples and s ome forms amok), but they may also be regarded as purpos eful even des irable. T rance is the most common s ocially institutionalized altered s tate of cons cious nes s, and poss ess ion is the most common cultural explanation 318 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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trance. In s ome belief s ys tems, s pirits are thought to permanently within a person and may even s erve as an explanation for a variety of s cientifically defined such as epileptic s eizures , s chizophrenia, and slowgrowing viral encephalopathy. It is more usual for stay within a pers on for brief periods of time. W es tern expres sions such as “What got into you? ” and “What poss ess ed you to do that? ” reflect this old belief. In the spirit pos sess ion belief probably is the most ancient prototype of many medical dis orders, s uch as an axis I ps ychiatric disorder, in which people theoretically can disposs ess ed of a dis eas e which comes on them. In situations, pos ses sed persons may be diagnos ed as ill their own culture, as is the case in s ome culture-related syndromes. A world view that allows for spirit pos ses sion can be unders tood fully only on its own terms and not scientifically; within a given culture, s pirit poss ess ion be quite logical, and the pantheon of consens ually validated spirits is unlike a projected paranoid ps eudocommunity. C ultural s ettings conducive to the occurrence of spirit pos ses sion are thos e in which an oppres sive s ocial structure s tifles pers onal protes t and weakens trust in the efficacy of social institutions and in direct actions to res olve s ocial conflicts. S ome healers make diagnoses and perform therapeutic acts while the influence of s pirits ; examples include C hris tian televangelis ts who P.619 are “moved” by the Holy S pirit and male S ufis (Mus lim), known in Morocco as the Hamads ha, who must tame 319 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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she-demon spirit of ‘A’is ha Qandis ha. However, mos t poss ess ed persons have a low s ocial status and are B y watching others, they typically learn how to react to spirits within them; s ome s pirits have a s pecific name agenda, whereas others may be ambiguous in their character and demands . P os sess ed persons become spirit carriers and are not personally res ponsible for what the s pirits force them to or s ay, although there always are some social on their behaviors . Malevolent spirits may demean, chas tis e, and caus e their carriers mental, bodily, and interpersonal harm. During positive experiences , may improve their own social s ituation as well as make as tute diagnoses and prescribe treatments for persons seeking help. T he s pirits are us ually judgmental and speak openly about social injus tice, abus ive and flawed family dynamics . T hey may call on es teem the carriers and to fulfill the carrier's des ires for certain poss ess ions and for improved relationships. men poss es sed by female spirits act like women, and women poss es sed by male spirits act like men, the cons truct of s exual identity is publicly examined. T he intricate dynamics of spirit poss es sion vary greatly cultures, and attempts to reduce and to explain them by us ing Wes tern ps ychiatric concepts are invariably unsuccess ful. Although s ome s pirit carriers may, be paranoid, ps ychotic, or hysterical, the proces s is not pathological. Analogous ly, the psychiatric process not be invalidated just becaus e s ome ps ychiatris ts are mentally ill.

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T he number of pers ons who, to s ome extent, fall into category of folk healer is large, and they range from the ludicrous to the sublime; examples include palm and card readers , astrologers, channelers , herbalis ts, New couns elors, psychic surgeons, and shamans. S hamans persons who follow a divers e call to healing and who receive and communicate instructions from s pirits. Different types of s hamans exis t in almos t all cultural groups , s uch as Haitian hungans , Wes t Indian Obeah P uerto R ican s piritis ts, and C hris tian faith healers. P sychos ocial profiles of s hamans s how that s ome are impos tors , s ome are mentally ill, and s ome are healthy, mature individuals . T rue shamans have an ability to recognize and to organize uncons cious needs and concerns , in thems elves and in their cultural group. T hose as piring to be shamans typically undergo an initiation that includes formal didactic training and recovery from a frightening, culturally-formulated, like experience. S ome W estern observers have regarded this experience as evidence of ps ychopathology—“the crazy witch-doctor.” S hamanic therapy usually takes place in a group is a public drama in which the patient and the shaman given strong support by the group. S hamans often thems elves as extraordinary persons, becaus e supernatural world and negotiating with s pirits is harrowing, even dangerous , work. Hallucinogens may taken to facilitate contact with s pirits ; an almos t instantaneous contact may be achieved when hallucinogenic snuff is blas ted up the s haman's nos e through a blowpipe, a practice of the Y amomomo in S outh America. T he s haman's tas ks include the 321 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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of los t s ouls, the pacification and exorcis m of demons, the provis ion of counter-magic, often by suppos edly sucking out harmful stones and animal parts from a person's body. B y demons trating objectively that has been dispelled, the s haman may effect cures suggestion. Other s hamanic treatments that may be therapeutic include herbal and other medications, surgery, bandaging, and chiropractics. F inally, prescribe steps through which patients can s tabilize cure and demonstrate their healthy s tate. P atients may told to perform acts of atonement and to adopt a new name or a new manner of dress . T he varieties and contexts of folk healing rituals are so that it is impos sible to generalize about them all, but shared commonalities can be delineated: F olk healing often is a group phenomenon, even a s ingle person is identified as sick; healer–patient relations hips are not emphasized. Healing groups are often ongoing rather than time limited. T hey occur with some regularity, and may drop in or drop out of the groups whenever desire. Healing groups may be quite large, sometimes involving hundreds of pers ons , thus enhancing support for participation, the magnificence of the ritual, and, through contagion, the manifestation of desired effects, s uch as trance states and Healing rituals are public events . Attendees include not only identified patients or troubled persons, but also family, friends , community members , and cult 322 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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devotees . P ers ons who are healed and prove to be adept at healing others may rise through the ranks to as sistant and then primary healers with a personal following. Alterations in consciousness are central to many healing experiences . W hen in a trance, healers or patients may expres s thoughts and emotions that otherwis e might be repress ed or suppres sed. T his expres sion may be therapeutic in its elf, but it als o often s erves to call attention to interpersonal and social conflicts that are troubling the entire group. T hese conflicts have a better chance of res olution when they are brought out in the context of a controlled healing ritual, rather than in private confrontations . Als o, becaus e s uggestibility during altered states of cons cious nes s, patients res pond positively to the s ugges tion that their experience clearly indicates success ful therapy. T he concept of insight, as usually unders tood by ps ychiatris ts, does not play a role in folk healing P erhaps the most psychiatrically detailed s tudy of a healing ritual is that of the P acific Northwes t C oast G uardian S pirit ceremonial described by W olfgang 1982. T he ceremonial appears to be therapeutic for society as a whole, as well as for depres sed, alcoholic, aggres sive pers ons . Initiates are reduced to a state of infantile dependency during 10 days of seclusion in the quasi-uterine shelter of the dark longhouse. P ers onality depatterning and reorientation are accomplis hed 4 days of alternating s ens ory overload and deprivation, 323 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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which result in rapidly alternating s tates of techniques include sleep deprivation, fasting to the of dehydration and hypoglycemia, rhythmic drumming and chants, blindfolding, restricted mobility, forced runs the woods, and s udden grabbing of initiates to stage a symbolic clubbing to death of their diseased, faulty Initiates then go through a phase of phys ical training, as s wimming in ice-cold water and dancing to the point exhaustion. T his is accompanied by intense and instruction in tribal lore. T he mythic theme of the ceremonial is death and rebirth. Initiates are “reborn” when they fully accept the wis dom of their culture, they s ee the G uardian S pirit in a dream or vis ion, and they are given new clothes and a new identity. A large number of tribal group members participate in the S uccess ful initiates who straighten out their lives may invited to return as leaders in s ubs equent ceremonials . A number of Native American tribes have the inges tion of peyote and other cons ciousnes s hallucinogens to achieve a religious and healing experience. However, the Navajo, perhaps the mos t therapeutically oriented of all cultures , focus instead on mind-numbing, ritual, group sings that may last as long P.620 1 week to treat illness es . P atients first undergo s elfpurification by bathing, sweating, and emes is. T he are invoked through specific s ongs and prayers, and healing powers are channeled onto a symbolic design then onto the patient, while tribal members work to reharmonize the patient's natural, s upernatural, and human environments . Ancient, relevant myths are 324 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and the gods are compelled to help, provided that the ceremony is performed s incerely and accurately. Analogous to the C hristian belief in demons is the belief in jnun (masculine singular: jinn), whims ical but potentially malevolent spirits. W hen insulted or they may pos sess a person and caus e depres sion, ps ychos is , s udden blindnes s, seizures, anorexia, or paralysis of the face and limbs. T reatment may the spirit, but sometimes, when the s pirit res ides permanently within a person, treatment is aimed at placating it by following its orders and by joining therapeutic cults . S imilar s pirits, as well as a healing are termed zar in northeast Africa and the Arabian penins ula. Zar illness often is diagnosed when us ual herbal, medical, and magical treatments fail to cure a person. V ictims, who are us ually frus trated women, elaborate healing rituals with their families, friends, and cult devotees . W hen a spirit's special s ong is played, entranced victim must dance and tell everyone what and favors her spirit wants to be appeased with to stop symptoms. T his thinly veiled attempt to get attention desirable things us ually is effective, at leas t V ictims may attend fairly regular zar rituals not only for ongoing therapy, but also as a form of entertainment.

C linic al Ps yc hiatric Prac tic e T he history of modern American ps ychiatry reveals that various s chools , each fairly certain, at the time, that held the key to unders tanding and treating mental have aris en, made contributions , and eventually have found lacking. T hus , in one period, intrapsychic conflict and the need for accurate interpretations were 325 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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T his was followed by an emphasis on interpersonal relations hips , replete with schizophrenogenic mothers, double binds , and catch 22s . Next came s ocial embodied by the community mental health movement. T he current new s chool is biologically oriented and guilt-relieving, politically savvy, and financially reimbursable brain disease metaphor for mental Opposite to reductionis m is synthesis , the core of the cultural ps ychiatric approach. T his approach demands cons ideration of all the biological, ps ychological, and social forces that impinge on mentally ill pers ons and treatment. It broadens the biopsychosocial model by pointing out that culture overarches and provides meanings for biological, psychological, and s ocial cons tructs, such as brain dis eas e, ins ight, and trance. However, the use of this approach in everyday clinical practice is quite difficult; it is eas ier to go with the flow one's culture, becaus e it feels right and natural, and because there are incentives to do s o. T he role of culture often becomes apparent only when ps ychiatris ts as sess and treat patients whose cultural backgrounds differ from theirs . T he s pecial problems arise in s uch s ituations can be resolved only if are able to adapt their s tandard procedures . T his need adaptability in clinical practice may be regarded with skepticism by those ps ychiatris ts who have embraced certain theory or approach that they apply to all However, from a cultural perspective, no one ps ychological, or social approach can fulfill the needs patients. DS M-IV -T R provides an outline for a cultural formulation designed to ass is t in the s ys tematic and treatment of patients. T he formulation calls for data 326 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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on (1) the cultural identity of the patients , including ethnicity, involvement with original and host cultures, language abilities; (2) the cultural explanations and of dis tres s used by patients and their community concerning their illnes s or situation; (3) the cultural impacting patients' s ocial situations , including work, religion, and kin networks; (4) the cultural and s ocial differences between the patient and clinician that may affect as ses sment and treatment, including problems communicating, negotiating a patient–clinician relations hip, and dis tinguishing between normal and pathological behaviors ; and (5) the formulation of an overall cultural ass es sment for diagnosis and care.

As s es s ment E thnic stereotyping is a problem not only for the but also for the patient and for society as a whole. T his practice is ins idious ly fostered in s cientific and popular articles, books , and polls that lump groups of people together in one category, s uch as African Americans , whites, or C atholics , and make generalizations. need to know about the various ethnic identities of patients as well as their current importance. One as sume that all Hispanics are alike; MexicanP uerto R ican Americans , for example, share as many cultural differences as they do commonalities . S ocial is a major variable. T his basic information may be through direct ques tioning and by observation of the patient's language, dres s, knowledge of social and interpersonal style. C linicians s hould not jump to conclusions bas ed on knowledge of a patient's culture. Having visited a 327 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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homeland or community, having read a book about it, having a pers onal friend whos e cultural heritage is to that of the patient does not make one an expert, although it may help clinicians to ask appropriate questions and alert them to poss ibilities , for example, a P uerto R ican may engage in s piritis m or that a G reek immigrant may believe in the evil eye hex. It is better to approach ethnic patients without preconceived notions even the mos t basic areas ; in s ome cultures, for sibling may include a person other than those regarded brothers or sis ters in the W es t. Attitudes and with authority figures should be determined. An upperclas s Anglo patient is apt to react negatively to an authoritarian s tance by a ps ychiatris t, but a patient another culture may regard such a stance as and helpful. S imilar attention should be given to toward s ex-related roles; male patients from a culture emphasizes machismo may have difficulty in working a female clinician and so may distort their complaints history. C linicians mus t determine whether patients' reluctance discuss certain topics is the result of pers onal s hynes s, ps ychopathology, or adherence to their s ocial group's customs and etiquette. F rank and detailed ques tions sexuality, especially in the initial evaluation, may be perceived as inappropriate and even offens ive by from cultures in which sexuality is cons idered a private matter. E thnic patients may be touchy about many such as immigration s tatus, family relationships , and finances . An Algerian man with a long history of panic disorder evaluated in an American clinic with a chief complaint 328 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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need medicine.” He told the ps ychiatris t that he had unable to find a job in 6 months and that he depended the charity of several people at the local mos que at he was allowed to sleep. He planned to return home for week, to get married, and to return to his current When asked how he planned to s upport himself and a wife, he became angry and said, “that is none of your business .” He refused any more conversation and demanded medication. T he psychiatris t P.621 explained that the question he had asked was routine that he was concerned about the patient's welfare. T he patient was given a 1-month supply of medication but not keep his return appointment. T he case als o typifies many Muslim patients who expect only medications ps ychiatris ts; in P akistan, ps ychiatric patients usually therapy but rather demand intravenous (IV ) fluids, in to demons trate to family and friends that their illnes s is medical. In contras t, s ome Hindu patients may regard ps ychiatris t as a type of guru and accept advice and guidance, es pecially if family members can be drawn the proces s. Mains tream Americans may talk about depress ion, hallucinations , and conflicts , but persons from other cultures may talk about s omatic pains , liver problems, heavenly or s atanic visions , brain ache, and s hadowy figures . T he us e of ps ychological terms and constructs expres s distress is a relatively recent phenomenon in cours e of human his tory; it is neither s uperior nor to somatic presentations. However, ps ychiatris ts may befuddled by patients reared in cultures in which 329 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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ps ychologizing s eems to be an odd way of selfIn fact, s omatic pres entations may be advantageous in they avoid the s tigma of mental illness . Als o, they may serve to elicit help and social s upport without directly confronting persons or institutions who might retaliate agains t the patient. It is true that adminis tration of medications labeled as antidepres sants is often us eful treating patients with s omatic presentations , but the complex pos sibilities as sociated with somatization may completely miss ed if they are regarded me rely as depres sive equivalents. V erbal and nonverbal communication patterns vary greatly among cultural groups. T seng and J ohn F . McDermott provide the following examples: T he J apanese patient nods his head and keeps saying (yes).…T he hai and the nod probably show only polite participation in the convers ation. T he Hawaiian may your eyes because he was brought up by a who taught that eye contact is rude and has an meaning.…T he S amoan's miss ed appointment may no more than a cultural-social cas ualnes s toward fixed dates and arrangements.…T he C hinese client who “My mother is always kind,” when the mother has been dead for some time is not neces sarily s uffering from unrealized, incomplete grief. T he C hines e language past tens e verb forms .…P eople of Oriental background tend to smile and laugh when they are embarras sed, anxious, or sad. Ass es sment of emotionality and motor behavior is influenced by the cultural norms of the ps ychiatris t and the patient. R es erved Anglo psychiatrists may interpret flamboyant or seemingly overs incere behavior of some 330 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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Mediterranean area and Middle E as tern patients as histrionic, whereas the patients may judge the to be uncaring. T he diagnosis of hyperactivity in often depends on the tolerance levels of family, and ps ychiatris ts. A study involving ps ychiatris ts from Asian countries who were s hown videotapes of active children demons trated great national differences in thresholds for diagnosing hyperactivity. Hallucinations may be a symptom of psychosis, but, among some His panic groups, they may be ass ociated with milder ps ychopathology or may even be normal. A teenage girl who has vis ions of the V irgin may s imply be indicating her own purity. W hen persons may experience positive hallucinations in they receive advice and s upport from a dead parent. as sess ment of delusions can be tricky, because, by definition, a delus ion is a belief cons idered fals e by members of a society. T he exis tence of the devil verified s cientifically, yet so many people believe in the devil that such a belief cannot per se be considered delus ional. Although there is no s uch entity as the race, belief in it among G ermans in the Nazi era was widespread that it could not be regarded as delusional. V arious subcultural religious cults , political groups, and organizations , s uch as the white s upremacis t Aryan B rotherhood, may hold beliefs considered false by persons in s ociety at large, but they are probably not delus ional in a traditional ps ychiatric s ens e; exceptions include odd beliefs that may result in s uicide pacts or truly harmful behaviors. C ases involving established religions , s uch as J ehovah's W itness es and C hris tian S cience, in which pers ons may refus e certain medical 331 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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treatments when severe bodily harm and even death ensue, are us ually handled by the legal s ys tem; courts generally have upheld the rights of adults to withhold neces sary medical treatment for thems elves but not for minors under their control. B ehaviors that may appear ps ychotic may, in fact, be normal when unders tood in their cultural context; a traditional C hines e treatment for kidney deficiency disorder requires an adult to drink the firs t morning of a young boy. C onversely, some behaviors that may appear normal may be pathological. Among the Amis h, example, symptoms of mania may include racing one's horse and buggy, driving a car, using illegal drugs, with a married person, excess ively us ing a public telephone, and treating lives tock too roughly. However, recent years, the “E nglis h” (outside) world has intruded Amish society, so that teenagers engaging in the previous ly lis ted behaviors may be acting out as to manic. P sychiatrists must not only ass ess patients vis their particular cultural groups but als o must as ses s each patient's group vis -à -vis the mainstream culture which the group is a part. W hen in doubt, the should as k members of the patient's social group if cons ider the patient's beliefs and behaviors to be T his process also allows the ps ychiatris t to ass es s, superficially, the s ocial group itself. P atients experience and des cribe their illness es , ps ychiatris ts diagnos e and treat dis eas es. E ach has her own way of comprehending the patient's condition. is extremely important for the ps ychiatris t to elucidate patient's explanatory model of the illness . What does patient think caused the illness ? How is the illness 332 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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affecting the patient's mind and body? T hrough what mechanisms does the illnes s work? Does the illness name? What does the patient think will happen if the illness goes untreated? W hat treatment does the think may be effective? W hat treatments have already been tried? If the patient's explanatory model differs that of the psychiatrist, then as sess ment and treatment become problematic. S pecial problems arise when the psychiatris t and the patient do not s peak the s ame language. T here is a tendency to diagnos e more psychopathology when bilingual patients are interviewed in E nglis h rather than their native tongue, for example, slow speech may depres sion and grammatical errors, a thought dis order. Interpreters function best when they have s ome with and training in mental health. Wes termeyer has described three models in which interpreters may (1) as an as sistant to the ps ychiatris t who conducts the interview, (2) as a partner to the psychiatrist in a interaction with the patient, (3) as a primary interviewer the presence of and under the direct s upervis ion of the ps ychiatris t. Interpreters must be taught when to translations that are word-for-word summaries or elaborations of what the patient pres ents. It is helpful the ps ychiatris t to inquire about the trans lator's feelings about and identification with the patient, the patient's cultural group, and social clas s or caste differences might dis tort the accuracy of the translation. S imilarly, patients s hould be as ked about their level of comfort and confidence in the translator. F amily members interpreters pos e s pecial problems in that they may their trans lations to achieve a specific goal, s uch as 333 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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ensuring hospitalization or s pecial treatment. P.622 F inally, great caution s hould be us ed in interpreting the res ults of ps ychological tes ts and rating s cales unless have been validated for the cultural group under cons ideration. More and more, such tes ts and scales , suitable for use in s pecific groups, have become C linicians s hould not attempt to us e their own because the results may be quite mis leading. In a study of 1,005 adult, low-income, primary care patients New Y ork C ity, the typical profile of a pers on among 20.9 percent of those who endorsed ps ychotic was a s eparate or divorced Hispanic who s poke a primary language. Although the rating ins truments translated from E nglis h to S panish and then backtranslated to identify and to correct translational difficulties , they were not validated for the mainly immigrant Dominican and P uerto R ican groups under study. It is likely that many of the so-called ps ychotic symptoms were really misperceptions of s timuli with depress ion and anxiety, a well-known in C aribbean cultures .

Therapy P sychiatrists are trained in what anthropologists call an approach in which scientific and presumably valid cons tructs apply to all patients, although there is a for atypicality. T he emic approach eschews cons tructs and, instead, attempts to dis cover patients' unders tandings of their illness es as experienced within context of their cultures . T he culturally s ens itive 334 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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ps ychiatris t balances the etic and emic approaches some cases , may attempt to “convert” patients to the ps ychiatric pers pective of their condition. However, some patients' explanatory models for mental illnes s be embedded within a cultural world view that is to change by negotiation or education. In s uch cases, ps ychiatris ts mus t be flexible in their therapeutic and must respect the patients' beliefs. If ps ychotic for example, inflexibly attribute their symptoms to a work hex, psychiatris ts may support family efforts to obtain folk antidotes or protective amulets and may attribute s pecific antihex properties to the medicine that they prescribe. T his is not trickery on the part of ps ychiatris ts (patients will detect insincerity quickly) but adaptation of s cientific therapy to make it acceptable to patients. T he better the ps ychiatris ts' unders tanding of patients' explanatory models , the better they are able develop an adaptive strategy. In s ome cultures, even color of the medication may alter its effectiveness for patient. P os sible medication s ide effects , even minor ones , mus t be explained in great detail, because some ethnic patients may become noncompliant at the first inkling of a side effect, although, out of respect or deference to the ps ychiatris t, they may s tate that they still taking their medication. T he field of ethnopsychopharmacology, pioneered by K en-Ming showing that genetic and dietary ethnic differences alter responses to medication. Many Asian patients, for example, metabolize benzodiazepines slowly and to lower dos es of lithium (E skalith) and haloperidol (Haldol) than do C aucas ians. Mains tream psychotherapy often focus es on the 335 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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achievement of independence as a result of working through conflicts . T he goal and the process us ed to it may be inappropriate for patients from many cultural groups . T herapy with a Hindu in India, for example, focus on restoration of the patient within a family and a social group that values dependence and the of angry thoughts; therapy with a Hindu Indian to the United S tates , however, may have a different Immigrant patients may be torn between maintaining values of their homeland and adopting thos e of their country. T he process of acculturation may be painful, therapeutic attempts to hasten the process may exacerbate the situation with resultant depres sion, and even acute psychotic episodes . Immigrants often best when they are able to retain some of their old and behavior patterns and to participate in ins titutions and rituals that have been transplanted from their homeland. Immigrant children through their in schools tend to acculturate rapidly and to act as socialization agents for adult family members ; the proces s may be a caus e of intergenerational s trife. P sychotherapy with patients from different ethnic and social backgrounds may require much flexibility and awarenes s of s tated and unstated is sues that must be addres sed. T rust is an is sue in a white therapis t–black patient relationship, whereas s tatus contradiction is an is sue when the s ituation is revers ed, and identity is an is sue when the patient and ps ychiatris t are black. from groups who believe thems elves to be victims of discrimination may be unwilling to engage in selfdisclos ure unless the ps ychiatris ts ans wer questions thems elves . S ome patients may present gifts or may 336 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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their families to sess ions. P s ychiatris ts mus t be able, in these ins tances , to dis tinguish between ps ychologically and culturally motivated disorders . S ometimes , it is des irable to collaborate with folk In 1978, the W orld Health As sociation and United C hildren's F und (UNIC E F ) is sued a joint declaration on primary health care which called on clinicians to folk healing practices that were proven or considered the community to be helpful. C ollaboration is feasible when the ps ychiatrist and the folk healer are ethical practitioners who respect each other's s kills and patient, for example, may accept medication and hospitalization from a ps ychiatris t and psychological social help from a folk healer. It is not uncommon for a patient independently to seek help from ps ychiatris ts folk healers at the same time. R ecognition of the importance of culture in as sess ing treating patients is evidenced by a 2002 report of the G roup for the Advancement of P s ychiatry. It provides to-date, helpful examples of cultural formulations and culturally informed therapy on s ix patients: a middle depres sed, alcoholic, sexually troubled Irish American whos e s ymptoms subsided after he was reintroduced spirituality through AA and who then entered a to pursue a religious vocation; a middle aged, devout Muslim, P akistani housewife with severe depres sion acculturation and personality problems who believed had been hexed and was helped during a 5-year individual and couples therapy; a F ilipino-American medical student with social phobia and academic problems whos e culturally mediated distorted thoughts were helped with cognitive-behavioral therapy; a 30337 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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old black, K enyan immigrant with major depres sion, alcohol and cocaine dependence, and religious and spiritual problems who was helped by an inpatient interdisciplinary team that he likened to a traditional, African, tribal “C ouncil of E lders ”; a 30-year-old, s ingle, dysthymic “good C atholic girl” who resolved her oedipal and rage is sues with ps ychodynamic psychotherapy; 56-year-old E cuadorian, B aptis t minis ter with many personality problems who finally trusted a S panishspeaking therapist with whom he could dis cuss is sues without fear of being criticized, denounced, or stigmatized. J ust as culture strives to organize a society into a integrated, functional, s ens e-making whole, so too cultural psychiatry s trive to make clinical psychiatry logically integrated, functional, and s ens e making. insights from cultural psychiatry are applicable to the entire spectrum of ps ychiatric practice, from ps ychoanalys is to ps ychopharmacology.

S UG G E S TE D C R OS S S ection 4.2 covers s ociology and ps ychiatry. An review of s ocioeconomic as pects of health care is contained in S ections 51.5a and 52.2. Also relevant to sociocultural iss ues in psychiatry is the discus sion of ps ychiatry (in S ection 52.1).

R E F E R E NC E S P.623 Alarcon R D, F oulks E F , V akkur M. P ers onality 338 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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and C ulture. New Y ork: W iley; 1998. *Al-Is sa I, ed. Handbook of C ulture and Mental Inte rnational P e rs pe ctive . Madison, C T : International Univers ities P ress ; 1995. B erry J W , P oortinga Y H, P andey J , eds . Handbook C ros s C ultural P s ychology. 2nd ed. B oston: Allyn B acon; 1996. B olhenlein J K , ed. P s ychiatry and R e ligion. DC : American P s ychiatric P res s; 2000. B os well J . C hris tianity, S ocial T ole rance , and Homos e xuality. C hicago: University of C hicago 1980. B rown LB . T he P s ychology of R e ligious B e lie fs . Academic P res s; 1987. C omas-Diaz L, G riffith E E H. C linical G uide line s in C ultural Me ntal He alth. New Y ork: W iley; 1988. C rapanzano V , G arris on V , eds . C as e S tudie s in P os s e s s ion. New Y ork: W iley Inters cience; 1977. Des jarlais R , E is enberg L, G ood B , K leinman A. Me ntal H ealth: P roble ms in L ow Income C ountries . Y ork: Oxford Univers ity P res s; 1995. *F avazza A. B odies Unde r S ie ge : S e lf-Mutilation Modification in C ulture and P s ychiatry. 2nd ed. 339 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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J ohns Hopkins University P ress ; 1996. F avazza A. P s ychoB ible: B e havior, R eligion, and B ook. C harlottes ville, V A: P itchs tone P ublis hing; F ernando S . Me ntal H ealth, R ace , and C ulture . New S t. Martin's P ress ; 1991. *G alanter M. C ults : F aith, H ealing, and C oe rcion. New Y ork: Oxford University P ress ; 1999. *G roup for the Advancement of P s ychiatry. C ultural As s es s ment in C linical P s ychiatry (F ormulate d by C ommittee on C ultural P s ychiatry, R e port No. 145). Was hington, DC : American P sychiatric P ublis hing; Hollifield M, G eppert C , J ohns on Y , F ryer C : A V ietnames e man with s elective mutism: T he of multiple interacting “cultures ” in clinical ps ychiatry. T rans cult P s ychiatry. 2003;40:329. J elek W G . Indian He aling: S hamanic C e re monialis m P acific Northwe s t. S urrey, C anada: Hancock Hous e; J ones J W . C onte mporary P s ychoanalys is and New Haven, C T : Y ale Univers ity P res s; 1991. K irmayer LJ : As klepian dreams: T he ethos of the wounded healer in the clinical encounter. T rans cult P s ychiatry. 2003;40:248–277. K leinman A. R ethinking P s ychiatry: F rom C ultural 340 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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C ate gory to P e rs onal E xpe rie nce . New Y ork: F ree 1988. K oenig HC , ed. Handbook of R e ligion and Me ntal S an Diego: Academic P res s; 1998. K urtz E . Not G od: A H is tory of Alcoholics Wayzeta, MN: Hazeldon E ducational S ervices; Littlewood R . T he B utte rfly and the S erpe nt: E s s ays P s ychiatry, R ace , and R e ligion. London: F ree B ooks ; 2000. Mezzich J E , K leinman A, F abrega H, P arron DL. and P s ychiatric Diagnos is . W ashington, DC : P sychiatric P ress ; 1996. P arament K I. T he P s ychology of R e ligion and Y ork: G uilford P ress ; 1997. P edersen P B , Iraguns J G , Lonner W J , T rimble J E , C ouns e ling Acros s C ultures . 4th ed. T hous and S age; 1996. P odvoll E M: S elf-mutilation within a hospital setting. Me d P s ychol. 1969;42:213–221. R andi J . T he F aith He ale rs . B uffalo, NY : B ooks ; 1989. R izzuto AM. T he B irth of the L iving G od. C hicago: Univers ity of C hicago P ress ; 1979. 341 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/4.1.htm

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S atcher D. S urge on G e nerals ' R eport on Me ntal C ulture, R ace , and E thnicity. R ockville, MD: U. S . Department of Health and Human S ervices; 2001. S imons R C . B oo! C ulture, E xpe rience, and the R efle x. New Y ork: Oxford University P ress ; 1996. *T seng W S . Handbook of C ultural P s ychiatry. S an Academic P res s; 2001. T s eng W S , McDermott J F . C ulture, Mind and New Y ork: B runner, Mazel; 1981. Ward D, ed. C ulture and Altere d S tate s of B everly Hills, C A: S age; 1989. Warner M. Alone of All He r S e x: T he Myth and C ult V irgin Mary. New Y ork: Landon House; 1976. Wes termeyer J . P s ychiatric C are of Migrants . Was hington, DC : American P sychiatric P ress ; 1989.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 5 - Quantitative a nd E xperimenta l Methods in P sychiatry > 5.1 E pidemiology

5.1: E pidemiology J uan E . Mezzic h M.D., Ph.D. Tevfik B edirhan Üs tün M.D., Ph.D. P art of "5 - Quantitative and E xperimental Methods in P sychiatry"

G eneral C onc epts E pidemiology is one of the fundamental sciences of health and a major approach to the unders tanding and advancement of medicine and health care. is a useful tool for clinicians to link their work to populations and complete the clinical picture. It perspective about the health of the general population, including the caus es and courses of thes e illness es . As concept of health is undergoing dis cernible expans ion, subject and methods of epidemiology require growing differentiation and refinement. C onsequently, it is important that epidemiology be understood and discuss ed in a comprehensive manner s o as to the fulfillment of its mis sion and broad objectives . In line with the above pers pectives , this chapter on ps ychiatric epidemiology, although concise, attempts to take a broad look at its subject matter. It s tarts with an examination of its definition, evolution, and context, striving for a capsular understanding of the of this burgeoning field, as well as of its his torical and 343 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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cross -sectional contextualization. It proceeds to review methods of epidemiology, including its key cons tructs variables , the design of epidemiological s tudies (iss ues types ), and the properties , forms, and validation of epidemiological instrumentation. Next, some important epidemiological findings are pres ented and commented on as they deal with the dis tribution of mental disorders and its related factors , of disability and the burden of disease, and of the positive aspects of health social s upports , and quality of life), as well as findings concerning the application of epidemiological methods health care and the formulation and evaluation of policies . T he final section explores future perspectives, including the integration of genetic and environmental analyses , a fuller cons ideration of the social matrix and cultural frameworks , and the more active us e of informational, and communication technologies , all contributing to the broadly based development of international class ification and diagnostic systems for health and their effective us e for health restoration and health promotion at clinical and population levels.

Definitions of E pidemiology and Ps yc hiatric E pidemiology T he etymological roots of epidemiology include (diseases vis iting a community) and logos (their s tudy). and the cons ideration of the origins of epidemiology within the medical field seem to have led the R andom Hous e Dictionary of the E nglis h L anguage to define epidemiology narrowly as “the branch of medicine with epidemic diseases.” T he evolving broadening of the range of diseases 344 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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to epidemiology and an incipient interest for its contextualization contributed in recent decades to definitions s uch as that in Maus ner & B ahn's “the study of the distribution and determinants of and injuries in human populations .” T his notion is s till quite prevalent. An emerging new concept of epidemiology pres ents discipline as the s tudy of health and dis eas e as a full spectrum across the human life s pan with a population approach, including etiological factors, comorbidities, and uses and outcomes of clinical care. line with this, Mervyn S us ser propos es cogently that epidemiology is the s tudy of the occurrence, caus es , control of health events in human populations . F urthermore, the las t 2001 edition of the Dictionary of E pidemiology, fourth edition, defines epidemiology as study of the dis tribution of health-related s tates or in specified populations and the application of this to the control of health problems. T o arrive at a reasonable definition of the specific field ps ychiatric epidemiology, it should be helpful to be cons istent with the emerging concept of epidemiology outlined above—concerned with both ill and positive as pects of health—as well as with a modern concept of ps ychiatry involving the diagnos is and treatment of mental disorders and the promotion of mental health. T hus, ps ychiatric epide miology may be defined as the of the dis tribution of mental illnes s and pos itive mental health and related factors in human populations . the principal pos itive mental health variables to be cons idered are individual s trengths , s ocial functioning participation, social s upports , and quality of life. T hes e 345 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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positive health aspects are, of cours e, not only relevant mental health, but also to general health. Among factors , one could include contributing etiological as sociated general health conditions , and cours e characteristics , mental health s ervices, and mental health policies . E vidence-based medicine enhanced by experience and wis dom is a basic methodological approach for epidemiological study.

E volution of the C onc epts of E pidemiology and Ps yc hiatric E pidemiology T he intricacies of epidemiology in its goals and can be organized paradigmatically acros s recent in ways reflective of the prevailing cultural framework social matrix. In effect, E zra and Mervyn S us ser have propos ed an elegant s chema formulating the evolution modern epidemiology in terms of the following eras and symbols : P.657 1. T he era of s anitary statis tics (firs t half of the 19th century), emblematized by the concept of mias ma, and focus ed on foul and toxic environmental conditions. 2. T he era of infectious dis eas e epidemiology (late century through the firs t half of the 20th century), emblematized by germ theory. 3. T he era of chronic dis eas e epidemiology (second of the 20th century), allegorized with a black box, involved with a myriad of ris k factors. 346 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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4. An emerging era of ecological epidemiology, allegorized with C hines e boxes, and concerned gene–environment interactions and the different layers of the social matrix. F urther delineation of thes e paradigms is provided in T able 5.1-1, which als o includes features of the and preventive approaches characteris tic of each era. schema is valuable not only to organize and explain complex history of epidemiology, but also to point out importance of public health as an ultimate goal in each era, transcending variations in social circums tances instrumental methodology.

Table 5.1-1 Four E ras in the E volut Modern E pidemiology E ra

Paradigm

Analytical Approac h

Preventi Approac

S anitary statis tics half of 19th century)

Mias ma: poisoning by foul emanations from s oil, and water

Demons trate clus tering of morbidity and

Draining, sewage, sanitatio

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Infectious disease epidemiology (late 19th century through firs t half of 20th century)

G erm single relate one to one to specific diseases

Laboratory is olation culture from disease experimental transmis sion, and reproduction of les ions

Interrupt transmis (vaccine is olation the affec through quarantin and feve hospitals and, ultimately antibiotic

C hronic disease epidemiology (s econd half of 20th century)

B lack box: expos ure related to outcome without neces sity for intervening factors or pathogenes is

R is k ratio of expos ure to outcome at individual level in populations

C ontrol r factors b modifyin lifes tyle (diet, exercise, etc.) or agent food, etc environm (pollution pass ive smoking, etc.)

E cological epidemiology

C hines e boxes :

Analys is of determinants

Apply bo informati

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(emerging)

relations within and between localized structures organized in a hierarchy of levels

and outcomes at different levels of organization: within and acros s contexts (us ing new information systems ) in depth (us ing new biomedical techniques)

and biomedic technolo to find leverage efficaciou levels, fr contextu to

F rom S us ser M, S us ser E : C hoosing a future for II. F rom black box to C hinese boxes and ecoJ P ublic He alth. 1996;86:674–677, with permiss ion. T he above schema is also applicable to ps ychiatric epidemiology, although the his tory of this specialized started in full force in the cours e of the 20th century— es pecially in its second half—and has now entered energetically into the 21st century. T hus, psychiatric epidemiology as a recognized dis cipline today largely corres ponds to the chronic diseas e era and, at a s tage walk into more tentatively, to the era of ecological epidemiology, the general s chema outlined earlier. 349 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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It would be useful now to examine briefly the various phases or generations of ps ychiatric epidemiology that corres pond principally to the types of des ign and instrumentation used for epidemiological inves tigation.

F irs t-G eneration S tudies F irst-generation studies, which tended to be relatively unsystematic inquiries, often dealing with treated populations, extended typically through the mid-20th century. S ome illustrative examples follow. In 1838, J ean E tienne E s quirol documented that the number of individuals admitted to hospitals in P aris because of insanity had increased fourfold in 15 years (from 1786 to 1801). A s tudy of the prevalence of mental derangement and retardation in Mass achus etts us ing key informants (general practitioners, clergy) and hospital records 2,632 “lunatics ” and 1,087 “idiots ” that needed care. J oseph G oldberger et al. determined in the 1920s, case-control methods, that pellagra was connected to nutritional deficiency. W ithout s pecifying specific nutrients, dietary changes led to drastic reductions of pellagra in institutionalized populations . B rugger's study in 1929 attempted to es timate the prevalence of mental disorders in a defined population (T huringia, G ermany), using a census method. R obert F aris and W arren Dunham investigated the geographical distribution of all patients hos pitalized for the firs t time between 1922 and 1934 in C hicago. T hey found that the rate of schizophrenia decreas ed progres sively with distance away from the center of the 350 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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city (from 46 to 13 percent of all admis sions ), leading to the formulation of a number of explanatory proposals.

S ec ond-G eneration S tudies S econd-generation studies were conducted after World War II, taking advantage of the extens ive interes t generated by the perceived frequency of mental in war s ettings and information and instrumentation emerging from profes sional work with such cas es and situations. T hey es tablis hed community s urveys as a tool in ps ychiatric epidemiology. T hey us ed either symptom checklists or relatively uns tructured as basic information-gathering methodology. S ome key studies of this type follow. T he Midtown Manhattan S tudy engaged s pecially social workers to conduct interviews of community res idents and collect s ymptom and other checklis t T he study as sumed that mental illnes s was distributed fundamentally as a continuum from normality and that was anchored adequately by ps ychos ocial impairment dysfunctioning). On the bas is of ps ychiatris ts ' review of collected data, it was found that 23 percent of the was severely psychiatrically impaired. T he S tirling C ounty S tudy in New Y ork ass es sed 1,010 individuals in the community via lay interviewers us ing questionnaire. Additional information was obtained general practitioners and psychiatrists in the area. R es earch ps ychiatris ts then reviewed the obtained us ing the American P sychiatric As sociation's P.658 first edition of the Diagnos tic and S tatis tical Manual of 351 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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Me ntal Dis orde rs (DS M) as a reference and concluded prevalence of mental disorders was 20 percent. A s tudy of social clas s and mental illnes s in a treated population in New Haven, C onnecticut, was conducted August Hollings head and F rederick R edlich. T hey higher prevalence of mental dis orders in individuals of lower socioeconomic clas ses . T hey als o found that in lower socioeconomic clas ses tended to be treated electroconvuls ive treatment (E C T ) and medication, whereas thos e in higher class es tended to be treated ps ychotherapy.

Third-G eneration S tudies T hird-generation studies have characteris tically used structured interview data aimed at identifying s pecific ps ychiatric disorders, as well as more s ophis ticated statis tical techniques . F undamental to the of survey interviews that were not only more s tructured, but actually s pecific in the lis t of questions to be and s cheduled in the order in which they were was the establishment of ps ychiatric nosologies with explicit inclusion and exclus ion diagnostic criteria (as signment rules to particular categories of ps ychiatric disorders ). T he us e of operational or explicit diagnostic criteria for diagnosis of mental disorders was first proposed by E dward S tengel in his international review of clas sifications. T he earlies t set of explicit diagnostic reported in the scientific ps ychiatric literature was that published by J osé Horwitz and J uan Marconi in 1966 in Latin America for alcohol abuse and thos e by B erner in Aus tria for psychotic disorders. However, the 352 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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criteria s ets firs t us ed for the development of fully structured and s cheduled s urvey interviews were those included in DS M-III, which were bas ed on the earlier of J ohn P . F eighner et al. and R obert S pitzer et al. In cours e, the value of psychiatric nos ology developments a new generation of epidemiological findings was reciprocated by the use of population epidemiological res ults for the refinement of psychiatric nosologies . has articulated a promis ing relationship between diagnosis and population epidemiology. Illus tratively, four major epidemiological s tudies corres ponding to this third generation are outlined from a methodological perspective. T he E pidemiological C atchment Area (E C A) s tudy trained lay workers to adminis ter the Diagnostic S chedule (DIS ), a fully s tructured and scheduled instrument aimed at identifying a s et of DS M-III categories , to individuals in several institutional and community s amples in available U.S . s ites. T he National C omorbidity S urvey (NC S ) was aimed at appraising the prevalence of a s et of ps ychiatric in as sociation or not with s ubs tance use dis orders, in a representative U.S . national household sample. It also inves tigated ris k factors for mental illness . G iven its national s cope, this study was able to explore s everal contrasts of interests, s uch as that between urban and rural areas . T his s tudy, as did the preceding one, used trained lay interviewers to administer, in this cas e, the C ompos ite International Interview S chedule (C IDI), a structured and scheduled interview. T his instrument focus ed in identifying DS M-III-R , as well as s ome and tenth revision of the Inte rnational S tatis tical 353 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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C las s ification of Dis e as e s and R e late d He alth 10), mental disorders .

F ourth-G eneration S tudies T he firs t three generations of psychiatric studies outlined above have been characterized and differentiated from each other by design and instrumentation variables, but are all s imilar in their on mental disorders . It is pos sible now to elucidate a generation in ps ychiatric epidemiology investigations , which is characterized by a broader focus that certainly includes mental disorders but uses more frameworks, such as both ill and pos itive health, and with meaning, culture, and other interpretative T he emergence of thes e broader s tudies has , in part, heralded by what Arthur K leinman has termed the ne w wave of e thnographie s . Also dis cernible in this array of epidemiological s tudies is their subs tantial interest and involvement in the development and formulation of health policies . F or illustrative purpos es , three recent studies follow. T he B razilian Multicentric S tudy of P s ychiatric combined a highly structured epidemiological cross sectional design with an anthropological interpretation the meaning of ris k factors. A representative s ample of 6,470 adults was s creened for the pres ence of ps ychopathology, with a s ubs ample selected for diagnostic psychiatric interviews with a B razilian DS M-III. T his evolved into a nes ted cas e-control s tudy which all s ubjects positively diagnosed as having a nonps ychotic dis order were cons idered cases and compared to a random sample of thos e not having 354 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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evidence of any disorder. T he results sugges ted that gender (and related social proces ses and roles ) has to taken as a fundamental dimens ion. T hey further that any theoretical interpretation of the findings s hould cons ider the fundamental is sue of meaning with a sociocultural matrix. T he National S urvey of Mental Health and W ell-B eing Aus tralia engaged a national population s ample with the C IDI to elicit IC D-10 mental disorders . Of relevance to its consideration as fourth generation is this Australian s tudy also investigated years of life lost, quality of life, and use of mental and general health services . Its impact on the development of national policies s eems to have been cons iderable. T he World Mental Health S urvey (W MH) is a World Health Organization (W HO) initiative that aims to examine the form and frequency, s everity, as sociated disability, and treatment of mental dis orders in more 14 countries. T he novelty of this s tudy is not only the simultaneous application of s imilar ins truments in different countries , but also the as sess ment of social cons equences, burden of disease, and service delivery comprehensive manner. T he initial report of the study edited by R onald C . K es sler and T evfik B edirhan covered a total of 60,559 community adult res pondents from general population s amples in 14 countries (s ix developed, eight developed) in different world regions . T he as sess ments were carried out within the WMH of the W HO C omposite International Diagnostic T he es timated lifetime prevalence of having any WMHdisorder (according to DS M-IV criteria) ranged widely 8.6 percent in S hanghai to 47.3 percent in the United 355 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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S tates. At least one-third of the lifetime cas es had a month epis ode. In the United S tates, 33.7 percent of cases were mild, whereas, in Nigeria, 81.6 percent of cases were mild. S erious dis orders were as sociated in countries with substantial disabilities, such as being us ual-role in the pas t year. Although severity of a is strongly related to treatment in all countries, 30 to 53 percent in developed countries and 72 to 83 percent in less developed countries received no health care treatment. T his is not merely a matter of limited res ources , as the number of treated mild and cases s eem to exceed the number of untreated serious cases in all countries . T hese findings put in perspective many pieces regarding the need and utilization of and illness impact on the lives of people and provide us eful insights about the organization of mental health services . F or example, many mental dis orders s eem to in late childhood and adolescence and progres s into serious dis orders with significant social cons equences, which appears to reinforce the need for early clinical interventions . P.659

Purpos es and Us es of E pidemiology In a clas sic paper written in 1955, the B ritish epidemiologist J eremy N. Morris proposed a number of us es for epidemiology. Despite their relatively early formulation, they are widely acknowledged as still relevant. T hey are s ummarized and briefly commented below.

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His torical s tudie s : T his refers to the importance of having a chronological pers pective in the s tudy of health and illness in human populations . T he preceding section on the evolution of general and ps ychiatric epidemiology illus trates the value of appraisals. Also relevant here is the longitudinal depiction of changes in patterns of disease distribution in human populations. C ommunity diagnos is : It has long been that epidemiology furnis hes crucial information on health of a community (i.e., on its diagnos is in a fundamental s ens e). E fforts to conceive community health indices are relevant here (e.g., D. F . 1966). T his application of epidemiology als o has implications for clinical care in terms of situational contextualized clinical diagnosis and of the identification of high-morbidity areas. Apprais al of an individual's health pros pe cts : T his is based on relevant population studies and made on the likelihood of life or death of an as a member of the res earched population. S uch inferences may refer to risk factors , as well as to expectation and life lived with dis abilities . Health s ervice s and ope rational re s earch: S cientific inves tigations on the organization and performance health services are becoming an area of active res earch. F or this, epidemiological methods can be quite helpful—from prevalence s tudies to the as sess ment of need for care to the evaluation of treatment coverage and outcomes. C omple ting the clinical picture : W hen initially 357 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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by Morris , this use of epidemiology was best by determining gender and age factors ass ociated with a disease. In mental health, this purpos e is exemplified, in particular, by the of a nosological profile afforded by community surveys , which have been used for development of ps ychiatric clas sifications in IC D-10 and DS M-IV , discuss ed by T im S lade. Ide ntification of s yndrome s : T he use of for the elucidation of different types of “peptic ulcer” and for distinguishing Alzheimer's dis eas e from multiinfarct dementias is illus trative here. Models could be built to as sociate ris k and other factors to signs , s ymptoms, and course to generate nosological hypothes es. More recently, to use ethnographical approaches along with epidemiological methods for elucidating new syndromes, such as ataque de nervios and chips ychos is , that before were neglected as exotic, culture-bound syndromes have begun to emerge. C lue s to caus e s : T here are s ubs tantial indicators us e of epidemiology in clarifying the etiology of clinical problems . E xamples include the of nutritional deficiencies , indus trial cancers , smoking to lung cancer, and occupational T he searching for causes of dis eas e and protective factors for health may lead to better prevention Within the emerging multilevel paradigm, epidemiology is not a “head-counting” activity. It is systemic s cientific activity that ans wers clinical and public health questions with proper analys es of risk factors , outcomes, and other ass ociated variables. 358 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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also offers a broader perspective of overall health and health care provision in a s ociety. policy makers and other health stakeholders can epidemiological information as a strategic input for decis ion making on priorities and res ource As epidemiology enters a new “ecological” era, concerned with understanding internal and external connections , investigations formed by a multilevel framework and cons idering a wide array of contributors may become increasingly frequent. E ach of the us es outlined above is applicable to epidemiology. It should be mentioned, however, that, in addition to these seven us es —which rather explicitly to work with illness or pathology—the emerging expansion of the concept of health to include pointedly positive health as pects (i.e., s ocial participation and supports, quality of life) suggests that the inves tigation these aspects will become a s ignificant new use of epidemiology.

ME THODS IN P S YC HIA TR IC E P IDE MIOL OG Y T his s ection reviews the conceptual and procedural that are us ed in epidemiology to fulfill its purposes and goals . F irst, the bas ic cons tructs and parameters in epidemiology and health are considered. K ey and dimensional meas ures and prototypical des igns of epidemiological s tudies are examined next. T he last subs ection outlines the types of ins truments us ed in ps ychiatric epidemiology.

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in E pidemiology Dis eas e, Illnes s , Dis order, and T he terms dis e as e , illne s s , dis order, and s yndrome recognized forms of pathology. Dis e as e and illne s s represent crys tallized or es tablis hed entities of severity and with definite implications for the individual and for public health. Dis e as e is often used with biomedical connotations, referring to a condition with specific etiopathogenesis , whereas illne s s is often used with experiencial and sociocultural connotations . T here however, no wide agreement on these dis tinctions . S yndrome repres ents a condition characterized by a particular symptom profile, the etiology, clinical significance or severity of which is variable. Dis orde r is term midway between a disease or illness and a in terms of cons istency, correlates, and s ignificance. the complexity, intricacy, and variable significance of ps ychiatric conditions included in standard mental and behavioral nosologies, dis order is the term that has preference at the current stage in nosological formulations. Important features of diseases or dis orders of epidemiological interest include (1) cours e of illnes s . refers to the age and mode of onset, the episodic or continuous presentation of illness , and the s table, improving, or worsening progres sion of the illnes s. (2) C omorbidity. T his is a complex and intricate term that refers to the cooccurrence or copresentation of two disorders . It has been argued that comorbidity may sometimes involve two faces of the s ame bas ic clinical condition or cons titute artifactual consequences of a 360 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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particular nosological architecture. C omorbidity may place within the domain of mental disorders (e.g., depres sion and alcoholism) and acros s chapters of the (e.g., depres sion and arterial hypertension).

Dis ability F unctioning is an umbrella term that encompass es the bodily functions and personal activities of an individual. Dis ability refers to limitations in functioning that may place at the following different levels. P.660 





B ody level: e.g., brain and nervous s ys tem P ers onal level: e.g., limitations in personal care and daily activities S ocietal level: e.g., restrictions in s ocial and in available s ocial supports

Other Health P roblems O the r health proble ms is the term used in the current 10 to refer to conditions of clinical interes t that are not diseases s e ns o s tricto and may explain presentation to health services for evaluation and care. E xamples acce ntuated pers onality, hazardous us e of s ubs tances , burn-out s yndrome .

R is k F ac tors R is k factors are characteristics , variables, and hazards make it more likely that a given individual will develop a disorder. T hey can res ide within the individual (e.g., 361 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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personality and temperament), with his or her family or community (e.g., life events), and with the environment (e.g., certain chemicals ). Us ually, there is an ass umed plaus ible caus al ass ociation between the ris k factor disorder or health problem.

P os itive Health P os itive health is the counterpart of ill health, which, as listed above, includes disease, illness , dis order, and related health problems . P os itive health reflects growing interest in a more comprehens ive concept of health. S uch a concept was already enshrined as “a complete phys ical, social and emotional well-being and not merely the absence of illness ” in the constitution of WHO. P res ently, pos itive health encompass es such as effective pers onal care, good interpers onal occupational functioning, social s upports, and quality of life.

C linic al C are C linical care refers to the array of actions or taking place in health s ervices. B road categories of care include the following: Diagnos is : T his is an evaluative process and formulation conducted by health profes sionals in collaboration with the patient (or cons ulting family, and pertinent members of the community. Illus trative of modern diagnostic concepts and procedures are the recent World P s ychiatric Ass ociation's International G uidelines for Ass es sment (IG DA). 362 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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T re atme nt: T his refers to the array of profes sional interventions —in cooperation with the consulting person and family—aimed at improving the presented and restoring health. Health promotion: T his refers to a s et of actions at empowering the cons ulting pers on to raise the of his or her health. As s uch, health promotion can regarded as relevant to both public health and care.

C ontext of E pidemiology C ritical as pects of the context of epidemiology include following domains : S ocial environme nt: T his includes human as pects environment at various levels of aggregation (i.e., family, community, nations, and humankind). divers ity and political cons iderations als o play a role in this domain. P hys ical environme nt: T his includes climate, finances , transportation, and other material G e ne tic e ndowme nt: T his includes the genetic illness and health. R ecent analyses of the human genome have pointed out that the express ion of genetic factors is largely influenced by factors . T hese concepts and factors are, of cours e, interrelated. R obert E vans and G reg S toddart offer a modern perspective on thes e interrelations through an schema pres ented in F igure 5.1-1. It reflects the 363 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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of the field and outlines the interactive influences of various individual and social factors, as well as health on the various faces of health. T he latter involves or illnes s, health and function, and a sense of well-

FIGUR E 5.1-1 R elationships among s ocial and factors , health care, and the various as pects of health. (F rom E vans R G , S toddart G L. P roducing health, health care. In: E vans R G , B arer ML, Marmor T R , S ome P e ople He althy and O thers Not? T he Health of P opulations . New Y ork: Aldine de G ruyter; with permiss ion.)

K ey C ategoric al and Dimens ional Meas ures in E pidemiology 364 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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T he meas urement of key variables in epidemiology is guided by the s caling requirements of the type of involved (categorical vers us dimensional), as well as historical and cus tomary considerations .

Meas ures for C ategoric al Variables V ariables that are s tructured in terms of discrete or types (e.g., disorders , inpatient versus outpatient are measured through nominal scaling arrangements , as a s tandardized typology or class ification of S ome of the most frequently us ed measures in this follow: P roportion or pe rce ntage : T his is a widely us ed of frequency for all categorical variables —for percentage of emergency psychiatric evaluations res ult in inpatient admiss ions (as oppos ed to outpatient referrals). P revale nce : T his indicates the proportion of in a given population who have a dis order at a particular point or period in time. It is usually expres sed in percentages. F or point prevalence, time of meas urement is to be s pecified—for percentage of a village's inhabitants who pres ented manifestations of generalized anxiety disorder on 1, 2003. P eriod prevalence is often meas ured by 1month, 6-month, and 1-year intervals —for example, percentage of a village's inhabitants who a s chizophrenic disorder during calendar year Incide nce : T his indicates the proportion of new a dis order that emerge in a population during a specified time interval (us ually 1 year). An 365 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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es timation of incidence may be obtained through anamnestic means , whereas a careful appraisal requires two surveys of the population involved— at the beginning and another at the end of the of P.661 interes t. A refined index, described by Olli incidence de ns ity, which deals with poss ible over time and los s at follow-up of individuals in the ris k population and is defined as an average rate over the period of interes t. O dds ratio: T his index involves a comparis on of the presence of a ris k factor for dis eas e in a s ample of diseased subjects and nondis eased controls. In words , it compares the proportion of cas es to noncases in a s ample expos ed to a given risk to proportion of cases to noncases in a nonexpos ed sample.

Meas ures for Dimens ional Variables V ariables that are meas urable with dimens ional s cales informationally more powerful (convey more detailed structured information) and mathematically and statis tically more tractable than yes or no categorical variables . In other words , although categorical are measured in terms of the pres ence or abs ence of variable, dimens ional variables are meas ured in to the extent of their presence—for example, a score of in a 100-point scale. Many variables of epidemiological interest, particularly 366 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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those corres ponding to pos itive health (e.g., functioning and quality of life), are meas ured with dimens ional variables .

Meas ures of A s s oc iation Indices of intervariable as sociation or relations hips on the s caling of the variables involved. C ontingency tables are us ed to apprais e the interrelation between categorical variables, and their statis tical significance is expres sed through the chi-square statis tic. P roduct–moment correlation coefficients convey the degree of as sociation between dimens ional variables. can vary from –1, indicating perfectly negative or as sociation, to +1, indicating full s ame-directional as sociation, with 0 express ing no ass ociation at all between the inves tigated variables . P oint biserial correlation coefficient is an adjus ted correlation index designed to meas ure the ass ociation between a binomial variable (e.g., presence versus of a given disorder) and a dimens ional one (e.g., level occupational functioning).

Multivariate A nalys es C omplex s ituations involving several variables as contributors or predictors call for multivariate analys es . S uch analyses are facilitated when the predictor and predicted variables are dimens ionally meas ured. procedures allow the identification of the smalles t and most efficient set of predictors. W hen the predicted variable is categorical, reducible to binomial, it is to use a logistic regres sion model to elucidate a 367 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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multivariate predictor.

Des ign of E pidemiologic al S tudies T he most important is sue in designing epidemiological studies involves its population s e tting—that is , a clinic treated population vers us a community or general population. T raditionally, a general population was regarded as always the proper s etting for C linical populations have begun to emerge as an additional proper focus of epidemiological s tudies . T his in line with the enormous significance and cost of care in today's world and with the opportunity that medical centers offer to inves tigate the relations hip between environmental and biological factors of illnes s.

C ros s -S ec tional vers us L ongitudinal P ers pec tives C ros s -sectional versus longitudinal perspectives another crucial des ign is sue in psychiatric Most studies have been cross -sectional in design, reflecting the fact that many des criptive research questions call for s uch designs and that this type of is simpler and les s expensive to conduct. Other questions , including thos e involving etiological hypothes es, the elucidation of a chain of events , and developmental cons iderations , call for longitudinal designs. Longitudinal des igns include cohort and cas e-control studies and us ually involve a time interval between and effect. C ohort s tudie s characteristically engage a sample (cohort) from a well-defined population with a particular expos ure or nonexpos ure status ), 368 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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followed up for a specified time to determine whether a particular health outcome emerges. C ohort studies divided into prospective studies and retros pective In the pros pective type, expos ure s tatus is determined the initiation of the longitudinal s tudy; in the type, exposures are determined at a pas t point. C as e control s tudie s engage identified cases of a particular disorder and control s ubjects (thos e without the and follows them up. T his des ign is particularly s uited the study of rare disorders and for the exploration of poss ible ris k factors. C ase-control s tudies are attractive because of their convenience and relatively low cos t. A major limitation is recall bias , es pecially when corroborating information cannot be obtained.

F amily S tudies F amily s tudies represent a significant type of epidemiological s tudy s timulated by the interest aris ing about genetic contributions to the development of disorders . T hese studies examine aggregation of families that may be due to heredity or shared environmental ris k factors. F amily studies may us e population s amples or s amples of cases as certained through probands, including family case-control

Health S ervic es R es earc h Health s ervices research has become a major area of inves tigation, s timulated by the complexity of the organization of clinical s ervices and the magnitude and intricacy of its financing. C haracteris tic of this type of is a naturalis tic approach, which involves appraising proces s and outcome of s ervices in their regular 369 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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E pidemiological methods, including descriptions of the types and extent of s ervices provided and the levels of unmet need for service, are applicable to this field. Illus tratively, health s ervices research deals with such as the following: (1) Need: W ho comes to care? C overage of service: W ho gets care? (3) How much res ources are required to meet the need for care? (4) are the outcomes of health care?

L ife S pan S tages R es earc h Life s pan stages res earch address es the complexity of human development by dividing it into three childhood and adolescence, adult development, and age. S tudies on the dis tribution of mental disorders in childhood and adolescence are challenged by the and instability of ps ychopathology during these years. Most epidemiological studies have been conducted adult samples. Attention must be paid to basic features adult development, s uch as res ilience as a protective and levers for health promotion. Old age brings new challenges to the methodology of epidemiological res earch—from meas urement of nosological to late-life risk factors to the role and needs of

C ultural and International C ultural and international frameworks are emerging as fundamental for health studies in general and epidemiology in particular. C ulture pervades and unders tanding of life and health (both ill and as pects ). T he vitality of new res earch in cultural has led to the development of practical tools, such as cultural formulation, 370 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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P.662 which may be helpful for clinical care and may als o enhance epidemiological des criptions. T he interactive nature of today's world makes it compelling to cons ider international pers pectives in health at all its levels —governmental (e.g., WHO) and (e.g., W orld P sychiatric As sociation).

E videnc e-B as ed A pproac hes E vidence-based approaches to medicine and have attracted wide attention as efforts to upgrade the solidity and quality of information on which health care public health are bas ed. It is important to place in perspective such efforts , given the complexity of the field. As indicated by s ome of their most authoritative proponents , evidence-based medicine is about individual clinical expertis e and the best external T he need for balancing hard data with informed wis dom extensible to public health policy development.

Ins truments for E pidemiologic al S tudies Ins trument P roperties T he apprais al of the quality and relevance of for meas uring the variables of interes t in epidemiology us ually conducted in terms of their reliability, their or usefulness , and their feas ibility or administrability.

R E L IAB ILITY R eliability refers to the quality of an instrument to yield similar or cons istent results across various 371 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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such as time (test–retest reliability) and evaluators (interrater reliability). F or categorical variables, s uch as identification of ps ychiatric dis orders, the most reliability index is the kappa coefficient (κ), the formula which follows: where p ois the proportion of observed agreement and the proportion of chance agreement. F or the not infrequent case of multiple raters multiple categorical diagnos es , an extens ion of the κ been designed and operationalized. F or the reliability or agreement among raters us ing scales, the mos t frequently us ed statis tical index is the intraclas s correlation coefficient.

VAL IDITY V alidity refers to the quality or s trength of an ins trument meas ure the variable or cons truct it is suppos ed to meas ure. In line with this , validity is thought to to the faithfulness , relevance, and usefulness of the instrument to reflect the reality of interes t. validity is regarded as the most fundamental quality of instrument. However, it is not always s imple to validity directly. T he following repres ent common approaches to the es timation of an instrument's C rite rion validity: According to this approach, the validity of a new ins trument is determined by comparing the res ults or meas urements it yields to those obtained with an ins trument of widely relevance and value. F or example, the validity of a depres sion s cale could be es timated by correlating 372 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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res ults to those of the Hamilton Depres sion S cale. F ace or conte nt validity: T his is as sess ed by having experts in the field determine the extent to which a new instrument is relevant to its intended purpose covers the informational areas pertinent to that purpos e. Dis criminant validity: Here, an attempt is made to determine if a new instrument is well able to distinguish between s amples of populations presumed to be quite different from each other in instrument's domain or field of application. Illus tratively, the dis criminant validity of a new depres sion s cale could be indicated by the extent which it yields higher scores in a s ample of people than in another sample of healthy C ons truct validity: T his corresponds to the validity of an instrument (i.e., to the extent that it yields res ults consis tent with the theory underlying domain and design. F or example, if it is properly as sumed that an anxiety disorder is s ubs tantially caus ed by environmental s tres s, a new scale to measure the pres ence of that anxiety disorder would be expected to yield high scores among recently exposed to a s erious dis as ter.

FE AS IB IL ITY OR ADMINIS TR AB IL ITY T his evaluative parameter refers to the cas e of use of instrument, as well as low cos t and access ibility.

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T here is a large number and variety of ins truments for evaluation of ps ychopathology and mental disorders . S ome are of a s creening nature. T hese include, first, instruments for detecting the likelihood of an individual having mental disorders (which are us ually bas ed on affective s ymptoms and, in some cas es, other such as social dysfunction). T his type of s creening instrument may be used as the firs t of a two-stage in which they are followed by a s econd in-depth instrument. S econd, s creening instruments may also represent a preliminary attempt at detecting the of a particular dis order, s uch as a depres sive or anxiety disorder. F or the full evaluation of mental disorders , including the identification of specific forms of them, structured or s emistructured interviews —often adminis tered by trained nonclinicians —have become standard in epidemiological s tudies . W ell-trained or psychiatrists , us ing adequate nosologies and criteria, can als o repres ent an adequate approach to ps ychopathological evaluation in epidemiology, the cost of s uch profes sional services and the lower explicitnes s of the proceedings may repres ent limitations and are usually restricted to validation A s election of instruments for general screening and full identification of a substantial s et of mental disorders are pres ented below.

INS TR UME NTS FOR G E NE R AL PS YC HOPATHOLOG IC AL S C R E E NING G e ne ral He alth Q ue s tionnaire (G HQ): T his is one earliest s creening instruments to have received acceptance in a variety of settings. It was 374 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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David G oldberg and collaborators . Its complete version is compos ed of 60 items , mostly affective symptoms. S horter versions of 28 and 12 items exis t. Adequate reliability and validity have been documented. S elf-R eporting Q ues tionnaire (S R Q): T his designed as part of a W HO project to s creen for disorders in primary health care settings. It includes items —20 on depres sive and anxiety s ymptoms, on ps ychotic phenomena, one on epileps y, and five related to alcohol abuse—and has been adjusted in length for use in different world s ettings . P ers onal H ealth S cale : T his ins trument, developed J uan Mezzich and ass ociates, is bas ed on an prototypical model for the definition of psychiatric illness and includes 10 items (s ix affective ps ychological and somatic symptoms , three social dys function, and one on global s elfof illnes s and need for clinical care). It can be completed in 2 to 4 minutes and has s everal versions with documented reliability and validity. P.663

INS TR UME NTS FOR FULL PS YC HIATR IC DIS OR DE R S DIS : T his fully structured and s cheduled diagnos tic interview was originally designed to identify a set of DS M-III mental dis orders through interviews 375 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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conducted by lay interviewers. It was most prominently applied in the E C A s tudy in five U.S . C IDI: T his structured interview was built on the DIS approach and was extended to identify sets of disorders in DS M-IV and IC D-10. It has been a number of studies, including the U.S . NC S and WMH. S tandardize d C linical As s e s s me nt for (S C AN): T his modular ins trument was built on the tenth edition of the P res ent S tate E xamination (a structured interview for ps ychiatric s ymptoms) and categorical diagnos tic algorithm (C AT E G O). It has us ed in a national s urvey of ps ychiatric morbidity in G reat B ritain. B oth P S E and S C AN were used in Longitudinal S tudies of S chizophrenia. Mini-Inte rnational Ne urops ychiatric Interview T his brief structured diagnos tic interview, recently developed by David S heehan and collaborators , at the identification of a s et of DS M-IV and IC D-10 mental disorders in multicenter clinical trials and epidemiological s tudies . It can usually be less than 30 minutes. It has been validated against C IDI and the S tructured C linical Interview for DS M-

Ins truments for the A s s es s ment of Dis ability and F unc tioning WHO PS YC HIATR IC DIS AB IL ITY AS S E S S ME NT S C HE DUL E T he WHO developed a new version of the Disability Ass es sment S chedule (W HO-DAS II) as a general 376 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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of functioning and disability that reflects major life domains and is sensitive to change. T his endeavor on the development of the revis ion of the International C las sification of F unctioning, Disability, and Health and aims to develop a common metric tool that is culturally applicable, psychometrically reliable and valid, and for health s ervices research, s uch as the evaluation of needs and outcomes . W HO-DAS II was conceived as a general health state ass ess ment meas ure that can be for multiple purposes , s uch as epidemiological s urveys , clinical us e, or as a potential description system to contribute to s ummary meas ure of population health. It gives a general s core as well as different profiles on cognition, mobility, s elf-care, interpers onal relations , participation in the community.

INTE R NATIONAL C L AS S IFIC ATION OF FUNC TIONING , DIS AB IL ITIE S AND (IC F) T he International C lass ification of F unctioning, and Health (IC F ) is a major revis ion of the International C las sification of Impairments , Dis abilities, and (IC IDH). T he first edition ass umed that disabilities exclusively from illnes ses. T he s econd considered that disabilities might res ult from the interaction among illness es, the pers on, and the s ocial environment. In disability is conceptualized here as involving at body, personal, and social levels —impairments , limitations , and participation restrictions. An outline of IC F is presented in T able 5.1-2. A checklis t as sess es presence and severity of various functional limitations. F igure 5.1-2 displays the interactions between the 377 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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components of the IC F .

Table 5.1-2 An Overview of the C las s ific ation of Func tioning, Dis a (IC F)  

Part 1: Func tioning and Dis ability

 

Part 2: Fac tors

C omponents

B ody functions and structures

Activities and participation

E nvironm factors

Domains

B ody functions and structures

Life areas (tas ks , actions)

E xternal on functi disability

C ons tructs

C hange in body functions (phys iological)

C apacity, executing tas ks in a standard environment

F acilitati hindering of feature phys ical, and attitu

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world  

C hange in body structures (anatomical)

P erformance,   executing tas ks in the current environment

P os itive as pect

F unctional and s tructural integrity

Activities, participation (function)

F acilitato

Negative as pect

Impairment

Activity limitation

B arriers/

 

 

P articipation res triction (disability)

 

F rom W orld Health Organization. Inte rnational C las s ifica and H ealth (IC F ). G eneva: World Health Organization; 2

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FIGUR E 5.1-2 Interactions among the components of International C lass ification of F unctioning, Dis ability and Health. (F rom W orld Health Organization. Inte rnational C las s ification of F unctioning, Dis ability and H ealth G eneva: W orld Health Organization; 2001, with

GL OB AL AS S E S S ME NT OF S C AL E T he G lobal As sess ment of F unctioning S cale combination, social dys function and severity us ing a 100-point scale. It is used to ass ess of DS M-IV and DS M-IV -T R .

Ins truments to A s s es s C ontextual F ac tors : L ife E vents , S tres s ors , S upports ME AS UR ING L IFE E VE NTS 380 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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T he apprais al of s tres sors and life experiences as contributors to the emergence of mental dis orders represents an intricate challenge. Interesting here is approach of G eorge B rown, which addres ses the definitions of life events, stress , and contextual threat. practical and s imple proposal to evaluate the presence frequent threatening experiences was offered by T erry B rugha et al.

APPR AIS AL OF A S TANDAR D S E T OF C ONTE XTUAL FAC TOR S T his may be attempted using the Z-coded categories of C hapter XXI of IC D-10. As part of the development of multiaxial system for IC D-10, a s chema was des igned the reporting of contextual factors that may influence diagnosis, treatment, and prognos is of mental

Ins truments to A s s es s Quality of Q uality of life as a notion has become increasingly with the recognition that the impacts on health and health care–seeking behavior are often determined not just by s ymptoms and s igns, dis orders , or but also by s ubjective global appraisals of health. T his es pecially important for health conditions that are either recurrent or of a long duration (as is the case with a number of mental P.664 health conditions). T he concept has also gained in the pharmacoeconomic literature. Quality of life can thus be cons idered an operational meas ure of overall health and well-being. 381 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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T here are a growing number of procedures and tools to as sess health-related quality of life. S ome were for the evaluation of individuals experiencing specific illness es, psychiatric and nonpsychiatric. Others quality of life generically and are most appropriate as of a comprehens ive as sess ment of health status . T he Quality of Life Ins trument (W HOQoL) is noteworthy for broad international anchorage, careful development, wide range of content. T he W HOQoL was developed through an international cross -cultural collaborative to measure people's s elf-perception of their pos ition in in the context of the culture and value s ys tems in which they live and in relation to their goals , expectations , standards , and concerns . It has been extensively us ed is being currently revis ed to reflect new frameworks for meas uring health and health-related outcomes. T he item Quality of Life Index, developed by J uan Mezzich collaborators , is also wide in content (phys ical and emotional well-being, personal and social functioning, social s upports , and personal and spiritual fulfillment) also quite efficient, us ing a culture-informed rating and validated in terms of s everal language versions .

E P IDE MIOL OG IC A L F INDING S ON IL L NE S S A ND HE A L TH T his s ection presents selected recent findings on distribution and patterns of mental disorders , positive as pects of health, clinical care, and health T hese epidemiological res ults are presented principally tabular form.

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As an illustration of findings on distribution of mental disorders in a broad population, R onald K ess ler et al. reported on the lifetime and 12-month prevalence of III-R disorders in a U.S . national household sample 5.1-3). T he lifetime prevalence of any NC S dis order found to be 48.0 percent. Of the broad categories of disorders , substance us e dis order (26.6 percent) was most common, followed by any anxiety disorder (24.9 percent) and any mood dis order (19.3 percent). Of the specific disorders , major depress ion was most (17.1 percent), followed by alcohol dependence (14.1 percent).

Table 5.1-3 L ifetime and 12-Mont Dis orders  

Fem

Male

 

Lifetime

Dis orders

%

12-Mo

(S E )

%

Lifetime

(S E )

%

(S E )

Mood disorders

 

 

 

 

 

 

    Mania

1.6

0.3

1.4

0.3

1.7

0.3

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    Major depres sion

12.7

0.9

7.7

0.8

21.3

0.9

    Dysthymia

4.8

0.4

2.1

0.3

8.0

0.6

    Any mood disorders

14.7

0.8

8.5

0.8

23.9

0.9

Anxiety disorders

 

 

 

 

 

 

    G eneralized anxiety disorder

3.6

0.5

2.0

0.3

6.6

0.5

    P anic disorder

2.0

0.3

1.3

0.3

5.0

1.4

    S ocial phobia

11.1

0.8

6.6

0.4

15.5

1.0

    S imple phobia

6.7

0.5

4.4

0.5

15.7

1.1

    Agoraphobia 3.5 without panic

0.4

1.7

0.3

7.0

0.6

    Any anxiety disorder

0.9

11.8

0.6

30.5

1.2

19.2

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S ubstance disorders

 

 

 

 

 

 

    Alcohol abuse

12.5

0.8

3.4

0.4

6.4

0.6

    Alcohol dependence

20.1

1.0

10.7

0.9

8.2

0.7

    Drug abus e

5.4

0.5

1.3

0.2

3.5

0.4

    Drug dependence

9.2

0.7

3.8

0.4

5.9

0.5

    Any subs tance disorder

35.4

1.2

16.1

0.7

17.9

1.1

Other disorders

 

 

 

 

 

 

    Antis ocial personalitya

4.8

0.5

—

—

1.0

0.2

    Nonaffective 0.3 ps ychos is b

0.1

0.2

0.1

0.7

0.2

Any NC S disorder

0.2

27.7

0.9

47.3

1.5

48.7

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NC S , National C omorbidity S tudy; S E , s tandard error. aAntisocial

personality was only as sess ed on a lifetime b

bNonaffective

psychosis : s chizophrenia, s chizophrenifor delus ional disorder, and atypical psychosis. F rom K es sler R C , McG onagle K A, Zhao S , et al.: Lifetim ps ychiatric disorders in the United S tates: results from th P s ychiatry. 1994;51:8–19, with permiss ion. Als o of high interest, the NC S found that 79 percent of ps ychiatrically ill people pres ented with comorbidity involving two or more ps ychiatric disorders . More than of all lifetime disorders occurred in 14 percent of the population. T he figures obtained in the NC S were higher than obtained in the E C A s tudy. F urthermore, lifetime prevalence of “any mental disorder” with the C IDI was found to vary greatly, from more than 40 percent in the U.S . and the Netherlands to 20 percent in Mexico and percent in T urkey. C omplementing the above-mentioned National C omorbidity S tudy in the United S tates , findings from a recent study conducted as part of the W HO World Health S urvey in 12 different settings are presented in T able 5.1-4. C onsiderable variations can be noted countries . Quite consistently, the results obtained in the United S tates tended to be highes t (e.g., 47.3 percent lifetime prevalence of any dis order investigated, and 386 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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percent as 12-month prevalence), whereas those in S hanghai, C hina, tended to be the lowes t (e.g., 8.6 percent as lifetime prevalence of any disorder and 4.5 percent as 12-month prevalence).

Table 5.1-4 L ifetime (L T) and 12 C ompos ite Internationa  

Moodb

Anxiety

 

LT

12-Mo

LT

1

 

%

SE

%

SE

%

SE

%

Americas

 

 

 

 

 

 

 

    C olombia

19.5

1.2

9.9

0.8

13.2

0.7

6.2

    Mexico

11.9

0.7

6.9

0.5

10.0

0.7

5.

    United S tates

28.6

0.9

18.2

0.7

21.4

0.8

9.8

E urope

 

 

 

 

 

 

 

    B elgium

13.3

1.9

6.2

1.1

14.4

1.1

5.0

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    F rance

22.0

1.5

9.7

0.9

23.3

1.3

6.4

    G ermany

14.1

1.3

5.9

0.8

10.9

0.8

3.4

    Italy

10.9

0.9

5.0

0.6

10.2

0.6

3.

    Netherlands 15.2

1.0

7.2

0.9

17.5

1.4

4.8

    S pain

10.0

1.0

5.2

0.6

11.6

0.6

4.4

    Ukraine

11.3

1.0

7.4

0.8

16.1

1.2

8.8

Middle E as t and Africa

 

 

 

 

 

 

 

    Lebanon

13.3

1.3

10.9

1.2

11.7

1.0

6.3

    Nigeria

5.8

0.7

3.3

0.4

3.2

0.3

1.0

Asia

 

 

 

 

 

 

 

    J apan

8.4

0.9

4.7

0.8

8.5

0.7

3.0

    P R C

5.9

1.2

3.4

0.7

4.6

0.6

2.7

    P R C S hanghai

3.9

1.0

2.6

0.8

3.7

0.8

1.8

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P R C , P eople's R epublic of C hina; S E , s tandard error. aAnxiety

disorders include agoraphobia, generalized anx disorder, s ocial phobia, and specific phobia. Mood dis or Impulse-control disorders include bulimia, intermittent ex past 12 months of symptoms of three child-adoles cent d defiant disorder). S ubstance disorders include alcohol o met full criteria at some time in their life and who continu currently do not meet full criteria for the dis order. Organ were not us ed. bB ipolar

disorders were not ass ess ed in the E uropean S G ermany, Italy, the Netherlands, and S pain). 3 Intermittent dDrug

explosive dis order was not as sess ed in the

abus e and dependence were not as sess ed in the

F rom W orld Mental Health S urvey C ons ortium: P revalen Organization World Mental Health (W MH) S urveys. J AM One of the most important s ettings for appraising the prevalence of mental disorders is primary health care. David G oldberg and Y ves Lecrubier s tudied s uch prevalence with the C IDI in 15 cities acros s all and found that the prevalence of all mental dis orders varies from 53 percent in S antiago, C hile, to 7.3 S hanghai, C hina, with an average acros s sites of 24 percent. Likewise, depres sive disorder ranged from 30 percent in S antiago to 2.6 percent in Nagas aki, J apan. S ome interesting contrasts acros s continents are 389 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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(T able 5.1-5).

Table 5.5-1 Prevalenc e of Major Dis orders in Primary Health

C ities

C urrent Alcohol Depres s ion Generalized Dependenc (%) Anxiety (%)

Ankara, T urkey

11.6

0.9

1.0

Athens , G reece

6.4

14.9

1.0

B angalore, India

9.1

8.5

1.4

B erlin, G ermany

6.1

9.0

5.3

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G roningen, the Netherlands

15.9

6.4

3.4

Ibadan, Nigeria

4.2

2.9

0.4

Mainz, G ermany

11.2

7.9

7.2

Manches ter, 16.9 UK

7.1

2.2

Nagasaki, J apan

2.6

5.0

3.7

P aris, F rance

13.7

11.9

4.3

R io de J aneiro, B razil

15.8

22.6

4.1

S antiago, C hile

29.5

18.7

2.5

S eattle,

6.3

2.1

1.5

S hanghai, C hina

4.0

1.9

1.1

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V erona, Italy

4.7

3.7

0.5

Total

10.4

7.9

2.7

F rom G oldberg DP , Lecrubier Y . F orm and frequency of acros s centres. In: Üs tü T B , S artorius N, eds. Me ntal Illn C are : An International S tudy. C hichester, U.K .: J ohn W i permis sion. As an example of international work with specific ps ychiatric disorders , E zra S us ser et al. reported on delineation of acute and trans ient ps ychotic dis orders C handigarh, India. On examining the dis tribution of duration of illnes s for 46 cases of nonaffective acute ps ychos is , they found a bimodal dis tribution of this variable, with 80 percent of the cases lasting less than weeks and 20 percent lasting more than a year. T his supports the nosological s eparation of acute trans ient ps ychos is from s chizophrenia. T he distribution of mental disorders in children and adoles cents in North C arolina was recently reported on E . J ane C ostello et al. Us ing the C hild and Adolescent P sychiatric Ass ess ment (C AP A) as a structured they found that by age 16, one in three adoles cents indications of having a mental disorder. A similar (30 percent) was obtained by K es sler et al. for 15-yearin the NC S . 392 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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More broadly, the prevalence of child and adolescence disorders in recent studies across the world are comparatively in T able 5.1-6. T his prevalence varied 23 percent in S witzerland to 13 percent in India.

Table 5.1-6 Prevalenc e of C hild Adoles c ent Dis orders , S elec ted S tudies C ountry

Age

Prevalenc e (%)

E thiopia a

1–15

17.7

G ermany b

12–15

20.7

India c

1–16

12.8

J apand

12–15

15.0

S paine

8, 11, 15

21.7

S witzerlandf

1–15

22.5

US A g

1–15

21.0

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aT ades se

B , et al.: C hildhood behavioural Ambo district, Wes tern E thiopia: I. P revalence es timates. Acta P s ychiatr S cand. 1999;100 97. bWeyerer

S , C as tell R , B iener A, et al.: treatment of ps ychiatric disorders in 3–14-yearchildren; results of a representative field study in small rural town region of T rauns tein, Upper Acta P s ychiatr S cand. 1988;77:290–96. c Indian

C ouncil of Medical R esearch (IC MR ). E pidemiological S tudy of C hild and Adole s ce nt P s ychiatric Dis orders in Urban and R ural Are as . Delhi: IC MR ; 2001.

dMorita

H, S uzuki M, S uzuki S , et al.: P s ychiatric disorders in J apanes e s econdary s chool children. C hild P s ychol P s ychiatry. 1993;34:317–322. e G omez-B eneyto

M, B onet A, C atala MA, et al.: P revalence of mental dis orders among children in V alencia, S pain. Acta P s ychiatr S cand. 357. fS teinhausen

HC , Metzke C W , Meier M, et al.: P revalence of child and adolescent ps ychiatric disorders : the Zurich E pidemiological S tudy. Acta P s ychiatr S cand. 1998;98:262–271.

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gS haffer

D, F isher P , Dulcan MK , et al.: T he Diagnos tic Interview S chedule for C hildren 2.3 (DIS C -2.3): description acceptability, rates, and performance in the ME C A study. J Am C hild Adole s c P s ychiatry. 1996;35:865–877.

P.665

Findings on Dis abilities T he proportion of all disability-adjus ted life years attributed to neuropsychiatric disorders has been found be 12 percent in the G lobal B urden of Diseas e S tudy. 5.1-7 lists the leading caus es of disability-adjus ted life years in all ages and both s exes —unipolar depres sive disorders is in fourth place, and two other behavioral conditions (s elf-inflicted injuries and alcohol us e are included among the top 20 health conditions .

Table 5.1-7 L eading C aus es of Dis ability-Adjus ted L ife Years in Ages , B oth S exes  

Health C onditions

Perc ent

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of Total

1.

Lower res piratory infections

6.4

2.

P erinatal conditions

6.2

3.

Human immunodeficiency virus /acquired immunodeficiency syndrome

6.1

4.

Unipolar depres sive disorders

4.4

5.

Diarrheal diseases

4.2

6.

Is chemic heart dis eas e

3.8

7.

C erebrovascular disease

3.1

8.

R oad traffic accidents

2.8

9.

Malaria

2.7

10.

T uberculos is

2.4

11.

C hronic obs tructive pulmonary disease

2.3

12.

C ongenital abnormalities

2.2

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13.

Meas les

1.9

14.

Iron-deficiency anemia

1.8

15.

Hearing los s, adult-onset

1.7

16.

F alls

1.3

17.

S elf-inflicted injuries

1.3

18.

Alcohol us e dis orders

1.3

19.

P rotein-energy malnutrition

1.1

20.

Osteoarthritis

1.1

F rom Murray C J L, Lopez AD, eds . T he G lobal of Dis e as e . B oston: Harvard University P ress ; with permis sion. Neurops ychiatric conditions account for 31 percent of years of life lived with dis ability. T able 5.1-8 identifies leading caus es of years of life lived with dis ability in all ages and both sexes . F ive of the top 20 health are mental—unipolar depres sive dis order, alcohol us e disorders , schizophrenia, bipolar affective disorder, and Alzheimer's disease and other dementias. T . B . Üs tün as sociates have prepared an update of the initial B urden of Dis eas e S tudy, confirming and extending the 397 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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importance of depress ion as a public health problem.

Table 5.1-8 L eading C aus es of Years of Life L ived with All Ages , B oth S exes  

Health C onditions

Perc ent of Total

1.

Unipolar depres sive disorders

11.9

2.

Hearing los s, adult-onset

4.6

3.

Iron-deficiency anemia

4.5

4.

C hronic obs tructive pulmonary disease

3.3

5.

Alcohol us e dis orders

3.1

6.

Osteoarthritis

3.0

7.

S chizophrenia

2.8

8.

F alls

2.8

9.

B ipolar affective dis order

2.5

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10.

Asthma

2.1

11.

C ongenital abnormalities

2.1

12.

P erinatal conditions

2.0

13.

Alzheimer's disease and other dementia

2.0

14.

C ataracts

1.9

15.

R oad traffic accidents

1.8

16.

P rotein-energy malnutrition

1.7

17.

C erebrovascular disease

1.7

18.

Human immunodeficiency virus /acquired immunodeficiency syndrome

1.5

19.

Migraine

1.4

20.

Diabetes mellitus

1.4

F rom Murray C J L, Lopez AD, eds . T he G lobal of Dis e as e . B oston: Harvard University P ress ; with permis sion.

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F urther illustration of significant epidemiological on disabilities is furnis hed by the National S urvey of Mental Health and W ell-B eing in Aus tralia. F igure 5.1-3 health conditions in Aus tralia and their as sociated disability, expres sed as years of life lost through Mental disorders exceeded all the other major health categories in this regard.

FIGUR E 5.1-3 Y ears of life lost through disability (Y LD), Aus tralia, 1996. (F rom Mathers C , V os T , S tevenson C . B urde n of Dis e as e and Injury in Aus tralia. C anberra: Aus tralian Ins titute of Health and W elfare; 1999, with permis sion.)

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Findings on Pos itive As pec ts of T he National S urvey of Mental Health and W ell-B eing Aus tralia included meas urement of well-being at the strong request of cons umers and caregivers. W ellwas apprais ed with the s ingle-item Life S atis faction with 0 percent indicating “terrible” and 100 percent representing “delighted.” T he mean s core for the Aus tralian adult population was 70.4 percent. Men and women had very similar mean scores. W ell-being was higher in people with tertiary education and in thos e owning or purchasing their homes. It was lower in individuals with physical or mental dis orders, depres sion. It was higher in mild us ers of alcohol than was in abs tainers and heavy us ers . Of particular was the existence of a few individuals with current or depress ive disorders who reported high life Quality of life, us ing the S panish version of the Quality Life Index (QLI-S p), was s tudied in a S panis h sample by E s ther Lorente et al. T he mean scores of items of the QLI-S p and the average s core in this community sample composed of 489 men and 70 percent univers ity s tudents and 30 percent having other occupations —is presented in T able 5.1-9. W ithin framework of this 0- to 10-point scale, the average obtained in this community s ample was 6.98 (quite cons istent with the findings of K eith Dear et al. in Aus tralia). T here was not a significant difference in the average s cores of men and women. T he scale item presenting the highest loading on the s ingle factor underlying the scale was “personal fulfillment.” More recently, S aavedra and as sociates studied an adapted version of the QLI-S p on a statis tical s ample of 2,418 401 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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households in Lima, P eru, and found a mean average of 7.64, with no highly significant differences among or gender groups .

Table 5.1-9 Quality of L ife in a S panis h C ommunity S ample (489 Men and Women) Quality of L ife Indexa Items

Mean

S tandard Deviation

1. P hys ical well-being

6.58

1.65

2. well-being

6.48

1.74

3. S elf-care/independent functioning

7.31

1.48

4. Occupational

7.48

1.56

5. Interpers onal

7.68

1.56

6. S ocial emotional

7.46

1.81

7. C ommunity support

6.67

1.54

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8. P ersonal fulfillment

6.78

1.76

9. S piritual fulfillment

6.04

1.95

10. G lobal perception of quality of life

7.27

1.65

Average

6.98

1.11

aS core

range: 0 (bad) to 10 (excellent).

F rom Lorente E , Ibáñez MI, Moro M, et al.: Indice calidad de vida: es tandarización y características ps icométricas en una muestra española. S alud Integral. 2002;2:45–50, with permiss ion. P.666 P.667 A s tudy of sociodemographics, self-rated health, and mortality in the United S tates was conducted by P . et al., who analyzed data from the 1987 National E xpenditure S urvey on a representative sample of U.S . civilians. S elf-reported health was measured with the Medical Outcome 20-Item S hort F orm (S F -20) (health perceptions, phys ical function, role function, mental health). P hysical function s howed the greates t 403 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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decline with age, whereas mental health increased Women reported lower health for all s cales except role function. G reater income was as sociated with better health, least marked for mental health. C ompared P.668 with whites, blacks reported lower health, whereas reported higher health. Lower s ocioeconomic s tatus being black were factors as sociated with lower health status and higher mortality, women reported health status but exhibited lower mortality, and Latinos reported higher health s tatus and exhibited lower mortality.

Findings on C linic al C are T here is a trend worldwide to diversify the s ettings for mental health care. T he extent and patterns of this are being investigated by the W HO Atlas S urvey on Health R es ources by as king governments to complete questionnaires about mental health resources. T he distribution of ps ychiatric beds per 10,000 population WHO regions is presented in F igure 5.1-4. It shows availability rates are highest in E urope (9.3) and the Americas (3.6) (which includes North America and America) and are quite low (under 1.0) in the res t of the world.

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FIGUR E 5.1-4 P s ychiatric beds per 10,000 population World Health Organization (W HO) regions . (F rom W orld Health Organization. Atlas of Me ntal H ealth R e s ource s W orld 2001. G eneva: World Health Organization; 2001, permis sion.) According to the previous ly mentioned Atlas S urvey, median numbers of ps ychiatris ts per 100,000 are 1.0 worldwide, 9.0 in E urope, 1.6 in the Americas , in the E astern Mediterranean, and under 0.28 in the 405 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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the world. T he median numbers of ps ychiatric nurses 100,000 population are 2.0 worldwide, 27.5 in E urope, in the Americas, 1.1 in the W estern P acific, and under the res t of the world. T he median rates of ps ychologists working in mental health are 0.4 worldwide, 3.0 in 2.8 in the Americas , and under 0.2 in the res t of the F inally, the median rates of social workers in mental care are 0.3 worldwide, 2.35 in E urope, 1.9 in the and under 0.4 in the res t of the world. F ocus ing attention on Aus tralia, G avin Andrews et al. as certained the use of the s ervices of different types of health profess ionals for mental problems. T his s tudy documented the predominant roles of general practitioners and even other health profes sionals (including nurses, pharmacists , and welfare above that of psychiatrists , for the care of people experiencing mental disorders (even a large number of these) (T able 5.1-10).

Table 5.1-10 Us e of Profes s ional S ervic es for Mental Problems in Aus tralia, 1997 C ons ultations No Dis order for Mental (%) Problems

Any Dis order (%)

3 Dis orders (%)

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G eneral practitioner onlya

2.2

13.2

18.1

Mental health profes sional onlyb

0.5

2.4

3.9

Other health profes sional onlyc

1.0

4.0

5.7

C ombination of health profes sionals

1.0

15.0

36.4

Any health profes sionald

4.6

34.6

64.0

aR efers

to individuals who had at leas t one cons ultation with a general practitioner in the previous 12 months but did not consult any other type of health profess ional. bR efers

to individuals who had at leas t one cons ultation with a mental health profes sional (ps ychiatris t, psychologist, mental health team) in the previous 12 months but did not consult any other type of health profes sional. 407 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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c R efers

to persons who had at least one with another health profes sional (nurse, nonps ychiatric medical s pecialis t, pharmacist, ambulance officer, welfare worker, or counselor) the previous 12 months but did not cons ult any other type of health profes sional.

dR efers

to persons who had at least one with any health profes sional in the previous 12 months. F rom Andrews G , Henderson S , Hall W : comorbidity, dis ability and s ervice utilization: overview of the Aus tralian National Mental Health S urvey. B r J P s ychiatry. 2001;178:145–153, with permis sion. J yrki K orkeila et al. inves tigated the factors predicting readmiss ion to psychiatric hospitals in F inland during early 1990s. T he mos t prominent factors were previous admis sions , long lengths of s tay, and identification of ps ychotic or personality dis orders. T hes e P.669 findings pointed out that, des pite recent emphasis on community care, a continuing need for inpatient for some ps ychiatric patients seems to exist. Illus trating the importance of primary health care for people presenting mental disorders , M. G . R owe et al. found that one in five women and one in ten men 408 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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their primary phys icians have been recently depress ed. B ernardo Ng et al., surveying nonpsychiatrist rural C alifornia, documented the need for enhanced postgraduate training on depres sion for primary care phys icians .

Findings on Mental Health Polic y T he WHO Atlas S urvey Minis tries of Health revealed percent of countries in the world have no mental health policies , 30 percent have no national mental health programs, 25 percent have no mental health percent have no s pecific budget for mental health, and percent have no regular mental health training for care personnel. T hese figures are preliminary, and the survey is now being enhanced in collaboration with the World P s ychiatric Ass ociation. Illus trating the value of pointed inves tigations in the complex mental health field to upgrade health and policies , T able 5.1-11 displays the relations hip between women experiencing domestic violence and then contemplating s uicide in eight developing countries in Latin America, Africa, and As ia. In all the s tudy s ites , than twice the percentages of women ever phys ical violence by an intimate partner contemplate committing suicide, as compared to women never experiencing such domestic violence.

Table 5.1-11 R elations hip Domes tic Violenc e and C ontemplation of S uic ide 409 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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Perc entage of Women Who E ver Thought of C ommitting S uic ide (P <.001) Never E xperienc ed Phys ical Violence by Intimate Partner

E ver E xperienc ed Phys ical Violence by Intimate Partner

B razila (N = 940)

21

48

C hile b (N = 422)

11

36

E gyptb (N = 631)

7

61

India b (N = 6,327)

15

64

Indonesia c (N = 765)

1

11

P hilippines b

8

28

C ountry of S tudy

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(N = 1,001) P erua (N = 1,088)

17

40

T hailanda = 2,073)

18

41

aWorld

Health Organization. W HO S tudy on Health and Dome s tic V iole nce . G eneva: World Organization; 2001. 2 International

Network of C linical E pidemiologists . W orld S tudie s of Abus e in F amily E nvironme nts . Manila: International Network of C linical E pidemiologists ; 2001. c Hakimi

M, Hayati E N, Marlinawatie V U, et al. for the S ake of Harmony: Domes tic V iolence and Women's Health in C entral J ava. Y ogyakarta, Indonesia: P rogram for Appropriate T echnology Health; 2001.

With reference to instrumentation for mental health the us e of standard diagnostic systems is of s ignificant relevance. Darrel R egier et al. have highlighted discrepancies in mental dis order rates obtained different interviews and surveys and dis cuss ed their implications for determining treatment need. T . B . 411 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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al. have further examined the intricacy of need for treatment. Dealing more broadly with diagnos tic a s urvey of leading psychiatrists across the world (205 res pondents from 66 different countries) conducted by J uan E . Mezzich documented that IC D-10 is now the frequently us ed and valued class ification s ys tem for diagnosis and training, and DS M-IV is more valued for res earch purposes . Acces sibility to diagnostic manuals training appeared limited, particularly for the res earch criteria, primary care, and multiaxial vers ions of IC D-

FUTUR E DIR E C TIONS In line with the pers pectives for a multidimens ional, ecological, and culturally informed epidemiology enunciated by S us ser and S us ser and Naomar F ilho, it appears that, for the continuous development the field both as a solid s cientific and profes sional discipline P.670 and a rich contributor to public health, the following cons iderations are pertinent. A multilevel architecture would be valuable for unders tanding the complexity of an epidemiology of illness and health, an epidemiology helpful to advance life goals of the culturally divers e population of today's world. S uch an architecture would involve the of biological, psychological, and s ocial factors , of and s ubjective approaches , and of statis tical and anthropological information. E ven less intricate fields than epidemiology, now more than ever, require alliances and partnerships bas ed on 412 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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joint commitment to agreed objectives . F igure 5.1-5 articulates the contributions of a number of s takeholder groups (health profess ionals , policy makers , health services , health financing, and proactive communities) toward the promotion of healthy individuals and populations. As pointed out by Lowell Levin, public participation is es sential for health care quality. He for the value of expanding and deepening the dialogue among public interes t groups and the health dialogue that is honest, courageous , and res pectful.

FIGUR E 5.1-5 Integrating s takeholders ' pers pectives commitment toward a healthy pers on and a healthy 413 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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population. T he enormous and intriguing findings emerging from genetics and the neuros ciences must be incorporated the discuss ions and formulations of ps ychiatric epidemiology. T he deciphering of the human genome leading us to recognize the crucial role of the to activate the express ion of genetic influences . In the exploration of new biologically bas ed nos ologies , the of endophenotypes as intermediary between and phenotypes may be helpful here (F ig. 5.1-6).

FIGUR E 5.1-6 G ene-to-behavior pathways prototype. (F rom Üs tün T B : T oward a clinical epis temology of disorders . P aper pres ented at the WP A-WHO F orum on Integrating C oncepts and P artners towards a New IC D. 414 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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International C ongres s of P s ychiatry, C aracas, October 2003.) Als o crucial for the conceptual and methodological advancement of epidemiology—in interaction with multiple groups across the world—will be the optimal of the new informational and communicational technologies . T his would include the development of Internet knowledge-base platforms, es tablis hment of pertinent intranets , design of ins titutional W eb sites, organization of electronic journals . Illus trative of the challenges and opportunities ahead is the upcoming development of a new international clas sification and diagnostic s ys tem of value for clinical care and public health. It will require the bes t s cientific efforts to refine the epistemological bases of a s ound us eful diagnostic system, include emerging findings of etiological pertinence, res olve current controvers ies on comorbidity, incorporate es sential as pects of positive health, and adopt more effective models of and formulation. It must also integrate mental health clas sification more fully within general health P.671 clas sification and engage res earch groups and representatives from across the world actively and res pectfully. One hopes that through the exercise of s cientific dedication and profes sional wis dom and a perspective that attends creatively to patterns of illness and health, 415 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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ps ychiatric epidemiology, as allegorized by Diego painting (F ig. 5.1-7) (evocatively titled as both His tory Me dicine and P eople in De mand of He alth), will be a helpful contributor to the advancement of clinical care and public health for all peoples in the world.

FIGUR E 5.1-7 Diego R ivera's His tory of Medicine, Or in Demand of He alth.

S UG G E S TE D C R OS S Other quantitative and experimental methods in ps ychiatry are discus sed in C hapter 5. T he mental disorders is dis cuss ed in S ection 9.1, and international ps ychiatric diagnoses in S ection 9.2. S chizophrenia is the s ubject of C hapter 12; mood are covered in C hapter 13; anxiety dis orders are the of C hapter 14; s ubs tance-related dis orders are 416 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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C hapter 11; s omatization dis order is dis cuss ed in 15; and personality dis orders are the s ubject of

R E F E R E NC E S Almeida-F ilho N, Mari J , C outinho E , F rança J , J , Andreoli S , B us nello E : B razilian multicentric ps ychiatric morbidity: methodological features and prevalence estimates. B r J P s ychiatry. Andrews G , Henders on S , Hall W: P revalence, comorbidity, dis ability and s ervice utilization: of the Australian National Mental Health S urvey. B r P s ychiatry. 2001;178:145–153. Aspinwall LG , S taudinger UM, eds . A P s ychology of Human S tre ngths : F undame ntal Q ue s tions and Dire ctions for a P os itive P s ychology. W ashington, American P s ychological Ass ociation; 2002. B erganza C E : B roadening the international base for development of an integrated diagnos tic s ys tem in ps ychiatry. W orld P s ychiatry. 2003;1:38–40. C os tello E J , Mustillo S , E rkanli A, K eeler G , Angold P revalence and development of psychiatric childhood and adolescence. Arch G e n P s ychiatry. 2003;60:837–844. Dear K , Henderson S , K orten A: Well-being in Aus tralia—findings from the National S urvey of Health and W ell-being. S oc P s ychiatry P s ychiatr 417 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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E pidemiol. 2002;37:503–509. G oldberg DP , Lecrubier Y . F orm and frequency of mental disorders acros s centres. In: Üs tün T B , N, eds. Me ntal Illne s s in G e neral He alth C are : An Inte rnational S tudy. C hichester, U.K .: J ohn W iley; Henders on S : T he national survey of mental health well-being in Australia: impact on policy. C an J P s ychiatry. 2002;47:819–824. Horwitz J , Marconi J : E l problema de las el campo de la s alud mental. Definiciones aplicables es tudios epidemiológicos. B ol O ficina S anit P anam. 1966;60:300–309. Hyman S E : Neuroscience, genetics, and the future ps ychiatric diagnosis. P s ychopathology. 144. J enkins R , B ebbington P , B rugha T S , F arrell M, Meltzer H: B ritis h psychiatric morbidity s urvey. B r J P s ychiatry. 1998;173:4–7. K es sler R C : T he W orld Health Organization C ons ortium in P s ychiatric E pidemiology (IC P E ): work and future directions —the NAP E Lecture 1998. Acta P s ychiatr S cand. 1999;99:2–9. *K es sler R C , Üstün T B : Initial report from the WHO Mental Health S urvey. J AMA. (in pre s s .)

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K irmayer LJ , Minas IH: T he future of cultural an international perspective. C an J P s ychiatr. 2000;45:438–446. K uyken W, Orley J : WHO Quality of Life S ci Me d. 1995;41:1403–1409. Mezzich J E : An empirical prototypical approach to definition of psychiatric illnes s. B r J P s ychiatry. 1989;154:42–46. Mezzich J E : International s urveys on the use of IC Dand related diagnostic s ys tems. P s ychopathology. 2002;35:72–75. Mezzich J E : F rom financial analysis to policy development in mental health care: the need for broader conceptual models and partnerships. J Health P olicy E con. 2003;6:156–158. Mezzich J E , B erganza C E , von C ranach M, J orge K as trup MC , Murthy R S , Okasha A, P ull C , S artorius S kodol A, Zaudig M, eds .: E s sentials of the W orld P sychiatric Ass ociation's International G uidelines for Diagnos tic Ass es sment (IG DA). B r J P s ychiatry. (S uppl 45):S 37–S 66. Mezzich J E , C ohen NL, R uipérez MA, P érez C , Liu J , Mahmud S : T he S panish vers ion of the Life Index: presentation and validation. J Ne rv Ment 2000;138:301–305. 419 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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Mezzich J E , F abrega H, eds . C ultural P sychiatry: International P ers pectives . P s ychiatr C lin North Am. S eptember, 2001. Mezzich J E , K raemer HC , W orthington DR , C offman Ass es sment of agreement among several raters formulating multiple diagnoses . J P s ychiatr R e s . 1981;16:29–39. P.672 Murray C J L, Lopez AD, eds . T he G lobal B urden of B os ton: Harvard University P res s; 1996. R egier DA, K aelbert C T , R ae DS , F armer ME , K es sler R C , Norquis t G S : Limitations for diagnos tic criteria and as sess ment instruments for mental disorders : Implications for research and policy. Arch P s ychiatry. 1998;55:109–115. R obins LN, Helzer J E , C roughan J , R atcliff K S : Diagnos tic Interview S chedule: its his tory, characteristics , and validity. Arch G e n P s ychiatry. 1981;38:381–389. S aavedra J E , Malpartida C , Nizama M, V as quez F , L, Huaman J , Arrelano C , P omalima M, G uerra M, R obles Y , G onzalez S , S agas tegui A, V argas H, C hirinos R , Diaz R (Instituto E specializado de S alud Mental): E s tudio E pidemiologico Metropolitano en S alud Mental 2002. Anales de S alud Me ntal (L ima). 420 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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2002;18(1,2). S ackett DL, R osenberg W MC , G ray J AM, Haynes R ichardson WS : E vidence based medicine: what it what it isn't. B MJ . 1996;312:71–72. S chmolke MM, Lecic-T os evski D, eds .: Health as an integral component of clinical care. Dynamic P s ychiatry. 2003;36(s pecial is sue). S heehan DV , Lecrubier Y , S heehan K H, Amorim P , J anavs J , Weiller E , Hergueta T , B aker R , Dunbar Mini-International Neurops ychiatric Interview the development and validation of a s tructured diagnostic psychiatric interview for DS M-IV and IC DJ C lin P s ychiatry. 1998;59(S uppl 20):22–57. S lade T . Us ing E pide miology to Inform C las s ification P s ychiatry [diss ertation]. Australia: S chool of Univers ity of New S outh Wales; 2002. S pitzer R L, W illiams J B W , G ibbon M, F irst MB : T he S tructured C linical Interview for DS M-III-R (S C ID). I. His tory, rationale, and description. Arch G e n 1992;49:624–629. S tengel E : C lass ification of mental disorders . B ull Health O rgan. 1950;21:601–663. S ullivan DF . C onceptual problems in developing an index of health. U.S . Department of Health, Welfare. US P H P ublication No. 1000, S eries 2, No. 421 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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Was hington, DC : U.S . G overnment P rinting Office; *S us ser M, S uss er E : C hoos ing a future for epidemiology. I. E ras and paradigms . Am J P ublic 1996;86:668–673. Üstün T B : Mains treaming mental health. B ull W orld Health O rgan. 2000;78:412. Üstün T B , Ayus o-Mateos J L, C hatterji S , Mathers C , Murray C J R : G lobal burden of depres sive dis orders the year 2000. B r J P s ychiatry. 2004;184:386–392. *Üstün T B , C hatterji S , B ickenbach J , K os tanjsek N, S chneider M: T he international class ification of functioning, dis ability and health: a new tool for unders tanding dis ability and health. Dis abil R ehabil. 2003;25:565–571. Üstün T B , C hatterji S , R ehm J : Limitations of paradigm: It does n't explain “need.” Arch G e n 1998;55:1145–1146. Üstün T B , C his holm D: G lobal “burden of disease”— study for ps ychiatric dis orders. P s ychiatr P rax. (S uppl 1):S 7–S 11. *Üstün T B , Mezzich J E : E pilogue of international clas sification and diagnosis: critical experience and future directions. P s ychopathology. 2002;35:199– Wing J K , B abor T , B rugha T , B urke J , C ooper J E , 422 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/5.1.htm

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J ablenski A, R egier D, S artorious N: S C AN. C linical As sess ment in Neuropsychiatry. Arch G e n P s ychiatry. 1990;47:589–593. Wing J K , C ooper J E , S artorius N: Meas ure and C las sification of P s ychiatric S ymptoms : An Manual for the P S E and C AT E G O P rograms. C ambridge University P ress ; 1974. World Health Organization. T e nth R e vis ion of the Inte rnational C las s ification of Dis eas e s and R elated P roblems (IC D-10). G eneva: World Health 1992. World Health Organization. Inte rnational of F unctioning, Dis ability and He alth (IC F ). G eneva: Health Organization; 2001. WHO International C onsortium in P sychiatric E pidemiology: C ros s-national comparisons of the prevalences and correlates of mental disorders . B ull W orld He alth O rgan. 2000;78:413–426. *WHO W orld Mental Health S urvey C onsortium: P revalence, s everity, and unmet need for treatment mental disorders in the W orld Health Organization. World Mental Health (W MH) S urveys . J AMA. (in

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 6 - T heories of P ers onality and P s ychopathology > 6.1: C las P s ychoanalys is

6.1: C las s ic Ps yc hoanalys is W. W. Meis s ner M.D., S .J . P art of "6 - T heories of P ers onality and P sychoanalysis has existed s ince before the turn of the 20th century and, in that s pan of years, has es tablished its elf as one of the fundamental dis ciplines within ps ychiatry. T he science of ps ychoanalys is is the ps ychodynamic unders tanding and forms the fundamental theoretical frame of reference for a variety forms of therapeutic intervention, embracing not only ps ychoanalys is its elf but als o various forms of ps ychoanalytically oriented psychotherapy and related forms of therapy using ps ychodynamic concepts . current efforts are being directed to connecting ps ychoanalytic unders tandings of human behavior and emotional experience with emerging findings of neuros cientific res earch. C onsequently, an informed clear understanding of the fundamental facets of ps ychoanalytic theory and orientation is es sential for student's grasp of a large and s ignificant s egment of current ps ychiatric thinking. One of the difficulties in pres enting s uch a synthetic account is that it must draw its material from more than century of thinking and theoretical development. Although there is more than one way to approach the divers ity of such material, the material in this chapter is 424 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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organized along historical lines, tracing the emergence analytical theory or theories over time but with a good deal of overlap and s ome redundancy. B ut there is an overall pattern of gradual emergence, progress ing from early drive theory to s tructural theory to ego object relations and on to s elf-ps ychology, inters ubjectivism, and relational approaches .

R OOTS OF THINK ING P sychoanalysis was the child of S igmund F reud's He put his s tamp on it from the very beginning, and it be fairly said that, although the s cience of has advanced far beyond F reud's wildes t dreams, his influence is still strong and pervasive. In understanding origins of ps ychoanalytic thinking, it is us eful to keep in mind that F reud hims elf was an outstanding product of the scientific training and thinking of his era.

S c ientific Orientation F reud was a convinced empirical s cientis t whose early training in medicine and neurology had been in the progres sive s cientific centers of his time. He s hared the conviction of mos t of the s cientists of his day that law and order and the systematic study of phys ical and neurological process es would ultimately yield an unders tanding of the apparent chaos of mental When he began his study of hys teria, he believed that brain phys iology was the definitive scientific approach that it alone would yield a truly s cientific understanding. With his own increasing clinical experience, F reud was forced to modify that bas ic scientific credo, but it is 425 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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significant nonetheles s that he maintained it in one or another form throughout the whole of his long career. own efforts to elaborate a scientific phys iology of phenomena were, in the end, to prove frustrating and disappointing. After abandoning that attempt, contained in the long-lost pages of the P roje ct for a S cie ntific P s ychology (1895), he continued to believe that, the clinical material he dealt with forced him to work on level of ps ychological reflection, there was a close and intimate connection between phys ical and psychical proces ses.

On A phas ia Although a good deal of attention has been paid to F reud's P roje ct as express ing his early model of the more recent attention has been drawn to his important neurological work O n Aphas ia (1891), in which F reud advanced his earliest views of the relation between structure and function in the brain. F ollowing J ohn Hughlings J acks on's emphasis on the complex between thought and language, F reud challenged the prevailing notions of brain localization of function advanced by P ierre B roca, K arl W ernicke, T heodor and others . R ather than thinking in terms of brain à la B roca's speech center, F reud related the functions speech to functional capacities in a widespread visual, acoustic, tactile, and even kines thetic reflecting generalized changes in the functioning of the brain as a whole. T hus, he viewed simple functions , s uch as perception or memory, as phys iologically complex and involving multiple brain systems . In his view, it was the dis ruption in the network that was respons ible for various forms of 426 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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rather than des truction of s pecific centers. F ollowing J acks on's differentiation between mind and brain and his concept of functional retrogress ion from higher levels of organization to lower, F reud regarded aphas ia as reflecting retrogress ion to earlier developmental s tates of speech development. He attributed s peech functions to a “zone of language” that was independent of anatomical location, a position that res onated with his later stipulations regarding hysteria which s ymptoms were not related to anatomical lesions but had to do with meaning and symbolization related network of as sociations. In any cas e, the concepts he developed in his s tudy of aphas ia later reemerged in ps ychological theory, specifically, concepts of mental representation, cathexis , s ymbol formation, and word and object representation. T he view of from higher to lower levels of functioning seems to P.702 foreshadow his later doctrine of regress ion, and his comments on forms of paraphas ia read like a draft of the ps ychopathology of everyday life.

The P rojec t T he effort to bridge the chas m between psychological proces ses and neurological mechanis ms reached a intens ity in F reud's attempt to cons truct a “scientific ps ychology”—that is , a psychology bas ed on principles. E arnes tly dedicated to the s cientific ideals of Hermann Helmholtz's approach to phys iology and ps ychology, he conceived the s cheme of elaborating a complete ps ychology that would be bas ed on the 427 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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phys icalis tic s upposition of the Helmholtz school. F or nearly 2 years , from 1895 to 1897, F reud s truggled these ideas. F inally, in the white heat of intens e in a period of no more than 3 weeks , he wrote out what known today as the P roje ct. W hen the intensity of his inspiration had begun to wane, F reud became discouraged with what he had written and finally, in disgust, threw it into a des k drawer where it was to for years . In 1898, he wrote in dis couragement and to his friend W ilhelm F lies s that he was “not at all to leave the psychology hanging in the air without an organic basis. B ut apart from this conviction [that there must be s uch a basis] I do not know how to go on, theoretically nor therapeutically, and therefore must behave as if only the ps ychological were under cons ideration.” It was his intention that the P roje ct be des troyed, but after his death, his papers came into hands of thos e who recognized its importance, and it finally published posthumous ly. If it brought F reud's neurological period to a brilliant clos e, it also opened way to the broad vis tas of psychoanalysis and, in important and significant ways, determined the shape ps ychoanalytic principles were to take. F reud's understanding of the principles of mental functioning traditionally formed the core of explanations of how the mental apparatus works and functions, but within the last half century, the central position of thes e principles has come into ques tion. T he P roje ct was on two principal theorems: firs t, the idea that the system was compris ed exclus ively of neurons, by “contact barriers ” (F reud's express ion for s ynaps es); second, a quantitative concept of neural excitation (Qn) 428 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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transmitted from cell to cell in the nervous s ys tem and either s tored or discharged, thus accounting for various forms of nervous activity. T he energy in this early was simply a form of quantitative excitation within an open-system neuronal reflex model, but it quickly surplus meaning as a hypothetical substance with hydros tatic properties . Out of these simple elements , in combination with a set of regulatory principles , F reud elaborated his complex and ingenious account of functioning. T he bas ic model used in the P roje ct on a reflex apparatus whose function was withdrawal stimuli, particularly excess ive s timuli, and discharge of accumulated excitation as governed by the cons tancy principle and the neces sity of withdrawing from stimulation in accordance with the unple as ure principle . When F reud finally surrendered his effort to formulate ps ychology in terms of a physical model, he was forced shift to a more s pecifically psychological model of the mental apparatus but without completely abandoning ideas in the P roje ct. His thinking remained tied to the phys icalis tic model of energy s ys tems and their distribution. S urrender of his objective of explaining mental life in terms of phys iological and neurological proces ses was more a compromise than a s urrender. view, the mind pos sess ed certain dynamic properties that the ps ychological model had to be cons tructed according to the dynamic laws and principles inherent current physical theories of the dis tribution and of the flow of energy. Nonetheless , psychic energy was clearly distinct and different from the metabolic energy the brain and referred s pecifically to purpos eful s triving. P sychic energy became the central concept around 429 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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F reud erected his economic model of mental P s ychic e nergy was that energy, as sumed to be the mental apparatus deriving from ins tinctual drives, related to affective experience, es pecially anxiety, and modified in various ways by ps ychic s tructures , always with a tendency toward discharge. Although it derived from instinctual drives , it had no specified relations hip phys ical energies ass umed to be operating in corres ponding neural structures. In any case, the concept prevailed that ps ychic energy represented a purely quantitative and nonqualitative capacity for work, which the ps ychic apparatus carried by the transformation, storage, discharge, or delay of discharge of psychic energy. In the clas sic theory, the instinctual drives impose this demand for work on the mind. Not only does the concept of energy as work potential divorce it from the hydros tatic model, but separating the economic principle from connections ps ychic energy removes it from the line of causal in other words , economic principles are not principles efficiency—they are principles of quantitative E fficiency (caus ality, work) belongs to energic factors . However, the regulatory principles, as ess ential to the economic perspective, were originally formulated in of the regulation of ps ychic energies and have been viewed almos t exclus ively in s uch terms ever s ince. may retain s ome validity in economic rather than terms as regulatory principles of how the mental works (T able 6.1-1). Other questions remain regarding place of the drives in relation to the capacity for work or force and whether the drives are the only guarantee of connection between the mind and the phys ical 430 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Table 6.1-1 E nergic Princ iples B as ed on the P rojec t R evis ed Princ iple

E xplanation

E ntropy

S igmund F reud: T endency for energy in any physical s ys tem to flow from a region of high energy regions of lower energy; tendency of system toward homogeneity; tendency of s ys tem to spontaneously diminish the of energy available for work.

 

R evised: A revised schema the physical model for ps ychic proces ses in favor of a model bas ed on motivation and tendency of psychic s ys tems to and achieve purpos eful goals .

C ons ervation

F reud: T he s um of forces any isolated (clos ed) system remains cons tant.

 

R evised: T he psychic apparatus not a clos ed s ys tem, but open, does not operate on the bas is of 431

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clos ed-system dynamics. Neuronic inertia

F reud: Neurons tend to dives t thems elves of quantities of excitation. Application of entropy and cons ervation to neuronal activity.

 

R evised: G eneral psychic to resolve s ituations of conflict, tension, affective imbalance (including anxiety, fear, guilt, shame, depres sion) in favor of greater balance and more harmonious integration with other ps ychic s ys tems.

C ons tancy

F reud: T he nervous system tends maintain its elf in a state of tension or level of excitation. to a level of constant excitation is achieved by a tendency to immediate energic discharge (through the path of leas t res is tance).

 

R evised: T endency of ps ychic functions to return to a s tate of res ting potential as contextual stimulus conditions and the 432

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of feedback-regulated conditions the same and related ps ychic systems allow. Nirvana

F reud: T he dominant tendency to reduce, keep cons tant, or remove the internal ps ychic tension due to the excitation of s timuli; the tendency to reduce the level of excitation to a minimum; of constancy principle; expres sed pleas ure principle, ultimately in death ins tinct.

 

R evised: T his principle has no in an economically revised but is replaced by an oppos ite tendency to seek stimulation, to seek complex rather than stimulation.

P leasureunpleasure

F reud: T endency of mental apparatus to s eek pleas ure and avoid unpleasure. Unpleas ure is to the increas e of tension or level excitation, whereas pleas ure is to the release of tension or discharge of excitation. T he pleas ure principle thus follows the economic requirements of

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cons tancy.  

R evised: Indicates the degree of functional satis faction/diss atis faction and efficacy derived from effective/ineffective operation of ps ychic s ys tems; pleasure succes sful transition from to actual operation of the ps ychic function(s ) and achievement of purpos eful and wis hed-for goals .

R eality

F reud: Modification or delay of energic discharge adapting pleas urable dis charge according the demands of reality.

 

R evised: Modification or delay of ps ychic functioning as mutually conditioned by the internal of intra- and inters ys temic within the mental apparatus ; limiting conditions for s pecific functions outside the mind are determined by reality factors.

R epetition

F reud: T endency of ins tinctual forces , as a result of inertial tendencies, to repeat patterns of 434

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discharge even when res ulting in unpleasure.  

R evised: R ather than resulting inertial energic dynamics, may relate to stabilization of functions and s tructural integrations, thus contributing to development and the continual proces s of as similating and accommodating to reality.

F reud used ps ychic energy both as a device to observable phenomena and as a construct in his model the mind. P eople have only begun to appreciate the to which F reud used the neurological and energic terminology of Helmholtz and G ustav F echner as metaphorical devices to express his psychological cons tructs. T he use of s uch metaphors may have us efulnes s, es pecially in expres sing iss ues of conflict development dealt with by ps ychoanalys is — that lend themselves readily to verbal metaphorical hypothes es and les s readily to mathematical quantification. As F reud's viewpoint became ps ychological, his use of concepts of drive and energy became increas ingly metaphorical, as in T hre e E s s ays (1905). P robably after 1900, F reud became aware of the limitations of his theory, es pecially the system and hydraulic aspects of his model, which 435 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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prompted further revisions . After his abandonment of P roje ct, he preferred to think of his theories as purely ps ychological, but even s o, the energic ass umptions carried over into s tructural theory.

C ritic is ms of Ps yc hic E nergy All these uncertainties and ambiguities come to roos t in contemporary criticisms of ps ychic energy. T he statements s ummarize the objections and the reas ons critics conclude that the class ic notion of ps ychic can no longer be tolerated in a contemporary ps ychoanalytic theory: P sychic energy is not measurable, so we are tes t any quantitative as sumptions of the theory. T he relationship between neural energies in the and ps ychic energy remains vague and poorly unders tood, and therefore any laws for the transformation of one to the other remain elusive. T he hydraulic analogy is outmoded, and the view of ps ychic energy was based on a simplified view of caus ality and a misleading equation of ps ychic with physiological energy as an explanatory T he model is internally contradictory P.703 and lacks cons is tency; it pres ents a logically closed system that misinterprets metaphor as fact; it tautological renaming of obs ervable ps ychological phenomena in energic terms, which mas querades explanation; it is unable to explain all the relevant data; it tends to lead to a false s ense of 436 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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particularly to the extent that it offers ps eudoexplanations that are incons is tent with knowledge of neurophys iology. R ather than serving a bridge between ps ychoanalys is and physiology, es pecially neurophys iology, it becomes a barrier to interdisciplinary communication and integration. T he human organis m is in s ome degree tens ion seeking and maintaining, whereas the energic is based on the principle of tension reduction. P sychic energy comes in multiple forms , s uch as libidinal, aggres sive, narcis sistic, and various of neutralized energies, bound energies, and fus ed energies. T he difficulty here has not so much to do with the varying manifes tation of energies in forms but, rather, with the idea that the differences inherent in the energies themselves . T his objection focus es on the differentiation of the energy its elf, as oppos ed to the idea that various manifestations of ps ychic energy may be determined by the through which they are express ed—qualitative differences would be due to the patterned control, channeling, and mediation of intervening In the analogous cas e of physical energy, the differences of the various forms, s uch as heat and are not attributed directly to energy as s uch but, rather, to the physical channels through which the energy is express ed. B y implication, qualitative differences undercut the idea of the id as chaos cons isting only of energy and its modes of discharge. T here are also problems with the energic metaphor its elf. F reud did not clearly dis tinguis h drive and 437 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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energy as biological, phys iological, or ps ychological and connected them almost exclusively with the sexual drive. T he terms share both physical and ps ychological reference: C athexis is both an electrochemical charge and a wish. T his opened door not only to conceptual errors but als o to the of an ess entially nonanalytical model to explain analytical material. If energy s erves as a metaphor for experience, it is merely descriptive and not explanatory; if it stands some neurophys iological function, any explanatory value res ts on dualistic mind–brain as sumptions. T he notion of psychic energy does not meet criteria of accepted scientific method. S pecifically, it internally contradictory and lacks consis tency; it presents a logically clos ed system that metaphor as fact; it involves a tautological observable and experienced psychological phenomena in energic terms that masquerade as explanations ; it is unable to explain all of the data, especially the phenomena of pleasurable tension, exploratory behavior, and s timulus hunger; tends to lead to a false s ense of explanation, particularly ins ofar as it offers ps eudoexplanations are incons is tent with current knowledge of neurophys iology; and it promotes a form of mind– body dualis m—dualistic interactionis m—that P.704 prevents integration of ps ychoanalytic concepts related sciences of the mind and behavior. T he metaphor is given s urplus meaning, which elevates 438 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to an objective phenomenon and introduces circularity, vitiating any verification of drive–energy concepts . T he energic metaphor is incons istent with current neurophys iological unders tanding bas ed on of selective inhibition rather than energy depletion the all-or-none nature of the nervous impuls e rather than fluid dynamics . T he us efulnes s of the energic model for clinical purpos es has been ques tioned. Using a model for qualitative events limits both the range depth of explanation. S uch quantitative trans lation persis ts in the name of presumed objectivity and in belief that it offers a more s cientific view of clinical conceptions . T he drive-discharge model interprets in terms of discharge, thus blurring any distinction between drive and motive. B ut in the clinical libido and s exuality do as sume s ignificant connotations of meaning and motive. E ven if and motive do not exclude quantitative dimens ions , the quantitative cannot s ubstitute for the qualitative. On the basis of such s lender pos tulates , F reud complex and ingenious account of mental functions. He was unable, however, to provide a s atis factory account either defense or cons cious nes s. In both cas es , he embroiled in a continuing regres s in which he s eemed unable to stop. Des pite a variety of ingenious feedback loops that he built into the s ys tem—F reud was many decades ahead of his time in envisioning informational servomechanis ms —he was unable to complete the functioning of his s ys tem without violating the demands 439 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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of his mechanical principles . He thus introduced into system a major concess ion to vitalis m, an observing T his obs erving ego was able to s ee danger for the mobilization of defens es and was able to s ens e the indication of quality in cons cious experiences. T he ego remained as a sort of primary “willer” and ultimate “knower,” a pers onal center within the theory that could not be reduced to the phys icalistic terms of postulates and that cons equently enjoyed a s ignificant degree of autonomy. One of the persis tent difficulties inherent in the of ps ychic energy is that, because of the original mode which F reud expres sed his economic views, the hypothes is has become overidentified with the of psychic energy. T here is little doubt that theory cannot do without a principle of economics . It is impos sible to express or unders tand matters of quantitative variation, degrees of intensity, levels and intens ity of motivation, or informational communication to explain how individual subjects are able to make choices among conflicting motivations and goals to about the resolution of conflict—or, for that matter, to explain the whole range of affective, motivational, and structural concepts that form the backbone of ps ychoanalytic unders tanding—without invoking the concepts and iss ues of quantity and intens ity that led F reud from the very beginning to postulate an point of view. T he s hifting focus on informational- and communication-based concepts does not escape the for economic governing principles.

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In the decade from 1887 to 1897, F reud turned his attention to the s erious study of the disturbances of his hysterical patients , and, in this period, the beginnings ps ychoanalys is took root. T hese slender beginnings threefold aspect: emergence of ps ychoanalys is as a method of inves tigation, as a therapeutic technique, as a body of scientific knowledge bas ed on an fund of information and basic theoretical propos itions . T hese early res earches flowed out of F reud's initial collaboration with J os eph B reuer and then, from his own independent investigations and developments.

The C as e of Anna O. B reuer was an older phys ician, a distinguished and es tablis hed medical practitioner in the V iennes e community. K nowing F reud's interes ts in hysterical pathology, B reuer told him about the unusual cas e of a woman he had treated for approximately 1.5 years, December 1880 to J une 1882. T his woman became under the pseudonym F räulein Anna O., and s tudy of difficulties proved to be one of the important s timuli in development of ps ychoanalys is . Anna O. was , in reality, B ertha P appenheim, who later became independently famous as a founder of the work movement in G ermany. At the time she began to B reuer, s he was an intelligent and s trong-minded of approximately 21 years of age who had developed a number of hys terical symptoms in connection with the illness and death of her father. T hese symptoms paralysis of the limbs , contractures, anesthesias, visual disturbances , disturbances of speech, anorexia, and a 441 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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distress ing nervous cough. Her illness was also characterized by two distinct phases of cons cious nes s: relatively normal, but the other reflecting a second and more pathological personality. Anna was very fond of and clos e to her father and with her mother the duties of nurs ing him on his deathbed. During her altered s tates of cons cious nes s, Anna was able to recall the vivid fantasies and intens e emotions s he had experienced while caring for her It was with cons iderable amazement, both to Anna and B reuer, that when s he was able to recall, with the as sociated express ion of affect, the s cenes or circums tances under which her s ymptoms had aris en, symptoms could be made to disappear. S he vividly described this process as the “talking cure” and as “chimney sweeping.” Once the connection between talking through the circums tances of the s ymptoms and the dis appearance the symptoms themselves had been es tablis hed, Anna proceeded to deal with each of her many s ymptoms after another. S he was able to recall that, on one when her mother had been absent, s he had been her father's beds ide and had had a fantas y or which s he imagined that a snake was crawling toward father and was about to bite him. S he s truggled try to ward off the snake, but her arm, which had been draped over the back of the chair, had gone to sleep. was unable to move it. T he paralysis persisted, and unable to move the arm until, under hypnosis, s he was able to recall this s cene. It is easy to s ee how this kind material mus t have made a profound impres sion on It provided convincing demons tration of the power of 442 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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unconscious memories and s uppress ed affects in producing hysterical s ymptoms. In the course of the s omewhat lengthy treatment, had become increasingly preoccupied with his and unusual patient and, cons equently, spent more more time with her. In the meanwhile, his wife had increasingly jealous and resentful. As soon as B reuer to realize this, the sexual connotations of it frightened and he abruptly terminated the treatment. Only a few hours later, however, he was recalled urgently to bedside. S he had never alluded to the forbidden topic sex during the cours e of her treatment, but s he was experiencing hysterical childbirth. F reud s aw that the phantom pregnancy was the logical termination of the sexual feelings she had developed toward B reuer in res ponse to his therapeutic efforts. B reuer had been unaware of this development, and the experience was quite unnerving. He was able to calm Anna down by hypnotizing her, but then he left the house in a cold and immediately s et out with his wife for V enice on a second honeymoon. P.705 According to a version that comes from F reud through E rnest J ones, the patient was far from cured and later to be hospitalized after B reuer's departure. It seems ironical that the prototype of a cathartic cure was , in far from success ful. Nevertheles s, the cas e of Anna O. provided an important starting point for F reud's thinking and a crucial juncture in the development of ps ychoanalys is. 443 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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S tudies on Hys teria T he collaboration with B reuer brought about publication of “P reliminary C ommunication” in 1893. E s sentially, and B reuer extended J ean C harcot's concept of hysteria to a general doctrine of hys teria. Hys terical symptoms were related to psychic traumata, clearly and directly but als o s ometimes in a s ymbolic disguis e. Obs ervations bas ed on these later cas es es tablis hed a connection between pathogenesis of common hys teria and that of traumatic neurosis; in cases, trauma is not followed by sufficient reaction and thus kept out of cons cious nes s. T hey obs erved that individual hys terical symptoms seemed to disappear when the event provoking them clearly brought to life, with the patient describing the event in great detail and putting accompanying affect words . F ading of a memory or loss of its ass ociated depends on various factors, including whether there been an energetic reaction to the event that provoked affect. T hus, memories can be regarded as traumata have not been sufficiently abreacted. T hey noted that splitting of cons cious nes s, so striking in clas sic cases hysteria as “double cons cious nes s,” is present to at rudimentary degree in every hys teria. T hey des cribed basis of hys teria as a hypnoid s tate—that is , a state of diss ociated cons ciousnes s. T hey believed achieved its curative effect on hys terical s ymptoms by bringing to an end the emotional force of the idea that not been s ufficiently abreacted in the firs t ins tance. It this by allowing strangulated affect to gain dis charge through speech, thus s ubjecting it to as sociative 444 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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correction, integrating it with normal cons cious nes s. “P reliminary C ommunication” created cons iderable interes t and was followed in 1895 by S tudie s on which B reuer and F reud reported on their clinical experience in the treatment of hysteria and proposed a theory of hys terical phenomena. F reud's cas e proved to be extremely s ignificant because they formed the original basis for much of his ps ychoanalytic F reud concluded from thes e observations that an experience that had played an important pathogenic together with its subsidiary emotional concomitants, accurately retained in the patient's memory even when apparently forgotten and unrecoverable by voluntary recall. He postulated that repres sion of an idea from cons ciousnes s and exclus ion from any modification by as sociation with other ideas was an ess ential condition development of hysteria. At this early s tage, F reud regarded repress ion as intentional and believed it as the bas is for convers ion of a s um of neural When cut off from more normal paths of ps ychic as sociation, this sum of excitation would find its way all more easily along a deviant path leading to somatic innervation. T he basis for s uch repress ion, he argued, be a feeling of unpleasure derived from the between the idea to be repres sed and the dominant of ideas constituting the ego. Moreover, as one symptom was removed, another developed to take its place. T he illnes s could be even by a person of s ound heredity as the res ult of appropriate traumatic experiences. It should be noted F reud's view was quite different from B reuer's, the origin of hys teria to hypnoid s tates. In F reud's view, 445 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the actual traumatic moment, the incompatibility of forces its elf on the ego so that the ego repudiates the incompatible idea. T his reaction brings into being a nucleus for crys tallization of a s eparate psychic group somehow divorced from the ego. T his process res ults the splitting of cons cious nes s characteris tic of acquired hysteria. T he therapeutic process consists in this s plit-off ps ychical group to unite once more with main mas s of cons cious ego ideas . In every cas e of based on sexual traumas , F reud believed that from the presexual period, which produce little or no on the child, can attain traumatic power at a later date memories when the girl or married woman begins to acquire an unders tanding of and exposure to adult life. On the basis of thes e cas es, F reud recons tructed the following s equence of steps in the development of hysteria: (1) T he patient had undergone a traumatic experience, by which F reud meant an experience that stirred up intense emotion and excitation and that was intens ely painful or dis agreeable to the individual; (2) traumatic experience represented to the patient s ome or ideas incompatible with the “dominant mas s of ideas cons tituting the ego”; (3) this incompatible idea was intentionally diss ociated or repres sed from (4) the excitation as sociated with the incompatible idea was converted into s omatic pathways, resulting in hysterical manifes tations and s ymptoms; (5) what was in consciousness was merely a mnemonic symbol only connected with the traumatic event by as sociative links that are frequently enough disguis ed; and (6) if the memory of the traumatic experience can be brought 446 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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cons ciousnes s and if the patient is able to releas e the strangulated affect as sociated with it, then the affect is discharged, and s ymptoms dis appear.

Freud's Tec hnic al E volution One interesting aspect of the S tudie s on H ys te ria is the evolution in F reud's development of technical to the treatment of hys teria. R es ulting from his early interes t in hypnosis , as well as his exposure to techniques both in C harcot's clinic and later at Nancy, F reud began us ing hypnos is extens ively in treating his patients when he opened his own practice in 1887. In beginning, he us ed hypnotic s uggestion to enable patients to rid thems elves of their symptoms . It became quickly obvious, however, that, although patients res ponded to hypnotic s uggestion and tried to treat the symptoms as if they did not exist, the s ymptoms nonetheless reas serted themselves again during the patient's waking experience. B y 1889, then, F reud was s ufficiently intrigued by cathartic method to use it in conjunction with hypnotic techniques as a means of retracing the his tories of symptoms. In his early efforts , he stayed quite close to notion of the traumatic origins of hysterical s ymptoms . C ons equently, the goal of treatment was res tricted to removal of s ymptoms through recovery and of suppres sed feelings with which symptoms were as sociated. T his procedure has since been described “abreaction.” However, as in the case of hypnotic suggestion, F reud was still s omewhat diss atisfied with res ults of this treatment approach. T he beneficial hypnotic treatment s eemed to be transitory; they 447 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to las t, or seemed effective, only as long as the patient remained in contact with the phys ician. F reud that alleviation of s ymptoms was in fact dependent in some manner on the pers onal relations hip between patient and phys ician.

F rom Hypnos is to A nalys is F reud had begun to feel that inhibited sexuality may a role to play in production of the patient's s ymptoms. suspicion of a sexual as pect in the treatment of such patients was amply confirmed one day when a female patient awoke from a hypnotic sleep and suddenly her arms around his neck. F reud s uddenly found the same pos ition in P.706 which B reuer had found hims elf during his earlier treatment of Anna O. P erhaps bolstered by B reuer's experience and apparently able to learn from it, F reud not panic or retreat in the face of this sexual advance. R ather, the peculiar obs ervant quality of his mind was to dis engage its elf sufficiently so that this experience could be treated as a s cientific obs ervation. F rom this point on, F reud began to understand that the therapeutic effectivenes s of the patient–phys ician relations hip, which had s eemed so mys tifying and problematic to him until this time, could be attributed in fact to its erotic bas is . T hese obs ervations were to the bas is of the theory of transference that he later into an explicit theory of treatment. In any event, these experiences reinforced his dis satisfaction with hypnotic techniques. He became aware that hypnosis 448 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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masking and concealing a number of important manifestations that seemed to be related to the cure or, in s ome cases, to the inability of the patient to achieve a definitive resolution of the neurosis. Later, diss atis faction with hypnosis became more specific in he could see that continued us e of hypnos is precluded further investigation of transference and resis tance phenomena. F reud had also dis covered that many of the patients in private practice were in fact refractory to hypnos is. gradually did he come to recognize that what seemed be his inability to hypnotize a patient might often be due to a patient's reluctance to remember traumatic events. He was able later to identify this reluctance as res is tance. T he vagaries of the hypnotic method did satis fy F reud, and he believed it necess ary to develop approach to treatment that could be us efully applied regardless of whether the patient was hypnotizable. C ons equently, although F reud continued to us e techniques as a bas ic approach to treatment of began to experiment with it and gradually succeeded in modifying the technique.

C ONC E NTR ATION ME THOD One of the patients whom F reud found to be refractory hypnotic technique was E lizabeth von R . F or the first in this cas e, F reud decided to abandon hypnosis as his primary therapeutic tool. He bas ed his decis ion to alter technique on the obs ervation of Hippolyte B ernheim although certain experiences appeared to be forgotten, they could be recalled under hypnosis and then subs equently recalled consciously if the physician were 449 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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as k the patient leading ques tions urging reproduction these critical memories. F reud thus evolved his method concentration. T he patient was asked to lie on a couch and close her S he was then instructed to concentrate on a particular symptom and to recall any memories as sociated with it. T he method was substantially a modification of the technique of hypnotic s uggestion. F reud press ed his on the patient's forehead and urged her to recall the unavailable memories. F reud's graphic descriptions of technique carry with them the unavoidable impress ion that he was struggling agains t a force he sensed in the patient and agains t which he found himself battling, as though in hand-to-hand combat. He came slowly, by of this laborious experience, to realize that the is olation certain memory contents was a matter of the operation mental forces generating cons iderable power that kept complex of pathogenic ideas separate from the mass cons cious ideation. T his substantially provided him with the empirical notion of resistance and with the metapsychological perspective of the mind as terms of psychic forces.

FR E E AS S OC IATION T he material presented in such graphic detail in Hys teria reflects dramatically the evolution of F reud's technique in the direction of his more definitive to ps ychoanalys is . He became increas ingly convinced the late 1890s that the process of urging, press ing, questioning, and trying to defeat the resistance offered the patient—all of which were part and parcel of the “concentration” method—rather than facilitating 450 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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overcoming of the patient's res is tances , actually with the free flow of the patient's thoughts. P iece by then, F reud gave up the concentration method. this progress ive evolution, the basic principle of ps ychoanalys is—free as sociation—was focus ed and articulated. G radually, F reud surrendered his technique forehead press ure as well as the requirement that clos e their eyes while lying on the couch. T he only remnant of this earlier procedure persisting in the of ps ychoanalys is is the use of the couch. T he of the central principle of ps ychoanalysis was the product of F reud's evolution. T he evolution of F reud's as sociative technique to progres s until it had been perfected. T he continued with increas ing reliance on the patient's capacity to freely manifes t mental contents without suggestive interference on the part of the therapis t. B y end of the 19th century, F reud had more or les s es tablis hed his as sociative technique. He described it the following terms : T his [technique] involves some psychological of the patient. W e must aim at bringing about two changes in him: an increas e in the attention he pays to own psychical perceptions and the elimination of the criticis m by which he normally s ifts the thoughts that occur to him. In order that he may be able to his attention on his self-observation it is an advantage him to lie in a restful attitude and to s hut his eyes. It is neces sary to insis t explicitly on his renouncing all of the thoughts that he perceives . W e therefore tell him that the succes s of the ps ychoanalysis depends on his noticing and reporting whatever comes into his head 451 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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not being mis led, for ins tance, into suppres sing an idea because it s trikes him as unimportant or irrelevant or because it s eems to him meaningles s. He must adopt completely impartial attitude to what occurs to him, it is precis ely his critical attitude which is respons ible his being unable, in the ordinary cours e of things , to achieve the des ired unraveling of his dream or idea or whatever it may be. In jus t a few years more, clos ing of the eyes was also abandoned. T hus, free ass ociation became the technique of psychoanalysis . In fact, it was this technique that opened the door to exploration of dreams , which became one of the primary sources of bolstering the nascent psychoanalytic point of view.

Theoretic al Innovations T he theoretical point of view in S tudie s on H ys te ria was relatively complex. B reuer adopted the point of view hysterical phenomena were not altogether ideogenic— that is , that they were not determined s imply by ideas. fact, the phenomena of hysteria may be determined by variety of causes, some brought about by an explicitly ps ychical mechanis m but others without it. Although called hysterical phenomena were not necess arily by ideas alone, their ideogenic as pects were described as hysterical. T he contribution of F reud and B reuer was that they focus ed on investigation of these ideogenic as pects and dis covered s ome of their origins. P articularly, the concept of neuronal excitation, conceived of as s ubject to process es of hydraulic flow discharge as in the P roje ct, was of fundamental in understanding hysteria as well as neurosis in 452 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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A careful reading of B reuer's theoretical s ection in of Hys te ria makes it abundantly clear that what he propos ed was a P.707 reworking of the ingenious ideas of F reud's P roje ct, specific application to the explanation of hysterical phenomena. B reuer described two extreme conditions central nervous system (C NS ) excitation, namely, a waking state and the s tate of dreamles s s leep. W hen brain performs actual work, greater cons umption of energy is required than when it is merely prepared to work. T he phenomenon of s pontaneous awakening take place in conditions of complete quiet and without any external s timulus. T his demonstrates that development of ps ychic energy is based on vital of neural elements thems elves . B reuer also provided an explanation of hysterical conversion. His basic explanatory concept—originally propos ed by F rench ps ychiatris ts, particularly P ierre J anet—was the notion of hypnoid states. S uch s tates believed to resemble the basic condition of dis sociation obtaining in hypnos is . T heir importance lay in the that accompanied them and in their power to bring splitting of the mind. T he s pontaneous origin of s uch states through autohypnosis was identifiable relatively frequently in a number of fully developed hysterics. states often alternated rapidly with normal waking E xperience of the autohypnotic s tate was found to be subjected to a more or les s total amnes ia while the was in the waking s tate. Hys terical convers ion seemed take place more eas ily in such autohypnotic s tates than 453 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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waking states , similar to more facile realization of suggested ideas in states of artificial hypnos is . Neither hypnoid states during periods of energetic work nor unemotional twilight states were pathogenic. T he reveries, however, filled with emotion and states of arising from protracted affects did s eem to be Occurrence of s uch hypnoid s tates was important in genes is of hysterical phenomena becaus e they made convers ion easier and prevented, by way of amnes ia, the converted ideas from wearing away and losing their intensity. It mus t be said that F reud was not s ympathetic to concept of hypnoid s tates, although, at this s tage, had not been able to bring hims elf to reject it. T he concept, in fact, did not explain very much. T he state was used as an explanation for hysterical s tates, the occurrence and function of hypnoid states were in no way explained or s upported—they were postulated. T he only explanatory attempt made was in terms of a hereditary dis pos ition to such states. T his unproven postulate was one that F reud's scientific could not accept. T he spirit of F reud's treatment of the psychotherapy of hysteria was quite different from that embodied in theoretical treatment. His discus sion of the treatment of hysteria in S tudie s of H ys te ria gives one a good s ens e extent to which F reud had moved away in his own thinking from the somewhat res trictive formulations of P roje ct. He pointed out that each individual hys terical symptom seemed to disappear more or les s when the memory of the traumatic event provoking it brought into cons cious awareness along with its 454 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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accompanying affect. It was neces sary that the patient describe such traumatic events in the greates t poss ible detail and be able to expres s verbally the affective experience connected with it. F reud believed that the basic etiology of the acquisition neuros is had to be located in s exual factors. Different sexual influences operated to produce different neurotic disorders . Us ually, the neurotic picture was and purer forms of either hysterical or obs es sional were relatively rare. F reud did not regard all hys terical symptoms as ps ychogenic in origin so that they could all be effectively treated by a ps ychotherapeutic procedure. In the context of his theory and technique at that time, he found that a significant number of patients could not be hypnotized despite an apparently certain diagnosis of hysteria. In these patients, F reud believed he had to overcome a certain ps ychic force in the force that was s et in oppos ition to any attempt to bring the pathogenic idea into cons cious nes s. In the therapy, experienced himself engaging in s ometimes forceful ps ychic work to overcome this intens e counterforce. T he pathogenic idea, however, des pite the force of res is tance, was always clos e at hand and could be by relatively easily acces sible as sociations. T he patient seemed to be able to rid himself or hers elf of s uch turning them into words and des cribing them. Nevertheles s, F reud's experience was that, even in which he was able to surmise the manner in which were connected and could tell the patient before the patient had actually uncovered it, he could not force anything on the patient about matters in which the was es sentially ignorant nor could the therapis t 455 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the product of the analys is by arous ing the patient's expectations .

R es is tanc e T he basic question that confronted F reud and B reuer to do with the mechanism that made pathogenic memories unconscious. T he divergence in their points view was not simply a matter of theoretical differences. F reud's own thinking underwent a definite trans ition, the transition seemed to be bas ed primarily on his experience in dealing with his patients . In the he and B reuer had agreed that their hys terical patients undergone traumatic s exual experiences. T hes e experiences were not available to cons cious T hey had als o agreed, at leas t for a time, that recovery these forgotten experiences during an induced state resulted in abreaction and cons equent improvement. F reud discovered that his patients were often quite unwilling or unable to recall the traumatic memories. defined this reluctance of his patients as re s is tance . As clinical experience expanded, he found that, in the majority of patients he treated, resis tance was not a of reluctance to cooperate—that is , the patients engaged in the treatment process and were willing to obey the fundamental rule of free as sociation. T he generally seemed to be well motivated for treatment, frequently enough, it was particularly patients who most dis tres sed by their s ymptoms who s eemed most hampered in treatment by resistance. F reud's was that res is tance was a matter of the operation of forces in the mind, of which the patients themselves 456 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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often quite unaware, that maintained the exclus ion cons ciousnes s of painful or dis tres sing material. F reud described the active force that worked to exclude particular mental contents from cons cious awareness re pre s s ion, one of the fundamental ideas of theory.

R epres s ion T he concept of repress ion, together with its related of defens e, came to be the bas ic explanation for phenomena in F reud's thinking. T he notion of reflects one of the basic hypothes es of ps ychoanalytic theory, namely, that the human mind includes in its operation basic dynamic forces that can be s et in oppos ition and that s erve as the source of powerful motivation and defense. F reud described the of repress ion in the following terms : A traumatic experience or a s eries of experiences, us ually of a nature and often occurring in childhood, had been “forgotten” or “repress ed” because of their painful or disagreeable nature; but the excitation involved in stimulation was not extinguished, and traces of it in the uncons cious in the form of repres sed memories . T hese memories could remain without pathogenic until some contemporary event, for example, a love affair, revived them. At this juncture, the s trength the repress ive counterforce was diminis hed, and the patient experienced what F reud termed the return of re pre s s ed. T he original sexual excitement was revived found its P.708

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way by a new path, allowing it to manifes t itself in the of a neurotic s ymptom. T hus , the s ymptom res ults from compromise between repres sed desire and the mass of ideas constituting the ego.” T he whole process repress ion and the return of the repress ed was thus conceived of as involving conflicting forces —that is , the force of the repres sed idea s truggling to expres s itself agains t the counterforce of the ego s eeking to keep the repress ed idea out of consciousness . F reud's development of the notions of repres sion and res is tance was based primarily on his studies of cases conversion hys teria. S pecifically, in s uch cases , he that impulses that were not allowed acces s to cons ciousnes s were diverted into paths of somatic innervation, resulting in such hysterical symptoms as paralysis, blindness , dis turbances of s ens ations , and manifestations. Despite this early emphas is on hysteria as the prototype of repres sion, F reud believed that the basic propos ition that s ymptoms res ulted from compromise between a repress ed impuls e and other repress ing forces could be applied to obs es sivecompuls ive phenomena and even to paranoid ideation. T he logical consequence of this hypothesis was that treatment process during this period focused primarily enabling the patient to recall repres sed sexual experiences , so that the accompanying excitation could allowed to find its way into consciousness and be discharged along with the revivified and previous ly dammed-up affects .

S educ tion Hypothes is and Infantile S exuality 458 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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One additional aspect of psychoanalytic theory with s triking clarity from these early researches into hysteria. Invariably, when inquiring into the histories of hysterical patients , F reud found that the repres sed traumatic memories that seemed to lay at the root of pathology had to do with s exual experiences. His became increas ingly focused on the importance of early sexual experiences , us ually recalled in the form sexual s eduction occurring before puberty and often rather early in the child's experience. F reud began to that these seduction experiences were of central importance for understanding the etiology of ps ychoneurosis . Over a period of s everal years, he continued to collect clinical material that seemed to reinforce this important hypothes is . He even went so to dis tinguis h between the nature of the seductive experiences involved in hys terical manifes tations and those involved in obs ess ional neurosis. In the case of hysteria, he believed that the s eduction experience had been primarily pass ive—that is , the child had been the pass ive object of seductive activity on the part of an or older child. In obs ess ive-compuls ive neuros is , he believed the s eduction experience had been active the part of the child. T hus, the child would have actively and aggres sively pursued a precocious s exual What was significant in all of this development was that F reud had taken literally the accounts his patients had given him in the form of forgotten but revived memories of such s exual involvement. T he patients provided him with “tales of outrage” committed by s uch relatives or caretakers as fathers , nursemaids, or uncles. F reud devoted little attention to the role of the child's own 459 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ps ychological experience in the elaboration of thes e B ut, little by little, he began to have s ome s econd about thes e s o-called memories . S everal factors contributed to his doubt. F irs t, he had gained additional insight into the nature of pathological process es from clinical experience and his increas ing awarenes s of the of fantasy in childhood. S econd, he simply found it hard believe that there could be s o many wicked and adults in V iennes e s ociety. T he third influence, which undoubtedly was of major significance in this recons ideration, was his own s elf-analysis. As this important proces s of self-analysis progres sed, F reud began to have more and more reason to call the seduction hypothes is into question. During this time, 1893 to 1897, F reud was s till using the combined technique of pres sure and suggestion with relatively as surance. Often, he insisted that patients recall the seduction s cene s o that much of the evidence on which the seduction hypothes is was based was open to the charge of s uggestion. C ons equently, as F reud became more aware of the role of s ugges tion in his technique, doubts about the s eduction hypothesis grew apace. In S eptember 1897, his doubts came to a focus , and he to his good friend F lies s as follows: And now I want to confide in you immediately the great secret that has been slowly dawning on me in the las t months. I no longer believe in my ne urotica [theory of neuros es]. T his is probably not intelligible without an explanation, after all, you yours elf found credible what I was able to tell you. S o I will begin historically [and tell you] where the reasons for disbelief came from. T he continual disappointment in my efforts to bring a single 460 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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analysis to a real conclusion; the running away of who for a period of time had been mos t gripped [by analysis]; the abs ence of the complete s ucces ses on I had counted; the pos sibility of explaining to mys elf the partial success es in other ways, in the us ual fas hion— was the first group. T hen the s urprise that in all cas es , father, not excluding my own, had to be accus ed of pervers e—the realization of the unexpected frequency hysteria, with precisely the s ame conditions prevailing each, whereas s urely s uch widespread perversions children are not very probable.… T hen, third, the insight that there are no indications of reality in the unconscious, s o that one cannot distinguish between and fiction that has been cathected with affect. [Accordingly, there would remain the s olution that the sexual fantasy invariably seizes upon the theme of the parents .] F ourth, the consideration that in the most reaching psychoses the unconscious memory does not break through, s o that the s ecret of childhood is not disclos ed even in the most confus ed delirium. If thus s ees that the unconscious never overcomes the res is tance of the conscious, the expectation that in treatment the oppos ite is bound to happen, to the point where the uncons cious is completely tamed by the cons cious, als o diminishes. It is obvious that at this period F reud was struggling his own great reluctance to abandon the s eduction hypothes is. T he doubts and the clarifying realization he expres sed to F liess were depress ing. After all, he put in years of effort and had compiled a significant amount of evidence to bolster this s eduction was only with reluctance that he could s urrender it. He 461 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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sens ed, however, that, in s urrendering the s eduction hypothes is, new poss ibilities for psychological were opened up. In fact, this juncture in the of F reud's thinking was crucial. T he abandonment of seduction hypothes is , with its reliance on actual seduction, forced F reud to turn with new realization to inner fantasy life of the child. It can be s aid, in the real sens e, that this shift from an emphasis on reality factors to an attention to and an unders tanding of the influence of inner motivations and fantas y products marks the real beginning of the ps ychoanalytic movement. In this attempt to distinguish ps ychic reality and fantas y from actual external events ps ychoneurosis from perversion, ps ychoanalys is its elf on a new and highly significant dimens ion. W hat emerged from this shift in direction was a dynamic of infantile sexuality in which the child's own life played the s ignificant and dominant role. T his replaced the more static point of view in which the child represented an innocent victim whos e eroticis m was prematurely disrupted at the hands of uns crupulous adults . P.709 T he turning point was one of extreme significance for F reud hims elf. Increas ingly, he turned his attention to own self-analysis and put increasing reliance on it. He wrote to F liess , “My s elf-analysis is in fact the most es sential thing I have at present and promises to of the greatest value to me if it reaches its end.” More more, he became involved in the s tudy of dreams , all more s o as he developed the technique of free 462 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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which provided him with a tool for exploring the as sociative content underlying the dream experience. concerned hims elf ever more s o with the nature of infantile sexuality and with the inner s ources of fantas y and dream content, namely, the uncons cious drives . In recent years, this s o-called abandonment of seduction hypothes is has been s ubjected to severe criticis m on the grounds that it tended to minimize the role of actual s eduction, which looms as a pervasive problem in our contemporary s ociety. B ut in F reud's defens e, it s hould be said that he never denied that seduction was a problem; he knew well enough that it exis ted, but it was not for him a path to deeper unders tanding of the dynamic as pects of ins tinctual infantile sexual life. B y 1897, when the hypothesis of actual s eduction had fallen in the dust at F reud's feet, he could look to a of significant accomplis hments . T he fundamental of psychic determinis m and the operation of a dynamic unconscious were es tablis hed, and concomitantly, a theory of psychoneurosis based on the idea of psychic conflict and the repress ion of disturbing childhood experiences had become clearly established. particularly in the form of childhood sexuality, had been unveiled as playing a significant but previous ly underemphasized or ignored role in the production of ps ychological s ymptoms. More s ignificantly, perhaps , F reud had arrived at a technique, a method of inves tigation, that could be exploited as a means of exploring a wide range of mental phenomena that had previous ly been poorly understood. Moreover, the horizons of psychoanalytic interest had begun to 463 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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rapidly. F reud's attention was no longer focus ed on limited forms of ps ychopathology. It had begun to out, reflecting the wide-ranging curios ity and interes ts F reud's mind and to embrace the unders tanding of dreams , creativity, wit, and humor, the everyday experience, and a hos t of other normal and culturally s ignificant mental phenomena. had indeed come to life.

INTE R P R E TA TION OF DR E A MS C urrently, the whole area of sleep and dream activity is one of the most exciting and intens ely studied as pects ps ychological functioning. T he discovery of rapid eye movement (R E M) cycles and the definition of the stages of the sleep cycle have s timulated an intense extremely productive flurry of research activity into the neurobiology of dreaming. A whole new realm of fres h important ques tions has been opened as a result of activity, and ps ychoanalys ts are drawing much closer more comprehens ive unders tanding of the links patterns of dream activity and underlying neurophys iological and ps ychodynamic variables. As is learned about this fascinating and complex question, one comes much clos er to understanding the nature of dream process and the dream experience its elf. In this context, it is difficult to look back and to the uniqueness and originality of F reud's immersion in dream experience. Only when F reud's attention had refocused to the s ignificance of inner fantasy by reason of abandonment of the s eduction hypothesis and in the context of his developing the technique of as sociation, did the s ignificance and value of the 464 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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inves tigation of dreams impres s on him. F reud became aware of the s ignificance of dreams in his experience his patients when he realized that, in the process of as sociation, his patients frequently reported their along with the ass ociative material that seemed with them. He dis covered little by little that dreams had definite meaning, although that meaning was often hidden and disguis ed. Moreover, when he encouraged patients to as sociate freely to the dream fragments , he found that what they frequently reported was more connected with repres sed material than ass ociations to events of their waking experience. S omehow, the content s eemed to be closer to the uncons cious and fantas ies of the repress ed material, and dream material seemed to facilitate dis clos ure of this content.

Theory of Dreaming T he rich complex of data derived from F reud's clinical exploration of his patients' dreams and the profound insights derived from his ass ociated investigation of his own dreams were distilled into the landmark publication in 1900 of T he Inte rpre tation of Dre ams . B asing his on thes e data, F reud presented a theory of the dream paralleled his analys is of psychoneurotic symptoms. viewed the dream experience as a cons cious an uncons cious fantas y or wish not readily access ible cons cious waking experience. T hus, dream activity cons idered one of the normal manifestations of unconscious process es. T he dream images represented uncons cious wis hes or thoughts disguis ed through a proces s of symbolization 465 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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and other distorting mechanisms. T his reworking of unconscious contents constituted the dream work. postulated the exis tence of a “cens or,” pictured as guarding the border between the unconscious part of mind and the precons cious level. T he censor exclude uncons cious wis hes during conscious s tates during regres sive relaxation of sleep, allowed certain unconscious contents to pas s the border, yet only after transformation of uncons cious wishes into dis guised experienced in the dream contents by the s leeping subject. F reud as sumed that the cens or worked in the service of the ego—that is , as s erving the s elfobjectives of the ego. Although he was aware of the unconscious nature of the process es, he tended to the ego at this point in the development of his theory more restrictively as the s ource of cons cious process es reasonable control and volition. It s hould not be that, even in S tudie s on Hys teria, repres sion was s till envis ioned in intentional and volitional terms. F reud's deepened appreciation of the unconscious dimens ion these proces ses led him to view the ego as in some unconscious, one of the reasons for his formulation of structural theory in 1923.

A nalys is of Dream C ontent F reud's view of dream material was that it contained content that has been repress ed or excluded from cons ciousnes s by defens ive activities of the ego. T he dream material, as cons cious ly recalled by the simply the end result of uncons cious mental activity place during sleep. F reud believed that the ups urge of unconscious material was s o intense that it threatened interrupt s leep its elf so that he envis ioned one function 466 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the cens or was to act as a guardian of s leep. Ins tead of being awakened by these ideas , the s leeper dreams. F rom a more contemporary viewpoint, it is known that cognitive activity during sleep has a great deal of S ome cognitive activity follows the description that provided of dream activity, but much of it is more realistic and more consis tently organized along logical lines. T he dreaming activity that F reud analyzed and described is probably more or less as sociated with stage 1 R E M periods of the s leep–dream cycle. T he called manifes t dream that embodies the experienced content of the dream, which the s leeper may or may be able to recall after waking, is the product of dream activity. Uncons cious thoughts and wishes that in view threatened to awaken the sleeper were des cribed “latent dream content.” P.710 F reud referred to uncons cious mental operations by latent dream content was transformed into the manifes t dream as the dre am work. In the proces s of dream interpretation, he was able to move from the manifest content of the dream by way of ass ociative exploration arrive at the latent dream content that lay behind the manifest dream and that provided it with its core In F reud's view, there were a variety of s timuli that dreaming activity. T he contemporary unders tanding of dream process , however, s uggests that dreaming takes place more or les s in conjunction with the patterns of central nervous activation that characterize certain phases of the sleep cycle. What F reud believed be initiating stimuli may in fact not be initiating at all but 467 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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may be merely incorporated into the dream content, determine to that extent the material in the dream thoughts. S timuli could aris e from various sources.

NOC TUR NAL S E NS OR Y S TIMUL I A variety of s ens ory impres sions, such as pain, hunger, thirst, or urinary urgency, may play a role in dream content. T hus, ins tead of disturbing one's s leep leaving a warm bed, a s leeper who is in a cold room who urgently needs to urinate may dream of voiding, and returning to bed. F reud's view would have been that the activity of dreaming preserved and safeguarded the continuity of sleep. It is known now, however, that the function of dreaming is cons iderably more complex and cannot be regarded simply as preserving sleep, although there is still room for this proces s to be counted among the dream functions.

DAY R E S IDUE S One of the important elements contributing to s haping the dream thoughts is the residue of thoughts and and feelings left over from experiences of the day. T hes e res idues remain active in the unconscious like sensory s timuli, can be incorporated by the s leeper into thought content of the manifest dream. T hus, day res idues could be amalgamated with unconscious drives and wis hes deriving from the level of instincts. T he amalgamation of infantile drives with elements of the day's residues effectively disguises the infantile impuls e and allows it to remain effective as the driving force behind the dream. Day res idues may in thems elves be quite s uperficial or trivial, but they 468 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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significance as dream ins tigators through unconscious connections with deeply repress ed instinctual drives wis hes .

R E PR E S S E D INFANTILE DR IVE S Although these various elements may be determining as pects of the thought content of the dream the es sential elements of the latent dream content from one or several impulses emanating from the repress ed part of the uncons cious . In F reud's s chema, ultimate driving forces behind dream activity and dream formation were the wis hes , originating in drives , from an infantile level of ps ychic development. T hese drives took their content s pecifically from oedipal and oedipal levels of psychic integration. T hus, nocturnal sens ations and day res idues played only an indirect determining dream content. A nocturnal stimulus , however intens e, had to be as sociated with and with one or more repres sed wis hes from the to give rise to the dream content. T his point of view some revis ion because it s eems that, in s ome phas es nighttime cognitive activity, the mind is able to proces s res idues of daytime experience without much indication connection with unconscious repres sed content. in phases of cognitive activity during sleep that bear stamp of dreaming activity as F reud described and it, this ess ential link to the repres sed probably s till some validity.

S ignific anc e of Dreams Once F reud's attention had definitively shifted to the of inner process es of fantasy and dream formation, the 469 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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study of dreams and the process of their formation became the primary route by which he gained acces s unders tanding uncons cious proces ses and their In T he Inte rpre tation of Dre ams , he maintained that dream s omehow repres ents a wish fulfillment. He bolstered this hypothes is with a cons iderable amount documentation, including exhaus tive analysis of his dreams . T here is a more general tendency today to view the activity as express ing a broader spectrum of proces ses, keeping the as pect of wish fulfillment as among the dimens ions of dream activity but not as an absolute principle, as it s eemed to be in F reud's T he manifest dream content may represent imaginary fulfillment of a wish or impulse from early childhood, before such wis hes have undergone repres sion. In childhood, and even later in adulthood, however, the acts to defend its elf agains t unacceptable instinctual demands of the unconscious. W is h fulfillment in the proces s is usually quite obs cured by the extensive distortions and disguis es brought about by the dream work so that it often cannot be readily identified on a superficial examination of the manifest content.

Dream Work T he theory of the nature of dream work became the fundamental description of the operation of proces ses —the bas ic mechanis ms and the manner of operating—that s tands even today as an unsurpas sed foundational account of uncons cious mental T he focus of F reud's analysis was on the proces s by unconscious latent dream thoughts were disguis ed and 470 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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distorted in s uch a fashion as to permit their express ion and translation into conscious manifes t content of the dream. However, these unconscious process es , part of fruit of his inves tigation, found ready application and extrapolation not only to understanding the formation of neurotic s ymptoms but als o, more broadly, to a whole range of unconscious productivity. T he theory of dream work consequently became the basis for a wideanalysis of uncons cious operations that found in F reud's s tudy of everyday experiences, as well as creativity, jokes, and humor, and a variety of culturally based activities of the human mind. As pects of the work are as follows.

R epres entability T he basic problem of dream formation is to determine how it is that latent dream content can find a means of representation in the manifes t content. As F reud s aw it, the state of s leep brought with it relaxation of and, concomitantly, latent uncons cious wis hes and impulses were permitted to press for dis charge and gratification. B ecaus e the pathway to motor expres sion was blocked in the s leep state, thes e repres sed wis hes impulses had to find other means of representation by of mechanis ms of thought and fantasy. Activity of the dream censor provided continual res is tance to of thes e impulses, with the result that the impulses had be attached to more neutral or “innocent” images to be able to pass the scrutiny of cens orship and be allowed cons cious expres sion. T his dis placement was made poss ible by s electing apparently trivial or ins ignificant images from residues of the individual's current ps ychological experience and linking thes e trivial 471 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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dynamically with latent uncons cious images, on the bas is of s ome res emblance that allowed links to be established. In the proces s of facilitating economic express ion of latent unconscious contents at the same time, maintaining the distortion that was es sential for uncons cious contents to es cape the repress ing action of the censor, the dream work us ed a variety of mechanisms, making it pos sible for more images to represent repres sed infantile components. T hese mechanis ms included symbolis m, dis placement, condensation, projection, and s econdary revision. P.711

S YMB OL IS M S ymbolis m is a complex process of indirect that in the ps ychoanalytic us age has the following connotations : A s ymbol is repres entative of or s ubs titute for some other idea from which it derives a secondary significance that it does not poss es s itself. A s ymbol represents this primary element by a common element that thes e ideas s hare. A s ymbol is characteris tically sensory and concrete nature, as oppos ed to the idea it repres ents , which may be relatively abs tract and complex. A s ymbol provides a more condens ed express ion of the idea represented. S ymbolic modes of thought are more primitive, both ontogenetically and phylogenetically, and repres ent 472 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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forms of regres sion to earlier stages of mental development. C ons equently, symbolic tend to function in more primary process or regress ed conditions : in the thinking of primitive peoples, in myths, in s tates of poetic inspiration, particularly, in dreaming. A s ymbol is thus a manifes t express ion of an idea is more or less hidden or s ecret. T ypically, the us e the symbol and its meaning are unconscious. T hus , symbols tend to be used s pontaneous ly, and unconsciously. T he use of s ymbols is a sort of secret language in which instinctually determined content can be reexpress ed as other images ; for example, money can s ymbolize feces , or windows symbolize the female genitals . Many questions still pers is t about the origins of proces ses; the s tage of development in which they become organized; the extent to which they require altered states of consciousness , such as the sleep their implementation; and the degree to which symbolic expres sion is related to underlying conflicts . C urrent formulations regard the symbolic function as a uniquely human trait involved in all forms of human mental from the most primitive expres sion of infantile wishes to the most complex creative process es of literary, religious , and s cientific thinking.

DIS PL AC E ME NT T he mechanis m of dis place me nt refers to the transfer amounts of energy (cathexis ) from an original object to subs titute or symbolic representation of the object. 473 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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B ecaus e the s ubs titute object is relatively neutral—that less inves ted with affective energy—it is more to the dream cens or and can pass the borders of repress ion more easily. T hus, whereas s ymbolism can taken to refer to the substitution of one object for displacement facilitates dis tortion of unconscious through transfer of affective energy from one object to another. Des pite the transfer of cathectic energy, the of the uncons cious impulse remains unchanged. F or example, in a dream, the mother may be represented visually by an unknown female figure (at leas t one who less emotional significance for the dreamer), but the content of the dream nonetheless continues to derive from the dreamer's unconscious instinctual impulses toward the mother.

C ONDE NS ATION C onde ns ation is the mechanism by which s everal unconscious wis hes , impuls es, or attitudes can be combined into a single image in the manifest dream content. T hus , in a child's nightmare, an attacking may come to represent not only the dreamer's father may als o repres ent s ome aspects of the mother and some of the child's own primitive hostile impuls es as T he converse of condens ation can als o occur in the work, namely, an irradiation or diffusion of a s ingle wis h or impulse that is distributed through multiple representations in the manifest dream content. T he combination of mechanisms of condens ation and provides the dreamer with a highly flexible and device for facilitating, compress ing, and diffus ing or expanding the manifest dream content, which is 474 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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from latent or unconscious wishes and impulses.

PR OJ E C TION T he proces s of projection allows dreamers to rid thems elves of their own unacceptable wis hes or and experience them as emanating in the dream from other people or independent sources. Not s urprisingly, figures to whom these unacceptable impuls es are in the dream often turn out to be those toward whom subject's own unconscious impulses are directed. F or example, the individual who has a s trong repres sed to be unfaithful to his wife may dream that his wife has been unfaithful to him; or a patient may dream that she has been sexually approached by her analyst, although is reluctant to acknowledge her own repress ed wishes toward the analyst. S imilarly, the child who dreams of a destructive monster may be unable to acknowledge his her own destructive impulses and the fear of the power to hurt the child. T he figure of the monster cons equently is a res ult of both projection and displacement.

S E C ONDAR Y R E VIS ION T he mechanis ms of symbolism, dis placement, condensation, and projection are all characteristic of relatively early modes of cognitive organization in a developmental s ens e. T hey reflect and expres s the operation of the primary process . In the organization of the manifest dream content, however, primary-proces s forms of organization are supplemented by a final that organizes the absurd, illogical, and bizarre aspects the dream thoughts into a more logical and coherent 475 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T he distorting effects of symbolis m, displacement, and condensation thus acquire a coherence and rationality are necess ary for acceptance on the part of the more mature and reasonable ego through a process of secondary revis ion. S econdary revision thus us es intellectual proces ses that more closely resemble organized thought proces ses governing rational s tates cons ciousnes s. It is through secondary revision, then, the logical mental operations characteris tic of the secondary process are introduced into and modify work.

AFFE C TS IN THE DR E AM WOR K In the process of dis placement, condens ation, or projection, as F reud hypothesized, the energic component of the ins tinctual impulses is s eparated its repres entational component and follows an independent path of expres sion in the form of affects or emotions . T he repress ed emotion may not appear in manifest dream content at all, or it may be experienced a considerably altered form. T hus , for example, hostility or hatred toward another individual may be modified into a feeling of annoyance or mild irritation in the manifest dream express ion, or it may even be represented by an awareness of not being annoyed— is , a conversion of the affect into its absence. T he affect may poss ibly be directly transformed into an oppos ite in the manifes t content, for example, as when repress ed longing might be represented by a manifes t repugnance or vice vers a. T hus, the viciss itudes of and the transformation by which latent affects are disguis ed introduce another dimens ion of dis tortion into the content of the manifes t dream. T he vicis situdes of 476 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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affect, then, take place in addition to and in parallel proces ses of indirect repres entation that characterize viciss itudes of dream content.

R egres s ion In the seventh theoretical chapter of T he Interpre tation Dreams , F reud provided a model of the ps ychic as he understood it at the turn of the 20th century. Not only was the model a description of the functioning of dreaming mind, but it als o repres ented a broader conceptualization of the ps ychic apparatus as it in both pathological and normal human experience, P.712 as he had formulated previously in the P roje ct. It clear that the economic model, on which F reud had expended such intense effort in the 1890s and had seemingly abandoned in frus tration, had come back to reass ert itself, now in a new language and in a different setting. T he lines of continuity and parallels between model of the mind in the P roje ct and the model of the seventh chapter could not be appreciated until the manus cript of the P roje ct was rediscovered after death. T he model was an elaborate construction bas ed on a notion of a stimulus –res ponse mechanis m. In normal waking experience, s ens ory input is taken into the receptor end of the apparatus and then process ed in a number of mnemonic s ys tems of increasing degrees of elaborateness and complexity. After varying degrees of proces sing, the impuls e is s ubs equently dis charged through the motor effector apparatus . In the dream 477 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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motor effector pathways are blocked so that, instead of discharge through motor s ys tems, excitation is forced move in a backward or regress ive direction through the mnemonic s ys tems and back toward s ens ory systems . During waking hours, the path leading from levels of the apparatus through precons cious to levels is barred to the dream thoughts by activity of the cens or. In sleep, however, this pathway is again made more available becaus e res is tance of the censor is diminis hed in s leep. C onsequently, uncons cious and their instinctual determinants could press to through the perceptual apparatus, as is particularly the case in hallucinatory dream experiences. T hus , dreams could be des cribed as having a regres sive character. C ons is ting specifically of the turning back of an idea the sensory image from which it was originally derived, regress ion is an effect of the resistance opposing of psychic energy ass ociated with the thought into cons ciousnes s along the normal path. R egress ion is contributed to by simultaneous attraction exercised on thought by the presence of ass ociated memories in the unconscious. In dreams , regress ion is further facilitated by diminution the progres sive current flowing from continuing s ensory input during waking hours. R egress ion, as F reud is es sentially a regres sion to the originating s ource of impres sion in the revers al he describes within the apparatus, but it also is a regres sion in time. F reud distinguished s everal forms of regres sion, namely, a topographical regress ion involving a regress ion in cons cious to unconscious s ys tems within the mental model; a temporal regres sion according to which the 478 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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mental proces s refers back to older ps ychical particularly thos e deriving from an infantile level of development; and formal regress ion, in which more primitive methods of expres sion and repres entation the place of the more normal ones . “All these three of regres sion,” F reud commented, “are, however, one bottom and occur together as a rule; for what is older in time is more primitive in form and in psychical lies nearer to the perceptual end.”

P rimary and S ec ondary P roc es s P erhaps the most central aspect of the functioning of mental model, clos ely related to the formulations of the P roje ct, has to do with F reud's notions of the primary secondary process es. T o begin with, the impulses and instinctual wishes originating in infancy serve as the indis pensable nodal force for dream formation. T he energic conception of these drives follows the bas ic economic principles laid down by the P roje ct (T able T hey are elevated states of psychic tens ion in which energy is constantly s eeking discharge according to cons tancy principle and the pleas ure principle. T he tendency to discharge, however, is oppos ed by ps ychic s ys tems. T hus , F reud envisioned two fundamentally different kinds of ps ychic process es involved in the formation of dreams . One of these proces ses tends to produce a rational organization of dream thoughts , which was of no les s validity in terms contact with reality than normal thinking. However, another s ys tem—the firs t psychic s ys tem in F reud's schema—treats the dream thoughts in a bewildering irrational manner. He believed that a more normal train 479 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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thought could only be s ubmitted to abnormal psychic treatment if an uncons cious wis h, derived from infancy and in a s tate of repres sion, had been transferred to it. res ult of the operation of the pleas ure principle, the firs t ps ychic s ys tem is incapable of bringing anything disagreeable into the context of the dream thoughts. It unable to do anything but wish. Operating in with the demands of this primary system, the system can only cathect an unconscious idea if it can inhibit any development of unpleasure that may have proceeded from the coming to awarenes s of that idea. Anything that may evade that inhibition is equivalently inacces sible to the s econd s ys tem, as well as to the because it is promptly eliminated in accordance with unpleasure principle. T he ps ychic proces s derived from the operation of the system is referred to as primary proce s s . T he process res ulting from the inhibition impos ed by the s econd system is referred to as the s e condary proce s s , and it reflects the operation of the s ys tem of inhibition and sketched in the P roje ct. T he s econdary s ys tem thus and regulates the primary s ys tem in accordance with principles of logic, rationality, and reality. Among the wis hful impulses derived from infantile impulses, there some whos e fulfillment is a contradiction of the and ideas of secondary process thinking. T he these wishes can no longer generate an affect of but is unpleasurable. T his formulation, it s hould be forms the bas is for F reud's later elaboration of the principle, as oppos ed to the reality principle. T he secondary process organization of preconscious aimed at avoiding unpleas ure, at delaying instinctual 480 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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discharge, and at binding mental energy in accordance with the demands of external reality and the subject's moral principles or values . T hus, functioning of the secondary process is closely connected with the reality principle and is governed, for the mos t part, by the dictates of the reality principle.

Topographic al Theory B eginning with abandonment of the s eduction with the concomitant turning of F reud's interes ts to proces ses of fantas y and dream formation, and ending with publication of T he E go and the Id in 1923, in which F reud propounded his s tructural model of the psychic apparatus, F reud's thinking was cas t largely in terms of topographical theory.

B as ic As s umptions T here were a number of as sumptions underlying thinking that s erved as lines of continuity between stages of his investigations and helped him to organize thinking in terms of success ive models of the mental apparatus. T he firs t as sumption was that of determinism,” according to which all ps ychological including behaviors , feelings , thoughts, and actions, caus ed by—that is , are the end res ult of—a preceding sequence of causal events . T his ass umption derived F reud's Helmholtzian convictions and repres ented application of a bas ic natural science principle to ps ychological unders tanding; but it was also reinforced F reud's clinical observation that apparently hysterical s ymptoms , which had been previous ly attributed to s omatic etiology, could be relieved by 481 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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relating them to past, apparently repress ed, T hus, apparently arbitrary pathological behavior could tied to a caus al psychological network. T he second ass umption is that of “unconscious ps ychological process es.” T his ass umption derived cons iderable amount of evidence gathered through the us e of hypnosis , but it was als o cons olidated by experience of the free ass ociating of his patients past experiences to awarenes s. T he uncons cious which s urvived and was able to influence present experience, was found to be governed by s pecific regulatory P.713 principles, for example, the pleas ure principle and the mechanisms of primary proces s that differed radically those of cons cious behavior and thought process es . the unconscious process es were brought within the of psychological understanding and explanation. T he third as sumption was that “unconscious conflicts ” between and among psychic forces formed basic elements at the root of ps ychoneurotic difficulties . T his ass umption related to F reud's experience of and the drive to repres sion in his patients . T he full realization of this aspect of psychic functioning came with awarenes s that the reports of patients represented not memories of actual experiences but, rather, unconscious fantas ies . T he ass umption of uncons cious forces accounted for the process that created those fantas ies and brought them into conscious ness during as sociation. It als o accounted for the agency that the coming to cons cious nes s of s uch fantasies . T his 482 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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counterforce that clas hed with the sexual drives and diverted them into fantas ies or s ymptoms was related the function of censorship as developed in the dream theory and, later, to the operation of ego instincts that were set in opposition to the s exual ins tincts . T he final ass umption of the topographical theory was there exis ted “ps ychological energies ” that originated in instinctual drives . T his as sumption was derived from observation that recall of traumatic experiences and accompanying affect resulted in dis appearance of symptoms and anxiety. T his sugges ted, therefore, that displaceable and transformable quantity of energy was involved in the psychological process es res ponsible for symptom formation. F reud originally ass umed that this quantity was equivalent to the affect, which became dammed up or strangulated when it was not expres sed and, thus , was trans formed into anxiety or conversion s ymptoms . After he had developed his of ins tinctual drives, this quantitative factor was of as drive energy (cathexis ). As noted previous ly in discuss ion of the P roje ct, the ass umption of psychic energies s erved F reud as an important heuristic T he us efulnes s of the metaphor and its necess ity as a as sumption of analytical theory have been ques tioned found wanting.

Topographic al Model F reud's thinking about the mental apparatus at this was bas ed on the class ification of mental operations contents according to regions or s ys tems in the mind. T hese systems were des cribed neither in anatomical spatial terms but, rather, were s pecified according to 483 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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relations hip to cons cious nes s. T he topographical has ess entially fallen into disfavor because of its limited us efulnes s as a working model of psychoanalytic largely because it has been s urpas sed and s upplanted the structural theory. T he topographical viewpoint, however, is still useful for clas sifying mental events descriptively by quality and degree of awarenes s. a tendency currently to revive aspects of the model of the mind in viewing mental process es as descriptively more or less cons cious or unconscious, than as reflecting operation of a mental structure as in systemic unconscious of clas sic metapsychology.

C ons c ious nes s T he cons cious system is that region of the mind in perceptions coming from the outside world or from the body or mind are brought into awarenes s. Internal perceptions can include intros pective observations of thought proces ses or affective states of various kinds . C ons cious nes s is, by and large, a subjective the content of which can only be communicated by language or behavior. It has also been regarded ps ychoanalytically as a s ort of superordinate s ens e which can be s timulated by perceptual data impinging the C NS . It was as sumed that the function of cons ciousnes s used a form of neutralized psychic called atte ntion cathe xis . T he nature of cons cious nes s was described in les s F reud's early theories , and certain aspects of are not yet completely unders tood and are actively debated by ps ychoanalys ts. F reud regarded the system as operating in close as sociation with the 484 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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preconscious. T hrough attention, the s ubject can cons cious of perceptual s timuli from the outside world. F rom within the organis m, however, only elements in preconscious are allowed to enter consciousness . T he of the mind lies outside awareness in the uncons cious . B efore 1923, however, F reud als o believed that cons ciousnes s controlled motor activity and regulated qualitative distribution of psychic energy.

P rec ons c ious T he preconscious s ys tem consists of thos e mental proces ses, and contents that are, for the mos t part, capable of reaching or being brought into cons cious awarenes s by the act of focus ing attention. T he quality preconscious organizations may range from realityoriented thought s equences or problem-solving with highly elaborated secondary proces s s chemata all way to more primitive fantasies, daydreams , or dreamimages, which reflect a more primary proces s T hus, it s tands over and agains t unconscious which the trans formation to consciousness is accomplis hed only with great difficulty and by dint of expenditure of cons iderable energy in overcoming the barrier of repress ion. T he preconscious has been amplified by recent neuros cientific study of memory. An es sential between episodic memory and procedural memory. E pisodic memory deals with pas t events in the experience that are us ually autobiographical or in content. Other memories , however, have more to do with skills and habitual patterns of behavior, as, for example, riding a bike, driving a car, playing the piano, 485 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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grammatical rules, s ocial norms of politeness and etiquette, and so forth. T hes e are as pects of normal living and behavior that people rarely, if ever, think about—people just do them, but the procedures are embedded in our memories and are readily applied without any effort to recall them. In fact, any effort to them more than likely only interferes with their T hese memory s ys tems, along with others that can be differentiated, are apparently s erved by different neural circuits and have different connections with and behavior.

Unc ons c ious Uncons cious mental events , namely, thos e not within cons cious awarenes s, can be des cribed from several viewpoints . One can think of the unconscious descriptively, that is , as referring to the s um total of all mental contents and proces ses at any given moment outside the range of cons cious awarenes s, including preconscious. One can als o think of the uncons cious dynamically, as referring to thos e mental contents and proces ses are incapable of achieving cons cious nes s becaus e of operation of a counterforce of cens ors hip or T his repres sive force or “countercathexis ” manifests in ps ychoanalytic treatment as res istance to T he unconscious mental contents in this dynamic cons ist of drive representations or wishes that are in meas ure unacceptable, threatening, or abhorrent to the intellectual or ethical s tandpoint of the individual. T his res ults in intraps ychic conflict between the repress ed forces and the repress ing forces of the mind. W hen 486 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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repress ive countercathexis weakens, this may result in formation of neurotic s ymptoms. T he symptom is thus viewed as ess entially a compromise between forces . T hese uncons cious mental contents are als o organized on the basis of infantile P.714 wis hes or drives and strive for immediate discharge, regardless of the reality conditions . C onsequently, the dynamic unconscious is believed to be regulated by the demands of primary process and the pleas ure F inally, there is a s ys temic sense of the unconscious referring to a region or system within the organization the mental apparatus that embraces the dynamic unconscious and within which memory traces are organized by primitive modes of as sociation, as by the primary proces s. T his s ys temic view of the unconscious is cons idered, in a specifically sens e, as a component subsystem within the topographical model and in the s tructural theory is attributed to the id. C ons equently, the systemic unconscious can be described in terms of the following characteristics in F reud's view: Ordinarily, elements of the systemic unconscious inacces sible to consciousness and can only cons cious through acces s to the preconscious, excludes them by means of cens ors hip or R epress ed ideas, consequently, may only reach cons ciousnes s when the cens or is overpowered ps ychoneurotic symptom formation), relaxes (as in dream s tates), or is fooled (in jokes). 487 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T he unconscious s ys tem is exclusively ass ociated primary process thinking. T he primary process has its principal aim facilitation of wis h fulfillments and instinctual dis charge. C ons equently, it is intimately as sociated with—and functions in terms of—the pleas ure principle. As s uch, it disregards logical connections , permits contradictions to coexis t simultaneously, recognizes no negatives, has no conception of time, and repres ents wis hes as fulfillments . T he unconscious s ys tem als o uses primitive mental operations that F reud identified in the operation of the dream proces s. Moreover, the quality of motility, characteristic of primary process thinking and of unconscious energy, is als o linked to the capacity for creative thinking. Memories in the uncons cious have been divorced their connection with verbal s ymbols. F reud discovered in the cours e of his clinical work that repress ion of a childhood memory could occur if energy was withdrawn from it and, especially, if the verbal energy was removed. W hen the words are reconnected to the forgotten memory traits (as ps ychoanalytic treatment), it becomes recathected and can thus reach cons cious nes s once more. T he content of the uncons cious is limited to wis hes seeking fulfillment. T hes e wishes provide the force for dreams and neurotic s ymptom formation. has already been noted that this view may be overs implified. T he unconscious is clos ely related to the ins tincts . this level of theory development, the instincts are cons idered to consist of s exual and s elf488 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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(ego) drives. T he unconscious is believed to mental representatives and derivatives , particularly the sexual instincts.

Dynamic s of Mental Func tioning F reud conceived of the ps ychic apparatus , in the of the topographical model, as a kind of reflex arc in the various s egments have a spatial relationship. T he cons ists of a perceptual or sensory end through which impres sions are received; an intermediate region, cons isting of a s torehous e of unconscious memories ; motor end, closely ass ociated with the preconscious, through which instinctual dis charge can occur. In early childhood, perceptions are modified and s tored in the form of memories . According to this theory, in ordinary waking life, the mental energy as sociated with uncons cious ideas discharge through thought or motor activity, moving the perceptual end to the motor end of the apparatus . Under certain conditions, such as external frus tration or sleep, the direction in which energy travels along the revers ed, and it moves from the motor end to the perceptual end instead of the other way around. It tends to reanimate earlier childhood impres sions in earlier perceptual forms and res ults in dreams during or hallucinations in mental disorders . T his reversal of normal flow of energy in the ps ychic apparatus is the “topographical regress ion” discuss ed previously. F reud s ubs equently abandoned this model of the mind a reflex arc, he retained the central concept of and applied it later in s omewhat modified form in the theory of neurosis . T he theory states that libidinal 489 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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frus tration res ults in revers ion to earlier modes of instinctual dis charge or levels of fixation, which had previous ly determined by childhood frustrations or excess ive erotic s timulations. F reud called this kind of revers ion to instinctual levels of fixation libidinal or ins tinctual re gres s ion.

Framework of Ps yc hoanalytic R epres s ed vers us R epres s ing T hroughout his long lifetime and in the course of many twis tings and turnings of the theoretical developments his thinking, F reud's mind was dominated by a to des cribe many as pects of mental functioning in contrasting polarities; s ome of the primary polarities that of subject (ego) vers us object (outer world), versus unpleas ure, and activity versus pas sivity. T he fundamental and dominant dualism is between the and contents of the mind viewed as repres sed and unconscious and those forces and mental agencies res ponsible for the act of repress ing. Although the persis tence of such bas ic dualis m in ps ychoanalytic thinking has clear advantages and undoubtedly helps unders tand some fundamental as pects of the mind, should not forget that s uch paradigms may prove to be overly res trictive. T here is real ques tion in the current of psychoanalysis as to whether s ome of these basic dimensions may not, in fact, be limiting the of ps ychoanalytic theory to grow apace with the expanding horizons of both clinical experience and experimental, es pecially neuroscientific, exploration. historical role and the present vitality of the bas ic ps ychoanalytic dualism, however, s hould not be undervalued because they provide a powerful tool for 490 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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unders tanding and treating clinical pathology.

INS TINC TUA L THE OR Y All human beings have s imilar ins tincts . T he actual discharge of these ins tinctual impuls es is organized, directed, regulated, or even repres sed by functions of individual ego, which mediates between the organism the external world. Historically, F reud's exploration of instincts in ps ychoanalys is preceded his development structural theory and his concern with ps ychology of ego.

C onc epts of Ins tinc ts One of the firs t problems to be dealt with in considering the theory of ins tincts is what is meant by the term “instinct.” T he problem is made more complex by the variation in usage between a primarily biological and F reud's primarily psychological concept. T he difficulties are als o compounded by the complexities in F reud's own us e of the term. T he term “instinct” was introduced primarily by students of animal behavior, P.715 referring generally to a pattern of s pecies -specific based mainly on potentialities determined by heredity was therefore considered to be relatively independent learning. T he term was applied to a great variety of behavior patterns, including patterns described in such terms as a maternal ins tinct, a nes ting instinct, or a migrational instinct. S uch usage resis ted success ful phys iological explanation and tended to introduce a strong teleological connotation, thus implying some 491 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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of purposefulness , as in the concept of a s elfinstinct. F reud adopted this us age unques tioningly, but validity has been ques tioned even by strong of ins tinctual theory among animal behaviorists , for the line between instinctual and learned behavior has become increas ingly more complex and debatable. dichotomy of nature/nurture can no longer be simplis tically or rigidly maintained. T hus , instinctually derived patterns of behavior are s een to be modifiable in the interes ts of adaptation. E thologis ts cons equently prefer to s peak s imply of s pecies -typical behavior patterns that are based on innate equipment that mature and develop or are elicited through a degree of environmental interaction. F reud, of cours e, took as the bas is of his thinking the concept of instinct, but in adopting it for his purposes, transformed it. Actually, F reud's own formulation of the notion of ins tinct underwent contextual modification s o that he actually offered a variety of definitions . P erhaps most cogent was the following: “An ‘instinct’ appears to as a concept on the frontier between the mental and somatic, as the ps ychical repres entative of the s timuli originating from within the organis m and reaching the mind, as a meas ure of the demand made upon the for work in cons equence of its connection with the It is immediately evident that the bas ic ambiguity in the concept of instinct between biological and as pects continued to influence F reud's thinking about instinctual drives and remains latent in s ubs equent ps ychoanalytic usage of the term. F reud hims elf varied the emphasis he placed on one or another aspect of concept s o that s ubsequent discus sions of the concept 492 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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instinct in psychoanalysis have varied similarly emphasis on biological aspects and emphasis on ps ychological as pects .

Theory of the Ins tinc ts When F reud began his investigation into the nature of unconscious drives, he s trove cons is tently to base ps ychoanalytic theory on a firm biological foundation. of the mos t important of his attempts to link and biological phenomena came when he bas ed his theory of motivation on instincts. F reud viewed ins tincts a class of borderline concepts that functioned between mental and organic s pheres. C ons equently, his use of term “instinct” is not always consistent because it emphasizes either the psychic or biological aspect of term in varying degrees in varying contexts. then, libido refers to the s omatic proces s underlying the sexual instinct, and at other times , it refers to the ps ychological representation its elf. T hus , F reud's quite divergent from the Darwinian implications of the term “instinct,” which imply innate, inherited, unlearned, and biologically adaptive behavior. T he cleares t formulation of the notion of instinct is as a concept of functions between the mental and the s omatic realms ps ychic representative of stimuli, which come from the organism and exercise their influence on the mind. they are a meas ure of the demand made on the mind work as a result of its connection with the body.

C harac teris tic s of the Ins tinc ts F reud ascribed to ins tinctual drives four principal characteristics : s ource, impetus , aim, and object. In 493 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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general, the s ource of an ins tinct refers to the part of body from which it arises, the biological substratum gives ris e to the organis mic s timuli. T he source, then, to a s omatic proces s that gives rise to s timuli, which represented in the mental life as drive repres entations affects. In the case of libido, the s timulus refers to the proces s or factors that excite a specific erotogenic T he impe tus or pre s s ure be hind the drive is a economic concept referring to the amount of force or energy or demand for work made by the instinctual stimulus . T he aim is any action directed toward or tens ion releas e. T he aim in every instinct is which can only be obtained by reducing the s tate of stimulation at the s ource of the ins tinct. T he object is person or thing that is the target for this s atis factionseeking action and that enables the instinct to gain satis faction or dis charge the tens ion and thus gain the instinctual aim of pleasure. F reud commented that the object was the mos t characteristic of the instinct becaus e it is only to the extent that its characteris tics make satis faction poss ible—a view that has been s ignificantly revised in light of object relations . At times, the s ubject's own may s erve as an object of an instinct as , for example, masturbatory activity. Although this early view of the instinctual object long held s way in ps ychoanalytic thinking, it has come under some serious criticis m C ons iderably more weight is put on the significance of objects of libidinal attachment, particularly by object relations theoris ts. Increas ingly, it has become that the ps ychoanalytic concept of instincts is unles s it includes and derives from a context of object 494 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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relatednes s. Moreover, it cannot be said s imply that the objects of infantile drives are the mos t variable characteristic of the instinct becaus e attachment to the primary objects , particularly the mothering object, is of utmos t s ignificance developmentally.

C ONC E P T OF L IB IDO T he ambiguity in the term ins tinctual drive is reflected in us e of the term libido. B riefly, F reud regarded the instinct as a ps ychophysiological process that had both mental and phys iological manifes tations . E ss entially, us ed the term libido to refer to “the force by which the sexual instinct is repres ented in the mind.” T hus, in its accepted sense, libido refers s pecifically to the mental manifestations of the s exual ins tinct. F reud recognized early that the sexual instinct did not originate in a or final form, as represented by the stage of genital primacy. R ather, it underwent a complex process of development at each phase of which the libido had specific aims and objects that diverged in varying from the s imple aim of genital union. T he libido theory thus came to include all of these manifestations and complicated paths they followed in the course of ps ychos exual development.

INFANT S E XUAL ITY It had long been s upposed, as one of the favored analytical lore, that F reud's belief on infantile sexuality cons tituted an as sault on the cherished ideas of 19thcentury and V ictorian thinking and that he was violently attacked for his views of the erotic life of young seems, however, that his significant contribution, the 495 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T hre e E s s ays on the T heory of S e xuality, came to light a revolutionary work but as part of a flood of literature dealing with s exual problems . F reud had become convinced of the relationship sexual trauma, in both childhood traumata and the of psychoneuros is, and disturbances of sexual as related to the s o-called actual neuros es —that is , hypochondriasis, neurasthenia, and anxiety neuroses. F reud originally viewed these conditions as related to misuse P.716 of sexual function. T hus , for example, he believed neuros is to be due to inadequate dis charge of s exual products, leading to the damming up of libido that was then converted into anxiety. Als o, he attributed neuras thenia to excess ive masturbation and a in available libidinal energy. In any case, these studies F reud to an awareness of the importance of s exual in the etiology of ps ychoneurotic s tates.

PAR T INS TINC TS F reud described the erotic impulses arising from the pregenital zone as compone nt or part ins tincts . T hus , kiss ing, s timulation of the area s urrounding the anus , even biting the love object in the course of lovemaking examples of activities as sociated with these part T he activity of component instincts or early genital excitement may undergo displacement, as, for the eyes in looking and being looked at (s coptophilia), may consequently be a s ource of pleas ure. Ordinarily, these component ins tincts undergo repres sion or 496 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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a restricted fashion in s exual foreplay. More young children are characterized by a polymorphous pervers e s exual disposition. T heir total sexuality is relatively undifferentiated and encompass es all of the instincts. In the normal course of development to adult genital maturity, however, thes e part instincts are presumed to become s ubordinate to the primacy of the genital region.

A ggres s ion and E go Ins tinc ts T he aggres sive drives hold a peculiar place in F reud's theory. His thinking about aggres sion underwent a evolution. E arly in his thinking, his attention had been preoccupied by the problems posed by libidinal drives . was quite aware of the aggress ive components often expres sed in the operation of libidinal factors, but he not long avoid taking explicit account of the more destructive aspects of ins tinctual functioning. Undoubtedly, also, the horrors and des tructiveness of World W ar I made a s ignificant impres sion on him s o he began to realize more profoundly the s ignificance of destructive urges in human behavior. B y 1915, F reud arrived at a dualistic conception of the instincts as divided into sexual instincts and ego He recognized a sadis tic component of the sexual but this s till lacked a s ound theoretical basis. Oral, and phallic levels of development all had their sadis tic components. Devoid of any manifes t eroticism and covering a wide range from s exual perversions to of cruelty and des tructiveness , the s adis tic as pects certainly had different aims from the more s trictly Increasingly, F reud s aw the s adis tic component as 497 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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independent of the libidinal and gradually segregated it from the libidinal drives. Moreover, impulses to control, tendencies toward the acquis ition and exercis e of and defens ive trends toward attacking and des troying manifested a strong element of aggres siveness . It then, that there was s adism as sociated with the ego instincts as well as with the libidinal ins tincts . F reud again followed the dualistic bent of his mind and postulated two groups of instinctual impulses, two qualitatively different and independent sources of instinctual impulses with different aims and modalities . With the publication of T he E go and the Id in 1923, gave aggress ion a s eparate s tatus as an instinct with a separate s ource, which he pos tulated to be largely the skeletomus cular s ys tem, and a separate aim of its namely, des truction. Aggres sion was no longer a component instinct nor was it a characteris tic of the instincts; it was an independently functioning instinctual system with aims of its own. T he elevation of aggress ion to the s tatus of a s eparate instinct, on a par with sexual instincts, dealt a severe to any lingering romantic notions of the es sentially or exclusively benign nature of man. Aggress ion and destructiveness were seen as inherent qualities of nature such that aggres sive impuls es were elicited whenever an individual was sufficiently thwarted or abused. F reud's new formulation als o drew attention to the specific role of aggres sion in forms of as well as to understanding of the developmental proces ses through which aggress ion could be normally integrated and controlled. It s hould be noted that aggres sion remains a problem 498 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ps ychoanalytic thinking even today. Although a great has been learned about the operation and vicis situdes aggres sion s ince F reud originally struggled with it, still a great deal that remains to be learned about its nature, its origins , and the conditions that produce and unleas h it as well as the developmental factors that contribute to its pathological deviations and to its more cons tructive integration in the realm of human functioning. S ome more recent revis ions of aggress ion it les s in terms of des tructive or s adistic aims but more broadly as a capacity for effective action in the face of obstacles or opposition-embracing capacities for and s elf-as sertion and as related to patterns of rather than as a biologically determined drive force.

L ife and Death Ins tinc ts When F reud introduced his final theory of life and instincts in B eyond the P le as ure P rinciple in 1920, he what can now be seen as an inevitable and logical next step in the evolution of the instinct theory he had been developing. It was nonetheles s a highly s peculative attempt to extrapolate the directions in which his theory was taking s hape to the broad realm of principles. One can recall that F reud's thinking about instincts always casts its s hadow in a dual modality. In beginning, he had dis tinguished s exual and ego T his dis tinction provided the bas ic dichotomy for the explanation of ps ychological conflict and the unders tanding of psychoneurosis. T he introduction of the life and death ins tincts must be seen in the cours e of this development and as the inherent duality of instinctual theory to the level of 499 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ultimate and final biological principle. F reud had not divorced his notion from the underlying economic principles derived from principles of entropy and cons tancy. T he constancy principle was extended to Nirvana principle, the objective of which was ces sation all s timuli or a state of total rest. It was only a small, subs equent s tep that led F reud from the formulation of Nirvana principle to the death ins tinct, or T hanatos. postulated that the death ins tinct was a tendency of all organisms and their component cells to return to a total quies cence—that is , to an inanimate state. In opposition to this instinct, he set the life ins tinct, or referring to tendencies of organic particles to reunite of parts to bind to one another to form greater unities, in sexual reproduction. In F reud's view, the ultimate destiny of all biological matter, driven by the inexorable tendencies of all life to follow principles of entropy and cons tancy (with the exception of the germ plasm), was return to an inanimate state. He believed that the dominant force in biological organisms had to be the death ins tinct. In this final formulation of life and death instincts, the instincts were cons idered to represent abstract biological principles, which transcended the operation of libidinal and aggres sive drives. T he life death ins tincts repres ented the forces underlying and aggres sive ins tincts . C ons equently, they general trend in all biological organis ms . Needles s to s ay, F reud's extravagant s peculation has subjected to severe criticis m. It is impos sible to argue a general biological principle exis ts merely on the basis clinical observation. If the inherent destructivenes s of some states of psychopathology can permit the 500 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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of P.717 destructive forces operating in the individual psyche, it no means points to the exis tence of inherent and biologically determined forces of self-destructive However one regards the argument as a biological speculation, for thes e thinkers , it has little relevance as ps ychological speculation. On the contrary, the life and death ins tincts are alive and flourishing in K leinian and F rench analytical circles . T he school of analysts the lead of Melanie K lein constitute the most significant group of ps ychoanalytic theorists who embrace the instinct. K leinian analysis bases a considerable portion its unders tanding of intrapsychic process es on the operation of the life and death ins tincts . In K lein's work with severely dis turbed children, she ascribed the manifestations of aggress ive instincts in s uch children the operation of the death instinct. T his point of view seems to collapse the intervening s teps in the of ins tinctual theory and makes almost any of des tructive aggres sion a direct expres sion of the instinct. Although contributions of K lein and her to the psychopathology of childhood dis turbances are significant, other s chools of analytical thinking have not followed their lead in this conceptualization of the instincts.

NA R C IS S IS M A ND THE DUA L THE OR Y T he concept of narcis sism holds a pivotal pos ition in development of psychoanalytic theory. It was F reud's 501 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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dawning realization of the importance of narcis sism led him to important modifications in his unders tanding libido and his instinct theory. At the s ame time, F reud's examination of narciss is m and its related clinical phenomena led to an increasing concern with the and functions of the ego. It mus t be said that the introduction of and focus on narcis sis m have had broad implications and reverberations in psychoanalytic since F reud's day. T he whole problem of narcis sism remains difficult and problematic for psychoanalys is . problem of pathological narcis sis m remains a focus of active interest, thinking, and clinical concern even T he problem has s pecial relevance with regard to forms of character pathology, which are relatively to therapeutic intervention. F reud observed that in cases of dementia praecox (s chizophrenia), libido appeared to have been from other people and objects and turned inward. He concluded that this detachment of libido from external objects might account for the loss of reality contact s o typical of these patients. He s peculated that the libido had then been reinves ted and attached to the patient's own ego, res ulting in megalomaniacal and s uggesting that this libidinal reinves tment found expres sion in their grandios ity and omnipotence. F reud also became aware at the same time that was not limited to these ps ychotic manifes tations . It also occur in neurotic and, to a certain extent, even in “normal” individuals under certain conditions . He noted, for example, that in s tates of phys ical illness and hypochondriasis, libidinal cathexis was frequently withdrawn from outs ide objects and from external 502 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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activities and interests. S imilarly, he s peculated that, in sleep, libido was withdrawn from outs ide objects and reinvested in the pers on's own body. T hus, he believed could be that the hallucinatory intens ity of the dream experience and the intensity of the emotional quality of the dream might res ult from the libidinal cathexis of fantas y repres entations of the people who compos ed dream images . F reud also appealed to the basically narcis sistic form of object choice in perversions, particularly homosexuality. T he introduction of narcis sism into his theory played a significant role because it required that he reconcile his theory of libido with what now s eemed to be a libidinal force operating within the ego. F reud originally thought the reinvestment of libido as directed to the ego as T his formulation has given rise to a considerable in the understanding of narciss istic libido. A decis ive reorganization of the concept of narciss is m was by Heinz Hartmann when he pointed out that it was accurate to regard narciss is tic libido as attached not to ego as such but to the s elf. T he ego, as an intraps ychic cons truct, is oppos ed to the self as related to external objects extraps ychically. T he proper opposition, then, between object libido and narciss is tic libido is that the former is attached to object repres entations, whereas latter is attached to s elf-representations. T his important shift in the unders tanding of narcis sis m has opened an area of theoretical reconsideration that is still very flux and has introduced into psychoanalytic thinking the concept of s elf as an important, albeit as -yet-ill-defined, intraps ychic s tructural component.

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Narc is s is m and the C hoic e of L ove Objec t R eference was made earlier to the crucial role of early object relations hips in later choice of love objects. found that a deepened unders tanding of the of narcis sis m made it eas ier to unders tand the basis for choice of certain love objects in adult life. A love object might be chos en, as F reud put it, “according to the narcis sistic type,” that is , because the object res embles subject's idealized self-image (or fantasized s elfP os sibly the choice of object might be an “anaclitic in which cas e the object might res emble someone who took care of the s ubject during the early years of life. In summary, the concept of narcis sis m occupies a and pivotal pos ition in ps ychoanalytic theory. W ith the introduction of the concept of narcis sism, it became obvious that the concept of the “individual” and the individual's “body” and “ego” could no longer be us ed interchangeably. It became clear that further unders tanding and advances in psychoanalytic theory depended on a clearer definition of the concept of self its more adequate delineation from the concept of ego. Attempts to implement s uch understanding have into focus the ambiguities in the concept of the ego and have underscored the need for the s ys tematic study of development, structure, and functions. Attention to narcis sistic phenomena has als o enlarged the unders tanding of a variety of mental disorders as well various normal psychological phenomena. T hese are dis cuss ed in relation to treatment iss ues .

S TR UC TUR A L THE OR Y A ND E G O 504 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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P S YC HOL OG Y T he topographical theory was ess entially a trans itional model in the development of F reud's thinking and an important function in providing a framework for development of his bas ic ins tinct theory. However, the problems inherent in the topographical theory once again, the need for a more systematic concept of ps ychic s tructure. T he main deficiency of the topographical model lies in its inability to account for extremely important characteristics of mental conflict. T he firs t important problem was that many of the mechanisms that F reud's patients us ed to avoid pain or unpleasure and that appeared in the form of res is tances during psychoanalytic treatment were thems elves not initially access ible to consciousness . drew the obvious conclus ion that the agency of repress ion, therefore, could not be identical with the preconscious because this region of the mind was , by definition, easily access ible to consciousness . T he problem was that he found that his patients frequently exhibited an uncons cious need for punis hment or an unconscious s ens e of guilt. According to the model, however, the moral agency making this demand was allied with the P.718 antiinstinctual forces available to cons cious nes s in the preconscious level of the mind.

From Topographic al to S truc tural Pers pec tive T he germination of the shifting currents of F reud's 505 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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thinking finally came to fruition in his abandoning the topographical model and replacing it with the structural model of the psychic apparatus in T he E go and the Id. introduction of the structural hypothesis initiated a new era in psychoanalytic thinking. T he structural model of mind, or the “tripartite theory” as it is often called, is comprised of three distinct entities or organizations the ps ychic apparatus—the id, the ego, and the T he terms have become s o familiar and the tendency hypos tas ize them so great that it is well to bear in mind their nature as scientific cons tructs. T he terms are theoretical cons tructs that have as their primary the specific groups of mental functions and operations that they are intended to organize and integrate into higher-order s ys tems. E ach refers to a particular mental functioning, and none of them expres ses or represents the sum total of mental functioning at any time. Although they are often s poken of as though they functioned as quasiindependent systems , they are, nonetheless , ultimately coordinated aspects of the operation of the mental apparatus representing mental actions of the person. Attribution of agency to any one them is a form of misplaced concretenes s because actions and functions are bas ically thos e of the thems elves . Moreover, unlike such phenomena as sexuality or object relations, id, ego, and superego are empirically demonstrable phenomena in themselves must be inferred from the observable effects of the operations of specific psychic functions .

His toric al Development of E go Ps yc hology 506 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T he evolution of the concept of ego within the of the historical development of psychoanalytic theory parallels to a large extent the s hifts in F reud's view of instincts and can be divided into four phases. T he first phase ended in 1897 and coincided with the of the early ps ychoanalytic formulations . T he s econd phase extended from 1897 to 1923, thus s panning the development of psychoanalys is proper. T he third from 1923 to 1937, saw development of F reud's theory the ego and the gradual emergence to prominence of ego in the overall context of the theory. P arallel to this development was the evolution of F reud's thinking anxiety. F inally, the fourth phas e, coming after F reud's death, saw the emergence and s ys tematic a general psychology of the ego as well as a s hifting of focus from the operation of ego functions themselves the broader social and cultural contexts within which ego developed and functioned.

F irs t P has e: E arly C onc epts of the In the initial phase, the ego was not always precisely defined. R ather, it referred to the dominant mass of cons cious ideas and moral values that were dis tinct impulses and wis hes of the repress ed unconscious. ego was concerned primarily with defense, a term soon replaced with the notion of repress ion, so that repress ion and defens e were regarded as the neurophys iological jargon of the P roje ct, the ego described as “an organization… whos e presence with pas sages of quantity (of excitation).” T ranslating into the language of psychology, the ego was regarded an agent defending against certain ideas that were unacceptable to consciousness . T hese ideas were 507 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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be primarily sexual in nature and were initially believed have been engendered by premature s exual trauma real s eduction. P resumably, becaus e memory of s uch trauma led to arous al of unpleas ant and painful affects , they evoked a defens ive res ponse and repress ion of original thought content. T his repres sion, however, led damming up of energy and the consequent production anxiety. F unctioning of this “early ego” was to a degree because its primary purpos e was to reduce tension and thus avoid unpleas ant affects connected sexual thoughts , but in the process of repress ion, it seemed to evoke an equally unpleasant affect s tate, anxiety.

S ec ond P has e: His toric al R oots of P s yc hology During the years preceding publication of T he E go and Id, analysis of the ego as such received little direct attention becaus e F reud was concerned primarily with instinctual drives —their repres entatives and transformations. C onsequently, references to defens e defens ive functions were much les s frequent. T he clarification of these concepts required further of the ego, its functions , and the nature of its It was during this s econd phase that F reud grappled these problems and gradually approached the more definitive res olution provided by the s tructural theory. T he ego's relations hip to reality is particularly relevant this connection. As noted earlier, the concept of a secondary process implies the ability to delay instinctual drives in accordance with demands of reality. T he capacity for delay was later to be as cribed 508 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the ego. T he progres sion from pleasure principle to principle in childhood involves a similar capacity to “postpone gratification” and thereby conform to the requirements of the outside world. F inally, if neither the preconscious nor the ego instincts were s olely respons ible for repress ion or cens ors hip, was repress ion to be achieved? F reud tried to ans wer question by pos tulating that ideas are maintained in the unconscious by a withdrawal of libido or energy In the manner characteristic of unconscious ideas , however, they cons tantly renew their attempt to attached to libido and thus reach cons cious nes s. C ons equently, the withdrawal of libido must be repeated. F reud described this process as “countercathexis .” Again, however, if such is to be cons is tently effective agains t uncons cious must be permanent and must its elf operate on an unconscious basis. Understanding of ps ychic s tructure, specifically of the ego, which could perform this complicated function, was clearly called for and cons tituted s till another indication of the need for the development of ego psychology. T hus , the way was pointed toward the third phas e, wherein the ego was delineated as a s tructural entity and s eparated from the instinctual drives .

Third P has e: F reud's E go With publication of T he E go and the Id, the phase of introduction and development of F reud's own theory of the ego was accomplis hed. T he ego was pres ented as structural entity, a coherent organization of mental proces ses and functions, primarily organized around 509 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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perceptual-cons cious system, but it also included structures res ponsible for res is tance and uncons cious defens e. T he ego at this s tage was relatively pass ive weak. Its functioning was s till a res ult of press ures from id, s uperego, and reality. T he ego was the rider on the id's hors e, more or less obliged to go the id wished to go. T he as sumption remained that the ego was not only dependent on forces of the id but was somehow genetically derived and differentiated out of id. F reud had yet to recognize any real development of ego comparable to the phases of libidinal development. During this period, the view of the ego underwent transformation. S ome of the details of this development took place in connection with F reud's theory of anxiety. Inhibitions , S ymptoms , and Anxie ty in 1926, F reud repudiated the conception of ego as subservient P.719 to the id. S ignal anxiety became an autonomous for initiating defense, and the capacity of the ego to pass ively experienced anxiety into active anticipation underlined. Here, too, the relatively rudimentary conception of the defens ive capacity of the ego was enlarged to include a variety of defens es that the ego at its dis pos al and could us e in the control and id impulses . Moreover, elaboration of F reud's of the reality principle introduced a function of that allowed the ego to curb ins tinctual drives when prompted by them led to real danger. T he effect of this trans formation of his theory of the ego was threefold. F irs t, it brought the ego into prominence a powerful regulatory force respons ible for integration 510 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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control of behavioral res pons es . S econd, the role of was brought to center stage in the theory of ego functioning. It had been banished to the wings in the preceding quarter century, but concern with the function of the ego again brought it back to E ven s o, the conception of adaptation here was rudimentary and limited to the ego's capacity to avoid danger. T he notions that F reud was evolving during phase provided the foundation for the later concept of autonomy of the ego, as developed by later theoris ts. F inally, it was toward the end of this period that F reud finally made explicit the as sumption of independently inherited roots of the ego that were quite independent the inherited roots of the ins tinctual drives. T his formulation was taken over by Hartmann and s erved as the bas is for his notion of primary ego autonomy, which cons equently s timulated the developments of the fourth phase.

F ourth P has e: S ys tematization of P s yc hology If the third phase can be thought of as culminating in F reud's work on the defense mechanis ms of the ego, fourth phas e can be s een as taking its initiation from publication of Hartmann's work on the ego and adaptation. Hartmann's work primarily focused on two as pects of F reud's later notions of the ego, namely, the autonomy of the ego and the problem of adaptation. Dis cus sion of the apparatuses of primary autonomy the bas is for a doctrine of the genetic roots of the ego a development of the notion of epigenetic maturation. Hartmann's treatment of adaptation als o brought the adaptational point of view into focus in such a way that 511 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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has become generally acceptable as one of the basic metapsychological as sumptions of ps ychoanalytic Although this development of thinking about the ego an important advance, many psychoanalys ts began to that it created an imbalance in the theory and that, by increasingly focus ing on the mechanical and as pects of ego functioning, it left a picture of functioning and dys functioning that s eemed relatively mechanistic and inhuman. Moreover, there developed widening s plit between the id, the vital s tratum of the mind and the dynamic s ource of ps ychic energies, and nonins tinctual, nondynamic structural apparatuses of ego. C onsequently, the id increas ingly came to be the source of ins tinctual energies —the image of the seething cauldron—without the repres entational or directional qualities that s o long characterized F reud's views of the instincts and their functions. T he other extremely important as pect of the fourth is reemergence of the importance of reality in its and most profound meanings as a significant ps ychoanalytic thinking. T his is in many ways a direct extrapolation of Hartmann's thinking about adaptation because the adaptive functioning of the organis m has directly to do with fitting in with the requirements of external reality and adaptively interacting with the environment, not only the inanimate but als o the and s ocial environment.

S truc ture of the Ps yc hic Apparatus F rom a structural viewpoint, the ps ychic apparatus is divided into three groups of functions des ignated as id, ego, and s uperego and dis tinguis hed by their different 512 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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functions . T he id is the locus of the instinctual drives under domination of primary process . It operates according to dictates of the pleas ure principle, without regard for the limiting demands of reality. T he ego, however, represents a coherent organization of whos e task is to avoid unpleasure or pain by oppos ing regulating the dis charge of instinctual drives to conform demands of the external world. T he regulation of id discharges is also contributed to by the third structural component of the psychic apparatus, the s uperego, contains the internalized moral values, prohibitions , standards of the parental imagoes .

Id F reud s eparated the ins tinctual drives in his tripartite theory into a separate compartment, the vital stratum of the mind, and in s o doing reached the culminating point of the evolution of his theory of ins tincts . In contrast to concept of the ego as an organized, problem-solving capacity, F reud conceived of the id as a completely unorganized, primordial reservoir of energy, derived the instincts , and under the domination of primary proces s. It was not, however, s ynonymous with the unconscious because the structural viewpoint was in that it demons trated that certain functions of the ego, specifically certain defenses against uncons cious instinctual pres sures, were unconscious; for the most the superego also operated on an uncons cious level.

E go T he cons cious and precons cious functions typically as sociated with the ego—for example, words, ideas, or 513 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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logic—do not account entirely for its role in mental functioning. T he dis covery that certain phenomena that emerge most clearly in the psychoanalytic treatment setting, s pecifically repress ion and res is tance, both as sociated with the ego, could themselves be pointed out the need for an expanded concept of the as an organization retaining original clos e relations hip cons ciousnes s and to external reality and yet variety of unconscious operations in relationship to and their regulation. Once the s cope of the ego had thus broadened, cons cious nes s was redefined as a quality that, although exclusive to the ego, cons titutes only one of its qualities or functional as pects rather separate mental s ys tem its elf, as in the topographical model. No more comprehens ive definition of the ego is than the one F reud himself provided toward the end of career in O utline of P s ychoanalys is : Here are the principal characte ris tics of the e go. In cons equence of the pre-es tablis hed connection sens e and perception and muscular action, the ego voluntary movement at its command. It has the tas k of self-preservation. As regards external events, it that task by becoming aware of s timuli, by storing up experiences about them (in the memory), by avoiding excess ively strong s timuli (through flight), by dealing moderate s timuli (through adaptation) and finally by learning to bring about expedient changes in the world to its own advantage (through activity). As internal events, in relation to the id, it performs that by gaining control over the demands of the ins tinct, by deciding whether they are to be allowed satisfaction, by 514 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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postponing that s atisfaction to times and circums tances favourable in the external world or by s uppress ing their excitations entirely. It is guided in its activity by cons ideration of the tension produced by stimuli, these tens ions are present in it or introduced into it. P.720 T hus, the ego controls the apparatuses of motility and perception, contact with reality, and, through of defense, inhibition of primary instinctual drives .

OR IG INS OF THE E G O If the ego is defined as a coherent s ys tem of functions mediating between ins tincts and the outs ide world, one must concede that the newly born infant has no ego or, best, the mos t rudimentary of egos. Nonetheles s, the neonate certainly has a rather complex array of intact capacities and both sensory and motor functions . however, little coherent organization of thes e s o that must say that the ego is at bes t rudimentary. Developmental ego ps ychology is then faced with the problem of explaining the process es that permit modification of the id and the concomitant genes is of ego. F reud believed that the modification of the id occurs as res ult of the impact of the external world on the drives. P res sures of external reality enable the ego to energies of the id to do its work. In the proces s of formation, the ego seeks to bring the influences of the external world to bear on the id, substitute the reality principle for the pleasure principle, and thereby to its own further development. In s ummary, F reud 515 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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emphasized the role of ins tincts in ego development particularly, the role of conflict. At first, this conflict is between the id and the outside world, but later, it is between the id and the ego itself.

DE VE L OPME NT OF THE E G O T he proces ses by which the internal world is built up by which s tructure is consolidated within the self are referred to under the heading of internalization. F orms internalization—incorporation, introjection, and identification—are various ly connected with of the ego. Incorporation was originally conceived of as an activity derived from and based developmentally on the oral phas e and was considered as a genetic precurs or identification. However, even though incorporation fantas ies are often as sociated with internalizing they are by no means identical and may be quite independent. S ome authors envision incorporation as mechanism of primary identification, aimed at a primary union between ones elf and the maternal object. Incorporation as a mechanism of internalization seems involve a primitive oral wis h for union with an object. union has a quality of totality and globalization so that the internalization of the object, the object loses all distinction and function as object. T he external object is completely ass umed into the pers on's inner world. Incorporation is thus operative in infantile or relatively regress ive conditions. Introje ction is perhaps the mos t central process in development of the s tructural apparatus involving ego and s uperego. Introjection was originally des cribed by 516 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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F reud in Mourning and Melancholia as a process of narcis sistic identification in which the lost object is introjected and thus retained as a part of the internal structure of the psyche. F reud later applied this mechanism to the genes is of s uperego, making introjection the primary internalizing mechanism by parental imagoes were internalized at the close of the oedipal phas e. T he child tried to retain gratifications derived from thes e object relations hips , at least in through the proces s of introjection. B y this mechanis m, qualities of the person who was the center of the gratifying relationship are internalized and as part of the organization of the s elf. F reud referred to internalized product as a pre cipitate of abandoned cathe xis . Ide ntification has often been confused with introjection, partially becaus e the two proces ses were treated in an overlapping and s omewhat interchangeable fashion by F reud. T here are, nonetheless , grounds for maintaining distinction between them. Ide ntification is , properly speaking, an active s tructuralizing proces s that takes within the s elf by which the s elf cons tructs the inner cons tituents of regulatory control on the bas is of elements derived from the model. W hat cons titutes the model of identification can vary considerably and can include introjects, structural aspects of real objects , or even value components of group structures and group cultures. T he process of identification is specifically an intras ys temic structuralizing activity attributed to the functions of the s elf, related to its synthetic function, affecting structural integration in all parts of the ps ychic apparatus, including superego. 517 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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FUNC TIONS OF THE E G O T he ego comprises an organization of functions that in common the task of mediating between ins tincts and the outside world. T hus , the ego is a subsystem of the personality and is not s ynonymous with the s elf, the personality, or character. Any attempt to compile a complete list of ego functions has to be relatively Invariably, the list of basic ego functions s uggested by various authors differs in varying degrees. T his is limited to s everal functions generally conceded to be fundamental to ego operation.

C ontrol and R egulation of Ins tinc tual Development of the capacity to delay immediate discharge of urgent wis hes and impulses is ess ential if ego is to ass ure the integrity of the individual and fulfill role as mediator between id and outside world. Development of the capacity to delay or pos tpone instinctual dis charge, like the capacity to tes t reality, is clos ely related to the progres sion in early childhood pleas ure principle to reality principle.

R elation to R eality F reud always regarded the ego's capacity for relations hip to the external world among its principal functions . T he character of its relationship to the world may be divided into three components : (1) the of reality, (2) reality testing, and (3) the adaptation to reality.

S ens e of R eality T he sens e of reality originates simultaneous ly with the 518 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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development of the ego. Infants firs t become aware of reality of their own bodily s ens ations . Only gradually do they develop the capacity to dis tinguis h a reality their own bodies .

R eality Tes ting R eality te s ting refers to the ego's capacity for objective evaluation and judgment of the external world, which depends first on primary autonomous functions of the ego, s uch as memory and perception, but then also on relative integrity of internal structures of s econdary autonomy. Under conditions of internal s tres s, in which regress ive pulls are effectively operating, introjective as pects of inner psychic structure can tend to dominate and, thus, become s usceptible to projective dis tortions that color the individual's perception and interpretation the outside world. B ecause of the fundamental of reality tes ting for “negotiating” with the outside world, its impairment may be ass ociated with severe mental disorder.

A daptation to R eality Adaptation to re ality refers to the capacity of the ego to the individual's resources to form adequate solutions based on previously tested judgments of reality. It is poss ible for the ego to develop not only good reality tes ting, with perception and grasp, but als o to develop adequate capacity to accommodate the individual's res ources to the s ituation thus perceived. Adaptation is clos ely allied to the concept of mastery, both in res pect external tasks and to the instincts. It should be distinguished from adjustment, which may entail 519 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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accommodation to reality at the expense of certain res ources or potentialities of the individual. T he adaptation to reality is closely related to P.721 the defens ive functions of the ego. T he mechanism may s erve defensive purposes from one point of view simultaneously s erve adaptive purposes when viewed from another perspective. T hus, in the obs ess ivecompuls ive person, intellectualization may s erve important inner needs to control drive impulses, but by the same token, from another perspective, the activity its elf may s erve highly adaptive functions in dealing with the complexities of external reality.

Objec t R elations hips T he capacity for mutually s atisfying relations hips is one the fundamental functions to which the ego contributes , although s elf–other relations hips are more properly a function of the whole person, the s elf, of which the ego functional component. S ignificance of object and their disturbance—for normal psychological development and a variety of ps ychopathological were fully appreciated relatively late in the clas sic ps ychoanalys is . T he evolution in the child's for relations hips with others , progres sing from to social relations hips within the family and then to relations hips within the larger community, is related to capacity. Development of object relations hip may be disturbed by retarded development, regress ion, or conceivably by inherent genetic defects or limitations in the capacity to develop object relations hips or 520 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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impairments and deficiencies in early caretaking relations hips . T he development of object relations hips clos ely related to the concomitant evolution of drive components and the phas e-appropriate defens es that accompany them.

Defens ive F unc tions of the E go As was pointed out previous ly, in his initial formulations and for a long time thereafter, F reud cons idered repres sion to be virtually s ynonymous with defens e. More specifically, repres sion was directed primarily agains t the impulses, drives, or drive representations and, particularly, agains t direct of the sexual instinct. Defense was thus mobilized to instinctual demands into conformity with demands of external reality. W ith development of the structural view the mind, the function of defens e was ascribed to the Only after F reud had formulated his final theory of however, was it poss ible to study the operation of the various defense mechanis ms in light of their in res pons e to danger s ignals . T hus, a s ys tematic and comprehensive study of ego defens es was only presented for the first time by Anna F reud. In her class ic monograph T he E go and the Me chanis ms of De fe ns e , s he maintained that whether normal or neurotic, uses a characteris tic repertoire of defens e mechanisms but to varying On the basis of her extensive clinical s tudies of she described their ess ential inability to tolerate instinctual stimulation and discus sed proces ses the primacy of s uch drives at various developmental stages evoked anxiety in the ego. T his anxiety, in turn, 521 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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produced a variety of defens es. W ith regard to adults, ps ychoanalytic investigations led her to conclude that, although res is tance was an obstacle to progress in treatment to the extent that it impeded the emergence unconscious material, it als o cons tituted a us eful information concerning the ego's defensive operations.

G enes is of Defens e Mec hanis ms In the early s tages of development, defens es emerge res ult of the ego's s truggles to mediate press ures of and the requirements and s trictures of outs ide reality. each phas e of libidinal development, as sociated drive components evoke characteris tic ego defens es . T hus, example, introjection, denial, and projection are mechanisms as sociated with oral-incorporative or oralsadis tic impulses, whereas reaction formations, s uch shame and disgust, us ually develop in relation to anal impulses and pleas ures . Defens e mechanisms from phases of development pers is t side by s ide with thos e later periods. W hen defens es ass ociated with phases of development tend to predominate in adult over more mature mechanisms, such as s ublimation repress ion, the personality retains an infantile cast.

C las s ific ation of Defens es T he defens es used by the ego can be categorized according to a variety of clas sifications, none of which inclusive or takes into account all of the relevant Defenses may be class ified developmentally, for in terms of the libidinal phase in which they aris e. T hus, denial, projection, and distortion are as signed to the stage of development and to the correlative narciss is tic 522 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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stage of object relations hips. C ertain defens es , such as magical thinking and regres sion, cannot be categorized in this way. Moreover, certain bas ic developmental process es , such as introjection and projection, may als o s erve defens ive functions under certain s pecifiable conditions. T he defens es have also been clas sified on the bas is of particular form of psychopathology with which they are commonly ass ociated. T hus, the obs es sional defens es include isolation, rationalization, intellectualization, and denial; however, defens ive operations are not limited to pathological conditions. F inally, the defens es have clas sified as to whether they are simple mechanisms or complex, in which a single defens e involves a or compos ite of s imple mechanis ms . T able 6.1-2 gives brief clas sification and description of s ome of the bas ic defens e mechanisms mos t frequently us ed and mos t thoroughly inves tigated by ps ychoanalys ts.

Table 6.1-2 C las s ific ation of Defens e Mec hanis ms Narcis s is tic Defens es P rojection

P erceiving and reacting to unacceptable inner impulses and their derivatives as they were outside the s elf. On 523

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ps ychotic level, this takes the form of frank delus ions about external reality, usually persecutory, and includes perception of one's own feelings in another with subs equent acting on the perception (ps ychotic delus ions). Impuls es may from id or s uperego (hallucinated recriminations). Denial

P sychotic denial of external reality, unlike repres sion, perception of external reality more than perception of internal reality. S eeing, but refusing to acknowledge what one s ees , or hearing, and negating what is actually are examples of denial and exemplify the clos e of denial to s ens ory Not all denial, however, is neces sarily ps ychotic. Like projection, denial may in the service of more or even adaptive objectives. Denial avoids becoming of some painful aspect of

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reality. At the psychotic level, the denied reality may be replaced by a fantas y or delus ion. Dis tortion

G ross ly res haping external reality to suit inner needs , including unrealistic megalomaniacal beliefs, hallucinations , wis h-fulfilling delus ions, and using feelings of delus ional superiority or entitlement.

Immature Defens es Acting out

T he direct expres sion of an unconscious wis h or impulse action to avoid being of the accompanying affect. T he unconscious fantas y, involving objects , is lived out impulsively in behavior, thus gratifying the impulse more than the prohibition against it. On a chronic level, acting out involves giving in to impulses to avoid the tens ion that 525

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from postponement of expres sion. B locking

An inhibition, usually temporary in nature, of affects es pecially, but pos sibly also thinking and impuls es . It is clos e to repress ion in its but has a component of arising from the inhibition of the impulse, affect, or

Hypochondrias is

T ransformation of reproach toward others aris ing from bereavement, lonelines s, or unacceptable aggres sive impulses into s elf-reproach somatic complaints of pain, illness , and so forth. R eal may als o be overemphasized exaggerated for its evas ive regress ive poss ibilities . T hus, res ponsibility may be guilt may be circumvented, instinctual impuls es may be warded off.

Introjection

In addition to the developmental functions of proces s of introjection, it als o

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serves s pecific defensive functions . T he introjection of loved object involves the internalization of of the object with the goal of clos enes s to and cons tant presence of the object. cons equent to separation or tension arising out of ambivalence toward the is thus diminished. If the is a los t object, introjection nullifies or negates the los s taking on characteristics of object, thus, in a sens e, internally preserving the E ven if the object is not los t, internalization usually a s hift of cathexis , reflecting a significant alteration in the object relations hips . Introjection of a feared object serves to avoid anxiety internalizing the aggres sive characteristic of the object thereby putting the under one's own control. T he aggres sion is no longer felt as coming from outs ide but is taken within and us ed

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defens ively, thus turning the subject's weak, pass ive into an active, s trong one. clas sic example is “identification with the aggres sor.” Introjection can also be out of a s ens e of guilt which the s elf-punis hing introject is attributable to the hostile, destructive of an ambivalent tie to an object. T hus, the s elf-punitive qualities of the object are over and establis hed within one's s elf as a s ymptom or character trait, which represents both the and the preservation of the object. T his is als o called ide ntification with the victim. P as siveaggres sive behavior

Aggress ion toward an object expres sed indirectly and ineffectively through pass ivity, masochism, and turning agains t the s elf.

P rojection

Attributing one's own unacknowledged feelings to others ; it includes severe

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prejudice, rejection of through s uspicious ness , hypervigilance to external danger, and injus tice P rojection operates correlatively to introjection, such that the material of the projection is derived from the internalized configuration of the introjects . At higher levels of function, projection may the form of misattributing or misinterpreting motives , attitudes, feelings, or of others. R egress ion

A return to a previous s tage development or functioning to avoid the anxieties or involved in later s tages. A return to earlier points of fixation embodying modes of behavior previous ly given up. T his is often the res ult of a disruption of equilibrium at a later phas e of development. T his reflects a basic tendency achieve ins tinctual or to es cape ins tinctual by returning to earlier modes

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and levels of gratification later and more differentiated modes fail. S chizoid fantasy

T he tendency to use fantasy and to indulge in autis tic retreat for the purpos e of conflict res olution and gratification.

S omatization

T he defens ive conversion of ps ychic derivatives into bodily symptoms; tendency to react with somatic rather than ps ychic manifes tations . Infantile s omatic responses replaced by thought and during development (desomatization); regress ion earlier somatic forms or res ponse (resomatization) res ult from unres olved and may play an important in ps ychophysiological reactions .

Neurotic Defens es

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C ontrolling

T he excess ive attempt to manage or regulate events or objects in the environment in the interes t of minimizing anxiety and s olving internal conflicts.

Dis placement

Involves a purposeful, unconscious s hifting from one object to another in the of solving a conflict. Although the object is changed, the instinctual nature of the impulse and its aim remain unchanged.

Dis sociation

A temporary but dras tic modification of character or sens e of pers onal identity to avoid emotional dis tres s; it includes fugue states and hysterical convers ion

E xternalization

A general term, correlative to internalization, referring to the tendency to perceive in the external world and in external objects components of one's own pers onality, including instinctual impuls es , conflicts,

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moods , attitudes , and s tyles thinking. It is a more general term than projection, which is defined by its derivation from and correlation with specific introjects . Inhibition

T he unconscious ly limitation or renunciation of specific ego functions , s ingly in combination, to avoid anxiety aris ing out of conflict with ins tinctual impuls es , superego, or environmental forces or figures.

Intellectualization

T he control of affects and impulses by way of thinking about them instead of experiencing them. It is a systematic excess of thinking, deprived of its affect, to agains t anxiety caused by unacceptable impulses.

Is olation

T he intraps ychic s plitting or separation of affect from content res ulting in of either idea or affect or the displacement of affect to a

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different or substitute content. R ationalization

A justification of attitudes, beliefs, or behavior that might otherwis e be unacceptable by an incorrect application of justifying reasons or the invention of a convincing fallacy.

R eaction formation

T he management of unacceptable impulses by permitting express ion of the impulse in antithetical form. T his is equivalently an expres sion of the impulse in negative. W here instinctual conflict is pers is tent, reaction formation can become a character trait on a basis , usually as an aspect of obses sional character.

R epress ion

C ons is ts of the expelling and withholding from cons cious awarenes s of an idea or It may operate either by excluding from awareness was once experienced on a cons cious level (s econdary

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repress ion) or by curbing and feelings before they have reached cons cious nes s (primary repres sion). T he “forgetting” of repress ion is unique in that it is often accompanied by highly symbolic behavior, which suggests that the repress ed not really forgotten. T he important dis crimination between repres sion and the more general concept of defens e has been discus sed. S exualization

T he endowing of an object or function with s exual significance that it did not previous ly have, or a less er degree, to ward off anxieties connected with prohibited impulses.

Mature Defens es Altruis m

T he vicarious but cons tructive and instinctually gratifying service to others . T his mus t 534

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distinguished from altruistic surrender, which involves a surrender of direct or of instinctual needs in favor of fulfilling the needs of others to the detriment of the self, with vicarious s atis faction being gained through introjection. Anticipation

T he realis tic anticipation of or planning for future inner discomfort: implies overly concerned planning, and anticipation of dire and dreadful poss ible outcomes .

Asceticism

T he elimination of directly pleas urable affects to an experience. T he moral element is implicit in s etting values on s pecific pleas ures . Asceticism is directed against all “base” pleas ures cons ciously, and gratification derived from the renunciation.

Humor

T he overt express ion of without pers onal discomfort immobilization and without

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unpleasant effect on others . Humor allows one to bear, yet focus on, what is too terrible to be borne, in to wit, which always involves distraction or dis placement away from the affective is sue. S ublimation

T he gratification of an whos e goal is retained but whos e aim or object is from a socially objectionable one to a s ocially valued one. Libidinal sublimation involves desexualization of drive impulses and the placing of a value judgment that subs titutes what is valued by the superego or s ociety. S ublimation of aggres sive impulses takes place through pleas urable games and Unlike neurotic defens es , sublimation allows instincts to be channeled rather than dammed up or diverted. in sublimation, feelings are acknowledged, modified, and directed toward a relatively significant pers on or goal s o

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that modest ins tinctual satis faction res ults. S uppres sion

T he cons cious or decis ion to pos tpone attention to a cons cious impuls e or conflict.

Adapted from V aillant G E . Adaptation to L ife . Little, B rown; 1977; S emrad E . T he operation of defens es in object los s. In: Moriarity DM, ed. T he of L ove d O nes . S pringfield, IL: C harles C . 1967; and B ibring G L, Dwyer T F , Huntington DS , V alens tein AA: A s tudy of the ps ychological principles in pregnancy and of the earlies t child relationship: Methodological cons iderations . P s ychoanal S tud C hild. 1961;16:25.

S ynthetic F unc tion T he s ynthetic function of the ego refers to the ego's capacity to integrate various aspects of its functioning. involves the capacity of the ego to unite, organize, and bind together various drives, tendencies , and functions within the personality, enabling the individual to think, feel, and act in an organized and directed manner. the synthetic function is concerned with the overall organization and functioning of the ego in the selfand cons equently mus t enlis t the cooperation of other 537 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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and nonego functions in its operation. Although the synthetic function subserves adaptive functioning in the ego, it may als o bring together forces in a way that, although not completely adaptive, an optimal s olution for the individual in a particular at a given moment or period of time. T hus , the of a s ymptom that repres ents a compromis e of tendencies, although unpleasant in some degree, is nonetheless preferable to yielding to a dangerous instinctual impuls e or, conversely, trying to s tifle the impulse completely. Hysterical convers ion, for combines a forbidden wis h and the punis hment for it a physical s ymptom. On examination, the s ymptom turns out to be the only poss ible compromise under the circums tances .

A utonomy of the E go Although F reud only referred to “primal, congenital ego variations ” as early as 1937, this concept was greatly expanded and clarified by Hartmann. Hartmann a bas ic formulation about development that the ego id differentiate from a common matrix, the so-called undifferentiated phase, in which the ego's precurs ors inborn apparatuses of primary autonomy. T hese apparatuses are rudimentary in nature, pres ent at birth, and develop outs ide the area of conflict with the id. area Hartmann referred to as a “conflict-free” area of functioning. He included perception, intuition, comprehension, thinking, language, certain phases of motor development, learning, and intelligence among functions in this conflict-free sphere. E ach of these functions , 538 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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P.722 P.723 however, might als o become involved in conflict secondarily in the course of development. F or example, aggres sive, competitive impulses intrude on the impuls e learn, they may evoke inhibitory defens ive reactions on part of the ego, thus interfering with the conflict-free operation of these functions .

P rimary A utonomy With the introduction of the primary autonomous functions , Hartmann provided an independent genetic derivation for at leas t part of the ego, thus es tablis hing it an independent realm of psychic organization that was totally dependent on and derived from the instincts . T his was an ins ight of major importance because it laid the foundations for the emerging doctrine of ego autonomy and meant that the analys is of ego development would have to cons ider an entirely new set of variables quite separate from thos e involved in instinctual

S ec ondary A utonomy Hartmann obs erved that the conflict-free sphere derived from s tructures of primary autonomy can be enlarged that further functions could be withdrawn from the domination of drive influences . T his was Hartmann's concept of s econdary autonomy. T hus, a mechanism arose originally in the s ervice of defense agains t drives may in time become an independent s tructure, that the drive impuls e merely triggers the automatized 539 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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apparatus. T hus, the apparatus may come to serve functions than the original defensive function, for example, adaptation or s ynthes is . Hartmann referred to this removal of s pecific mechanis ms from drive as a process of change of function.

S uperego T he origins and functions of the superego are related those of the ego, but they reflect different viciss itudes . B riefly, the s uperego is the las t of the structural components to develop, resulting in F reud's analysis from resolution of the oedipal complex. It is concerned with moral behavior based on uncons cious behavioral patterns learned at early pregenital stages development. F requently, the superego participates in neurotic conflict by allying its elf with the ego and thus impos ing demands in the form of conscience or guilt feelings. Occasionally, however, the superego may be allied with the id agains t the ego. T his happens in severely regres sed reaction, in which functions of the superego may become s exualized once more or may become permeated P.724 by aggres sion, taking on a quality of primitive (us ually anal) destructivenes s.

HIS TOR IC AL DE VE L OPME NT In a paper written in 1896, F reud described ideas as “s e lf-re proaches which have re-emerged from re pre s s ion and which always relate to some s e xual act was performed with pleas ure in childhood.” T he activity 540 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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a s elf-criticizing agency was also implicit in F reud's discuss ions of dreams, which pos tulated existence of a “cens or” that did not permit unacceptable ideas to enter cons ciousnes s on moral grounds . He first dis cuss ed concept of a special s elf-critical agency in 1914, that a hypothetical s tate of narcis sis tic perfection in early childhood; at this stage, the child was his or her own ideal. As the child grew up, admonitions of others self-criticis m combined to destroy this perfect image. compens ate for this los t narciss ism or to recover it, the child “projects before him” a new ideal or ego-ideal. It at this point that F reud s ugges ted that the psychic apparatus might have still another structural special agency whos e task it was to watch over the make s ure it was measuring up to the ego-ideal. T he concept of the superego evolved from thes e of an ego-ideal and a s econd monitoring agency to its preservation. Again in 1917, in Mourning and Me lancholia, F reud of “one part of the ego” that “judges it critically and, as were, takes it as its object.” He s uggested that this which is s plit off from the res t of the ego, was what is commonly called cons cie nce . He further s tated that this self-evaluating agency could act independently, could become “diseased” on its own account, and s hould be regarded as a major institution of the self. In 1921, referred to this self-critical agency as the ego-ide al and held it res ponsible for the s ens e of guilt and for the reproaches typical in melancholia and depres sion. At point, he had dropped his earlier distinction between ego-ideal, or ideal s elf, and a s elf-critical agency, or cons cience. 541 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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In 1923, however, in T he E go and the Id, F reud's the superego again included both these functions—that the s uperego repres ented the ego-ideal as well as cons cience. He als o demonstrated that operations of superego were mainly uncons cious . T hus, patients were dominated by a deep sense of guilt lacerated thems elves far more hars hly on an unconscious level they did conscious ly. T he fact that guilt engendered by superego might be eas ed by suffering or punishment apparent in the case of neurotics who demonstrated an unconscious need for punis hment. In later works, elaborated on the relations hip between ego and superego. G uilt feelings were ascribed to tens ion these two agencies , and the need for punis hment was expres sion of this tens ion.

OR IG INS OF THE S UPE R E G O In F reud's view, the s uperego comes into being with res olution of the Oedipus complex. During the oedipal period, the little boy wishes to poss es s his mother, and little girl wis hes to pos ses s her father. E ach must, contend with a substantial rival, the parent of the same sex. T he frustration of the child's pos itive oedipal this parent evokes intense hostility, which finds not only in overt antagonistic behavior but also in thoughts of killing the parent who stands in the way with any brothers or sisters who may also compete for love of the desired parent. Quite unders tandably, this hos tility on the part of the is unacceptable to parents and, in fact, eventually unacceptable to the child as well. In addition, the boy's sexual explorations and masturbatory activities may 542 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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thems elves meet with parental disfavor, which may be unders cored by real or implied threats of castration. T hese threats and, above all, the boy's obs ervations women and girls lack a penis convince him of the castration. C onsequently, he turns away from the situation and its emotional involvements and enters the latency period of ps ychosexual development. He renounces the sexual express ions of the infantile G irls , when they become aware of the fact that they penis (in F reud's terms , they have “come off badly”), to redeem the los s by obtaining a penis or a baby from father. F reud pointed out that, although the anxiety surrounding castration brings the Oedipus complex to end in boys, in girls it is the major precipitating factor. renounce their oedipal s trivings, first, because they fear the loss of the mother's love and, second, because of disappointment over the father's failure to gratify their wis h. T he latency phas e, however, is not s o well girls as it is in boys , and their pers istent interest in relations is expres sed in their play; throughout grade school, for example, girls “act out” the roles of wife and mother in games that boys s crupulous ly avoid. T his the bas ic outline of F reud's theory of the superego.

E VOL UTION OF THE S UPE R E G O What, indeed, is the fate of the object attachments up with res olution of the Oedipus complex? F reud's formulation of the mechanis m of introjection came into play here. During the oral phase, the child is entirely dependent on the parents. Advancing beyond this the child must abandon these earlies t s ymbiotic ties the parents and form initial introjections of them, which, 543 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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however, follow the anaclitic model—that is , they are characterized by dependence on the parents . T hus, diss olution of the Oedipus complex and the abandonment of object ties led to rapid acceleration of introjection process . T hese introjections from both parents became united formed a kind of precipitate within the self, which then confronted other contents of the ps yche as the T his identification with the parents was based on the child's s truggles to repres s ins tinctual aims that were directed toward them, and it was this effort of that gave the s uperego its prohibiting character. It is for this reas on, too, that the s uperego res ults, to such a extent, from introjection of the parents' own s uperegos. Y et, becaus e the s uperego evolved as a result of of ins tinctual desires, it had a clos er relation to the id did the ego itself. Its origins were more internal; the originated to a greater extent in relation to the external world and was its internal repres entative. F inally, throughout the latency period and thereafter, child (and later the adult) continues to build on these identifications through contact with teachers , heroic figures , and admired people, who form the s ources of child's moral standards, values , and ultimate and ideals. T he child moves into the latency period endowed with a superego that is, as F reud put it, “the to the Oedipus complex.” Its structures at firs t might be compared to the imperative nature of demands of the before it developed. T he child's conflicts with the continue, of cours e, but now they are largely internal, between his or her own ego and superego. In other the s tandards , res trictions , commands, and 544 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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impos ed previously by the parents from without are internalized in the child's s uperego, which now judges guides behavior from within, even in the abs ence of the parents .

C UR R E NT INVE S TIGATIONS OF THE S UPE R E GO E xploration of the s uperego and its functions did not with F reud, and such s tudies remain of current active interes t. R ecent interes t has focus ed on the between superego and ego-ideal, a distinction that periodically revived and abandoned. At pres ent, the s upe re go refers primarily to a self-critical, prohibiting agency bearing a close relationship to aggres sion and aggres sive identifications . T he ego-ideal, however, is a kinder function, bas ed on a transformation of the abandoned perfect state of narcis sism, or s elf-love, exis ted in early childhood and has been integrated with positive elements P.725 of identifications with the parents . In addition, the of an ideal object—that is , the idealized object choice— has been advanced as dis tinct from the ideal self. theoris ts regard the ego-ideal as an aspect of s uperego organization derived from good parental imagoes . A s econd focus of recent interes t has been the contribution of the drives and object attachments in the pre-oedipal period to the development of the superego. T hes e pregenital (es pecially anal) the superego are generally believed to provide s ome of the very rigid, strict, and aggres sive qualities of the 545 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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superego. T hes e qualities s tem from projection of the child's own sadis tic drives and primitive concept of based on retaliation, which is attributed to the parents during this period. T he hars h emphasis on absolute cleanliness and propriety that is sometimes found in rigid individuals and in obsess ional neurotics is based some extent on this s phincter morality of the anal One result of these developments is that the between oedipal dynamics and s uperego development have been s ignificantly diluted in the s ense that preoedipal s uperego precurs ors and pre-oedipal s uperego functions are better unders tood on one hand, and postoedipal adaptive integrations, especially with ego functions , on the other hand, have modified the unders tanding of s uperego functions .

P S YC HIC DE VE L OP ME NT— INTE G R A TION OF P HA S E S A ND OB J E C T As his clinical experience increased, F reud was able to recons truct to a certain degree the early s exual experiences and fantasies of his patients . T hese data provided the framework for a developmental theory of childhood s exuality, which, in the subs equent cours e of ps ychoanalytic developmental exploration based on observation of childhood behavior, has been widely corroborated, accepted, and elaborated by theoris ts . T hese views have been s ubjected to cons iderable revis ion and development, as well as and rejection, in ens uing years . P erhaps an even more important source of information that contributed to F reud's thinking about infantile s exuality was his own analysis, begun in 1897. He was gradually able to 546 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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memories of his own erotic longings in childhood and conflicts in relations hip to his parents, related to his oedipal involvement. R ealization of the operation such infantile s exual longings in his own experience suggested to F reud that these phenomena might not res tricted only to the pathological development of neuros es, but that es sentially normal individuals might undergo similar developmental experiences. T he progres sive integration of psychos exual developments and object relations has been further elaborated in phases of instinctual development, Margaret Mahler's separation-individuation process , and E rik E rikson's epigenetic s equence.

Phas es of Ps yc hos exual T he earlies t manifes tations of infantile s exuality aros e relation to bodily functions that were bas ically such as feeding and development of bowel and bladder control. T herefore, F reud divided these stages of ps ychos exual development into a s ucces sion of developmental phas es, each of which was believed to build on and s ubsume accomplis hments of the phases —namely, the oral, anal, and phallic phases . oral phase occupied the first 12 to 18 months of the infant's life; next, the anal phas e, until approximately 3 years of age; and, finally, the phallic phase, from approximately 3 to 5 years of age. F reud postulated that, in boys , phallic erotic activity es sentially a preliminary stage for adult genital activity. contrast to the male, whos e principal s exual organ remained the penis throughout the course of ps ychos exual development, the female had two 547 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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erotogenic zones , the clitoris and the vagina. F reud believed that the clitoris was preeminent during the infantile genital period but that erotic primacy after puberty was transpos ed to the vagina. R ecent sexual inves tigations have cas t some doubt on a s upposed transition from clitoral to vaginal primacy, but many analysts retain this view on the basis of their clinical experience. T he ques tion for the time being remains unresolved. F reud's basic s chema of the psychosexual s tages was modified and refined by K arl Abraham, who further subdivided the phas es of libido development, dividing oral period into a s ucking and biting phas e and the anal phase into a des tructive-expulsive (anal sadis tic) and a mastering-retaining (anal erotic) phase. F inally, he hypothes ized that the phallic period cons is ted of an phase of partial genital love, which was designated as true phallic phas e, and a later, more mature genital F or each of the stages of psychosexual development, F reud delineated s pecific erotogenic zones that gave to erotic gratification. T able 6.1-3 provides an overview current, more or les s tentative, views on ps ychosexual development.

Table 6.1-3 S tages of Development Oral S tage 548 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Definition

E arlies t s tage of development in which the infant's needs , perceptions, and modes of expres sion are primarily centered mouth, lips, tongue, and other organs related to the oral zone.

Des cription

Oral zone maintains dominance in ps ychic organization through approximately the first 18 mos of Oral s ensations include thirs t, hunger, pleasurable tactile stimulations evoked by the nipple its s ubs titute, and s ensations to swallowing and s atiation. Oral drives cons is t of two components: libidinal and aggres sive. S tates of oral tension lead to s eeking for gratification, as in quiescence at of nurs ing. Oral triad cons is ts of to eat, sleep, and reach that relaxation that occurs at the end of sucking jus t before ons et of s leep. Libidinal needs (oral erotis m) predominate in early oral phase, whereas they are mixed with more aggres sive components later (oral sadis m). Oral aggres sion biting, chewing, s pitting, or crying. Oral aggres sion connected with

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primitive wis hes and fantas ies of biting, devouring, and destroying. Objectives

E stablish a trusting dependence nursing and s ustaining objects , es tablis h comfortable express ion and gratification of oral libidinal needs without excess ive conflict or ambivalence from oral s adistic wis hes .

P athological traits

E xces sive oral gratifications or deprivation can res ult in libidinal fixations contributing to traits. S uch traits can include excess ive optimism, narciss ism, pess imism (as in depres sive or demandingness . E nvy and jealousy often as sociated with oral traits.

C haracter traits

S uccess ful resolution of oral phas e res ults in capacities to give to and receive from others without excess ive dependence or envy, capacity to rely on others with a sens e of trus t as well as with a of self-reliance and self-trus t. Oral characters are often excess ively dependent and require others to

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give to them and look after them are often extremely dependent on others for maintaining self-es teem.

Anal S tage Definition

S tage of ps ychos exual prompted by maturation of neuromuscular control over sphincters, particularly anal sphincters, permitting more voluntary control over retention or expulsion of feces .

Des cription

P eriod extends roughly from 1–3 of age, marked by recognizable intens ification of aggress ive drives mixed with libidinal components in sadis tic impulses. Acquisition of voluntary s phincter control as sociated with increas ing shift pass ivity to activity. C onflicts over anal control and s truggles with parents over retaining or expelling feces in toilet training give rise to increased ambivalence together struggle over separation, individuation, and independence. 551

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Anal e rotis m refers to s exual in anal functioning, both in precious feces and presenting as a precious gift to the parent. s adis m refers to express ion of aggres sive wishes connected with discharging feces as powerful and destructive weapons. T hes e often displayed in fantasies of bombing or explosions . Objectives

Anal period is marked by striving independence and s eparation from dependence on and control of parents . Objectives of sphincter control without overcontrol (fecal retention) or los s of control (mess ing) are matched by to achieve autonomy and independence without excess ive shame or self-doubt from los s of control.

P athological traits

Maladaptive character traits , often apparently inconsistent, derive anal erotis m and defenses against Orderliness , obs tinacy, willfulnes s, frugality, and are features of anal character. defens es agains t anal traits are

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effective, anal character reveals of heightened ambivalence, lack of tidiness , mess iness , defiance, and s adomas ochis tic tendencies. Anal characteristics and defens es typically s een in obs es sivecompuls ive neuros es. C haracter traits

S uccess ful resolution of anal provides bas is for development of personal autonomy, a capacity for independence and personal without guilt, a capacity for s elfdetermining behavior without a sens e of shame or s elf-doubt, a of ambivalence and a capacity for willing cooperation without either excess ive willfulnes s or selfdiminution or defeat.

Urethral S tage Definition

T his s tage not explicitly treated by S igmund F reud but s erves as transitional s tage between anal phallic stages . It s hares s ome characteristics of anal phase and some from subs equent phallic 553

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Des cription

C haracteris tics of the urethral often s ubs umed under phallic Urethral e rotis m, however, refers pleas ure in urination as well as pleas ure in urethral retention analogous to anal retention. is sues of performance and control are related to urethral functioning. Urethral functioning may als o have sadis tic quality, often reflecting persis tence of anal s adistic urges . Loss of urethral control, as in enures is , may frequently have regress ive s ignificance that reactivates anal conflicts.

Objectives

Is sues of control and urethral performance and loss of control. clear whether or to what extent objectives of urethral functioning differ from thos e of anal period.

P athological traits

P redominant urethral trait is competitivenes s and ambition, probably related to compens ation for shame due to loss of urethral control. T his may be start for development of penis envy, related to feminine s ens e of shame and inadequacy in being unable to

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male urethral performance. Als o related to iss ues of control and shaming. C haracter traits

B es ides healthy effects analogous those from anal period, urethral competence provides s ens e of and s elf-competence bas ed on performance. Urethral is area in which s mall boy can and try to match his father's more adult performance. R esolution of urethral conflicts s ets stage for budding gender identity and subs equent identifications .

Phallic S tage Definition

P hallic s tage begins s ometime during 3rd yr and continues until approximately end of 5th yr.

Des cription

P hallic phas e characterized by primary focus of s exual interests, stimulation, and excitement in genital area. P enis becomes organ principal interes t to children of both sexes, with lack of penis in 555

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being considered as evidence of castration. P hallic phas e with increase in genital accompanied by predominantly unconscious fantas ies of sexual involvement with opposite-sex parent. T hreat of cas tration and related anxiety connected with over mas turbation and oedipal wis hes . During this phase, oedipal involvement and conflict are es tablis hed and consolidated. Objectives

T o focus erotic interest in genital area and genital functions . T his foundation for gender identity and serves to integrate residues of previous stages into predominantly genital-sexual orientation. E stablishing oedipal s ituation es sential for furtherance of subs equent identifications s erving basis for important and enduring dimensions of character organization.

P athological traits

Derivation of pathological traits phallic-oedipal involvement are sufficiently complex and subject to such a variety of modifications so

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that it encompas ses nearly the of neurotic development. Iss ues, however, focus on cas tration in males and penis envy in females . P atterns of identification from res olution of oedipal complex provide another important focus of developmental distortions . of castration anxiety and penis defens es agains t them, and of identification are primary determinants of the development human character. T hey also and integrate res idues of previous ps ychos exual stages so that or conflicts deriving from preceding stages can contaminate and oedipal resolution. C haracter traits

P hallic s tage provides foundations for emerging s ens e of sexual of a s ens e of curios ity without embarrass ment, of initiative guilt, as well as a s ens e of mastery not only over objects and people in environment but also over internal proces ses and impuls es. of the oedipal conflict gives rise to internal s tructural capacities for regulation of drive impulses and

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their direction to constructive ends . T his internal s ource of regulation is the superego, bas ed on identifications derived primarily parental figures.

Latency S tage Definition

S tage of ins tinctual relative quies cence or inactivity of s exual drive during period from res olution of the Oedipus complex until pubes cence (from approximately yrs of age until approximately 11– yrs of age).

Des cription

Ins titution of superego at close of oedipal period and further maturation of ego functions allow cons iderably greater degree of control of ins tinctual impuls es. S exual interes ts generally believed be quiescent. P eriod of primarily homos exual affiliations for both and girls as well as a sublimation libidinal and aggres sive energies energetic learning and play exploring environment, and 558

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becoming more proficient in with world of things and people around them. P eriod for development of important skills. R elative s trength of regulatory elements often gives rise to of behavior that are somewhat obses sive and hypercontrolling. Objectives

P rimary objective is further integration of oedipal and cons olidation of sex-role and s ex roles . R elative quies cence and control of ins tinctual impuls es allow for development of ego apparatuses and mas tery of s kills . F urther identificatory components may be added to the oedipal ones basis of broadening contacts with other s ignificant figures outside family (e.g., teachers , coaches , other adult figures ).

P athological traits

Danger in latency period can aris e either from lack of development of inner controls or excess of them. Lack of control can lead to inability to sufficiently sublimate energies in interes t of learning and of skills; exces s of inner control,

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however, can lead to premature clos ure of personality development and precocious elaboration of obses sive character traits . C haracter traits

Latency period frequently regarded as period of relatively unimportant inactivity in the developmental schema. More recently, greater res pect has been gained for developmental process es in this period. Important cons olidations additions are made to basic postoedipal identifications and to proces ses of integrating and cons olidating previous attainments in ps ychos exual development and es tablis hing decis ive patterns of adaptive functioning. T he child can develop a sense of industry and capacity for mastery of objects and concepts that allows autonomous function and a sense of initiative without risk of failure or defeat or a sens e of inferiority. T hes e are all important attainments that need to be further integrated, ultimately as the es sential basis for a mature life of satis faction in work and love.

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Genital S tage Definition

G enital or adoles cent phas e from onset of puberty from 11–13 of age until young adulthood. C urrent thinking tends to s ubdivide this s tage into preadoles cent, early adoles cent, middle adoles cent, adoles cent, and even periods.

Des cription

P hysiological maturation of of genital (s exual) functioning and attendant hormonal systems leads intens ification of drives, particularly libidinal drives . T his produces a regress ion in pers onality organization, which reopens of previous s tages of development and provides opportunity for reres olution of conflicts in context of achieving a mature sexual and adult identity. Often referred to as a s e cond individuation.

Objectives

P rimary objectives are ultimate separation from dependence on attachment to parents and es tablis hment of mature, 561

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noninces tuous, heterosexual relations . R elated are achievement mature sense of personal identity and acceptance and integration of adult roles and functions that new adaptive integrations with expectations and cultural values . P athological traits

P athological deviations due to inability to achieve s ucces sful res olution of this s tage of development are multiple and complex. Defects can arise from whole s pectrum of psychosexual res idues becaus e developmental tas k of adolescence is in a s ense a partial reopening and reworking reintegrating of all of thes e as pects of development. P revious unsuccess ful resolutions and fixations in various phas es or of psychosexual development produce pathological defects in the emerging adult personality.

C haracter traits

S uccess ful resolution and reintegration of previous ps ychos exual stages in adoles cent genital phas e set s tage normally fully mature pers onality with

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capacity for full and satis fying potency and a self-integrated and cons istent s ense of identity. T his provides bas is for capacity for s elfrealization and meaningful participation in areas of work, love, and in creative and productive application to s atis fying and meaningful goals and values.

Development and Objec t R elations C urrent theories in ps ychoanalytic psychiatry have increasingly on the importance for later of early disturbances in object relationships —that is , a disturbance in the relations hip between the child's and the significant objects in the environment, the mothering object. F rom the very beginning of the child's development, F reud regarded the s exual instinct “anaclitic” in the sense that the child's attachment to feeding and mothering figure was based on the child's utter phys iological dependence on the object. T his view the child's earliest attachment s eems consis tent with F reud's understanding of infantile libido developed on basis of his insight, acquired early in his clinical that s exual fantasies of even adult patients typically centered on early relationships with their parents . In event, throughout his descriptions of libidinal phases of development, F reud made constant reference to the significance of children's relationships with crucial 563 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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in their environment. S pecifically, he pos tulated that the choice of a love object in adult life, the love relationship its elf, and object relations hips in other s pheres of and activity depend largely on the nature and quality of the child's object relations hips during the earliest years life.

Objec t R elations during P regenital P has es At birth, the infant's respons es to external stimulation relatively diffus e and dis organized. E ven so, as recent experimental res earch on neonates has indicated, the infant is quite responsive to external stimulation, and patterns of res pons e are quite complex and relatively organized, even s hortly after birth. E ven neonates of a hours of age respond s electively to novel s timuli and demonstrate remarkable preferences for complex, as compared with simple, patterns of s timulation. T he res ponses to noxious and pleas urable stimuli are also relatively undifferentiated. E ven so, sensations of cold, and pain give ris e to tens ion and a corresponding need to seek relief from painful s timuli. At the life, however, the infant does not res pond s pecifically to objects as objects . A certain degree of development of perceptual and cognitive apparatus es is required, as as a greater degree of differentiation of s ens ory P.726 P.727 impres sions and integration of cognitive patterns, babies are able to differentiate between impres sions 564 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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belonging to thems elves and thos e derived from objects. C ons equently, observations and inferences on data derived from the first 6 months of life mus t be interpreted in the context of the child's cognitive functioning before self–object differentiation. In thes e first months of life, human infants are cons iderably more helpless than any other young mammals . T heir helples snes s continues for a longer than in any other s pecies. T hey cannot survive unless are cared for, and they cannot achieve relief from the painful disequilibrium of inner phys iological states help of external caretaking objects . Object relations hips the most primitive kind only begin to be established an P.728 infant firs t begins to gras p this fact of experience. In the beginning, an infant cannot dis tinguis h between its own lips and its mother's breas ts, nor does an infant initially as sociate s atiation of painful hunger pangs with presentation of the extrins ic breast. B ecaus e the infant aware only of its own inner tension and relaxation and unaware of the external object, longing for the object exis ts only to the degree that the disturbing s timuli and longing for satiation remains unsatis fied in the absence of the object. W hen the s atisfying object appears , and the infant's needs are gratified, longing disappears. G radually, but als o rather quickly, the becomes aware of the mother herself, in addition to her breast, as a need-satis fying object.

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T his experience of unsatis fied need, together with the experience of frus tration in the absence of the breas t need-satis fying release of tension in the presence of breast, forms the bas is of the infant's firs t awarenes s of external objects . T his firs t awarenes s of an object, the ps ychological s ens e, comes from longing for something that is already familiar and for something actually gratified needs in the pas t but is not available in the pres ent. T hus, it is basically the infant's hunger in this view that in the beginning compels recognition of the outside world. T he first primitive reaction to objects, putting them into the mouth, then becomes unders tandable. T his reaction is consistent the modality of the infant's first recognition of reality, judging reality by oral gratification, that is, whether something will provide relaxation of inner tens ion and satis faction (and s hould thereby be incorporated, swallowed) or whether it will create inner tens ion and diss atis faction (and cons equently s hould be s pit out). E arly in this interaction, the mother s erves an important function, that of empathically res ponding to the infant's inner needs in such a manner as to become involved in proces s of mutual regulation, which maintains the homeostatic balance of the infant's physiological needs and proces ses within tolerable limits . Not only does this proces s keep the child alive, but it sets a rudimentary pattern of experience within which the child can build elements of a basic trust that promote reliance on the benevolence and availability of caretaking objects . C ons equently, the mother's administrations and res ponsiveness to the child help to lay the mos t rudimentary and es sential foundation for subsequent 566 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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development of object relations and the capacity for entering the community of human beings. As differentiation between the limits of self and object gradually es tablis hed in the child's experience, the becomes acknowledged and recognized as the s ource gratifying nouris hment and, in addition, as s ource of erotogenic pleas ure the infant derives from sucking on breast. In this s ens e, s he becomes the first love object. quality of the child's attachment to this primary object is the utmos t importance, as developmental and theoris ts have demonstrated. F rom the oral phas e the whole progress ion in psychosexual development, its focus on success ive erotogenic zones and as sociated component ins tincts , reflects the quality of child's attachment to the crucial figures in the environment as well as the strength of feelings of love hate, or both, toward these important people. If a fundamentally warm, trusting, secure, and affectionate relations hip has been es tablis hed between mother and child during the earlies t s tages of the child's career, least theoretically, the stage is s et for development of trus ting and affectionate relationships with other human objects during the course of life.

ANAL PHAS E AND OB J E C TS During the oral s tage of development, the infant's role not altogether pas sive becaus e, caught up as it is in a proces s of mutual interaction, the infant makes its own contribution to eliciting certain res ponses from the mother. T he activity, however, is more or les s and dependent on such phys iological factors as level of activity, irritability, or res ponsivenes s to stimuli. 567 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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speaking, however, the infant's control over the feeding res ponses is relatively limited. C ons equently, primary onus remains on the mother to gratify or the demands of the infant. In the trans ition to the anal period, however, this changes s ignificantly. T he child acquires a greater of control over behavior and particularly over sphincter function. Moreover, for the firs t time during this period, demands are placed on the child to relinquish some of freedom by reason of expectations to accede to parental demands to use the toilet for evacuation of and urine. However, the primary aim of anal eroticis m enjoyment of the pleasurable s ens ations of excretion. S omewhat later, s timulation of the anal mucos a retention of the fecal mas s may become a s ource of more intense pleasure. Nonetheles s, at this stage of development, the demand is placed on the child to regulate gratification, to surrender some portion of the gratification at the parent's wis h, or to delay according to a s chedule es tablis hed by the parent's It can be readily s een that one of the important as pects the anal period, therefore, is that it s ets the stage for a contest of wills over when, how, and on what terms the child achieves gratification.

PHAL L IC PHAS E AND OB J E C TS T he pass age from anal to phallic phas e marks not only transition from pre-oedipal to beginnings of the oedipal level of development but also marks completion of the work of s eparation individuation and, in the normal of development, achievement of object cons tancy. T he oedipal s ituation evolves during the period extending 568 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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from the third to the fifth year in children of both s exes.

Oedipus C omplex In the normal course of development, the so-called pregenital phas es are regarded as primarily autoerotic. P rimary gratification derives from s timulation of erotogenic zones , whereas the object serves a although s econdary and ins trumental, role. A shift begins to take place in the phallic phas e in which phallus becomes the primary erotogenous zone for sexes, thus laying a foundation for and initiating a s hift libidinal motivation and intention in the direction of objects. T he phallic phas e sets the s tage for the fundamental task of finding a love object, a dynamic moves to another level of progres sion in establis hing relations of the oedipal period and beyond to more mature adult object choices and love relationships . T he phallic period is also a critical phase of development for the budding formation of the child's own sense of identity—as decis ively male or female—based on the child's discovery and realization of the significance of anatomical s exual differences . T he events as sociated the phallic phas e also set the stage for the predis pos ition to later psychoneuroses. F reud used the term O e dipus complex to refer to the intense love relations hips , together with their as sociated rivalries, hostilities , and emerging identifications , formed during this period between the child and parents.

C as tration C omplex T here is s ome differentiation between the s exes in the pattern of development. F reud explained the nature of 569 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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discrepancy in terms of genital differences. Under circums tances , he believed that, for boys , the oedipal situation was resolved by the castration complex. S pecifically, the boy had to give up his strivings for his mother becaus e of the threat of castration—castration anxiety. In contrast, the Oedipus complex in girls was evoked by reason of the cas tration complex, but unlike boy, the little girl was already cas trated, and as a turned to her father as bearer of the penis out of a disappointment over her own lack of a penis . T he little was thus more threatened by a los s of love than by castration fears. P.729

The B oy's S ituation In boys, development of object relations is relatively complex than for girls becaus e the boy remains to his firs t love object, the mother. T he primitive object choice of the primary love object, which develops in res ponse to the mother's gratification of the infant's needs , takes the s ame direction as the pattern of choice in res ponse to opposite-sex objects in later life experience. In the phallic period, in addition to the attachment to and interes t in the mother as a source of nouris hment, he develops a strong erotic interes t in her and a concomitant desire to pos sess her exclus ively sexually. T hes e feelings us ually become manifest at approximately 3 years of age and reach a climax at 4 years of age. With appearance of the oedipal involvement, the boy begins to show his loving attachment to his mother 570 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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as a little lover might—wanting to touch her, trying to in bed with her, proposing marriage, expres sing wis hes replace his father, and devis ing opportunities to s ee naked or undres sed. C ompetition from s iblings for mother's affection and attention is intolerable. Above however, the little lover wants to eliminate his arch mother's husband. His wishes may involve not merely displacing or s upers eding father in mother's affection eliminating him altogether. T he child understandably anticipates retaliation for his aggress ive wis hes toward father, and thes e expectations in turn give rise to a anxiety in the form of the “castration complex.” T his s omewhat simplified picture of the res olution of Oedipus complex is cons iderably more complex in the actual cours e of development. Usually, the boy's love his mother remains a dominant force during the period infantile sexual development. It is known, however, that love is not free of some admixture of hostility and that child's relations hip with both parents is to some degree ambivalent. T he boy als o loves his father, and at times when he has been frustrated by his mother, he may her and turn from her to seek affection from his father. Undoubtedly, to some degree, he loves and hates both parents at the same time. In addition, F reud's of an es sentially bisexual basis of the nature of the complicates matters further. On the one hand, the boy wants to pos sess his mother and kill the hated father On the other hand, he als o loves his father and seeks approval and affection from him, whereas he often to his mother with hos tility, particularly when her demands on her husband interfere with the of the father–son relations hip. T he ne gative O e dipus 571 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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complex refers to those situations in which the boy's for his father predominates over the love for the and the mother is relatively hated as a dis turbing in this relations hip.

The G irl's S ituation Understanding of the little girl's more complex oedipal involvement was a later development. B ecause it could be regarded as equivalent to the boy's development, it raised a number of questions that proved to be more difficult. F reud could not get beyond viewing female sexual development as a variant of male development. S imilar to the little boy, the little girl forms an initial attachment to the mother as a primary love object and source of fulfillment for vital needs . F or the little boy, mother remains the love object throughout his development, but the little girl is faced with the tas k of shifting this primary attachment from the mother to the father to prepare herself for her future sexual role. was bas ically concerned with elucidating the factors influenced the little girl to give up her pre-oedipal attachment to the mother and to form the normal attachment to the father. A s econdary ques tion had to with the factors that led to the diss olution and of the Oedipus complex in the girl s o that paternal attachment and maternal identification would be the for adult s exual adjus tment. T he girl's renunciation of her pre-oedipal attachment to the mother could not be satisfactorily explained as res ulting from ambivalent or aggress ive characteristics the mother–child relationship, for s imilar elements influenced the relations hip between boys and the 572 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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figure. F reud attributed the crucial precipitating factor to anatomical differences between the s exes—specifically the girl's discovery of her lack of a penis during the period. Up to this point, exclusive of cons titutional differences and depending on variations in parental attitudes in relating to a daughter in comparis on to a the little girl's development parallels that of the little F undamental differences , however, emerge when s he discovers during the phallic period that her clitoris is inferior to the male counterpart, the penis . T he typical reaction of the little girl to this dis covery is an intens e sens e of los s, narcis sis tic injury, and envy of the male At this point, the little girl's attitude to the mother changes. T he mother had previous ly been the object of love, but now s he is held res ponsible for bringing the girl into the world with inferior genital equipment. T he hostility can be s o intens e that it may persist and color future relations hip to the mother. W ith the further discovery that the mother also lacks the vital penis, the child's hatred and devaluation of the mother becomes even more profound. In a desperate attempt to compens ate for her “inadequacy,” the little girl then to her father in the vain hope that he will give her a or a baby in place of the mis sing penis . Obvious ly, the F reudian model of feminine development has undergone, and is currently cons iderable revis ion. T he charge has been made, and justifiably so, that masculine phallic-oedipal was the primary model in F reud's thinking and that feminine development was viewed as defective by comparis on. F reud saw women as basically weak, dependent, and lacking in conviction, s trength of 573 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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character, and moral fiber. He believed thes e defects the res ult of failure in the oedipal identification with the phallic father because of female castration. T he internalization of aggres sion was both cons titutionally determined and culturally reinforced. T hese concepts must now be regarded as obs olete. hypothes es of a pass ive female libido, arrest in ego development, incapacity for s ublimation, and s uperego deficiencies in women are outdated and inadequate. Differences in male and female ego and s uperego development may be defined, but there are no grounds for judging one to be s uperior or inferior to the other. are simply different. As Harold B lum obs erved: development cannot be des cribed in a s imple reductionism and overgeneralization. F emininity cannot be predominantly derived from a primary masculinity, disappointed maleness , masochistic resignation to fantas ied inferiority, or compens ation for fantas ied castration and narcis sistic injury. C astration reactions penis envy contribute to feminine character, but penis envy is not the major determinant of femininity.” T he adequate conceptualization and unders tanding of feminine ps ychology and its development are still very much in process . T here is much that is poorly and much more that is hardly unders tood at all. C urrent res earch has given partial s upport to and convincing refutation of F reud's ideas. C urrent views emphasize role of primary femininity and conflicts in identification with the mother as determining the course of development of feminine gender identity rather than the outmoded views of castration anxiety and penis envy. It clear in all this that F reud was s imply wrong about 574 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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this whole area, but much of what he des cribed may simply expres sed what he was able to observe in the women of his time and reflected the influence of toward women in his society and culture. T imes however, and the culture and the place of women in it have changed and are changing. T o that extent, are different, and much of their ps ychology is different, too. P s ychoanalytic unders tanding must inevitably lag behind these changing patterns of ps ychological experience, but a new view of feminine development functioning is gradually emerging.

Mahler's S eparation–Individuation Proc es s A utis tic P has e Mahler has conceptualized the proces s of development terms of phas es of s eparation and individuation. T he phase of development s he describes is the autis tic P.730 “During the first few weeks of extrauterine life, a s tage absolute primary narcis sism, marked by the infant's awarenes s of a mothering agent, prevails. T his is the we have termed normal autism. It is followed by a dim awareness that need s atis faction cannot be by oneself, but comes from somewhere outside the T he tas k of the autis tic phas e is the achievement of homeostatic equilibrium of the organis m within the new extramural environment, by predominantly phys iological mechanisms.” T o the external obs erver, newborn infants s eem to 575 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to their mothers in a condition of unique dependence res ponsiveness . T his relations hip is , however, at leas t first, purely biological bas ed on phys iological reflexes ordered to the fulfillment of basic biological needs. It is only as babies ' egos begin to develop, along with the organization of perceptual capacities and memory which allow for the initial differentiation of self and that infants can be s aid to experience s omething of themselves, to which they can relate, as satis fying inner needs. T his dawning awareness of the external object is a mos t s ignificant s tate in the psychological development of children and involves not only cognitive and perceptual developments but also goes hand in with the organization of rudimentary infantile drives and affects in relation to emerging object experiences . T he emergence of the psychological need-satis fying relations hip to the object or part-object occurs during oral phase of libidinal development. It should be noted, however, that the notion of the oral phas e of and the concepts of need-satis fying relationships are equivalent. T he oral phas e is primarily concerned with libidinal development and stress es predominance of oral zone as the main erotogenic zone. T he concept of need-satis fying relationship, however, is not concerned directly with iss ues of drive development but, rather, the characteristics of object involvement and object relations hip.

S ymbiotic P has e T his awareness signals the beginning of normal “in which the infant behaves and functions as though and his mother were an omnipotent s ys tem—a dual 576 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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within one common boundary.” T he symbiotic phas e is described as a “hallucinatory or delusional omnipotent fusion with the representation of the mother and, in particular, the delusion of a common boundary between two phys ically s eparate individuals.” T hese boundaries become temporarily differentiated only in state of “affect hunger” but disappear again as a result need gratification. Only gradually does the child form more s table part-images of the mother such as breas ts, face, or hands . C ons equently, the object is recognized separate from the s elf only at moments of need so that, once the need is satis fied, the object ceases to exis t— the infant's (s ubjective) point of view—until a need arises . Moreover, from the infant's perspective, the relations hip is not to a specific object (or part-object) rather to a function of the object s atisfying the need the pleas ure accompanying that function. It is only the specific object—that is , the whole object—becomes important to the child as the need-satis fying function it performs that one can regard the child's development moving beyond the level of need-satis fying toward the attainment of object constancy. T hus, it is useful to distinguish between need as a s tage of development in object relations hips , to but not s ynonymous with the oral phas e of libidinal development, and need s atisfaction as a determinant in object relations hips at every level of development. T he satis faction of various kinds of psychological needs continues to play a role at all levels of object but the satis faction of s uch needs cannot be used as a distinguishing characteris tic of the specific stage of satis fying object relations hips. As objects become 577 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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increasingly differentiated in the child's experience, representations achieve increasing ps ychological complexity and value in a context of increasingly and s ubtle needs for a variety of input from objects. Development of object constancy implies a constant relations hip to a specific object, but within that relations hip, the wish for s atis faction of needs and the actual s atis faction of thos e needs may still be a component of the object relationship.

S eparation and Individuation HATC HING During this period, the child with effort gradually differentiates out of the symbiotic matrix. T he first behavioral s igns of such differentiation s eem to aris e at approximately 4 or 5 months of age at the high point of the s ymbiotic period. T he firs t stage of this proces s of differentiation is described as “hatching” from the symbiotic orbit: In other words , the infant's attention, which during the months of symbios is was in large part inwardly focus ed in a coenesthetic vague way within the orbit, gradually expands through the coming into being outwardly directed perceptual activity during the child's increasing periods of wakefulnes s. T his is a change of degree rather than of kind, for during the s ymbiotic the child has certainly been highly attentive to the mothering figure. B ut gradually that attention is with a growing s tore of memories of mother's comings and goings, of “good” and “bad” experiences ; the latter were altogether unrelievable by the self, but could be 578 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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“confidently expected” to be relieved by mother's minis trations.

PR AC TIC ING As the child's differentiation and separation from the mother gradually increase, there is a move to the or “practicing” subphase of s eparation–individuation. practicing period can be us efully divided into an early practicing period and a practicing period proper. T he practicing phas e begins with the infant's earlies t ability move physically away from the mother by locomotion, that is , crawling, creeping, climbing, and ass uming an upright sitting position. Moving away from the s afe protective orbit of the mother has its risks and uncertainties , however. In the early practicing phas e, is frequently a pattern of vis ually “checking back to mother” or even crawling or paddling back to her to or hold on as a form of “emotional refueling.” T he practicing period proper is characterized by the attainment of free upright locomotion. It is marked by three interrelated developments that contribute to the continuing process of s eparation and individuation. are (1) rapid bodily differentiation from the mother, (2) es tablis hment of a s pecific bond with her, and (3) and functioning of autonomous ego-apparatuses in connection and dependence on the mothering figure.

R APPR OC HE ME NT As this testing of the freedom of individuation by approximately the middle of the s econd year of life, child enters the third s ubphas e of rapprochement: He now becomes more and more aware, and makes 579 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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greater and greater us e, of his physical separatenes s. However, s ide by side with the growth of his cognitive faculties and the increasing differentiation of his life, there is als o a noticeable waning of his previous imperviousness to frus tration, as well as a diminution of what has been a relative obliviousness to his mother's presence. Increas ed separation anxiety can be first this cons is ts mainly of fear of object loss , which is be inferred from many of the child's P.731 behaviors . T he relative lack of concern about the presence that was characteris tic of the practicing subphase is now replaced by s eemingly constant with the mother's whereabouts, as well as by active approach behavior. As the toddler's awareness of separateness grows —stimulated by his maturationally acquired ability to move away phys ically from his and by his cognitive growth—he seems to have an increased need, a wish for mother to share with him one of his new skills and experiences , as well as a need for the object's love. T he crisis in the rapprochement phase is particularly of s eparation anxiety. T he child's wishes and des ires to separate, autonomous , and omnipotent are tempered an increas ing awarenes s of the need for and on the mother. Ambivalence is characteris tic of the phase of the rapprochement subphase. T here is a between the child's need to use the mother as a extension, as having her magically fulfill wis hes , and realization that, with the child's increas ing the mother becomes less available and more distant. 580 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the mother's availability and the reass urance of her continuing love and support become all the more important.

OB J E C T C ONS TANC Y As developments of the rapprochement phase are gradually realized, the child enters the fourth and final phase of s eparation and individuation, namely, the of consolidation of individuality and the beginnings of emotional object cons tancy. At this s tage, there are significant developments in the s tructuralization and integration of the ego as well as definite signs of internalization of parental demands reflecting the development of s uperego precursors . Attainment of object cons tancy marks a transition from the stage of need-satis fying relationships to a more ps ychological involvement with objects . Object implies a capacity to differentiate between objects and maintain a meaningful relations hip with one specific object regardless of whether needs are being satis fied. S uch object cons tancy als o implies s tability of object cathexis and, s pecifically, the capacity to maintain emotional attachments to a particular object in the face frus tration of needs and wis hes in regard to that object. T his achievement als o implies the capacity to tolerate ambivalent feelings toward the object and the capacity value that object for qualities that it pos ses ses over beyond the functions that it may s erve in satis fying and in gratifying drives . T o summarize, it can be said that the notion of object cons tancy implies involvement of a number of s pecific elements that are central to further emergence of the 581 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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meaningful capacity for relationships with objects. elements include perceptual object cons tancy; the capacity to maintain drive attachment to a s pecific regardless of whether it is pres ent; the capacity to both loving and hostile feelings toward the s ame object to maintain a loving relationship with the object in the face of hostile and destructive impuls es ; the capacity to maintain significant emotional attachment to a s ingle specific object; and, finally, the capacity to value the for qualities and attributes that it pos ses ses in itself, in virtue of its own uniqueness as individually and exis ting, and as independent of any need-satis fying function it may serve.

E riks on's E pigenetic S equenc e: Ins tinc tual Zones and Modes of E go Development E rikson made a major contribution to the concept of development in his study of the relations hip between ins tinctual zones and the development of modalities of ego functioning. E rikson's theory links as pects of ego development with the epigenetic timetable of instinctual ps ychos exual development by postulating a parallel relations hip between specific of ego or ps ychos ocial development and specific libidinal development. During libidinal development, particular erotogenic zones become loci of stimulation development of particular modalities of ego functioning. T he relationship between zones of ins tinctual and their corres ponding modalities of ego functioning is easily s pecifiable in pregenital levels of development, E rikson projects this basic modality of relationship, 582 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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extending it to the limits of the life cycle. T he firs t modality of development is related to the oral phase, s pecifically to s timulus qualities of the oral T his early s tage is called the oral-re s piratory-s e ns ory and it is dominated by the firs t oral-incorporative mode, which involves the modality of “taking in.” Other modes are als o operative, including a second oralincorporative (biting) mode, an oral-retentive mode, an oral-eliminative mode, and, finally, an oral-intrus ive T hese modes become variably important according to individual temperament but remain subordinated to the first incorporative mode unless the mutual regulation of the oral zone with the providing breast of the mother is disturbed, either by a los s of inner control in the infant defect in reciprocal and res pons ive nurturing behavior the part of the mother. T he emphas is in this stage of development is placed on the modalities of “getting” “getting what is given,” thus laying the necess ary ego groundwork for eventually “getting to be a giver.” T he second s tage, also focus ed on the oral zone, is marked biting modality becaus e of the development of teeth. phase is marked by development of interpersonal patterns, centered in the s ocial modality of “taking” and “holding” onto things. S imilarly, with the advent of the anal-urethral-muscular stage, the “retentive” and “eliminative” modes become es tablis hed. E xtens ion and generalization of these over the whole of the developing mus cular s ys tem the 18- to 24-month-old child to gain some form of selfcontrol in the matter of conflicting impulses s uch as “letting go” and “holding on.” When this control is disturbed by developmental defects in the anal-urethral 583 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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sphere, a fixation on modalities of retention or can be es tablis hed that can lead to a variety of disturbances in the zone itself (s pas tic), in the muscle system (flabbiness or rigidity), in obses sional fantas y (paranoid fears ), and in s ocial spheres (attempts at controlling the environment by compulsive E rikson laid out a program of ego development that reached from birth to death: T he individual pass es the phases of the life cycle by meeting and resolving a series of developmental ps ychos ocial crises . T hese phases of the life cycle and their respective accomplis h s everal things. F irs t, they make it clear that development is open ended and never finished. T he capacity to success fully resolve any one crisis depends on the degree of resolution of the preceding cris es. One can form a mature and integral sens e of identity only to the extent that one has meaningful s ens e of trus t, autonomy, initiative, and indus try. S ucces sful resolution at any level lays the foundation for engaging in the next developmental S econd, they clarify the relation between the various phases of development and earlier phas es of libidinal development. T he latter had been the bas ic of earlier efforts of ps ychoanalysis, but E rikson's developmental s chema gave a better unders tanding of way in which earlier libidinal developmental residues carried along in the cours e of growth and were built later developmental efforts of the ego. P s ychoanalysis not previously had the conceptual tools to deal with this problem, particularly in regard to the pos tadoles cent phases of the life cycle. F inally, E rikson's treatment of crises as s pecifically ps ychos ocial brought into focus 584 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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fact that the development of the ego was not merely a matter of intrapsychic vicis situdes dealing with the economics of inner psychic energies. It was that, but it was also a matter of the interaction and “mutual regulation” between the developing human organis m significant people in its environment. E ven more it is a matter of mutual regulation evolving between the growing child and the culture and traditions P.732 of society. E riks on has made the s ociocultural integral part of the developmental matrix out of which personality emerges .

Trus t vers us Mis trus t T he crisis of trus t vers us mis trus t is the first crisis the infant must face. It takes place in the context the intimate relations hip between infant and mother. infant's primary orientation to reality is erotic and on the mouth. T he primary locus for s ignificant contact with reality, therefore, is oral. T he typical situation in the infant experiences oral eroticism is the feeding relations hip. Depending on the quality of experience feeding contacts , the child learns to accept what is by the warm and loving mother, to depend on that mother, and to expect that what she provides will be satis fying. T he importance of the child–mother here s hould not be underes timated. T he child's oral orientation is largely biologically determined; the mother's feeding orientation is not only a product of biological factors but als o of a complex proces s of development in which her sense of identity as a female 585 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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and as a mother plays a vital part. Any defect in her identity, thus , has important cons equences for the of the interaction between herself and her child. S uccess ful resolution of this initial phase of interaction entails a dis pos ition to trus t others , basic trust in capacity to receive from others and to depend on them entrus t oneself), and a sense of s elf-confidence. Uns ucces sful res olution of this cris is results in the these same qualities and relative dominance of such oppos ite qualities as mis trust and lack of confidence. C ons equently, the des ignations “basic trust” and “basic mistrust” stand for a complex of personality factors characterizing s ucces sful or uns ucces sful resolution of first cris is .

A utonomy vers us S hame and S elfT he second s tage of psychosexual development is eroticism. B iologically, this stage is marked by a fuller s tool and maturation of the neuromuscular to a point sufficient to allow control of s phincter governing retention and releas e of waste materials . Likewise, the anal zone becomes a source of erotic stimulation through pleasurable sensations of retaining releas ing. P sychos ocially, this period is marked by emergence in the child of self-awarenes s as a separate independent unit. G rowing mus cular control is accompanied by increasing capacity for autonomous expres sion and s elf-regulation, which typically centers problems of s phincter control of the s o-called anal T he ego thus enters into interactions of ass ertivenes s other wills in the s ocial environment, particularly with parents . S uccess fully resolved, the cris is of autonomy 586 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the foundation for a mature capacity for self-as sertion self-expres sion, a capacity to res pect the autonomy of others , an ability to maintain s elf-control without los s of self-es teem, and a capacity for rewarding and effective cooperation with others . T he corres ponding defect lays the foundation of fals e autonomy that must feed on the autonomy of others by domination and excess ive demands or of an exces sive rigidity that can be in the fragile autonomy of the compuls ive (anal) personality. Inability to achieve bas ic autonomy implies the lack of s elf-es teem reflected in a sense of shame the lack of s elf-confidence implied in s elf-doubt.

Initiative vers us G uilt When the child enters the play age, the maturing reaches a developmental s tage in which the serving functions of locomotion and language are sufficiently organized to permit facile use. T he motor equipment has reached a sufficient level of to permit not merely performance of motions but a ranging experimentation in locomotion. T he child to “tes t the limits ” of this new-found capability. T he activity becomes vigorous and intrusive. A s imilar crys tallization of function occurs in the us e of language, which becomes an exciting new toy calling for experimentation and the s atis faction of curios ity. T he child's mode of activity is marked by intrus ion: intrus ion into other bodies by physical attack, into other's by activity and aggres sive talking, into s pace by locomotion, and into the unknown by active curiosity. this activity is accompanied by a growing sexual and a development of the prerequisites of s pecifically masculine or feminine initiative, which are conditioned 587 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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development of a phallic eroticism. If the cris is of initiative is success fully resolved, positive res idues are provided for development of conscience, sens e of respons ibility and dependability, s elfand a certain independence in the mature personality. stage is therefore crucial for the formation of the based on the introjection of authoritative, and parental, prohibitions . T he uns ucces sful resolution provides the bas is for the harsh, rigid, moralistic, and punis hing s uperego that serves as the dynamic source basic s ens e of guilt.

Indus try vers us Inferiority T he period of infantile (phallic) s exuality and the period adult s exuality (puberty) are s eparated by the so-called latency period in which the child's interest is generally diverted to other matters. T he child takes a step up the level of imaginative exploration and play to a level which participation in the adult world is foreshadowed. Wes tern culture, children are sent to school, where begin to learn skills that will equip them to take their places one day in adult society. T heir interests turn to doing and making things; in general, they become involved in developing the neces sary technology for living. T hey are drawn away from home and its close as sociations and plunged into the matrix of the s chool system. T hey learn the reward s ys tems of the school society and as similate the values of application and diligence. T hey als o ass imilate the implicit cultural of work and productivity. T hey achieve a sense of the pleas ure of work, of the satisfaction of a task accomplis hed, and of the merit of pers everance in 588 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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enterprises . In other words, normally developing add to their evolving personality a s ens e of industry. danger at this stage is that a lack of s ucces s in meeting demands of the s chool society and inability to res olve ps ychos ocial crisis produce a sense of inadequacy and inferiority.

Identity vers us Identity C onfus ion T he pass age to adolescent years is marked by an period of phys iological growth and sudden maturation genital organs . T he ps ychos exual phas e of puberty is accompanied on the psychos ocial level by a kind of organization or crys tallization of the residues of the preceding formative phas es. T he developmental preparations for participation in adult life mus t now to take a more or less definitive s hape, s o the must begin to experiment with es tablis hing a future role and function within adult s ociety. T he adolescent mus t develop a confident sense of s elf-awarenes s the ability to maintain inner samenes s and continuity on the confidence that this awareness is matched by samenes s and continuity of his or her meaning to T his particular ps ychosocial crisis is therefore vulnerable and s ens itive to s ocial and cultural T he context of the cris is is specifically interpersonal, such, its s ucces sful res olution becomes all the more tenuous and problematic. In a s pecial sense, achieving sens e of pers onal identity requires an awareness of the context of relations to reality within which the self forms and maintains its own proper identity. P.733 589 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Intimac y vers us Is olation T he status of adulthood is marked on the ps ychos exual level by achievement of genital maturity. On the ps ychos ocial level, this development is paralleled by es tablis hment of s ignificant interpers onal relations hips that complement the previously formed identity in the social s phere. T ypically, the emerging sexual drive on another individual of the opposite s ex as its object. elements of s exual identification, which are ess ential as pects of personal identity, are naturally expres sed as es tablis hed by the standards of inters ex behavior of the society and culture. T he intimate ass ociation of male female in a clos e interpers onal union is thus an of their own identities as well as a culturally approved institution (marriage). T his fact does not mean that the sexual act is the only path to a s ens e of intimacy. F rom point of view of pers onality development, the crucial element is the capacity to relate intimately and meaningfully with others in mutually s atis fying and productive interactions . T he pattern of s uch selfrelations depends in large meas ure on the identity one accepted as his or her own. T he inability to achieve a success ful res olution of this ps ychos ocial crisis res ults in a sense of personal T he incapacity to es tablis h warm and rewarding relations hips with others is but a reflection of the to realize a s ecure and mature s elf-acceptance. Interpersonal relations hips become strained, s tiff, or formal. E ven if a façade of pers onal warmth can be there is a rigidly maintained inner wall that is never breached, a wall defended by intellectualization, 590 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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distancing, and s elf-absorption.

G enerativity vers us S tagnation “G enerativity” points to a primary concern with es tablis hing and guiding the s ucceeding generation (through genes and genitality). In E riks on's terms , “G enerativity, as the instinctual power behind various forms of s elfles s ‘caring,’ potentially extends to man generates and leaves behind, creates and (or helps to produce).” It mus t also be recognized, however, that other areas of altruistic effort cannot be excluded. P erhaps “productivity” or “creativity” are terms. S uch creativity can as sume a myriad of forms , on the native endowment of the person; but realized generativity is als o determined to a large extent by the identity the individual has accepted and by the extent which one is capable of interacting maturely and cooperatively with others . C onsequently, success ful res olution of this crisis depends closely on the degree succes s achieved in the res olution of the preceding of identity and intimacy. Moreover, true generativity has its goal enrichment of the lives of others ; it involves a direct concern with the welfare of others, exclusive of concern over self-interes t.

Integrity vers us Des pair Integrity marks the culmination of development of the personality in E rikson's s chema. It means acceptance oneself and all aspects of life and integration of thes e elements into a stable pattern of living. It implies the experience of and adjus tment to the trials and troubles 591 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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life as well as to its rewards and joys. C ons equently, exis tence holds no fear; the ego has res igned its elf to acceptance of life itself and to acceptance of the end of that life in death. Integrity thus repres ents the fully developed personality in its mos t mature selfT he inability to achieve ego integration res ults often in kind of despair and an unconscious fear of death: T he life cycle, given to every human as his or her own, has been accepted. T he person who does not achieve is doomed to live in basic s elf-contempt. T he parallel lines of development and their interrelation are indicated in T able 6.1-4.

Table 6.1-4 Parallel L ines of Dev Ins tinc tual Phas es

S eparation– Individuation

Objec t R elations

Ps yc hos

Oral

Autism, symbios is

P rimary narcis sism, needsatis fying

T rus t/mi

Anal

Differentiation, practicing, rapprochement

Needsatis fying, object cons tancy

Autonom doubt

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P hallic

Object cons tancy, Oedipal complex

Object cons tancy, ambivalence

Initiative

Latency

—

—

Indus try/

Adoles cence G enitality, secondary individuation

Object love

Identity/i confusio

Adulthood

—

Intimacy generati integrity/

Mature genitality

C urrent C ons iderations In recent years , a fres h current has entered the of analytical developmental theory. In s ome degree reacting to the work of F reud and Mahler, on the bas is observational s tudies of very young infants , the view of infant emerged as active, s urprisingly well organized at the very beginning of life, and as attuned to and interactive with the mothering figure in complicated and quite sophis ticated ways. P articular objections to approach to s eparation–individuation focus ed on her of pathological terms (autism, s ymbiosis) to des cribe developmental phas es of normal infants and the fact her extens ive observations were often too overlaid with 593 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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metapsychological terms that obs cured the boundary between fact and theory. T he work of Daniel S tern particularly pres ented a different view of the infant and focus ed attention on other important aspects of development that had been treated only tangentially in previous studies. S tern's observations brought into clearer focus the affective and interactional matrix between mother and child and directed attention more specifically to the emergence of a s ens e of self than had previous ly been available. T o begin with, S tern's baby was calm, alert, cognitively well organized, and highly res ponsive to interactive with the mother. T he extent to which the was preadapted to s timuli from the mother and active eliciting certain res ponses from the mother, whether caretaking or affective, cast a different light on early of development. T he relation between mother and child proved to be more active and interactive than had previous ly been appreciated. Also following in the wake Heinz K ohut's s elf–selfobject views and the developments that arose from them, much of the of mother–child interaction was cast in terms of the relational and intersubjective models of relating. S tern centered his interest on study of a subjective sense of separately from s tudy of the ego, which had held stage in Mahler's view. Whether such a separate s elf is neces sary or whether the s eparation–individuation proces s and object relations theory already covered ground remain debatable ques tions. C ertainly, Mahler's concentration on the sense of identity and selfcannot be P.734 594 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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discounted, but S tern emphas ized inters ubjective relatednes s, sugges ting “a deliberately s ought s haring experiences about events and things.” All these interactions, including the highly intimate bodily interchanges between mother and child, are steeped in affective res onances. S tern carefully traced the of a core s ens e of s elf out of increasingly complex and s elf–other experiences , es pecially with the mother, taking place within an intens ely affective ambiance leading to development of an affective core in self-experience. T his proces s leads ultimately to es tablis hing a degree of libidinal self-cons tancy sens e of self as relatively integrated and independent, relatively durable and s table, as differentiated from but involved in complex relationships , and as an active agent capable of causing effects and influencing the surrounding environment. Whether and to what extent this approach to development of the s elf and its affective resonances is contradictory to the Mahlerian s chema or is open to eventual integration remains a s ubject of debate. the at times oppos itional s tance that advocates of one the other view ass ume, the potential exists for these pers pectives in the hope of deepening the unders tanding of the complexities of human development. C ritics have pointed out that these approaches may be looking at children in different contexts of obs ervation—the S tern baby in periods of relatively calm and unconflicted interaction with the mother, Mahler's baby in contexts of greater conflict separation. It may be that the obs ervations of both 595 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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are valid enough and need to be brought together to accomplis h a more complete view of the developing infant. C ertainly S tern's focus on the emergence of the adds a fres h direction of inquiry more congruent with evolving theoretical concepts of the self in

OB J E C T R E L A TIONS THE OR Y One of the important developments in psychoanalysis , which emerged more or less in parallel to the evolution ps ychoanalytic ego psychology, is object relations Only gradually over the years have these parallel and somewhat independent courses of theoretical development converged into complementary rather oppos itional pers pectives . T he development of class ic ps ychoanalytic theory through elaboration of a ego ps ychology has led inexorably in the direction of better understanding of the adaptive functions of the particularly the close involvement between the ego and reality in its functioning and development. One dimension of the problem of reality in ps ychoanalytic theory is the whole question of object relations . T he integration of thes e complementary currents of thinking provides a more comprehens ive basis for about the mind as it functions not only intrapsychically interpersonally in its relation to others as important sources of the s ocial environment of the human

Origins T he origins of the object relations view can bes t be from the contribution of K lein. K lein's theorizing based its elf on F reud's later instinct theory, primarily on the death ins tinct as the main theoretical prop of her 596 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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metapsychology. W orking primarily with very young children, she des cribed instinctual dynamics in the firs t years of life. Driven by the death ins tinct, the child was compelled to rid him- or hers elf of intolerable, impulses (predominantly oral) and to project them externally. T he earliest recipient of thes e projected impulses was the mother's breast, which provided satis fying nourishment and satiation (good breas t) but often deprived and did not s atis fy (bad breast). At this stage, the images of the breast are part-objects that infant had yet to combine into a single whole object, mother. E arly frustration of oral needs, even in the firs t of life, reinforced these trends s o that the bad breas t became a pers ecutory object that was hated, feared, envied. E xperience of the bad breas t and its ass ociated persecutory anxiety formed the earlies t developmental stage in K lein's theory: the paranoid-schizoid position. bad breast withheld gratification and thus stimulated child's primitive oral envy, provoking s adistic wis hes to penetrate and destroy the mother's breasts and body. boys , these primitive des tructive impulses gave rise to fear of retaliation (bas ed in part on projection) in the of castration anxiety; in girls, the primitive envy was expres sed in envy of the mother's breast during the developmental phas e and later was transformed into envy during the genital phas e. K lein held that by the of weaning, the child was capable of recognizing the mother as a whole object poss es sing good and bad qualities . B ut the combination of good and bad qualities a s ingle object—previous ly separated in part-objects— created a dilemma: Des tructive attacks on the bad 597 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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also des troyed the good and needed object. T his prevented the child from unleas hing aggres sive agains t the object and lay the basis for the depres sive position, in which aggres sion was turned against the rather than against the object. T he guilt ass ociated with destructive wishes against the object was the precursor cons cience. K lein's emphas is in the child's developmental fell on the proces ses of introjection and projection, from basic instinctual drives, and their interactions with the important and primary objects of the child's early experience. P rojection of des tructive s uperego permitted acceptance of good introjects (internalization good objects ), thus alleviating the underlying paranoid anxiety. T he projected s uperego elements were later reintrojected to become the agency of guilt and early forms of obsess ional behavior. T he K leinian emphasis good and bad introjects concentrated on vital relations hips to objects at the earlies t level of child development, and the delineation of the internal structuring of the child's inner fantasy world in terms of the viciss itudes of these introjects , or internal objects , provided the basis and the rudimentary content for an object relations view of development. T hus K lein's “inner world” was peopled by internal that were either good or bad and with whom the individual was involved in intrapsychic interactions and struggles that were in many ways as real as thos e on with the real objects outside the person. In fact, saw external object relations as derived from and influenced by projective content derived from the object relations . K lein has been generously criticized 598 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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her almost blind interpretation of all forms of destructive intent as manifes tations of the death for her inability to distinguish among the various kinds intraps ychic content (lumping object representations , representations, internal objects , fantas ies, and structures of various kinds together indiscriminately treating them in a unitary fas hion), for her tendency to subs titute theoretical inferences for observations , and, finally, for her marked tendency to predate the of intraps ychic organizations that are generally thought other theorists to be achieved only in later stages, for example, locating the origin of the superego the firs t year of life rather than in resolution of the situation in latency. In any case, K lein's observations and formulations had tremendous impact, particularly in bringing into prominence the role of aggres sion in pathological development, in making theoris ts of development much more aware of the early developmental precurs ors of structural entities, and particularly in providing the rudiments and foundations for an emergent theory of object relations . Wilfred B ion extended and applied K lein's ideas, developing the ramifications of the notion of projective identification—a process , originally described by K lein, which a subject dis places a part of the s elf into an and then identifies with that object or elicits a res ponse the object corres ponding to qualities of the projection. B ion applied this notion to a wide range of psychotic cognitive operations . He developed the metaphor of “container” P.735 599 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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and the “contained” to expres s the manner in which projective identification occurs , es pecially in the of mother–child and analyst–patient interaction. T he child/patient projects toxic or des tructive contents onto the mother/analys t, who, in turn, absorbs, modifies , or “contains ” it so that it becomes available in more form for s ubs equent reinternalization by the res ulting in a healthier modification of the child/patient's pathogenic introjects. B ion als o contributed s ignificantly to the understanding of group process es by demonstrating the “basic as sumptions ” that operate on unconscious emotional level in therapeutic groups and expres sed in patterns of fight-flight, pairing, and dependence.

E G O A ND OB J E C TS B eginning around 1931, R onald F airbairn s hifted the emphasis in his thinking specifically to the problem of analysis. F airbairn's contribution was to bring personal object relations into the center of the theory. Whereas ego in F reudian theory had been regarded as a modification of the id, developed s pecifically for the purpos e of impulse control and adaptation to the demands of reality, F airbairn conceived of the ego as core phenomenon of the psyche. R ather than an organization of functions , he conceived of it more specifically as embodying a real s elf—that is , as the dynamic center or core of the personality. Ins tead of basing his theory on the ins tinctual drives as the basic concept, F airbairn shifted the emphasis to the ego and everything in human ps ychology as specifically an 600 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ego functioning. With this reorientation, there came a parallel of the instinctual pers pective. T he libido or instincts in general, rather than mechanisms for energic discharge, were regarded as ess entially object seeking. zones were not the primary determinants of libidinal but, rather, channels that mediated the primary relations hips with objects, particularly with relationships with objects that had been internalized during early life under the press ure of deprivation and frustration. E go development itself was characterized by a process whereby an original state of infantile dependence, on a s ymbiotic union with the maternal object, was abandoned in favor of a s tate of adult or mature dependence based on differentiation between self and object. T hus, F airbairn conceptualized the proces s in terms of the vicis situdes of relations with objects rather than the viciss itudes of ins tinctual T he basis for much of F airbairn's theorizing is his experience with s chizoid patients . He contrasted the dilemma of the s chizoid with that of neurotic patients whom he felt clas sic ps ychoanalytic theory was bas ed. saw that the schizoid was not primarily concerned with control of threatening impulses toward s ignificant but that the is sue for this kind of patient was es sentially that of having an ego capable of forming object at all. T he relations hip to objects presented a difficulty, because of dangerous impulses arising in connection them, but becaus e the ego was weak, undeveloped, infantile, and fragile. In the s truggle to overcome this weaknes s, the schizoid's impulses became antisocial. T hus, object relations theory in its bare es sentials 601 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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a number of bas ic points that differentiate it from theory. F irs t, the ego is conceived of as whole or total birth, becoming s plit or los ing inner unity as a result of early bad experiences in object relations hips, in relation to the mothering object. T his point differs radically from the clas sic theory, according to which the ego begins as undifferentiated and unintegrated and achieves unity through the course of development. S econd, libido is regarded as a primary life drive of the ps yche, the energic source of the ego's s earch for relatednes s with good objects , which is ess ential for growth. T hird, aggress ion is regarded as a natural defens ive reaction to frustration of the libidinal drive rather than s pecifically as an independent instinct. the structural ego pattern that emerges when the ego unity is lost involves a pattern of ego s plitting and formation of internal ego–object relations . T he shift in emphas is toward the primacy of the environment and the influence of objects on the cours e development has es tablis hed a definite trend in ps ychoanalytic thinking and has been advanced in the work of B ritish theoris ts, among whom the work Michael B alint and Donald W innicott stands out. particularly has emphas ized the importance of early interactions between mother and child as determining factors in the laying down of important components of ego development. C urrently, there is ample room for overlap and integration in the approaches and formulations of both object relations theorists and more clas sic ps ychoanalytic ego theorists . S uch integration advanced to the point that they are generally regarded forming at least complementary as pects of a common 602 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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theory, if not a more comprehens ive and unified theory such. B oth B alint and W innicott were concerned with levels early developmental failure that were es sentially preoedipal, were manifested in forms of pers onality that are more primitive and more difficult to treat than us ual neurotic disorders , and s eemed to involve critical as pects of the relationships with objects early in the of development and corres pondingly do not fit well with clas sic ps ychoanalytic s tructural theory with its basic on is sues of intraps ychic conflict. B alint envisioned s everal layers of psychological functioning in analysis. T he first is the familiar genital centering on triadic relations hips and concerned specifically with intrapsychic conflicts . T hese conflicts quality of relationships were usual and familiar material most analytical proces ses and could be treated by use adult language in verbal interpretations . T here was, however, a s econd, deeper level in which the meaning of words no longer had the same impact, and interpretations were no longer perceived as meaningful the patient. T his was the level of preverbal experience. referred to this level of impairment in object relations as the bas ic fault. B alint recognized that at this level of preverbal experience any attempt to address or the child's experience in adult language is bound to fail. P roblems arose in analysis when efforts were made to interpret events from this preverbal level in adult or secondary process terms. B alint dis tinguis hed between forms of regress ion that described as benign and malignant. T he benign was more or les s an extension of the basic notion of 603 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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us ual analytic regress ion to a level of primitive with primary objects. S uch a regres sion was gradual, tempered, and modulated according to the patient's capacity to tolerate and productively integrate the res ulting anxiety. During this regress ion, the analyst's empathic res ponsivenes s and recognition made it for the patient to withstand this uns tructured and to keep the anxiety within manageable limits . At level of the bas ic fault, the lost infantile objects can be mourned, and the quality of the relationship with them was open to reworking so that the patient's basic as sumptions governing his or her interaction with the internal and external object world could be reformed. During phas es of benign regres sion to this preverbal pregenital level of object relationship in the analysis, analyst could usually provide an adequate degree of empathic acceptance and recognition, rather than verbalized interpretations, of this level of the patient's unstructured and regres sive experience, without any need to es cape or subvert this level of experience through interpretation. B alint felt that the dynamics at level are more primitive than can be adequately in terms of conflict because they derive from the bas ic form of dual relations hip involved in early mother–child interaction—that is , the basic fault. In contras t, malignant regres sion tends to be and extreme; the ego is prematurely overwhelmed by traumatic and unmanageable anxiety. P.736 T his anxiety prevented any effective reworking of fundamental disturbances in object relations hips, re604 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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creating and reinforcing the basic fault, rather than creating the conditions for its therapeutic revis ion. At even deeper level, beyond the reach of analytic lay the area of creativity; that is, an idiosyncratic, uncommunicable, and objectless area that lies beyond conventional express ion. R egress ion to the level of the bas ic fault was a quite different and distinct phenomenon than the more usual oedipal regres sions experienced in the analysis of neurotics . In the oedipal regress ion, the aim was gratification of infantile instinctual wishes. R egres sion the level of the basic fault, however, sought a basic recognition by the therapist, as well as protective and cons ent to express the inner core of creativity that at the heart of the patient's being and accounts for the capacity to become ill or well. B alint used the notion of primary love at this deepes t level to describe libido from a frus trating object in the effort to certain inner harmony in which it becomes pos sible to recover the conditions of early care and tranquility. He referred to a “harmonious interpenetrating mix-up” to describe this early, almos t undifferentiated interaction the infant and environment. T he analogy he used was of breathing air; the organism cannot exis t without air, air and the organis m are seemingly ins eparable, but cutting off the supply of air reveals both the organism's need for it and the dis tinction between air and the organism. In terms of primary love as it came to bear in analysis, then, the patient would s eek a basic form of recognition from the analys t, as he had from significant objects in the patient's early life experience. Winnicott als o was concerned with the earlies t phase 605 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the mother–child relationship and the importance of he des cribed as “good-enough mothering” for the personality development. T he cours e of development involved movement from an early stage of total or absolute dependence toward a more adult phase of relative independence. As he saw it, the inherited potential for growth was s trongly influenced by the of maternal care. T his potential for development is affected even from the moment of conception. E ven before birth, the child becomes inves ted by a strong narcis sistic cathexis that allows the mother to identify the child and to become empathically attuned to the child's inner needs, as if the child were—and indeed extension of her own s elf. W innicott called this early prenatal involvement of mother and child in the womb a primary mate rnal preoccupation. T his set the stage for development of a holding relations hip in which the mother becomes sensitively attuned to the infant's and s ens itivities and is both phys ically and emotionally res ponsive to them, thus providing a phys ical, phys iological, and emotional ambiance, protection, and security for the absolutely dependent infant. As the infant moves from this early stage of absolute dependence toward a more relative dependence, awarenes s of personal needs and of the exis tence of mother as a caretaking object grows. T he optimal relations hip at this s tage involves a continuation of protective holding, along with an optimal titration of gratification and frus tration. As a result of this optimally attuned relationship between the patterning of infantile drives and initiatives and their harmonious fitting in with maternal s ens itivities and res ponsivenes s, there is a 606 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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developing s ens e of reliable expectation that the needs will be satisfied without the threat of excess ive withdrawal of the mothering object and without the threatening, overwhelming, and s hort-circuiting of the infant's initiatives as a res ult of excess ive maternal impingements. In the course of normal development, this allowed for emergence of a certain omnipotence from which the gradually retreats with the experiences of tolerable degrees of frus tration by and s eparatenes s of the object. Although the mother continues her holding at phase, she must yet allow enough s eparation between herself and the developing infant to permit expres sion the baby's needs and initiatives that form the rudiments an emerging s ens e of self. If she is too distant, too unrespons ive, or not s ufficiently present, anxiety arises is accompanied by the fading of the infant's internal representations of her. T he transition from a phas e of abs olute dependence to one of relative dependence represents a crucial development in the capacity for object relations . It is accompanied by a critical transition from total to the capacity for objectivity in the perception of and relation to objects. T he transition from s ubjectivity to objectivity is accomplished by development of transitional phenomenon, expres sed in the firs t the emergence of trans itional objects . T hese objects the child's first object poss es sions that are perceived separate from the emerging self—the firs t “not me” poss ess ions. F rom the study of infant behavior, argued that the transitional object was a substitute for maternal breas t, the first and mos t s ignificant object in 607 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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environment to which the infant related. T he object exis ts in an intermediate realm contributed to by the external reality of the object (the mother's and by the child's own s ubjectivity. T his intermediate realm is at once both subjective and objective without being exclusively either. Winnicott referred to this realm as the re alm of illus ion, intermediate area of experience that embraced both and external reality and may be retained in areas of functioning having to do with such imaginative as creativity, religious experience, and art. In its form, however, the transitional object commonly experienced in childhood development may take the of a particular object, a blanket, a pillow, or a favorite or teddy bear to which the child becomes intens ely attached and from which it cannot be s eparated without stirring up severe anxiety and dis tres s. Attachment to object is an immediate displacement from the figure of mother and represented an important developmental step, insofar as it allows the child to tolerate increasing degrees of separation from the mother, us ing the transitional object as a substitute. T he mother participates in this intermediate transitional realm of illus ion by her res pons iveness to the infant's to continually create her as a good mother. In her sens itivity and res ponsiveness , s he functions as a enough mother. However, her inability to provide such adequate mothering, either by exces sive withdrawal or excess ive intrusion and control, may result in of a false self in the child bas ed on compliance with the demands of the external environment, a condition that reflects a developmental failure and results in a variety 608 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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often s evere character pathologies. When s uch patients are s een as adults , they are neurotic nor ps ychotic but s eem to relate to the world through a compliant s hell that is not quite real to them to the analys t. T hey are often mistrustful without being specifically paranoid, they appear withdrawn and disengaged and s eem able to relate only by means of protective s hell, which s eems apparently obsess ive compliant but which s eparates and isolates them from meaningful contacts with their fellows , even as it their only bas is for relations hip. T hese dis turbed personality types reflect a bas ic impairment in very object relations , particularly in the mutuality and res ponsiveness of very early mother–child interaction. Infants who developed in the direction of a false self have not experienced the security and mutual of such a relationship. S uch mothers are empathically of contact with the child and react largely on the basis their own inner fantas ies, narciss is tic needs, or conflicts. T he child's s urvival depends on the capacity adapt to this pattern of the mother's respons e, which is gross ly out of phase with the child's needs . T his es tablis hed a pattern of gradual training in compliance with whatever the mother was capable of offering, than s eeking out and finding what is needed and C ons equently, the child's needs, ins tinctual impulses, wis hes , and initiatives , instead of becoming a guide to s atis fying growth experiences and enlarging capacities to interact meaningfully with objects, from the very beginning a threat to the harmony of the relations hip with the mother, who remains to effective feedback from the child. 609 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Winnicott's attempts to formulate principles of for such basically impaired patients built on the model good-enough mothering. T his called for a capacity for holding, for empathic res ponsiveness , and for a P.737 capacity for creatively playful exchange that allowed patient's capacities for growth to emerge and flouris h, permitting expansion of the patient's authentic sense of self, which remains hidden behind the external facade false-self compliance.

A TTA C HME NT THE OR Y Another more recent development in the study of relations hips with objects has taken the form of attachment theory. Attachment theory takes its origin in the work of J ohn B owlby. In his s tudies of infant attachment and s eparation, B owlby pointed out that attachment cons tituted a central motivational force and that mother–child attachment was an ess ential medium human interaction that had important consequences for later development and personality functioning. Attachment theoris ts have s tudied patterns of early attachment and related them to patterns of adult interaction with s ignificant objects. Us ing the Adult Attachment Interview (AAI), developed by Mary Main others , they document the nature of internal working models of early attachment relations. B oth attachment theoris ts and object relations theorists emphasize the significance of the mother's empathic respons ivity to infant needs for s elf-development and relatedness , the importance of the mother–child involvement for 610 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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personality development, and the role of the mother as catalys t for age-appropriate development. S tudy of infant respons es in the S tranger S ituation, an arrangement for obs erving the quality of parent–child interaction and the effects of s eparation, led to of four categories of infant behavior: secure, avoidant, res is tant, and disorganized-disoriented. T hes e patterns could be related to attachment attitudes in adults on basis of the AAI. S ecure infants were related to s ecure relatively autonomous patterns of attachment and interaction in adults , avoidant infants were ass ociated an adult pattern of dis mis sing relationships as or s ignificant, resis tant infants connected with a preoccupied adult s tance in which s ubjects were preoccupied with past attachments often with angry or fearful emotions, and the disorganized-disoriented related to an unres olved and dis organized pattern in adults s uggesting more severe dis turbance in self– relations . T hese findings provide an extension and specification of an object relations approach as well as providing specific empirical and observational methods more detailed study of the development of object relations from childhood to adulthood.

P S YC HOL OG Y OF THE S E L F Over the las t two s core and more of years , the concept the self has been emerging with increasing emphasis definition as a central notion in the deepening ps ychoanalytic unders tanding of the organization and functioning of the human psyche. Although the regarding the unders tanding of the s elf are s till very in flux, and the place of the notion of the s elf in 611 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ps ychoanalytic theory remains tentative and uncertain, is sues address ed by the ps ychology of the self seem to of sufficient significance and to have gained a more or permanent place in psychoanalytic thinking s o that a cons ideration of thes e iss ues is warranted in this presentation. T he is sues to which a self-ps ychology addres ses itself by no means new to psychoanalys is . P art of the stems from the ambiguity in F reud's use of the term standing ambiguous ly both for the ego as part of the mental apparatus, a s tructural agency, and for the experiential subjective and personal sense of s elf. T he decis ion of the editors of the E nglish S tandard E dition translate Ich to the term “ego” tended to s hift the of the term toward the more impersonal structural of agency and away from the more s ubjective implications. T here are pas sages where it is quite clear F reud uses the G erman term s e lbs t as s ynonymous the term Ich, referring to the s ubjectively experienced self—the person as such. T his unres olved ambiguity and the progres sive s hift in implications of the term ego have left a certain vacuum ps ychoanalytic metapsychology. T his deficit has been attacked by a number of thinkers as reflecting a lack of personal ego or a s ens e of s elf-as -agent in theory. P artly in an attempt to deal with this is sue, the notion of the self has been focused by various analytic thinkers in a variety of contexts . K ohut's development self psychology has been a major s timulus to renewed interes t in the self. T he self psychology movement came into prominence largely as the res ult of K ohut's efforts in the late 1960s, 612 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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there was a his tory of development of a self-concept in ps ychoanalys is well before that. Development of a of the self in the context of the structural theory was stimulated by Hartmann's distinction between ego and self, terms that had been left ambiguous by F reud: T he was an intrapsychic organization of functions , whereas self was cas t in terms of a s elf-representation that then became the object of narciss istic libido but als o was specifically connected with object relations . In these the ego was related to and interactive with other intraps ychic s tructures , for example, superego, and the was concerned with object relations and self–object interactions. T his distinction also clarified the differentiation of object-libido and narciss istic libido because the self was the repository for secondary narcis sism and, as s uch, distinct from the ego. Hartmann's distinction between the ego and the s elf the self in representational terms . T he s elf was conceptualized either as a complex repres entation, organized and synthesized as a function of the ego or, later theorists , in structural terms as a more complex supraordinate integration of the tripartite structures is , embracing the tripartite entities as s ubordinate subs tructures ). T he former view regarded the self as the repres entational world, whereas the latter ass igned to the realm of internal ps ychic s tructure. T he of emphas is and formulation regarding these two perspectives remain a pers istent problem in developing cons istent concept of the self.

K ohutian S elf Ps yc hology S elf ps ychology, as a s eparate movement within 613 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ps ychoanalys is, takes its origin from contributions of and his followers. K ohut linked the origin of the s elf to narcis sism, viewing the s elf as the result of a s eparate of narcis sis tic development that progres ses through a series of archaic narciss istic structures toward a mature and cohesive s elf-organization. K ohut argued that narcis sism went through a separate of development independent from object libido and object relations . In his view, the original primary differentiates in the course of development and in res ponse to laps es in parental empathy into two configurations, the grandiose self and the idealized parental imago. T he grandios e s e lf involves an and exhibitionis tic image of the self that becomes the repository for infantile perfection; the ide alize d parental imago, in contrast, trans fers the previous perfection to admired omnipotent object or objects. F urther normal development of the grandios e self leads to more forms of ambition, s elf-es teem, s elf-confidence, and pleas ure in accomplis hment. T he idealized parental likewise becomes integrated into the ego ideal with the mature values, ideals , and s tandards it repres ents. P athological pers istence of the grandiose self results in intens ification of grandios ity, exhibitionis m, shame, depres sion, hypochondriacal concerns, and of P.738 self-es teem. Loss of the idealized object or the object's love can res ult in narcis sis tic imbalance, the individual vulnerable to depress ion, depletion, poor self-es teem, failure of ideals and values , and even 614 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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fragmentation. K ohut bases his s elf ps ychology on the need, both the cours e of development and during the cours e of for empathic interaction with s e lfobje cts . T he original selfobject is the mother or caretaking person who empathic res ponse to s elfobject needs in the infant in form of love, admiration, acceptance, joyful warmth, and respons ivenes s, communicating a sense valued and cherished exis tence to the child. Human continue to s eek objects to fulfill these basic s elfobject needs throughout life. F ailures to fulfill such needs can res ult in the formation of pathological psychic and patterns of behavior during development and pathological character s tructures during adult life. (T his analysis comes close to W innicott's views on goodmothering.)

E volving C onc epts of the S elf T he direct line of development of the notion of the s elf ps ychoanalys is, as previously discus sed, is best traced to Hartmann's effort to clarify the ambiguity latent in F reud's use of the term Ich. Hartmann distinguis hed from the s elf by ass igning the res pective terms to frames of explanatory reference. T he ego referred to specific intraps ychic agency whose frame of reference action was within the intrapsychic s tructure and in to other intraps ychic entities , for example, s uperego id. T he self, in contrast, had its proper frame of relations hip to objects . T hus formulated, the notion of self came to be regarded as roughly equivalent to the concept of the person as s uch. In an effort to clarify the theoretical implications of the 615 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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early thinkers , following Hartmann's lead, came to the self in repres entational terms —that is , as referring the self-representation, which was then regarded as a subordinate function of the ego. Another point of view, however, sees the s elf as a s tructural organization, envis ioned as a fourth focus of organization in addition the tripartite entities or as a s upraordinate organization, including the tripartite s tructures and perhaps structural as pects. P art of the difficulty is that the notion of the self can be looked at from a variety of perspectives. T he s elf can seen as agent, or as object, or even in locational terms res pect to questions of what is inside or outside of the mind or the ps ychic s tructure and what it might mean parts of the s elf to be internalized or externalized. T he representational view of the s elf seems to lend its elf clearly to a view of the s elf as object, that is , as what cognitively and experientially gras ped of the s elf as an object of inner experience. S uch an experienced s elfobject must have repres entational qualities to be cognitively relevant. B y the s ame token, the s tructural perspective seems to be mos t congruent with the view the s elf-as -agent, as a s ource of psychic integration activity, and as s ynonymous with the originating s ource personal action and awareness . T he s tructural as pect the self-as -agent, with particular reference to its of conscious s ubjectivity, comes clos est to s atisfying demand for a “personal ego” in the theory. T he theory of the s elf remains at this juncture uncertain and very much in flux. However the ultimate conceptualization may be res olved, it s eems apparent the ps ychology of the s elf will continue to gain a 616 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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permanent place in ps ychoanalytic thinking and theory. is poss ible to specify s ome of the theoretical gains of emerging role of the s elf-concept: T he self as a theoretical construct provides a focus formulating and unders tanding the complex integrations of functional process es that involve combinations of functions of the respective component agencies . T his has specific application such complex activities as affects, in which all of ps ychic s ys tems s eem to be in one way or other represented; complex s uperego integrations in such formations as value s ys tems; and other complex interactions of ps ychic s ys tems that fantas y production, drive-motor integration, or cognitive-affective proces ses. T here is room here cons iderable reworking and refocusing of traditional ps ychoanalytic ways of looking at and ps ychic phenomena in terms of the s elf as a system. T he self-concept provides a more specific and less ambiguous frame of reference for the articulation of self–object interrelations hips and interactions , including the complex areas of object relations and internalizations . T he emergence of a self-concept provides a locus the theory for articulating the experience of the personal s elf, either as gras ped intros pectively and reflectively or experienced as the originating source personal activity. T his s ens e of the self-as -subject provides a place within the theory for an account of subjectivity and s ubjective meaning. 617 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T his approach raises an important metapsychological is sue; namely, the relations hip between the organization of the s elf and the tripartite entities . T he organization of the s elf and the organization of tripartite entities cannot be s imply identified. T he s elforganization operates at a different level of psychic organization than do the s tructural entities; moreover, structural entities in the strict theoretical s ens e are unders tood to be organizations of specific functions . concept applies not only to the ego as such but als o to superego and the id. Although the theory at various attributes more or les s personalized, metaphors to the operation of thes e s tructures , their theoretical intelligibility is nonetheles s given in terms of the organization of s pecific functions attributed to the res pective s tructures.

R elational and Inters ubjec tive Approac hes T hese more recent approaches to understanding the analytical interaction derive from a form of epistemology in which transference was regarded as res ulting from the interaction of analys t and patient. cons tructivist view contras ts with the more objectivist view of ego ps ychology and object relations . T he attention is focused on the here-and-now interaction the patient rather than on the inner dynamics of the patient's mental life and experience. T his effects a s hift from a one-person to a two-person ps ychology in which the ongoing interactions , whether cons cious or unconscious, between the participants are central, and transference and countertransference are regarded as 618 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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mutually cocreated by both. T his approach was further developed into a view of analytical interaction in inters ubjective and relational terms. T he self ps ychological emphasis on s elf– transference has encouraged movement away from cons iderations of the analyst's stance as neutral or observational, ques tioning the analyst's subjectivity, authority, and capacity to know any objective reality the patient. On these terms, pers onality development is dependent on the interpersonal field insofar as ps ychic is continually being remodeled in terms of both past present relations hips and not determined by fixed patterns deriving from pas t unconscious conflicts . T he concept of personality as developing within a relational matrix calls for a central focus on the intersubjective within the relations hip between analys t and patient. It is this aspect of the analytical situation that is explored interpreted in the interest of bringing about personal growth in the patient. T he analyst's technical neutrality and objectivity are rejected in this approach as illus ory little more than express ions of the analys t's position. Within a s elf–selfobject or intersubjective relation, neutrality is precluded as P.739 potentially traumatizing and destructive to potential cons olidation of the self. An inevitable cons equence of these approaches is that they do away with the notion of the unconscious and undercut any sense of transference as reflecting unconscious aspects of the patient's inner psychic life because trans ference is anew in the pres ent analytical interaction. 619 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Ps yc hology of C harac ter T he development of the concept of character in ps ychoanalys is has drawn increasingly clos er to the that are latent in a ps ychology of the s elf. C haracter come to s tand for a unique combination of the components of the individual's psychic organization reflects the basic elements of that person's personality organization and style. T he implications of the concept character, then, lie much clos er to the framework of the personality functioning as a whole, rather than to ps ychic agencies . T he concept of character can vary widely in meaning, depending on whether it is us ed in a moralistic, sociological, or general s ens e. Application of the in ps ychoanalysis has remained res trictive despite the that theoretical propos itions concerning the meaning of character have undergone an evolution that parallels evolution in ps ychoanalytic theory, particularly in the theory of the ego. During the period when F reud was developing his ego theory, he noted the relations hip between certain character traits and particular ps ychos exual components. F or example, he that obstinacy, orderlines s, and pars imonious nes s as sociated with anality. He noted that ambition was related to urethral eroticis m and that generos ity was related to orality. He concluded, in his paper on and Anal E roticism,” that permanent character traits represented “unchanged prolongations of the original instincts, or sublimation of thos e instincts, or reactionformations against them.” In 1913, F reud made an important distinction between 620 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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neurotic s ymptoms and character traits : Neurotic symptoms come into being as a result of failure of repress ion, the return of the repress ed; character traits their exis tence to the succes s of repress ion or, more accurately, of the defens e s ys tem, which achieves its through a persistent pattern of reaction formation and sublimation. Later, in 1923, with increas ed of the phenomenon of identification and the formulation of the ego as a coherent s ys tem of functions , the relations hip of character to ego development came into sharper focus . At this point, F reud obs erved that the replacement of object attachment by identification (introjection), which s et up the los t object inside the also made a significant contribution to character formation. A decade later, in 1932, F reud emphasized particular importance of identification (introjection) with the parents for the construction of character, with reference to superego formation. S everal of F reud's disciples made important to the concept of character during this period. A major share of K arl Abraham's efforts were devoted to the inves tigation and elucidation of the relations hip oral, anal, and genital eroticism and various character traits. Wilhelm R eich made an important contribution to the ps ychoanalytic unders tanding of character when he described the intimate relations hip between resistance treatment and character traits of the patient's R eich's obs ervation that res is tance typically appeared the form of thes e s pecific traits anticipated Anna later formulation concerning the relationship between res is tances and typical ego defens es. T he development of psychoanalytic ego psychology 621 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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led to an increasing tendency to include character traits among the properties of the ego, s uperego, and egoIt s hould be noted, however, that character is not synonymous with any of these properties . the emphasis has been extended from an interes t in specific character traits to a cons ideration of character its formation in general. P sychoanalys is has come to regard character as the pattern of adaptation to and environmental forces , which is typical or habitual given individual. T he character of a person is from the ego by virtue of the fact that it refers largely to directly obs ervable behavior and s tyles of defense, as as of acting, thinking, and feeling. T he clinical value of concept of character has been recognized by and ps ychoanalys ts and has become a meeting ground the two disciplines. T he formation of character and character traits res ults the interplay of multiple factors. Innate biological predis pos itions play a role in character formation in its instinctual and ego fundaments . T he interactions of forces with early ego defenses and with environmental influences, particularly the parents, constitute the major determinants in the development of character. V arious early identifications and imitations of objects leave their lasting s tamp on character formation. T he degree to which the ego has developed a capacity tolerate delay in drive dis charge and to neutralize instinctual energies , as a result of early identifications defens e formation, determines the later emergence of such character traits as impulsiveness . F inally, a authors have s tres sed the particularly clos e ass ociation between character traits and the development of the 622 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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ideal. T he development of the ego-ideal must be unders tood in the context of the developmental viciss itudes of narciss is m. It is in this respect that the ps ychoanalytic concept of character begins to parallel more common us e of the term characte r in a s omewhat moral sense. T he exaggerated development of certain character traits at the expense of others may lead to character dis orders later in life. At other times , s uch distortions in the development of character traits can produce a vulnerability in personality organization or a predis pos ition to ps ychotic decompensation.

C L A S S IC P S YC HOA NA L YTIC TR E A TME NT C ertain aspects of the therapeutic technique that F reud developed and that were later expanded by his are closely related with ps ychoanalytic theory. One of distinctive as pects of the ps ychoanalytic approach to treatment in general is its cons is tent attempt to therapeutic us ages and approaches with the unders tanding of psychic functioning available from ps ychoanalytic theory. In its origins and clinical application, ps ychoanalys is is uniquely a theory of

Analys is vers us Analytic al Ps yc hotherapy One of the chronically recurring is sues among analys ts whether and to what extent psychoanalys is is distinguishable from ps ychotherapy. T here are distinguishing features between them as more or les s forms: the us e of couch in analysis, not in therapy; free as sociation as a primary method in analysis, not in 623 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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intens ive and long-term s cheduling in analys is , not in therapy; emphasis on neutrality, abstinence, and interpretation on the part of the analyst in analys is, not therapy; and the central focus on transference and countertransference in analysis , not in therapy. Over years , however, forms of psychotherapy have evolved modifying all of these criteria and res ulting in a of psychotherapeutic interventions , ranging from ps ychoanalys is at one end to diluted forms of ps ychotherapy at the other. T he dis tinction between explorative vers us supportive therapy parallels this continuum s o that many variants of the analytical have aris en in which both components are us ed in degrees . S ome of this variation has come about by of the expans ion of P.740 analytical techniques to the widening scope of ps ychopathology and the corres ponding challenge of adapting analytical techniques to these patient needs. Another factor, however, has been the rejection of traditional analytical approaches and methods accompanying rejection of more traditional analytical theories. One conclus ion is that better means for determining what patients are better served by what forms of therapy needs to be developed.

Analytic al Proc es s S ome of the origins of F reud's approach to treatment been cons idered, particularly in the development of his basic techniques of free as sociation and in his growing awarenes s and interpretation of the trans ference. In 624 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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es sence, modern ps ychoanalytic treatment procedures differ from thos e that F reud originally developed in one fundamental respect. E arly in his approach to therapy, F reud believed that recognition by the phys ician of the patient's unconscious motivations, the communication this knowledge to the patient, and its comprehens ion the patient would of its elf effect a cure. T his was his doctrine of therapeutic insight. F urther clinical however, has demonstrated the fallacy of these expectations . S pecifically, F reud found that his discovery of the unconscious wis hes and his ability to impart thes e to the patient s o that they were accepted and were ins ufficient. S uch ins ight might permit clarification the patient's intellectual apprais al of problems , but the emotional tensions for which the patient sought were not effectively alleviated in this way. T his led to a s ignificant breakthrough. F reud began to that the succes s of treatment depended on the ability to unders tand the emotional significance of an experience on an emotional level and depended on the patient's capacity to retain and use that insight. In that event, if the experience recurred, it elicited another reaction; it was longer repress ed, and the patient would have undergone a ps ychic economic change. F reud's formula for this process was: “Where id was , there ego be.” F reud thus elaborated a treatment method that minimal importance to the immediate relief of to moral s upport from the therapist, or to guidance. T he goal of ps ychoanalys is was to pull the neuros is out by roots, rather than to prune off the top. T o accomplis h 625 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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it was necess ary to break down the pregenital, deep crys tallization of id, ego, and s uperego and bring underlying material near enough to the surface of cons ciousnes s s o that it could be modified and reevaluated in light of reality. T his method the clas sic ps ychological treatment from more ps ychodynamic forms of psychotherapy. T he patient is unaware of the repress ion of the forces conflict and the ps ychic mechanisms of defens e the us es . B y isolating the bas ic problem, the patient has protected her- or himself against what s eems, from the patient's view, to be unbearable suffering. No matter it may impair functioning, the neurosis s eems preferable to the emergence of unacceptable wis hes ideas . All the forces that permitted the original are thus mobilized once again in the analys is as a res is tance to this threatened encroachment on territory. No matter how much the patient may cons ciously with the therapist in the analys is, and no matter how painful the neurotic symptoms may be, the patient automatically defends agains t reopening of old wounds with every s ubtle resource of defense and res is tance available. In dis cuss ing the analytical proces s, one must clarify basic distinction between the analytical proces s and analytical s ituation. T he analytical proce s s refers to the regress ive emergence, working through, interpretation, and res olution of the trans ference neurosis. T he s ituation, however, refers to the s etting in which the analytical process takes place, specifically the relations hip between patient and analyst bas ed on the therapeutic alliance. 626 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T he regress ion induced by the analytical situation (instinctual regres sion) allows for a reemergence of infantile conflicts and thus induces formation of a transference neuros is . In the class ic transference the original infantile conflicts and wishes become on the pers on of the analyst and are thus and relived. In the analytical regres sion, earlier infantile conflicts are revived and can be s een as a the repetition compulsion. R egres sion has a dual from one point of view, it is an attempt to return to an earlier state of real or fantasy gratification, but from another point of view, it can be seen as an attempt to master previous traumatic experience. T he regres sion the analytical s ituation and the development of transference are preliminary conditions for the mas tery unresolved conflicts. T hey can also represent and unconscious wis hes to return to an earlier s tate of narcis sistic gratification. T he analytical process must its elf out in the face of this dual potentiality and tension. If the analytical regress ion has a des tructive potentiality (ego regres sion) that mus t be recognized and guarded agains t, it also has a progres sive potentiality for and reworking infantile conflicts and for achieving a reorganization and consolidation of the pers onality on a more mature and healthier level. As in any crisis, the risk of regres sive deterioration mus t be agains t the promise of progres sive growth and T he therapeutic importance of the criteria of can be easily recognized becaus e patients who are to achieve the progres sive potentiality of the analytical regress ion cannot be expected to realize a good therapeutic res ult. T he determining element within the 627 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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analytical s ituation against which the regress ion must balanced and by which the destructive or cons tructive potential of the regres sion can be meas ured is the therapeutic alliance. A firm and stable alliance offers a buffer against exces sive (ego) regres sion and also basis for pos itive growth.

The A nalytic al R elation T he analytical or therapeutic relation is compounded of least three components that are coexistent, mutually interacting and influencing, and intermingled at all in the analytical process . Although cons tantly to influence the patterns of interaction between analyst and patient and determining the cours e of the proces s, they can be us efully distinguished in that they point to differentiable is sues and aspects of the therapeutic proces s and call for different therapeutic res ponses and interventions . T hey are the trans ference and countertransference, the therapeutic alliance, and real relation.

TR ANS FE R E NC E T hrough free as sociation, hidden patterns of the mental organization that may be fixated at immature levels and refer to events or fantas ies in the patient's private experience are brought to life and activated in relation with the analyst. In the s imples t model of transference, the analyst is gradually invested with emotions us ually ass ociated with significant figures in past. T he patient dis places or projects feelings directed toward thes e earlier objects onto the analys t, then becomes alternately a friend or enemy, one who 628 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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nice or frustrates needs and punishes, or one who is or hated as the original objects were loved or hated. Moreover, this tendency pers is ts so that, to an extent, the patient's feelings toward the analys t feelings toward the specific people being talked about more accurately, those about whom the patient's unconscious is talking. T his transference object acts as lens through which the patient views the analyst, him or her in the image of the trans ference As unresolved childhood attitudes and feelings emerge and begin to function as fantasized projections toward analyst, he P.741 or s he becomes for the patient a phantom compos ite figure repres enting various important people in the patient's early environment or objects represented in or her inner world. T hos e earlier relations hips are reactivated with s ome of their original affective vigor, expos ing in some degree the roots of the patient's disturbance. T he concept of transference has cons iderable elaboration over time, res ulting in multiple variants, broadening its connotations to include every emotional connection to the analyst, and extending the transference model to encompas s the widening range ps ychopathology addres sed by ps ychoanalys is . in transference and their des criptions are contained in T able 6.1-5. Unders tanding trans ferences requires exploration of mechanisms involved in their formation their dynamic interactions . T he bas ic mechanisms by which trans ferences are effected—displacement, projection, and projective identification—are des cribed 629 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T able 6.1-6.

Table 6.1-5 Trans ferenc e Libidinal transferences    F ollow the class ic model and us ually in milder forms as pos itive trans fe rence re actions but can the form of more intens e and disturbing erotic trans fe rences . T hey are derivatives of phalliclibidinal impulses and may be permeated by pregenital influences. T hey may occur with varying degrees of intens ity and in mild forms not even require interpretation if they contribute and s upport the therapeutic relation. S igmund recommended that they call for interpretation only when they begin to serve as a res is tance. Aggress ive transferences    T ake the form either of negative or more pathological paranoid transferences . Negative trans fe rences are seen at all levels of ps ychopathology but may predominate in s ome borderline patients who tend to s ee the relations hip in terms of power and victimization, regarding the therapist as omnipotent and whereas the patient experiences him- or hers elf helpless , weak, and vulnerable. However, 630 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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transferences are identifiable in varying degrees all analyses and usually require specific and interpretation. T ransferences of defense    Oppos ed to trans fe rences of impuls e ; defense agains t impuls es finds its way into the rather than the impuls es themselves. In this form transference, attention shifts from drives to the defens ive functioning so that trans ference is no longer merely repetition of instinctual cathexes includes as pects of ego functioning as well. T ransference neuros is    Involves the re-creation or more ample of the patient's neurosis enacted anew within the analytical relation and at leas t theoretically as pects of the infantile neurosis. T he neuros is usually develops in the middle phase of analysis, when the patient, at firs t eager for improved mental health, no longer cons is tently displays s uch motivation but engages in a continuing battle with the analys t over the desire attain some kind of emotional satisfaction from analyst so that this becomes the most compelling reason for continuing analys is. At this point of the treatment, the transference emotions become important to the patient than alleviation of dis tress 631 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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sought initially, and the major, unresolved, unconscious problems of childhood begin to dominate the patient's behavior. T hey are now reproduced in the trans ference, with all their pentup emotion.    T he trans ference neurosis is governed by three outstanding characteris tics of ins tinctual life in childhood: the pleas ure principle (before effective reality testing), ambivalence, and repetition compuls ion. E mergence of the transference is us ually a s low and gradual process , although in certain patients with a propens ity for trans fe rence re gre s s ion, particularly more hysterical patients , elements of transference and trans ference may manifes t thems elves relatively early in the analytical process . One situation after another in life of the patient is analyzed and progress ively interpreted until the original infantile conflict is sufficiently revealed. Only then does the transference neuros is begin to s ubs ide. At that termination begins to emerge as a more central concern.    C ontemporary opinion is divided as to its importance and centrality, whether it forms to the extent F reud believed, and whether it is for success ful analysis —for some, it remains an es sential vehicle for analytical interpretation and therapeutic effectivenes s; for others , it may never

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develop or, to the extent that it does , may play a central role in the proces s of cure. T ransference psychosis    Occurs when failure of reality testing leads to of self–object differentiation and diffus ion of self object boundaries . T his may reflect an attempt to fus e with an omnipotent object, investing the s elf with omnipotent powers as defense agains t underlying fears of vulnerability and T ransference psychosis may als o include transference elements in which fusion carries the threat of engulfment and loss of self that may precipitate a paranoid trans fe rence re action. Narciss is tic transferences    C larified by Heinz K ohut (1971) as variations of patterns of projection of archaic narcis sistic configurations onto the therapist. T hey are based projections of narciss istic introjective both s uperior and inferior—the superior form reflecting narcis sistic s uperiority, grandiosity, and enhanced self-es teem, and the inferior oppos ite qualities of inferiority, self-depletion, and self-es teem. T he therapist comes to represent, in K ohut's terms , either the grandios e s elf in mirror trans fe rences or the idealized parental imago in ide alizing trans fere nce s . In idealizing 633 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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all power and s trength are attributed to the object, leaving the subject feeling empty and powerles s when s eparated from that object. with the idealized object enables the subject to regain narcis sis tic equilibrium. Idealizing transferences may reflect developmental disturbances in the idealized parent imago, particularly at the time of formation of the ego by introjection of the idealized object. In some individuals , narciss istic fixation leads to development of the grandiose self. R eactivation analysis of the grandiose s elf provides the bas is formation of mirror trans ferences, which occur in three forms : archaic merge r trans fe rence , a les s archaic alter-ego or twins hip trans fe rence , and trans fe rence in the narrow s e ns e . In the most merger trans ference, the analyst is experienced as an extension of the subject's grandios e s elf thus, becomes the repos itory of the patient's grandiosity and exhibitionism. In the alter-ego or twinship transference, activation of the grandios e self leads to experience of the narciss is tic object similar to the grandiose self. In the most mature of mirror transference, the analyst is experienced a s eparate pers on but, nonetheles s, one who becomes important to the patient and is accepted by him or her only to the degree that he or s he is res ponsive to the narcis sistic needs of the reactivated grandios e s elf.

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S elfobject transferences    R epres ent extens ions of the s elf-ps ychology paradigm beyond merely narcis sis tic T he selfobject involves investment of the s elf in object s o that the object comes to serve a s elfsustaining function that the self cannot perform its elf—either in maintaining fragile s elf-cohes ion in regulating self-es teem. T he other is, thus , not experienced as an autonomous and separate or agency in its own right but as pres ent only to serve the needs of the self. T ransference in this reflects a continuing developmental need that satis faction in the analytical relation.    S elfobject trans ferences reflect the underlying need s tructure the patient brings to the relations hip bas ed on the predominant pattern of selfobject deprivation or frus tration and the corres ponding seeking for the appropriate form of selfobject involvement. T hes e configurations been described as the unders timulated s e lf, the overs timulate d s elf, the overburdene d s elf, and fragme nting s e lf. Other des criptions of s elfobject need translate patterns of trans ference based on narciss is tic dynamics into the of the relationship between self and s elfobject, as mirror-hungry pers onalities and ideal-hungry personalities . V ariations on the mirroring transference theme include the alter-ego–hungry

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personality, the merger-hungry personality, and, contrast, the contact-shunning pers onality. In transferences derived from s uch pers onality configurations, the clas sic meaning of has undergone radical modification. R ather than displacements or projections from earlier object relational contexts, the patient brings to bear a based in his or her own currently deficient and defective character s tructure—a need to the object in a dependent relationship to or s tabilize his or her own ps ychic integration. T ransitional relatedness    T his transference model is based on Donald Winnicott's notion of the trans itional object. T ransference in more primitive character is regarded as a form of trans itional obje ct which the therapist is perceived as outside the but is inves ted with qualities from the patient's archaic s elf-image. T he transference field in this is envis ioned as a transitional s pace in which the transference illus ion is allowed to play itself out. T ransference as psychic reality    R eflects the need of each participant in analysis draw the other into a s tance corres ponding to his her own intrapsychic configuration and needs as reflection of the individual subject's psychic 636 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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T his regards the clas sic view of transference, on dis placement or projection from past objects, inadequate, res ulting in further diffus ion of of trans ference as equivalent to the individual's capacity to create a meaningful world or to inform the world with meaning. In this rendition, transference becomes equivalent to the patient's ps ychic reality s o that any dis tinction between the meanings given to reality and the meanings inherent in transference are lost. T ransference in these terms becomes all-encompas sing, and whatever dis tinguishing and dynamic s ignificance may have had fades into obscurity. In this form of transference, there does not s eem to be any definable mechanis m at work other than involved in the subject's psychic reality. T he view of his or her environment and his or her impres sion of objects of his or her experience, including the analytical object, are from ordinary cognitive and affective proces ses characterizing his or her involvement and res ponsiveness to the world about him or her. T ransference as relational or intersubjective    T he relational or intersubjective view of transference as emerging from or cocreated by subjective interaction between analyst and analysand transforms transference into an interactive phenomenon in which individual

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intraps ychic contributions from either participant are obs cured. T rans ference in this sense is not anything individual to or intrapsychically derived from the patient but is based on the pres ent ongoing interaction between analys t and patient coconstructing trans ference. On these terms , analysis of transference has little to do with past derivatives and everything to do with the ongoing relation with the analyst, primarily in the form of interpersonal enactments . T ransference in this is no longer a one-person phenomenon but a two-person transference–countertransference interaction. T he s upposition is that there is no thing as trans ference without countertrans ference and no such thing as countertransference without transference. T he patient is thus relieved of any burden of a pers onal dynamic unconscious reflecting developmental viciss itudes and of a life history. T ransference is created anew in immediacy of present analytical interaction as the product of mutual influence and communication between analys t and analysand, probably relying some form of mutual projective identification to sustain the interactive connotation.

Table 6.1-6 Trans ferenc e Mec hanis ms 638 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Dis placement    T he basic mechanis m of class ic transference paradigms in which an object representation from any level or combination of levels of the subject's developmental experience is dis placed the representation of the new object, namely, the analyst, in the therapeutic relations hip. Dis placement is the bas ic mechanis m for based transferences , both positive and erotic, as as for aggress ive and es pecially negative transferences . B y and large, displacement transferences tend to play a more dominant role neurotic disorders in which phallic-oedipal (and to less er degree pre-oedipal) dynamics tend to play dominant, although not exclus ive, role. P rojection    P rocess by which qualities or characteristics of self-as -object, us ually involving introjections or representations, are attributed to an external and the subs equent interaction with the object is determined by the projected characteris tics. the analyst/object may be s een as sadis tic—that as poss ess ing the sadis tic character of the analysand/s ubject, an aspect of the s ubject's s elf is denied or dis owned by the subject. P rojection tends to play a more prominent, although again 639 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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exclusive, role in formation of transferences in primitive character dis orders but can be found in variously modified forms throughout the s pectrum of neuroses. B ecause projections derive primarily from the configuration of introjects cons tituting patient's s elf-as -object, the effect of projective or externalizing transferences is that the image of therapist comes to repres ent part of the patient's own s elf-organization rather than simply an object representation.    P rojections derived from destructive introjects provide the basis for both negative and paranoid transference reactions . T hos e based on the victim/introject res ult in the patient relating to the therapist as his or her victim and him- or hers elf as suming a hos tile or s adistic pos ition as a destructive aggress or or victimizer to the victim. T hen again, projection based on the aggres sor/introject results in the patient relating the therapist as an aggres sor and him- or herself as suming a weak, vulnerable, or mas ochis tic in which he or she becomes a pass ive and victim to the therapist's des tructive aggress ion. S imilar patterns can take place around is sues involving introjective configurations of narcis sistic s uperiority and inferiority.    However, projective dynamics in s elfobject transferences seem to involve more than

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projections becaus e these forms of transference tend to draw the analyst into meeting the pathological needs of the s elf. If anything is projected, it is an infantile wis hed-for imago, one lacking earlier in the patient's experience, as , for example, an empathic and idealized parental On the other hand, trans itional transferences , despite their considerable overlap with s elfobject phenomena, tend to involve a more explicit projective element as the s elf-related contribution the transitional experience. P rojective identification    T he concept of projective identification was first propos ed by Melanie K lein, arguing that the projection of impuls es or feelings into another person brought about an identification with that person bas ed on attribution of one's own qualities that other. T his attribution served as the bas is for sens e of empathy and connection with the other. these terms, projective identification was a taking place solely in the mind of the one    P rojective identification is often appealed to as mechanism of trans ference, or more exactly transference–countertransference interactions , particularly in K leinian usage. C onfus ion arises the failure to clearly distinguish between and projective identification. T he notion of

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projective identification added to the bas ic of projection the notes of diffusion of ego boundaries , a los s or diminis hing of self–object differentiation, and inclusion of the object as part the self.    Later elaborations of the notion of projective identification transformed it from a one-body to a two-body phenomenon, describing interaction between two s ubjects , one of whom projects something onto or into the other, whereon the introjects or internalizes what has been projected. Ins tead of the projection and introjection taking place in the same s ubject, the projection now place in one and the internalization in the other. latter usage has led to extensive extrapolation of concept of projective identification to apply to object relations of all s orts , including T he emphasis in K leinian transference is les s on influence of the pas t on the pres ent but rather the influence of the internal world on the external in here-and-now interaction with the analys t.

P.742

C OUNTE R TR ANS FE R E NC E If the patient is capable of trans ference in the analytical interaction, the analyst is correspondingly capable of 642 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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countertransference, meaning that the analys t engages the interaction with his or her own burden of elements coming from his or her own developmental past or elements that may be activated in the course of his or interaction with the patient, es pecially in res pons e to patient's transference. Originally, countertransference a matter of a res ponse in the analys t's unconscious affecting his or her view of and reaction to the patient, recent views tend to see it as encompas sing the total affective res ponse of the analyst to the patient, whether cons cious or unconscious, and as reflecting more res ponses arous ed in the present interaction with the patient than influences coming from the analyst's pas t experience or uncons cious . When patient transference and analys t countertransference are caught up in an interaction, res ult is a transference–countertransference E arly views of countertrans ference saw it as interfering the work of the analys is , as it may often do, but recent revis ions have emphas ized the contributions to more effective analytical work arising from attention to and of countertrans ference res pons es in the course of an analysis. C ountertrans ference has thus become as inevitable and not necess arily destructive to the analytical process . T he author's opinion is that it is insofar as it reveals unconscious factors that would otherwis e remain hidden but that therapeutic and effect cannot be achieved through countertransference as s uch but only through the us e made of it from the vantage point provided through the therapeutic alliance. If the therapis t finds him- or herself annoyed at a patient, it is not therapeutically 643 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to express or act out the annoyance on the patient. it is useful to analyze the s ources of the anger in his or past experience and find a cons tructive way to deal in relation to the patient.

THE R APE UTIC AL L IANC E T he therapeutic alliance is bas ed on the one-to-one collaborative relations hip that the patient establishes in interaction with the analyst. T his interaction deals with those aspects of the therapeutic relation that enable patient and analyst to engage meaningfully and productively in the analytical process with the objective achieving therapeutic benefit for the patient. T he terms the alliance are negotiated between analyst and obviously, not any terms of their working together do only thos e that can predictably contribute to or s et the stage for their effectively working together. T he alliance these terms includes at least the following elements : empathy, trust, autonomy, respons ibility, authority, freedom, hones ty, and neutrality. All these elements pertinent to the role of the patient in analysis as to the analyst. T he therapeutic alliance allows a s plit to take place in patient's ego—that is , the observing part of the ego can ally its elf with the analyst in a working relations hip, which allows it to gradually identify with the analys t in analyzing and modifying defens es put up by the defensive ego against internal danger situations . Maintenance of this therapeutic s plit, well as the relationship to the analyst involved in the therapeutic alliance, requires maintenance of s elf– differentiation, tolerance and mastery of ambivalence, 644 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the capacity to dis tinguish fantasy from reality in the relations hip. In many analyses, consequently, the requires work and effort to es tablis h and can thus one of the objectives of the analytical work. In no cas e the alliance be taken for granted P.743 or ass umed because the propens ity of all patients to various s ubtle forms of misalliance is pervas ive. If they not carefully looked for and attuned to, s uch can easily dis tort the cours e of an analys is and only become apparent when they reach a point of cris is or impas se. In more severely dis turbed pers onalities, a greater tendency to dis ruptions of the alliance rather than mis alliances , which can destroy an analytical and often require extreme efforts to salvage the Maintenance of the therapeutic alliance requires that patient be able to differentiate between the more and the more infantile as pects of the experience in relations hip to the analyst. T he therapeutic alliance a double function. On one hand, it acts as a s ignificant barrier to excess ive regress ion of the ego in the proces s; on the other hand, it s erves as a fundamental as pect of the analytical s ituation, against which the feelings, and fantas ies evoked by the transference can be evaluated, meas ured, and interpreted. In many pathological conditions —some character neuroses, borderline pers onalities , and more s evere neurotic disorders —it may be difficult to maintain a clinical distinction between therapeutic alliance and the transference neuros is . T he therapeutic alliance derives from the mobilization 645 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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specific ego resources relating to the capacity for relations and reality tes ting. T he analyst mus t direct attention toward eliciting the patient's capacity to es tablis h s uch a relations hip that is able to withstand inevitable distortions and regres sive as pects of the transference neuros is . It is inevitable that the features of the therapeutic alliance be carefully and unders tood and ultimately integrated with the analysis of the trans ference neuros is. T his point is particularly and graphically displayed in the analysis of hysterical patients . T he initial transference neuros is of patients tends to pres ent primarily oedipal material, but analysts have learned to appreciate the importance of underlying oral factors in the genes is of many disorders . In the terminal stages of analys is of these patients, it becomes increasingly clear that res olution oedipal conflicts depends on the s uccess ful analys is of earlier conflicts stemming from the pregenital level of development. S pecifically involved are conflicts , us ually an oral level, that are related to achieving early object relations and the acceptance of reality and its T hese elements, however, are s pecifically thos e that the developmental basis of the therapeutic alliance.

R E AL R E L ATION R eality pervades the analytical relationship. On one there is the reality of the pers onalities and of analys t and analysand; on the other, there are the realities of time, place, and circums tance external to analytical s etting but constantly influencing the course the analytical relation. T hese include realities of the location of the analyst's office, the phys ical the furniture and decorations in the room, the 646 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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geographical location itself, and even how the analys t dress es; they all have their effects in the analytical and influence how the P.744 patient experiences the pers on of the analyst. T he surrounding circums tances that create the framework the analytical effort—the patient's financial s ituation, marital s tatus, and job demands ; arrangements for payment of the fee; whether the patient has ins urance what kind; what kinds of press ures are pus hing the into treatment; accidental factors such as illness , interfering obligations —are reality factors extrinsic to analysis but exercis ing significant influence on the analytical relations hip and how it is es tablis hed and maintained. T he most important and central reality for the patient is the person of the analys t. E very analys t has his or her cons tellation of personal characteris tics, including manneris ms , style of behavior and speech, habits of gender, way of going about the task of managing the therapeutic s ituation, attitudes toward the patient as a human being, prejudices , moral and political views , and personal beliefs and values. T hes e are all relevant of one's real exis tence and personality as a human T hey are realities that play a role in the therapeutic relations hip and are entirely dis tinct from transference countertransference. In terms of the analytical process , none of this is lost on the patient who is observant of and s ensitive to the smallest details of the analyst's real pers on. T he same considerations operate from the s ide of the analyst in relation to the patient. 647 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Tec hnic al A s pec ts T he analytical technique is always adapted to the idios yncras ies of the patient's developmental needs , and defens ive cons tellation. Analytical do not stand in is olation but are part of a living, proces s that is intended to induce and achieve internal ps ychic growth.

FR E E AS S OC IATION T he corners tone of the psychoanalytic technique is free as sociation. T he patient is encouraged to use this as far as pos sible throughout the treatment. T he function of free as sociation, besides obvious ly content for the analys is , is to help to induce the regress ion and relatively pass ive dependence with es tablishing and working through the trans ference neuros is . T hus, free ass ociation is conjoined with the techniques that induce such regres sion, namely, lying the couch, not being able to see the analyst, and conducting the analysis in an atmos phere of quiet and res tful tranquility. One als o cannot simply regard the proces s of free as sociation as s omething that takes place in is olation the patient. In fact, the proces s is more complex, more difficult to conceptualize, and increasingly mus t be the context of and in reference to the more relations hip between analyst and patient. T he patient's free as sociating is a function of the more basic relations hip. Moreover, it is increasingly clear from a contemporary perspective that much more is required patient than s imply free as sociating. It is not enough for 648 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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the patient to lay back and allow s elf-surrender to a position of pass ive dependency within the analytical relations hip without at the same time being able to mobilize basic ego res ources in the service of mastery, gaining insight, mobilizing executive and synthetic capacities, and, ultimately, being able to as sume a less pass ive and more active and autonomous function the analytical relations hip. Obviously, there is a in the mobilization of thes e capacities in the patient, varies from phas e to phase of the analytical process .

R E S IS TANC E T he most conscientious efforts on the part of the say everything that comes to mind are never succes sful. No matter how willing and cooperative the patient may be in attempting to free ass ociate, the res is tance are apparent throughout the course of every analysis. T he patient paus es abruptly, corrects him- or herself, makes a slip of the tongue, s tammers , remains silent, fidgets with s ome part of clothing, asks irrelevant questions , intellectualizes , arrives late for finds excus es for not keeping them, offers critical evaluations of the rationale underlying the treatment method, s imply cannot think of anything to s ay, or even cens ors thoughts that do occur and decides that they banal or uninteres ting or irrelevant and not worth mentioning. T he development of resis tance in the analysis is quite automatic and independent of the patient's will as the development of the transference itself. T he s ources of res is tance are just as uncons cious as sources of transference. T he emotional forces, however, that give 649 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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to resistance us ually are defending against thos e producing the trans ference. T hus, res is tances tend to emerge more in the middle phase of the analys is, in regress ive emergence of the trans ference is a central concern. T he analys is becomes a recurring field of between the tendencies toward transference and those toward res is tance, manifes ted by the involuntary inhibition of the patient's efforts to ass ociate freely. T his inhibition may las t for moments or days or may pers is t through the whole course of the analys is . R es istance may take place in all phases of the its quality and significance are different depending on analytical task at hand. In any case, the patient's enables the analys t to evaluate and become familiar the defens ive organization of the patient's ego. In this the pattern of resistance not only offers valuable information to the analys t but also offers a channel by which the patient can be approached therapeutically. T he significance of this basic conflict is clear. It is a repetition of the very same s exuality–guilt conflict that originally produced the neuros is its elf. T ransference may be a form of resistance, in that the wis h for gratification in the analys is can circumvent and es sential goals of treatment. C onsequently, the res is tance, particularly trans ference res is tance, is one the analyst's primary functions . It als o accounts in cases for the extended time period required for ps ychoanalytic treatment. No matter how s killful the analyst, res is tance is never absent. In the light of relational and intersubjective on the analytical proces s, the concept of resistance fallen out of favor in that any s uch phenomenon is a 650 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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byproduct of the interaction between analyst and T here is, then, no resistance coming from the patient rather is contributed by both participants . R es is tance only be dealt with by examining the interaction caus ing and not by interpretation of the patient's defens es . T his point of view remains highly controvers ial.

INTE R PR E TATION Interpretation is the chief tool of the analys t in efforts to reduce uncons cious res is tance. As mentioned earlier, the early stages of the development of psychoanalytic therapeutic techniques, the sole purpos e of was to inform the patient of his or her unconscious Later, it was des igned to help the patient understand res is tance to s pontaneous self-awarenes s. In current ps ychoanalytic practice, the analyst's function as interpreter is not limited to s imply paraphrasing the patient's verbal reports but, rather, to indicating at appropriate moments what is not reported or is implicit what is reported. C ons equently, as a general rule, analytical interpretation does not produce immediate symptomatic relief. On the contrary, there may be a heightening of anxiety and an emergence of further res is tance. If a correct interpretation is given at the proper time (mutative interpretation), the patient may react either immediately or after a period of emotional s truggle which new as sociations are offered. T hese new as sociations often confirm the validity of previous interpretations and add s ignificant additional data, thus disclos ing motivations and experiences of the patient of which the analys t could not previously have been 651 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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G enerally s peaking, P.745 it is not so much the analyst's insight into the patient's ps ychodynamics that produces progress in the analys is it is the patient's ability to gain this insight the analyst can facilitate this proces s by reducing unconscious resis tance to s uch self-awarenes s appropriate, carefully timed interpretation. T he most effective interpretation is timed so that it is given by the analyst in s uch a way as to meet the emerging, if and half formed, awarenes s of the patient. T hus , the analyst mus t gauge the capacity of the patient at any given moment to hear, as similate, and integrate the content of a given interpretation. Another important as pect of interpretations is that they cannot be s een in isolation from the total context of the analytic situation and the analytic proces s. An interpretation, both as given by the analys t and as received by the patient—and that includes elements of both transference neurosis and therapeutic alliance— takes place within the context of the therapeutic relations hip. T hus, the giving and receiving of interpretations are cloaked with a series of meanings unavoidably influence both the capacity of the patient accept and integrate interpretations and the analys t's sens e of offering and providing such interpretations. E xperience has s hown that, at best, the therapeutic benefits produced by virtue of the analyst's unilaterally provided insights are only temporary. T hose interpretations are most effective and of lasting therapeutic value that are arrived at by the delicate 652 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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dialectic arising from the mutually facilitated and awarenes s of both patient and analyst.

MODIFIC ATIONS IN TE C HNIQUE S T here are no shortcuts in psychoanalytic treatment. P sychoanalytic treatment typically extends over a of years and requires interminable patience on the part both analyst and patient. R igid adherence, however, to fundamental principles of psychoanalytic technique is impos sibility. F or example, the immediate situation may be s o serious for the patient that the must pay commons ens e attention to its practical implications. T hose patients whose early childhood extraordinarily deficient in love and affection so that have a basic developmental defect in their capacity for one-to-one relations hip and, consequently, in their capacity to sus tain a therapeutic alliance must be given more s upport and encouragement than usually by strict ps ychoanalytic technique. T he analyst's role in the early s tages of analysis in to es tablis h the therapeutic alliance is of particular importance. As noted, with the primitive patients, the es tablis hing of a therapeutic alliance can be the more significant aspect of the treatment proces s and can persis t as a problem through most of the analys is. es tablis hing the therapeutic alliance for mos t patients is significant aspect of the analytic process . T he nature and the degree of the analys t's active intervention in the opening hours of analys is are s till matters of considerable dis cuss ion and controversy. transference neuros is us ually develops only gradually, that attempts at premature interpretation in the early 653 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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hours may not be productive and may even be counterproductive. T his has tended to foster the us e of prolonged silences , lack of responsivenes s, rigidity, relative lack of participation in the analys is on the part the analyst, as if any reference to the analytic situation to the pers on of the analyst or to the patient's feelings about the analys t was to be taken as contrary to developing a transference interpretation and, thus, to avoided. Often, however, s erious problems in the subs equent s tages of analysis of the transference can due to a failure to es tablis h a meaningful alliance in the initial s tages of treatment. T hus, suitable interventions the analyst in the early stages of treatment can help patient in es tablishing such a meaningful therapeutic alliance. P atients who are more borderline or very narciss is tic es tablis h a strong personal tie and strong feelings of attachment and relations hip with the analys t before can develop sufficient interes t and motivation for treatment. Moreover, s uch a s trong object tie with the analyst for these more primitive patients is an absolute neces sity if the destructive effects of excess ive are to be avoided. Development of sufficient trust is es sential for these patients if they are to establish any meaningful alliance. T hes e are difficult problems, because experience also sugges ts that every deviation from analytic technique that such special conditions compel tends to prolong the length of treatment and to cons iderably increase its viciss itudes and problems. S uch modifications in analytical technique us ually go under the heading of “parameters ,” and they remain a cons iderable source of dis cus sion and controversy 654 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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analytical therapis ts. A significant trend today is the increasing tendency of analys ts to treat more difficult complex cases ; thus , the neces sity for introducing modifications in various aspects of the treatment corres pondingly increas es . As a res ult, what might previous ly have been thought of as parameters are increasingly accepted as valid technical practices . T he res olution of such difficulties in as sess ing and modifications of techniques mus t ultimately rest on the basis of clinical experience.

R es ults of Treatment T he therapeutic effectivenes s of ps ychoanalys is problems in its evaluation. Impartial and objective are handicapped in attempts to apprais e therapeutic res ults by the fact that s o many patients state that they have been analyzed when no s uch procedure was, in undertaken or when it was undertaken by s omeone us ed the title of analys t and who had little of analytical s cience and technique. Other patients been in analysis only for a very short time and then discontinued treatment on their own initiative or were advis ed that they were not suitable candidates for analytical treatment. E xcept for ps ychoanalys ts thems elves , profes sionals, as well as lay people, demonstrate varying degrees of confusion as to what ps ychoanalys is is and what it is not. No analyst can ever eliminate all the personality and neurotic factors in a given patient, no matter how thorough or success ful the treatment. Mitigation of the rigors of a punitive s uperego, however, is an es sential criterion of the effectivenes s of treatment. 655 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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do not us ually regard alleviation of s ymptoms as the significant aspect in evaluating therapeutic change. absence of a recurrence of the illnes s or a further need ps ychotherapy is perhaps a more important index of value of ps ychoanalys is . T he chief bas is of evaluation, however, remains the patient's general adjus tment to life—that is , the capacity for attaining reas onable happines s, for contributing to the happines s of others, ability to deal adequately with the normal viciss itudes stress es of life, and the capacity to enter into and mutually gratifying and rewarding relationships with people in the patient's life. More s pecific criteria of the effectivenes s of treatment include the reduction of the patient's uncons cious; neurotic need for s uffering; reduction of neurotic inhibitions; decreas e of infantile dependency needs ; an increas ed capacity for respons ibility and for relations hips in marriage, work, and social relations. important criteria are the capacity for pleas urable and rewarding sublimation and for creative and adaptive application of the patient's own potentialities . T he most important criterion of the s ucces s of treatment, the releas e of the patient's normal potentiality, which been blocked by neurotic conflicts, for further internal growth, development, and maturation to mature personality functioning. Des pite the methodological difficulties and complexities outcome s tudies , extens ive empirical evaluations from number of centers P.746 have demons trated the effectivenes s and relative 656 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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of psychoanalysis and ps ychoanalytic therapy for appropriately s elected cases in the ps ychoneurotic conditions, pers onality disorders , and forms of s elfpathology. T herapeutic outcomes have been more guarded in cas es of ps ychosomatic illness , more levels of personality dis order, and ps ychoses .

S UG G E S TE D C R OS S T he ps ychoanalytic perspective is relevant to virtually every chapter of this book. Of particular interes t are the discuss ion of E riks on in S ection 6.2, other schools in S ection 6.3, and approaches derived from ps ychology and philosophy in S ection 6.4. Neurodevelopmental theory of s chizophrenia is S ection 12.5. P s ychological treatments of mood are covered in S ection 13.9; anxiety dis orders in 14; personality dis orders in C hapter 23; psychoanalys is ps ychoanalytic ps ychotherapy in S ection 30.1; of psychotherapy in S ection 30.11; and psychotherapy with the elderly in S ection 51.4h.

R E F E R E NC E S B alint M. P rimary L ove and P s ycho-Analytic New Y ork: Liveright; 1965. B lum HP : Mas ochis m, the ego ideal, and the of women. J Am P s ychoanal As s oc. 1976;24 Diamond D, B latt S J : Attachment res earch and ps ychoanalys is. 1. T heoretical considerations . 2. implications. P s ychoanal Inquiry. 1999;19:4–5. 657 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Diamond D, B latt S J , Lichtenberg J : Attachment res earch and ps ychoanalys is . 3. F urther reflections theory and clinical experience. P s ychoanal Inquiry. 23(1). E rikson E H. C hildhood and S ocie ty. New Y ork: 1963. E rle J B , G oldberg DA: T he cours e of 253 analyses selection to outcome. J Am P s ychoanal As s oc. 2003;51:257. F airbairn W R D. P s ychoanalytic S tudies of the London: R outledge and K egan P aul; 1972. *F enichel O. T he P s ychoanalytic T he ory of Y ork: Norton; 1945. F reud A. T he ego and the mechanisms of defense. T he W ritings of Anna F re ud. V ol II. 1936. New Y ork: International Universities P res s; 1975. F reud S . O n Aphas ia: A C ritical S tudy. New Y ork: International Universities P res s; 1953. *F reud S . T he S tandard E dition of the C omple te P s ychological W orks of S igmund F re ud. 24 V ols. Hogarth P ress ; 1953–1974. *G reenberg J R , Mitchell S A. O bje ct R e lations in P s ychoanalytic T he ory. C ambridge, MA: Harvard 658 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Univers ity P res s; 1983. Hartmann H. E s s ays on E go P s ychology. New Y ork: International Universities P res s; 1954. Hartmann H. E go P s ychology and the P roble m of Adaptation. New Y ork: International Univers ities 1958. Hins helwood R D. A Dictionary of K leinian T hought. London: F ree Ass ociation B ooks; 1991. K ohut HS . T he Analys is of the S e lf. New Y ork: International Universities P res s; 1971. K ohut HS . T he R es toration of the S e lf. New Y ork: International Universities P res s; 1977. K ohut HS . How Doe s Analys is C ure ? C hicago: of C hicago P ress ; 1984. Levin F M. P s yche and B rain: T he B iology of T alking Madis on, C T : International Universities P res s; 2003. Loewald HW . P ape rs on P s ychoanalys is . New Y ale Univers ity P res s; 1980. Mahler MS , P ine F , B ergman A. T he P s ychological the Human Infant. New Y ork: B asic B ooks ; 1975. Mass on J M. T he C omple te L e tte rs of S igmund W ilhe lm F lie s s 1887–1904. C ambridge, MA: 659 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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Univers ity P res s; 1985. Meis sner WW . Inte rnalization in P s ychoanalys is . Y ork: International Universities P res s; 1981. *Meiss ner W W. T he T he rape utic Alliance . New Y ale Univers ity P res s; 1996. Meis sner WW . T he E thical Dile mma of Dialogue . Albany, NY : S tate University of New Y ork P res s; 2003. Mitchell S A. R elational C once pts in P s ychoanalys is . C ambridge, MA: Harvard Univers ity P ress ; 1988. *Moore B E , F ine B D. P s ychoanalys is : T he Major New Haven, C T : Y ale Univers ity P res s; 1995. R ichards AD, T ys on P : T he psychology of women: P sychoanalytic perspectives. J Am P s ychoanal 1996;44. R izzuto AM, Meis sner WW , B uie DH. T he Dynamics Human Aggres s ion: T heore tical F oundations , Applications . New Y ork: B runner-R outledge; 2004. S chafer R . As pects of Inte rnalization. New Y ork: International Universities P res s; 1968. S hapiro T , E mde R N: R esearch in psychoanalys is : P roces s, development, outcome. J Am P s ychoanal 1993;41[S uppl]. 660 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/6.1.htm

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S tern D. T he Inte rpe rs onal W orld of the Infant. New B as ic B ooks; 1985. S tolorow R , Atwood G . C onte xts of B eing: T he Inte rs ubje ctive F oundations of P s ychological L ife. Hillsdale, NJ : Analytic P res s; 1992. T yson P , T yson R L. P s ychoanalytic T he orie s of Deve lopme nt. New Haven, C T : Y ale Univers ity 1990. Winnicott DW . P laying and R e ality. New Y ork: B as ic B ooks ; 1971.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 7 - Diagnosis and P s ychiatry: E xamination of the P s ychiatric P s ychiatric Interview, H is tory, and Mental S ta tus E xa mination

7.1: Ps yc hiatric Interview, His tory, and Mental S tatus E xamination E kkehard Othmer M.D., Ph.D. S ieglinde C . Othmer Ph.D. J ohann Philipp Othmer M.D. P art of "7 - Diagnos is and P s ychiatry: E xamination of P sychiatric P atient"

INTR ODUC TION Goal of the C linic al Ps yc hiatric Interview T he goal of the initial diagnostic clinical psychiatric interview is to collect s pecific, detailed information 15 topics . T hese topics cons titute the ps ychiatric evaluation. Acquiring the databas e of information for these 15 topics enables the interviewer to make compatible with the revis ed fourth edition of Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV five axes and to develop a treatment plan acceptable to the patient: I. Identifying data. T he patient's name, s ex, age, marital s tatus, and vital s igns. 662 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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II. C hief complaint. T he chief complaint in the patient's own words . Alternatively, signs of dis ordered functioning observed by the interviewer. III. Informants . A list of all informants, their reliability, level of cooperation; also previous hospital records , available. S uch informants are es sential in circums tances that prevent the patient from adequate information. C hoos ing the right s et of informants is more important than having a great number of informants. IV . R eas on for admiss ion or cons ultation. T he referral source; in case of hos pitalization, statement of status —voluntary versus involuntary—and the why hos pitalization is the safest and least environment for treatment. V . His tory of pres ent illnes s. E arly manifestations and recent exacerbations of all ps ychiatric disorders present (Axis I and II); review of diagnoses and treatments given by other providers. V I. P sychiatric dis orders in remis sion. P s ychiatric presently in remiss ion, es pecially substance abus e disorders ; ps ychiatric disorders firs t diagnosed in childhood and adolescence and their treatments . V II. Medical his tory. All medical dis orders past and and their treatments and childhood disorders that involve the central nervous system (C NS ). F or pregnancy status —es pecially if on psychotropics or expecting the us e of ps ychotropics and precautions agains t pregnancy and concomitant treatment. On all patients, but particularly in liais on work, the medical history includes the 663 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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interrelation of medical and ps ychiatric conditions. V III. S ocial history and premorbid pers onality. E arly developmental history. Description of premorbid personality as baseline for patient's best level of functioning. Impact of Axis I and II dis orders on patient's life. T he patient's psychosocial and environmental conditions predisposing to, precipitating, perpetuating, and protecting against ps ychiatric disorders. P remorbid vers us morbid functioning. P resent s upport s ys tem. IX. F amily history. P sychiatric history of first-degree relatives , including treatment respons e as a genetic predisposition for the patient. X. Mental s tatus examination. Appearance, cons ciousnes s, psychomotor functions , s peech, thinking, affect, mood, s ugges tibility, and thought content; cognitive functions, such as orientation, memory, intelligence, and executive functions; and judgment. XI. Diagnos tic formulation. S ummary of biological, ps ychological, and s ocial factors contributing to the patient's ps ychiatric disorder. XII. Differential diagnos is . Dis cuss ion of diagnos tic based on overlapping symptomatology. XIII. Multiaxial psychiatric diagnos is . Information on all axes . XIV . Ass ets and s trengths . Inventory of patient's knowledge, interes ts , aptitudes, education, and employment status to be us ed in the treatment XV . T reatment plan and prognos is . Account of 664 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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ps ychopharmacological, ps ychological, and s ocial treatment modalities planned, frequency of visits, list of providers ; discharge criteria if inpatient. How does the interviewer get comprehensive, clinically significant, reliable, and valid information to cover points in a restricted time frame of 20 to 90 minutes? acquire the communication skills needed for this task, interviewer has to mas ter the range between disordercentered and patient-centered interviewing s tyles and apply them to the four components of the interview: rapport, techniques , mental s tatus, and diagnos ing.

Dis order-C entered vers us P atientC entered Interviewing S tyles P sychiatric interviewing is a s pecial form of human communication. T he interviewer asks the patient to disclos e complaints , s hare problems, and reveal According to the difficulties that the patient experiences with this reques t, the interviewer shifts the focus disorder-centered and patient-centered interviewing. Dis order-centered interviewing is bas ed on a atheoretical model of ps ychiatric dis orders called the me dical P .795 mode l, which is the official model s upported by the American P s ychiatric Ass ociation (AP A) and the W orld Health Organization (W HO) codified in DS M-IV -T R and the International C lass ification of Dis eas es (IC DT his framework views ps ychiatric disorders as s imilar medical dis orders, using criteria for diagnos is as 665 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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identifiable clus ters of occurrences from a res tricted of symptoms , s igns, and behaviors that caus e and mortality. E ach disorder can be differentiated from other psychiatric disorders ; each has a typical natural history, often occurs in increased frequency in firs trelatives , with specific comorbidities, and with predictable treatment respons es . Whereas the an infectious dis order is established by tests that determine the pres ence or absence of a specific agent, tes ts confirming the etiology of a diagnosis in ps ychiatric disorders are not available. E xcept for the presence of es tablis hed or s us pected genetic etiology is incomplete. S pecific genetic les ions or susceptibilities, perhaps arising through multifactorial genetic factors, which form the basis of the current paradigm of the etiology of psychiatric disorders , to be determined. T he triggers for ps ychiatric disorders remain a mys tery, as do the triggers for the onset of infectious diseas es and medical conditions . R is k present in more people than actually develop the T o establish a psychiatric diagnosis based on this descriptive medical model, the interviewer chooses proven, s ymptom-oriented, open-ended ques tions with relatively narrow s cope followed up by closed-ended, nonleading ques tions centering on the dis order. P rerequisites for this style are the knowledge of the IV -T R criteria and the 15 topics to be covered. T his disorder-centered interview style works for mos t cooperative patients , patients whose communication are not impaired by their Axis I and II dis orders or their defens e mechanisms. Disorder-centered interviewing driven by the patient's help-seeking behavior. 666 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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for dis order-centered interviewing can be acquired the firs t few years of training. In contras t, patient-centered interviewing is bas ed on intros pective model, which emphas izes the individuality the patient's experience. T his model attends to the intraps ychic battle of conflicts . It is s ens itive to the patient's educational, emotional, intellectual, and social background, the personality, and the individual cons tellations tracing their arrival to individual circums tances and the individual's unique respons e (cognitive-behavioral model). One example of the intros pective model is the ps ychodynamic model. Interviewing based on the psychodynamic model uses nonstructured, open-ended ques tions with a broad encouraging free as sociation. T he ps ychodynamic posits the etiology of psychiatric s ymptoms as to often unconscious inter- and intrapersonal conflicts . explores and interprets behaviors and s equences of answers . In this model, the interviewer strives to help patient overcome self-defeating intra- and interpersonal conflicts. T he prerequis ite for s uch an interview is the interviewer's experience and unders tanding of coping styles, the knowledge of how Axis I and II disorders interfere with the doctor–patient interaction (transference), and how to manage such interference. S witching to the patient-centered s tyle may become neces sary if the patient puts up res is tance and and becomes difficult to interview. T o acquire in patient-centered interviewing is a lifelong endeavor, training for excellence in most s ports. T he disorder-centered and patient-centered styles do not exclude each other. T hey are end points 667 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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continuum. T he interviewer's mobility and flexibility in gliding between the two extremes determine the efficiency, reliability, validity, and quality of data T he degree of the patient's impairment determines to which extent the disorder-centered interview has to be augmented by patient-centered s trategies.

Five Phas es of the Ps yc hiatric and Four C omponents T he ps ychiatric interview progres ses over time, which be arbitrarily subdivided into five phas es. T hes e cover sequentially the 15 (I to XV ) topics of the evaluation. P hase 1: W arm-up and C hief C omplaint (I to IV ) P hase 2: T he Diagnos tic Decision Loop (V ) P hase 3: His tory and Databas e (V I to X ) P hase 4: Diagnos ing and F eedback (XI to XIV ) P hase 5: T reatment P lan and P rognosis (XV ) T he five phas es divide the ps ychiatric interview longitudinally. C ros s -sectionally, the interview cons is ts four components, which the interviewer must continuously monitor and propel throughout. R apport focus es on the doctor–patient relations hip; a rapport is a prerequisite for an effective interview. is es tablis hed in the opening; with a cooperative and insightful patient, there is often little problem in es tablis hing and maintaining a good rapport. However, patients who are uncooperative or s how poor ins ight, es tablis hing a workable rapport with the patient 668 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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a central iss ue. T e chnique refers to the approaches the interviewer keep an interview “on track.” It includes s kills to appropriately select questions to arrive at a diagnosis. G ood technique is necess ary to therapeutically engage and work with difficult patients . Me ntal s tatus as sess ment captures the patient's experiences , symptoms, signs, behaviors , thought cognitive level of functioning, insight, and judgment during the actual time of the interview. F ormal testing mental s tatus may take place late in the interview; however, in a patient with a s ignificantly altered mental status —whether it be a bois terous, irritable, and uninterruptible manic patient, a minimally responsive depres sed patient, or a paranoid patient—his or her mental s tatus plays a s ignificant role in the interview. Diagnos ing pursues a progres sion in the diagnostic decis ion proces s from chief complaint to final

R A P P OR T Interviewing relies on rapport, from the F rench verb rapporte r, to bring back—that is , to bring back the res ponse to the sender. C reating this feedback interviewer and patient is the es sence of It is rooted in a s tream of nonverbal signals. Language adds precision and complexity. If the patient's mental status interferes with this interaction, the interviewer from as sess ing a disorder to managing the patient's mental s tatus —that is , the disorder-centered interview becomes patient centered.

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C entered Interviewing and R apport With a cooperative patient, the interviewer starts out in disorder-centered mode, checking whether DS M-IV -T R criteria for ps ychiatric disorders are met. He or she that the patient seeks help voluntarily and will answer questions . As the interviewer acts in a profes sional manner; does not P.796 insult or offend the patient; and asks clear, unders tandable, and relevant ques tions ; the expects the patient will res pond. R apport follows . In contras t, with a difficult patient, the interviewer shifts a patient-centered mode. T o obtain a comprehensive diagnosis and to judge the patient's capacity for staying treatment, the interviewer explicitly focuses on es tablis hing a cooperative relationship with the patient. E ight elements determine the quality of this relations hip (T able 7.1-1).

Table 7.1-1 R apport in Dis orderC entered and Patient-C entered Interviewing S tyles Dis orderE lements C entered R elations hip Interview

PatientC entered Interview

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P ers pective

T he interviewer is in charge, knows diagnostic criteria of the disorder.

P atient holds the key to the symptoms; without the patient's genuine contributions , a valid diagnosis cannot be made.

C omfort

Most patients quickly become comfortable with the interview situation; no special attention needed. Minor discomfort by the patient may be

T he patient and interviewer need to experience comfort. T he interviewer has to address tension, es pecially with anxious and suspicious patients.

E mpathy

T he interviewer as sess es symptoms and expres ses unders tanding.

T he interviewer as sess es suffering and expres ses empathy.

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Ins ight

Most patients know they a dis order.

T he patient not accept having a disorder. T he interviewer has to decreas e the distance between the patient's and the view of the patient's ps ychiatric problems .

Alliance

T he interviewer cannot diagnose or treat the illness if the patient does not tell what is wrong. the patient becomes uncooperative, the interviewer may remind the patient of that fact.

S triving for alliance sets tone of the interview. T he interviewer identifies the patient's illness as the common enemy us ing the patient's level of ins ight.

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E xpertise

T he interviewer us es a s et of DS M-IV -T R — derived generic questions to as sess ps ychiatric disorders .

T he interviewer individualizes questions the s pecific manifestations of the patient's disorders . T he patient contributes the knowledge about his or her problems . T he interviewer contributes his or her knowledge about ps ychiatric disorders and their treatment.

G uidance

Usually at the end of the interview, the interviewer discuss es the treatment plan and obtains verbal acceptance

T hroughout, interviewer defines the cooperative roles of interviewer and patient in the treatment proces s.

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from the patient. T rus t

E xpected byproduct of thorough, detailed interviewing.

R es ult of purpos eful development of several levels relating, i.e., providing comfort, empathy, insight, expertise, and guidance.

Pers pec tive Depending on the patient's behavior, the interviewer focus es his or her attention either on the diagnos tic proces s (i.e., the dis orders to be explored) or on the patient's immediate emotions and needs without the interview to turn into an ad hoc ps ychotherapy sess ion. Although the knowledge of the diagnos tic is es sential for the interviewer, their implementation requires that the patient provide genuine, detailed answers . A patient who states , “Y ou are the doctor, decide,” tries to s kirt his or her part. R ecognizing dependency needs, the interviewer corrects the view by making him or her aware of the expected input. 674 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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C omfort Many patients quickly become comfortable with the interview s ituation. However, if the patient appears anxious, is trembling, or has a moist hands hake or a pulse, the interviewer may addres s s uch discomfort indirectly: “Have you s een a psychiatrist or couns elor before? ” or directly: “Y our pulse is over 100. Is there problem with your heart? ” T he interviewer may give the patient time to calm down by offering something to or by as sess ing demographics : “Do you live in this neighborhood? ” T he interviewer als o s hould pay to his or her own comfort if the patient is intimidatingly aggres sive or demanding, offens ively flirtatious , or and addres s this problem. A 42-year-old, red-faced, married Iris hman who was accused by his wife of drinking too much entered the office accompanied by his dog, a mixed breed of wolf G erman s hepherd. T he dog circled through the interviewer's office inces santly. Interviewer (I): Mr. M., your dog distracts me from with you. C an you have the dog sit? P atient (P ): (G leaming) Are you scared? I: (T he dog keeps circling in the room and s taring at the interviewer) I know neither you nor your dog. W ould like me to be s cared? P : It depends what you will tell me. I: W hat are you scared of that I would tell you? P : T hat I'm an alcoholic and s hould s top drinking. I: (Laughing) And if I don't, you have the wolf eat me? 675 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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P : (Also laughing) I: B ut you really have to tell me. Do you want to stop drinking? P : No. I don't. I: W hat did you want to accomplis h when you came P : My wife s ays s he'll divorce me if I don't s top. I: S o you don't want to s top? Y ou jus t want to hide your drinking better? P : I gues s that's right. I: I appreciate your hones ty. Mos t people who are for drinking too much and get threatened with divorce job loss try to con me and poss ibly themselves by they want to stop. Y ou don't. If you ever want to s top, I believe you can do it becaus e you are hones t with P : (T o the dog who is s till circling the room) Molly, here. S it! (Molly obeys) I: T hank you.

E mpathy F or a s ymptom to be counted, it has to caus e the impairment or dis tres s. W hen a patient describes his or P.797 her symptoms, the interviewer can follow up by getting precis e description of duration and frequency of symptoms or, alternatively, especially if the interviewer encounters denial (“otherwis e, I'm healthy”), by as king about the impairment and dis tres s that the s ymptom caus es and express ing empathy. A 74-year-old, white, married, former chief executive 676 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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officer of a large company. P : I can't sleep. Otherwis e, I'm healthy. I wake up at 4 and can't go back to s leep. I: Do you also have problems falling as leep? P : Off and on. B ut I can handle that. I: W hat about waking up in the middle of the night? P : Once or twice. I may have to go to the bathroom. I: B esides your early morning insomnia, do you have other problems ? P : No. I'm really pretty healthy. I: Do you feel depres sed? P : No. I: Do you have any hobbies? P : I do volunteer work. I: C an you s till do it? P : Y es. I think it s erves a good purpos e. I help young entrepreneurs through the ZZZ foundation. Alternative: P : I can't sleep. Otherwis e I'm healthy. I wake up at 4 and can't go back to s leep. I: W hat does your ins omnia do to you? P : It wrecks my life. I tos s and turn in my bed. I'm tired during the day and worried about my s leep. W hen come over, I'm bored. T hey s ound so trivial. I: (Mirroring the patient's facial expres sion, frowning, lips, then bending forward) W e have to put our heads together and find a way to get rid of your problem. T he empathic, patient-centered approach invites the patient to express his or her thoughts and feelings 677 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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his or her symptoms and describe his or her actions. approach breaks through the patient's denial of being depres sed, which the descriptive, s trictly symptomgathering approach does not do. T he interviewer's res ponse reflects the patient's affect and propos es a counteraction more convincing and genuine than a statement such as, “I unders tand your s uffering.” T he empathic res ponse follows the golden rule: Imagine thinking and feeling from the patient's level of ins ight. the patient know that you can understand his or her of view and initiate caring.

Ins ight A conflict about the nature of psychiatric s ymptoms and disorders can aris e between the interviewer and the patient. Undetected or unres olved, s uch a conflict of may lead to a breakup of the doctor–patient T herefore, the interviewer has to be aware of such differences and s trive for congruency. If the patient with the interviewer's view, the therapist calls this congruency full ins ight. W ith res pect to the acute hallucinations , delus ions , and manic s ymptoms , agree that the patient has very limited ins ight into the pathological nature of these perceptions, beliefs , and behaviors . T o change the patient's view, confrontation logical arguments are ineffective. Initially, the has to emulate the patient's view and intervene at the of the patient's unders tanding. A 38-year-old, divorced, male railroad worker. P : It's coming up again, even after 20 years . T hey can't go of it. 678 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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I: Of what? P : Y ou know what, [expletive]! I: C an you help me out? P : (W ith a suspicious look) T hat I jacked off in the that hunting trip. At work, they are making digs again. I: W hat are you doing about it? P : I try to ignore it but it's getting hard. I: W ell, you are doing the right thing. don't do or say anything. don't let them know that they get to you. I will give you some medication that will make it eas ier to get over it. P : Okay. R ather than taking a dis order-centered view and telling the patient that he has a pers ecutory delus ion, which to be treated with medication, the interviewer the delus ion from the patient's viewpoint that “real” is happening to him. T his patient-centered does not challenge the patient's fals e fixed perception works on his level of ins ight, s till providing effective therapeutic intervention, a neuroleptic, and support for behavior—namely, to keep his persecutory perceptions hims elf. P atients with a pers onality dis order may recognize that certain behaviors caus e distress to family members but feel the family s hould change and be more tolerant than having to change. A 46-year-old, male, fundamental Lutheran minister. P : My wife wants a legal separation and that tears me As a minister, I s hould be able to s et an example for 679 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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congregation. I can't have that s eparation. I: W hy does s he want that s eparation? P : S he s ays I get s o angry and critical with her and the S he can't take my anger outbursts any more. I: Do you think you get angry as s he says? P : Y es. It's my job. If I feel I get excus es or my kids or wife violate commandments of C hris tian conduct, I become like G od's hot s word cutting into butter. I: Do you feel your anger is too much and out of proportion? P : No. I think it's jus tified. I: C an you not get angry if you wanted to? P : T hat's hard to do. Maybe I carry my profes sion too into my family. I: W ould it be of advantage to you if you had more of a choice to become angry or not? If you increas ed your degree of freedom? P : I probably could live with that. I: W e both have to put our minds to work on increas ing power of free will. T he interviewer dis cus ses the patient's anger outburs ts as a res ult of a narcis sistic perfectionis tic personality disorder but as a challenge congruent with the patient's needs . S uccess ful anger control can increase the narcis sistic pride and his choices while helping the relations hip at the s ame time. R apport is strengthened identifying the patient's level of ins ight and interviewing him from the patient's perspective.

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After the interviewer unders tands which s ymptoms, and behaviors the patient identifies as disordered, he she P.798 can explicitly split this part off as sick. T he interviewer explore with the patient what both can contribute to repair the s ick. B ecause the patient guards the box of his or her broken functions , he or she has to be willing to open it so that the interviewer can examine contents and dis cuss with the patient options for repair. T he interviewer stress es the need for an alliance. the patient says , “Y ou are the doctor, I do what you the interviewer may reply: “Y ou are the patient, and we both have to put our heads together to come up with best plan to s ucceed. I need your input and consent.”

E xpertis e S ome patients feel they can receive empathy and from family members and friends . S o what is the interviewer's edge? T he interviewer can provide at four things for the patient and may make him or her of that fact implicitly or explicitly. T he ps ychiatris t can acknowledge that he or she unders tands the disorder. or s he can emphasize that the patient is not alone, that others share the s ame disorder. T he interviewer can out that the patient's personality to deal with the is unique and can contribute to improve the disordered functions . He or she can appreciate the s ymptoms and signs of the dis order and the dis tres s that it caus es . He she may demons trate s uch knowledge by asking for specific s ymptoms that the patient tried to keep a 681 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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such as : I: W hom in your family have you trusted enough to your obsess ions ? P : Nobody. How do you know that I feel embarrass ed talk about it to my family? T he interviewer may give the patient feedback about is known about the dis order. P atients who read about condition in books and on the Internet may evaluate interviewer more in terms of how much he or s he than by how much he or she cares . If the interviewer not know the ans wer to a patient's question, he or she clearly s tate that he or s he does not know but, “Let's out.” S ome patients are s us picious about the interviewer's expertise but do not want to offend him or her with their distrust. If the interviewer senses reluctance, he or she explore the nature of the doubts rather than ignoring them and hoping that the patient learns to trus t him or her. T he interviewer may pass over positive feedback the patient but, as a rule, should address negative even though he or she may feel uncomfortable in doing so. T he interviewer ins tills hope. R elated to providing a perspective and giving an outlook is the interviewer's ability to emphasize the positive factors regarding the patient's disorder, such as treatability, and the patient's personality, such as intelligence, resilience, and ability self-criticize.

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P atients rank the therapis t's leadership third after and empathy. F rom the beginning of the interview, the interviewer sets milestones for the progress ion of the encounter. T he interviewer can reach s ubgoals , s uch es tablis hing rapport and collecting information for the diagnostic process with the patient's agreement and cooperation. T hus , if the interviewer reads the patient's expectations for the interview and makes his or her congruent to these expectations , he or s he steers the interview with an invis ible hand. T he more the is willing to explain his or her ques tions and and their rationale and give options , the eas ier it to guide the patient through the interview with little conflict. S pecial s ituations may arise. Dependent may s hy from res ponsibility and des ire to be nurtured the “strong, all-powerful protector.” T he oppos itional patient or the patient with persecutory feelings may get irritated by any hint of rule s etting and may rebel the interviewer. P : W hat do you ask me for? I'm paying you to s olve my problems . It really does not make me feel good that always have to as k me for my view. don't you know enough that you can do it on your own? Or is this one those ps ychobabble tricks to pretend that you need my input? With s uch a difficult patient, the interviewer may have tes t different approaches to s ecure cooperation. I: It's your problem that we are dis cuss ing. It's your to get help. It's your information that we need to make plan. S o you are part of the s olution. I can't do anything without having you on my side s o that we can both face 683 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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your problems and find out what works best to resolve them. R ight now your problem is that you can't come to agreement with me on how to tackle your problems . discuss why that is and what your thinking is . A patient's negative res ponse to the interviewer's cooperative approach may have deep-rooted of becoming dependent. S uch fear may reach far the present interview s ituation. Not all interpers onal conflicts, s uch as negative trans ference and countertransference, can be s olved in a time-efficient manner. T he patient may need medication or referral to different provider.

Trus t F rom the beginning, the interviewer shows s ens itivity to the patient's needs and comforts the patient. If the accepts such caring, the interviewer can forge a therapeutic alliance. B uilding on it, the interviewer's targeted questions prove his or her unders tanding and expertise, which qualify him or her as a guide for the patient's care. T he interviewer's res pect for the dignity allows the patient to trus t him or her. T rus t is rapport's summit.

TE C HNIQUE T he patient interacts on one of three levels with the interviewer: F irst, the patient cooperates. He or she complains about different areas of malfunctioning and suffering and seeks help. S econd, he or s he res ists, cautious , anxious, or s us picious and holding back embarrass ing, painful information. T hird, he or s he defens ive s trategies and obstructs the interviewing 684 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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proces s.

Interviewing Tec hniques for the C ooperative Patient T he majority of outpatients and voluntarily admitted inpatients cooperate. As a general principle, even with cooperative patients , the interviewer should formulate questions from the patient's vantage point and us e familiar language. T he interviewer relies on five to achieve a crisp, well-flowing dialogue: openers, clarifications, covering a topic, steering, and transitions.

Openers T o initiate the interview or to explore a new topic, the interviewer chooses ques tions of s pecific target and T he patient's res ponses s hape the follow-up questions . Opening ques tions or s tatements target a problem of varying s cope. Narrow s cope: “What troubles bring you here to see me? ” T he interviewer expects a prioritized list of difficulties . P roblem: T he patient rambles. P.799 S olution: T he interviewer narrows the s cope of the question or curbs the res pons e. F or instance: P : (R es ponds with a long lis t of events that went wrong his or her life). I: J us t tell me what problem has troubled you most the last 3 days. P : T hat I can't sleep. B road s cope: “G ive me a s ens e of how your life is 685 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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T he interviewer expects the patient to put problems symptoms into a life perspective. S uch a broad works well for an intelligent, educated patient who can condense, abstract, and prioritize his or her life experiences . It fails with a patient with obsess ivecompuls ive disorder (OC D) by confusing the patient increasing indecis iveness and anxiety. It puts a patient with bipolar dis order into overdrive. He or she may the interviewer with circumstantial details and loosely connected thoughts. B road ques tions also fail for a who gives literal ans wers. A 23-year-old, white, s ingle medical s tudent. I: W hat brought you here? P : My mother's car. A patient with ps ychotic s ymptoms or low intelligence may give s uch concrete ans wers. Inability of the interviewer to adjus t the s cope of the ques tions can disrupt the flow of the interview and threaten rapport. A s upervis ed interview (supervis or [S ]) by a res ident with a white, newlywed woman (P ) in her early thirties. (1) R : W hat's going on in your life? P : (Looking around helples sly, s hrugging s houlders , blushing) I don't know. (2) R : W ell, for ins tance, have you felt depress ed? P : Is that what you think? (3) R : No. T his is jus t an example. I wanted to know could help you. P : I don't know whether you can help me. (4) R : W hy don't you tell me what has been happening 686 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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lately in your life. P : (Hunching down in her chair) My hus band got promoted. W e bought a new hous e. (5) R : T hat's not really what I meant. P : (After a paus e) I don't really know what you mean. T he supervis or intervenes: (6) S : Well, you jus t said your hus band got promoted you are moving into a new house. Has that caused any stress for you? P : Oh yes . (7) S : Help me understand what s tres ses you out about move into a new hous e. P : I can't help him enough. I feel s o bad. (8) S : What kind of help can you not give him? P : I should be able to go out and buy things for the new house. B ut I can't. I get all choked up when I go to a (9) S : I can s ens e your frus tration. W hat bothers you the s tores ? P : T here are s o many people. When the interviewer noticed that question 1 (Q1) was broad, he or she went to the oppos ite extreme and clos ed-ended ques tion (Q2). Noticing the confusion, interviewer returned to an open-ended approach (Q3), the patient became s o anxious that she could not read intent of the ques tion. T he interviewer noticed her and reformulated Q1 but mis sed her clue in A4. After res ident voiced his frus tration (Q5), s he responded with frus tration of her own (A5). T he s upervis or intervened linking the content the patient had provided (A4) to her stress —that is , her anxiety level. T he patient's 687 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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showed the effectiveness of this intervention. An experienced interviewer monitors the effectivenes s his or her ques tions by how closely the ans wers match intent of the ques tions and adjus ts the scope of the questions .

C larific ation T o clarify an ans wer, the interviewer usually asks for specifics, probes the patient's reasoning, or offers leads .

S PE C IFIC ATION P roblem: T he patient's complaint is vague. S olution: interviewer uses s pecifying questions that focus on the Ws of interviewing: W hat? W hen? W here? W ho? Why? Alternatively, the interviewer may as k for general or examples or focus on the lates t s pecific occurrence then generalize the occurrence. A 26-year-old, white, unemployed, s ingle woman. (1) I: What kind of problems make you seek my help? P : I have many problems. (2) I: Is there any one problem that has troubled you P : (After a long hes itation) I wake up in the middle of night. (3) I: How does that trouble you? P : I really don't know. I can't explain. (4) I: What do you feel like when you wake up? P : K ind of leery. (5) I: Did you wake up las t night? 688 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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P : Y es. (6) I: What time was that? P : 3:30 AM (7) I: What did you feel? P : I don't know. J ust leery. (8) I: Did you see anything? P : (P uzzled) My cat's hair s tood up straight. (9) I: What did you hear? P : A nois e in the kitchen. (10) I: W hat is making that noise? P : I don't know. (11) I: W hat did you feel? P : A breeze. (12) I: Does this happen every night? P : J us t about. (13) I: Y ou wake up and the cat's fur stands up on end, hear the noise in the kitchen, and you feel a breeze? P : T hat's right. (14) I: S omething that makes you leery is going on and means (raising his voice) there is … ? P : A s pirit. A spirit lives in my place. P.800 T he set of specifying ques tions adds up to a which the interviewer summarizes in Q13. When the patient accepts that summary (A13), the interviewer induces the patient to complete a s entence designed to capture the patient's interpretation of her leeriness . 689 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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PR OB ING P roblem: T he patient denies recurrence of past and s tres ses emphatically that he or she is healthy. emphasis alerts the interviewer to the presence of S olution: T he interviewer as ks for recent changes —not problems —and for the patient's interpretation. A 47-year-old, white, married woman who had recently moved to town reports that she has been treated in the past for major depress ion. S he emphasizes that s he is doing jus t fine and that s he only wants checkups of her past problems. S he works in her husband's law answering the phone, filing, and typing. I: Is there anything new going on in your life s ince you moved here? P : Y ou know, I'm glad that you asked. I've always had problems getting up. B ut now I'm wide awake at 5:30 I: W hy do you think that is? P : My s is ter is a nun, and at that time, s he goes to New Orleans . And that's when she communicates with I: How does s he do that? Does she call you? P : Oh no. W e've been close. It's with telepathy. T he patient's s trong intention was to be certified as healthy and as ymptomatic. T his emphas is alerted the interviewer to s crutinize the patient's recent history, discovering a delus ion that, as the interviewer learned later, was an early indicator of relapse for this patient.

LE ADING P roblem: A male patient, when as ked how he feels , 690 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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answers : I don't know. S olution: (1) T he interviewer how the patient dealt with others las t week. T hus , behaviors may have to take the place of a mood (2) T he interviewer asks the patient to try to remember how he recently felt. W hile the patient tries to his posture and facial express ion may change. T he interviewer reads that emotion and feeds his or her reading back to the patient for his confirmation. T his technique, however, is suggestive and leads the res ponse. T he interviewer has to remain cognizant of poss ibly distorting input. A 28-year-old, white, married man knocks holes in the of his kitchen with his fis ts. He also reports problems sleeping. I: C an you tell me how you feel mos t of the time? P : I don't know. I: T ry to remember how you felt yes terday. P : (Looks down, closes his eyes , makes a fis t, then I: Y ou get a frown on your face. Y our knuckles turn Y ou appear tense… angry… anxious. P : Angry! Y eah. I: T hen a brief grin ran over your face. W hat were you thinking just now? P : T hes e Mexicans … when they buy one tire from me, bring their kids … they come with all their family. Like them. I: Y ou get angry… then you s mile… your feelings quickly. P : (P uzzled) I guess . I: Mixed up… up and down… bouncing around? 691 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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P : My wife s ays I'm up and down. T he patient can reexperience some feelings but cannot read and express them hims elf.

C overing a Topic After opening a topic and clarifying the answers, the interviewer collects information linked to this topic to draw the big picture. Helpful techniques include as king events that are as sociated in time or are logically interrelated. T he interviewer may finally s ummarize he or s he has learned.

AS S OC IATING When ass ess ing clinical symptomatology, the us ually encounters one major symptom (i.e., the chief complaint). However, ps ychiatric disorders occur as syndromes rather than single symptoms. T herefore, interviewer asks what other s ymptoms concurred in with the chief complaint: “What else happened during time of your crying s pells ? ” or “What else happened your crying s pells were worst? ” or “What else when you had your s pell the last time? ” If the patient only a few s ymptoms , the interviewer may actively ask disturbances in sleep, appetite, s ex drive, ability to ability to relate to others .

INTE R R E L ATING T he interviewer uses interrelating when referring to the same theme, s uch as medical his tory, ps ychiatric history, or work or marital history. S uch interrelating represents logical connections. P roblem: A patient an illogical interrelations hip. S olution: T he interviewer 692 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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addres ses the illogical connection. A 38-year-old, married, black, male airline engineer. I: W hat brought you here? P : My wife wanted me to have a s econd opinion. I: About what? P : About Alicia and the televis ion. T he pain in my groin should have stopped by now. I: F ill me in. W hat do Alicia and the televis ion have to with your groin pain? P : Man, don't you unders tand? I felt it most when I watched televis ion. I: W hat does that have to do with Alicia? P : Alicia knows about witchcraft. S he's a medium. S he my new televis ion set is bewitched. I have to bring it to her hous e. I: Did you take it over there? P : Of cours e. B ut my pain is still there. I: B esides your groin pain, was the television doing anything els e to you? P : It gave me mes sages. I: W hat kind? P : I noticed it mainly with politicians. T hey hold their with the fingers pointing down, and I unders tand immediately what they mean. I: W hat do they mean? P : Is n't it obvious? T hat my life is going down. I: W hat does your wife think about all that? P : Oh, she's mad with me. S he thinks that Alicia ripped 693 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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off and that I need to s ee a ps ychiatris t.

S UMMAR IZING S ummarization should be informal, s upportive, and interactive. P roblem: T he patient gets eas ily While the interviewer as sess es the history of present illness , the patient mentions that her mother had s imilar problems . When talking about the medical his tory, the patient adds that her only s ibling, her older brother, admitted for detoxification. W hen reviewing the s ocial history, the patient mentions that her father is the only person in the immediate family who did not have any ps ychiatric problems. T o give clos ure to the topic of history, the interviewer pulls together P.801 and s ummarizes informally the data that belong to this topic but were collected at different parts of the “Let me make sure I'm keeping up with what you told about your family history.” P roblem: T he patient's answers are vague, and it takes interviewer several specifying ques tions to collect information. S olution: T he interviewer supportively summarizes the topic intermittently, “We are getting there,” to nudge the patient to complete the topic. P roblem: A patient describes a good relations hip but her facial expres sion contradicts the words . S olution: interviewer gives an interactive summary and confronts the patient with incons is tencies to provoke his or her protes t and to probe his or her true convictions . A 19-year-old, s ingle, white woman. 694 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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I: Y ou described to me some of the conflicts that you with your s tepfather, right? (P atient nods .) B ut you said they were really minor. Y ou learned to tolerate each did I catch that? (P atient looks down.) B ut while you saying “tolerate,” some spit came out of your mouth. P : (T hrowing her head back and rolling up her eyes) I be unders tanding because of my mother. He really me a lot.

S teering Ins ide a topic and between topics , the interviewer the flow of information. T he main choices are to encourage the patient to continue or to redirect the of attention.

C ONTINUATION T he interviewer tends to the patient's talk by raising eyebrows or uttering hmmms to signal to the patient nonverbally to continue. He or she may use short phrases, such as “And? ” “T hen what? ” “How is that? ” if or her nonverbal signals get ignored. T he interviewer also use phrases s uch as “T hat's interesting,” “What a surpris e!” “R eally? ” “Oh, no!” to reward the patient with or her attention and to encourage the patient to

E C HOING T he interviewer may echo a part of what the patient said. He or s he may intend to prod the patient to or to s hift the emphasis.

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S olution: T he interviewer follows the new lead. Alternatively, the interviewer may delay the transition: “What you are s aying is very important. W e will come to this topic. B ut before we do, let's finis h up on… (old topic).” P roblem: T he patient introduces all irrelevant topics, s uch as the problems of other people or political opinions about current events. S olution: T he us es redirection. He or s he interrupts the patient and to return to the previous topic. If the patient repeatedly gets dis tracted by irrelevant s ubjects , the interviewer overtly educate the patient, saying: “We have to cover several topics. Let's not get dis tracted. Let's continue we were talking about before.” If the patient remains overtalkative, a request to make the patient just ans wer series of yes -or-no questions or multiple-choice may help. If the interviewer is not vers atile and s killful us ing redirection, the entire interview may derail.

Trans itions T o cover the 15 s ections of the clinical interview, the interviewer has to transition from a completed topic to a new one. T hese trans itions can be s mooth, abrupt.

S MOOTH TR ANS ITIONS S mooth trans itions connect topics without the s eam becoming apparent. P roblem: T he patient s tartles new topics get introduced. S olution: (1) T he patient introduces a change in topic and the interviewer follows the new lead. (2) T he interviewer portrays different as part of a larger theme. F or example: I: B oth of your parents had problems with drinking. 696 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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did this affect your relations hip with them? P : W ell, it was rough. T here was a lot of fighting going T hus, the interviewer has trans itioned effectively from topic of family history to social his tory. T he interviewer address es a caus e-and-effect that also leads to smooth transition. (3) T he interviewer references a point in time to s moothly link events that occurred together. Interviewers often have problems in transitioning to the testing of orientation and recent memory. T hey may introduce this topic with a such as , “P sychiatrists routinely as k s ome s trange questions , s uch as what is today's date? ” T o create a smooth transition, the interviewer may link questions about orientation to the problems that the patient has reported. I: Y ou s aid you have felt down in the dumps and could sleep well for the las t 3 weeks . S uch moods can affect memory and s ometimes the ability to track time. Have encountered those problems? P : I don't think s o. I: S o you had no problems with tracking time? P : Hmmm. Not really. I: C an we test it? P : G o right ahead. I: W hat's the date today?

AC C E NTUATE D TR ANS ITIONS An accentuated transition emphas izes the start of a topic. P roblem: T he patient loses attention and interes t 697 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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the interview. S olution: T he interviewer announces a topic and fres hens the patient's interest.

AB R UPT TR ANS ITIONS T he interviewer jumps into a new topic without the patient. P roblem: T he patient's his tory shows many contradictions. T he patient s eems to be lying. S olution: T he interviewer jumps back and forth among different elements of the patient's story. T he patient cannot quickly enough the true events of his or her s tory with invented ones .

Interviewing the R es is ting Patient F or the initial interview, a patient may decide not to talk about certain s ubjects. He or s he may overtly express her refusal: “I don't want to talk about this .” the patient may divert his or her answer to a different topic. T he reas on for s uch refusal is often a fear of los s face. S ix techniques help to overcome res istance.

S haring C onc ern P roblem: T he patient refuses to dis clos e details of an because he or she is not certain about legal S olution: T he interviewer shares the patient's concern points out the negative cons equences that secrecy have for the unders tanding of the problem. A 57-year-old, white, retired man has a problem with rage. P : I've done s ome bad things in my life. P.802

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I: S uch as… ? P : (P ause) S uch as bumping off two people. Do you report that if I tell you? I: W e could discuss the circums tances in general I have to document it. If you talk about it, it would help to understand your rage attacks better. I understand concern. Y ou may want to cons ult your lawyer.

E xpres s ing A c c eptanc e P roblem: A patient with OC D fears that the interviewer may think he or she is “crazy” and therefore gives and misleading ans wers. S olution: R eass uring the and s howing unders tanding and acceptance of his or symptoms help to reveal the “ridiculous” symptoms. Accepting certain symptoms as normal often reduces patient's embarrass ment.

C onfrontation P roblem: B y the patient's behavior and open refus al, a patient res is ts dis cuss ing a topic. S olution: C onfronting patient repeatedly with his or her refus al or pointing out his or her evasive s trategies or exploring the reasons the res is tance and describing the consequences for diagnosis and treatment may convince the patient to be more open.

S hifting F oc us P roblem: A patient res is ts a particular line of questions he or she dreads . S olution: S hifting the approach losing s ight of the topic, the interviewer often secures answers that he or s he desires . T he interviewer may neutral ground or to a different angle to find a new 699 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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point. A 57-year-old white man. I: W hen did you s tart having problems with your mental health? P : Oh that's all a thing of the past. I've forgotten most And I'd rather talk about my future. I: Okay. Y ou are divorced now. W ould you like to get married again? P : Oh, yes . I: W hat went wrong with your first marriage? P : My wife got mean with me when I firs t got sick when was 23 years old. I: I'm s orry to hear that. S o she did not really support S he did not believe in the phras e “for better, for P : T hat's right. I: W hat was it that bothered her? P : T hat I as ked the same ques tions over and over that I felt s o bad, checked things , and was hed my S he said I leave 30 dirty towels a day. S he dumped me when I was 28. T he patient did not want to recall the s ymptoms that him s o much trouble in the pas t but was ready to his past his tory in connection with his s till unresolved, painful divorce.

E xaggeration P roblem: A patient experiences a minor failure as a infraction and feels that he or she will lose the interviewer's support if he or s he admits to it. S olution: 700 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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interviewer exaggerates the patient's actions to make them fit s uch inflated guilt feelings. S uch exaggeration may help the patient to regain pers pective and give up or her resis tance. A 49-year-old man refus ed to discuss his s hortcomings bank teller. I: S o you must have cleaned out the vault and got with it. P : (W ith a thin s mile) No, not quite that bad. I: Not that bad? B ut you s aid it is s o bad that you could talk about it. P : I made a private long-distance call without reporting And I've worried about it ever since. Do you think I still report it?

Induc tion to B ragging P roblem: A patient hides his or her true motives for reques t of a s ick leave to remain in good standing with interviewer. S olution: T he interviewer challenges the patient's cleverness and induces bragging to uncover patient's motives . A 47-year-old man, 290 lbs , reques ting sick leave from job because of s tres s on his delivery s ervice job. I: S o you deliver all thes e advertis ing brochures. P : (W ith a broad grin) Y es, and I'm doing a good job that, but I'm stress ed out now. T hat's the first time I try route getting disability. I: Y ou look quite content to me. Maybe you need a vacation rather than a sick leave. 701 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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P : I've us ed up all my vacation at the beginning of the Now I need s hort-term disability. I: Y ou s aid this is the first time you tried this route. W hy don't you tell me why you really want the s ick leave? P : I'm telling you. T hes e 7 years at the job have really a toll on me. I feel I need time off. I: I wonder whether you have learned how to work the system. P : I've been at it for 7 years. (W ith a grin) I should be at it. I: How is that? What do you mean being good at it? P : I have that quiet spot clos e to the cemetery where I look at a lake. T hat's where I take a break from all that driving. (S heepishly) I just dump some of the printings . I: Y ou wouldn't have enough miles on your car if you that. P : don't you think I know that? I run out to my place grab s ome lunch. T hat gives me the miles. Induction to bragging revealed the patient's antis ocial features behind his request for s tres s relief and sick

Interviewing the Defens ive Patient Defense mechanis ms may dis rupt the interviewing proces s. Nevertheles s, the interviewer has to deal with them. T he DS M-IV -T R groups 31 defens e mechanisms seven levels of adaptation. T he interviewer can spot a defense mechanis m by its observable, characteristic behavior (T able 7.1-2). T he interviewer may identify the emotional conflicts , and the proces ses that activate the defens e if the 702 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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interferes with the interview. If the interviewer identifies defens e mechanism, he or s he may determine its levels. F or each of the levels, a general s trategy is that may help the interviewer to address the defens e.

Table 7.1-2 Defens e Mec hanis ms on (DS M-IV-TR ) Defens e Mechanis m

Obs ervable B ehavior or S ymptom

E motional C onflic t and S tres s ors

High adaptive level

 

 

Affiliation

F ormation of work and troubleshooting teams ; s triving for cooperation

Is olation, imperfection, res ponsibility

Altruis m

Unconditional offer of help

Defeat in competition

Anticipation

P redicting

S udden,

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probable events overwhelming and planning threats countermeasures Humor

Highlighting amus ing of threat

F ailure, loss , destruction

S elf-as sertion

E xpres sion of impulses in socially acceptable form

F ear, anxiety, and anger

S elf-observation

R eflection on own feelings, impulses, and thoughts

F ear, anxiety, failures, aggres sion

S ublimation

S ocially acceptable behavior

Unacceptable feelings or impulses

S uppres sion

Avoidance of discuss ing

P ainful event, sadis tic or

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painful problems , wis hes , or feelings

sexual

Mental inhibitions level

 

 

Dis placement

P hobias

F ear and threat by an object or love and hate for an object

Dis sociation

Multiple personality, fugue, amnes ia

P romis cuous , hostile, or irrespons ible behavior, painful events

Intellectualization

Abs tract thinking, doubting, indecis ivenes s, generalizations

Dis turbing feelings and thoughts

Is olation of

Obsess ions, talking about emotional

P ainful emotions and memories

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without feeling R eaction formation

Devotion, s elfsacrificing behavior, correctnes s, cleanliness

F eelings of hostility and disinterest

R epress ion

G aps in

T hreatening memories , feelings, wis hes

Undoing

C ompulsive behavior

S adistic wis hes , unacceptable impulses

Minor image distortion level

 

 

Devaluation

Derogatory statements about others or self, “sour grapes ” about a goal

P os itive qualities of others , unattainable goal

Idealization

E xaggerated praising of s elf

Negative qualities of

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others

or s ignificant others

Omnipotence

S elfpresumption, entitlement

Inferiority feelings, failure, low self-es teem

Dis avowal level

 

 

Denial

S tubborn and angry negation of some reality obvious to others

P ainful reality

P rojection

Ideas of reference, prejudice, suspicious nes s, injus tice

Hos tility, unacceptable attitudes, wis hes ,

R ationalization

S elf-serving explanations justification of behavior

S ocially unacceptable impulses, low self-es teem

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Major image distortion level

 

 

Autistic fantasy

Daydreaming

Uns atis fied impulses and wis hes

P rojective identification

Accus ing others of causing distress , and anger

Hate, anger, and hostility

S plitting of selfimage or image of others

Idealization alternating with devaluation of self or others

E xperience of negative and positive qualities of or others

Action level

 

 

Acting out

V iolent acts, stealing, lying, rape

S exual and aggres sive impulses

Apathetic withdrawal

Decreas ed emotions , activity, and social

Needs, impulses, wis hes

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interactions Help-rejecting complaining

Depicting oneself with pity as victim

Hos tility and reproach toward others

P as sive aggres sion

P rocras tination, lack of followthrough

Aggress ive, hostile impulses, res entment

Level of defens ive dysregulation

 

 

Delusional projection

P ers ecutory delus ions

Overpowering, unacceptable and uncontrollable impulses

P sychotic denial

Negation of obvious reality

Overpowering, painful reality

P sychotic distortion

Obvious ly unrealistic statements and claims and

Overpowering, unacceptable impulses and reality

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irrational

F rom Othmer E , Othmer S C . T he C linical Interview Us in American P s ychiatric P res s; 2002:82–85, with permiss io

High A daptive L evel T hese eight defense mechanis ms can be viewed as for the patient. I: I admire your sens e of humor. It will help you to deal better with your depres sion. Y ou are able to take the V iennes e approach and say, “T he s ituation is hopeless not serious.”

Mental Inhibitions L evel T he seven defens e mechanisms on this level deprive patient of s ome degrees of freedom in P.803 P.804 decis ion making. Us ually, the patient has insight into pathological nature of phobias, obs ess ive-compuls ive behavior, and diss ociative identity disorders without aware of the underlying process . In the cas e of intellectualization, is olation of affect, reaction formation, 710 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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and repress ion, the patient miss es that a defense mechanism inhibits his or her ability to recognize his or true feelings. C onfrontation with the observable may allow the patient to recognize his or her true I: W hat value do you attach to life? P : I feel as a C hristian it is a sin to even think about G od gave us our life and he is the one who s hould take I: Y ou mentioned s uicide when I just wanted to know you think about life. P : don't you think s uicide is a s in? I: I'm more concerned about your generic answer. It your feelings . What are your feelings about your life? P : (S tarts crying) It's awful. I would not care if I didn't up in the morning.

Minor Image Dis tortion L evel A patient may idealize an interviewer at the beginning the interview and s ubs equently devaluate the because of a minor perceived failure, s uch as as king embarrass ing question. W hen idealization, devaluation, omnipotence interfere with the interview, the overt behavior itself may have to be address ed. I: How quickly I end up in the doghous e! Let's find out what got me there.

Dis avowal L evel F rom the three defense mechanis ms on the dis avowal level, projection is the most dis ruptive during an 711 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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A patient accuses the interviewer of not liking her. as ked whether she hers elf dis likes the interviewer, she answers , “How could I like you if you don't like me? ” he as ks her whether there is anything that she does like about him s he ans wers: “T he way how you make feel. I don't like s ex.” S olution: T he interviewer has to the patient aware that her feelings and not his actions caus e her difficulties. He may accept her feelings as and repeatedly discuss them with her to neutralize

Major Image Dis tortion L evel T he three defens e mechanisms on this level have to be identified and addres sed but not interpreted. A 45-year-old, white, married truck driver avoided his mother for s everal years because he believed s he him s ick. He then quit his job because his coworkers rejected him. He felt hate and anger toward them. In interview, he told his psychiatrist that his questions making him sick. T he interviewer pointed out to him he had felt the same way about his mother and later his coworkers . Avoiding his mother and quitting his job not give him peace of mind. T herefore, he and the interviewer had to find new ways of dealing with the patient's s ocial dis comfort other than accusing people next to him. “Let's work on your anger and distrust of and others . With your help, we can find out what and medications make you less sensitive to other remarks.” T he interviewer recognized the accus ations as identification. Instead of an interpretation that is usually not effective, the interviewer offered s upport and 712 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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medication.

A c tion L evel P roblem: A patient acts out his or her anger. S olution: interviewer sets limits rather than trying to interpret the behavior. T he diagnosis helps to decide which combination of behavioral and medical intervention is neces sary to manage this patient.

L evel of Defens ive Dys regulation T he three defens e mechanisms on this level produce ps ychotic s ymptoms. If, for instance, the interviewer challenges a delus ion as nons ens ical, the patient may angry and dis trus tful and break off the interview. T herefore, the interviewer has to adopt the patient's vantage point and offer s upport accordingly. A 43-year-old, white, s ingle farmer claims that night caus e his headaches. I: I will protect you agains t these spacemen. I'll put you the hospital, and I will give you medication that will you immune to their attacks . P : S o you believe me that s pacemen cause my I: I can't tell you that. B ut I know that you feel this, and I know that the medication may help. R ecognizing the behaviors that, according to a ps ychodynamic view, repres ent an unconscious mechanism is in the realm of des criptive ps ychiatry. However, descriptively oriented ps ychiatris ts doubt the validity of the underlying ps ychological mechanisms therefore prefer behavioral and medical management 713 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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interpretation.

ME NTA L S TA TUS T he third component of ps ychiatric interviewing is the online monitoring of the patient's mental status . T he interviewer screens the mental s tatus to detect signs symptoms of mental disorders (T ables 7.1-3 and 7.1-4) four as sess ment methods: observation, conversation, exploration, and testing.

Table 7.1-3 Quantitative C hange Frequenc y, Duration, and Intens ity o S tatus Func tions S ec ondary to S o and II Dis orders Func tion As s es s ment Method

C ategory

Inc reas ed In

Appearance (O)

Apparent vs . stated age

AD, MDD, S chiz with chronic cours e, S R D, precocious puberty

MA

 

G rooming and

OC -P D,

AD,

Dec In

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clothing

His trP D, narcis sistic (mint condition),

SRD

 

E ye contact

DelD (hos tile)

GA MA

 

Nutritional status

SRD (antihistamine us e), MDD atypical, S D; us e of medication: olanzapine, valproic sodium, clozapine, lithium, mirtazapine

SRD (s tim AN, (cac

Attitude toward interviewer E , T)

C ooperation

Dependent P D, His trP D, MA

Ds ps y feat MA into MD AsP con

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C ons cious nes s Alertnes s (O, C , T )

SRD (s timulants), G AD, posttraumatic stress paranoid D

SRD (alc sed

P sychomotor (O, C , T )

P os ture

MA

MD dem

 

Movements

 

 

 

   R eactive

MA, G AD,

MD (cat

 

   G rooming

S ocP h, G AD

MD

 

   S ymbolic

MA, cluster B PD

MD (cat

 

   Illustrative

MA, S D

MD (cat

 

   E xpress ive

MA, G AD, His trP D

MD (cat

 

   G oal directed

MA, ADD

MD

S peech (C ,

Articulation

—

SRD

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T)

neu Ds

 

F low

MA

P D,

 

S peed

MA, G AD

P D,

 

V olume

MA

MD

 

Latency of res ponse

MDD

MA

 

Inflection

MA

MD

T hinking (C , T)

S peed

MA, S R D

MD AD, P ar dise

 

Abs traction

—

Men reta S ch fron dem

 

T ightness of as sociation

OC D, OC -P D

MA SRD

 

G oal directedness

—

MA OC

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SRD Affect (O, C , T)

Quality

MA

MD AN, nerv inte exp

 

R eactivity

MA, S D, AD, retarded MDD, OC D

AD, OC

 

 

MA, S D, His trP D

MD S ch

 

Intens ity

MA, AnxD, E atD

MD

 

R ange

MA

S ch GA

 

Appropriateness

—

S ch with ps y feat

Mood (E , T )

Quality

MA, S R D

MD E at

 

S tability

MDD

AsP

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mix SD  

Intens ity

MA, OC D

MD

 

Duration

OC D, OC MDD

B ID cyc

T hought content (C ,

C ongruency of delus ions and hallucinations to mood; pathological content (s ee T able 7.1-4)

S chizoaffective — D (s ee T able 7.1-4)

C ognition (C , E , T)

S ee T ables and 7.1-6

—

S ee 7.17.1-

Ins ight (C , E )

B eing s ick, needing help

—

AD, MA P ick

J udgment (C , E)

F uture plans, dealing with friends and money

—

MA S ch P ick

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AD, dementia of Alzheimer's type; ADHD, attentiondeficit/hyperactivity dis order; AN, anorexia nervosa; Anx disorder; As P D, antis ocial pers onality disorder; B ID, bip C , convers ation; D, dis order; DelD, delusional disorder; exploration; E atD, eating dis orders; G AD, generalized a disorder; HistrP D, histrionic pers onality disorder; MA, m major depress ive disorder and depress ion; O, observati obses sive-compuls ive disorder; OC -P D, obsess ive-com personality dis order; P D, personality dis order; P ick's , P i S chiz, schizophrenia; S D, somatization disorder; S ocP h phobia; S R D, s ubs tance-related dis orders; T , testing.

Table 7.1-4 Qualitative C hanges in Mental S tatus Func tions to S ome Axis I and II Ps yc hiatric Dis orders and S yndromes Func tion As s es s ment Method

S ymptom, S ign

Dis order, S yndrome

Appearance (O)

Needle marks

SRD

 

S cars on

MDD, B ID,

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and wris t

borderline P D, Cl B PD

 

Inappropriate attire

MA, P sychD

 

Miss ing eyelashes, eyebrows, hair

ID, trichotillomania

 

B itten-off nails

ID, AnxD, P sychD

 

R eddened, chapped hands

OC D

 

E xces sive or tattoos

Cl B PD

C ons cious nes s Hyperalertness (O, T )

S R D (sedative withdrawal or stimulant

 

S R D sedation (Intox), ps ychiatric D due to a medical condition

Lethargy, s tupor, coma

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P sychomotor (O, C , T )

R igidity

P arkD, neuroleptic malignant syndrome, extrapyramidal symptoms

 

T remor

Idiopathic, S induced, S withdrawal, P arkD

 

T ics (motor,

T OUR , other D

 

R es tles s squirming, overflow

ADHD

 

C horeatic, athetotic movements

TD

 

B uccolingual movements

TD

 

C ataleps y

S chiz, D with ps ychotic features, AD, F LD

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G egenhalten (oppos ing movement)

S chiz

 

E chopraxia

S chiz

 

P seudoaphonia, ps eudoparalysis, ps eudoseizures

C onvers ion D

 

Avoidance of touching

OC D

 

Apraxia

F LD, AD, NeurolD

 

S eizures

S R D (sedative withdrawal)

 

C ataplexy

Narcolepsy

 

Micrographia

P arkD

 

S tereotypical movements

P ervas ive developmental D

S peech (C , T)

S tuttering, stammering

AnxD, generalized anxiety D,

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NeurolD  

V ocal tics

T OUR

 

Aphasias

F LD, AD, NeurolD

 

P us h of speech

MA

T hinking (C , T)

B locking and derailment

P sychD

 

C ircumstantiality

OC D

 

F light of ideas

MA

 

Loose as sociations

MA, P sychD, S chiz

 

P ers everation

F LD

 

V erbigeration

P sychD (catatonia), NeurolD

 

P alilalia

NeurolD

 

C lang

S chiz, MA

 

Nons equitur

S chiz

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F ragmentation

S chiz

 

R ambling

Delirium, S R D

 

Driveling

Aphasia (W ernicke's ), S chiz

 

Word salad

P sychD, Aphasia (global)

 

T angentiality

S chiz, D with ps ychotic features

Affect (O, C , T)

Lability

B ID, S R D,

 

Inappropriateness D with ps ychotic features

T hought content (C ,

S uicidality, homicidality

MDD, S R D, S chiz, B ID

 

Hallucinations, delus ions

B ID, MDD, S chiz, S R D,

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Obsess ions, compuls ions

OC D

 

P anic attacks

MDD, panic D

 

Medically unexplained pain

S omatization

 

Derealization, depers onalization

Dis sD

C ognition (C , E , T ; see 7.1-6)

C onfabulation

Amnes tic D

 

Dis sociative amnes ia

Dis sD

AD, dementia of Alzheimer's type; ADHD, deficit/hyperactivity dis order; AnxD, anxiety B ID, bipolar disorder; B P D, borderline pers onality disorder; C , convers ation; C l, cluster; C onvD, conversion dis order; D, disorder; Dis sD, disorder; E , exploration; F LD, frontal lobe impulse-control disorder; Intox, intoxication; MA, mania; MDD, major depres sive dis order and depres sion; NeurolD, neurological disorders; O, observation; OC D, obsess ive-compuls ive disorder; P arkD, P arkins on's dis eas e; P D, pers onality 726 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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P sychD, ps ychotic dis orders ; S , substance; S chiz, schizophrenia; S R D, s ubs tance-related dis orders; tes ting; T D, tardive dyskinesia; T OUR , T ourette's disorder.

Obs ervation F or obs ervation, the interviewer does not need the patient's cooperation. B esides sex and race, the interviewer obs erves appearance, level of ps ychomotor functions , body language, and affect. T hrough the power of obs ervation, S herlock Holmes deduce a pers on's life his tory and occupation. the as tute interviewer, obs ervation can give clues to diagnosis.

C onvers ation E ven if the patient refuses to speak about him- or his or her s ymptoms or s uffering, the interviewer can conclus ions from convers ation about the patient's thinking, affect, thought content, concentration, intelligence, insight, and judgment. P.805 P.806

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P.807

E xploration E xploration requires the patient's willingness to disclose information about mood; content of thinking, such as obses sions , compuls ions, s uicidal ideation, delus ions , hallucinations , panic attacks, avoidance behaviors , and “spells;” amnes ias; personality changes; and pain sens ations. T o verify his or her impres sion, the may feed back to the patient his or her reading of symptoms and s igns ass es sed during the interview. the patient's mental s tatus becomes the object of exploration.

Tes ting T es ting of the patient's mental functions , whether intact impaired, demands the highest degree of cooperation. T es ting adds a quantitative component to the interview. C ombining obs ervation, convers ation, exploration, and tes ting, the interviewer screens at least 12 mental functions often affected by ps ychiatric disorders . T able 3 lists the mental s tatus function and the method of its as sess ment, the categories that are as sess ed for the individual functions, the mental dis orders that may show an increas e, and the mental disorders that may s how a decrease in the s pecific category. T he interviewer signs and s ymptoms of disorders in thes e mental s tatus functions . T able 7.1-4 lists mental s tatus functions and as sess ment methods, symptoms and s igns, and the disorders and syndromes in which the s ymptoms and are frequently encountered. T he mental status functions 728 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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T ables 7.1-3 and 7.1-4 are discus sed subsequently. In T ables 7.1-3, 7.1-4, 7.1-5, and 7.1-6 the term MDD to des ignate major depres sive dis order as well as depres sion due to other disorders , such as dys thymia, bereavement, or adjus tment dis order, substance us e, general medical condition.

Table 7.1-5 C hange in E motional R e Indic ator of S ome Ps yc hiatric A Dis orders E motion

E vent

Action

S urprise

Unexpected E valuation, stimulus integration

P T S D, MA, G AD, P anD,

Interes t

Need reducing stimulus

MA, ADHD

E xploration

Inc reas e

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E lation

E xpected satis faction of need

S atisfaction of need

MA

C ontentment

C ompleted need satis faction

R elaxation

—

Anger

Obstacle

Des truction of obs tacle

MA, delus ional disorder, ADHD clus ter B intermittent explosive disorder, subs tancerelated disorder, P anD,

Dis gus t

Intrusion

E xpuls ion withdrawal

Anorexia nervos a, bulimia nervos a, OC D, S pecP H, S ocP H

Anxiety

T hreat

Avoidance

S ocP H,

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agoraphob S pecP H, P T S D, OC D S adnes s

Loss

Undoing, MDD, replacement histrionic

G uilt

V iolation of code

R emorse, selfpunis hment

MDD, borderline PD

ADHD, attention-deficit/hyperactivity disorder; AsP D, an disorder; G AD, generalized anxiety dis order; ID, impuls e MA, mania; MDD, major depress ive disorder and depres obses sive-compuls ive disorder; P anD, panic disorder; P disorder; P T S D, posttraumatic s tres s disorder; S chiz, sc social phobia; S pecP H, s pecific phobia.

Appearanc e T able 7.1-3 lists quantitative and T able 7.1-4 qualitative changes in appearance that may be due to a disorder. T he onset of some disorders is age related 7.1-3). G ender is ass ociated with certain diagnoses . instance, anorexia and bulimia nervos a, somatization disorder, and major depres sion are more common in women, whereas antis ocial pers onality disorder and alcohol abus e predominate in men. 731 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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R ace and ethnic background are important: F irs t, acros s racial and ethnic boundaries may be impeded. S econd, the attitude toward mental illness varies from culture to culture and may delay cons ultation. T hird, and ethnicity affect the incidence of some psychiatric disorders .

Attitude T he patient's attitude reflects his or her disorder and her evaluation of the doctor–patient relationship. A patient may hide his or her uncooperative attitude vaguenes s, memory los s, or one-word ans wers or it openly. He or she may refus e to ans wer ques tions or refuse to be tested.

C ons c ious nes s Most common disturbances of consciousness are due intoxication or substance withdrawal res ulting in or decreas ed reactivity. More s evere disturbances of cons ciousnes s (T able 7.1-4) can be as sess ed by tes ts (T able 7.1-6).

Ps yc homotor Func tion B es ides posture, humans dis play types of movements differ in their purpose (T able 7.1-3). R eactive are directed toward a new stimulus , such as respons es phone ringing or door knocking. G rooming movements control appearance, s uch as straightening out clothes , or mus tache. S uch movements frequently indicate discomfort with the s ituation. S ymbolic movements are culture s pecific and can replace language. Instead of saying, “We will win,” a pres idential candidate, for 732 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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may form a V with his or her arms . During an interview, patient may s ometimes make an unintended symbolic gesture that reveals hidden thoughts . Illus trative movements duplicate what is s aid—they are E xpres sive movements reflect in a rudimentary form motor action that a patient would like to undertake in res ponse to an emotion-provoking stimulus ; for an angry patient who says he or she will take on his or employer ass umes an erect posture and makes a fis t anticipating a fight. G oal-directed movements occur as part of a phys ical action, s uch as reaching for a coffee P sychiatric dis orders can affect frequency P.808 P.809 P.810 and intens ity of such movements (T able 7.1-3), but can also induce qualitative changes , s uch as movements specific to psychiatric or neurological disorders (T able 7.1-4).

S peec h S pe e ch is a motor function driven by the patient's proces ses. T herefore, mos t disorders that affect motor functions in frequency and intensity affect s peech as R apid s peech is seen in mania and in anxiety disorders (T able 7.1-3). A cons tant rapid flow of speech that can interrupted is called pus h of s pee ch. If it is difficult to interrupt, it is called pre s s ure of s pee ch. B oth forms are in mania (T able 7.1-4). Qualitative changes of s peech 733 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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us ually of diagnos tic significance (T able 7.1-4). If centers in the brain are damaged, specific forms of (inability to s peak) occur. B edside tests help to which type of aphasia is pres ent (T able 7.1-6). Developmental disorders affect s peech. S peech is noticeably impaired in patients with low intelligence quotient (IQ) or with dementias .

Thinking T he interviewer judges thinking according to the categories listed in T able 7.1-3. T he interviewer's impres sion and a patient's report may conflict. S ome patients report racing thoughts but talk with a normal or even s lowly. S uch a mismatch may be more anxiety disorders , ps ychotic dis orders, or hypomania; mania, racing thoughts are us ually accompanied by increased rate of speech. T he ability to unders tand the abstract meaning of words varies with the level of intelligence and is not pathognomonic for T he ability to abstract can be tested by as king for communality of categories and proverb interpretation (T able 7.1-6). C oncreteness of thinking in firs t-episode ps ychos is may be as sociated with lack of insight. Ass ociation between s entences can be loos ened by ps ychiatric disorders (T ables 7.1-3 and 7.1-4). seem to jump from topic to topic and their goal gets phenomenon called flight of ideas (T able 7.1-4). T he as sociations between thoughts can become very clos e, and the patient may be unable to omit irrelevant making his or her thinking circumstantial. S ome lose the goal of their ans wer but touch on the general topic, called tange ntial thinking (T able 7.1-4). 734 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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Affec t Affect communicates to the interviewer the emotional value that the patient puts on his or her experience. interviewer sees affect expres sed in the patient's face, and body movements. He or she hears it in the patient's voice. E xternal events and internal such as thoughts , ideas , and memory, evoke affect. interviewer has to explore to what extent immediate circums tances , s uch as being press ured by a family member to see a ps ychiatris t, contribute to the pres ent affect. T he nine basic emotions that C arroll Izard and others have identified are transcultural, innate (T able 7.1-5). E ach is triggered by a s pecific event and urges the individual to take a s pecific action (T able 7.1T he quality of the firs t four emotions —surpris e, elation, and contentment—is positive; the last five have negative quality—anger, dis gus t, anxiety, sadness , and guilt. Most psychiatric dis orders influence affect and mood (T able 7.1-5). T hey shift a patient's emotional res ponse toward a dominating affect and mood, thus increas ing intens ity of that specific affect but at the s ame time res tricting the range of res ponsiveness . F or instance, mania and some substance-related dis orders, elation dominates . In depres sion, sadnes s and guilt are In eating dis orders , disgust is prominent, and in anxiety disorders , anxiousness is of course prevalent. the interviewer gets significant clues about ps ychiatric disorders by noticing the shift in quality and intensity of affect (T ables 7.1-3 and 7.1-5). F urthermore, disorders influence the reactivity of affect. F or instance, patients with bipolar disorder may dis play dramatic, 735 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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changes in quality and intens ity of affect in respons e to changing thought content (T able 7.1-3). T he then observes a labile affect (T able 7.1-4). P s ychiatric disorders with psychotic features often affect the appropriatenes s of affect to thought content. A patient may report and s how elation but have delus ions of forced to commit suicide, thus showing thought content incongruent to mood. F or instance, a patient may while describing her mother's funeral (T able 7.1-4). Without being sad or depres sed, s ome patients may an affective res ponse, which is often des cribed as flat bland affect in contrast to full affect. T o evaluate affect, interviewer may explore the patient's res ponse to listed in T able 7.1-5. F or instance, he or she may ask a sales man, “How does it make you feel when you P.811 meet a representative of a competing company in your territory? ” T he mixture of anger about the obs tacle, about the intrus ion, and anxiety about the threat may valuable clues of the patient's emotional second method to as sess mood is by brief tests (T able 6). W ith respect to affect, the interviewer can as k the patient to enact the nine bas ic affects (T able 7.1-6). As these areas, patients may exhibit situationally driven res ponses due to recent s tres sors or external circums tances of the interview.

Mood Mood refers to the predominant, longer-lasting quality experienced emotion. T herefore, if the interviewer to evaluate the patient's mood, he or s he has to ask. 736 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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interviewer can judge to what extent the observed and the reported mood corres pond to each other. A patient with high s ocial skills can often dis play an affect inconsistent with the mood. T his apparent discrepancy between affect and mood occurs more frequently when the patient speaks. W hen the patient lis tens and feels unobs erved, the happy mask may drop. P rolonged of depress ion, as s een in major depres sive dis order, pathological stability and duration of mood. A patient OC D or obses sive-compuls ive personality dis order also report that his or her dysphoric mood las ts for a time, yet it may be unstable becaus e of his or her outburs ts . Depending on the severity of a ps ychiatric disorder, the predominant mood can be intens e.

Thought C ontent During exploration, the interviewer s earches the past for the occurrence of pathological thought content (T able 7.1-4). T o as sess suicidality, the interviewer discuss the patient's quality of life, thus getting a better reading of suicide risk than with direct ques tioning. F ollow-up questions for s uicide risk include past immediate intent, lethal plan, availability of means, history of suicide, and perceived outcome. C oncurrent presence of psychotic features , s uch as command hallucinations , as well as depress ion, s ubs tance recent los s of s ocial support, male gender, white race, middle age or older, may increas e the ris k of s uicide. comorbidity of major depres sion and s ubs tance use disorder leads to the highes t ris k of s uicide. A for risk factors of s uicide is helpful: S AD P E R S ONS . S ex: W omen are more likely to be attempters , men 737 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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more likely to be committers. Age: Highest rate of s uicide is in teenagers and the elderly. Depress ion: 15 percent commit s uicide. Previous attempts : 10 percent of previous finally s ucceed. E thanol abuse: 15 percent of alcoholics commit suicide. R ational thinking los s, ps ychos is. 10 percent of schizophrenics commit suicide. S ocial support is lacking. Organized plan increases the suicide risk. No s pouse increas es the suicide risk. S ickness . C hronic illness increas es the risk. Homicidality may become apparent if the interviewer discuss es the patient's enemies . As in the ass es sment suicidality, previous homicidal attempts or completions , intent, lethality of plan, and available means have to be as sess ed. P atients at risk for homicide are those with persecutory delusions, antis ocial pers onality disorder, subs tance-related dis orders. T o increas e the likelihood a patient admits to homicidal ideas or plans , us e the golden rule: Approach the s ubject from the patient's of view as understandable. Use questions s uch as “Are there people in your life who have harmed you and deserve to die for what they have done? ” “Are there people whom you wis h to be dead? ” If the patient an intent to harm s uch foes, introduce the s ubject of 738 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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management, including warning of identified victims , which is the interviewer's duty. C ontrary to expectation, tell the patient about the duty to warn has only minimal impact on the alliance with the patient. When asked about experiences with extrasensory perception (E S P ), the patient may report hallucinations and delus ions. Hallucinations and delus ions can be according to the patient's level of insight (T able 7.1-6). Hallucinations and delus ions are also evaluated by mood congruency. B ecaus e the patient usually has insight into obsess ions , compuls ions, panic attacks, unexplained pain, derealization, and depers onalization, the interviewer can explore these thought contents and experiences with targeted ques tions. However, the may consider s ome obsess ions and compuls ions as embarrass ing and may attempt to hide them.

C ognition T he interviewer judges cognition by the patient's ability comprehend ques tions and express the res pons es . the interviewer finds no evidence of a cognitive disturbance during conversation and exploration, he or she s till may select a few brief tes ts that as ses s attention, recent memory, remote memory, abs traction, and intelligence (T able 7.1-6).

Ins ight T he interviewer asks the patient to what extent he or feels s ick. Us ually, a patient with schizophrenia, mania, dementia, or s ubs tance-related dis orders may deny sick, yet s ome s uch patients have partial insight. T hey acknowledge being depres sed but explain that the 739 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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depres sion is a res pons e to the scolding voices. A may acknowledge that he or s he needs help but deny being sick. S uch a patient may accuse other people factors —the employer, the spous e, the lack of as being the cause of his or her problems . Insight is reported as being good, fair, or poor. A more technique is to des cribe to what extent the patient recognizes being s ick.

J udgment R eview of significant life events , money management, personal relations hips reflects a history of the patient's judgment. J udgment often varies in accordance with patient's s tate of illness . In patients with bipolar judgment may deteriorate during mania but may be intact during euthymic or even depres sed states . a patient's current judgment in comparis on with his or historical judgment may provide a meas ure of the of a disorder. If a patient's judgment is not apparent or inconsistent with the diagnosis , judgment can be more formally ass es sed. S ome psychiatrists us e ques tions the Wechs ler Intelligence T est to as sess judgment. E xample: W hat do you do when you first detect a fire in crowded theater? S uch questions do not involve the patient's affect, mood, and motivation and, therefore, fail to meas ure the appropriatenes s of judgment. A powerful question is to as k about future plans. If these plans appear consis tent with the educational and res ources , the patient appears to have appropriate judgment.

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T es ting is a highly structured form of exploration. T o valid res ults, the patient has to be fully compliant. T he majority of the brief tests that a psychiatric interviewer us es at the beds ide or office meas ure s ome as pect of cognitive function (T able 7.1-6). Interviewers s elect bedside tests according to the patient's complaints or demonstrated P.812 cognitive deficits apparent during the interview. T able 6 s hows the function to be tested, the test, the of abnormal res ponse, the clinical evaluation, and key examples of dis orders that may tes t positive. T able 7.1covers 15 cognitive and three noncognitive functions — affect, suggestibility, and abnormal perception. T he of two of the noncognitive functions and the s taging of hallucinations as part of abnormal perception are discuss ed above. S ugges tibility may be tes ted if the patient shows dis sociative s ymptoms. A high degree of suggestibility need not be a weakness but can be a strength us ed for therapeutic purpos es . T hus, suggestibility is not a s ymptom of a ps ychiatric However, high sugges tibility is a prerequisite for diss ociative disorders and conversion disorder, in patient nearly automatically convinces him- or hers elf being amnes tic of a particular traumatic event amnes ia) or feels , for ins tance, that he or she is (conversion dis order). T he interviewer uses s ome of the cognitive tes ts in diagnostic interviews —that is , vigilance or short- and long-term memory, orientation, abstract thinking, and intelligence. S evere anxiety, major 741 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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depres sion with ps ychomotor retardation, and deficit/hyperactivity disorder (ADHD) may interfere with concentration and lead to the impres sion of an recent memory. If the interviewer evidences poor concentration, he or she should make an effort to error-free immediate recall. Major depres sion and other noncognitive ps ychiatric disorders may interfere only retrieval of information and not with storage. Hints or multiple-choice options may help to overcome the retrieval block. If s torage of information is impaired, as in dementia of Alzheimer's type, this help fails . T he interviewer may focus on evaluating abstract thinking (T able 7.1-6) and intelligence testing if the quality of patient's answers during the interview s ugges ts that concentration, orientation, and memory are intact. T he interviewer selects any one of the other tests in T able when he or s he believes that a particular function may impaired and needs documentation. If not already ass es sed, at the end of the mental s tatus examination, the interviewer evaluates four risk factors the patient's and others ' safety, summarized by the acronym S OAP . T he interviewer explores which of the major psychiatric dis orders is responsible for thes e key factors and makes plans for their immediate S uicidality, homicidality, phys ically as saultive, unpredictable, explosive, and self-injurious and implied or overt threats . Organic disturbances of cognitive functions : disorientation, memory dis turbances, decline of executive functions , aphas ias and apraxias that prevent the patient from exercising the activities of 742 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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daily living (ADL). Alcohol and other s ubstance abuse, ranging from occasional social us e to uncontrollable addictive behavior and dependency that may endanger the patient's and others ' safety on the road and in legal, marital, occupational, and financial s tatus. Psychotic features, such as delus ions, es pecially delus ions of control, and hallucinations , es pecially command hallucinations , and their dangerous nes s the patient's obedience to thes e experiences . here are illogical thinking and speech and catatonic behavior. T he interviewer compares the patient's psychiatric with the patient's mental s tatus to confirm the impres sion. Incons is tencies have to be explored. S uch inconsistencies may raise the pos sibility of incomplete as sess ment by the interviewer or of factitious lying, or malingering on the patient's part.

DIA G NOS IS F or the treatment plan, the interviewer verifies one or more Axis I or II, or both, ps ychiatric diagnoses and excludes others . T he interviewing s tyle matches the patient's res ponses. Us ually, a s trategy that strikes a balance between a dis order- and a patient-centered approach is appropriate. T he diagnostic process can arbitrarily divided into five phases.

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diagnostic loop (F ig. 7.1-1). T he interviewer may link decis ions in an order s uggested by the clues that the patient offers.

FIGUR E 7.1-1 Diagnos tic decision loop for ps ychiatric disorders . C C , chief complaint; Dx, diagnos is ; Hx, 744 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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N, no; NOS , not otherwise specified; S xs, symptoms ;

Openings for C hief C omplaint T he interviewer s elects one out of several poss ible openings that leads to the patient's genuine chief complaint (B ox A in F ig. 7.1-1). B elow are s ome

DIR E C T QUE S TIONING “What brought you here? ” “What kind of problems do have? ” “What's going on in your life? ” S uch ques tions target the patient's chief complaint and may lead to the history of the pres ent illnes s.

C ONFR ONTATION WITH A S IG N T he interviewer confronts the patient with a poss ible of a mental illness , s uch as wearing dark glass es walking with a cane, exuding the smell of alcohol, or having s lurred s peech, cold and clammy hands , ataxic or bruis es on the face. I: I notice you are wearing dark glass es. P : (Looking behind the interviewer at the door, Y es , I don't like people to s ee my eyes. T hey can look through me and read my mind. I: Is this fear the reas on why you came? P : My colleagues at work really look at me. T hey want get into my head, but I won't let them. S uch an entry leads the interviewer to the chief the history of present illness , and the mental status 745 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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evaluation.

ME DIC AL HIS TOR Y P : (Obviously anxious ; her hands make wet imprints on interviewer's des k) I: Have you ever been to a psychiatrist's office before? P : Never. I'm s o as hamed. Why do you have C enter” written above your door? I had a hard time because of that. I: W ell, have you had the same feeling at your family doctor's office? P : Of cours e not. I: W hat did you see the general practitioner for? P : Oh, I have a thyroid condition. I'm on S ynthroid. I: Any other medicines you take? Here, the interviewer s hows sensitivity to the patient's anxiety. T o give the patient time to calm down, the interviewer ass es ses the P.813 medical his tory first before returning to the ps ychiatric chief complaint, which may center on anxiety and persecutory thoughts.

FAMILY HIS TOR Y P : (After the greeting ceremony) I never thought I have to s ee a ps ychiatris t myself. I: Oh? Who had to s ee a ps ychiatris t before you? P : My mother did. S he was in and out of psychiatric 746 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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hospitals . I: T ell me about it. It may give us some clues about own problem. F amily history provides a link to the chief complaint.

S OC IAL HIS TOR Y P : (Looking around, anxious) I didn't expect Monet and Degas prints at a doctor's office. I: Do you have any art background? P : W ell, not really, but I'm a profess ional fundrais er, sometimes we run into some interes ting pieces . I have developed an eye for it. And art really interests me. I: How long have you been into fundraising? P : F or 12 years now. And it has n't always been easy. T he interviewer picks up on the patient's clue and with the s ocial his tory, which leads to stress ors in the patient's life and offers an entry for the chief complaint. P.814 After the interviewer has s olicited a chief complaint, he she clarifies the chief complaint and translates it into a DS M-IV -T R criterion if poss ible (s ee the s ection

Phas e 2: Diagnos tic Dec is ion L oop T he chief complaint leads to a diagnostic decision loop, which as sists the interviewer in including and excluding DS M-IV -T R Axis I and II disorders and in ass es sing history.

C linic al S ignific anc e: Morbidity— 747 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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Mortality T he firs t s tep is to determine whether the elicited chief complaint caus es increas ed ris k of mortality or morbidity—that is , interferes with the patient's life, or health or requires treatment or hos pitalization (B ox B F ig. 7.1-1). T his concept of a psychiatric disorder is on the pres ence of dysfunction that causes the patient handicap. A 27-year-old white hous ewife, Ms . C heryl X. I: Y ou s ay that for the last 3 weeks you have been so that you cannot go to the mailbox. W hat other have you experienced? P : I startle when the phone rings. I don't want to leave house. My husband has to do the s hopping. It all weeks ago in church. I had to run out of the service. My husband came after me, and then I felt like a knife was rammed into my chest. I could not breathe. I: W hat did you do? P : I thought I had a heart attack and had to die. B ut in emergency room, they took an electrocardiogram and drew blood and told me after a few hours that my heart okay. And they told me to make an appointment with I: Did you use any alcohol or drugs at that time? P : No. Drugs never. As a teenager, I drank beer. It me to talk to the boys . B ut that was many years ago. In the cas e of C heryl X., the symptoms led to an department visit and interfered with the patient's ability leave the house. Morbidity was obvious. Its degree can as sess ed with the G lobal As sess ment of F unctioning S cale. C heryl X. may be rated G AF 35 becaus e s he is 748 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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able to leave the hous e. If the interviewer cannot clinical s ignificance, the option is to diagnos e no ps ychiatric disorder (a “no” res ponse to B ox B in F ig.

S ymptoms A s s oc iated and Not A s s oc iated with the C hief C omplaint T he interviewer gathers s ymptoms that occur approximately at the s ame time as the chief complaint (B ox C in F ig. 7.1-1). E xcluded should be symptoms , or laboratory res ults that the chief complaint s uggests cannot be verified. In the cas e of C heryl X., the interviewer found symptoms ass ociated with the chief complaint. At the same time, the interviewer excluded cardiac dis orders drug and alcohol abus e as ass ociated conditions. Infrequently, the interviewer may elicit a chief complaint without being able to identify ass ociated s ymptoms . In case, he or s he cons iders a ps ychiatric disorder not otherwis e s pecified (NOS ), or, if clinical significance is lacking, he or s he may not diagnose a ps ychiatric at all (a “no” res ponse to B ox C in F ig. 7.1-1).

C riteria for A xis I or II Met? After the interviewer has elicited with open-ended questions a lis t of symptoms ass ociated with the chief complaint, he or she checks whether s ufficient criteria an Axis I or II dis order are met (B ox D in F ig. 7.1-1). If the diagnosis can be made (B ox E ). If no, additional questions have to be as ked to satisfy the s et of criteria needed for a diagnos is . An incomplete set of criteria only allow a diagnos is NOS (a “no” res ponse to B ox D F ig. 7.1-1). 749 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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Ms. C heryl X.'s initial ans wers s ugges t the ons et of panic disorder with agoraphobia. At this point, the interviewer may as k whether an attack like the one church s ervice had occurred before and, if s o, how F urthermore, the interviewer may elicit other symptoms that have occurred during the panic attack but were not spontaneously mentioned by the patient.

L ongitudinal His tory vers us C ros s S ec tional C omorbidity After the interviewer has established a psychiatric the interviewer reaches a major decision point in the diagnostic process . He or she has to decide whether to as sess other comorbid psychiatric dis orders or purs ue history of the already es tablis hed dis order (B ox F in 7.1-1). In the cas e of C heryl X., the interviewer could either the presence of other anxiety disorders , s uch as social phobia, s pecial phobias, OC D, and generalized anxiety disorder, mood disorders, or s ubs tance-related or follow up on historical symptoms of panic dis order agoraphobia (B ox F in F ig. 7.1-1). I: T he attack that you had in church is called a panic If you think back, have you ever experienced any type spell like this ? P : No. I don't think so. Wait… Y ou know, when I was in high s chool, we had to jog, and then we had to work on the high bar. All of a s udden, I felt I could not breathe, had to lie down. B ut I never had anything like that I: Have you ever had the feeling you could not leave house? 750 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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P : W hen I was 12, I did not want to go back to s chool the s ummer vacation. How does the interviewer decide whether to pursue comorbid disorders or the history of the already disorder? F irst, if the patient provides a clue, the interviewer may follow the lead. F or instance, if C heryl X. had said, had the attack, I s tarted drinking again,” the interviewer would follow this lead and explore this comorbidity of alcohol abus e. If C heryl X. had said, “Now that you ask all these questions about my attack, I think I've had mild ones before,” the interviewer would take the of the panic dis order. S econd, the interviewer may follow up on comorbidity if the chief complaint or as sociated s ymptoms suggest presence of a more serious ps ychiatric disorder. F or instance, if C heryl X. mentions s he cannot go to the mailbox becaus e the neighbors do not like her, the interviewer may want to explore the presence of ideas reference or pers ecutory delus ions. S uch exploration lead to disorders with psychotic features and reveal poss ible homicidal and suicidal tendencies . T hird, the clinical s ignificance of the disorder may the interviewer: If the disorder is s evere, the interviewer may purs ue its his tory; if the dis order is mild, the interviewer may explore comorbidity to exclude a more severe disorder. F ourth, if the patient is circums tantial or has difficulties focus ing or abstracting, the interviewer may complete history of the disorder already diagnos ed to avoid 751 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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confusing the patient. F inally, if leads are lacking, the interviewer is left with arbitrary decision. P.815

S earc h for an A dditional C hief C omplaint If the interviewer screens for comorbidity (a “yes ” to B ox E in F ig. 7.1-1), he or she searches for an chief complaint. Ms. C heryl X. I: B esides your panic attacks and your difficulty with leaving your home, do you have any other problems? If C heryl X. mentions a second chief complaint, the interviewer loops back to B ox B , ass es sing clinical significance and ass ociated symptoms (B ox C ), the decis ion whether the s ymptoms fulfill sufficient for an Axis I or II ps ychiatric disorder (B ox D). Depending on the symptomatology, the interviewer complete the diagnostic decis ion loop B through H times . W ith each newly made diagnosis, the lengthens the lis t of es tablis hed Axis I and II disorders , shortens the lis t of unexplored dis orders, and may add the list of excluded disorders .

S c reening for A dditional Diagnos es If the interviewer runs dry of new chief complaints or significant ps ychiatric s ymptoms, he or she may switch from open-ended to clos ed-ended ques tions and 752 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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screen for all those psychiatric dis orders that have not been covered yet (B ox H in F ig. 7.1-1). C losed-ended screening questions , mos t well res earched, are in T able 7.1-7. F or each pos itive answer, the may es tablis h clinical s ignificance. T he S tandardized Ass es sment of P ers onality–Abbreviated S cale example, may be a helpful screening tool for disorders .

Table 7.1-7 S c reen for Dis orders (Axis I and II) Dis order

Ques tions

C ognitive disorders

Use tes ts of memory, aphas ia, and apraxia in T able 6.

Mental retardation

While you were in s chool, did anyone ever s ay that you were very s low learner?

 

Did you ever have to go into a special education clas s when were in s chool?

S ubstance-

Has heavy drug or alcohol us e 753

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related disorders

ever caus ed you problems in life?

 

Have you ever used pot, s peed, crack, heroin, ice, or any other drugs to make yours elf feel

P sychos is

Have you ever heard voices or seen things that no one else hear or see?

 

Have you ever felt your mind or body was being s ecretly controlled or controlled agains t your will?

 

Have you ever felt others to hurt you or really get you for some special reas on, maybe because you had s ecrets or powers of s ome sort?

 

Have you ever had any other strange, odd, or very peculiar things happen to you?

 

If yes to any of the above: Did happen even when you were drinking or taking drugs?

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B ipolar disorder, manic

Have there ever been times you felt unus ually high, charged up, excited, or res tless for 1 at a time?

 

Have there ever been times other people s aid that you were too high, too charged up, too excited, or too talkative?

 

Have these high, excitable ever s tayed with you most of the time for at least 1 week?

Major depres sive disorder

Have there ever been times you felt unus ually depres sed, empty, s ad, or hopeless for days or weeks at a time?

 

Have there ever been times you felt very irritable or tired of the time for hardly any reas on at all?

 

Have these feelings ever stayed with you most of the time for as long as 2 weeks?

P anic dis order

Have you ever had sudden or attacks of nervousness , 755

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or a strong fear that jus t s eems come over you all of a sudden, of the blue, for no particular reason?  

If yes : Did you have thes e even though a doctor said that there was nothing s eriously wrong with your heart?

P hobic disorders

Have you ever been much more afraid of things the average person is not afraid of? Like heights, animals, needles, thunder, lightning, the sight of blood, or things like that?

 

Have you ever been so afraid to leave home by yours elf that you would not go out, even though you knew it was really s afe?

 

Have you ever been afraid to go into places like s upermarkets , tunnels, or elevators becaus e were afraid of not getting out?

 

Have you ever been so afraid of embarrass ing yourself in public that you would not do certain 756

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things most people do? Like eating in a res taurant, using a public restroom, or s peaking out in a room full of people?  

If yes to any of the above: W hen your fears were the s tronges t, you try to avoid or s tay away (name feared s timulus) you could?

Obsess ivecompuls ive disorder

Have you ever been bothered certain embarrass ing, s cary, or ridiculous thoughts that came into your mind over and over even though you tried to ignore or s top them?

 

If yes : P lease describe them.

 

Have you ever felt you had to repeat a certain act over and even though it did not make much sense? Like checking or counting something over and over or washing your hands and over again, although you knew they were clean?

P os ttraumatic

Have you ever experienced 757

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stress

flashbacks when you found yours elf reliving s ome terrible experience over and over

G eneralized anxiety disorder

Have there ever been days at a time when you felt extremely nervous, anxious , or tense for special reas on?

 

If yes : Have you s ometimes felt this way even when you were at home with nothing s pecial to

 

If yes : Have these nervous or anxious feelings ever bothered you off and on for as long as 6 months or more at a time?

S omatization disorder

Have you had a lot of phys ical problems in your life that forced you to see different doctors?

 

If yes : Have doctors had trouble finding what caused these phys ical problems ?

 

Did you start having any of problems before you were 30 years of age?

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Dis sociative disorder

Do you experience at times a of memory for hours or longer without being under the of a drug?

 

If yes : Do you travel during s uch periods?

 

Have you felt not yours elf, or you been told that you use a name other than your own?

S exual disorders

Do you have problems with your sex life?

 

Do you get s exually aroused by expos ing yours elf, by female undergarments , by rubbing agains t noncons enting people, by children?

 

Do you intensely wish to be a member of the opposite s ex?

Anorexia nervos a

Have you ever deliberately lost much weight on a diet that people started to s erious ly about your health?

 

If yes : W ere you afraid of 759

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fat even when other people s aid you were thin enough? B ulimia nervos a

Did you ever have a problem binge eating, when you would so much food so fas t that it you feel s ick?

 

If yes : W hen you were doing did you feel your eating binges were not really normal?

 

If yes : W as the urge to binge sometimes so strong that you could not stop, even though you wanted to?

 

If yes : After you had binged, did you often feel depres sed, as hamed, and dis gusted with yours elf?

 

If yes : Did you ever vomit after eating, us e laxatives, or excess ively exercise?

Adjustment disorder

In the las t 3 months, have you been very worried or upset something that happened to Like the death of a loved one, 760

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of a job, s eparation, divorce, an accident, serious illness , or that sort of thing?  

If yes : Do you feel that you had more trouble handling this situation than most people have had?

S leep

Do you have insomnia or to fall as leep or wake up at a desired time?

 

Do you have s leep attacks the day, or do you feel always tired?

 

Do you snore or wake up for air?

 

Do you have nightmares, wake in terror, or do you s leepwalk?

P ers onality disorders

 

   C luster A

Are you a person who usually is suspicious of other people, who does not care much about the company of other people, or 761

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realizes that things have a meaning beneath the s urface? C lus ter B

Are you a person who feels that you want to be paid attention to and be res pected you have to really put it on, express yourself loudly, and make your point?

 

Do you feel you are denied what you are entitled to?

C lus ter C

Are you a person who, to feel anxious, tries to be perfect, in to others , does what they to do, or tries to avoid public expos ure?

Adapted from Othmer E , P enick E C , P owell B J . P s ychiatric Diagnos tic Inte rvie w-R evis e d (P DI-R ). Manual and Adminis tration B ookle t. Los Angeles : Wes tern P sychological S ervices ; 1989. If the patient endorses any of the symptoms targeted the s creening questions, the interviewer loops back in diagnostic decision loop P.816 to search for clinical s ignificance (B ox B ) and 762 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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symptoms (B ox C in F ig. 7.1-1). T his active process yields psychiatric disorders in remiss ion, es pecially subs tance-related dis orders, and dis orders that start during childhood, such as learning dis abilities, deficit disorder with and without hyperactivity, conduct disorder, and personality dis orders. Active screening the disorders (B ox H in F ig. 7.1-1) as sures their the multiaxial diagnos es and their effect as factors for current psychiatric dis orders (T able 7.1-8). Ins truments s uch as the P sychiatric Diagnostic (P DI) or the S tructured C linical Interview for DS M-IV ensure diagnostic thoroughness . T he interviewer may keep track of all disorders excluded by negative the screen, thus lengthening the lis t of excluded ps ychiatric disorders.

Table 7.1-8 B iops yc hos oc ial C on Pres enting as Predis pos ing, Prec i Perpetuating, and Protec tive Fac Ps yc hiatric Axis I Dis orders Fac tor

B io

P redisposing P os itive ps ychiatric family history; delay in

Ps yc ho

S oc ia

Impaired premorbid personality, is olation,

Negle low ed poor p role m

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reaching developmental miles tones ; ps ychiatric disorders firs t diagnosed in infancy, childhood, or adoles cence; medical history (head injury, central nervous system disorders Axis III)

suspicious nes s, poor impulse control, anxiousnes s, perfectionism, presence of personality disorders II), low adaptive defens e mechanisms

antis o behav subs ta pover

P recipitating

Onset of severe disorders

S tres s intolerance, poor impulse control, s elfpity, blaming (projection)

T raum job or increa (Axis

P erpetuating

C hronic medical

P oor ins ight, judgment, and impulse control; low noncompliance with R x.

S ocia unem pover

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P rotective

G ood health maintenance, absence of chronic medical disorders

G ood ins ight, judgment, and impulse control; high IQ; with R x. (high ego s trength, high adaptive defens e mechanisms)

E xten suppo well-p satis fy

IQ, intelligence quotient; R x., prescription.

Taking the P s yc hiatric His tory After the interviewer has established the presence of or more ps ychiatric Axis I and II disorders , he or s he es tablis hes their history if not already done during the diagnostic looping. T he interviewer may follow a going either backward from the pres ent (e.g., when did happen last before this time) or forward, s tarting with childhood. Important points of the history are onset, cours e, and treatment respons es . T he onset can be ass es sed with a double question: did you first notice a symptom of your pres ent disorder? Up to which age do you feel you were at your best and had no ps ychiatric problems ? Often, patients give different ages for the end of their healthy, premorbid state and the beginning of their 765 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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ps ychiatric disorder. I: W hen did you first experience any problems with depres sion? P : During the s eventh grade, I had a time where I did want to get out of bed, felt tired and s ad all the time, did not even want to talk to my friends on the phone. I: F or how long did this las t? P : T wo or 3 months . P.817 I: If you look back on your life, when was the las t time you felt at your best and did not have any problems ? P : Maybe when I was 8 years old. I remember in the or third grade, I was often tearful for no reason. It did last very long. My mother told me that I was very T he answers to thes e two ques tions indicate that the patient had either a preexisting pers onality disorder or prolonged prodromal s tate to the onset of his or her depres sive dis order. T his dual questioning is a tool to identify premorbid states , personality dis orders, and prodromal s tates to Axis I psychiatric dis orders. T he onset of personality dis orders can be traced back focus ing on a s ymptom or behavior of which the patient aware, s uch as shyness or problems with authority F or example: W hen did you first notice that you were When did you firs t notice that you rebelled agains t authority figures? An alternate approach is to identify a pres ent conflict the interviewer judges to be due to a personality 766 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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and s earch the patient's past for s imilar conflicts . T he interviewer should be able to trace pers onality back to at least teenage years becaus e they repres ent lifelong patterns of maladjus ted behaviors . T he course the ps ychiatric dis order can help to confirm the of the Axis I disorders . T o draw a profile of the cours e of a psychiatric disorder gives an idea about exacerbations and remis sions . Of importance are the intervals in which the dis order to be in remis sion. T hes e intervals can identify the capacity of functioning when relatively well and can to define the goal of treatment. P atients often have difficulties in relating their ps ychiatric history to years . T he interviewer s hould introduce anchors of memorable events, s uch as getting married, moving, or changes. His tory of treatment res pons es provides information what treatments have led to improvement, remis sion, failure, or adverse effects . T reatment respons e may be judged as being consis tent or not cons is tent with the diagnosis.

P s yc hiatric Dis orders in F ull or R emis s ion T he diagnostic decision loop als o helps to detect ps ychiatric disorders in full or partial remis sion. T hey be lis ted according to the developmental s tages before adulthood such as disorders diagnosed in infancy, childhood, and adolescence.

Phas e 3: His tory and Databas e Diagnos ing ps ychiatric dis orders may arouse the 767 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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sens itivities and activate defenses. S uch respons es mostly abs ent when family, medical, and even s ocial history and routine mental s tatus items are as sess ed. T herefore, the interviewer can take a dis order-centered approach.

Medic al His tory (A xis III) T he medical his tory is of importance to the ps ychiatric interviewer for three reasons: (1) Medical dis orders can caus e s ymptoms of panic, anxiety, depres sion, and delus ional thinking diagnosed as “ps ychiatric disorder to a medical condition;” (2) s ide effects of medications prescribed for medical disorders may mimic ps ychiatric symptoms and dis orders; and (3) any medical disorder its treatment can complicate course and treatment of ps ychiatric disorders and vice vers a. Drug–drug interactions can range from mild to s evere. B iopsychosocially, a chronic medical disorder may be a predis pos ing and perpetuating factor of a ps ychiatric disorder. T he onset of a s evere medical disorder may precipitate a psychiatric dis order (T able 7.1-7). A 51-year-old farmer without a family or personal of any ps ychiatric disorder developed a severe after he had a myocardial infarction. He feared that his phys ical incapacity to work might prevent him from paying off his expensive equipment. T he absence of a medical disorder in combination with good health maintenance is a protective factor in the agains t psychiatric disorders . A dual approach helps to detect medical dis orders, asking open endedly for the patient's medical health and reviewing all s ys tems as 768 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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us ually done in general medicine. T he open-ended questions may be followed by a request to lis t all disorders that the patient pres ently is treated for, by specialist, and with which medications. A his tory of surgeries and medication allergies rounds up this first approach. T he review of systems covers all medical specialties .

F amily His tory P sychiatric Axis I and II disorders are familial. twin and adoption studies s uggest that the familial occurrence is not merely learned but follows a genetic disposition. T he familial occurrence in firs t-degree and their treatment respons e can therefore confirm the patient's diagnosis and predict P.818 the treatment response. F urthermore, the parental history may provide a prognostic look into the patient's cours e. T herefore, family his tory is the most important predis pos ing factor of the biological part of the patient's biops ychos ocial condition. T he drawing of a pedigree men as s quares and women as circles is an effective as sess the family his tory with the patient's P sychiatrically affected members are repres ented by blackened s hapes, questionable members are striped. Names, ages, type of dis order, and treatment all fit into genogram.

Developmental His tory E ven if a psychiatric diagnosis during childhood or adoles cence is not made, the interviewer s hould 769 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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five important areas: Developmental miles tones: delayed ps ychomotor speech development and toilet training may point to early developmental problems . Ability to learn in school: s low learning or repetition the first grade may point to mental retardation; circums cribed deficits, s uch as dyslexia or may indicate a learning disorder. Attention problems with hyperactivity and poor impulse control may contribute to s ubs tance abus e and to the development of a personality disorder, as antis ocial pers onality disorder. Dis ciplinary problems may cover a broad range. Arguments with teachers , objections to rules, tantrums, resentfulnes s, and vindictivenes s point to oppos itional defiant dis order. F ighting, stealing, vandalis m, and school discipline problems characterize males ; lying, truancy, running away home, substance us e, and pros titution characterize females with conduct dis order. F urthermore, symptoms s uch as violent behavior toward peers, or animals and fire setting also sugges t disorder, which, in later adoles cence, may progress antis ocial pers onality disorder. T he earlier the conduct dis order, the worse the prognos is and the greater the risk for later mood, anxiety, and s ubs tance-related disorders . During childhood and adolescence, social with decline in hygiene, truancy, and anger may herald s chizophrenia; phobias , obsess ions , 770 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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compuls ions, and depress ive symptoms may adulthood ps ychiatric disorders .

S oc ial His tory A biographical, detailed s ocial history of key life events may be informative but may not serve the ass es sment social factors in the patient's ps ychiatric disorders . T he relations hip between s ocial factors and ps ychiatric disorders is reciprocal. T o teas e out this reciprocal relations hip is the interviewer's tas k in addition to sociodemographic fact finding. T he interviewer s hould target four topics: P remorbid vers us pos tmorbid psychosocial functioning. P remorbid functioning repres ents the highes t level of patient performance meas urable by the social component of the G AF . T he difference between the pres ent and the past G AF scores meas ures the morbidity caused by the ps ychiatric disorder. T he return to the premorbid level of functioning is a goal of ps ychos ocial rehabilitation. T herefore, the interviewer wants to clarify the premorbid vers us pos tmorbid level of functioning res pect to family life and work, including s chool and military, friends , and community functions such as church and s ocial organizations. S ocial factors as ris ks for psychiatric dis orders. factors can predispose to a ps ychiatric dis order, precipitate its onset, perpetuate its cours e, or the patient agains t morbid influences (T able 7.1-7). history of physical, s exual, and emotional abus e, rejection and neglect during upbringing, and 771 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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provis ion of poor role models can become a predis pos ing factor for the development of disorders . F or ins tance, patients with dis sociative disorders , including diss ociative identity disorder, often report a history of physical and s exual abus e, es pecially during childhood. B arring memory distortions, the pres ence of abuse can often be confirmed by outside evidence. S evere lifetrauma can predis pos e and precipitate the onset of posttraumatic stress disorder (P T S D). Acute or stress ors , s ingle or multiple, can predis pos e, precipitate, and perpetuate adjus tment disorders symptoms of depres sion, anxiety, or dis turbances conduct. T hes e factors are listed on Axis IV as ps ychos ocial and environmental problems. S ocial support. In contras t, the absence of abus e, rejection, and neglect and the pres ence of strong, positive role models and an extensive s upport in the pas t and present that s ecured adequate childrearing and education can be s trong protective factors against exacerbations of ps ychiatric S ocial support can improve prognos is. It can the patient to comply with treatment. Negative impact of ps ychiatric disorders on s ocial advancement. P s ychiatric dis orders can impede patient's s ocial development and can lead to demotion, job los s, and divorce.

Mental S tatus E xploration and T he interviewer monitors the patient's mental s tatus throughout the interview. T oward the end, the 772 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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us ually address es some mental status areas directly, es pecially by exploration (T ables 7.1-3, 7.1-4, and 7.1and tes ting (T able 7.1-6). If not previously ass ess ed, interviewer explores ris k factors s uch as s uicidality, homicidality, cognitive impairment, s ubs tance abus e, ps ychotic symptomatology, including command hallucinations .

Phas e 4: Diagnos ing and Feedbac k T hroughout the s es sion, the interviewer collects data he or s he organizes in a biopsychosocial formulation— as sets and s trengths , differential diagnos es, if and multiaxial diagnos is . He or she feeds this back to the patient when the interviewer dis cus ses the evaluation of the patient. T he interviewer also us es this information in phase 5 when he or s he proposes the treatment plan and dis cuss es the prognostic outcome.

B iops yc hos oc ial F ormulation T he interviewer may summarize the findings of the in the form of a biopsychosocial formulation. T he biops ychos ocial conditions that contribute to the development, ons et, and course of a ps ychiatric can be clas sified according to their impact as precipitating, perpetuating, or protective factors (T able 7.1-8).

A s s ets and S trengths T he interviewer als o as sess es the patient's ass ets and strengths . T his evaluation should be made in terms. It includes the patient's knowledge, interes t, aptitude, experience, education, and employment 773 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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all items that are clos ely related to the protective T able 7.1-8.

Differential Diagnos is Initial ps ychiatric diagnostic interviews may yield incomplete, vague, and contradictory information s o the interviewer believes he or she cannot make a with confidence. A differential diagnos is that weighs the pros and cons for a group of Axis I and II psychiatric disorders may then take the place of a s pecific T he advantage of the differential diagnosis is that it comprehensively captures the perimeter of ps ychopathology that the interviewer takes into P.819

Multiaxial Diagnos is DS M-IV -T R encourages multiple diagnoses on Axis I T he more pervasive disorder receives priority over the pervas ive one. F or instance, a patient who has the diagnosis of schizophrenia may not receive the diagnosis of dysthymic dis order because dys thymic disorder is believed to be an as sociated feature of schizophrenia. If a psychiatric disorder is judged to be to a medical condition, such as reserpine-induced depres sive dis order, the interviewer should not make additional diagnosis of major depress ive disorder. T R us es a host of s pecifiers to increas e the precis ion diagnosis. T heir dis cuss ion exceeds the frame of this chapter. However, some determinations are particularly us eful:

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P rincipal diagnos is . T he interviewer as signs this determination to the psychiatric disorder that mos t reliably and comprehensively explains the pres ent symptomatology and is the focus of treatment. P rovis ional diagnos is . T he interviewer believes a patient fulfills sufficient criteria for a particular ps ychiatric diagnosis; however, the interviewer documentation for some of the criteria. P s ychiatric dis orde r NO S . T he patient does not sufficient s ymptoms to fulfill criteria for a specific diagnosis, even though the information appears accurate and complete. P as t ps ychiatric diagnos is . T his widespread term is replaced in DS M-IV -T R by s pecifiers such as “in full remis sion, partial remis sion, or residual state.”

A xis III Dis orders T hese are the medical disorders . If a medical dis order cons idered as the caus e of the psychiatric dis order, it listed on Axis I as a mental disorder due to a general medical condition and on Axis III as medical disorder.

A xis IV On Axis IV , the interviewer lis ts psychosocial and environmental problems that were pres ent during the preceding year of the diagnos is and that may affect diagnosis, treatment, cours e, and prognosis. However, stress ors that clearly relate to the pres ent psychiatric disorder, s uch as a life-threatening trauma in P T S D, also be included even if they fall outside the 1-year frame. DS M-IV -T R lists nine categories that us ually 775 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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as stress ors : problems with primary support group, environment, education, occupation, hous ing, health care access , legal system, and psychosocial environmental.

A xis V: G lobal A s s es s ment of F unc tioning T he G AF scale is a dual scale. It measures two ps ychiatric disorders: severity of s ymptoms and level of ps ychos ocial functioning. It ranges from 100 (s uperior functioning, no s ymptoms ) to 1 (persistent danger to others and self with inability to maintain minimal hygiene). T he interviewer as signs a s core that reflects lowest level of either of the two. T his score can be through key points of the patient's psychiatric history, it can trace the cours e of the illnes s. Usually, the interviewer measures the present level of functioning the highest level of functioning during the last year.

Phas e 5: Treatment Plan and In phas e 5, the roles of interviewer and patient stay revers ed: T he interviewer ans wers the patient's asked unasked ques tions . T he interviewer decides firs t which level of care the patient requires . He or she discuss es the patient the divers e treatment options and their poss ible advers e effects. T he interviewer may identify immediate targets of treatment and tell the patient what to expect if he or she cooperates . T he interviewer's interventions are most effective if he or s he has been to forge an alliance with the patient. If the patient is severely disabled, such as being s uicidal, homicidal, violent, or ps ychotic, or has los t impulse control, is 776 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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disoriented, or intoxicated, the patient may need hospitalization. Most patients can be treated as outpatients without interruption of their work s chedule. S ome need temporary disability or home supervision. T he interviewer des igns a biopsychosocial treatment T o improve the biological condition, the interviewer us e medication. Most ps ychotropic medications have a delayed ons et of action, as , for example, the s elective serotonin reuptake inhibitors (S S R Is) and mood T herefore, the interviewer may, for the immediate temporary effect, combine s ubs tances with delayed of action with thos e with an immediate ons et, such as anxiolytics, low dos ages of atypical neuroleptics, and, rarer cases , s timulants . A woman who has a major depress ion with retardation and no history of substance abuse who in 3 days wants to attend her daughter's wedding may be prescribed a s timulant for the day of the fes tivity. F urthermore, s he may des ign s trategies to manage key symptoms of the disorders behaviorally or cognitively. the ps ychological dimension, the interviewer may ps ychotherapeutic interventions used in cognitive that increase ins ight, correct perceptual distortions and maladjus ted behaviors , and support ps ychological functioning. S ocial conditions may be improved, for instance, by activating family s upport, with s hort-term relief of s tres s sick leave, by arranging vocational rehabilitation, or by facilitating the ventilation of traumatic events. us ed in interpers onal ps ychotherapy may help. R eferral a ps ychologist or s ocial worker as cas e manager may 777 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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cons idered. T he interviewer may contras t the natural history of the untreated disorder with the cours e that be achieved if the patient cooperates fully and the treatment is effective. T he patient's clear unders tanding the difference can be a s trong motivating factor for the patient's compliance.

P S YC HIA TR IC INTE R VIE W: A T he four components of interviewing are integrated and run s imultaneously. T heir course can be divided into phases, illustrated in the s ample interview below.

Phas e 1: Warm-up and C hief T he interviewer puts the patient and him- or hers elf at (rapport). T he interviewer s ets the scope of the openended screening ques tions (technique); observes the patient's appearance, movements , s peech, and affect (mental s tatus ); and notices clues and the chief (diagnosis).

Phas e 2: Diagnos tic Dec is ion L oop Interviewer and patient forge an alliance (rapport). T he interviewer progress es from questions with broader to narrower s cope. In case of an acute trauma, s uch as in cases of bereavement, divorce, rape, or recently cancer, the interviewer reduces anxiety by address ing emotions evoked by the trauma (technique). He or she explores the thought content, such as hallucinations , delus ions, obs ess ions, compulsions , avoidance panic attacks , and dangerousnes s to others and self (mental s tatus ). He or s he relates the chief complaint P.820 778 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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to concurring symptoms , s igns, precipitating events, stress ors . He or she verifies and excludes specific diagnoses (diagnosis).

Phas e 3: His tory and Databas e T he interviewer demons trates expertis e in handling the patient's problems and offers guidance (rapport). He or transitions from topic to topic to fill in gaps, follow and reconcile inconsistencies (technique). He or she probes judgment and ins ight and tes ts cognition and suggestibility (mental s tatus). T he interviewer as sess es patient's s ocial, family, and medical history (diagnosis).

Phas e 4: Diagnos ing and Feedbac k T he interviewer dis cus ses the diagnos is with the and s ecures the patient's acceptance (rapport). He or explains the nature of the disorder and the treatment options (technique). He or s he reflects on the patient's behavior during the interview (mental s tatus) and summarizes the diagnostic findings on five axes (diagnosis).

Phas e 5: Treatment Plan and T he interviewer outlines the future therapeutic relations hip, his or her availability, and the need for compliance (rapport) and obtains consent for the treatment plan (technique) using the patient's language and level of insight (mental status ). T he interviewer the prognos tic outlook with the patient (diagnosis).

S ample Interview 779 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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Ms. Lorraine R . is a 56-year-old, white, mildly obese with puffy, red eyes, and washed out mascara who is tearful and shaking.

P has e 1: Warm-Up and C hief (1) I: Hello, Ms. R . I'm Dr. O. P lease come in and take P : (W alking slowly into office, with a quivering voice) P lease call me Lorraine. (slumping into the chair) (2) I: What's going on? (P ause) Y ou are all tears. … P : (Looking up, sobbing, breathing rapidly, and her s houlders ) I cried all night. I heard my voice again and again: “S orry, Ms. R . It's s tage 1 cancer.” (3) I: Y our friend J oan called me yesterday. S he told really had to see you today. P : Y eah. It hit me yesterday afternoon. (C rying) I called because she went through the s ame thing. (4) I: S o that's why J oan called me. P : Y es, s he said you had helped her. (wipes her nos e, crying) (5) I: (Looking at her with concern) Hmm. I'm glad s he this way. P : (W iping her eyes but with a firmer voice) I had the biops y yesterday morning. (6) I: When did he first s us pect it? P : (E ven more collected) A week ago. I had a and he told me he felt a lump. (7) I: How did that s trike you? P : Like an out-of-body experience. I heard it without hearing it. 780 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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(8) I: And yes terday? P : It hit me right here. (grabbing her ches t) I couldn't crying. (her eyes fill with tears again)

R APPOR T T he patient reques ted to be called by her firs t name, expres sing her need to have a pers onal, close, dependent relationship to the interviewer (ans wer 1 T he interviewer address ed the patient's tearful affect, immediately s hifting toward a patient-centered interviewing mode. W hen the patient reported that s he cried all night (A2), the interviewer avoided with her (Q3) by saying s omething s uch as , “Y ou must really been torn up.” Ins tead of cathars is , the put her emotional pain into a social framework to her of her s upport s ys tem and steered her toward a cognitive management of her emotions . R eferring to he introduced her relations hip to the interviewer as a model of alliance.

TE C HNIQUE T he interviewer opens by addres sing the patient's status . T he patient res ponds by des cribing her chief complaint (Q2, A2). As a continuation technique, the interviewer points to the urgency of the patient's (Q3), which res ults in the des cription of the trauma and patient's emotional res ponse (A3 to A8) aided by (Q6 to Q8).

ME NTAL S TATUS T he patient displayed a sad affect, which intensified she reported the gynecologis t's telephone call. 781 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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this affect reacted to the interviewer's neutralizing (Q4, 5), excluding a melancholic depress ion. T he initial emotion to the gynecologist's telephone call indicated a diss ociative traumatic respons e (A7), which raised the pos sibility that the patient is s uggestible. T he patient's emotional res ponsivenes s confirmed her reactivity (A8) noted above (A4, 5), excluding the poss ibility that her affect was frozen into a depress ive but reacted according to thought content.

DIAG NOS IS In the dual opening approach, by asking for the chief complaint and by confronting the patient with her affect, the interviewer found an economic, individualized pathway to her chief complaint (Q2; B ox A in F ig. 7.1C larifying her emotions (Q7), the interviewer found a diss ociative traumatic response (A7), s ugges ting the of an acute s tres s disorder, which may turn into an P T S D if untreated. Alternatively, an adjus tment with mixed anxiety and depress ed mood could be cons idered.

P has e 2: Diagnos tic Dec is ion L oop (9) I: C ould you s leep? P : (W iping her eyes again, even though she is not Not at all. All night I heard the gynecologist's voice: “S orry, Ms. R ., it's s tage 1 breas t cancer.” (10) I: S o you relived the bad news … P : (Interrupting) Over and over again. His voice stirred up. (S itting up erect) Like from a bad dream. After the mammogram, I was , like, in a daze. Nothing sank in. 782 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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her eyes) (11) I: S o it really s hook you up. P : (Looking pas t the interviewer) Y eah. I forgot to make new appointment. I didn't even fix my breakfast this morning. F elt, like, paralyzed. No appetite. (B ites her lip) Instead, I started smoking again. F ive cigarettes yesterday and one this morning. (12) I: Has anything like this ever happened to you P : Not really. … when my husband asked me for a felt numbed at firs t, but we had problems for a long (13) I: E ver felt down like you feel now? P : (T ilting her head left to right) During the las t 5 years, felt down most of the time. I never felt really normal, work kept me busy. (14) I: Did you get any treatment for depres sion lately? P : Not recently. Only for s moking. B ut 15 years ago, I treated for depress ion with P rozac and then again 10 ago before I got divorced. P.821 (15) I: W hen you were depress ed in the past, what in your life? P : I stayed away from people (with a s igh), even from own family. B ut I wanted them to tell me that that they love me. I did not want to do anything. I was so tired all time, couldn't fall as leep but overs lept in the mornings . ate a lot of junk food and gained weight. (16) I: How did you value your life then? P : I dropped to an all-time low. (17) I: Did you ever want to die? 783 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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P : I wished I wouldn't wake up in the morning. (18) I: E ver tried to do anything to hurt or kill yours elf? P : (W ith a frown) I thought about it, but I have my (19) I: Did you get down when you had your children? P : No. (20) I: T he baby blues? P : (W ith an open smile) No. I felt good. (21) I: Did those suicidal thoughts come back since yesterday? P : (F irmly) No. I want to live. (22) I: W hen you felt down and depress ed, did you feel that people were agains t you? P : I was hiding from them. (23) I: Did you ever get s o down that your thoughts became loud? P : I thought I was worthless . (24) I: Did you hear voices telling you that? P : No, jus t my thoughts . (25) I: E ver heard any voices when nobody was P : No. (F rowning) I don't think I was crazy. (S haking head) (26) I: S o your depres sion was never so severe that heard voices or that you were s erious about killing yours elf? P : I thought I was los ing it, but I didn't hear or see And then I would smoke more and that helped my (27) I: Did your mood ever become s o good that you full of energy or didn't seem to need much s leep? P : (W ith a laugh) I don't think so. 784 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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(28) I: E ver become hypersexual. … have affairs. … frowns and s hakes her head), or go on buying s prees ? P : S ometimes when I was depress ed, I liked to buy but it didn't make me feel better. (T he corners of her mouth drop) (29) I: Have cleaning s prees? P : (W ith a sour s mile) No, jus t chain-smoking sprees . (30) I: W ere you a heavy smoker? P : T wo and a half packs a day. (Looking down) B ut I months ago. (Looking the interviewer in the eye) (31) I: W hat helped you quit? P : (F ast, with a firm voice and nodding) T he patches Zyban. I took them for 2 months. (32) I: How did that help you? P : (S miling) It lifted my mood, too. (33) I: Y ou felt depres sed? P : I think I have always been s omewhat unhappy—for last 4 or 5 years , or more. Did not want to do much, irritable and anxious , and cried easily. (S wallows) (34) I: Did you ever feel better in between? P : (S haking her head) Maybe for a few weeks , but it lasted. (35) I: How did Zyban help? P : I started to do more things and felt better. I could smoking. (36) I: Did you drink als o? P : (W ith dis gus t) I hate alcohol. It makes me woozy. (37) I: Do you drink coffee? P : No. I drink soda pop with caffeine. 785 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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R APPOR T R apport remained intact. T he patient actively in the interview, interrupting the interviewer (A10) and volunteering details in answering the interviewer's questions , thus engaging in a cooperative alliance (A9 11, 14, 15, 26, 28, 30, 33). Her ans wers portrayed insight into the pathological nature of her mood symptoms. T he interviewer worded the empathic statement (Q11) in a manner that elicited a des cription her traumatic symptoms. B ecause the patient showed emotions freely, the interviewer believed that the was comfortable with him (A9 to 11, 13, 15, 18, 20, 21, to 34, 36), making interventions to improve rapport unnecess ary.

TE C HNIQUE T he interviewer completed the coverage of the topic of recent traumatic res ponse (Q9 to 12). S he followed the interviewer's smooth transition when the interviewer screened for depres sion (Q13 to 15), s uicidal (Q16 to 18), postpartum depres sion (Q19, 20), symptoms (Q22 to 26), mania (Q27 to 29), nicotine addiction (Q30 to 32), dysthymia (Q33 to 35), and (Q36) and caffeine us e (Q37). T he interviewer the patient's evas ive answers (A22, 23, 26) by more questions for hallucinations (Q24, 25) and by the patient's res ponses (Q26). T he patient agreed with the interviewer's summaries , documenting good verbal unders tanding (Q10, 11, 26).

ME NTAL S TATUS T he patient res ponded with relevant details to closed786 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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ended ques tions or statements (Q9 to 14, 17 to 30, 33, 36, 37), showing that she remained verbally productive spite of her depres sed affect. S he handled open-ended questions in an appropriate, goal-directed manner 16, 31, 32, 35), s howing her ability to focus and to questions accurately. Her affect remained reactive and appropriate to the content of her ans wers (A9 to 11, 13, 18, 20, 21, 25, 27 to 32, 36) but showed a depress ive (A9, 11, 15, 18).

DIAG NOS IS T he interviewer ass es sed symptoms ass ociated with chief complaint (Q9 to 11; B ox C in F ig. 7.1-1), reliving traumatic experience, derealization (A10), and functioning (A10, 11; B ox B in F ig. 7.1-1), confirming initial impress ion of a firs t-time acute traumatic disorder (A12; B ox D in F ig. 7.1-1). W ith Q13, the interviewer searched for a second chief complaint (a “yes ” B ox G in F ig. 7.1-1) and found 5 years of anhedonia 33 to 35) with only s hort remis sions of a few weeks suggesting dys thymic disorder, which the interviewer not pursue any further. T he interviewer also clinical s ignificance for a third chief complaint, (A14; a “yes ” res ponse to B ox G in F ig. 7.1-1). T his complaint was as sociated with s everal s ymptoms (B ox F ig. 7.1-1): s ocial withdrawal, los s of initiative, and insomnia (A15), death wish (A17), suicidal feelings of worthles snes s (A23), and losing her mind A history of s uicide attempts (A18) or present suicidal thoughts (A21) were miss ing. T hese findings confirmed diagnosis of major depress ive disorder currently in remis sion (A14; B ox D in F ig. 7.1-1). T he patient persecutory delus ions (A23) or hallucinations (A23 to 787 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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excluding a major depress ion, s evere, with ps ychotic features (B ox D in F ig. 7.1-1). Actively, the interviewer s creened for ess ential of other ps ychiatric disorders (B ox H in F ig. 7.1-1). T he interviewer excluded mania (A27 to 29) and alcohol (A36; B ox H in F ig. 7.1-1) but found evidence for dependence in early partial remis sion (A29 to 33). T he reported depress ed, irritable, and anxious feelings may have been related to nicotine P.822 dependence and intermittent withdrawal because smoking relieved the depres sed feelings (A26). Alternatively, the depres sive symptoms could be part of dysthymic dis order with late onset (A33, 34) that, smoking, was improved by Zyban (bupropion) (A35).

P has e 3: His tory and Databas e ME DIC AL HIS TOR Y (38) I: W hat prescription medications or over-themedicines do you take? P : No pres criptions any more. My gynecologist stopped hormones when he felt the lump. B ut I have a chronic cough, and I take some cough drops . (39) I: Do you have any other medical problems? slowly) S uch as thyroid problems ? Diabetes? High press ure? A head injury? Allergies ? P : (S haking her head) No, not that I know of.

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(40) I: W ho in your family had problems with mood like you? P : My three kids are okay, but I'm adopted (her voice cracking). I don't know my biological parents or (41) I: Y our voice changed when you said adopted. P : Y eah. My adoptive parents always told me I was (W ith s ad contempt) Y es , s pecial. I always fought

DE VE L OPME NTAL HIS TOR Y (42) I: How did you feel in school? P : I felt I had to prove mys elf, but I was a good student. (43) I: And in front of a clas s? … or in front of spells of anxiety? P : I got a lump in my throat and butterflies in my but it excited me. I could do it.

S OC IAL HIS TOR Y AND S UPPOR T (44) I: How do you feel about rejection now? P : T hat's the worst. I feel my daughter will s tay away me. S he will reject me because of my cancer. (45) I: S tay away from you? How's that? P : W ell… I s tayed away from my cous in for her las t when she had breas t cancer. I panicked when I saw did not know how to deal with it. Now I feel I'll lose my daughter over this . And I don't know what to do. (46) I: Do you have other children? P : Y es. I als o have two s ons , all are from my ex. (47) I: How is their support? 789 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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P : G ood. B ut my daughter is my friend, and I hate to her. I couldn't bear it. None of my children know what depres sion is. T hey are all so healthy. (48) I: W hat about your ex? P : W hat's left of him is a big s ettlement. He divorced marry his s ecretary. He rejected me, too, when I went through the changes. (49) I: S o you experienced rejection. W hat images mind? P : My cousin. (W ith express ion of fear and disgust) she s hriveled away when s he had cancer. How I could take it when she s hriveled away. (50) I: S o you can't s hrivel away yourself. P : Y ou're right. B ut how do I do that? (51) I: B y rejecting yourself. R eject your cancer! S tay F ear and depres sion may weaken your immune P : E verybody tells me I can do it. My friends s ay I can it. (W ith a thin smile and frown) I heard it over and over again since yesterday. (52) I: T hey don't want you to s hrivel away. P : T hat's right. T hey don't want me to shrivel away. sigh of relief) T hey say it for their own s ake. (53) I: T hat's right. T hey don't want to see you s hrivel like your cousin. (With emphasis) Y our friends and your daughter look at you as an example. T hey want you for their own s ake. Do you have any ties to religion? P : No. I'm not going to mas s, but I believe in a higher power. (54) I: Do you pray? P : No. 790 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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(55) I: Y ou told me you s ee your cous in s hrivel away. you work through your eyes ? P : Y es. I'm an interior des igner. (56) I: Oh? How did that start? P : I have a college degree in des ign. Decorating my profes sion. I still enjoy my work and my colleagues.

ME NTAL S TATUS E XPL OR ATION AND TE S TING (57) I: S o you can image things . W e will us e imagining fight your fears and your depres sions and teach you to imagine your cancer s hriveling. P : (S miles) (58) I: Let's s ee how s trong your imagining is. P leas e me your ring. (T he patient hands the interviewer her wedding band). I'm going to attach a string to your ring (interviewer does ). Let me s how you how one can the ring with imagining. (T he interviewer swivels his around away from his desk and sits now in front of the patient. T he interviewer holds the s tring in his right and unsupported arm with the ring hanging 1 in. above the floor.) Now I can swing the ring around like this the ring). I do this with my will power like we do many things . B ut I can also move the ring without s winging it voluntarily. (He brings the ring to a stands till.) I can just it hang down and s tart imagining. I imagine now that ring s tarts to swing… swing in a circle… swing in a (the ring moves s lightly back and forth, not in a circle). Now I imagine that the ring s wings in a circle, the circle gets rounder and rounder, the circle becomes bigger bigger (the ring actually swings in a circle of a 5-in. 791 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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diameter). Y ou can train yourself in imagining. (T he interviewer offers the s tring to the patient.) Now you try. P : (T akes the s tring with the ring) (59) I: S wing the ring around in a circle. P : (C omplies ) (60) I: T hat's what we don't want to do. W e want to us e imagination. Hold the swinging. P : (C omplies ) (61) I: Now let the ring hang down still and s tart that the ring s tarts moving. (T he ring swings back and forth in a 1-in. swing). Now imagine that the ring starts go in a circle, rounder and rounder, in a circle, bigger P.823 and bigger. (T he ring starts to move in a 3-in. circle). can train yourself to do this . It's called the pendulum tes ts your imagination. In addition to the ring tes t, the interviewer als o us es the sway test, the S piegel E ye T est, and the finger s ticking (s ee X. Mental S tatus E xamination). T he four tests patient's moderate ability to follow images with motor action. 61. P : (S miling and shaking her head as in disbelief) I us e my imagination to help me. B ecaus e the interviewer is in a tes ting mode, he als o examines orientation, recent memory, and abs traction interpreting proverbs and identifying the common category of bicycle and airplane and finds the patient to fully oriented and have intact cognitive functioning. F urthermore, the patient has at least average 792 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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because she could multiply 2 × 192 on the W ilson Approximate Intelligence T es t and by her res ponses to K ent T est. (62) I: W e need your fighting spirit. C an you believe? P : I don't trust eas ily. (63) I: C an you believe in s cience? P : I'm not sure. (64) I: Do you believe in medical science? P : I'm not sure, but I will do what they tell me. (65) I: I'm so glad that your cancer was detected at an stage and that you got your diagnos is 24 hours after biops y. T hat means treatment can s tart soon. Have met the oncologist? P : No. B ut I've heard of him. My friends recommend (66) I: S o you don't plan to go out of s tate to the X Ins titute? P : No. I'll s tay with the doctors here.

R APPOR T R eviewing the medical his tory s ignaled to the patient thoroughnes s and concern about her general health 39). T he interviewer address ed the cracking in her showing sens itivity to her affect about her adoption T he interviewer used her fear of rejection (A41 to 45) to explore her own rejecting of the cous in. T he interviewer channeled the patient's tendency to reject toward her cancer rather than toward hers elf (A51). T he built up her confidence in her ability to imagine her to shrivel (Q57) and to turn her imagination into action (Q58 to 61). T his approach initiated her positive 793 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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and cognitive res tructuring, including imagining. W ith these interventions , the interviewer added to the diagnosis -centered interview a patient-centered therapeutic intervention. S uch ad hoc crisis intervention activated the therapeutic alliance and put guidance into action.

TE C HNIQUE Using a smooth transition (Q38), the interviewer attempted to complete the database, opening up family, developmental, and social history with openquestions (Q38, 40, 42, 44), followed by clos ed-ended questions and s ome open-ended ones (Q47 to 49). the interviewer noticed a s ign of fear and s adness in patient's voice (A40), the interviewer clarified this sign (Q41) and s earched for as sociated s ymptoms to be fit the sign into a pos sible diagnosis . B ecause the expres sed fear and disgust (A49), the interviewer to make an immediate therapeutic intervention agains t her harmful self-image of shriveling away. T he reverted the patient's tendency to project on hers elf to projecting on her cancer (Q51). T his revers al fed into supportive s tatements of the patient's friends (Q51 to and initiated training in image control (Q55 to 61).

ME NTAL S TATUS T he patient showed fear of abandonment (A40, 44), poss ibly based on her phobia of physically crippling disease, which s he projects on her daughter. T ests of suggestibility (A58 to 61), orientation, recent memory, abstraction are within the normal range. S uggestibility tes ted for two reasons: (1) to examine whether 794 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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suggestibility can lead to pathological autos uggestions (i.e., diss ociative and conversion s ymptoms ), and (2) to increase the patient's control over imaging directing it agains t her cancer.

DIAG NOS IS T he medical his tory is pos itive for chronic cough (Q38, T he patient's fear of abandonment encountered during the as ses sment of the family history adds an additional chief complaint and reopens the diagnostic decision proces s (A40; B ox F in F ig. 7.1-1). T he interviewer the patient's developmental his tory for ass ociated symptoms of fear of rejection. S ocial phobia and disability (A42) are excluded, but the patient's respons e suggests the pos sibility of generalized anxiety in my stomach”), somatization, or conversion (“lump in my throat;” A43). Obsess ions and are not ass es sed. T he fear of rejection (Q44) s ignifies special phobia of phys ical decay (A49) also projected her daughter (A44, 45, 47), which intensifies her cancer. S he fears less premature death than because of her phys ical decay. T his specific phobia of terminal, crippling dis eas e (A45, Q49) is based on the defens es of s uppress ion and repress ion operating on a high adaptive and mental inhibition level, respectively. projection operated on the dis avowal level and not at level of defensive dys regulation, as is the cas e in projection. T he coding of defens es on a sixth axis, the defens ive functioning axis, is under cons ideration in the DS M-IV -T R . T he patient's average level of sugges tibility may lower ris k that her acute stress dis order progres ses to a 795 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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with pathological diss ociation (A61) as a result of autos uggestion. T he interviewer limited the predis pos ing, precipitating, perpetuating, and factors for the social history taking to the extent that it may be relevant for Axis IV . F or time reasons, the interviewer omitted exploration of relations hips to parents , coworkers, and friends other than J oan. her children, the patient did not seem to have support from her church or s elf-support from prayers (A53, 54) confidence in medical science (Axis IV ).

P has e 4: Diagnos is and F eedbac k (67) I: Let me tell you what I have learned from our meeting today. Y ou were overwhelmed when you that you have stage 1 breast cancer. Y ou felt numbed had flashbacks of the gynecologist's mess age. S uch res ponse may mark the ons et of an acute s tres s Y ou fear your friends , es pecially your daughter, will you as you avoided your cous in, so they don't have to with your was ting away. Y ou are sensitive to such abandonment becaus e lifelong you fought with the rejection that you imagined occurred from your parents . P : (E mphatically) Y es, yes , yes! W hat can I do about (68) I: B elieve in your daughter. S he does not have anxiety of s hriveling away. S he will not avoid you. W ith we want to fight the progres sion of your traumatic res ponse and prevent recurrence of depres sion. P : How? P.824 796 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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R APPOR T T he interviewer s hows his or her expertis e in the patient's dependency needs from the patient's point insight, namely, as s ens itivity to abandonment (Q67). patient accepts the diagnos is (A67) and s hows interes t the interviewer's approach to her treatment (Q68).

TE C HNIQUE With an accentuated trans ition, the interviewer the patient for the diagnos tic feedback, a role reversal. Now the interviewer and not the patient provides the of information (Q67).

ME NTAL S TATUS T he patient's affect has dramatically changed s ince the beginning of the interview. S he had switched from sadness , anxiety, and des pair to an emphatic approval the interviewer's feedback, express ing openness and interes t in the interviewer's treatment plan s howing her affective reactivity (A67).

DIAG NOS IS T he interviewer initiates the diagnos tic feedback bas ed biops ychos ocial information, including the patient's and s trengths , and multiaxial diagnoses .

P has e 5: Treatment P lan and (69) I: W ell, you have conquered your addiction to with your determination and with the help of Zyban or Wellbutrin, which is an antidepres sant. Y ou had in the pas t and W ellbutrin has helped you. S o did 797 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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S ince you started smoking again, I think Zyban can become our Old F aithful again. W e should s tart it now. you recall its major ris k? P : W hat do you mean? (70) I: T he potential for a seizure. P : Y es, I know. (71) I: Did you ever have a s eizure in your life? Like as child? P : No. (72) I: Did you have one when you took the Zyban? P : No. (73) I: Y ou told me you don't drink much. Alcohol withdrawal could poss ibly make you more sensitive to seizure risk by Zyban. P : I'm somewhat afraid of that. B ut Zyban made me well before. (74) I: If you wake up and have s oiled your clothes or your tongue, s top Zyban and call me immediately. your ability to tolerate the medication in the past gives an edge. P : I understand the risk, and I will take it again. (75) I: P s ychologically, you have strong feelings about rejection. T his feeling can hurt you, but it also can help you. P : How's that? (76) I: (W ith emphas is) It's you who rejects rather than being rejected. P : I can never do that. (77) I: Y ou've done it before. Y ou rejected the Y our determination agains t cigarettes helped you. 798 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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Zyban would not have made you s top smoking. It's you who make the drug work. Y ou noticed how it lifted your spirits. Y ou have to use this s pirit to tell yourself you everything you can to fight the cancer. S ee the stay with the treatment, and have the image of Y ou said yours elf others want you to be strong for their sake. Y our cancer will shrivel away, (with emphasis) you. Y ou think in images . W e will work to implant the image in your mind how the cancer is s hriveling under therapy. P : B ut my cous in's… (78) I: (Interrupting her) P urge that image like you the cigarettes. P urge it like you'll purge your cancer. image of your wasting cous in is a cancer of the mind. P : B ut how do I fight it? (79) I: W henever your cousin's image pops up in your straighten your posture, take a deep breath, and how your own body rejects cancer cells after removal the small lump in your breast. P : (W ith a questioning express ion in her face and straightening her posture) (80) I: As homework to strengthen your imagination, the pendulum as often as you can but at leas t three day. I will see you weekly at the beginning and work you on other imagining exercis es , on positive thoughts, and I'll check the effects of the Zyban and the need for additional medication to control anxiety and B ut I need your help. W e have to put our heads make it work. And we may as k your daughter to come with you and maybe even J oan. P : I will take my medication and try to work on the 799 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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I will also talk to my daughter and to J oan. (81) I: Our s ucces s depends on how well we can depres sion and anxiety. Y ou had success in smoking and depres sion in the pas t and that bodes for the future. P : (W ith a broad s mile) I feel s o much better now. I'll J oan and thank her for getting me here.

R APPOR T B ecaus e the patient has accepted the interviewer as expert, the interviewer continues this role as a guide for biops ychos ocial treatment plan: B iologically, the interviewer refers to the patient's pos itive experiences with Zyban and P rozac and emphas izes the concern the safety of treatment (Q69 to 74). P sychologically, interviewer uses the patient's thinking in images to combat her self-destructive vis ion. S ocially, the us es the patient's desire to be supported by her which rounds out the interviewer's role as a trustworthy guide.

TE C HNIQUE T he interviewer s ummarizes the patient's pos itive experiences and s trengths that she had s hown in the interview as a bas is for the treatment plan.

ME NTAL S TATUS T he prominent feature (Q,A69 to 81) is the patient's change from an anxious and doubtful to a confident

DIAG NOS IS T he patient's emotional reactivity to the interviewer's 800 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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input added to a favorable prognos is of the patient's traumatic stress reaction.

C as e S ummary I. IDE NTIFYING DATA Ms. Lorraine R . is a 56-year-old, white, divorced, mildly obese, C atholic woman and the mother of three who had an acute s tres s res ponse to a recent breast cancer.

II. C HIE F C OMPL AINT “I cried all night. I heard my gynecologis t's voice again again: S orry, Ms . R . It's s tage 1 breas t cancer.”

III. INFOR MANTS T he patient and her friend, a former patient, who reques ted that the patient had to be s een immediately.

IV. R E AS ON FOR C ONS UL TATION Acute s tres s respons e to a recent diagnosis of breast cancer.

V. HIS TOR Y OF PR E S E NT IL L NE S S T he day before the interview, the patient was with stage 1 breast cancer. S he cried all night and in her mind the gynecologis t's telephone mess age of having breas t cancer. T wo days ago, s he had been forewarned of such a diagnosis. S he felt “numb” and avoided dis cus sing it with her family and friends. S he never had experienced a life-threatening trauma T he patient reported concurrent depress ive s ymptoms with anhedonia and ruminations of being abandoned 801 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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because of her crippling dis ease, as she had avoided cous in dying of cancer. T hese chronic, continuous depres sive feelings were present over the last 5 years . patient had two periods of acute depres sive epis odes social withdrawal, los s of energy and initiative, P.825 overs leeping, overeating, weight gain, s ens itivity to rejection, and suicidal ideation but no attempts las ting several months. Her depres sion had responded to fluoxetine (P rozac). However, s he had no evidence of any mood elation, overactivity, excess ive s pending sprees , reduced need sleep, hypers exuality, or other symptoms of mania or hypomania. S he had no his tory of alcoholis m or abuse except for nicotine abus e for which s he was succes sfully with Zyban 5 months ago but had 1 day. S he reported avoidance behavior regarding a female cous in in her adopting family who became phys ically emaciated due to treatment-res is tant progres sive breas t cancer. T he patient gave no generalized anxiety disorder, panic dis order, or s ocial phobia. OC D was not ass ess ed. S he denied ever had any psychotic symptoms.

VI. PS YC HIATR IC DIS OR DE R S IN R E MIS S ION A major depress ive disorder, recurrent, was in for the last 10 years . Her nicotine abus e was in early remis sion, but s he had a relaps e for 1 day.

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P os itive for a recent diagnos is of breas t cancer s tage 1 chronic cough; menopause; no allergies.

VIII. S OC IAL HIS TOR Y AND PE R S ONALITY T he patient has been divorced for the las t 10 years. three children by the same man, works as an interior decorator, and is financially well off due to her divorce settlement and her present income. P remorbid personality: T he patient has a college education and functioned well before her firs t major depres sive and intermittently between two epis odes .

IX. FAMIL Y HIS TOR Y A ps ychiatric family history of parents and s iblings is unknown because of patient's adoption. However, her children show no evidence of ps ychiatric disorder.

X. ME NTAL S TATUS E XAMINATION A ppearanc e T he patient is a 56-year-old, mildly obese, white, woman who is alert, has good eye contact, and is cooperative during the interview. S he wore makeup, the tears had was hed out some of the mas cara.

Movements Appropriate reactive movements when address ed. G rooming movements were limited to wiping her eyes even when not crying. G oal-directed movements were appropriate but showed s ome s lowing when she the office and when s itting down. No illus trative movements but appropriate express ive movements 803 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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she discus sed how s he avoided her cousin.

S peec h V oice was quivering at the beginning of the interview. talked with normal rate and appropriate modulation. Initially, s he breathed rapidly with pumping of C omprehended ques tions well and answered in a goaldirected, precise, mildly dramatic manner, volunteering appropriate details.

Mood and A ffec t Mood was depress ed and anxious . Affect was s ad, and anxious but became brighter and hopeful toward end of the interview, showing reactivity.

Thought C ontent Denied any ps ychotic s ymptoms in the past or present. S he had decreased interes t in living during her two depres sed episodes but expres sed a s trong will to live now. No evidence of panic attacks . Obs ess ions or compuls ions not as sess ed. F earful of being abandoned like s he felt about her being given up for adoption. B rief dis sociative experience during the las t hours. S uggestibility approximately average.

C ognition Oriented to place, time, and pers on. R ecent memory is intact. S pelling backward and serial sevens are normal. was able to interpret proverbs and to abstract the commonalties of categories. Her IQ is at leas t average according to the W ils on Approximate Intelligence T est the K ent T est. 804 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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Ins ight Aware that she has a depress ive disorder and nicotine addiction but less insight into the pathological nature of her res pons e to the cancer diagnosis. Limited insight her fear of abandonment is not bas ed on facts but on projection of her own behavior toward her cous in.

J udgment Affected by her recent trauma. E xpected a terminal of cancer and abandonment not bas ed on facts of her prognos is or her daughter's behavior.

XI. DIAG NOS TIC FOR MUL ATION B iologic al P redisposing factors: E xcept for three healthy family history of ps ychiatric disorders is unknown. history of head injury. His tory of major depres sion poss ibly dysthymic disorder. B oth may negatively impact on her traumatic stres s respons e. P recipitating: C oncurrent cancer, future pain, and side effects of cancer therapy may worsen the of her acute s tres s disorder, major depress ion, and nicotine addiction. P erpetuating: His tory of intermittent smoking may lead to dysphoric withdrawal reaction. C oncurrent stage 1 breas t cancer. P rotective: G ood respons e to antidepres sant medication to both depres sion and s moking.

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P s yc hologic al P redisposing: P hobic respons e to crippling with avoidance and projection. B oth mechanisms operate on a level below mature adjus tment. Her ability to emotionally support hers elf is limited. P recipitating: T he patient fears a terminal cancer cours e and abandonment. P erpetuating: C ancer therapy will be a steady of her cancer risk. P rotective: P as t succes s with therapy for her depres sion and s moking, cooperation with S he avoided a pos sible conflict between local phys icians and out-of-town experts . T he patient receptive to controlling her images of the cours e of cancer.

S oc ial P redisposing: Interpreted her adoption as a by her biological parents. Avoided a cous in who cancer. Interpreted her divorce as rejection by her husband. Ass umed the victim role. P recipitating: E xperiences the gynecologis t's voice cold, replays his mess age repeatedly in her mind. P erpetuating: T he memory of the crippling and fatal cours e of the cous in's cancer. P rotective: Has strong s upport from her friend who had a pos itive res ponse to therapy; support from friends who have express ed confidence in her 806 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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to fight the cancer. T he patient is s till working as an interior decorator. S he enjoys her work and her colleagues, which distract her from her illness .

XII. DIFFE R E NTIAL DIAG NOS IS R is k for an acute s tres s dis order progress ing to a Adjustment disorder with anxious and depress ed mood Onset of a third major depres sive epis ode by acute s tres s S pecial phobia of crippling terminal illness T he patient developed a s pecial phobia but not an stress disorder to the terminal cours e of cancer in a S he res ponded with a major depress ion to her divorce. T herefore, a recurrence of major depress ion is likely. adjus tment disorder may be an initial res pons e P.826 but could progress to a major depres sive epis ode. intervention may reduce the risks for all three

XIII. MULTIAXIAL PS YC HIATR IC DIAG NOS IS Axis I: Acute s tres s dis order (308.3) Major depress ive disorder with atypical features , recurrent, in full remiss ion (296.36) 807 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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S pecific phobia (300.29) R ule out dysthymic dis order (300.4) Axis II: features of dependent and his trionic pers onality Axis III: B reast cancer, stage 1 R ule out chronic bronchitis R ule out as thma R ule out pulmonary cancer Axis IV : T raumatic res pons e to recent diagnosis of breast cancer F ear of los s of support Axis V : current G AF equals 35, highes t last year was

XIV. AS S E TS AND S TR E NG THS T he protective factors discuss ed in the s ection XI. Diagnos tic F ormulation are identical with the patient's as sets and s trengths .

XV. TR E ATME NT PL AN AND B iologic al B upropion (W ellbutrin/ Zyban) has helped her in past with both s moking and depres sion: bupropion, 150 mg #1 AM, in 1 week #1 twice a day (B ID). 808 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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In cas e of incomplete respons e, cons ider bupropion with fluoxetine (P rozac). P urs ue cancer therapy and make an appointment immediately.

P s yc hologic al P atient to take control and actively reject the V is ualize the cancer as s hriveling. Ins till hope by telling the patient that her cancer has been detected early and that early detection has excellent prognosis to res pond to therapy. Include her daughter in some of the upcoming sess ions.

S oc ial R eframe the fact that the patient has been s elected her adoptive parents as acceptance. Dis cus s her criticism of the husband, helping her to overcome the victim role and appreciate her own contribution to the divorce. E mphas ize the expediency of cancer diagnos is in hours, which allows timely treatment. P oint out s upport by her friend J oan.

P rognos is C ooperated with treatment in the past with good res ponse. P s ychiatric symptoms appear to be 809 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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with therapy, thus preventing disability. P sychiatric prognos is appears good. T he main ris k factor for ps ychiatric well-being is a poor res ponse to cancer therapy.

S UG G E S TE D C R OS S S ection 7.4 deals with the typical s igns and s ymptoms ps ychiatric illnes s, S ection 7.5 deals with neurops ychological and intellectual as ses sment of and S ection 7.9 deals with ps ychiatric rating s cales . S imilarly, C hapter 8, on the clinical manifestations of ps ychiatric disorders , is an es sential correlate to interviewing and examining the patient. S ection 2.1 with the clinical as ses sment and approach to diagnosis neurops ychiatry. S ection 3.1 on perception and and S ection 3.4 on the biology of memory amplify made in this section. S ection 29.1 includes more information on suicide, and S ection 29.2 includes information on other ps ychiatric emergencies . C hapter deals with mood disorders and suicide in children and adoles cents . As pects of normal and abnormal development are found in S ection 6.2 on E rik H. C hapter 32 deals extensively with normal development children and adoles cents; adult development is great length in C hapter 50; and normal aging is the of S ection 51.2c.

R E F E R E NC E S Ayd F J . L e xicon of P s ychiatry, Ne urology and the Neuros cie nce s . 2nd ed. P hiladelphia: Lippincott & W ilkins ; 2000. 810 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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B eck AT . T he Inte grate d P owe r of C ognitive Y ork: G uilford; 1997. B ennett MJ . T he E mpathic He ale r: An E ndange re d S pe cie s ? S an Diego: Academic P res s; 2001. C arlat DJ . T he P s ychiatric Inte rvie w. P hiladelphia: Lippincott W illiams & W ilkins ; 1999. C heng AT : Mental illnes s and s uicide. Arch G e n P s ychiatry. 1995;52:594–603. C hochinov HM: Dignity—cons erving care. A new for palliative care. Helping the patient feel valued. J AMA. 2002;287:2253–2260. C ox A, R utter M, Holbrook D: P s ychiatric techniques. A second experimental study: E liciting feelings. B r J P s ychiatry. 1988;152:64–72. *F irs t MB , F rances A, P incus HA. DS M-IV -T R Diffe rential Diagnos is . W ashington DC : American P sychiatric P ublis hing, Inc.; 2002. F ish F . C linical P s ychopathology. B ristol, UK : J ohn and S ons; 1967. G oodwin DW, G uze S B . P s ychiatric Diagnos is . 5th New Y ork: Oxford University P ress ; 1996. Hill C J : F actors influencing phys ician choice. 811 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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and H ealth S e rvice s Adminis tration. 1991;36:491– International G uidelines for Diagnos tic Ass es sment (IG DA): W orkgroup, W P A (World P s ychiatric Ass ociation). B r J P s ychiatry. 2003;182(S uppl S 59. Izard C . Human E motions . New Y ork: P lenum; Izard C . E motions in P e rs onality and New Y ork: P lenum; 1979. K eller MB , McC ullough J P , K lein DN, Arnow B , DL, G elenberg AJ , Markowitz J C , Nemeroff C B , J M, T has e ME , T rivedi MH, Zajecka J : A nefazodone, the cognitive behavioral-analysis ps ychotherapy, and their combination for the treatment of chronic depress ion. N E ngl J Me d. 2000;342:1462–1470. K endell R E : F ive criteria for an improved taxonomy mental disorders . In: Helzer J E , Hudziak J J , eds . P s ychopathology in the 21s t C entury. DS M-V and Was hington DC : American P s ychiatric P ublis hing, 2002:3–17. K es havan MS , R abinowitz G , De S medt G , S chooler N: C orrelates of insight in first episode ps ychos is . B iol P s ychiatry. 2002; 51:115S –116S . K lerman G L, W eis sman MM, eds . New Applications Inte rpe rs onal P s ychotherapy. W ashington DC : 812 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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P sychiatric P ress ; 1993. K raemer HC , Measelle J R , Ablow J C , E ss ex MJ , K upfer DJ : A new approach to integrating data from multiple informants in ps ychiatric as sess ment and res earch: mixing and matching contexts and perspectives . Am J P s ychiatry. 2003;160:1566– Ludwig AM, Othmer E : T he medical basis of Am J P s ychiatry. 1977;134:1087–1092. Moran P , Leese M, Lee T , W alters P , T hornicroft G , A: S tandardis ed As sess ment of P ers onality— Abbreviated S cale (S AP AS ): preliminary validation brief s creen for personality dis order. B r J P s ychiatry. 2003;183:228–232. *Othmer E , Othmer S C . T he C linical Intervie w Us ing IV -T R . V ol 1: F undame ntals . W ashington DC : P sychiatric P ublishing, Inc.; 2002. *Othmer E , Othmer S C . T he C linical Intervie w Us ing IV -T R . V ol 2: T he Difficult P atie nt. W ashington DC : American P s ychiatric P ublishing, Inc.; 2002. Othmer E , Othmer S C , Othmer J P : B rain functions ps ychiatric disorders. A clinical view. In: Diagnos tic dilemmas, part I. P s ychiatr C lin North Am. 566. Othmer E , P enick E C , P owell B J , R ead MR , Othmer P s ychiatric Diagnos tic Inte rvie w-R evis e d (P DI-R ). 813 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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and Adminis tration B ookle t. Los Angeles : Wes tern P sychological S ervices; 1989. P atterson W M, Dohn HH, B ird J , P atterson G : of suicidal patients : T he S AD P E R S ONS scale. P s ychos omatics . 1983;24:343–349. P ayne R W , Hewlett J HG . T hought Dis order in P atients. In: E ysenck HJ , ed. E xperiments in V ol. 2, P s ychodiagnos tics and P s ychodynamics . Humanities P res s; 1960. *S hea S C . P s ychiatric Inte rvie wing. T he Art of Unde rs tanding. 2nd ed. P hiladelphia: WB S aunders 1998. *S ommers -F lanahan R , S ommers -F lanahan J . Inte rviewing. New Y ork: J ohn W iley & S ons; 1999. T as man A, R iba MB , S ilk K R . T he Doctor-P atient R elations hip in P harmacotherapy. Improving E ffe ctive ne s s . New Y ork: G uilford P ublications; T atro DS , ed. Drug Inte raction F acts 2002. F acts C omparis ons . S t. Louis: A Wolters K luwer 2002. Warnock J K : T ips on taking the ps ychiatry and neurology oral exam. R es id S taff P hys ician. 123. Zimmerman M: What s hould the s tandard of care for 814 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/7.1.htm

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ps ychiatric diagnostic evaluations be? J Ne rv Ment Dis ord. 2003;191:281–286.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > 8 - C linic Manifestations of P s ychiatric Disorders

8 C linic al Manifes tations of Ps yc hiatric Dis orders J oel Yager M.D. Mic hael J . Gitlin M.D. Manifestations of ps ychiatric disorders expres s as a variety of alterations, from normal functioning, subtle to blatant, from intermittent to cons tant. S ome be recognized by laypeople from a dis tance. Detecting others may require discerning training and intimate familiarity with an individual over time. Deviations from normal, from mild to severe, may occur in intens ity, duration, timing and content of thoughts, emotions, and behaviors and may be highly context dependent. the subjective complaints, clinical s ymptoms , and signs ps ychiatric disorders requires his tory taking and formal examination proces ses that parallel thos e of general medicine. Many ps ychiatric complaints and dis orders to be understood in broad context, requiring a more thorough evaluation and comprehens ion of the interpersonal world, work role, family life, and culture is typical in general medical practice. T he nature and expres sion of ps ychiatric signs and s ymptoms are profoundly altered by the patient's strengths, coping capacities, ps ychological defens es , and s ituational 816 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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so that the clinical picture ultimately repres ents a between psychopathology and ps ychological s trengths . T he disturbed and dis turbing behaviors that obs ervers view as pathological must als o be unders tood as part the individuals ' attempts to cope with the biological, ps ychological, and environmental challenges they face. When attempts to cope overwhelm individuals' to respond, less adequate, more disorganized, and ineffective thoughts and behaviors emerge, and these comprise the impairments that pres ent in clinical situations. T he most important distinction between typical presentations of medical diseases and those of disorders is the greater importance in ps ychiatric of the patients ' sometimes idiosyncratic des criptions of or her qualitative internal states , s ubjective that are often difficult to des cribe in words . P oets and novelis ts are often more capable than clinicians at characterizing and delineating the precis e quality and experience of many psychiatric s ymptoms . Many and clinicians often find it difficult to accurately communicate a fully comprehens ible and reliable description of even familiar, s omewhat univers al feeling states . A 34-year-old s ociology profess or was trying to explain difference in the s ubjective experience of fatigue from chronic fatigue s yndrome versus the fatigue of her depres sive dis order. Whereas she was typically articulate, s he s tumbled over both trans lating somatic ps ychological feelings into words that would make to her doctor. After a few attempts , s he gave up, 817 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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her doctor s imply to trus t that there was a difference, she could distinguish the two s tates. T hese subjective descriptions of ps ychiatric symptoms inherently less reliable, or at leas t less objective, than directly meas urable and quantifiable data s uch as press ures , temperatures, and laboratory tes t res ults. A great deal of the res earch in psychiatric diagnosis over last 25 years has been concerned with increasing the reliability of observer-rated clinical s ymptom In many ways , this research has had the desired clinicians and res earchers us ing a variety of s tructured interviews can come to reasonable agreement on what symptoms patients are experiencing and whether thes e patients meet criteria for mos t of the specific disorders in the revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV However, one of the costs of this increasing reliability in many instances, been the narrowing of the field of clinical vision. T hat is , clinicians who rely structured interviews and checklis ts may become somewhat clos ed minded and ris k ignoring clinical phenomena that are very important but that may not be part of the s tructured interview framework or mental F urthermore, the ques t for reliability can lead only so describing phenomena for which there are few precis e words . An additional related difficulty can be s een in us e of nonclinical res earch s taff who are trained to interview individuals us ing s tructured interviews (as in large epidemiological s tudies ). In thes e instances , the for interrater reliability is often achieved at the expens e a more nuance-based appreciation of the different meanings of subjective s ens ations , es pecially when the 818 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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interviewer has no clinical experience with which to interpret the subject's descriptions . Des pite these difficulties, a thorough as sess ment of the clinical history and des cription of the psychopathology and detailed account of the patient's s ubjective experiences are important for the following reasons: 1. S ignificant diagnostic dis tinctions are made on the basis of the his torical information and phenomenology. T he more detailed, complete, and correct the diagnosis , the more rational and precis e the treatment planning and the more reliable the prognos is . C onsider, for example, the importance accurately distinguis hing between neurolepticinduced akathis ia vers us anxiety s ymptoms related ps ychotic thinking. B as ed on which of these the clinician s elects , the therapeutic s trategy might diametrically opposite. 2. T he clinician's capacity to fully hear and a comprehensive understanding of the patient's internal experiences helps diminis h the patient's of isolation so characteris tic of P.965 many of thes e disorders and fos ters the growth of a therapeutic alliance, increasing the likelihood of treatment adherence. T his chapter focuses on (1) predisposing vulnerabilities and s tres sors in whos e context psychiatric signs, symptoms, and other manifestations appear, (2) the of psychiatric manifes tations , and (3) des criptions of 819 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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specific types of dis turbances seen in ps ychiatric 

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P R E DIS P OS ING V ULNE R AB ILIT IE S C HAR AC T E R IS T IC S OF P S Y C HIAT R IC S IG NS S Y MP T OMS S OMAT IC MANIF E S T AT IONS OF P S Y C HIAT R IC DIS OR DE R S

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DIS T UR B ANC E S IN P E R C E P T ION

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DIS T UR B ANC E S OF MOOD

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S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > V UL NE R AB ILIT IE S

PR E DIS POS ING VUL NE R AB IL ITIE S P art of "8 - C linical Manifes tations of P s ychiatric 820 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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G enetic and Intrauterine F ac tors G enetic vulnerabilities play an important role in the expres sion of many, if not mos t, psychiatric disorders . P rominent among these are dementias of the type, schizophrenia, unipolar and bipolar mood anxiety dis orders, alcohol dependence, and s ome personality traits . F or virtually all of these dis orders and traits, what is largely unknown at this point is the nature the inherited vulnerabilities . Intrauterine proces ses contribute to many psychiatric disorders . F or example, maternal s tarvation and infections during the second trimes ter of pregnancy been implicated in the pathogenesis of s chizophrenia. Maternal s moking and low birth weight may be ris k in the pathogenesis of attention-deficit disorders in children. Maternal alcoholism may lead to fetal alcohol syndrome, a major caus e of developmental disability.

C ons titutional F ac tors C ons iderable research demons trates that, by birth and shortly afterward, infants differ widely in their s pontaneous activity levels and thres holds , and duration of their reactions to external s timuli; the regularity or irregularity of certain biological rhythms as s leep; tendencies to approach or withdraw from new stimuli; the speed and degree of adaptation; attention span and dis tractibility; the persistence of behavior; qualities of mood. B ased on such early behaviors , may be described as having easy or difficult temperaments , quick or slow to warm up. however, is not immutable. T here are discontinuities 821 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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time, and the development of temperament and its impact on personality development is at least, in part, a function of the goodness of fit with a child's family. Nevertheles s, thes e temperamental qualities correlate somewhat with behavioral problems , at least through childhood. Aside from temperament, other persistent normal variations in personality development s eem to be cons titutionally related and may influence s ubs equent res ilience or vulnerability. T raits , such as introversion, extrovers ion, and neuroticis m, appear to be relatively enduring and s table personality dimens ions. Other temperamental qualities that endure include novelty seeking, being relatively open to new experiences , and stick-to-it-iveness . S ubtypes of intelligence, s uch as related to conceptual, mathematical, musical, and interpersonal abilities, have been postulated as separate genetic determinants and patterns of development. T he type A and B pers onality patterns , and res ilient personalities, high-strung, sensitive, fuss y, irritable, and pes simis tic characteristics have all been described as generally lifelong qualities that originate in early childhood. E ven dimensions of character, concepts about the s elf in relation to others that over time through s ocial learning and maturation of interpersonal behavior, have been s hown to have moderate heritability. T hese include s uch qualities as directedness , the ability to engage cooperatively with others , and the capacity to “transcend” the self by developing a sense of one's place or purpos e in the social context. Other characteris tics relevant to psychopathology but 822 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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diagnostically specific may als o be inherited. T hes e ps ychos is proneness , cognitive s tyles (such as obses sionality or detail orientation), and emotional reactivity (which is part of the dimension of T he relations hip between the inheritance of these traits and the patterns of transmis sion of specific ps ychiatric disorders is unknown.

P hys iologic al S tres s ors P hysiological vulnerability may res ult from longproblems or from newly acquired ones. All of the metabolic, toxic, infectious , and other caus es of illness produce increased vulnerability to psychiatric disturbance. S tudies have s hown higher us e of services by those who are phys ically ill and higher than expected prevalence of physical dis ease among the ps ychiatrically impaired. S ome children with prepubertal onset, obses sivecompuls ive disorder (OC D), and tic disorders that have episodic symptom cours e have been found to have pediatric autoimmune neuropsychiatric disorders as sociated with s treptococcal (group A β-hemolytic streptococcus) infections (P ANDAS ). Accompanying symptoms during epis odes of exacerbation are lability, s eparation anxiety, nighttime fears and bedtime rituals , cognitive deficits , oppos itional behaviors , and motoric hyperactivity. In P ANDAS , patients ' flare-ups of behavioral problems are commonly as sociated with documented group A β-hemolytic s treptococcus or s ymptoms of pharyngitis and upper res piratory infections. Human immunodeficiency virus (HIV ) infection leading 823 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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seropositivity and acquired immune deficiency (AIDS ) vividly illus trates the multiple and complex ways which s tres sors can lead to ps ychiatric disturbances . patients' ps ychiatric s ymptoms may represent organic changes that are the direct effects of the virus on the central nervous s ys tem (C NS ), producing changes in cognition, personality and mood, expectable ps ychological adjus tment responses of the patients in res ponse to an overwhelming life-threatening dis order, the emergence of latent or quiescent primary problems provoked by the ps ychological s tres s of the illness . Adding to the complexity, s ome individuals with clus ter B pers onality traits may engage in excess ive taking behaviors , increasing the likelihood of viral expos ure; they may then be at higher ris k for ps ychiatric s ymptoms/dis orders in res ponse to being positive because of their preexisting cluster B traits . A 42-year-old phys ician noticed the ons et of decreased stamina, fatigue, disinterest in work, and weight gain without a feeling of increas ed appetite. B ecause his initially believed he was getting depress ed, he ps ychiatris t. After the initial interview, the psychiatrist ordered a standard chemistry s creening panel that revealed a thyroid-stimulating hormone of 48 mIU/L. was referred to an endocrinologist and treated for his hypothyroidism, and all of his depres sive s ymptoms disappeared.

E nvironmental S tres s ors C omplex relations hips exis t between the occurrence of various life events, particularly threatening, 824 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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and uncontrollable negative events, and the of psychiatric symptoms . In general, such undes irable events predis pos e individuals to develop psychiatric symptoms, es pecially if they already have a preexisting ps ychiatric disorder. After exposure to the s ame stress ors , s uch as a s erious accident or act of violence, P.966 individuals who previously had anxiety disorders are prone than thos e without such his tories to develop s ymptoms of pos ttraumatic s tres s dis order Other factors , such as gender, may als o predict ris k of developing P T S D, with women more likely to develop disorder given the same expos ure to stress . Although individual res ponses vary widely, truly catas trophic such as incarceration in a concentration camp, caus e enduring psychiatric disturbances in a high percentage survivors regardless of whether they had prior problems . S imilarly, the s tres s -related consequences combat also vary widely, s o that s ome heavily combatexpos ed veterans develop long-lasting P T S D, whereas others develop very few pers istent symptoms . T he of a parent or s pous e, divorce, and major physical affect some people profoundly and others hardly at all the long run. S ignificant s tres sors are likely to be more traumatic during early development rather than later or certain critical developmental periods, compared with other times. F or example, the los s of a parent at a very young age is likely to be more traumatic and have profound and lasting effects than the los s of a parent adult. T he combined impact of negative life events and poor 825 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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emotional and practical s ocial s upports is important in predicting the emergence of at least s ome ps ychiatric disturbances . One B ritis h s tudy found that women who were depres sed were much more likely to have lost a parent at an early age, to be relatively hous ebound three or more young children, and to lack a good relations hip with a spous e or other confidant. In that study, at leas t, biological vulnerability to depres sion seemed less important than the accumulation of life circums tances in the development of the disorder. P eople who are ordinarily very competent in all role functions may fall apart completely when a s upportive spous e who has bols tered them and taken care of their needs s uddenly dies. P atients presenting with a major depress ive epis ode have experienced more uncontrollable actual and threatened los ses s uch as death of a spouse in the year before onset. not all ps ychiatric disturbance is attributable to easily identified, provoking negative life events; indeed, some major negative life events that at first glance appear to have preceded the ons et of a serious ps ychiatric disturbance may, in fact, have occurred only after the ps ychiatric disturbance actually began. F or example, someone who attributes the ons et of depres sion to been fired from a job several months previous ly may already have been functioning s uboptimally at that time and may have been fired as a cons equence of a depres sion-induced decline in role function. C ertain environmental features can counter the effects environmental s tres sors and protect agains t S table families and friends, good financial and s upportive churches and communities offer s ome 826 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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protection. R es earch has s hown that individuals with ps ychiatric disturbances have fewer s ocial supports normal controls. T his may be due to friends' and withdrawal from deviant behaviors or to the disturbed individual's withdrawal from deleterious family and relations hips . In contrast, physically ill people have social s upports than others , perhaps reflecting their to recruit help in times of need. Of course, the quality, well as the quantity, of s ocial s upports is important. As been demonstrated in schizophrenia and mood for example, negative relations hips even in close may have deleterious effects, both in initiating and in sustaining psychiatric disturbance. T he negative impact of a physiological or stress or is clos ely related to its pers onal meaning. F or example, the los s of a spouse who has been demented, dis abled, and burdens ome ordinarily has a different impact than the los s of a vital, s upportive, spous e. F inally, an elegant s tudy has demons trated the of genetic vulnerabilities with advers e life events . In a study involving s everal hundred young adults followed prospectively, genetic vulnerability to depress ion was conferred by certain polymorphis ms of the serotonin receptor. Over a period of several years , individuals one or two copies of the short allele of the 5hydroxytryptamine T promoter polymorphism exhibited more depres sive symptoms, diagnosable depress ion, suicidality in relation to stress ful life events involving finances , housing, employment, and relations hips than individuals homozygous for the long allele. T his provides strong evidence for gene–environment 827 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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interactions, in which a pers on's respons es to environmental insults are moderated by his or her makeup. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > OF P S Y C HIAT R IC S IG NS AND S Y MP T O M

C HAR AC TE R IS TIC S OF PS YC HIATR IC S IGNS AND S YMPTOMS P art of "8 - C linical Manifes tations of P s ychiatric S igns and symptoms form the two major categories of clinical phenomena. C lass ically, for most medical the distinction between the two is clear. S ymptoms subjectively experienced dis turbances that are not neces sarily observable by others . P atients complain of symptoms—ches t pain, headache, tingling sensations. S igns are abnormalities that are obs ervable by an examiner, including thos e that are eas ily evident in the cours e of a routine encounter with the patient as well those elicited only through specific physical, mental or laboratory examinations. In psychiatry, the line between s ymptoms and signs is often blurrier than in general medicine. F or ins tance, phenomena often cons idered to be symptoms of ps ychiatric disorders may not be experienced as ps ychiatric problems by patients. Hearing an angel's may repres ent a manifes tation of a psychotic disorder, 828 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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the patient may vigorous ly dis pute that the experience ps ychopathological s ymptom. Additionally, auditory hallucinations are often cons idered to be signs of a ps ychotic dis order, even though, by their very nature, are subjective internal experiences (s ymptoms ). complicating the distinction, s ome ps ychiatric phenomena, s uch as the class ic ps ychological defens e mechanisms, may only be inferred from s peech and behaviors but are not directly observable. S igns and symptoms are said to be pres ent when the of normal variability are s urpass ed. Abnormalities may manifest as alterations in amplitude (e.g., excess es or deficits ), duration, intensity, timing, and modifiability of phys iological events , perceptions, emotions, thoughts , motor activities . T hese limits are often arbitrary. include the number of hours of sleep, the intens ity of anger, or the extent of mood lability. However, for other experiences , the dis tinction between normal and abnormal is qualitative, not quantitative. F or s ome phenomena, “any” is “too much.” In mainstream culture, for ins tance, any experience of thoughts being broadcast out loud is cons idered pathological. T hes e and s ymptoms mus t all be considered in context: what constitutes normal varies from culture to culture from s ituation to situation. A behavior or subjective experience that may be defined as s ymptomatic in one context may be perfectly acceptable and within normal bounds in another. A phenomenon s hould be abnormal only if it s eems deviant within the patient's specific culture after its full phys iological and environmental context is taken into account and if it caus es personal or interpersonal impairment. T oo 829 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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phenomena prematurely mis labeled as turn out to be perfectly unders tandable and nonpathological once the whole s ituation is appraised. C onvers ely, s ome examiners are loath to label certain phenomena as ps ychopathological even when they are, for fear of s tigmatizing the patient. P.967 On the other hand, some relatively normal-appearing behaviors , or behavioral omis sions , may signal impairments . F or example, individuals may overtly or covertly us e s o-called s afety behaviors to avoid feared outcomes , but these behaviors may in fact perpetuate very pathological s tates they are intended to alleviate because they may prevent the individual from facing directly dealing with their problems or from the cognitive distortions that may be underpinning the problems in the first place. E xamples of safety include drinking alcohol to deal with insomnia, cons istently talking about traumatic events in an intentionally affectles s manner to put off dealing with as sociated emotions, and avoiding mas turbation to delus ionally imagined persecutors who go around castrating masturbators. Although, on the s urface, behaviors may not in thems elves appear to be pathological, they cons titute les s -than-satis factory mechanisms and may coincide with those commonly described in the psychoanalytical and psychological literatures , s uch as reaction formation, dis sociation, others . Within cultures, mos t interpersonal interactions are carefully regulated by tight sets of rules and controls 830 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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cons trained by reasonably well-defined s ets of expectations and acceptable limits . E ven s light from these acceptable limits are quickly perceived by laypeople, as well as profes sionals, becaus e deviances are often experienced as threats . Deviations amplitude, duration, and intensity can occur in facial expres sions , gestures, pos tures, vocalizations, and other express ions of emotion and thought. A s mall increase in the rate of speech, an intrus ion into one person's conversation by another who does not allow proper paus es , a gesture that comes jus t a bit too a face, an exces sively rigid or distant s tance, or a gaze is too staring or too avoidant each s ignals s ocial insensitivity and alerts the observer to deviant

R eliability P roblems Among the core difficulties in psychiatric evaluation has been that multiple obs ervers may note different symptoms or interpret signs differently when the same patient. T hese dis crepancies may be due to differences in the patient's s tatus or in information imparted by the patient from examination to in the obs ervers' definitions of the s ymptoms or signs in question, and differences in perceiving and interpreting the patient's respons es to general presentation or questions within the interview. T hese three types of reliability problems are called information variance , crite rion variance , and obs e rvation bias . A s ubstantial amount of information variance in clinical practice the impos sibility of as king all ques tions within the time available for clinical evaluation. As an example, in one study, the rate of sexual side effects increas ed from 14 percent when depending on spontaneous patient report 831 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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to 58 percent when the interviewer directly as ked about these side effects. A 37-year-old woman, treated with a selective reuptake inhibitor (S S R I) for the las t 2 years , s aw a ps ychiatris t on relocating to a new city. As part of the history, her new ps ychiatrist as ked about s exual side effects from the antidepress ant. S he acknowledged she had new-onset anorgas mia for 2 years since she started the antidepres sant. When as ked why she had discuss ed this with her previous psychiatrist, she said he had never asked, and she was too embarras sed to spontaneously mention it. Although good interrater reliability can be achieved for most s ymptoms of Axis I disorders , this may not hold for pers onality disorders or for s ome s pecific F urthermore, good interrater reliability may occur cons istently only under optimal circumstances and may not be as common in clinical practice. E ven when s imply res ponding to direct ques tions about symptoms, patients may res pond differently depending the interviewer's manner, how the ques tions are as ked, their personal sense of trust or s afety, whether they answered these questions before, the amount of cuing that may signal the “desired” res ponse, their fatigue, or host of other variables. Most clinicians still rely heavily on their own clinical intuition and s ubjective res ponses to patients as part of diagnostic ass es sment. However, thes e clinical whether accurate or not, are often bas ed on as sumptions , comparisons with other patients not well 832 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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remembered, or dis tortions based on the clinician's personal experiences. W hen the bas es for these can be identified and described clearly, they may prove be reliable and valid. However, intuitions are often wrong—simple trust in intuition alone is not s ufficient. T hus, a clinician's sense that a patient is angry and potentially violent may result from the patient's s ubtle verifiable) body language and tone of voice, or it may represent a countertransference distortion that is not prompted by any obs ervable patient behavior. In this regard, clinicians are becoming more aware of the presence of the s o-called inters ubjective field in clinical encounters . T his term recognizes the fact that clinical phenomena that emerge from the patient are often dependent on the nuances of behavior and perception that the clinician brings to the encounter. T he clinician's contributions may powerfully shape how the patient behaves and what the patient reveals, in turn seriously distorting what the clinician perceives. C linicians often too quickly label behaviors as inappropriate when they do not appreciate and unders tand contextual or cultural cons iderations. Appropriateness depends heavily on context, and definitions of what is proper in a given context may also highly s ubjective. Appropriate behavior (or dres s) in parts of C alifornia may be inappropriate in B os ton. A intens ity of emotional express ion leading to a clinical description of “cons tricted affect” may reflect cultural norms or a ps ychopathological state.

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Until ps ychiatry dis covers reliable diagnos tic laboratory tes ts to define clinical s yndromes, the field will continue cons truct diagnostic categories based on the clustering signs and s ymptoms within specific time frames . pathognomically s pecific s igns or symptoms rarely ps ychiatry; virtually all ps ychiatric symptoms are nonspecific and are us ually s een in many different disorders . Depress ed mood, for example, occurs in a variety of diagnostic groups , including major disorder, s chizophrenia, some pers onality disorders, organic mood syndromes , and s o on. E ven the s ofirst-rank s ymptoms of s chizophrenia des cribed by K urt S chneider are diagnostically nonspecific. T hey are with some frequency in otherwis e clas sic depress ive bipolar disorders . Apathy offers another good example an important nons pecific phenomenon. Although is often part of depres sion, research has s hown this symptom to be a clinically dis tinct s yndrome. Apathy is marked by lack of s pontaneity, initiation, and as well as lack of activity and interest in friends, family, hobbies. Apathy and the as sociated symptom of amotivation may exis t in their own right without the presence of s ignificant depres sion, as in initial phas es abstinence from cocaine and in other syndromes characterized by reduction in dopaminergic tone, s uch frontotemporal dementias , P arkins on's dis eas e, or progres sive s upranuclear palsy. P.968 In general medicine, symptoms not recognized as part clearly defined s yndrome are often described as being unknown origin. T hus, a fever that cannot be as cribed 834 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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known disorder, such as pneumonia, is des cribed as a of unknown origin. G iven the nons pecific nature of ps ychiatric symptoms, it seems wis e to us e s imilar conventions , referring to hallucinations of unknown or depress ed mood of unknown origin when a cannot be clearly linked to a well-described syndrome. However, the dominance of the categorical s ys tem of DS M-IV -T R and the demands of a health care and insurance system that requires a specific diagnosis for reimbursement make this type of diagnos tic thinking unlikely in the near future. E ven though individual s igns and symptoms may be organized into s yndromes and dis orders, they often cours es of their own. T hus, in the appearance or the res olution of a disorder, certain ass ociated s igns and symptoms may appear very early or may pers is t after the others have waned. F or example, in the restricting form of anorexia nervosa, exces sive exercise is often first s ymptom to appear and the las t to abate even after dieting has s topped. In s ome cases, certain s igns and symptoms that are commonly ass ociated with a given disorder may not appear. E ach sign and s ymptom may have its own pattern and variable respons e to In the treatment of s chizophrenia, for example, some patients experience rapid res olution of hallucinations have pers istent delusions without ever having any thinking dis orders, whereas others may have no hallucinations or delus ions but s till have prominent thinking dis orders.

S ign and S ymptom C ategories S igns and symptoms have been categorized in a 835 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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ways: s tate versus trait, primary vers us secondary, and form versus content. T he s tate ve rs us trait distinction to whether the sign or s ymptom is an enduring characteristic of the pers on (“traits ”) or time-limited phenomena as sociated with s pecific Axis I disorders , are us ually s tate phenomena. However, some enduring traits may also be s ymptoms . A person who always a great deal, chronically exhibits catas trophic thinking, feels subjectively nervous in many different since early childhood may have trait anxie ty. However, such symptoms of anxiety are pres ent only during a specific time frame, for example, over a 9-month period conjunction with a full depres sive syndrome, they are described as state-related symptoms. At times , trait state symptoms may be one and the s ame. F or one s tudy, patients who had remis sion of their with treatment s till showed relatively high rates of and s leep disturbances . In thes e circums tances , longsymptoms of fatigue and s leep disturbances may be trait markers of the depres sive dis order as well as symptoms of the acute depress ive epis ode. During the acute stages of ps ychiatric disorders marked by state characteris tics, it is unwis e to infer that any of the prominent signs or s ymptoms are enduring traits, even those usually ass ociated with pers onality. T hus , a of dependent personality traits based on an acutely depres sed patient's behavior is often incorrect. manipulative behavior in the mids t of a hypomanic or manic epis ode should not be cons idered evidence for enduring manipulative traits unles s thes e behaviors are also pres ent when the mania has clearly res olved. Dis tinctions between primary and s econdary symptoms 836 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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have been confused by varying definitions of thes e T he distinction may refer to caus al relationships what is primary and secondary, temporal sequence between the two symptom sets, or inability to more unders tand the origin of the various s ymptoms. B asing distinction between primary and s econdary on caus ality implies that it is actually understood what is caus e and what is effect. In attention-deficit/hyperactivity dis order (ADHD), for ins tance, the attention deficit is believed to primary, whereas the hyperactivity is believed to be secondary, caus ed by the inability to attend. P atients develop s evere dependent personality traits and demoralization only after numbers of incapacitating ps ychotic mood episodes might be des cribed as having primary mood dis orders and s econdary pers onality disorders . C onceptual models of ps ychopathology in which s ome s igns and s ymptoms are s een as albeit ineffective, attempts to cope with more fundamental ps ychopathological deficits us e a secondary model. T o illus trate, E ugen B leuler viewed thought disorder as a primary symptom in whereas he viewed hallucinations and delusions as secondary s ymptoms, formed to help the patient cope with the chaos of the primary s ymptoms . T hese models must be viewed as hypothetical cons tructs only and with great caution because, in the vast majority of phenomena, little evidence indicates that one s ymptom more primary than another. T emporal s equence in the appearance of certain symptoms is regularly used as the basis for deciding primacy of certain s ymptoms , behaviors , or dis orders, trying to determine what is primary and what is 837 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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when substance abuse occurs in conjunction with depres sion or anxiety s ymptoms. T hese differences trivial but may have treatment implications because, for example, treating a primary mood disorder in a abusing patient (with a long course of medication) may quite different from simply expecting that, with sobriety, a s econdary mood dis order will res olve on its own. However, the primary–secondary distinction with mood and substance abus e problems , although logical, may not always be cons istent with treatment s tudies . an example, in one s tudy, patients with primary alcohol abuse and s econdary depres sion (whose depres sions should theoretically have responded to s imple sobriety) res ponded better to antidepress ants than to placebo. F urthermore, it is becoming increas ingly clear that the presence of certain preexisting psychiatric conditions , as personality dis orders , increas es one's vulnerability the subsequent development of other ps ychiatric disorders such as major depres sive dis orders. However, establishing temporal sequence with any certainty is typically difficult. T o illus trate, although a high comorbidity between bulimia nervos a and major depres sive dis order, in exces s of 50 percent in some studies, attempts to es tablis h which dis order is primary have been inconclusive. E ven with careful historical analysis, major depres sion precedes bulimia nervosa, bulimia nervosa precedes major depres sive episodes, the two conditions start concurrently in approximately equal percentages . Ultimately, making s imple categorical dis tinctions between primary and s econdary s igns, symptoms , and disorders is les s important than unders tanding the 838 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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contribution of each element as a thread in the and development of a given clinical pres entation. F rom this pers pective, each element can be viewed as dynamically affecting the appearance, manifestations, cours e of the others, exerting its own influence on the pathogenes is and treatment of the s pecific s yndromes as sociated dis orders. T his view is particularly important because, des pite the excellent conceptual contributions made by categorical diagnostic s ys tems, such as the American P s ychiatric As sociation's DS M-IV -T R , in practice dis tinctions are often fuzzy, and comorbidity among so-called categorically dis tinct disorders is often the rule rather than the exception. F or example, data the National C omorbidity S tudy s how that 14 P.969 percent of the population experience three or more comorbid psychiatric dis orders. In s uch individuals , the dynamic interactions and mutual influences of various signs and s ymptoms, and their biological become imposs ible to dis entangle. F urthermore, the categories that currently compris e IV -T R are not going to be the last word in the evolving history of ps ychiatric diagnosis . R ecent studies s how ps ychiatric signs and symptoms may be usefully into psychotic syndromes that differ in s ome res pects current DS M-IV -T R categories. In a large family s tudy probands with broadly defined s chizophrenia and illness and their first-degree relatives, using a statis tical technique called latent clas s analys is , K endler and colleagues found six clas ses of ps ychos is , including clas sic s chizophrenia, major depress ion, 839 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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schizophreniform disorder, bipolar s chizomania, schizodepress ion, and hebephrenia. Although these clas ses bore s ubs tantial res emblance to current or historical nosological cons tructs, s everal of them from DS M-IV -T R nosological cons tructs. In another the three factors ordinarily as sociated with s ymptoms schizophrenia, repres enting positive, negative, and disorganized symptom domains, were found not to be specific to schizophrenia but were found in other schizophrenia-spectrum ps ychos es and in nonschizophrenia-like psychotic conditions as well. Additionally, a dimensional view of ps ychopathology much recent data better than the categorical view that inherent in DS M-IV -T R . P ers onality disorders fit poorly a categorical scheme, and the frequent “comorbidity” of these dis orders likely reflects the descriptive overlap than the patient having two dis tinct dis orders . S imilarly, DS M-IV -T R , dysthymia and major depress ion are s een two mood disorders when recent s tudies indicate that they are more likely manifestations of one disorder that differs in course and intens ity.

C ontext S igns and symptoms are us ually not s tatic entities ; depending on the context, they often vary in intensity or even in their existence. T he depres sed mood of a melancholic depres sion may pers is t regardless of the external s ituation, whereas the depres sed mood in reactive depress ion may vanis h completely during situations —including a psychiatric interview—only to reappear at other times . S igns and s ymptoms that only in s pecific s ettings or with certain internal s tates 840 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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referred to as s tate depe nde nt. F or example, certain hallucinations or memories may be present only during states of drug or alcohol intoxication; in s ome patients, hives may erupt as a ps ychophysiological response during s tates of anger. Interpersonal context is also important. S ome people become violent only when involved in sadomasochistic relationships or in certain group s ettings such as adoles cent gangs . In gangs, press ures for conformity and expectations for behavior may provoke or release pathological that might otherwis e never be express ed by gang members individually.

P roblems and Impairments B eyond the class ic signs and symptoms of ps ychiatric disorders , recent attention has focused on the and impairments that ps ychiatric s igns, s ymptoms , and disorders generate in affecting s pecific role functions caus ing social and economic burdens for the patient others . T hese problems and impairments often cut traditional sets of s igns and s ymptoms of which categorical diagnos es are compris ed, affecting, for example, bas ic abilities to care for oneself and one's marital functioning, child rearing, wage earning, s chool performance, and s ocial behavior. T hey constitute the is sues with which patients and families contend, and need to appear on the problem lists that treatment and s pecific interventions target. S tudies reveal, for example, that the impairments imposed by major depres sion are cons iderable with regard to phys ical functioning, role limitations, and social functioning. P roblems s uch as violent temper outbursts , s exual aggres sion, or lack of job s kills , which may impair role 841 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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functioning in s everal spheres , must be directly regardless of the ass ociated DS M-IV -T R diagnoses. impairments enter determinations of ratings for Axis V the DS M-IV -T R , which address es the global functioning, and are of cons iderable importance in evaluating treatment outcomes. T able 8-1 lists s ome illus trative critical impairments that have been as often requiring urgent or intensive levels of care.

Table 8-1 Illus trative C ritic al Impairments That May R equire S ervic e-Intens ive Treatment, Intens ive Treatment S ettings , or Ac ute C are Anxiety

Medical ris k factor

Ass aultiveness

Medical treatment noncompliance

C ompulsions

 

C oncomitant medical condition

Mood lability

Delusions (nonparanoid)

Obsess ions

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Delusions (paranoid)

P hobia

Dis sociative s tates

P hysical abuse perpetrator

Dys phoric mood

P sychomotor

E ating dis order

P sychotic thought/behavior

F ire setting

R unning away

Hallucinations

S elf-mutilation

Homicidal thought/behavior

S exual trauma perpetrator

Inadequate health care skills

S ubstance abuse

Manic

S uicidal thought/behavior

Adapted from G oodman M, B rown J , Deitz P M. Managing Manage d C are II. A Handbook for Health P rofe s s ionals . 2nd ed. W ashington DC : American P s ychiatric P res s, Inc.; 1996. F urthermore, the relationship between symptoms and 843 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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disorders on one hand and functional impairments on other is not always s traightforward. F or example, in bipolar and unipolar mood disorders, many patients recover s ymptomatically from episodes but achieve premorbid psychosocial function either months later or not at all. In one review of previously published s tudies major depress ion, there was a consis tent lag time symptomatic and functional recovery. W hether this disparity between s ymptomatic and functional recovery reflects s ubtle residual symptoms, unrecognized disturbances , personality difficulties, or a combination factors is unknown. A 45-year-old teacher with a relatively severe major depres sion s topped work because of depress ive symptoms. He was treated with a combination of medication and psychotherapy and became as ymptomatic, with virtually complete normalization of mood, sleep, appetite, concentration, and energy. Nonetheles s, he felt unable to return to work s oon after the depres sion remitted, being unable to explain this than as s imply feeling “not ready” for the stress es of job he had done cons is tently for 15 years. P.970

Need for a C omprehens ive P ers pec tive A ps ychiatric disorder may be characterized by disturbances involving a wide variety of areas in the patient's life, including the biological, ps ychological, behavioral, interpersonal, and s ocial s pheres . In 844 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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common psychiatric s yndromes often manifes t in each these dimensions (T able 8-2). V iewing the patient from multiple perspectives, using the s o-called model (similar to the multiaxial approach of DS M-IV enables clinicians to cons ider ps ychopathology and its effects on a patient's life in the broades t pos sible T o illustrate, F igure 8-1 lists s ome clinical hypothes es commonly used by clinicians as they link collections of signs and s ymptoms into syndromes and cons ider the treatment options that logically follow.

Table 8-2 C ommon C urrent Hypothes es Us ed to As s es s and S ymptoms : Ways of Unders tanding the Patient's Problems B iologically derived hypothes es     R elated to a brain impairment or organic disorder     R elated to mood disorder     R elated to nonaffective functional psychosis     R elated to the abuse of drugs or alcohol

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    R elated to biologically mediated developmental is sues     As a dis order other than those listed above in biologically derived hypotheses category P sychodynamically derived hypotheses     R elated to personality and temperament s tyle     R elated to environmentally mediated developmental iss ues , s uch as abuse, neglect, traumatic events, and more subtle life process es regarding nurture by primary caregivers, with family, peers , and others in both s hared and nonshared environments     R elated to precipitating life events and their dynamic meaning     R elated to manifestations of unres olved grief     R elated to a current developmental cris is     R elated to ego functioning and as sociated ps ychodynamic iss ues S ocioculturally derived hypotheses     R elated to the nature and the s ocial effects of 846 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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stress ful life events     R elated to the extent, nature, and acces sibility practical (particularly financial) or emotional support, or both     R elated to definitions of and res ponses to breakdown in the sociocultural grouping     R elated to the patient's motivation, treatment goals , and the dynamics of the entry process to seeking     R elated to practical matters in negotiating and sustaining ongoing relationships with profes sional caregivers and care-giving s ys tems     As s ocial communication B ehaviorally derived hypotheses     As disordered thinking, feeling, or acting from s pecific antecedent events     As disordered thinking, feeling, or acting from reinforcing cons equences of the behaviors     As disordered thinking, feeling, or acting in res ponse to s ociocultural and biological events

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    As a deficit of behaviors (rather than behaviors ) in the areas of thinking, feeling, and acting     As compens atory behaviors us ed to for behavioral deficits     B y an analysis of areas of effective functioning

Adapted from Lazare A. Hypothesis testing in the clinical interview. In Lazare A, ed. O utpatie nt P s ychiatry: Diagnos is and T re atme nt. B altimore: Williams & W ilkins ; 1979.

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FIGUR E 8-1 B iological, ps ychological, and s ocial forces interact and affect the ps ychiatric health of a person. (Adapted from R ichmond J B , Lustman S L: T otal health: conceptual vis ual aid. J Me d E duc. 1954;29:23.) B ecaus e the amount of information gathered in a thorough as sess ment of a psychiatric disorder is potentially overwhelming, clinicians often tend to limit their fields of vision and appreciate only part of the 849 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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available information; the clinician's theoretical and other personal and cultural factors als o limit what perceived. R es earch has demons trated that clinicians to perceive primarily those signs and symptoms that most in accord with their theoretical points of view and with the tools they have available to treat ps ychiatric disorders , a phenomenon known as conce pt-drive n pe rce ption. T he theoretical bias es of clinicians s eem to related both to the microcultures of their training programs and to their own pers onality traits . S uch differences may lead one clinician to s ee a major mood disorder to be treated with medication, whereas sees a pervasive personality problem with depres sed mood to be treated with ps ychotherapy and to us e different technical terms to label roughly the s ame phenomena. A psychodynamic psychiatrist might s ee ps ychomotor retardation, whereas a neuropsychiatrist sees bradykinesia; a psychodynamicist might s ee depres sed affect and muted s peech, whereas a neurops ychiatris t s ees mask-like facies and apros odic speech; the psychodynamicist might s ee ruminative thought, whereas a neuropsychiatrist sees forced a psychodynamicist might s ee a grimace, whereas a neurops ychiatris t s ees a tic. G iven the extent to which words thems elves s hape our concepts of reality, the cons equences of us ing these different labels for very similar phenomena may be significant. F igure 8-1 illus trates concept-driven perception in which each clinician who adheres to a prominent contemporary of view perceives only s ome of the potentially available phenomena related to a ps ychiatric dis order. Although there is overlap, each observer als o perceives not appreciated by the others . At the s ame time, some 850 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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information that may be highly relevant to diagnosing treating the disorder may be mis sed by all the so clinicians 100 years from now will, no doubt, be able detect and unders tand the significance of signs and symptoms not appreciated by anyone today. T he intermittent nature of many ps ychiatric signs and symptoms; the potential unreliability, selective recall, false remembering of patients and others in reporting symptoms and events ; differing interpretations of information or obs ervations; and subjective driven biases that influence the clinician's perception of signs and s ymptoms all contribute to potential errors in data collection. T o help guard against mis information simplis tic unders tandings and formulations , whenever poss ible, complete as sess ment of a psychiatric patient requires cons ultation with family, friends, coworkers, other profes sional observers to enrich the history and provide s upplemental observations of the patient over time. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > S OMAT MANIF E S T AT IONS OF P S Y C HIAT R IC DIS O R DE

S OMATIC OF PS YC HIATR IC P art of "8 - C linical Manifes tations of P s ychiatric Most psychiatric dis orders and virtually all Axis I based disorders are characterized by dis turbances in least some bas ic physiological functions . Although 851 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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frequently nonspecific in nature, the s everity of thes e somatic signs and symptoms provides markers as to amount of biological disruption s een in the disorders caus e them. F urthermore, s omatic s ymptoms can als o caus e exacerbations of some dis orders. If untreated, proces ses can create destructive feedback loops in the disorder caus es symptoms , which then the disorder, which causes increases in the s ymptoms, so on. As examples , the ins omnia of manic or states , if untreated, caus es a marked wors ening of the mania; s imilarly, the weight los s of anorexia nervosa starvation P.971 effects, s uch as a preoccupation with food, thus exacerbating one of the hallmark features of the underlying disorder.

S leep Dis turbanc es Abnormalities of s leep may manifest in the amount, quality, and timing of sleep as well as by the pres ence abnormal events during s leep. Ins omnia is us ually defined by its s ubjective the sensation of sleeping poorly. Mos t, but not all, complaining of ins omnia demons trate some sleep abnormality if examined in a s leep laboratory. Insomnia a common, often chronic symptom or s ign of many different ps ychiatric disorders , including s ubs tance depres sion, generalized anxiety disorder, panic, mania which the diminis hed sleep does not always provoke a complaint), and acute s chizophrenia. It may als o occur cons equence of aging or as a s ymptom or dis order not 852 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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as sociated with other ps ychopathology. Ins omnia may also result from the ingestion of subs tances that alter normal sleep–wake cycle, including alcohol or and by the discontinuation of sedative-hypnotics. Although much attention is often paid to distinguishing patterns of ins omnia, such as difficulty falling as leep middle or terminal insomnia (early morning linking specific patterns to a s pecific dis order (for melancholic depres sion with terminal ins omnia), the clinical us efulness of thes e distinctions is unclear. A 62-year-old woman complained of chronic insomnia, characterized by both initial ins omnia and fitful s leep during the night. S he had a his tory of recurrent major depres sions in ass ociation with marked life stress ors had not had a depress ive episode for 10 years. A workup, including an extensive medical and psychiatric history, revealed no obvious caus e for the insomnia. mood was euthymic, and no evidence of sleep apnea other primary s leep disorder was apparent. S he was treated with low-dose trazodone, which was s omewhat effective and which s he used intermittently for the next few years. Hype rs omnia, characterized by either excess ive sleep or excess ive s leepiness during the day, is less common than insomnia. It, too, however, may reflect a number of different pathological s tates. S ome patients, especially thos e with a his tory of mania or hypomania, may exhibit hypersomnia. Hypers omnia also be s een during s timulant withdrawal, with us e of sedatives or tranquilizers, or in conjunction with variety of medical dis orders. In narcoleps y, the patient 853 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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sudden attacks of irresistible s leepiness , a symptom may be part of a broader syndrome that includes (s udden attacks of generalized muscle weakness to physical collapse in the pres ence of alert s lee p paralys is (waking from s leep with a s ens ation of being totally paralyzed that may persis t for minutes), hypnagogic hallucinations (vivid vis ual hallucinations occur at the point of falling asleep). Narcoleptic attacks often precipitated by unus ual states of arousal (e.g., cataplexy may immediately follow unres trained or orgas m). Daytime sleepines s may reflect s lee p this dis order, typically middle-aged patients severe s noring—often first reported by their bed partners —and periods when breathing s tops. T he condition P.972 res ults from s oft palate abnormalities that caus e intermittent airway obs truction throughout the night; patients awake repeatedly to find thems elves gas ping air. Ass ociated daytime fatigue is common in sleep P eriodic hypersomnia also occurs in the K le ine -L e vin s yndrome , a condition typically affecting young men in which periods of s leepiness alternate with confusional states , ravenous hunger, and protracted s exual activity. Intervals of days , weeks , or months may pass between these episodes. S omnambulis m, or sleepwalking, and s lee p te rror (night terror) are two sleep dis orders characterized, res pectively, by aimles s wandering with incomplete arousal and by acute anxiety and phys iological arous al without awakening. Although both disorders typically 854 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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begin in childhood, sleepwalking may be als o initially precipitated by s ome ps ychotropic medications. A 51-year-old woman with complex P T S D was treated olanzapine. W ithin 1 year after starting this medication, she had gained 35 lbs. During this period, her hus band noted that she often went to the refrigerator in the of the night, s ound as leep, and ate indiscriminately. he woke her during these episodes , she appeared and had no awarenes s of her purposive behaviors . T o best of her recollection, confirmed by her husband, treatment with olanzapine (Zyprexa), she had no somnambulistic phenomena. Nightmares are a common complaint, often as sociated with traumatic events , anxiety dis orders , and mood disorders , but not uncommon as an occasional event in otherwis e healthy individuals. V ivid dreams and nightmares may als o be a medication side effect. A 32-year-old woman was treated for a mild depress ion with an S S R I. Her s leep pattern before treatment had characterized by hypers omnia, s leeping between 10 12 hours nightly. S oon after the initiation of her S S R I antidepres sant, s he noticed that her sleep was not only shorter and more fractured but that s he had remarkably intens e dreams that s he remembered vividly. S he clear that thes e were not nightmares , just dreams with intens e colors and clarity, which s he rather enjoyed. S ensory s ymptoms during s leep, typically des cribed by patients as peculiar feelings in their legs caus ing an irresistible need to move around, are characteristic of re s tle s s le gs s yndrome . T he motor abnormality of 855 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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myoclonic jerking of the legs , awakening both patients and their partners, is known as nocturnal myoclonus .

A ppetite and Weight Dis turbanc es Aside from the anorexia of medical illnes ses , es pecially their later s tages, los s of appetite is mos t commonly in depress ive disorders , grief, some anxiety disorders, primary anorexia nervos a and as a s ide effect of some medications . Anorexia is often accompanied by tas te (e.g., foods begin to taste different, bitter, or flat have an unpleas ant aroma). In eating disorders , may resist hunger to res trict food intake to achieve a phys iologically unrealis tic low weight. Hyperphagia (increased appetite) occurs in s ome depres sed both with and without a history of mania or hypomania. B inge eating, of up to s everal thousand calories per episode, may occur as an attempt to s elf-soothe and emotionally self-regulate during times of increased and anxiety and as a key feature of bulimia nervosa or binge-eating dis order. Increased appetite may be s een, albeit rarely, in s ome hypothalamic dis orders or in temporal lobe dysfunction s uch as the K lüver-B ucy syndrome, in which it occurs in as sociation with placidity, hypersexuality, hyperorality, and other symptoms.

E nergy Dis turbanc es Normal energy levels vary cons iderably among people. S ome people fatigue easily and are perceived by thems elves and others as having “weak cons titutions,” whereas others appear to have almost boundles s and much less need for sleep. 856 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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F atigue is an common nons pecific s ymptom that both medical and ps ychiatric dis orders. It is also seen as an unexplained complaint in primary care practices ; in one s tudy, 24 percent of patients of fatigue received no medical or psychiatric diagnosis. His torically, fatigue not due to another disorder, in as sociation with “nervousness ,” has been des cribed terms such as as the nia, ne urocirculatory as the nia, ne uras the nia, and ps ychas the nia. C onsistent with this tradition, many fatigued patients, having been labeled depres sed or neurotic by their phys icians , are referred ps ychiatris ts after routine workup has ruled out anemia, hypothyroidism, sleep apnea, and other frequent caus es. R ecently, thos e patients with primary complaints of tiredness have been mos t commonly diagnos ed as chronic fatigue s yndrome (previous ly and incorrectly labeled E pstein-B arr viral s yndrome), a dis order characterized by fatigue las ting months to years , beginning soon after a viral syndrome. In addition to fatigue, chronic fatigue syndrome is characterized by myalgias and cognitive changes s uch as forgetfulness poor concentration. Although controversy still exists the extent to which cases of chronic fatigue s yndrome represent discrete postviral diagnostic s yndromes , mislabeled cas es of depress ion, or modern versions of ps ychas thenia, evidence continues to mount to that these s yndromes are discrete pos tinfectious and are not simply variants of or disguis ed mood or anxiety dis orders. A highly accomplis hed, energetic 40-year-old woman 857 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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referred for ps ychiatric cons ultation after her physicians were unable to offer a definitive phys iological diagnosis despite extensive medical workup after the acute ons et profound fatigue occurring in the wake of a mild viral illness . T his fatigue caus ed her to be totally and bedridden for many months and left her feeling helpless and distraught. It was exacerbated by even amounts of alcohol. T wo independent psychiatric evaluations concluded that the patient had no disorder. T he patient developed this syndrome after jogging near Lake T ahoe. E pidemiological s tudies were found that reported a s eries of other cases of profound fatigue originating in this particular area after vigorous exercise. V arious antidepres sants seemed to provide partial relief, but tolerance to their positive effects developed. T he fatigue s lowly improved over many 7 years after the original symptoms , the patient to experience waxing and waning fatigue but at a level than originally.

Dis turbanc es in S exual Drive As with energy, the normal range of s exual drives is S ome individuals are naturally lus ty, whereas others limited s exual des ire. Diminished s exual drive with impotence or decreas ed libido is seen in a wide variety neurological, metabolic, and other s omatic s yndromes. Among neurological disorders, complex partial seizures are commonly as sociated P.973 with hypos exuality, occurring in 50 percent of patients. P sychiatric dis orders known for diminis hed sexual drive 858 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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include depres sive dis orders, s chizophrenia, s ubs tance abuse dis orders, and marital conflict. Diminished libido, erectile dys function, and anorgasmia are als o common sequelae of many ps ychotropic agents, especially serotonergic antidepres sants . A depres sed 36-year-old man had an excellent antidepres sant res ponse to an S S R I but developed decreased sexual interest and anorgasmia with relative preservation of erectile function. W hen the s exual side effects did not diminis h after 4 weeks, his ps ychiatris t a number of potential antidotes. Although s ildenafil (V iagra) improved his erections s omewhat, his libido orgasmic function continued to be markedly impaired. R eluctantly, he and his ps ychiatris t agreed to s witch to different antidepres sant clas s that was not as sociated sexual s ide effects. Increased sexual activity may be s een in some neurological, drug-induced, and psychiatric dis orders. Manic patients frequently exhibit hypersexual interes ts and behaviors to an unus ual degree, compared with euthymic interes ts and behaviors . Hypersexuality is occasionally seen in conjunction with epileptic or in patients who have had diencephalic injuries . Altered sexuality, including fetis hes , s adomas ochis m, pedophilia, and other paraphilias , may be s een as ps ychiatric syndromes. In individuals whose previous sexual behaviors were within the bounds of social propriety for their groups , inappropriate sexual may s ignal early brain dis eas e or psychos is. C ross may occur in transves tites, transgenderis ts, 859 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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or, occas ionally, in other psychiatric conditions. A 54-year-old married engineer became preoccupied viewing pornographic sites on the Internet. He had been excited by the visual s timulation of early girls. He had never acted on these feelings, had never an affair s ince being married, and, even when younger, had always had cons ens ual sex with girls his own age. the advent of the computer, he had become preoccupied by finding and spending s ignificant of time on W eb s ites devoted to photos of young girls. E ventually, he was spending 3 hours daily at thes e sites . At that point, he sought treatment for a pattern of behavior that he believed he could not control at all.

A ppearanc e S tudies s how that clinicians often formulate an initial ps ychiatric diagnosis within 30 seconds of s eeing a Although approximately one-half of such initial impres sions prove to be incorrect, the remainder are validated by ps ychiatric history and mental s tatus examination, revealing jus t how much information is communicated by appearance and body language. Among the physical dis orders whose appearances coexistent ps ychiatric conditions are acromegaly, C us hing's s yndrome, Down syndrome, s ys temic lupus erythematosus, fetal alcohol s yndrome, K linefelter's syndrome, and W ils on's dis eas e, to name a few. T he general appearance of the s kin may s uggest the of occult ps ychiatric problems. T he general condition flush of the s kin may reveal hypervascularity and ruddiness , s uggestive of alcoholism, absces ses 860 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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of hypodermic needle abuse, tattoos indicative of group affiliations , or weathering and was ting indicative self-neglect and malnutrition. Healed s cars on the and arms sugges t a pattern of s elf-mutilation from depres sion, pers onality disturbance, or both. P atchy baldness , es pecially in conjunction with torn or infected cuticles , indicates trichotillomania, a syndrome of compuls ive hair pulling. P s ychophys iological symptoms reflecting ps ychiatric dis turbance include urticarial reactions and neurodermatitis , the latter resulting, in from s elf-excoriation, des tructive s cratching s econdary compuls ions, and unrelenting s ens ations of dis comfort. A 23-year-old woman who had recovered from a episode of anorexia nervos a as an adoles cent had recurrent depres sions and pers is tent personality disturbances characterized by odd and eccentric ideas , shyness , and avoidance. S he became enchanted with gothic themes, s pent hours on the Internet in chat featuring dark and morbid poetry, and s tarted to have herself tattooed. W ithin 1 year, s he had tattooed every inch of her upper extremities , s calp, and torso with complex, intricate, gothic des igns. S he acknowledged tattooing her s kin in such an extreme manner s erved to mark her as deviant and to warn people away from her. E xamination of the head and neck may reveal exophthalmos or puffy eyelids , s uggesting thyroid marked pupillary dilation with anxiety or s timulant mios is with narcotic abuse, abnormal pupillary Wilson's diseas e, s alivary gland enlargement in bulimia nervos a, or necros is of the nasal septum in cocaine among other s igns . F requent s ighing is a common 861 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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res piratory sign in depres sion. S imple sighing must be distinguished from res piratory dyskinesia in ps ychotic patients who have been treated with neuroleptics . T he latter may occur as an acute dyskinesia due to antips ychotic medication, or it may be a late and component of tardive dyskinesia. Deviant appearance is quickly perceived by laypeople profes sionals and may contribute to the frightened and stigmatizing s ocial withdrawal by strangers, as well as acquaintances, so often experienced by ps ychiatric patients. Akathis ia and dys tonic movements and parkinsonian s huffling gait in patients taking (es pecially the older, conventional antipsychotics), as as the dilapidated and unkempt appearance of some ps ychiatric patients, can immediately signal ps ychiatric patient status to obs ervers. T he term Diogene s has been used to des cribe old people who have filthy personal appearance and demons trate s evere s elfabout which they have no shame. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > T HINK ING

DIS TUR B ANC E S IN P art of "8 - C linical Manifes tations of P s ychiatric

Normal Thinking T hinking refers to the ideational components of mental activity, process es used to imagine, appraise, evaluate, forecast, plan, create, and will. Most thought involves 862 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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complex rules that are probably bes t currently approximated (albeit inexactly) by fuzzy-logic decisionmaking algorithms that use neural net technology, increasingly applied by s cientists and engineers in situations in which all-or-none, black-or-white thinking does not apply but in which multifaceted, contradictory, and competing poss ibilities and biases are the rule. of what is known about thinking derives from the s tudy language as the product (and reflection) of thought, yet great deal of thinking takes place preverbally and nonverbally. T hinking occurs in images, mus ic, and kines thetic sensations and in s ymbols other than ones. Attempts to trans mit preverbal and nonverbal thought us ing only words are frustrating P.974 and unsatisfactory. C reative artis ts have cons iderable difficulty describing the inner states of tens ion and inchoate awarenes s from which ideas are dis tilled. Ordinary thought is far from logical. S treams of thought are intruded on by competing thoughts and as sociations and by outs ide stimuli, and attention is distracted. Ordinary conversation is marked by as ides, interruptions , delays, and the los s of ideas . Decisions are often made on the bas is of very few cues inadequate evidence: P eople jump to conclus ions. are zealously held that are not s upported by evidence. T hinking in s tereotypes is more common than thinking logical categories ; from an evolutionary pers pective, thinking in s tereotypes and by approximation has probably been more adaptive than thinking in s trictly defined categories. T his tendency helps account for 863 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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clinicians ' tendencies to make diagnos es by and intuition bas ed on prototypes and to feel less comfortable us ing formal lis ts of criteria found in manuals such as DS M-IV -T R . C onsis tent with this recent study found that more than 60 percent of being treated for personality dis orders by clinicians had diagnosable personality dis orders when s trict DS M-IV criteria were applied. C ons iderable variation exis ts among individuals predominant cognitive s tyles , and an individual's s tyle thinking als o s hifts cons iderably from time to time. C ognitive s tyle refers to one's predominant manner of information process ing and decis ion making; the biases and dis tortions thinking process es make by of augmenting, elaborating, or minimizing incoming information; and the extent to which people use careful and deliberate logic versus intuition vers us thoughtless , anxiety-induced impuls ivity to guide decis ion making. some individuals , a particular cognitive style may come dominate that pers on's repertoire s o completely as to interfere with the flexible, adaptive responses required deal with the us ual variety of daily needs. An style of thinking is marked by attention to detail and hypervigilance concerning the pos sible implications of particular thought or event. T his may take the form of preoccupation with strict adherence to es tablished values, or beliefs. An obses sional s tyle may be highly adaptive in certain s ituations , as in profess ions meticulous detail s uch as librarians , computer programmers, and s urgeons . However, exces sively obses sionality may be maladaptive, as when s omeone scrupulously s ticks to the rules even when s uch 864 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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is self-destructive and short sighted. A hys te rical s tyle thinking is characterized by global, diffuse, emotionally laden evaluations of situations in which attention is given to details and nuances . T his style is poorly adaptive to detail-oriented work but may be in the arts , certain as pects of marketing and sales , and some social s ituations. A 36-year-old attorney reported difficulty at work he s ometimes got bogged down in trivial details about cases that he could not seem to drop. His mind him to follow s mall, usually irrelevant leads that his legalis tic sensibilities even though his clients and partners had no interes t in these aspects of the cases faulted him for was ting their time and money.

Types of Thinking B ecaus e of the different ways in which both normal and abnormal thinking expres ses itself, differences that are apparent to even a cas ual observer, attempts have made to s ubtype thinking by the extent to which logical versus nonlogical thought is used. Although less commonly used than before, S igmund F reud's division thought into primary and s econdary process thinking provides a us eful description class ification.

P R IMA R Y P R OC E S S P rimary proces s thinking, the more primitive type, is typically s een in dreams but is als o prominent in young children and in psychotic states . T his type of thinking disregards logic, permits contradictions to exist simultaneously, disregards the linear notion of time, 865 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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dominated by wis h and fantas y. It us es symbol, imagery, condensation, dis placement, and concretism its organization, creating the jumbled and incoherent of thinking characteristic of dreams . P rimary proces s thinking represents what has been loos ely and metaphorically called right brain thinking, ass ociated visual images and creative thought.

S E C ONDA R Y P R OC E S S S econdary process thinking is characterized by logic. contrast to primary proces s thinking, the s econdary proces s uses linear notions of time, clearly delineated abstract categories, and deductive rules of logic. T he abilities to think abstractly and to think in detail about future plans are characteristic of s econdary process thinking. Normal s econdary process thinking is also characterized by predictability, coherence, and redundancy. W ords , vocal inflections , and gestures important contextual cues and create a sense of overall coherence to the communication. Ideas follow one another in a s equence that is unders tandable to the listener. A non-F reudian typology of thought divides thinking three types : fantas y thinking, imaginative thinking, and rational or conceptual thinking. F antas y thinking allows the person to escape from, or deny, reality and can be in normal as well as pathological thinking. E veryone occasionally uses fantasy thinking when daydreaming. S ome diss ociative and ps ychotic phenomena illustrate most pathological manifes tations of fantasy thinking. Imaginative thinking merges fantasy and memory to generate plans for the future. R ational or conceptual 866 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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thinking uses logic to solve problems . R egardless of how one categorizes thought, people fluidly s hift from linear/s econdary, process /rational thought to fantasy/primary, process /nonlogical thought, as in the free ass ociative method us ed in During this proces s, individuals willfully surrender the controls that maintain s econdary process thinking and switch to the less controlled modes of primary proces s thinking in which thoughts are loosely as sociated by emotional as sociations or bas ed on peripheral, coincidental, loos ely similar, or trivial aspects of a Additionally, the fact that increas es in primary process thinking can be induced in normal people under experimental conditions or with fatigue s ugges ts that more primitive thought proces ses, such as those seen ps ychos is , are us ually inhibited by higher-order and that their appearance may be release that is , nonlinear or psychotic thinking may indicate the functional absence of thos e overriding control systems that ordinarily sift, evaluate, and regulate the form and flow of thought before it reaches consciousness . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > T HO UG DIS T U R B ANC E S

THOUGHT DIS TUR B ANC E S P art of "8 - C linical Manifes tations of P s ychiatric

Flow and F orm Dis turbanc es B ecaus e the underlying process es that govern thought 867 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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not unders tood, current systems for class ifying thought abnormalities are primarily descriptive. C onventional clas sification separates form and flow from the content thought, yet many types of abnormal thinking include both form and content abnormalities. T hus , although delus ions are us ually class ified as thought content disturbances , they are also marked by formal abnormalities , s uch as rigidity and impervious ness of thought to external influence or to information that contradicts the delusional idea. P.975 Although formal thought dis orde r typically refers to abnormalities in the form and flow or connectivity of thought, s ome clinicians us e the term broadly to any psychotic cognitive s ign or s ymptom. As with energy and s exuality, normal variations in the and form of thought are considerable. F or s ome thinking appears to be effortless —rapid and productive, exhibiting linear, goal-directed thoughts and creativity, with digres sions and occas ional leaps but always controlled and comprehensible. F or others, thinking is difficult exercise—a s low, painstaking process with low output, compared with other people, or “scattered,” with difficulty s taying with a topic or finis hing a single Most people experience admixtures of thes e extremes . Dis turbances in the flow and form of thought occur with regard to rate, continuity, control, and complexity. T hinking can be unusually slow or accelerated. S lowed retarded) thought, s uch as noted in depres sion, is goal directed but characterized by little initiative or 868 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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planning. P atients experiencing retarded thought often describe feeling that even s imple thought requires monumental effort, as if molass es were cluttering their thinking. T hese difficulties are express ed as s lowness decis ion making and as long latency of res ponse, increased pause times when speech is initiated and speech. T hought blocking, s een in schizophrenia, is experienced as the s napping off or as a s udden break train of thought, as if a wall s uddenly comes down, interrupting thinking (and speaking) in mid-sentence. an outside obs erver, without further explanation from patient, thought blocking may appear identical to withdrawal, a disturbance in the control of thought in which the patient feels as if some alien force has intentionally withdrawn the thoughts from T he patient's further des cription and explanation of the inner experience is necess ary to distinguish these two symptoms. A 35-year-old woman with s chizophrenia had a core delus ion that a group of beings/s pirits/forces watched over her, directing her behavior with variable intens ity. times , s he began to des cribe a part of her thinking to her psychiatrist, only to stop midway through, to go on with the discuss ion. At another time, she acknowledged that she was being told by the forces the ans wers to the psychiatrist's ques tions were too personal to divulge and that she had been instructed to stop talking. Accelerated rates of thinking, typically accompanied by fas t talking, can be seen as a normal variant. R apid speech, influenced heavily by cultural and s ituational 869 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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factors , only sometimes reflect truly rapid thought. (F or example, it is not at all clear that New Y orkers , who characteristically speak more quickly than people from some other cities, actually think at a fas ter rate. auctioneers and s ome radio and televis ion announcers speak with as tonishing rapidity, likely reflecting both innate capacities as well as learned psychomotor P res s ure of s pe ech—speech that is rapid, excess ive, typically loud—is characteristic of mania (or stimulant intoxication, and, occas ionally, anxiety. F light ide as occurs when the flow of thought increas es to the point at which the train of thought switches direction frequently and rapidly. T he as sociative links between conceptual topics during flight of ideas are comprehensible to the listener, although not without cons iderable effort at times . Listening to a flight of that is not overwhelmingly fast can be both a dizzying enjoyable experience for the listener, as exemplified by succes sful performance s tyle of certain contemporary comedians, notably R obin W illiams.

C ontinuity Dis turbances in the continuity of thought may take forms. In circums tantiality, the flow of thought includes many digress ive turns and as sociations, often including great deal of unneces sary detail. T ranscripts of circums tantial thought or s peech are marked by commas , subclaus es , and parenthetic as ides. in circums tantial thought or s peech, the speaker eventually returns to the point that was initially intended without having to be prompted by the listener. In contras t, in tange ntiality, the person's thought 870 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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further and further away from the intended point, ever returning, so that the pers on may not even what the original point was suppos ed to be. is a mild form of de railme nt in which there is a in as sociations. Loos e as sociations exemplify more derailment, in which the flows of ideas are no longer comprehensible to the listener becaus e the individual thoughts s eem to have no logical relation to one L oos e as s ociations are clas sically a hallmark feature of schizophrenia. In extreme cas es, the ass ociations of phrases and even individual words are and s yntax—the rules of grammar by which phras es organized into s entences and words into phrases — disrupted. W ord s alad describes the s tringing together words that s eem to have no logical ass ociation, and ve rbigeration describes the disappearance of unders tandable s peech, replaced by strings of utterances . C lang as s ociation refers to a sequence of thoughts stimulated by the s ound of a preceding word. F or a manic patient s aid, “I'll kill with a drill or a pill—G od, ill—what swill.” In echolalia, the patient repeats a just uttered by the examiner. R epetition of only the las t uttered word or phrase is called palilalia, a symptom most often in chronic s chizophrenia. P ers everation and s tereotypy are two other as sociative abnormalities in which the flow of thought or s peech appears to get stuck. In pe rs e veration, a sentence or is repeated, s ometimes several times over, after it is no longer relevant. P ers everation is commonly seen in delirium and other organic mental disorders . refers to the cons tant repetition of a phras e or a 871 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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in many different settings, irres pective of context. Dis turbances in the control of thought include pass ivity experiences and obses sional thinking. In de lus ional thought pas s ivity, patients experience their thoughts as being under the control of other forces . T hought pass ivity may take s everal forms: In thought ins e rtion, thoughts are experienced as having been within the patient's mind from the outside; in thought withdrawal, thoughts are whisked out of the mind; in thought broadcas ting, patients experience their as es caping their minds to be heard by others . T hese experiences are often combined with specific delus ions control, s eemingly to explain the pas sivity experiences . S everal of thes e phenomena were included by among the s o-called first-rank s ymptoms of T oday, these symptoms are viewed more broadly as nonspecific ps ychotic s ymptoms , more likely to be schizophrenia but not pathognomonic of the disorder. A 42-year-old man with s chizophrenia rarely went out his hous e and typically believed that others were toying with him during the few convers ations he had. W hen as ked about thes e feelings and behaviors , he the complete conviction that everyone could hear what was thinking. He found this very embarrass ing when in public and therefore liked P.976 to stay in his hous e. Additionally, when he did convers e with others, he attributed their as king him questions as form of mocking him becaus e he was s ure they knew he was thinking anyway. 872 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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O bs e s s ional thinking is s tereotyped, repetitive, thinking that is recognized as one's own thoughts . In contrast to patients with delus ional thought pas sivity, obses sional patients do not experience their thoughts being controlled by outs ide forces . Nonetheles s, they experience only partial control over the obses sional thoughts. T hey can, with great effort, s top thinking the obses sional thoughts but cannot prevent them from recurring. T hus , characteristic of obses sions are the subjective experience of compulsion and the resis tance it. In class ic obsess ional thinking, insight is retained, as bizarre as some obs ess ions are, patients know that these thoughts are irrational and their own. However, more recent s tudies have revealed that ins ight into obses sional thinking is more variable than had been previous ly believed, at times becoming delus ional. At times , obsess ions may be pervasive enough to the patient's cons cious nes s. Obses sions may be sequence of words, or elaborate, such as enumerating poss ible cons equences of a pas t behavior and a cascading sequence of typically catastrophic events. T ypical obs ess ional themes in OC D involve with dirt and contamination, fear of harming others , symmetry, and thos e related to health and appearance. Whenever s he drove her car over a bump in the road, year-old woman with OC D worried that s he had hit a pedes trian. B ecaus e s he could not s ee the body, she around the block to look for it. After s eeing no body in road, s he was trans iently reas sured but, within became concerned that the body may have rolled parked car. S he drove around the block for at leas t 30 minutes searching for the body when this obs es sional 873 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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thought poss ess ed her. Obsess ional thoughts are usually s een in conjunction compuls ive behaviors , which are rituals linked to the obses sions typically cons tructed to undo the effects of thought. T hus, contamination obs es sions are linked to cleaning rituals , fears of harming others lead to rituals , and s o forth. T he most prominent disturbance of thinking complexity an impaired capacity to think abstractly. Abs tract is the ability to as sume a mental set, to keep simultaneously in mind all of the aspects of a complex situation, to move from feature to feature as indicated the situation, and to abs tract common properties . C omplex thinking als o concerns the ability to simultaneously cons ider many different, vague, and as pects of s ituations; to appreciate differing and contradictory points of view; and to integrate thes e multiple dimens ions to form opinions that are marked differentiatedness and nuance. Normal individuals vary greatly in their abilities to engage in abs tract thinking— genius es in mathematics and theoretical phys ics leave most mortals far behind. C oncrete thinking is a in the ability to form abstract concepts, generally illus trated by literal mindedness and the inability to abstract the commonality of members of a group, for example, the fact that a flea and a tree are similar in they are both living things. C oncrete thinkers seem to free themselves from the literal or superficial of words . C oncrete thinkers may be more prone to prejudice and stereotypical thinking and more likely to manifest unidimens ional or “all-or-none” reactions to complex situations. C oncrete thinking can be seen in 874 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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individuals with lower intelligence, organic mental disorders , and schizophrenia. S chizophrenic patients also exhibit highly s elective dis turbances of E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > T HO UG H T

THOUGHT C ONTE NT P art of "8 - C linical Manifes tations of P s ychiatric T he normal content of thought, the buzzing, booming stream of cons cious nes s that constitutes the s tuff of everyday life, compris es awarenes s, concerns , beliefs, preoccupations, wishes, and fantasies occurring with various degrees of clarity, vividness , differentiation, imagination, and strength. Normal thought is often illogical, containing many beliefs and prejudices that be clearly contradictory but are nevertheles s held with pass ion and conviction. B elief s ys te ms are the scaffolding of thought, chains of impres sions , and expectations around which plans and behaviors are organized. B elief s ys tems may be setting general expectations and bias es about the that inform how incoming information is process ed; examples are optimism, pess imis m, and paranoia. beliefs are effervescent and fleeting, whereas others pervas ive, tenacious, enduring, and influential. T he enduring belief s ys tems are as sociated with behaviors cons istent with the belief, at times dominating interpersonal relationships and lifes tyles . S ome beliefs unique and private, whereas many are s hared by 875 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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A 48-year-old man had been deeply pes simistic s ince childhood. Although he had no vegetative features of depres sion, he believed and behaved as if the world an awful place dominated by dis honest and selfis h individuals . Having any goals seemed foolish to him, the nature of the world. He express ed thes e beliefs regularly to his children, to the dis may of his wife, who not share his belief system. Imaginative fantasy is an important component of thought. T he vivid, eidetic imaginations of young can produce vivid fantasies in which children become immersed, almost as if in hypnotic states. During many children develop imaginary companions as playmates. In later years , imaginative thinking in which previous ly separate streams of thought playfully with one another to produce new ideas may be the es sence of the creative reverie. Artis ts, writers , and scientis ts may retain access to thes e forms of thinking more readily than others. Meditative states of mind facilitate the emergence of imaginative insights . S uch thinking may also occur in dreams. Intrus ive reveries normal and common components of the us ual adult stream of consciousness . During periods of specific deprivation, s uch as starvation or s exual deprivation, elaborate wish-fulfilling daydreams frequently occur. Ide as are the contents of the stream of thought. T hos e are consistent with one's s ens e of self, compatible with individual's self-image, are called ego-s yntonic. Other thoughts that conflict with one's central values are ego-alien or ego-dys tonic. An ego-dystonic impulse to someone, incons is tent with one's predominant value systems , may generate a counteractive ego-syntonic 876 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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thought such as “you really don't mean it.” P.977

Dis turbanc es in Thought Abnormal beliefs and convictions form the core of content disturbances . C onsiderations of abnormality regarding beliefs and convictions must take the culture into account. B eliefs that may seem abnormal one culture or subculture may be commonly accepted another. F or example, religious hallucinations , to psychological or biological factors by contemporary Wes tern societies, are routinely attributed to religious spiritual causes by many other cultures . With regard to intens ity of conviction, distorted beliefs range on a continuum from overvalued ideas to the determined, unshakable belief that is characteris tic of fixed Abnormal beliefs and delus ions are, in most diagnostically nonspecific. Delusions are commonly in mania, depres sion, s chizoaffective dis order, dementia, and substance abuse–related syndromes, well as in schizophrenia and delus ional dis orders. O ve rvalued ide as are unreas onable and s ustained abnormal beliefs that are held beyond the bounds of reason. P atients with overvalued ideas have little or no insight into the fact that their ideas are very unlikely to valid; however, the ideas themselves are not as unbelievable as most delusions . T he distorted body images of body dys morphic disorder exemplify ideas . Morbid jealousy and preoccupation with a poss ible infidelity may constitute an overvalued idea if real evidence has ever existed to warrant suspicion. 877 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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A 42-year-old man who had a brief relationship with a woman was unable to accept the fact that s he no wanted to see him. He ruminated about every they had and interpreted s mall gestures in the past as indicating her undying love for him. His infatuation led to follow her repeatedly to work and school, and he pursued her relentless ly, to the point that s he brought charges against him for stalking. Ide as of re fere nce are false pers onalized actual events in which individuals believe that or remarks refer specifically to them when in fact they not. Ideas of reference may be les s firmly held than delus ional beliefs . A 24-year-old ps ychotic woman from a religious background was completely dis tracted when anyone in the room cleared his or her throat. S he explained that interpreted throat clearing as a distinct mes sage to her, reminding her that she was a s inner who needed to be cleaner and purer in her behaviors and thoughts.

Delus ions Delus ions are fixed, false beliefs , s trongly held and immutable in the face of refuting evidence, that are not cons onant with the pers on's educational, s ocial, and cultural background. T hus, delus ional thoughts can be understood or evaluated with at leas t s ome of patients ' interpers onal worlds , such as their involvements with religious or political groups. One of mind's primary functions is to generate beliefs, myths and meaning systems . T hese beliefs provide the 878 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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individual with a sense of personal and group identity with ways of unders tanding reality. T hey are mos t noticeable when s hared untestable beliefs form the for group cohes ion, as in religions and cults. S ome adhere to their cheris hed beliefs despite the plaus ible contrary evidence—for example, the fundamentalist s ects that take the biblical creation s tory literally. In the face of contrary evidence or grave threat, individuals often cling to their primary beliefs as matters of faith (i.e., alternative, nonrefutable bas es for unders tanding). T he strong faith with which religious , political, and nationalistic convictions are held, even at cost of death, s hows the power that untestable beliefs have on behavior. P otential mental health advantages religious beliefs have been demonstrated in epidemiological s tudies showing that those with a personal devotion report fewer depres sive symptoms . S ubjectively, delus ions are indis tinguishable from everyday beliefs. T herefore, the subjective experience delus ion is no different from the s ubjective experience believing that the earth is round or that one's s pouse is same pers on one married on his or her wedding day. B ecaus e of the identical experience of delus ions and strongly held beliefs, it is generally impos sible to argue patient out of a delus ional belief. T he content of is highly influenced by culture. As an example, in a comparing delus ions among Aus trian and P akis tani schizophrenic patients , persecutory delusions were predominant in both cultures , but differences were the sources of the persecutory beliefs. S imilarly, centuries ago, delusions of persecution often persecution by the devil and had religious 879 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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persecutory delusions today often take on technological, political, and social perspectives. A 38-year-old s chizophrenic woman was certain that profus ion of televis ion satellite dis hes in her were all meant to beam radio s ignals from alien civilizations far off into the s tars into her head, and that, turn, these satellite dis hes could pick up her thoughts beam them all over the univers e. S he was particularly embarrass ed by the fact that the sexual fantas ies s he frequently imagined would be publicly broadcast and her s infulness would become known. Although delus ions are diagnostically nonspecific, types of delus ions are more prevalent in one disorder another. F or example, although delus ions of control delus ional percepts are often s een in s chizophrenia, also occur, albeit less frequently, in ps ychotic mood disorders . S imilarly, clas sic mood-congruent delusions , with grandiose themes seen in mania or delus ions of poverty characteristic of depres sion, may also be s een schizophrenia. T able 8-3 lists s ome characteristics by which delus ions have been class ified. S imple de lus ions contain elements , whereas complex de lus ions may contain extensive elaborations of people, spirits , motives , and situations.

Table 8-3 C harac teris tic s of Delus ions 880 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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S imple vs . complex C omplete vs. partial S ys tematized vs . nons ys tematized P rimary (autochthonous ) vs . P ers ecutory vs. nonpersecutory How they affect behavior

S ys te matize d de lus ions are us ually res tricted or circums cribed to well-delineated areas and are as sociated with a clear s ensorium and abs ence of hallucinations . T hey are often is olated P.978 from other aspects of behavior. In contrast, nons ys te matize d de lus ions us ually extend into many of life, and new data—new people and situations —are cons tantly incorporated to further s upport the presence the delus ion. T he patient us ually has concurrent mental confusion, hallucinations , and s ome affective lability. Whereas the patient with a clos ed systematized system may go about life relatively unperturbed, the patient with a nons ys tematized delus ion frequently has 881 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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poor s ocial functioning and often behaves in respons e the delus ional beliefs . C omple te de lus ions are those held utterly without contrast, partial de lus ions are those in which the entertains doubts about the delus ional beliefs . S uch doubts may be s een during the s low development of a delus ion, as the delusion is gradually given up, or intermittently throughout its course. During an acute schizophrenic epis ode, a 23-year-old was completely convinced that the s ubtle pattern of superficial veins on his legs was evidence of “as tral domination” by extraterres trial beings . After 1 week of antips ychotic medication, he believed the veins were caus ed by others with s pecial powers but was less T wo weeks later, he denied believing that the patterns his legs were other than superficial veins and previous belief with a shrug. An autochthonous de lus ion is one that takes form in an instant, without identifiable preceding events, as if full awarenes s s uddenly burs ts forth in an unexpected insight like a bolt from the blue. T hese delusions may quite elaborate. After a 2-year period of gradual academic and interpersonal decline, a 21-year-old man had the conviction that certain songs played on the radio us ed voice in the role of lead singer. He could not explain this would be s o nor why this belief emerged s uddenly when it did. Aside from the autochthonous types, three other types 882 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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delus ions have been described as primary. Delus ional pe rce pt refers to the experience of interpreting a perception with a delus ional meaning, one that has enormous pers onal s ignificance to the patient. atmos phe re or de lus ional mood is a state of perplexity, sens e that s omething uncanny or odd is going on that involves the patient but in uns pecified ways . Ordinary events may take on heightened s ignificance, but the delus ional interpretations are fleeting, although the uncanny feeling stays . T ypically, after a period, fulldelus ions develop, replacing the delusional mood. Delus ional me mory is the memory of an event that is delus ional. As an example, a patient “remembered” his fourth-grade teacher s lipped lys ergic acid (LS D) into his apple juice; this memory s erved to his psychotic dis order. T he elaboration of false and their s ubsequent fixed belief may as sume proportions . A young schizophrenic woman attended a “trauma with her roommate and gradually came to believe that had been repeatedly s exually as saulted by her father the time s he was in the crib. W hat started out as vague dream-like images gradually coalesced into a series of “sens ed” memories that then took on specific vis ual images of her father's fingers penetrating her and of his looking down at her in the crib leering. Her parents horrified by these accus ations , and there was not a of evidence to corroborate her increasingly venomous accusations . P atients vary considerably in the extent to which they action in res ponse to delus ional thoughts . J ust as 883 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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can experience delusions of their thoughts being controlled (thought pas sivity), they may similarly experience their feelings, behaviors, and will as by outside forces. T hese de lus ions of control (or experiences ) occasionally, albeit uncommonly, res ult in dramatic self-destructive or aggres sive behaviors, as illus trated by the murderer who called himself S on of T his psychotic killer murdered a series of people in Y ork and claimed that he was the powerles s agent of a force that required him to commit the acts. T o defend thems elves and others agains t delus ional anticipated events, s ome patients may take bold and occas ionally destructive actions . A 38-year-old man with untreated s chizophrenia was transferred from jail to hospital for evaluation and treatment after s hooting (but not killing) his neighbor. explained that the neighbor had been “hass ling” him for months by making nois e in the middle of the night, laughing at him, and listening to his conversations through the wall. T he patient explained that he s hot the neighbor as a warning to back off. T able 8-4 lists s ome clas sic types of delus ions. less common than thos e involving paranoia, and influence, delus ions of mis identification are prominently reported because of their inherently intriguing nature. In C apgras ' s yndrome , the patient believes that s omeone close to him or her has been replaced by an exact double. In F ré goli's phe nome non, strangers are identified as familiar people in the life. In the de lus ion of doubles , patients believe that person has been physically transformed into 884 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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Table 8-4 S ome C las s ic Types o Delus ions Delusions of pers ecution Delusions of grandeur Delusions of influence Delusion of having s inned Nihilis tic delus ions S omatic delus ions Delusion of doubles (doppelganger) Delusional jealousy (Othello s yndrome) Delusional mood Delusional perception Delusional memory Delusions of erotic attachment (C lérambault's syndrome)

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Delusions of replacement of s ignificant others (C apgras ' s yndrome) Delusions of dis guis e (F régoli's phenomenon) S hared delusions (folie à de ux, folie à trois , folie famille)

Olfactory delus ions that one emanates a foul odor are common in s ocial anxiety s yndromes, in which are particularly concerned about potentially thems elves and others. P.979 Delusions are not only s een in isolated individuals . delus ions may occur in couples (folie à de ux) and in (folie à famille ). Many ps ychiatris ts cons ider group delus ions to be pres ent in s ome cults as well, but where the cutoff points occur between delus ions and other zealous beliefs held by larger, more traditional well-organized religious, political, and other groups is arguable. A husband and wife appearing at a ps ychiatric department both wore skullcaps made of sheets of aluminum foil. T he reas on for the caps, they concurred, was to ward off radio s ignals being beamed to their from outer s pace. T he hus band was a dominant personality who had originated this fixed delus ion. His 886 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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wife, a mild-mannered, pas sive pers on, s eemed to accepted her hus band's interpretation of events without challenging them at all.

Dis turbanc es of J udgment J udgment involves a complex and diverse group of functions that includes analytical thinking, social and ethical action tendencies , and depth of unders tanding insight. Analytical thinking includes the capacity to discriminate and to weigh the pros and cons of alternative actions. S ocial and ethical action tendencies clos ely related to culture and upbringing. T he evidence genetic factors in antis ocial pers onality disorder primarily by judgments that lead to criminal behaviors ) points to the additional role of cons titutional factors. Ins ight may reflect intelligence, learning, cognitive and the capacity to integrate intellectual knowledge emotional awarenes s. Impairments of judgment occur in many ps ychiatric disturbances . Anxiety s tates, intoxications , fatigue, and even group pres sures may caus e temporary of judgment in otherwis e normal individuals . In mood disorders , judgment may be impaired by either an exaggerated evaluation of ris k or failure in depres sion conversely, of inadequate appreciation of risk or mania. Organic brain damage and ps ychotic dis orders chronically impair any aspect of judgment in any regardless of premorbid character. P oor role models deviant s ocial backgrounds may lead to social and action tendencies quite different from thos e of the examiner. T hus, s omeone raised in a criminal may have s uperb analytical judgment and s elf887 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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which are, however, put to illegal us e. A 48-year-old man with bipolar disorder became depres sed. As part of his guilt s ymptoms, he believed he could no longer be a good enough husband and divorced his wife, des pite her protes ts. W hen his depres sion remitted, he realized the depth of his poor judgment and remarried his wife. J udgment may be impaired in one dimens ion and in others. Individuals may retain sound ethical when their analytical capacities fail or may retain analytical abilities for nonpersonal matters, although lacking ins ight into personal situations or behaviors. some people who can provide s ocially appropriate res ponses to traditional mental s tatus examination questions , s uch as what one would do in a movie fire broke out or what one would do with a stamped sealed addres sed envelope found in the s treet, might the same time be incapable of accurately as ses sing clinical or more pers onal matters s pecifically related to one's capacity to provide informed cons ent, such as pros and cons of receiving a medication or electroconvuls ive therapy (E C T ); regarding judgments neces sary to provide ones elf with food, clothing, and shelter; or ins ight into one's state of health or illnes s. apocryphal s tory about the delus ional patient able to accurately evaluate and fix a broken-down car that had stymied the mechanics, ending with the patient's declaring, “I may be crazy, but Iapos;m not stupid,” indicates the s elective nature of poor judgment within ps ychiatric disorders. T he term ins ight, usually in the context of self888 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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has been used in a variety of ways. B as ic ins ight refers superficial awareness of one's situation. In evaluating insight into one's ps ychiatric condition, bas ic insight allows an individual to acknowledge the pres ence of an illness . A deeper level of insight is operating when the patient has an intellectual appreciation of what is going (e.g., “I have hallucinations and delusions , and my have told me that I have s chizophrenia and mus t take medication”). S till deeper levels of insight reflect more complete cognitive and emotional appreciation of a situation (e.g., “I realize that I have s chizophrenia, that impairs my judgment and s ocial function at times, and I will have to take medications if I am to minimize my symptoms and try to make the mos t of my life. I feel profoundly disappointed about this affliction because it prevents me from achieving some of the goals Iapos ;ve always wis hed for. Nevertheless , I have do my bes t to over my disappointment and hurt feelings s o that I can whatever I can out of life.”). Of cours e, different depths of insight as s elf-awarenes s be evaluated in many other situations , s uch as phys ical illness , quality and nature of relationships , an of strengths and weakness es in profess ional s ituations, and s o forth. In formal studies of ins ight us ing standardized instruments , lack of insight correlates with poor outcome in s chizophrenia and bipolar disorder, medication noncompliance, and s uicidality. of ps ychosis does not necess arily correlate with insight. Impaired insight may be ass ociated with frontal lobe abnormalities. Ins ight may be as s eriously mania as in schizophrenia and, contrary to earlier may be lacking in OC D. 889 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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J udgment may be impaired by s everal factors , cognitive clouding (as in dis turbances of e.g., intoxication, s o that one's us ual analytical abilities impaired), self-deception, and impulsivity. S elf-de ce ption refers to the almost universal tendency hide certain iss ues about the external world or about oneself from various levels of awarenes s. S elffunctions as a coping s trategy, fos tering or maintaining comfortable perspectives about the world and avoiding confrontation with iss ues and realities that inevitably up painful conflicts or the need for difficult actions , thereby preserving emotional calm. In addition, s tudies suggest that self-deception enables us to act and to be perceived as more convincing in the service of goals , as in romantic relations hips or bus iness T herefore, although “kidding ours elves ” may reflect impaired judgment, it may at times also yield certain important strategic advantages . Impulsive judgment describes a tendency to avoid the time and thought to fully understand and integrate of the facts and levels of awarenes s required for decis ion making. Impuls ive judgment may occur only certain is sues or s ituations (s uch as how one picks inves tments ), s ignal an impaired state (s uch as intoxication), or reflect a pervas ive character trait. R apidly made judgments , and even s o-called s nap judgments , may not be maladaptively impuls ive, even when they involve very important areas of life. R apid decis ions can be very accurate, highly adaptive, and life-saving, es pecially if made against a background P.980 890 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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of great experience, wis dom, and forethought the area requiring the decision. B ecaus e, in clinical practice, the terms ins ight and judgment are often applied to individuals ' awareness decis ion making about their ps ychiatric s tatus, complex motivational states that incorporate insight and related to how one is dealing with one's problems , the called s tages of readiness for change, bear mention at point. Initially des cribed in relation to subs tance abus e, including alcoholism and smoking, these stages have received considerable attention and form an important as pect of clinical as sess ment acros s other diagnos tic categories s uch as eating dis orders. S everal s tages been described: (1) precontemplation: the pers on expres ses no intention to change (may be in denial); contemplation: the person acknowledges a problem states an intention to change within several months but not right away; (3) preparation: the pers on intends to something about changing in the near future and may have already made s ome false starts; (4) action: the individual has engaged in making s ustained behavior changes; (5) maintenance: the individual has been engaged in changed behavior for more than 6 months; and (6) termination: the individual has s ucceeded in the change and is unlikely to ever return to the original behavior.

Dis turbanc es of C ons c ious nes s C ons cious ne s s can be defined as s ubjective the self and environment. B iologists increasingly that a continuum of cons cious nes s exists , extending 891 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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lower animals through Homo s apie ns . However, cons ciousnes s is s ubject to conflicting definitions and conceptualizations , and exactly where cons cious nes s begins in evolution remains unclear. P hilosophers that it is the s ubjectivity of experience, the s o-called of consciousness , that clearly dis tinguis hes living cons ciousnes s from at least this generation's best of self-regulating automata, elegant computers, or All current attempts to even approach an of consciousness are very unsatis fying, and remains unexplained and as yet unexplainable from a scientific point of view. C ons cious nes s has been an emergent property of complex biological nervous systems , as a poorly understood general property of an even more mysterious and complex univers e, or as a phenomenon to be unders tood only in religious and spiritual terms. One of the bes t analyses to date of relations hips between the construction of a brain and poss ibility of consciousness has been s et forth by E delman, who believes that reflective cons cious nes s cannot occur until complex higher-order brain s ys tems evolve whose major functions are to monitor the experiences , activities, and results of activities of those lower-order brain s ys tems that deal directly with appraising and res ponding to the external and internal environments . S uch higher-order metas ys tems require presence of memory so that current and immediate impres sions can be checked and compared agains t experiences . T hese metas ys tems may us e a variety of sens or mechanisms to detect and signal their perceptions of various events. S ome of thes e s ens ors corres pond to feeling states , and some may initially to preverbal thought-like mechanis ms that 892 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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the capacity to develop and recognize abstract and, ultimately, conceptual language-based thought. C linically, conscious nes s can be considered from both qualitative as well as quantitative viewpoints. cons ciousnes s does not seem to be an all-or-none phenomenon. R ather, conscious experiences may gradually and phas ically shift in focus, intensity, and altered states of cons cious nes s may occur in which as pects of cons cious nes s, such as s ens ation, memory, orientation, and judgment, are enhanced or impaired relative to other as pects. Quantitatively, crude divis ions can be made between states depending on relative presence, or impairment, or total absence of cons ciousnes s. E ven within the single individual, cons ciousnes s is not a unitary phenomenon. Multiple streams of thought, operating at multiple levels of preconsciousness es appear to exist in all people of the time, with various elements in thes e coexis ting streams constantly shifting into higher or lower levels of cons cious awareness . In pathological states , even remarkable properties of cons cious nes s are s een, for example, the existence of cocons ciousnes s in humans have had commiss urotomies and of s eemingly multiple discrete consciousness es in patients with dis sociative identity disorders . E xperiments involving patients with commis surotomies the corpus callosum have shown the exis tence of two virtually separate s ys tems of cons cious nes s that s eem operate side by s ide. F or example, when in the cours e an experiment, the picture of a nude woman was only to the right brain (the left vis ual field) of a commis surotomized patient, the s ubject verbally 893 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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being aware of anything unusual (i.e., the left brain— verbal brain—was unaware). B ut, at the same time, he started to s quirm and blush, blurting out, “Oh, you have some machine!” S imilarly, when a cup was presented the right brain (left visual field) only, the patient denied seeing anything (left brain was unaware, and language output of the left brain indicated no awarenes s), but he was able to pick out the cup from an ass ortment of with his left hand (right brain control). T hat literal of verbal awarenes s from visual–spatial awareness in brain produces behavior that is at least superficially to that of patients who deny being consciously upset by an event but who react with s trong visceral res pons es . Although this formulation is s implistic, the s eparate cons ciousnes s for logical–verbal and for s patial–visual awarenes s demons trated in split brain experiments be crude analogs for more highly differentiated and discrete types of awarenes ses and modes of proces sing. F urthermore, the very fact that there are separate and, to s ome extent, competing modes of cons ciousnes s may increas e the likelihood of ps ychological distress becaus e the various modes are capable of yielding internally conflicting views of reality.

Ps yc hologic al and Phys iologic al Fac tors In ordinary states of alert consciousness , individuals able to deploy adequate amounts of attention to their surroundings and to reflective thought. Normal people vary enormous ly in their ability to pay careful attention different s ettings without being distracted; individual variations may reflect temperamental and cognitive differences as well as phys iological s hifts within the 894 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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individual. Many functions of attentive consciousness , including attention, planning, and the capacity to appropriately switch between mental tasks, s o-called distractor res istant memory, have been linked to the activity of specific neurons in area 46 of the prefrontal cortex. A s ens e of increased consciousness with heightened alertness , awarenes s, and sharper thinking may be experienced in s tates of highly arous ed emotional such as threat, s exual attraction, falling in love, or other high-stakes events such as hunting among primitives , sporting competitions, or performing in front of an important audience. High levels of arous al do not neces sarily guarantee effective attention becaus e cons ciousnes s depends on optimal arous al. T oo little arousal due to illnes s or fatigue may result in stimulation and mental lethargy, diminis hing the s ens e alertness and attentivenes s, whereas too much arousal may result in hyperintense alertnes s but distractibility scattered attention. P.981 C ons cious nes s involves , among other things , the experience of a continuous sense of s elf and of the environment, existing coherently in time and s pace. experience of time and its pas sage may be altered by in the level of awareness and by emotional s tates s uch boredom, concentration, pain, and discomfort. T he experience of time and s pace may be altered by marijuana, ps ychoactive and psychedelic drugs, and events directly affecting brain phys iology. 895 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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Dis turbanc es in the L evel of C ons c ious nes s Levels of cons ciousnes s (i.e., alertnes s, awareness , attentivenes s) may be pathologically increased or decreased. S uch changes are diagnostically and can occur in many different dis orders. W hen levels arousal and alertness are mildly elevated, as in or with the inges tion of small amounts of ps ychos timulants , s ubjective experiences are typically positive. In thes e s ituations, the pers on experiences intens e alertness , prolonged concentrating ability, and hyperesthesias in which perceptual vividness is heightened: C olors are brighter, s ounds are s harper, touch is more intens e than usual. W ith further arousal and cons cious nes s as s een in mania, more intoxications with amphetamines and cocaine, and catatonic excitement, attention fragments . Heightened alertness transforms into hypervigilance and paranoia, hyperesthesias become unpleasant. Diminished levels of cons cious nes s can be des cribed continuum. C louding of cons cious ne s s is marked by diminis hed awarenes s of s ens ory cues and diminished attentivenes s to the environment and to the s elf. S econdary process thinking is most notably and more primary process thinking emerges into cons ciousnes s. In this s tate, one's ability to appreciate subtleties and to think in a nuanced manner is and is replaced by more dichotomous all-or-none, stereotypical thinking. T he level of consciousness may fluctuate rapidly in relation to the internal phys iological state or to the degree of external s timulation. In of cons cious nes s, confus ion may occur with 896 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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to time, place, or person. T he patient is us ually highly distractible and unable to pay sus tained attention to a single s timulus. T orpor is a condition in which the patient is drowsy, as leep easily, and shows a narrowed range of and s lowed thinking. S tupor is a state of diminished cons ciousnes s in which the patient remains mute and although the eyes are open and may follow external objects. In the mos t extreme impairment of coma, there is no evidence of mental activity at all. T he patient es sentially appears to be functioning on a decorticate or decerebrate level. In akine tic mutis m, or coma vigil, patients with profound brainstem lesions appear to be awake with their eyes open, but there is in fact no evidence of consciousness . T he commonly G las gow C oma S cale incorporates these dimensions. Delirium, the acute confus ional state, is us ually characterized by a relatively abrupt onset and short duration of clouded, reduced, and fragmented impaired memory and learning; perceptual and abnormalities , s uch as hallucinations and delusions ; disrupted sleep; and other autonomic dysfunction. T he level of consciousness may be consistently diminis hed may fluctuate. T he electroencephalogram (E E G ) shows diffuse slowing. T ypical motor abnormalities include an increase in general res tless nes s, fine and tremors , and myoclonic jerks . Autonomic disturbances commonly include tachycardia, fever, elevated blood press ure, diaphores is , and pupillary dilatation. T he of delirium are legion, including s ys temic medical disorders , such as metabolic imbalances or infections, intracranial disorders due to traumatic, structural, and 897 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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electrical caus es , and drug intoxications and states . Atte ntional difficultie s are manifest by impairments in person's ability to deploy, focus, and s us tain attention. S ome attentional difficulties first appear in early as developmental problems of uncertain caus e and are described as attention-deficit disorders (inattentive or hyperactive types). S econdary attention-deficit may appear de novo in adulthood due to a variety of exogenous agents , psychiatric disorders , and late-life developmental and degenerative factors . In narcoleps y, characterized by s udden laps es into one's us ual ability to s tay alert and maintain is impaired. At times , the onset of profound s leepines s gradual, accompanied by hypnogogic phenomena, in which dream-like images invade cons cious nes s, and at other times the s hift in conscious ness appears to be instantaneous . T his s yndrome, occurring in 1 in 10,000 persons, is thought to be the s econd mos t frequent caus e of automobile collisions after alcohol intoxication.

Altered S tates of C ons c ious nes s C ons cious nes s may also be qualitatively changed, with production of altered s tates. Drugs such as (T ransderm) with s trong central anticholinergic some seizures, and, on occas ion, other conditions as sociated with delirium can induce twilight s tate s , like states of wakeful cons cious nes s in which attention poor, an admixture of primary and secondary proces s thinking appears , and patients fade in and out of Dream-like experiences intrude into the s tream of 898 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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conversation. E motional outburs ts or violent acts may occur during twilight s tates . Mys tical s tate s of cons cious nes s may occur in normal pathological conditions. Intense meditation and peak or epiphanic experiences , reported by more than 10 of normal individuals in community surveys, may a s ense that the s elf diss olves or expands , that the s elf fus es mystically with the cosmos, that time s tops , and universal meaning becomes clear. T hese perceptions be accompanied by a s ens e of rejuvenation and personal identity, ineffability, intens e emotionality, and concurrent perceptual changes. S uch experiences do ordinarily last more than a few minutes . Many people achieved these states through the use of ps ychedelic agents such as mes caline and LS D. R eports of a white at the end of a tunnel, described by individuals us ing ps ychedelics and in near-death experiences , have linked to specific neurophys iological pathways believed be stimulated under thes e conditions. A 43-year-old female accountant with no prior history of spiritual or religious practice s ustained a severe head in an automobile accident that left her comatos e for approximately 6 months . W hen s he awoke, s he that at some point during her coma, s he estimated in third month, s he experienced a profound mys tical experience, which included a glorious union with G od knowing that s he would not only awaken to return to but that all was “as it should be” with the univers e. After recovery, with ongoing motor impairment, she became profoundly spiritual, started attending church and teaching the B ible, and cons tantly evidenced a beatific 899 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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glow, which s he attributed to her mys tical experience. Although hypnosis lacks a cons ens ually accepted definition, its hallmarks are s elective attention, suggestibility, and diss ociation. Mos t, but not all, can be hypnotized to some degree. Up to 90 percent of people are capable of achieving a light trance, whereas to 20 percent are capable of entering a deep trance exhibiting remarkable hypnotic phenomena. Hypnos is occurs when the s ubject is P.982 in a s tate of heightened, not diminished, attention. E E G studies have s hown hypnotized subjects to be fully and alert. T he heightened concentration probably accounts for the unus ual levels of s ens ory and motor performance often s een under hypnos is and selfHypnotic phenomena include hypnotically induced hallucinations (including negative hallucinations in the subject s electively does not perceive sights , other s timuli), anesthes ia, sus tained motor behaviors acts of s trength ordinarily beyond the individual's and distortions of memory (both hypermnes ias and amnes ia). S everal phenomena that reveal the multiple nature of cons cious nes s, for example, also demons trable. E xperiments have s hown that even when a s ubject in deep trance has achieved profound hypnotic anesthesia and can, for example, keep a hand submerged in ice water for longer periods of time than us ual, part of the hypnotized subject's cons cious nes s continues to register exactly how painful the actually is and can s ignal the researcher about the 900 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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finger movements , without the s ubject having any cons cious awareness or dis turbance. T his called the hidde n obs e rver, has als o been s een in posts urgical patients who, under hypnotic trance after surgery, have been able to accurately recall in the operating room that occurred while they were under general anes thes ia. Dis sociative and phenomena have als o been induced with hypnos is . posthypnotic s uggestion, for example, s ubjects may out complex actions without any hint that they are doing so becaus e they were previous ly ins tructed to that way under hypnosis. W hen as ked why they are carrying out thes e activities, s uch subjects us ually various reasons , although s eemingly unaware of the reasons for their actions . It has been suggested, not entirely facetiously, that many normal daily activities conducted in a trance-like pos thypnotic s tate, and although thes e activities are attributed to conscious intention, they may in fact be carried out due to suggestion. Advertis ers know this well. Urticaria (hives) be hypnotically induced and hypnotically made to disappear. P lantar warts have been s ucces sfully with hypnos is , and, in these conditions, diminished supplies to their bas es have been demonstrated. It has recently been appreciated that yoga mas ters can exert remarkable control over basic bodily functions through self-hypnosis . As yet, little is known of the full extent to which heightened concentration may influence phys iological regulation.

S ugges tibility P athological sugges tibility may be seen in several conditions. Automatic obedience has been des cribed in 901 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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echolalia (the automatic repetition of a sentence or just uttered by another pers on), echopraxia (the mimicking of a movement performed by another and waxy flexibility (maintaining for a prolonged period time a pos ture in which one is placed), s ymptoms in catatonic states . In s ituations of group delusions , sometimes in cults, pas sive individuals adopt the delus ional beliefs of s tronger ones . In epidemic described among young women at the S alem witch in Arthur Miller's T he C rucible , distorted and even delus ional perceptions and beliefs may s weep over a group that has been highly arous ed by a charis matic leader. Autos ugge s tibility can be s een in the cons tructions of memories in which an individual progress ively comes believe that something that never happened in fact occurred. S uch false memories may be held with such great conviction that they are indis tinguishable from the memories of real events . B ecaus e of this, memories recovered during therapy (in which there is often great press ure to “remember” certain events) cannot be face value without corroboration from other s ources . V arious types and degrees of self-deception may be common in individuals who are more s uggestible.

DIS S OC IA TIVE P HE NOME NA Dis s ociation refers to the s plitting off from one another what are ordinarily closely connected behaviors, or feelings . Dis sociative s tates are those in which there disturbance or alteration in the normally integrated functions of identity, memory, or cons cious nes s and include trances , fugues , blackouts, multiple 902 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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(diss ociative identity disorder), and dis sociative Although diss ociative states are ordinarily believed to functional in nature, aris ing as an adaptive defense in individuals subjected to a great deal of trauma, at early ages , they occur regularly with a variety of neurological disorders , particularly thos e with partial complex seizures . In one series , one-third of patients complex partial seizures had dis sociative phenomena, including multiple pers onality. In these patients, the diss ociative phenomena were not related to the s eizure activity but to interictal alterations. As in pos thypnotic amnesia, elaborate activities can in diss ociative states for which the subject has no cons cious memory. T his amnesia is functional in and may be revers ed by hypnos is or drug-facilitated disinhibition, for example, with amobarbital (sodium Amytal) infus ion. In many of the functional dis sociative states , amnestic epis odes may occur for years or before the patient s eeks medical or ps ychiatric B lackouts are periods of amnes ia in alcoholism, other intoxications, or after head trauma. An alcoholic period may last for hours to days , after which the has no recollection of what transpired, although other observers attest to the fact that, during this period, the individual carried out multiple complicated behaviors . Although memory of the blackout is lost to the predominant cons cious nes s, during s ubs equent reintoxication, memories of events occurring during the previous blackout may be reawakened. T his known as s tate -de pendent me mory, occurs in many conditions as well, signifying that one's ability to specific memories may be highly influenced by specific 903 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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phys iological alterations due to external intoxicants or other unus ual phys iological states . A 43-year-old man with a 20-year history of s ustained alcohol abus e was unable during a period of s obriety to recall for hos pital s taff the names, phone numbers , and addres ses of his clos e friends and as sociates . S everal later, when he returned to the emergency department an intoxicated s tate, he was able to recall all of thos e details in a reas onably straightforward manner. P s ychoge nic fugue is characterized by prolonged which individuals carry out very complex activities having any recollection for their previous lives , or even names . T hey often travel away from customary locales and as sume entirely new identities. B y ps ychogenic fugue cannot be due to a neurological disorder. In comparis on, the dis continuity of experience ps ychoge nic amne s ia is typically more circums cribed does not involve as suming an entirely new identity. T he diss ociated memories and affects often reveal in dis guised form s uch as nightmares , intrus ive visual images, and convers ion s ymptoms. T ypically, in ps ychogenic amnesia, an individual may not be able to recollect what trans pired during a s pecific period, for example, before the age of 9 or 10 years in the context traumatic childhood; during catastrophic events, such traumatic, gruesome combat; P.983 or during less momentous events that a person prefers forget to preserve s elf-es teem by denying shameful, immoral, or illegal activities. 904 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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A 28-year-old infantryman could not recollect the of the combat s ituation in which he had been wounded and s everal of his comrades killed. S everal months afterward, he participated in a s eries of Amytalinterviews , during which the events of combat came to him. He recalled becoming panicky during the turning, and running away while s everal other s oldiers his s quad, s everal of whom were killed, yelled to try to him to stay in place and fight. After the interviews, he inconsolably and blamed himself, s omewhat for their deaths , wondering if his remaining in place and fighting might have saved their lives .

Dis s oc iative Identity Dis order Dis s ociative ide ntity dis orde r, previous ly known as pe rs onality dis orde r, is a chronic, diss ociative state in two or more s eparate ongoing identities or alternate in cons cious nes s. It us ually occurs in people as young children, were s everely and repeatedly brutalized. T he number of identities is variable, with cases reporting 25 or more identities . T he development diss ociated alter personalities is believed to be a lastprimitive ps ychological defens e against ines capable unbearable traumatic s ituations. T he pers onalities may of different ages and even different s exes. T ypically, presenting identity is dys phoric, anxious, and may have headaches and periods of blackout or and is not aware of the other personalities. A second identity is typically vivacious and uninhibited. Another identity may know all about the other pers onalities and has a wise pers pective on the life events leading to the problems and regarding poss ible s olutions . A clas sic 905 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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is described in a popular book and film T he T hre e E ve . In so-called channeling, dis sociated, complex part personalities are produced in trance states in which fictitious past lives or s pirit lives are created.

Gans er's S yndrome In G anser's s yndrome, the patient res ponds to by giving approximate or patently ridiculous answers , example, in respons e to the question “what sound does dog make? ” the patient answers “moo.” Additional features of the syndrome include alterations in cons ciousnes s, hallucinations (or conversion phenomena, and amnesia for the epis ode during which these symptoms are manifest. T his has mos t commonly been reported in prisoners and is generally believed to be a diss ociative s tate, although organic features may contribute.

Depers onalization and Derealization Depe rs onalization refers to an alteration in one's experience and awareness of the s elf, leading to being unreal or detached from one's own body, of like an automaton; it is often accompanied by the complaint that the individual lacks all feelings or experiences . T hose experiencing depersonalization frequently fear that they are going crazy. B ecaus e of fear, patients often endure depers onalization for long periods before des cribing them to a mental profes sional. Depersonalization is als o characterized frequent internal nonaudible dialogues between the participating self and the observing s elf but with full 906 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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awarenes s that both parties are the s ame person (a that distinguishes it from hallucinations ). Mild sens ory distortions —but not hallucinations —are commonly as sociated with the experience. Depers onalization is in a variety of neurological and ps ychiatric dis orders common in complex partial seizures . It may occur in context of depres sion, anxiety disorders , or certain personality dis orders, or it may occur as an entity by In derealization, individuals feel thems elves to be real feel that the world around them has s uddenly become unreal. Derealization often, but not always , depers onalization. T rans ient episodes of and derealization occur frequently in normal people, particularly during s tates of fatigue, sleep deprivation, stress ful situations s uch as bereavement, learning of a terminal diagnos is , or s udden awareness that one is to be in an inescapable vehicle collis ion. A 45-year-old mother of two underwent a breas t biops y a s uspicious lesion. Afterward, sitting in the surgeon's office, hearing him tell her that the lesion was she recalled feeling numb and dis tant, saying to if from a distance, that this was all a dream. S he felt as she were living in an “alternate reality” that would disappear and return her to the real world when s he left the office.

Dis turbanc es of the S elf At the mos t bas ic level, the key components of selfawarenes s are the reality and integrity of the s elf (that I one person), the continuity of s elf (that I am the same person now that I was in the past and that I will be in 907 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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future), the boundaries of s elf (that I can distinguis h between myself and the res t of the world as not-self), activity of self (that it is I who is thinking, doing, Additional components of a sense of s elf include body image and various s elf-evaluations , including s elfand ego-ideal (ideal s elf). B ody image is an individual's mental representation of his or her own body. S elfis believed to reflect how one meas ures up to the self-image. T o the extent that what one s ees in oneself approximates what one would like to be, s elf-es teem is positive. E go-ide als are fantas ies of the optimum one could ever wish to be. Any of thes e qualities may disturbed in psychiatric disorders . Within each individual is a group of s ocial selves comprised of the roles and identities that a pers on as sumes and that are evoked in various contexts . T he presenting “self” varies depending on the people with whom one interacts , s uch as parents , romantic partner, child, friend, or employer, and depending on what role as sumes , s uch as child, parent, colleague, or lover. Accompanying each of thes e “selves” are various objective and s ubjective self-awarenes s and s elfunders tanding.

Dis turbanc es in S ens e of S elf Dis turbances of the basic elements of self-awarenes s be seen in a variety of dis orders. Discontinuity are characteris tic of diss ociative states such as ps ychogenic amnesias and psychogenic fugue. Depersonalization reflects a mild disturbance in the awarenes s of s elf as the agent of activity. More severe disturbance is characteris tic of the psychotic pass ivity 908 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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phenomena seen in s chizophrenia. B oundary may be cons idered characteris tic of all psychotic s tates regardless of diagnos is . Dis orders of self-integrity are characteris tic of both diss ociative identity dis orders and s evere borderline personality dis orders in which a person's s elf-concept expres sion of this concept to others is erratic, leading sens e of uns table identity. F als e s e lf describes a pers ona or a faulty and limited superficial aspect of the personality that an individual builds up as a mechanism for adapting to a hostile to please, control, or negotiate with others and with hims elf or herself. However, the fals e s elf does not P.984 incorporate, integrate, or validate important needs , wants, values , and beliefs. T hrough s elfand denial, the individual may cons cious ly believe that “self” cons titutes his or her entire being. However, the self is a relatively fragile cons truction that has usually warded off and denied fundamental s trivings, which include needs for autonomy; acting with integrity; expres sing certain desires, beliefs , or talents ; or other unacknowledged aspects of the s elf. W hen these off needs finally break through and demand express ion various points in development, the defective false s elf collaps e, leading to a period of dis tres s and identity confusion, which individuals sometimes describe as a “nervous breakdown.” P atients with ps eudologia fantastica and the impos tor syndrome demonstrate extreme examples of 909 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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inconsistency in the sense of s elf. In ps eudologia patients compulsively s pin out webs of lies, ordinarily aggrandizing ones, and als o appear to be trying very to deceive themselves into believing that they are true. the impos tor s yndrome , s uch fantas ies are acted out and impostors who seem to fervently wis h that these fantas ies were their reality, as if they cannot accept thems elves and would be overwhelmingly as hamed to known for who they actually are. T he impostor compuls ively adopts the identities of others and may, example, show up properly attired at diplomatic and s ociety galas and interact with the other guests the as sumed identity. S ome famous impos tors have repeatedly insinuated thems elves into inner circles of society and government. T rans s exualis m is a syndrome characterized by the that one was born into a body of the wrong sex and marked by the desire, starting at an early age, to be a person of the opposite s ex. Male to female is reported most often. B oth ps ychodynamic and biological theories have been advanced to explain unusual phenomena. Of note, studies following who undergo s uccess ful male to female transgender surgery have not revealed higher rates of ass ociated ps ychopathology than in comparis on groups. S elf-es teem is a measure of one's self-appraisal in to one's values and ego-ideals. Negative self-es teem is characteristic of depres sive dis orders, many disorders , and situational failures . S uperficially inflated es teem may be s een in mania (or hypomania) or, in a fluctuating manner, with narciss istic and other disorders . 910 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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Although s ome individuals regard their ego-ideals as unattainable and are content to live as imperfect beings , others s trive to approximate their ideals. who feel driven to achieve unattainable ideal goals or become unrealis tically perfect ideal selves are likely to chronically dysphoric and have poor self-es teem their attempts to become their ego-ideals are doomed failure.

Dis orders of the Will C entral to the sense of self is the concept of will or P sychologically, will is linked to the concepts of intentionality and of transforming awareness and knowledge into initiating action, as the bridge between desire and action. F or individuals to manifes t normal they mus t be aware and feel desires —and these must aris e from within thems elves. C oncepts related to that may become the focus of clinical attention when disturbed include motivation and decision making (i.e., capacity to make choices ). P athologically heightened will, seen primarily in manic states , is characterized by excess ively intens e desires an overly facile capacity to make decis ions, with questions being decided on in an ins tant. With ps ychological energy, these individuals can start new cours es of action with as tonishing rapidity. C loser examination of thes e actions in more extreme cas es, however, reveals that they share much in common with decreased will in that the intens e desires and quick decis ions often reflect impulsivenes s, which can be cons idered an es cape from true willing and decision making, rather than enduring desires or thoughtful 911 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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decis ion making. T he term abulia has been us ed to des cribe the loss , impairment of the power to will or to execute what is in mind. Abulic individuals show a diminis hed sense of motive or des ire and impairment in making the from motive and des ire to execution of action. in will may be s een in a variety of psychiatric dis orders at the end of life, when patients have s urrendered their to live and are simply waiting to die. In schizophrenia, a diminis hed sense of will can be s een in pas sivity phenomena, already described above, as well as in negative (or deficit) s ymptoms that may affect feelings, and behaviors . T hes e include lack of drive, impers is tence at tasks, and a general inner flatnes s. Depress ed patients also des cribe volitional general apathy and anhedonia. P atients who inhale solvents (e.g., glue, gas oline, toluene), smoke marijuana very heavily, and chronically us e have a characteristic amotivational s yndrome . T he which this lack of motivation results from or contributes the chronic s ubs tance abus e is a matter of debate. In OC D, both the obsess ional thoughts and the rituals are experienced as ego dys tonic and not with the patient's conscious desires and will. S imilarly, although patients with anorexia nervosa initially have cons cious experience of willing and controlling their of food, during the course of the disorder, the sense of willfulnes s is replaced by one of pas sivity, of being subjugated by obses sional thoughts and compulsive behaviors that as sume control of the eating behavior. A 28-year-old woman with anorexia nervos a and OC D 912 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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described having as mental background nois e a loud audible thought that cons tantly tallied the caloric value not only of everything s he ate but also of all the foods others in her vicinity ate or that s he saw on s tore T his other stream of thinking occurred nons top, and, calculator, the thoughts constantly did s ums and the tally for the day. T hes e thoughts were experienced parallel to but s eparate from any other thinking in which s he happened to be engaged. Dis turbances of volition are among the more common complaints of patients with pers onality disturbances reques t ps ychotherapy. Individuals with dependent personalities are characterized by difficulties in making decis ions by themselves and often engage in cours es action contrary to their own des ires . S imilarly, with pas sive-aggres sive pers onalities obscure their desires by being excess ively involved in the demands made on them by others. T heir courses of action do not reflect their own decis ions s o much as the thwarting of others ' desires . P eople with compulsive personalities inflexible rules , thereby precluding cours es of action on independent evaluation, individual des ires, and decis ions. In other s ituations , they are indecis ive, sometimes making impulsive decisions at the las t when forced to decide. F inally, many individuals s eek treatment becaus e of self-designated disturbances of willing: T hey do not know what they want, or they make choices among several options, or they excess ively. Often, thes e problems may mas k other of wanting, commitment, taking initiative, hard work, succes s, making a mis take, P.985 913 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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being criticized, angering others, and of all the cons equences related to such actions.

Dis turbanc es of Orientation O rie ntation refers to one's awareness of time, place, person. Accurate orientation requires the integrity of attention, perception, memory, and ideation. occur primarily in organic mental dis orders (i.e., and toxic metabolic brain abnormalities) and in dis sociative and psychotic states . Normal individuals vary tremendous ly in their attention the details of time and in the extent to which their automatically keep time. S ome people have reliable in clocks by which they can awaken themselves at times or accurately gauge the pass age of time with uncanny accuracy, even in the absence of external in a psychotherapy ses sion, for example. Others have difficulty making judgments about time and may pathological lateness or habitually schedule more activities than could ever be accomplished in the time. P oor time judgments may be s een in a variety of ps ychiatric disorders, such as ADHD, or as an problem. B enign disorientation to time is common. few days in a hos pital bed, mos t people do not know exactly what the day or date is because they are not attending to or receiving their us ual cues. P athological time disorientation can be mild or s evere, with inaccuracies of es timation ranging from days to T he dates reported by disoriented individuals may have personal s ignificance such as thos e of important births, 914 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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marriages , or deaths. B ecaus e s patial cues are generally more available and obvious than temporal cues, dis orientation to place signifies a greater degree of cognitive impairment than disorientation to time and, therefore, rarely occurs in absence of time dis orientation. Dis oriented people may know, more or less , the type of place they are in knowing the specific place—patients may recognize they are in a hospital without being able to name the hospital. A 79-year-old former bus iness man with severe was able to s mile responsively in appropriate circums tances and seemed to follow convers ations, his deficits by his well-honed social s kills . When as ked concretely about either time or place, he became momentarily confus ed and then diss embled, s aying or four half sentences that were incomprehensible and then looking plaintively toward his wife for help. Dis orientation to person, a lack of awarenes s of one's identity, is typically s een only in advanced dementias as primary degenerative dementia of the Alzheimer's or in diss ociative states . In organically induced postconcus sion amnesia, transient global amnesia, presumably, psychogenic fugue s tates, knowledge of own identity may disappear, and a pers on may remain unidentified for an indefinite period until the memory for self returns.

Dis turbanc es of Memory Memory is not a unitary phenomenon. C apacities to remember vary for the different s ens es and 915 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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One pers on may have prodigious mus ical memory, the capacity to remember and reproduce whole pieces after one hearing, but be incapable of people's names or telephone numbers. E xceptionally detailed verbal memories have been as sociated with obses sional cognitive s tyles . When individuals with extraordinary memories complain of memory loss , ordinary memory tests may be inadequate to detect deficits , as their relative memory los s may have their capacities to a point within the range of most people. Memory functions have been divided into three s tages: registration, retention, and recall. R egis tration (or acquisition) refers to the capacity to add new material memory. T he material may be s ens ory, perceptual, or conceptual and may come from the environment or within the person. F or new material to be acquired, the person must attend to the information presented, and it must then be registered through the appropriate channels and then be proces sed or cortically R ete ntion is the ability to hold memories in s torage. numbers of neurons are believed to be involved in the storage of a s pecific memory, and it is believed that reverberating circuits are formed in which memory are held by means of changes in proteins or synaptic connectivity, or both. R ecall is the capacity to return previous ly stored memories to consciousness . Newly registered material is transferred incrementally immediate to short-term memory to long-term memory. Immediate memory lasts for 15 to 20 s econds ; s hortmemory (or recent memory) for several minutes up to 2 days (the time involved in new learning and its early 916 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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cons olidation); and long-term (or remote) memory for longer periods . Different physiological process es each of these stages of memory. B ecaus e of this, that affect immediate or s hort-term memory often spare long-term memory. T he process es by which memories transferred from short-term to long-term s tores are unknown. C ognitive s cientists now refer to s hort-term memory as working me mory, the s ys tem that briefly s tores and proces ses information needed for planning and R ecent studies s uggest that the working memory cons ists of at leas t two short-term memory buffers, one verbal and another for vis ual memories , plus a central executive that manipulates and coordinates information stored in the two buffers for problem s olving, planning, and organizing activities . P arallel proces sing s ys tems involving s pecific areas of the prefrontal cortex and brain areas appear to operate separately with respect various process es concerned with working memory. example, separate prefrontal areas appear to be in working memory functions concerned with object identity and spatial locations . Other studies s uggest that different types of memories stored and retrieved by different brain s ys tems, s o that there is at least a dual memory s ys tem. T he first sometimes called a conditioned-emotional s ys te m, or system for implicit me mory, or pe rce ptual me mory, or nonde clarative memory, is present from birth, through life, and is addres sable by situational, s ens ory, affective cues. P as t experiences are express ed images, behaviors , or emotions. T hese memories need involve any cons cious memories of a past experience. 917 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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C onditioned fear res pons es represent examples of memories elicited in this s ys tem. T he second s ys tem, sometimes called narrative -biographical me mory, or me mory, or re flective me mory, or de clarative memory, emerges during the preschool years and includes information s ignificant to the s elf. Memories are addres sable through intentional retrieval efforts , apart from the original learning conditions . T hey are as representing personally experienced events and compose the individual's life his tory, approximately equivalent to memory with cons cious nes s or memory awarenes s. C linical s tudies sugges t that, in at least amnes ias, implicit and explicit memory functions may diss ociated. Dis turbances in memory occur through the interruption registration, retention, or recall.

Dis turbanc es in R egis tration R egistration and short-term memory retention are impaired in disorders that affect vigilance P.986 and attention, such as head trauma, delirium, intoxications, psychosis, spontaneous or induced anxiety, depres sion, and fatigue. A variety of other metabolic and s tructural brain disturbances can affect short-term memory as well, particularly lesions the mammillary bodies , hippocampus , fornix, and as sociated areas . P atients with impaired attention and concentration who are able to demonstrate immediate recall may not be able to retain or recollect these items from s hort-term memory. B enzodiazepine us e has 918 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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as sociated with working memory difficulties, especially the elderly. S ome short-acting, high-potency benzodiazepines used as sleeping pills may be troublesome in this regard.

Dis turbanc es in R etention T he retention of memories is impaired in posttraumatic amnes ia as well as in a number of cognitive disorders as dementia of the Alzheimer's type and W ernickeK ors akoff s yndrome. T he latter, which ordinarily results from chronic thiamine deficiency seen with alcoholism, as sociated with pathological alterations in the bodies and thalamus .

Dis turbanc es in R ec all Dis turbances in recall can occur even when memories have been regis tered and are in s torage. At times , to recall may s ignify that the memory traces have dis appeared and are no longer retrievable. difficulties in recall can occur separately, as in the event of forgetting the name of a pers on or object, only spontaneously remember it hours or days later. In forgetting, more remote events are les s well than recent ones, and important events are most vividly retained in memory. S ome demented patients may los e memories for all events occurring after a specific date event, as if the s late has been wiped clean, but retain earlier memories . S ome individuals may progress ively erase memories s o that they recall only earlier and events. S pecific types of memory functions may be to selectively different control mechanisms in the brain. F or example, recent animal res earch s uggests that 919 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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endocannabinoids may facilitate the extinction of memories , but not their acquisition or consolidation, through their s elective inhibitory effects on local networks in the amygdala. A 27-year-old woman with P T S D s ymptoms related to history of childhood phys ical, emotional, and sexual developed a s ignificant and persistent habit of abuse. S he had tried a variety of s treet drugs but cannabis as her drug of choice. S he was certain that marijuana was far better than other drugs at enabling to “forget” and not dwell on the past while permitting to get about her us ual day-to-day tasks and Under us ual conditions, forgotten events can be with prompting, as sociative memories , or other forms stimulation such as hypnos is. As des cribed earlier, dependent memories are recall failures , reversed by reinstituting the context in which the memory was originally formed. Amnes ias are syndromes in which s hort-term and longterm memory is impaired within a state of normal cons ciousnes s. T hus , memory disturbances in delirium should, s trictly s peaking, not be considered amnes tic syndromes. Ante rograde amne s ia is the inability to or learn new information (and therefore to form new memories ) from a specific event onward; it typically follows head trauma, s tates of cerebral phys iological imbalance, or drug effects. P atients who receive E C T frequently have anterograde amnes ias during the of the treatments; the amnesia gradually fades over numbers of weeks. R etrograde amne s ia is an recalling memories that were es tablished before a 920 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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traumatic event, extending backward in time for periods. As memory is regained, the more remote memories us ually return first. A patient originally for the 3-month period before an accident may be left with amnes ia for events only a day or an hour before the accident. In organically caused retrograde amnes ias, remote memories are usually intact, amnes ia may exis t for more recent events. T his with ps ychoge nic (functional) amne s ia, in which the periods of forgotten events may be more s potty or selective. Hype rmnes ia, unus ually detailed and vivid memory, occur in gifted people, in as sociation with obs es sivecompuls ive and paranoid pers onality traits, and in hypnotic trances . Intrus ive me morie s may occur in signaling failure of the mechanisms that usually keep unwanted memories and information out of working memory. A 36-year-old man with mild developmental disability living on a remote and is olated ranch witnes sed his brother murder a violent, drug-dealing neighbor with a shovel. T he patient was implicated as an accomplice spent s everal years in jail. S tarting on the day of the murder and pers is ting on a daily basis for 5 years thereafter, the patient experienced vivid visual, and tactile images of the murderous act—reacting with strong emotions to all of thes e relived s ensations . T he images were particularly strong when the patient external s timulation and just before falling as leep. Although many forgotten memories can be recalled in hypnotic trance, retrospective falsification and 921 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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may als o occur under hypnosis. (Memories recalled hypnosis us ually are not accepted as evidence in R etrospective fals ification of memory, the development false memories , is called paramne s ia, also known as re connais s ance . C onfabulation is another common paramnesia in which the patient fills in memory gaps inaccurate information. T he respons es given to by patients who confabulate may reflect pas t or bizarre, fantas tic s tories. C onfabulation correlates with memory deficit and is believed to reflect frontal dysfunction and a failure of s elf-monitoring. is prominent in certain alcohol amnes tic s yndromes, as Wernicke-K ors akoff s yndrome, as well as other of the mammillary bodies , thalamus , or frontal lobes. Déjà vu is the s ens e that one has previous ly seen or experienced what is trans piring for the firs t time; it is a false impres sion that the current stream of has previous ly been recorded in memory. R elated phenomena are dé jà e ntendu, a sense that one has previous ly heard what is actually being heard for the time, and dé jà pe ns é , a feeling that one has at an time known or unders tood what is being thought for the first time. E xperiences of jamais vu, jamais e nte ndu, jamais pens é involve feelings that one has never s een, heard, or thought (res pectively) things that, in fact, one has. T hes e phenomena are all common in everyday may increas e in states of fatigue or intoxication and in as sociation with complex partial seizures or other ps ychopathological s tates. Deme ntia is a syndrome in which the es sential feature acquired impairment of s hort- and long-term memory as sociated impairments of abstract thinking, judgment, 922 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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personality changes , and other cortical disturbances . symptoms always involve more than one sphere of function. In later stages , demented P.987 patients may become helples s, too confused to us e a stove, and incapable of remembering the names of relatives . T hey may wander into dangerous situations , oblivious of their s urroundings . Dementias are caus ed variety of pathogenic proces ses, some of which are revers ible, s uch as hypothyroidis m and subdural hematoma, whereas others are irreversible, s uch as dementia of the Alzheimer's type and multiinfarct dementia. Although the characteristic cognitive disturbances seen in s evere major depres sive us ually called ps eudode me ntias , many believe that profound cognitive dysfunction meeting criteria for dementia ass ociated with depres sion s hould properly be labeled as a revers ible dementia T he presence of ps eudodementia, however, is the development of Alzheimer's disease (but not in all cases), indicating that the depress ion was a prodrome the primary cognitive disorder or that the pres ence of ps eudodementia marks thos e with an underlying progres sive cognitive dis order. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > P E R C E P T ION

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P art of "8 - C linical Manifes tations of P s ychiatric Normal perception first requires that the individual be capable of receiving information as s ens ations . T he must then be organized to make them meaningful and comprehensible such as dis tinguis hing figure from or focus ing attention s electively on s ome part of the sens ory field. T he organized entities are called states of sensory deficit, such as blindnes s, deafnes s, anesthes ia, perception is impaired, but perception is poss ible because individuals generally perceive information about an object through s everal sensory modalities concurrently. T he intensity of sensation and perception is affected by vigilance and attention. Highly focus ed attention, as in intens e concentration or may result in unus ually acute s ens ation and hyperesthesia, hyperacusis, or extraordinary vis ual F ocus ed attention may als o res ult in the inability to or perceive: Deep anes thes ia and negative induced by hypnosis are s imply induced failures to perceive what exists in the world. Humans us ually operate in an “average expectable environment” in which certain types and levels of input are expected and for which the nervous system is primed. E xces sive or inadequate s timulation in any modality, levels of input that are extraordinarily intense, the presentation of novel stimuli that are entirely from anything previously experienced by the individual can provoke dis torted perceptions in mos t normal F or example, total sensory deprivation produced in carefully controlled artificial environments may elicit 924 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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and auditory illusions and hallucinations . Individuals generally exhibit selective perception of the world, depending on what is s alient at the moment, and on his or her individual memories , emotions , fantas ies, values. P regnant women are more likely to perceive around them than are people who are not as with childbearing. T he intens ity of perceptions depends on individual sens itivities as well as on mood, anxiety, and us e. Unmedicated patients with s chizophrenia have deficits in olfactory acuity. Depres sed patients often describe that colors look faded, that the world looks was hed out or gray, even though their capacity to recognize specific colors is unchanged. S imilarly, often characterized by heightened perceptions, hype re s the s ia. W hen extreme, these intens e are uncomfortable. Hyperes thesia can also be seen benzodiazepine withdrawal, hallucinogen us e, and, occasionally, as part of an epileptic aura. T he intens ity of perception may vary with cognitive and other ps ychological and neurological factors . individuals tend to be augme nte rs and others bodily experiences . C hronic pain and s ome hypochondriacal syndromes may occur more among somatic augmenters . S elective deficits in the perception of emotions may E motional apros odies have been described in which patients with specific neurological deficits or are selectively unable to recognize the expres sion of emotion. T hes e have been linked by positron emis sion tomography (P E T ) s can to blunted activity in the right 925 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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prefrontal cortex and insula.

Illus ions P erceptual dis tortions in es timating s ize, s hape, and relations are common even in the absence of disorders , es pecially when one is fatigued or aroused. Illus ions are misinterpretations of real sensory stimuli, as when a child in a dark bedroom at night mons ters emanating from shadows on the walls . are playful and whims ical voluntary illus ions that can seen when one looks at ambiguously defined or evanescent images such as clouds or flames in a B oth the ons et and termination of thes e perceptions entirely voluntary. T railing, another visual illusion, is the perception that an object moving s teadily in space is followed by temporally distinct, after-images of itself. effect is that of a s eries of strobos copic photos . T his phenomenon may occur with fatigue and is typically with marijuana and mes caline intoxication, during withdrawal from S S R Is , or, les s commonly, in with nefazodone (S erzone).

Halluc inations Hallucinations are perceptions that occur in the corres ponding sensory s timuli. P henomenologically, hallucinations are ordinarily s ubjectively from normal perceptions. Hallucinations are often experienced as being private s o that others are not see or hear the same perceptions . T he patient's explanation for this is typically delus ional. can affect any s ens ory system and s ometimes occur in several concurrently. W hen perception is altered, 926 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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combinations of illus ions and hallucinations , and often delus ions as well, are frequently experienced together. some studies, 90 percent of patients with hallucinations also have delus ions, and approximately 35 percent of patients with delus ions als o have hallucinations. and early adolescents , however, are more likely to hallucinations in the absence of delus ions. 20 percent of patients have mixed s ensory (mostly auditory and visual) that may accompany functional, as well as organic, conditions . A given stimulus may evoke very different perceptual different people. T hree s cientists floated in sensory deprivation tanks for long periods. One experienced a few illusions and no hallucinations ; the second had many illus ions and a faint auditory and visual hallucinations ; and the third vivid, dramatic, and complex visual and auditory hallucinations . Hallucinations are experienced by many normal people under unus ual conditions. It has been es timated that between 10 and 27 percent of the general population experienced memorable hallucinations, mos t visual hallucinations . T he large majority of self-reported hallucinations in community s tudies , particularly hallucinations , have been ass ociated with depres sive subs tance use dis orders rather than frank ps ychotic disorders . Hypnogogic and hypnopompic hallucinations are predominantly visual hallucinations that occur during moments immediately preceding falling as leep and the transition 927 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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P.988 from s leep to wakefulness , respectively. Hypnagogic hypnopompic hallucinations both occur in normal and are also characteris tic s ymptoms of narcoleps y. In acute bereavement, up to 50 percent of grieving have reported hallucinating the voice or presence of the deceased, and after amputations , phantom limb hallucinations are common. P atients who become impaired often develop pseudohallucinations (i.e., visual hallucinations with pres erved insight) with preserved cognitive s tatus, the s o-called C harles B onnet parallel phenomenon is the emergence of hallucination, including musical hallucinations in individuals with acquired deafness . T hese obs ervations sugges t a “supers ens itivity deprivation” hypothes is that, when deprived of important and anticipated perceptual stimuli, the mental apparatus may overinterpret any sensory stimulation as evidence of the presence of the needed objects. A perceptual releas e theory suggests that hallucinations emerge from the combined presence of intense states internal arous al and diminis hed s ens ory input (including poor attention and poor capacity to s ort out relevant irrelevant input). T hus , diminis hed input from the environment (as in s ens ory deprivation) or reduced capacity to attend to and take in the input (as in states ) heightens the likelihood that internal sensations, images, and thoughts are interpreted as originating in outside environment. Hallucinations vary according to s ens ory modality, of complexity of the hallucinated experience, the levels 928 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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conviction about their reality, the clarity of their the location of their s ources of origin, the degree of volitional control over them, and the degree to which hallucination influences the pers on's behavior. Auditory hallucinations range in complexity from unstructured s ounds, such as whirring noises or whis pers, to ongoing multipers on dis cuss ions about the patient. T he s imple auditory hallucinations are more commonly ass ociated with organic ps ychos es such as delirium, complex partial s eizures , and toxic and encephalopathies. Auditory hallucinations are as sociated with s chizophrenia (seen in 60 to 90 patients) but are also frequently seen in ps ychotic disorders . T wenty percent of manic patients and les s 10 percent of depress ed patients experience auditory hallucinations . T hree types of auditory hallucinations commonly as sociated with s chizophrenia (which, however, are seen les s commonly in patients with ps ychotic and mania) are (1) audible thoughts des cribed as hallucinated voices that s peak aloud what the patient is thinking, (2) voices that give a running commentary on patient's actions , and (3) hearing two or more voices arguing with each other, often about the patient, who is referred to in the third person. A 42-year-old man with chronic schizophrenia that he had chronic and pers is tent daily auditory hallucinations . Although he was not quite clear about etiology of thes e voices, he s urmis ed that they were celes tial beings. W hen his ps ychos is was relatively could hear their discus sions about his behavior and 929 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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occasional commands , which he was able to ignore. his psychosis wors ened, the voices became more res ulting in s ocial withdrawal and a marked increas e in depres sion and s uicidal ideation. While auditory hallucinations in s chizophrenia are frequently mood neutral, hallucinations in patients with mood dis orders are characteristically cons is tent with mood. In psychotic depres sion, the voices may be unrelievedly critical and sadis tic, whereas in mania, the voices often refer to the patient's s pecialnes s. A 31-year-old bipolar man described a recurrent shift in the quality of auditory hallucinations as sociated with his changing mood s tates. W hen he was depres sed, hallucinations were unrelentingly critical of him, telling him that he did not deserve to live and that he should commit s uicide for the good of the world. T ypically, his severe depres sions alternated with irritable manic During those periods , auditory hallucinations not only him that he was great but also belittled and berated in his life and s ometimes instructed him to lash out and harm them when they thwarted his grandios e plans . C ommand hallucinations order patients to do things . the commands are benign reminders about everyday tas ks : “P ick up your s hoes ” or “C lean off the table.” However, the voices may also be frightening or commanding acts of violence toward the self or others such as “J ump off the roof, youapos ;re not worth or “P ick up the knife and kill your mother.” T hese vary in insistence and persis tence, and patients differ their capacities to ignore these commands. P atients marked pass ivity may be helpless in the face of 930 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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hallucinations and may feel impelled to carry out the orders. E ven though one study did not find command hallucinations to be as sociated with a higher risk of to the patient or others, the presence of command hallucinations and the patient's ability to resis t must be as sess ed carefully. A 46-year-old woman with s chizophrenia heard hallucinations on a daily basis for the last 20 years . her symptoms were relatively quies cent, the voices benign, and the commands referred to daily behaviors (s uch as “say thank you”). Under stress , her ps ychos is exacerbated and the voices became louder, more and commanded more complex and dangerous once precipitating a self-stabbing when the voices demanded it. V is ual hallucinations occur in a wide variety of and ps ychiatric disorders , including toxic disturbances , drug withdrawal syndromes, focal C NS les ions, headaches, blindnes s, schizophrenia, and psychotic disorders . Although visual hallucinations are generally as sumed to characteristically reflect organic disorders , they are s een in one-fourth to one-half of schizophrenic patients, often—but not always —in conjunction with auditory hallucinations . V is ual hallucinations range from s imple and elemental, which hallucinations consist of flashes of light or geometrical figures, to elaborate visions s uch as a flock angels . S timulation of one sensory modality s ometimes evokes perceptual distortions in another. Marijuana and 931 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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intoxication, for example, have been ass ociated with s yne s the s ia, an experience in which sensory seem fus ed. T his is also a normal experience for many people. Music may be experienced vis ually, the s ound fus ing with visual illus ions; a tactile s ens ation may be experienced as a color (e.g., a hot s urface may “feel In certain religious subcultures , vis ual hallucinations be experienced as normal. In one fundamentalist P entecostal church, worshipers danced themselves frenzy, and, without us ing any drugs, several shared visions of the V irgin Mary at the altar. A 45-year-old His panic farmer who lived in a rural farm area all of his life attended church regularly. He that he and others in his P.989 family were always aware of the presence of angels guarding over their lives . As they worked in the fields , they were often comforted by thes e angels, they took to repres ent the souls and s pirits of departed ances tors who had lived and worked in the same for hundreds of years . Autos copic hallucinations are hallucinations of one's phys ical s elf. S uch hallucinations may s timulate the delus ion that one has a double (doppe lganger). near-death, out-of-body experiences in which see themselves rising to the ceiling and looking down thems elves in a hospital bed may be autos copic hallucinations . In L illiputian hallucinations , the sees figures in very reduced s ize, s uch as midgets or dwarfs. T hey may be related to the perceptual 932 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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of macrops ia and microps ia, res pectively, the of objects as much bigger or s maller than they actually Haptic hallucinations involve touch. S imple haptic hallucinations , such as the feeling that bugs are over one's s kin (formication), are common in alcohol withdrawal syndromes and in cocaine intoxication. unkempt and physically neglectful patients complain of these sensations, they may be due to the pres ence of phys ical s timuli, s uch as lice. S ome tactile having intercours e with G od, for example—are highly suggestive of s chizophrenia but may also occur in syphilis and other conditions and may, in fact, be stimulated by local genital irritation. Olfactory and gustatory hallucinations, involving smell and tas te, res pectively, have most often been as sociated with organic brain dis eas e, particularly with the uncinate fits complex partial seizures . Olfactory hallucinations may be seen in ps ychotic depress ion, typically as odors of decay, rotting, or death. A 32-year-old woman with s chizophrenia des cribed over the 15 years of her illness , s he had experienced a array of hallucinations. S he initially noticed celestial auditory hallucinations that included angelic mus ic and comforting words . However, over the years, in with a pes simis tic turn of mind, the voices became demonic and threatening. At the s ame time, s he began experience s omatic hallucinations , consisting of s harp, intermittent electric currents being run through her s kin and genitals , which, she was convinced, were the work evil neighbors intent on driving her out of her With medication, she was partly able to perceive these 933 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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experiences as hallucinatory; however, most times, particularly when s he neglected to take medications , never doubted their authenticity. T he term ps eudohallucination has been us ed in two F irst, pseudohallucination refers to perceptions experienced as coming from within the mind (i.e., not at the boundary or outside the mind). Using this definition, loud voices that are alien, ascribed to other beings, but which the patient knows are actually within the mind rather than out in s pace, are ps eudohallucinations. T he term has als o been used to des cribe hallucinatory experiences whos e validity the patient doubts . A better term for this s econd phenomenon is partial analogous to partial delus ion. F unctional hallucinations rare hallucinations that occur only in connection with a specific external perception, for example, in the of a s ound, s uch as running water, or a color, or a place. However, unlike illusions , the hallucinated are not elaborations of the perception but are s imply triggered only in that s pecific context. Ictal hallucinations , occurring as part of seizure activity, typically brief, las ting only seconds to minutes , and stereotyped. T hey may be s imple images , s uch as of light, or elaborate ones , such as vis ual recollections past experiences . W hile the hallucinations are being experienced, the patient ordinarily experiences altered cons ciousnes s or a twilight s leep. Migrainous hallucinations are reported by 50 percent of patients with migraine. Mos t are simple visual hallucinations of geometrical patterns , but fully formed visual hallucinations , s ometimes with microps ia 934 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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and macropsia, may als o occur. T his complex has called the Alice in W onde rland s yndrome after Lewis C arroll's des criptions of the world in T hrough the G las s , which mirrored some of his own migrainous experiences . In turn, these phenomena closely visual hallucinations induced by psychedelic drugs mescaline. A flas hback is an intens e vis ual reexperience of highly charged past events , which are often replays of hallucinations . T hey are typically ass ociated with heavy of hallucinogens , s uch as LS D and mescaline, and occur months after the last drug ingestion. T he images may be s imple or complex geometrical patterns , or may consis t of previous ly experienced elaborate druginduced hallucinations . F las hback phenomena may be state dependent. F or example, visual hallucinations initially experienced with hallucinogens are more likely be subsequently experienced as flashbacks when the subject is smoking marijuana. In P T S D, s ome complex, intrus ive flashback-like images may attain a vividness . Images often include horrifying memories of traumatic events that may force thems elves repeatedly into cons cious nes s until they are acknowledged and worked through. Hallucinos is is a state of active hallucination occurring someone who is alert and well oriented. T his condition seen mos t often in alcoholic withdrawal, but it may als o occur during acute intoxications and other drugstates . A 21-year-old man used LS D daily for 3 days , after the visual hallucinations that firs t occurred while under 935 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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influence of the drug waxed and waned. He des cribed pareidolias with distracting images of animals when he looked at traffic lights, the sky, or billboards . T railers common after he turned his head. F inally, he saw colors when he stared at any object for more than a transient time period. He as sumed that these represented a lingering effect of the LS D and was not frightened by them. T he hallucinations disappeared 1 week.

B ody Image Dis tortion B ody image includes both perceptual and ideational components and may reflect primarily perceptual distortions or combinations of dis turbed perception and self-appraisal, or both. B ody image disturbances can occur as normal abrupt changes in the body (e.g., after amputation), in brain dis eas e, and in ps ychiatric disorders . P hantom phenomena are class ic body image problems in which amputated limb is s till felt to be pres ent. T he sensation may diminish gradually over time; the phantom feels as is receding into the stump. A 53-year-old maintenance worker underwent the traumatic amputation of both legs above the knees in a motor vehicle collision. F or more than a decade, after obtained and mas tered the us e of bilateral prosthes es, P.990 his mos t disturbing impairments were painful phantom limb experiences. He constantly felt as if both legs present but raw and s hattered. In s pite of optimal 936 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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pain medication management, thes e experiences persis ted, and the patient continued to s earch for a neuros urgeon who might alleviate the pain. Agnos ias , lack of awarenes s of some parts of the body, accompany brain damage, mos t often of the parietal lobe. P atients with obvious motor or s ens ory deficits may deny that any deficit exis ts at all (anosognosia), or the denial may be limited to one-half the body (hemiagnos ia), us ually the left side. In he midepe rs onalization s yndrome s , a les s common (hemis omatognos ia), patients feel that one of their miss ing, again us ually on the left side. B ody image distortions in which a limb feels too heavy (hypers chemazia) or weightles s (hyposchemazia) can occur as a cons equence of neurological conditions infarction of the parietal lobe. In duplication patients feel as if part or all of them has doubled (e.g., have two heads or two bodies ). T hese rare phenomena may occur in s chizophrenia, complex partial s eizures, migraine. Dys morphophobia refers to conditions in which patients distortedly perceive and intens ely dislike the shape of a particular body part. As such, these symptoms are misnamed because there is no true phobic component such as fear or avoidant behavior. F ine lines exist perceptual distortions and realistic but unhappy of one's body, given the high social values placed on phys ical appearance. Dys morphophobia may occur in context of some pers onality disorders or as an is olated disorder called body dys morphic dis order. In s ome dysmorphophobia res embles an overvalued idea. may develop dysmorphophobias in relation to any body 937 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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part; common concerns are hair, breas ts, penis s ize, shape of the nose, or the s hape of the entire body. F or some, changing the body part, as in rhinoplas ty for who do not like their nose, seems to effect a lasting positive change in body image, with patients becoming happier with thems elves and feeling more attractive for years or lifetimes. In s evere dysmorphophobia, patients may undergo multiple plas tic s urgeries and feel diss atis fied with every res ult. At times , the condition part of a larger and more pervas ive syndrome, such as anorexia nervosa. An attractive 19-year-old woman was preoccupied and perplexed by the fact that s he perceived her eyelids as being unequal in size and s hape and by the fact that cleft in her chin was too deep. S he spent hours each front of the mirror, trying to pos e in ways that, from her perspective, did not expose thes e facial blemis hes . sought cons ultation from a plas tic s urgeon, who her for psychiatric cons ultation. After 2 months of treatment with an S S R I, her preoccupations with appearance diminis hed considerably, and she was turn her attention to other is sues in her life. Hypochondriacal complaints also combine perceptual ideational distortions. S elective hypervigilance to bodily sens ations may res ult in a higher likelihood of of unpleas ant and potentially pathological body experiences among the “worried well,” hypochondriacal populations, patients with s omatization disorder syndrome), and s ome patients with panic disorder. B ody image distortions may, at times , be severe or S ome ps ychotic patients, either with schizophrenia or 938 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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depres sion, develop somatic delus ions. In depres sion, often express es its elf as a delus ion that part of, or the entire, body is rotting or filled with cancer. S ome bound s yndromes in non-Wes tern culture expres s thems elves with body image distortions s uch as koro, which the man fears that his penis is s hrinking into his abdomen. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > MO OD

DIS TUR B ANC E S OF MOOD P art of "8 - C linical Manifes tations of P s ychiatric Defining, describing, understanding, and categorizing moods have long been among the mos t important, and difficult, tas ks in ps ychiatry. T he language of feelings is filled with terms that s eem to have mos tly idios yncratic meanings , as patients, phenomenologists , and ps ychiatris ts all struggle both to describe inner and to correlate them with external behavior. E ven terms, such as mood, affe ct, emotion, and fe e lings , universal definition. T he most common convention, is us ed here, defines mood as a sus tained or prevailing subjective feeling tone or range of tones. Affe ct is the moment-to-moment feeling s tate, s ometimes rapidly shifting in response to a variety of thoughts and that the clinician can obs erve. E motions have been as moods and affects that are connected to specific or to the phys ical concomitants of moods and affects. F e e lings are the most poorly defined of all, leading K arl 939 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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J aspers to ultimately des cribe them as everything for which there is no other name. In common parlance, often profes sionally as well, these words are us ed interchangeably. T he term mood dis orders , for DS M-III-R and now DS M-IV -T R , replaced DS M-III“affective dis orders” to des cribe the s ame group of ps ychiatric syndromes. Moods , affects, and emotions can be des cribed by a number of important qualities : intens ity (shallow to range (broad to narrow [or flat]), stability (rigid to reactivity to external events (none to much), periodicity (periodic to aperiodic), congruence with thought (congruent [or appropriate] to incongruent), s peed of res olution (rapid to s low), and vis cosity (evanescent to persis tent). T he individual's lifelong predominant mood one component of temperament. T hus, for example, may be described as having a calm, buoyant, irritable, depres sive, anxious, or s ens itive temperament. Moods , affects, and emotions s erve as internal and external s ignal s ys tems. T hey signal the state of the individual to others and often elicit necess ary help and support from the environment. A baby's face communicates its s tate of need, tension, or thereby recruiting appropriate maternal interventions . adults , much of our mos t important interpers onal communications is trans mitted nonverbally through that s ignal the observer about our moods. P ositive communicated by a scowling or sullen face lead to perceive an angry mes sage regardles s of our words . Moods also have an infectious quality and serve important ways of influencing others . T hus, when we cheerfully toward others , they, in turn, are more likely 940 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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feel cheerful and to reciprocate that cheerfulnes s. Internally, moods , affects, and emotions let individuals know how well or how poorly they are doing, allowing them, for instance, to gauge the distance between self-appraisal and des ired s elf-expectations . F or individuals who des ire to master important goals and that they have a reasonably good chance of doing s o ordinarily experience pleas ant emotional s tates in to thes e goals. If something intervenes to prevent them from reaching thes e goals s o that there is an insurmountable gap between their des ires and the likelihood of s ucces s, they may feel hopeles s. In serving as s ignal systems , emotional states of tension, arous al, or anger us ually imply that some neces sary to secure their discharge or release. P.991 E motional states and their expres sion are regulated by biological, ps ychological, and cultural influences . F or example, emotional or affective lability, characterized rapidly s hifting emotions that seem unattached to the situation, typically occurs premens trually in some with varying periodicity in cyclothymic individuals and in those with cluster B pers onality disorders , and in to need states such as hunger, s leep deprivation, and sexual frustration. Mood shifts have als o been related environment-related phys iological influences s uch as seas onal changes in light. P s ychological regulation of emotions may be related to specific coping and the ability to s elf-soothe, which are determined. C onscious and preconscious mechanisms, including varieties of self-talk, may help 941 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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or inflame emotions . C ulture factors s ignificantly emotional express ion. Although the facial expres sions basic emotions are similar in all cultures studied, the and s tyle of emotional express ion permitted in relation specific contexts varies greatly from culture to culture from family to family. S ome cultures and families are lipped and inhibit the open express ion of emotion, whereas others encourage emotional display. Marked differences exis t among cultures in the emotional expres sion of acute grief, fear, pain, and affection.

Depres s ion T he term de pres s ion has been us ed variously to emotional state, a s yndrome, and a group of specific disorders . When s een as part of a syndrome or depres sion has autonomic, vis ceral, emotional, cognitive, and behavioral manifes tations , as illus trated T able 8-1. As a nonpathological, ubiquitous mood state lasting hours to days, but s ometimes longer, feelings of depres sion are s ynonymous with feeling s ad, blue, in the dumps , unhappy, and miserable. Depress ed common and appropriate after a dis appointment or F or mos t people, innate psychological res ilience, alternative coping options, and supportive social help alleviate these brief depres sive states and prevent them from becoming chronic. S ome individuals have chronically depres sed mood, tend to view the world as difficult place filled with obstacles and burdens , see thems elves as victimized, and lack hope for the future. extent to which constitutional, developmental, and ongoing avers ive life events contribute to this pervasive world view is unknown. P eople who, in early life, were deprived and traumatized may be less res ilient and 942 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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prone to chronic depress ive features than are others. R epeated failures and the impact of unrelenting, uncontrollable, and unpredictable negative life events set the s tage for learned helples sness in humans jus t they do in animals. A subs et of chronically depress ed individuals may als o have temperamental, biologically driven depres sion, often seen in conjunction with genetic loading for s evere mood dis orders. S ome depres sive states are normal and common to major unwelcome and undes irable life events . be re ave me nt best exemplifies this . In bereavement major los ses, s uch as the death of a parent, s pouse, or child, people experience s adness , pining, and yearning do not ordinarily have the feelings of guilt, and s elf-reproach that characterize depres sive F eelings of helpless nes s and hopeles sness may be temporarily present in bereavement, but they ordinarily pass with time. In uncomplicated cas es, the proces s of bereavement takes 3 to 6 months in the acute phas e up to 1 year for complete res olution. B ereaved people more likely to feel physically ill and seek general health care than at other times, and older widowers are more likely to die than age-matched nonbereaved controls. P athological grie f re actions , bereavements that last than 1 year, may be s een when the s urviving s pouse excess ively dependent on the deceased and is unable obtain emotional and practical (e.g., financial) support elsewhere or when the s urvivor is unable to grieve fully because of markedly ambivalent feelings toward the deceased. Dis tinguis hing between pathological grief grief triggering a depres sive epis ode may not always poss ible. T he inadequate express ion of grief due to 943 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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incomplete bereavement is believed to be pathogenic many subsequent ps ychiatric disorders . F or example, impulsive acting out among adoles cents who lost a parent is often as sumed to be due to unres olved grief. A variety of medical dis orders may cause depres sive syndromes. Mos t common among thes e are endocrine abnormalities , s uch as hypothyroidism and hyperparathyroidism, and C NS dis orders s uch as cerebrovas cular dis eas es and P arkinson's disease. Depress ions are more common in strokes affecting left anterior les ions than other locations . S ome es pecially antihypertens ive agents affecting adrenergic tone, s uch as res erpine (S erpas il) and poss ibly βmay als o trigger depress ions. T he importance of a diathesis in these iatrogenic depress ions is not yet Depress ive s yndromes and dis orders in general, are unques tionably familial and are likely to have contributions , es pecially in depress ions ass ociated with bipolar disorder. C ognitive features of depres sion are prominent. C haracterizing the exact nature of the memory us ing standardized tes ts has been difficult. T he tas ks requiring s us tained effort and elaborate cognitive proces sing may be more disrupted in depress ion than those tas ks that can be accomplis hed more T he so-called cognitive triad of depres sion cons is ts of pervas ive cognitive s chema related to feelings of worthles sness , helpless ness , and hopeless nes s — expectations that no one and nothing can, or is likely help now or in the future: “Iapos ;m not OK , the world is OK , and it's never going to get any better.” 944 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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S uicidal phenomena are of particular concern. S uicide common in s evere depres sive dis orders, with recent es timates of up to 9 percent of s uicidal hospitalized patients ending their lives in suicide. Depres sed compose the largest diagnostic group of all completed suicides. However, suicide occurs at high rates in other conditions as well, notably s ubs tance abus e disorders , schizophrenia, and s evere pers onality S uicide may occur in these conditions with or without a diagnosable comorbid depress ive dis order. Depress ed patients with comorbid alcohol abus e may be at particularly high ris k for suicide. Although cons istent, us eful, validated predictors of do not exis t, certain demographic features are with higher risk. T hese include being white, male, and older and living alone. In the ps ychiatric history, the most important factor is that of pas t suicide attempts . A history of violent behavior may also predict suicide. Murderers have a very high s uicide rate, es pecially who murder family members during episodes of violence. Among clinical signs , hopeless nes s, and s evere anxiety may predict increased s uicide ris k. S erious physical illness in as sociation with other ris k factors , s uch as depres sion, may place a patient at ris k. A genetic predis pos ition toward suicidal behavior acros s diagnostic lines and plays a role in suicide ris k. may reflect a tendency toward impulsive behavior, correlating with low C NS levels of 5acid (5-HIAA), the major metabolite of serotonin. S uicidal ges tures and various acts of self-mutilation are also common among impuls ive, dependent, and s elfhating depress ed people, for whom they serve as 945 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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releas ing behaviors and as cries for help that may desired s ocial support. B ecaus e s uicidal P.992 gestures have been ass ociated with an increased ris k subs equently completed s uicide, they should not be lightly. S uch self-harm behaviors have been s hown to persis t in patients with borderline pers onality disorder into the s ixth decade of life. C ontrary to earlier thinking, they do not appear to “burn out” with age. suicide may res ult when suicidal ges tures go awry or reckless behavior, s uch as taking unnecess ary ris ks in combat or driving while drunk, prove fatal.

E lated Moods E lated moods include euphoria, elation, exaltation, and ecstasy. T hey are marked by feelings of well-being and expansiveness , optimis m, capability, pleas ure, and S uch moods are normally experienced when life is very well, when long-sought-after goals are achieved, in states of love, religious fervor, and s piritual transcendence. P eak experiences and experiences of mys tic fus ion are often accompanied by feelings of exaltation and ecstasy. S exual pleas ure and some chemically mediated states of altered cons cious nes s also induce thes e feelings . Abnormal elated moods are primarily seen as part of states and from the effects of certain medications and street drugs . W hen subtle, as in hypomania, the mood be ebullient and brimming with s elf-confidence but with occasional irritability. Other characteristic s ymptoms of hypomania are increased energy, decreased need for 946 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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sleep, rapidly flowing thoughts, exces sive talking, self-es teem with a demanding nature toward others , diminis hed judgment. Mania is a more extreme s tate in which judgment and s leep are impaired to the point of marked functional disruption. As the mania irritability and anger increase, alternating rapidly with a brittle expans iveness . C ognitions become increasingly disorganized. P s ychotic s ymptoms , us ually involving themes of grandiosity or s pecialnes s, occur in 50 or more of manic patients . W ith increasing escalation the manic s tate, thinking becomes very fragmented, ps ychotic symptoms are more prominent, and the syndrome may appear indis tinguishable from acute schizophrenia. T hes e three manic states—hypomania, mania, and the ps ychotic, fragmented manic state— been referred to as s tage I, II, and III mania, Manic s tates occur in bipolar disorder, bipolar dis order otherwis e s pecified, and cyclothymia and as a mania caused by a variety of physical and toxic S uch s econdary manias may follow specific cerebral insults, accompany s ys temic disorders , or occur after inges tion of some drugs , including amphetamines, antidepres sants, bromocriptine (P arlodel), and corticos teroids , among others . Mania is the second most common neuropsychiatric disturbance induced by steroids, occurring in 30 to 35 percent of patients who develop s teroid-induced behavioral dis orders. Up to 12 percent of patients treated with levodopa (Larodopa) bromocriptine for parkins onism develop mania. R ight hemis pheric brain lesions are specifically ass ociated secondary mania. Although not a DS M-IV -T R diagnosis, hype rthymic 947 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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pe rs onality refers to personality characteris tics similar hypomania. T hese include unus ual energy, ebullience, confidence, intensity, and so forth but without either the episodic cours e or the functional impairment of hypomania. W hether hyperthymic personality s hould cons idered a bipolar s pectrum disorder or refers s imply high energy individuals is s till unclear.

A nxiety Like depress ion, the term anxie ty refers to a number of different entities : a normal transient feeling, often with adaptive functions; a s ymptom s een in a wide variety of disorders ; and a group of dis orders in which the of anxiety forms a dominant element. As a transient, disagreeable emotional state, anxiety may be adaptive, signaling anticipated or impending threat and neces sary action. In contrast to fe ar, the emotional that exis ts when a source of threat is precise and well known, anxiety occurs when the threat is not well P atients often find it difficult to des cribe feelings of precis ely; at its core, however, anxiety is characterized intens e negative affect, as sociated with an undefined threat to one's phys ical or ps ychological s elf. P atients terms such as te ns e , panicky, te rrifie d, jittery, ne rvous , wound up, apprehe ns ive , and worrie d, to describe their sens ations. Anxiety is additionally characterized by somatic, cognitive, behavioral, and perceptual T he somatic symptoms of anxiety are legion and often dominate; a partial list includes twitching, tremors , hot cold flas hes , s weating, palpitations , ches t tightness , difficulty s wallowing, nausea, diarrhea, dry mouth, and decreased libido. C ognitively, anxiety is characterized 948 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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hypervigilance, poor concentration, subjective fears of losing control or of going crazy, and thinking. B ehavioral symptoms include fearful withdrawal, irritability, immobility, and hyperventilation. P erceptual dis turbances, including depersonalization, derealization, and hyperesthesia (especially are als o common. T rait anxie ty refers to a lifelong pattern of anxiety as a feature of temperament. Individuals with trait anxiety skittish, are hypers ens itive to s timuli, are ps ychophys iologically more reactive than others, and exhibit catastrophic thinking. In contras t, s tate anxiety refers to episodes of anxiety that are tightly bound to specific s ituations and do not persist after the situation has abated. F re e -floating anxiety is by a pers is tently anxious mood in which the cause is unknown and in which large numbers of diverse and events all s eem to trigger and compound the In contras t, s ituational anxiety occurs only in relation to specific occasions or external stimuli, as in phobias. Anxiety s ymptoms can res ult from numerous physical conditions as well as from other psychiatric disorders . Many endocrine, autoimmune, metabolic, and toxic disorders , as well as medication s ide effects , are generate anxiety. T he ps ychiatris t must differentiate res ponse of the patient to an underlying condition (e.g., secondary anxiety) from symptoms generated by the primary disorder itself. In ps ychiatric populations, symptoms are prevalent among patients with organic mental disorders , depres sion, and s ubs tance abuse dis orders as well as in the s pecific anxiety In patients with s chizophrenia, anxiety mus t be 949 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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differentiated from akathisia, a common and often overlooked s yndrome of subjective restless ness , and agitation res ulting from antipsychotic medication. coexistence of anxiety s ymptoms and depress ion in depres sive dis order is substantial; anxiety s ymptoms, as anxious mood and irritability, are s een in the depres sed patients. Additionally, one-half to two-thirds patients with panic disorder experience a major episode during their lifetime. Medication and drug effects —from acute us e, s ide effects , or as part of withdrawal phenomena—are als o common causes of anxiety. Many patients with severe anxiety become dependent on anxiolytic drugs, including benzodiazepines, other s edatives, and alcohol, for symptom relief. During attempts to discontinue these subs tances , or s ometimes during their ongoing us e, confusing admixtures of anxiety symptoms , medication effects, and withdrawal s ymptoms may occur. Although all of the anxiety s ymptoms caused by drug are als o s een in primary anxiety disorders , perceptual disturbances , s uch as depers onalization and hyperesthesia, may be more common in s edativewithdrawal syndromes than in primary anxiety F rom a psychological point of view, anxiety may signal conflict between opposing des ires , wis hes , or beliefs the one hand and major disequilibria generated by negative life events on the other hand. R ole s trains , conflicts among the major social roles that form a identity P.993 —spous e, parent, child, wage earner, profes sional, 950 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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community member—are common s ources of anxiety. more important the conflict and the les s obvious the res olution, the greater is the ass ociated anxiety. F or example, anxiety s ymptoms may first emerge when an individual is confronted with an unavoidable, unhappy choice, such as between sustaining a marriage or accepting a career advancement requiring a major that is unacceptable to the spous e. At times, thes e conflicts may es cape cons cious awarenes s: S omeone feel anxious but not know why. Anxiety syndromes frequently res ult from a combination of several factors . person in a work conflict facing an important deadline try to alleviate initial anxiety s ymptoms by overwork, inges t caffeine or amphetamines to keep alert, then become exhausted and fatigued, and ultimately use alcohol exces sively to calm down, with each of these elements contributing s eparately to an anxiety s tate. C ertain developmental life s ituations are as sociated anxiety. S trange r anxiety develops when infants 6 to 8 months of age begin to recognize the difference mother and others. W hen children firs t go to s chool, anxiety symptoms are common; if the anxiety is s e paration anxie ty or school phobia may res ult. During adult life, anxiety often centers around is sues of and accomplis hment, both in pers onal and work life. P erformance anxie ty, or s tage fright, is a specific type pathological anxiety in which anxiety es calates to panic when public performance is required. In later life, the deterioration of one's body may engender anxiety to feelings of helpless nes s and de ath anxiety. P anic attack is a circumscribed epis ode of severe state anxiety las ting minutes to hours, with symptoms 951 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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es calating in a crescendo pattern. T he s ubjective experience is one of utter terror, fears that one will die, crazy, or los e control, accompanied by many of the somatic s ymptoms of anxiety mentioned above, severe ches t pains , marked s hortnes s of breath, and exhausting fatigue. Individual is olated panic attacks are common, with up to 30 percent of the general experiencing at leas t one attack each year. P anic occur more regularly, and typically more s everely, as of panic dis order or in as sociation with other anxiety disorders . In class ic panic dis order, the attacks are spontaneous; that is , they are not triggered by a predictable environment. In contras t, panic attacks as sociated with other anxiety disorders are triggered by specific s ituations s uch as in social anxiety disorder by social s ituations or in s pecific phobia by confronting the feared object or s ituation. P atients with other disorders may experience limited-symptom panic with epis odes characterized by less intens e anxiety fewer and milder physical s ymptoms such as isolated paresthes ias or difficulty breathing. T hese limitedsymptom attacks may represent aborted full-blown episodes that are not further exacerbated by secondary ps ychological reactions to the initial s ymptoms. A 43-year-old man with crippling shyness and s ocial phobia since youth started to experience increas ing episodes of shortnes s of breath and chest pain in his 30s. On numerous occasions , he called 911 for to take him to the local emergency room, fearing that was having a heart attack. T hese episodes increased frequency at the point in his life when his parents, who had previous ly supported and hous ed him, were 952 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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becoming ill and s howing s igns of not being able to continue to s us tain him. He gradually came to these episodes to be panic attacks and decreas ed the frequency with which he called for emergency s ervices. Although American psychiatry has s egregated panic attacks from other forms of anxiety, ass uming phenomenological, and biological differences, thes e distinctions are far from univers ally accepted. Much of E uropean ps ychiatry views panic as simply an extreme form of anxiety to be unders tood as part of a continuum intens ity. P hobias are irrational fears . In an effort to reduce the intens e anxiety attached to phobic objects and patients do their bes t to avoid the feared stimuli. T hus , phobias consis t both of the fears and the avoidance components. T he fear its elf may include all the of extreme anxiety, up to and including panic. In phobias , persistent, irrational fears are provoked by stimuli. T able 8-5 lists s ome illus trative phobias. specific phobias include fear of dirt, excreta, s nakes, spiders, heights, and blood (also termed blood-injury phobias ).

Table 8-5 S pec ific Phobias Phobia

Definition

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Acrophobia

F ear of heights

Agoraphobia

F ear of open spaces

Alektorophobia

F ear of chickens

Amathophobia

F ear of dus t

Amaxophobia

F ear of riding in a car

Apiphobia

F ear of bees

Arachibutyrophobia

F ear of getting peanut stuck on the roof of the mouth

Astrapophobia

F ear of lightning

Aviophobia

F ear of flying

B lennophobia

F ear of slime

C laustrophobia

F ear of enclos ed spaces

C ynophobia

F ear of dogs

Decidophobia

F ear of making decis ions

Didaskaleinophobia

F ear of going to school

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E lectrophobia

F ear of electricity

E phebiphobia

F ear of teenagers

E remophobia

F ear of being alone

G amophobia

F ear of marriage

G atophobia

F ear of cats

G ephyrophobia

F ear of cros sing bridges

G ynophobia

F ear of women

Hydrophobia

F ear of water

K akorrhaphiophobia F ear of failure K atagelophobia

F ear or ridicule

K eraunophobia

F ear of thunder

Musophobia

F ear of mice

Nyctophobia

F ear of night

Ochlophobia

F ear of crowds

Odynophobia

F ear of pain

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Ophidiophobia

F ear of snakes

P nigerophobia

F ear of smothering

P yrophobia

F ear of fire

S cholionophobia

F ear of school

S ciophobia

F ear of shadows

S pheks ophobia

F ear of wasps

T echnophobia

F ear of technology

T halas sophobia

F ear of the ocean

T riskaidekaphobia

F ear of the number 13

T ropophobia

F ear of moving or making changes

B ehavioral, ps ychodynamic, and biological theories all been advanced as caus es of phobias. S ome wellphobias, such as fear of animals, may result either early traumatic events (developing P.994 along the paradigm of class ic P avlovian conditioning) from displacements of early ps ychodynamic conflicts. 956 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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G enetic influences may also play a role in the of phobias . F or example, some individuals with bloodinjury phobias, which strongly cluster among biological relatives , may be genetically predis pos ed by vagal res ponses to certain stimuli. Animal models als o poss ible biological vulnerability. S ome monkeys that never previously been exposed to snakes become when placed in the presence of a snake. B ecaus e s uch res ponses obvious ly have adaptive value, it has been suggested that s ome human phobic res ponses also represent exaggerations of adaptive behaviors s haped evolutionary biology. C omple x phobias , more elaborate than s pecific phobias , involve fears related to a broader range of situations. Agoraphobia, the best known, fear of the marketplace, s ymbolizing a fear of open C urrent thinking sugges ts that agoraphobia is a reaction to panic attacks. In this view, individuals who become terrified of having panic attacks in public to the safety of their own homes, hoping to reduce the likelihood of panic attacks by avoiding places where were once triggered and where they may feel exposed embarrass ed. In s ocial anxiety dis orde r (s ocial phobia), patients overwhelmingly anxious and fear situations in which may be observed. In the limited type, only a few situations evoke the fear, s uch as speaking in public or us ing a public lavatory. In the general type, broadfears of s ocial s ituations globally hamper the person's interpersonal life.

A ggres s ion, Hos tility, and Violenc e 957 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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T he spectrum of aggres sive emotions and behaviors is characterized by heightened vigilance in response to a sens e of threat and enhanced readiness to attack. P hysiological tone may be geared for a fight. Ass ertivenes s, the adaptive as pect of thes e emotions , includes sens ing that something needs to be done and feeling willing and competent to take cons tructive T he manner and extent to which aggres sive emotions be expres sed varies from s ociety to s ociety and from situation to s ituation. T hes e emotions are among the carefully regulated because of their potential destructiveness . Acts of aggres sion are on a beginning with irritability, progres sing to verbal threats and intimidation, and extending to physical bullying and as sault to homicide, sometimes including acts of calculated violence and s adism. Irritability is an unpleasant feeling s tate characterized inner unease. In contrast to anger, irritability does not less en after an outburst. Often, others are more aware an individual's irritability than is the pers on him- or It is diagnos tically nons pecific, s een in a variety of phys iological states —ps ychotic, anxiety, and mood disorders —and as a lifelong temperamental quality. Hunger, s leepiness , s exual frus tration, and pain are the physiological triggers commonly as sociated with irritability. Individual differences in the tendency toward experiencing and express ing anger and violence are biological, developmental, and cultural in origin. S ome infants are irritable from birth. S ubtle early birth injuries and brain anoxia may increase the susceptibility of people to be violent. F urthermore, studies of E E G 958 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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in violent people s how increased abnormalities, in those with repeated violence and violence with little no obvious motive. S oft neurological s igns are also violent criminals. B iochemically, low cerebrospinal fluid (C S F ) 5-HIAA has been as sociated with a variety of impulsive behaviors, such as violent crimes , recurrent setting, and violent suicide attempts . C ons is tent with the hypothesis that an invers e exis ts between central serotonergic s ys tem function impulsive, aggress ive behavior, a few double-blind, placebo-controlled studies in patients with cluster B personality dis orders have demons trated that central s erotonergic function by using S S R Is reduces irritability and impuls ive aggres sive behavior. A 42-year-old woman was described by those who her as controlling, obs ess ional in s tyle, and rigid in expectations . W hen events in her hous e did not turn she wis hed or when others (husband and children) did behave according to her demands , s he became very irritable, yelling, criticizing, and berating. E ventually, agreed to treatment with an S S R I, which markedly diminis hed her reactivity to events. T he pos itive effect far more apparent to her family members than to the patient herself. T he pathological childhood triad of bed-wetting pas t the age of 6 years , s etting fires , and torturing animals has as sociated with s ubs equent violent behavior in adults . Interpersonally, s tudies show that violence-prone individuals require more personal s pace around their phys ical person than do others . V iolent individuals feel threatened when approached too clos ely, particularly 959 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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the rear. P sychological and social contributions are als o s trong. V iolence in families breeds violence, and battered often grow up to be battering adults. C ultural norms for the expres sion of violence differ cons iderably. In s ome socioeconomic and ethnic groups , violent gangs the energies of many adoles cent youth. F or some, behavior is an adolescent socialization pattern to prove one's manhood or womanhood. Like other organizations , violent gangs have detailed rules that inhibit and govern the express ion of violence. S ome unpredictable and uns ocialized violent people, loners , too violent to be contained even in gangs. Aggress ive and violent behavior is diagnostically nonspecific. V iolence in s chizophrenia may occur as a cons equence of paranoid delus ions , in res ponse to command auditory hallucinations , or secondary to pass ivity experiences . Manic patients and thos e in states may be violent, often in res ponse to minimal provocation. V iolent behavior commonly occurs in patients with antis ocial and borderline personalities (in latter often self-directed as well as other directed). behavior may occur in epileps y, although rarely during true ictal periods ; in frontal lobe syndromes as a phenomenon”; and in as sociation with abus ed particularly disinhibiting s edatives , such as alcohol, or stimulants such as amphetamines and cocaine, which increase irritability, aggres sivenes s, and paranoia. Impulsive violence may be provoked by a number of stimuli and s ituations. Alcohol is perhaps the most common dis inhibitor of violence. Intrafamilial violence, most common s etting for homicide, is frequently related 960 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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to alcohol intoxication. In epis odic dys control and intermitte nt e xplos ive dis orde r, violent behaviors erupt after a pers on has inges ted alcohol, a known as pathological intoxication. In these often outburs ts , the individual may confront or provoke any potential target for violence, including total s trangers police, but girlfriends, wives , and parents are frequent victims . P atients with epis odic dyscontrol commonly histories of violent sexual behavior, including rape, often while intoxicated, s peeding and reckles s driving, sometimes chasing down, s topping, and attacking motorists who they believe “get in their way.” An attractive 40-year-old woman had been highly after by rich and powerful men, several of whom she married and several of whom divorced her becaus e of uncontrollable rages . S he des cribed hers elf as “insanely jealous” in a flas h whenever she s aw her P.995 glancing at other attractive women, and her behavior flared out of control, particularly when she had been drinking alcohol. On one occasion, she bit off one husband's ear. S he attacked another with pots and nearly killing him. S he recognized how serious her problems were and s ought ps ychotherapy, medication (S S R Is were helpful), and anger management training help her control her emotions and behaviors .

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they dis played as children. P articularly if childhood tantrums produced the des ired res ult, learned tantrum behaviors may pers ist into adult life. Although s uch individuals may be pleas ant and s ociable when life is going well, they lack the capacity to tolerate frustration and are eas ily provoked by threats to s elf-es teem and image and by not having their own way. When or threatened, they may act like bullies , glare, s narl, shout, intimidate, pout and s ulk, and s ometimes be phys ically violent.

Dis plac ed R age When circums tances prevent the expres sion of rage directly agains t those people or institutions provoking frus tration, other outlets for aggres sion are often found. Acts of violence that are either calculated or wanton res ult. C ruelty to animals and fire setting may pers ist adult forms of destructive behavior. R ape, an act of intimidation, terror, and humiliation, may als o displace frus trations that are not expres sed more adaptively. S adism may occur with or without explicit s exual gratification. C alculated cruelty conducted s eemingly without anger or emotional arous al may reflect inadequate development of s ocial morality or individual cons cience, as in the conduct of torturers and some blooded murderers. In s ome s ocieties and under circums tances at certain times in history, such activity been s ocially sanctioned, s uggesting at leas t that some people lack inborn inhibitions agains t cruelty or A 50-year-old man with antis ocial pers onality disorder seen in a psychiatric emergency room for violent 962 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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During the cours e of the as sess ment, he described had been emotionally and phys ically abus ed by a father who whipped him repeatedly until he bled and chained him to a tree in the backyard. T his man grew feeling callous . He enjoyed intimidating and phys ically hurting others, as he often did in pris on. W ith a laugh smirk, he reflected on how he turned out to be “just like my old man.”

S elf-Mutilation F or a variety of reasons, in many different cultures and many different disorders , people commit acts of agains t themselves , ranging from body piercing to and burning to autoamputation. P sychotic patients may perform extremely self-destructive acts s hort of actual suicide that often have symbolic import, s uch as enucleating their eyes or castrating thems elves . with borderline pers onality dis orders or borderline traits may cut thems elves repeatedly with broken glas s or blades or burn themselves with cigarettes on arms, breasts, or other body parts . P atients typically deny these acts are meant to be s uicidal but describe the to feel external pain to mirror internal suffering, or to releas e tension, or to counteract diss ociative-like numbness . R ecently, self-cutting has become more common in teenagers , es pecially girls, as a tensionrelieving mechanis m. A 20-year-old college student was taken to the room by her friends , who were alarmed by the recent transvers e cuts on her arms. None of the cuts were enough to require s utures but, even when they had 963 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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healed, they left obvious s mall red s cars on her skin. In explaining her behavior, the s tudent described that she was upset, such as after a fight with her boyfriend negative telephone call with her parents, she became agitated, and cutting herself consis tently relieved the agitation and anxious feelings . T richotillomania is a syndrome of compuls ive hair res ulting in bald patches. It is often ass ociated with self-mutilatory behavior, such as picking the face, nails, cuticles to the point of infection and bleeding. T richotillomania may s ometimes be related to OC D. C hildren with L e s ch-Nyhan s yndrome , a developmental disability syndrome caus ed by a congenital metabolic abnormality, bite and pick at thems elves so as to do themselves great harm and routinely require res traint. Occas ionally, patients with T ourette's demonstrate compuls ive s elf-harming behavior.

Other Dis turbanc es of F eelings Diminished levels of emotional intensity may be s een in anxiety disorders , mood dis orders, and s chizophrenia. emotional flattening with blunted ability to feel joy is common in dys thymia. S ome patients with narciss istic borderline pers onality disorders complain of inner emptines s and pervasive boredom and ennui without demonstrating diminis hed affect in interviews . S imilarly, patients with prominent depers onalization describe numbed emotions . P athological levels of blunt or affe ct, indicating markedly diminished affective in relation to specific thought content, may be s een in chronic s chizophrenia (as part of the deficit s yndrome), some organic mental syndromes, and s evere 964 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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and as a s ide effect to many medications , including antidepres sants, antips ychotic medications, or tranquilizer use. Although the term blunte d affect is not clas sically us ed to describe the affective flatnes s of depres sion, it is not always easy to dis tinguis h between schizophrenic and depress ive flatness on phenomenological grounds. Anhe donia, the lack of pleas urable feelings from activities that ordinarily pleas ure, is als o s een as part of s evere depres sions or schizophrenia. C hronically ps ychotic patients often emotional deterioration in which affective experience expres sion are entirely unrelated to thought content. Inappropriate affect is incongruency of affective and thought content. T he patient may dis play loud and raucous laughter or giggling in relation to bland or s ad thoughts or may s how grief without apparent reason. Inappropriate affect sometimes indicates that the thoughts have private meanings for the patients ; the emotional expres sion might make better s ens e if the private meanings were understood. Inappropriate affect must be dis tinguis hed from affective express ions that actually be appropriate in a given s ubculture or ethnic group that is unfamiliar to the observer and from defens ive affect, s uch as the nervous laughter us ed to alleviate tension or ward off crying. Affe ctive (or mood) lability is characterized by rapid emotional s hifts, often within s econds to minutes. It is commonly s een during hypomanic s tates, late luteal phase dysphoric disorder (premenstrual s yndrome), pos tpartum blues, other of physiological instability, and in clus ter B pers onality disorders . P.996 965 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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A 51-year-old man with lifelong dys thymic dis order was treated with an S S R I. Although he had an excellent antidepres sant res ponse, 2 months after beginning treatment, he noted an affective flatness . He des cribed becoming as easily ups et as before treatment (which he and his wife interpreted positively), but also he his s ens e of joy, in being with his children or in nature, markedly blunted. He enjoyed pos itive events but with marked diminution of affective intens ity. Ale xithymia is difficulty identifying, describing, and differentiating feelings or distinguishing between and phys ical s ens ations . Alexithymic individuals often have constricted imaginations and fantas ies, are preoccupied with objects and events in the outside and have little private, pers onal internal life. When distress ed, the patients are s imply aware of not feeling well and us ually complain of s omatic s ymptoms, to frus trating interactions with their phys icians who cannot find phys ical caus es for the pres enting phys ical complaints . S ome view alexithymia as a condition in affect is communicated through somatic language. With regard to other feeling states that may contribute pathological conditions, recent writers have focus ed on the role of “shame” as a potentially important emotional mediator of specific types of narcis sis tic injury that may provoke s tates of depres sion, rage, P T S D, and suicide, among others . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > MO T OR AS P E C T S O F B E HAV IO R

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DIS TUR B ANC E S IN MOTOR AS PE C TS OF B E HAVIOR P art of "8 - C linical Manifes tations of P s ychiatric Motor behavior is normally finely coordinated, and adaptive, and neces sary activities are usually out efficiently. In ps ychiatric disturbances , motor abnormalities can involve generalized overactivity or underactivity or manifes t in a wide range of s pecific disorders of movement.

Overac tivity R es tle s s ne s s and agitation are diffus e increases in movement, us ually noted as fidgeting, rapid and leg or hand tapping, and jerky s tart-and-stop of the entire body, accompanied by inner tension. R es tles sness accompanies psychiatric conditions of emotional arousal or confusion, s uch as toxic s tates , mania, agitated depres sive dis orders, and anxiety disorders , as well as many medical disorders such as hyperthyroidism. In some depress ive states , agitation often accompanied by pacing and hand wringing. G eneralized overactivity, in which patients seem to increased phys ical energy, is distinguis hed from by its lack of inner tension and by more purposeful movements. It is commonly seen in mania, hypomania, and anorexia nervos a and as part of ADHD and in to stimulating drugs and medicines . 967 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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A 25-year-old extraordinarily restless man in a emergency room, whos e glances darted incess antly around the room, paced agitatedly, picked at his skin, shifted cons tantly on his feet, and jiggled his arms and legs. His speech was rapid, and his mood was irritable. had been us ing intravenous (IV ) methamphetamine on “run” for more than 1 week and was brought to the emergency room by relatives who were concerned that was s tarting to get paranoid. In catatonic exciteme nt, much less common now than the preneuroleptic era, patients exhibit dis organized overactive behaviors , including frantic jumping, of limbs , and seemingly s ens eless menacing or behaviors . S uch excitement is seen in mania, periodic catatonia, catatonic forms of s chizophrenia, and some culture-bound s yndromes such as amok. C onfus ional exciteme nt is a state of res tles sness and generalized purpos eless activity s een in ictal s tates, s ome acute intoxications, and deliria.

Dec reas ed Motor A c tivity G lobal reductions in motor activity—motor are seen in a variety of phys ical disorders , s uch as hypothyroidism, Addison's disease, s ome infectious postinfectious conditions , including C F S and pos tpolio syndrome, and other fatiguing conditions, as well as in some organic mental disorders , intoxications, schizophrenias , and depres sive dis orders. P overty of movement (akinesia, or more properly, hypokines ia) occur in schizophrenia and as a neuroleptic s ide effect. C hanges in the voice frequently accompany the motor activity in s chizophrenia and depress ion, with 968 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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normal inflection replaced by monotonous tone and prolonged speech latency. In s tuporous states , patients remain immobile, although their eyes are open, and are apparently awake. C onvers ion reactions are functional, nonphys iological, ps ychogenic impairments in sensory or motor C ommon motor forms include various paralyses and pareses, including limb paralyses, ataxias , and globus hys te ricus , the patient is unable to swallow. with as tas ia-abas ia have marked uns teadiness of gait. S ensory convers ion reactions include blindnes s, anesthes ia, and analges ia. S ome hyperes thes ias and syndromes may als o originate as conversion An 18-year-old s oldier from a very rural area was to the emergency room at an army pos t during his of bas ic training because his gait had become very unsteady. He was s tumbling into walls and seemed to maintain an erect posture. He found it necess ary to crutches to ambulate. T here was no history of us e. On examination, the s oldier was found to be tremulous , anxious , and homes ick. He had never been away from his family before and miss ed them deeply. When he was reas sured that he would be is sued a see his family, his demeanor changed, and his gait instantly improved. T o the amazement of his and drill sergeant, he was able to leave his crutches at door. T he diagnosis was as tas ia-abasia.

Mutis m Mutis m may res ult from a variety of peripheral muscle C NS conditions and from functional disorders. Mutis m 969 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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occur in profound depres sion, catatonic states, and conversion reactions. E le ctive mutis m is occasionally in acute adjustment disorders and some pers onality disturbances .

Motor Dis turbanc es Many motor disturbances are seen in psychiatric S ome form part of the core s ymptoms of the disorders ; some occur in disorders that, by their nature, bridge neurology and ps ychiatry (s uch as T ourette's others are acute or chronic medication side effects.

S imple Motor Phenomena TR E MOR T remors , involuntary oscillating movements of the head, may occur at res t or with movement. tre mors , which are minimal at res t and increase with activity, are P.997 characterized by small amplitude and high frequency. T hey are characteristic of anxiety, fatigue, and toxic or metabolic disorders , s uch as caffeinis m or hyperthyroidism, and are commonly s een in patients taking a number of different ps ychiatric medications , including lithium (E s kalith), valproate (Depakene), and stimulating antidepress ants. C oars e tre mors , with amplitude and lower frequency, are seen in P arkinson's disease and cerebellar dis eas e. As te rixis is a largeamplitude flapping tremor of the hands s een in hepatic disease. P arkins onian s ymptoms and s igns may be ps ychiatric disorders, particularly in patients taking 970 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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antips ychotic medications. S ymptoms include with marked decrease in normally spontaneous stiff gait with diminished arm s wing, pill-rolling nonintention tremors (which seem to be less common drug-induced parkinsonis m, compared with the type), express ionless soft and monotonous speech, micrographical handwriting, and cogwheel rigidity.

DY S TONIC MOVE ME NTS Although dystonic movements are s een in many neurological disorders , in ps ychiatric patients, they are almos t always s econdary to the us e of antips ychotic medications . Dys tonic reactions consis t of intermittent sustained muscle spasms, typically of the head or C ommon varieties include tongue spas ms causing dysarthria, torticollis (neck s pas m), and oculogyric which there is a forced upward gaze. Opisthotonus (s pas ms of paras pinal mus cles leading to an arched posture) is s een les s often. T hese reactions are most common in young males and typically occur s oon after beginning or increas ing the dos e of a conventional antips ychotic medication.

A K A THIS IA Akathis ia is a syndrome of motor res tless nes s seen predominantly in the context of antips ychotic and s ome antidepres sant medication use. It has subjective, as motor, components. S ubjectively, patients experience muscle tens ion, difficulty finding a comfortable body position, and inability to s top moving; they feel as they are “jumping out of their s kin.” Objectively, clas sically manifes ts by rocking from foot to foot while 971 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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standing, frequently cros sing and uncross ing the legs when seated, and pacing. S leep may be disturbed of phys ical discomfort. S ubjective components of may be difficult to distinguish from anxiety caused by primary disorder (typically s chizophrenia). R arely, the res tless nes s and inner agitation become sufficiently uncomfortable to provoke acts of violence. In ps eudoakathisia, objective s igns of akathisia are but the patient denies feeling res tless . A 45-year-old man with OC D and T ourette's syndrome being treated with fluvoxamine (Luvox), 200 mg per inadvertently took 400 mg per day for 3 days. On the day, he s tarted to feel increasingly agitated, his legs res tless and jittery, and he started to fidget. He also noted frequent s ighs in his breathing, his usual res piratory pattern. He recalled feeling these sens ations a decade earlier when a previous treated his T ourette's syndrome with haloperidol and that his psychiatrist had diagnos ed akathis ia. After discontinuing the fluvoxamine for 4 days , these all abated.

TA R DIVE DY S K INE S IA T ardive dys kine s ia is a movement dis order that occurs in the context of antips ychotic medication us e, occasionally after many months but more commonly years . T he abnormal movements may persist with or without continued medication us e or may diminis h or disappear over time. T he dyskinetic movements occur res t and can usually be temporarily s uppress ed or by purposeful action, dis traction, or sleep. T he 972 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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movements are varied. In the most common type, affects the face, es pecially the mouth and lips, tongue thrusting, chewing movements, lip s macking, and eye blinking are seen. Another common type is by choreoathetoid movements, such as writhing finger motions. In the less common but more s evere truncal dyskinesias, the tors o moves in thrusting motions , and res piratory dyskinesia is characterized by grunting and irregular breathing patterns. Other tardive (late) syndromes include tardive akathisia and tardive in which the abnormal movements emerge late in treatment or on medication dis continuation.

NE UR OL E P TIC MA L IG NA NT Neuroleptic malignant syndrome (NMS ), a potentially complication of antips ychotic medication, is by muscle rigidity, fever, diaphoresis, delirium, mutism, and blood pres sure abnormalities. S ome view NMS as most severe end of a spectrum that starts with antips ychotic-induced parkins onism, progres ses to extrapyramidal s yndrome with fever, and then to fulminant NMS .

R A B B IT S Y NDR OME T his uncommon drug-induced extrapyramidal often mis diagnos ed as tardive dys kines ia. It mos t res embles a limited express ion of a parkins onian P atients make rapid chewing movements s imilar to made by rabbits, ordinarily fas ter and more regular the orofacial tic of tardive dys kines ia. T he tongue is

B L E P HA R OS P A S M 973 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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B le pharos pas m is a rapid and violent repetitive, movement of the eyelids. T hes e movements are often side effect of antipsychotic or other medications but are also common in a variety of neurological disorders, including Meige's s yndrome and T ourette's s yndrome.

TIC S T ics are rapid, repetitive, often s pas modic jerking involuntary movements that s erve no apparent T he person may try to disguise or hide the tic in a seemingly purposive movement, and the movement ultimately be s haped into a mannerism. T ics are the feature of tic dis orders , are as sociated with other and may occur as a consequence of s timulant use. T ourette 's dis order is characterized by a chronic array of motor and vocal tics . T he tics may include coughs, clicks, or sniffs , whereas motor s ymptoms may include eye blinking, tongue protrus ions, facial hopping, and twitches. C omplex tics may merge into complex compuls ive behaviors such as squatting, deep knee bends, and retracing steps . C oprolalia, by sudden verbal outburs ts of obscenities, occurs in than one-third of T ourette's patients. Me ntal coprolalia an as sociated feature in which obscene words or suddenly intrude into cons cious nes s in an ego-dystonic manner. Obsess ive-compuls ive s ymptoms, as well as attention-deficit s ymptoms , are als o common in syndrome.

S E R OTONIN S Y NDR OME S erotonin s yndrome is a dis order caused by excess ive serotonergic input in the C NS , probably within the 974 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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hypothalamus. T he most common caus e of serotonin syndrome is the combination of two or more with serotonin-enhancing properties , us ually by mechanisms. It is characterized by res tles sness , hyperreflexia, diaphores is , shivering, tremor, changes, including fever, and mental s tatus changes , as confus ion.

Motor Dis turbanc es of Many of the abnormal movements ascribed to tardive dyskinesia and other antipsychotic-induced extrapyramidal s yndromes have been des cribed in P.998 chronically ps ychotic patients before the introduction of antips ychotic medications. In one s eries of 100 the large majority of whom were diagnos ed as schizophrenic, a review of medical records before 1955 revealed that abnormal purpos ive movements were in 83 percent, manneris ms and tics in 71 percent, abnormal eye movements in 27 percent, abnormal postures or facial movements in 42 percent, and gait abnormalities in 10 percent. T hese findings s uggest many patients with s chizophrenia have neurological symptoms not due to medications and that s evere ps ychiatric disorders may have a neurological as well.

C A TA TONIC B E HA VIOR S C atatonia refers to a broad group of movement abnormalities us ually as sociated with s chizophrenia also found in other dis orders s uch as mania, 975 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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many neurological dis orders (es pecially those involving the bas al ganglia, limbic system, diencephalon and lobes ), s ys temic metabolic dis orders, toxic drug states, periodic catatonia. C atatonic s tupor and excitement already been noted. S te re otypie s are repetitious , seemingly non–goal-directed, complex organized or pos tures that are believed to have private meanings the patient. E xamples include continuous ly and cross ing oneself or bless ing others in a religious waving in a stylized manner, and making profane T he stereotypic behaviors commonly seen in autistic children (constant s pinning or rocking) may provide soothing, steady sens ory input that helps the patients reduce the degree to which they are dis turbed by the ordinarily unpredictable and uncontrollable s timulation coming from the environment. B izarre pos turing may be seen in catatonia. One chronic schizophrenic routinely stood for hours on one leg with his arms in the like a crane. In echopraxia, the patient imitates the examiner's movements and in echolalia imitates if in mimicry. S ome catatonic patients exhibit waxy fle xibility, maintaining unusual postures in which they been posed for prolonged periods of time. Negativis m take the form of refusing to behave in a prescribed or resisting pass ive movement.

Other Movement Dis turbanc es G ait dis turbance s in patients with ps ychiatric disorders include a variety of neurogenic gaits consistent with disease, intoxications, and medication side effects . include the festinating gait of parkins onis m, spastic and ataxic gaits of neurological disease and ps ychiatric medications , waddling and reeling gaits as sociated 976 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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intoxications, and the nonphys iological gait seen in as tas ia-abasia, a form of convers ion disorder. manneris ms include clowning, prancing, military, and effeminate gaits . B ruxis m, chronic jaw clenching, may occur involuntarily during tens ion states , as an is olated occurrence during delta s leep, in which it has s ometimes been as sociated with benzodiazepine or alcohol us e, or in as sociation S S R I us e. In s evere cases, serious damage to dental and temporomandibular joint pain may occur. Myoclonus , characterized by focal muscle jerking, can caus ed in ps ychiatric patients by certain medications, as S S R Is or monoamine oxidas e inhibitors (MAOIs). Myoclonic jerks may be difficult to dis tinguish from tics, but the latter often repres ent larger mus cle groups and more highly organized motor patterns . Myoclonus may seen at res t but is more obvious during motor activity.

S eizure-L ike B ehaviors In addition to the generalized, petit mal and complex partial s eizures s een in s ome ps ychiatric patients, a number of nonepileptic s eizure-like behaviors mus t be distinguished. B reath-holding s pells , generally impulsive, and tantrum-like phenomena, us ually occur small children who hold their breaths during moments oppos itional rage and who may faint as a res ult. twitching motor movements may occur. T e mpe r in young children may look like seizures , es pecially to uninformed observer. T he children may lie on the floor, screaming and kicking, and do not res pond to the environment. C onvers ion s e izures (hysterical seizures, ps eudoseizures ) must be differentiated from genuine 977 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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epileptic seizures . P atients retain consciousness , lack abnormal reflexes , and are not incontinent. However, because so many convers ion seizures occur in patients who have genuine epileps y and who know a good deal about the condition, the differential diagnos is is sometimes difficult. C ompuls ive be haviors may occur relation to everyday activities, s uch as gambling, conquest, shopping, and watching T V , or in relation to subs tances such as alcohol, cocaine, narcotics, and Other compulsions involve reckless ris k-taking that provide s timulation and dispel dysphoric moods. S exual compuls ive perversions, such as exhibitionism sadomas ochis m, may serve similar purpos es . are seen in a variety of psychotic and nonps ychotic ps ychiatric disorders. T he cravings that underlie compuls ive behaviors are s trong motivating forces , and the compuls ive behaviors may regulate emotions. Unknown s imilarities may underlie all compulsive and addictive mechanisms. C urrent controversies s urround relations hips of compulsive, impulsive, and addictive behaviors . S ome authorities have propos ed that all should be s ubs umed under the rubric of a s o-called deficiency syndrome, resulting from various of gene polymorphis ms governing dopamine and mechanisms and including s erotonin, cannabinoid, and other transmitter s ys tems as well. F rom this the compuls ive, impulsive, and addictive behaviors all increase the amount of dopamine and potentially other transmitters in specific brain areas . S tudies in the pas t decade have shown that, in various s ubject groups, the T aq 1 a1 allele of the DR D2 gene is as sociated with alcoholism, drug abuse, s moking, obesity, compuls ive gambling, and several personality traits. S everal other 978 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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candidate genes are als o under investigation. S tudies also shown that certain impulse-like behaviors may be as sociated with very specific genetic polymorphis ms . In studies of patients with s evere obes ity, binge eating behavior was s een only in those individuals who had specific mutations in genes controlling the expres sion melanocortin 4 receptors . In OC D, the compuls ions are ritualized, repetitive behaviors that are performed with the goal of neutralizing, and undoing obses sional thoughts. intended to decrease anxiety, rituals are never more transiently s ucces sful. T he mos t common compulsions involve checking to make certain that gas jets and have been turned off and that windows and doors are locked, hand washing, repeating certain phras es , objects, and placing objects in a pres cribed order. A 47-year-old woman had always been fus sy about and cleanlines s but, s ince the birth of her child 14 before, had become increasingly obsess ed by S he spent 3 hours daily ritualis tically cleaning the apartment, using 3 to 4 rolls of paper towels daily. If a family member left even a fingerprint on a table, she became agitated and spent much time recleaning the surface and admonis hing the family member. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > LANG U AG DIS OR DE R S

LANGUAGE DIS OR DE R S 979 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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P art of "8 - C linical Manifes tations of P s ychiatric C ommunication difficulties may be due to dis orders of thinking as previous ly des cribed, abnormal s peech patterns in mood dis turbances and s chizophrenia, or primary s peech fluency disorders , such as stuttering stammering, dis orders of the articulation and P.999 speech apparatus , and C NS disturbances involved in hearing and speech generation (aphas ias ). Manic patients typically exhibit pre s s ured s pee ch, in the speed of word stream is accelerated. If severe, the speech may be garbled, imprecise, and difficult to unders tand. P atients with ps ychomotor retardation depres sion s peak s lowly and monotonously and have a long s peech latency in res pons e to questions . S chizophrenic patients may exhibit a variety of s peech abnormalities , including poverty of s peech and poverty content of speech (in which the amount of speaking is normal, but unders tanding the central mess age is or imposs ible). S chizophrenic patients may als o be to understand becaus e of the dys arthric effect of antips ychotic medication. Allus ory s pe e ch is vague, imprecis e, and hard to comprehend because too few cues and details are provided for the listener. S uch speech may be heard some patients with s chizophrenia or certain personality disorders or even normal individuals who wis h to sens e of mystery by just being s ugges tive, whose suspicious nes s causes them to be reluctant to s pell out clearly, or who believe that the listener is more 980 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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of their private codes , meanings , and allusions than is case. S tuttering and s tammering (ordinarily s ynonymous) disturbances in the rhythm and fluency of s peech due blocking, convuls ive repetition, or prolongation of T his dis order affects males two to three times as often females, and there is a high rate of familial Aphas ias , impairments of language produced by brain dysfunction, are ordinarily des cribed as being fluent nonfluent. In fluent aphas ias , which generally reflect dysfunction in the left temporal and parietal area, have a normal or even elevated verbal output, with logorrhea, but they ignore the s ocial conventions conversation. T hey produce many well-articulated with normal pros ody, but there is little informational content. T he fluent aphas ias are further divided to the extent of comprehension by the patient and the ability of the patient to repeat what the examiner s ays. principal fluent aphasias are W ernicke's aphas ia, conduction aphasia, anemic aphas ia, and transcortical sens ory aphasia. Nonflue nt aphas ias are characterized by s low and poor verbal output, difficulty with spontaneous s peech, omis sion of grammatical connecting words, and poor prosody. P atients may produce one-word replies or short phras es . B rain lesions that cause nonfluent typically tend to occur in the anterior left hemis phere. principal nonfluent aphas ias are B roca's aphas ia, transcortical motor aphas ia, global aphas ia, and the transcortical aphas ias . In apros odias , the nonverbal as pects of s peech, the 981 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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melody, paus es , timing, s tres s, accent, and intonation impaired. Damage to the right prefrontal region has as sociated with express ive apros odias, and damage to right temporal region and insula has been as sociated receptive aprosodias . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > INT E R P E R S ONAL R E LAT IONS HIP

DIS TUR B ANC E S OF INTE R PE R S ONAL R E L ATIONS HIPS P art of "8 - C linical Manifes tations of P s ychiatric Normal interpers onal relations hips include relationships with parents, children, s pous es , lovers , s iblings, family members , friends , colleagues , coworkers, and members of the larger community. T hes e relations hips ordinarily help provide for the satis faction of bas ic for affiliative needs , and for finding purpos e and in life. T hrough s table and s atis fying relationships , needs are met for intimacy, including love, s ex, and affection; to be cared for and nurtured, provide care, play, relax, dominate, and be productive through effort. Interpersonal relationships are carefully by means of interpers onal s igns and s ignals . T he which deviance from thes e patterns is tolerated in a relations hip varies from behavior to behavior, to relationship, family to family, and culture to culture. 982 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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Dis turbances in interpersonal relationships may be as characteristics attributable to a s ingle person or as characteristics of an interpersonal system. Individual disturbances are considered to be undes irable or maladaptive pers onality traits . W hen thes e traits are present to a s ignificant extent and interfere with social functioning or cause distres s, they may compose a personality dis order. Dis turbances of interpersonal relations hips have als o been des cribed at a systems (e.g., as dyadic and family patterns of system

P ers onality Traits and Dis orders P ers onality, variably defined, is the characteristic an individual's attitudes , behaviors , beliefs , feelings , thoughts, and values —the sum of a pers on's cognitive, and interpersonal attributes. P ersonality are the prominent and characteristic features of an individual's pers onality and do not imply ps ychopathology. As pects of pers onality are pres ent early life, and personality traits are relatively s table adoles cence onward, cons is tent acros s different environments , and recognizable by friends and acquaintances. T he term pe rs onality dis orde r s hould res erved for those consistent patterns of thought, and behavior that are inflexible and maladaptive. P ers onality disturbances manifest primarily in interpersonal contexts and in this way can be viewed interpersonal behavior disorders . T he determinants of personality are multiple and innate and early biological, developmental, and environmental factors inside and outs ide the home. T hrough learning and the environment, temperamental 983 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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factors (genetic or constitutional) are shaped into character. T he dimensional approach to pers onality and pathology characterizes individuals along a continuum traits. F ive dimens ions of temperament have been described that appear to be s omewhat independent to have strong genetic contributions: neuroticis m emotional, reactive, and thin s kinned, contrasting with emotional stability), extrovers ion (contras ting with introversion), opennes s (contras ting with dis comfort novel experiences ), agreeablenes s (contrasting with contrarines s), and cons cientious nes s (contras ting with fickleness ). T hese temperamental attributes may have implications for the course of psychotherapies that cut acros s diagnostic categories . Another dimens ion of personality not adequately dealt with in the DS M-IV -T R concerns moral behaviors such hones ty and integrity. T he extent to which individuals behave hones tly and with integrity differs cons iderably acros s individuals and in different s ituations. Deception and lying are common behaviors that occur in benign forms (e.g., in “white lies ”) and in pathological forms , ps ychiatrically important in antisocial and s ociopathic disorders , pathological liars , and malingerers. and lying may be difficult to as sess clinically in the of additional informants . S tudies of nonhuman primates indicate that, at leas t among chimpanzees, deception (equivalent to lying and dishones ty) is relatively and, in some situations , adaptive. Another pers onality typology characterizes personality along three dimensions related to temperamental characteristics pres umed to be strongly influenced 984 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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genetically: harm avoidance , nove lty s e e king, and de pendence . High s cores on the three dimens ions characterize inhibition and pess imism, impuls ive and exploratory behavior, and dependency and res pectively. Different personality types can be according to patterns of s cores on the three F or example, antisocial personalities are characterized high novelty seeking, low harm avoidance, and low dependence, whereas dependent characters have low novelty seeking, high harm avoidance, and high reward dependence. P.1000 DS M-IV -T R , by contrast, us es a categorical approach, both the large overlap among the DS M-IV -T R disorders and the clustering of these pers onality into three broad groups imply a lack of clear the currently defined categories . T he three DS M-IV -T R clus ters describe odd or eccentric types (clus ter A); dramatic, emotional, and erratic types (clus ter B ); and anxious and fearful types (clus ter C ). T he odd or eccentric group includes paranoid, s chizoid, and s chizotypal personality dis orders. P atients with personality dis orders have the core traits of being interpersonally dis tant and emotionally cons tricted. P aranoid personalities are quick to feel slighted and jealous, carry grudges , and expect to be exploited and harmed by others. S chizoid personalities lack or close relationships with others and are indifferent to praise or criticism by others. S chizotypal personalities display odd beliefs, engage in odd and eccentric 985 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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and practices , and exhibit odd s peech. T he dramatic, emotional, and erratic group includes borderline, histrionic, narciss is tic, and antis ocial personality dis orders. P atients with these pers onality disorders characteris tically have chaotic lives , and relations hips. B orderline pers onalities are unpredictable, angry, temperamental, unstable in relations hips , compuls ively interpersonal, and s elfdamaging with regard to sex, money, and s ubs tance His trionic personalities are attention s eeking, exhibitionis tic, s eductive, self-indulgent, exhibit exaggerated express ions of emotions, and are overconcerned with physical appearance. Narcis sistic personalities tend to be hypers ens itive to criticis m, exploitative of others, egocentric with an inflated s ens e self-importance, feel entitled to s pecial treatment, and demand cons tant attention. Antis ocial personalities are described almos t exclus ively by behavioral rather than affective or relational terms . T hey are truant, lie, steal, fights , break rules , are unable to s us tain work or and s hirk everyday res ponsibilities. T he anxious and fearful group includes avoidant, dependent, and obsess ive-compuls ive personality disorders . P atients with these dis orders are by cons tricting behaviors that serve to limit ris ks . As examples, avoidant people avoid relationships , personalities avoid being res ponsible for decisions , and obses sive-compuls ive people us e rigid rules that new behaviors. Avoidant personalities are to rejection and are reluctant to enter clos e spite of s trong desires for affection. Dependent personalities s how excess ive reliance on others to 986 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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major life decis ions, stay trapped in abusive for fear of being alone, have difficulty initiating projects their own, and cons tantly seek reass urance and praise. Obsess ive-compuls ive personalities exhibit restricted expres sions of warmth, tenderness , and generosity also exhibit stubbornness with a need to be right and to control decis ions; indecisive at times , they often use rigid application of rules and morals to the point of inflexible. A characteristic pers onality disturbance s een with lobe damage is referred to as organic pe rs onality the tenth revis ion of the Inte rnational C las s ification of Dis e as es and R e late d He alth P roble ms (IC D-10) and pe rs onality change due to a gene ral me dical condition DS M-IV -T R . Its features include irritability, jocularity with euphoria, inappropriate socially behavior, and impuls iveness . Other patients with to different areas of the frontal lobe, in contras t, exhibit apathy and indifference.

Interpers onal S ys tems C ouples and families have been studied as s ys tems in own right, and many qualities of these systems have identified as being clinically important. A scheme for categorizing relational dis orders has been propos ed for future editions of the DS M-IV -T R , but, as yet, no s ingle generally accepted typology of family psychopathology interactional types has been es tablis hed. However, elements of marital dis cord and harmony have been operationalized in s everal standard marital inventories. C haracteris tics of couples and families that have the most attention include the rules of communication, 987 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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such as thos e governing the directnes s or indirectness with which disagreement and conflict are address ed; manner (organized or chaotic) in which are conducted; taboo topics and secrets about which one can openly communicate; the nature and degree of emotional expres sion, including affection and anger; cohes iveness , loyalty, and compatibility of members; nature of the members' s hared identities on the one and their autonomous development and s eparateness the other; the extent to which members treat one res pectfully or take one another for granted and us e another; the dis tribution of power and decis ion making among members; the maintenance of generational boundaries (e.g., age-appropriate performance of life roles); and the members' orientation toward and concurrence and disagreement about important values involving moral, religious , intellectual, cultural, financial, occupational, and childrearing is sues, as well as as pirations, health practices, leisure activities, and belief systems . A characteristic family environment, called high emotion, has been identified that defines a relapsefamily environment in which one individual has schizophrenia, bipolar dis order, anorexia nervos a, or depres sive dis order. T his interactional pattern includes demeaning, intense pers onal criticis m (“Y ou are rotten lazy”) and emotional overinvolvement with the patient. As pects of overinvolvement can be meas ured quantifying the numbers of hours of face-to-face and by the extent to which relatives categorically as sert how the patients feel without ever bothering to as k the patients. Despite thes e descriptive generalizations, the 988 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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specific elements of high expres sed emotion families make patients vulnerable to relaps e are still obs cure. C ouple and family system difficulties are most likely to erupt during predictable s tres sful events in the normal family life cycle, s uch as during the newlywed period; pregnancy and childbearing; difficult or contentious childrearing; difficulties with parents, in-laws , and other extended family; insurmountable and unanticipated financial or career problems ; serious illness or death of child or relative; the children's adoles cence; departure children from the home; infidelity; and separation. Interpersonal attachme nt s tyle s , based on cognitive schemas that have been linked to earlier repeated experiences with caregivers, influence how individuals perceive and act within interpersonal relations hips. S pecific types that have been described include attachments (several s ubtypes include preoccupied, fearful, and anxious -ambivalent attachment), avoidant attachment (including angry-dismiss ive and withdrawn attachment), enmeshed attachment, unres olved attachment (in which s ignificant los ses have not been dealt with), and secure attachment styles . S pecific and s ubtypes have now been linked to certain types of health behaviors and clinical outcomes. F or example, diabetic patients with dismiss ive attachment s tyles , a found in approximately 25 percent of the general population and characterized by low trus t of others and excess ive self-reliance, s how a decreas ed ability to collaborate with providers and have poorer glycemic control than patients with secure attachment styles . In study at a primary care clinic, patients with insecure attachment s tyles reported more unaccounted for 989 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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symptoms than others. Among these, patients with preoccupied attachment had the highest primary care costs and us efulness , whereas patients with fearful attachment had the lowest, reflecting their res pective tendencies to overus e or underus e medical services . P.1001

Interpers onal Dis turbanc es in B ehavior Abnormal illne s s be havior (dysnos ognosia) is a pathological mode of experiencing, evaluating, and res ponding to one's own health s tatus des pite lucid and accurate apprais al and management options provided a health profes sional. T hese behaviors can be as interpersonal dis orders between patients and health care profes sionals. C entral to all of thes e behaviors is adoption of the sick role by the patient, who then in characteris tic interactions with health care which typically leave both the provider and the patient diss atis fied. P atients with abnormal illnes s behavior typically s eek repeated medical evaluations from a multitude of physicians, often undergoing a s eries of expensive laboratory tests . At times, the level of complaints provokes unneces sary invasive laboratory examinations or surgeries, which, in turn, thereby place the patient at genuine medical ris k. Abnormal illness behaviors may be unconscious or cons cious. Uncons cious abnormal illne s s be haviors those in which the patient believes the symptoms some genuine illness . T hese behaviors may occur in somatization disorder (in which multiple s ymptoms and 990 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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organ s ys tems are affected), convers ion disorders, somatoform pain dis order (in which no cause for the subjective level of pain can be found), and hypochondriasis (in which the primary fear is of having serious dis order). Abnormal illness behaviors in which patients act sick when they are fully aware that they not include malingering (in which external incentives — us ually financial—are the motivating factors) and factitious disorder with phys ical or ps ychological symptoms (Munchausen's s yndrome). In s yndrome , patients repeatedly and compulsively thems elves for medical care with feigned or selfillness . T hese self-induced conditions may be s o to ultimately caus e death: S ome patients inject with feces to caus e s ys temic infections that then hospitalization and intens ive care. W hen the s elfnatures of the illnes ses are dis covered, medical s taffs become outraged at these patients. T he patients rarely accept or cooperate with ps ychiatric care, s o few have been adequately s tudied. Most do not appear to be ps ychotic, but there seems to be a disturbance in personality s tructure. In Munchaus en's s yndrome by caregiver, us ually a parent, induces illnes s in a child. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > F UT UR E

FUTUR E PR OS PE C TS P art of "8 - C linical Manifes tations of P s ychiatric Like psychiatric diagnos tic clas sifications, fas hions ps ychiatric signs and symptoms change so that thos e 991 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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described above must be taken in his torical C haracteris tics once given prominence, s uch as the protuberances of the s kull s tudied by phrenologis ts a century ago, are no longer accorded much importance, whereas only in the past few decades have newly described clinical phenomena, s uch as family, emotion, and alexithymia, been appreciated. B ecaus e the shifts in what is considered relevant and becaus e the current dominance of biological res earch, it is easy as sume that the nuances of clinical, descriptive ps ychopathology are mostly of his torical interes t. As as the ultimate goals of clinical ps ychiatry are to help patients feel better and function better, attending to patients' s ubjective complaints with a firm knowledge of clinical descriptors will continue to be vital as pects of ps ychiatris ts' s kills . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 8 - C linica l Manifestations of P s ychiatric Dis orders > R E F E R E NC E S

S UGGE S TE D C R OS S R E FE R E NC E S P art of "8 - C linical Manifes tations of P s ychiatric T he ps ychiatric interview, history, and mental status examination are discuss ed in S ection 7.1. Additional definitions of typical signs and symptoms of ps ychiatric illness are included in S ection 7.4. P erception and cognition are dis cuss ed in S ection 3.1, memory in 3.4, and clas sification of mental dis orders in S ection 992 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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R E FE R E NC E S Amador X, David A, eds . Ins ight and P s ychos is . UK : Oxford University P res s; 1998. B errios G E , G ili M: Abulia and impulsiveness conceptual his tory. Acta P s ychiatr S cand. B ranson R , P otoczna N, K ral J G , Lentes K U, Hoehe Horber F F : B inge eating as a major phenotype of melanocortin 4 receptor gene mutations. N E ngl J 2003;348:1096. C as pi A, S ugden K , Moffitt T E , T aylor A, C raig IW , Harrington H, McC lay J , Mill J , Martin J , B raithwaite P oulton R : Influence of life s tres s on depress ion: Moderation by a polymorphism in the 5-HT T gene. S cience. 2003;301:291. C iechanowski P S , W alker E A, K aton WJ , R us so J E : Attachment theory: A model for health care and s omatization. P s ychos om Me d. 2002;64:660. C loninger R C , S vrakic DM, P rzybeck T R : A ps ychobiological model of temperament and Arch G e n P s ychiatry. 1993;50:975. C omings DE , B lum K : R eward deficiency s yndrome: G enetic aspects of behavioral disorders . P rog B rain 2000;126:325. C ommittee on the F amily, G roup for the 993 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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of P s ychiatry: A model for the clas sification and diagnosis of relational disorders . P s ychiatr S erv. 1995;46:926. C ons tantino J N, C loninger C R , C larke AR , Has hemi P ryzbeck T : Application of the s even-factor model of personality to early childhood. P s ychiatry R e s . 2002;109:229. C os ta P T J r, McC rae R R : S tability and change in personality ass es sment: T he R evised NE O Inventory in the Y ear 2000. J P e rs As s e s s . C richton P : F irst-rank s ymptoms or rank-and-file symptoms? B r J P s ychiatry. 1996;169:537. *C ummings J L. C linical Ne urops ychiatry. New Y ork: G rune and S tratton; 1985. Dapos;E s pos ito M, G ross man M: T he physiological of executive function and working memory. Neuros cie ntis t. 1996;2:345. Dhos sche D, F erdinand R , V an Der E nde J , Hofstra V erhuls t F : Diagnostic outcome of self-reported hallucinations in a community s ample of P s ychol Me d. 2002;32:619. F laum M, Arndt S , Andreasen NC : T he reliability of “bizarre” delus ions. C ompr P s ychiatr. 1991;32:59. F reeman D, G arety P A, K uipers E : P ers ecutory 994 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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Developing the understanding of belief maintenance and emotional distress . P s ychol Me d. 2001;31:1292. G eorge MS , P arekh P I, R osindky N, K etter T A, T A, Heilman K M, Herscovitch P , P os t R M: emotional prosody activates right hemis phere Arch Neurol. 1996;53:665. G oodman M, B rown J A, Deitz P M. Managing C are II: A Handbook for Mental He alth Was hington, DC : American P sychiatric P res s, Inc.; G oodwin F K , J amis on K R . Manic-Depre s s ive Y ork: Oxford Univers ity P res s; 1990. G riffiths T D: Musical hallucinos is in acquired P henomelonogy and brain substrate. B rain. 2000;123:2065. Harvey AG : Identifying safety behaviors in ins omnia. Nerv Me nt Dis . 2002;190:16. Hays R D, W ells K B , S herbourne C D, R ogers W, F unctioning and well-being outcomes of patients depres sion compared with chronic general medical illness es. Arch G e n P s ychiatry. 1995;52:11. Hilgard E R . Divide d C ons cious ne s s : Multiple Human T hought and Action. New Y ork: J ohn W iley; *J aspers K . G e ne ral P s ychopathology. C hicago: Univers ity of C hicago P ress ; 1963. 995 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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J udd LL, Akis kal HS , Maser J D, Zeller P J , E ndicott C oryell W , P aulus MO, K unovac J L, Leon AD, R ice J A, K eller MB : A prospective 12-year s tudy of subs yndromal and s yndromal depress ive symptoms unipolar major depres sive dis orders . Arch G e n P s ychiatry. 1998;55:694. K alechstein AD, Newton T F , Leavengood AH: syndrome in cocaine dependence. P s ychiatr R e s . 2002;109:97. K es sler R C , McG onagle K A, Zhao S , Nelson C B , M, E s hleman S , W ittchen H-U, K endler K S : Lifetime 12-month prevalence of DS M-III-R ps ychiatric in the United S tates: R esults from the National C omorbidity S urvey. Arch G e n P s ychiatry. K oenigs berg HW, Handley R : E xpress ed emotion: predictive index to clinical construct. Am J 1986;143:1361. Lazare A, ed. O utpatie nt P s ychiatry: Diagnos is and T re atme nt. 2nd ed. B altimore: Williams & Wilkins; Miller W R , R ollnick S . Motivational Inte rviewing: P reparing P eople F or C hange . 2nd ed. New Y ork: G uilford; 2002. Mintz J , Mintz LI, Arruda MJ , Hwang S S : T reatments depres sion and the functional capacity to work. Arch G e n P s ychiatry. 1992;49:761. 996 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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Montejo-G onzalez AL, Liorca G , Izquierdo AJ , A, B ousono M, C alcedo A, C arrasco J L, C iudad J , E , de la G andara J , Derecho J , F ranco M, G omez Macias J A, Martin T , P erez V , S anchez J M, V icens E : S S R I-induced s exual dysfunction: paroxetine, s ertraline, and fluvoxamine in a multicenter, and des criptive clinical s tudy of 344 patients. J S e x Marital T he r. 1997;23:176. Nayani T H, Davis AS : T he auditory hallucination: A phenomenological s urvey. P s ychol Me d. Nemiah J : Alexithymia: P resent, past—and future? P s ychos om Me d. 1996;58: 217. Nierenberg AA, K eefe B R , Les lie V C , Alpert J E , Worthington J J , R os enbaum J F , F ava M: R es idual symptoms in depres sed patients who respond to fluoxetine. J C lin P s ychiatry. 1999;60:221. P.1002 Oulis P G , Mavreas V G , Mamounas J M, S tefanis C linical characteris tics of auditory hallucinations . P s ychiatr S cand. 1995;92:97. P ilowsky I: T he concept of abnormal illnes s P s ychos omatics . 1990;31:207. P rochas ka J O, DiC lemente C C : T rans theoretical toward a more integrative model of change. 997 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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T he ory R es P ract. 1982;19:276. P urdon S E , F lor-Henry P : As ymmetrical olfactory and neuroleptic treatment in s chizophrenia. R es . 2000;44:221. *R apaport D, ed. O rganization and P athology of New Y ork: C olumbia University P ress ; 1951. R aymond NC , C oleman E , Miner MH: P sychiatric comorbidity and compulsive/impulsive traits in compuls ive s exual behavior. C ompr P s ychiatry. 2003;44:370. S achdev P , Loneragan C : T he present s tatus of J Ne rv Ment Dis . 1991;179:381. S ansone R A, G aither G A, S onger DA: S elf-harm behaviors acros s the life cycle: A pilot study of inpatients with borderline pers onality disorder. P s ychiatry. 2002;43:215. S chneider K . C linical P s ychopathology. New Y ork: and S tratton; 1959. S chwartz C E , Wright C I, S hin LM, K agan J , R auch Inhibited and uninhibited infants “grown up”: Adult amygdalar syndrome res ponse to novelty. S cience . 2003;300:1952. S hapiro D. Neurotic S tyles . New Y ork: B asic B ooks ;

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S ierra M, B errios G E : T he phenomenological depers onalization: C omparing the old with the new. Nerv Me nt Dis . 2001;189:629. *S ims A. S ymptoms in the Mind: An Introduction to Des criptive P s ychopathology. London: B ailliere 1988. S naith P : Anhedonia: A neglected s ymptom of ps ychopathology. P s ychol Me d. 1993;23:957. S obin C , S ackeim HA: P s ychomotor symptoms of depres sion. Am J P s ychiatry. 1997;154:4. *S tone MH. Abnormalities of P e rs onality: W ithin and be yond the R ealm of T re atme nt. New Y ork: W .W. 1993. S tope T , F riedman A, Ortwein G , S trobl R , C haudry Najam N, C haudhry MR : C omparison of delusions among schizophrenics in Austria and in P akis tan. P s ychopathology. 1999;32:225. T ada K , K ojima T : T he relationship of olfactory delus ional dis order to s ocial phobia. J Ne rv Ment 2002;190:45. T aylor C B , Arnow B . T he Nature and T re atme nt of Dis orde rs . New Y ork: F ree P ress ; 1988. T rumbell D: S hame: An acute s tres s respons e to 999 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/8.htm

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interpersonal traumatization. P s ychiatry. Ulloa R E , B irmaher B , Axelson D, W illiams on DE , DA, R yan ND, B ridge J , B augher M: P sychosis in a pediatric mood and anxiety disorders clinic: P henomenology and correlates . J Am Acad C hild P s ychiatry. 2002;39:337. Wes ten D, Arkowitz-Wes ten L: Limitations of Axis II diagnosing personality pathology in clinical practice. Am J P s ychiatry. 1998;155:1767. Y alom I. E xis te ntial P s ychotherapy. New Y ork: B asic B ooks ; 1980. Y udofs ky S C , Hale R E , eds . T e xtbook of 3rd ed. W as hington, DC : American P s ychiatric 1997.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 9 - C las s ification in P s ychia try > 9.1: P s ychiatric C las s ificati

9.1: Ps yc hiatric Mark Zimmerman M.D. R obert L . S pitzer M.D. P art of "9 - C las sification in P s ychiatry" In the chapter on nosology in the firs t edition of the C omprehe ns ive T e xtbook of P s ychiatry (C T P ), 1967, Henry B rill dis cuss ed the purpos es and clas sification, reviewed criticis ms of the class ification of mental disorders , and identified problems with applying the diagnostic manual to clinical practice. T hese same is sues remain relevant today and are discus sed in this chapter on class ification as well. At the time of the first edition of the C T P , the firs t edition of the Diagnos tic S tatis tical Manual of Me ntal Dis orde rs (DS M-I) was the official diagnos tic manual, although the second edition the Diagnos tic and S tatis tical Manual of Me ntal (DS M-II) was published 1 year later in 1968. B rill, of the American P s ychiatric Ass ociation's (AP A's ) C ommittee on Nomenclature and S tatistics from 1960 through 1965, delineated s ix advantages of the then current nomenclature: (1) wides pread use, thereby facilitating communication among profes sionals; (2) definition and delineation of the dis orders; (3) compatibility with the Inte rnational C las s ification of Dis e as es (IC D) diagnostic system; (4) clear guidelines compilation and reporting of patient diagnostic data; (5) comprehensive collection of diagnos tic terms in one 1001 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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source; and (6) eas e of us e. During the 35 years after chapter was publis hed, the AP A's diagnos tic manual been revis ed four times and plans are under way to the manual again within the next decade. Although of the iss ues regarding psychiatric clas sification have remained the s ame s ince the first edition of the C T P , because the AP A's DS M has grown in s tature, political forces have increas ingly voiced opinions regarding clas sification is sues, and discus sions about conceptual is sues in clas sification have raised new ques tions. T he present chapter is divided into nine s ections . It with a general description of the purpos es of Next, the chapter turns to the fundamental is sue underlying a class ification of mental disorders —the definition of mental dis order. T his s ection includes a discuss ion of the impact of the operationalization of mental disorder on the epidemiology of ps ychiatric disorders and an examination of the core component of DS M definition of mental disorder—“a behavioral, ps ychological, or biological dysfunction in the T his s ection ends with a review of J erome C . critique of DS M's definition of mental disorder and a review of his concept of dis order as harmful T he subs equent three s ections pres ent an overview of history of ps ychiatric class ification, the his tory of official clas sifications during the pas t two centuries, and the recent his tory of class ifications s ince the 1970s . T he revis ion of the fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ) clas sification is then described, highlighting and summarizing the features of disorders included in the current nomenclature. F ollowing this is a review of 1002 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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related to the use of DS M-IV -T R , and a summary of recent commentaries and research on the use of DS M clinical practice. F inally, s ome controversies in the clas sification of mental dis orders are described.

P UR P OS E S OF C L A S S IF IC A TION C las sification is the process by which the complexity of phenomena is reduced by arranging them into according to some established criteria for one or more purpos es. At present, the clas sification of mental cons ists of specific mental disorders that are grouped various clas ses on the bas is of s ome s hared phenomenological characteris tics. T he ultimate clas sification is to improve treatment and prevention efforts . Ideally, a clas sification of dis orders is based on knowledge of etiology or pathophysiology, becaus e this increases the likelihood of improving treatment and prevention efforts . T he purposes of a class ification of mental disorders involve communication, control, and comprehension.

C ommunic ation A clas sification enables users to communicate with other about the disorders with which they deal. T his involves us ing names of categories as s tandard ways of summarizing a great deal of information. When indicating that an individual has a particular disorder, confers information about the cluster of clinical features that the individual is experiencing without lis ting all of specific features that together cons titute the disorder. communication to be effective, there mus t be a high of agreement among us ers of the clas sification. 1003 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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C ontrol C ontrol of mental dis orders primarily refers to the prevention of their occurrence or the modification of cours e with treatment. C ontrol also refers to knowledge the cours e of a condition, as this too is often important clinical management.

C omprehens ion C las sification s hould provide comprehens ion or unders tanding of the caus es of mental disorders and proces ses involved in their development and maintenance. Dis orders can, of cours e, be treated knowledge of their etiology or pathophysiology. C omprehens ion is not an end in itself but is desired in clas sification because it usually leads to more effective treatment and prevention (i.e., better control).

WHA T IS A ME NTA L DIS OR DE R ? T here are many reas ons why mental health should care about the way in which me ntal dis order is defined. T he definition of P.1004 mental disorder guides dis tinguis hing pathology from what is normal. C ons equently, the definition of mental disorder can influence estimates of the prevalence of ps ychiatric disorders in the community, which, in turn, influences the allocation of public health expenditures . T he definition of mental dis order can impact which behavioral, cognitive, and emotional perturbations are included in the class ification, and the inclusion and exclusion of s pecific disorders from the DS M have 1004 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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source of criticism and controvers y. W hether a problem cons idered a dis order influences medical insurance reimbursement, and definitions of mental disorder have varied in mental health parity s tatutes in different Determination of the pres ence of mental disorder has potential legal implications in criminal cases and regarding disability determinations . Lack of conceptual clarity regarding the definition of mental disorder can contribute to abus es of ps ychiatric diagnoses as a of controlling or s tigmatizing socially undes irable behavior. F inally, lack of clarity in the conceptualization a fundamental, core is sue s uch as the definition of disorder reduces confidence in the profes sion as an authority regarding diagnostic iss ues and It s hould be noted that a definition of medical (nonps ychiatric) disorder is as elus ive as a definition of mental disorder, although this has not been the topic of much dis cuss ion. In fact, the definition of what a medical condition may attain greater vis ibility during coming years as technological advances improve the detection of pathology. F or example, there has been a recent growth of facilities offering full-body imaging procedures , s uch as computed tomography (C T ) detect occult illness es in their early stages . T he clinical significance of the early detection of abnormalities is unknown, because the natural course of the lesions detected at an early s tage is unknown. C onsequently, boundary between normal variation and pathology will challenged as the tools to detect gros s abnormalities improve in the absence of understanding pathophys iological mechanisms producing clinically significant pathology. 1005 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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Although it may be reass uring that difficulty in defining disorder is not limited to the mental health field, the question of what is a mental disorder s hould be to guide the development of the class ification. In to mos t medical disorders , mental disorders are manifested by a quantitative deviation in behavior, ideation, and emotion from a normative concept. T he debates over whether certain behaviors , ways of or emotional s tates s hould or should not be included in the DS M class ification (i.e., s hould or s hould not be cons idered disorders ) are grounded in ambiguities in definition of mental dis order. T he firs t DS M to offer a definition of mental dis order the third edition of the Diagnos tic and S tatis tical Me ntal Dis orde rs (DS M-III), and this definition has only slightly been modified in the revised third edition of the Diagnos tic and S tatis tical Manual of Mental (DS M-III-R ) and the DS M-IV -T R . T he history of the introduction of a definition of mental disorder into DS Mbegins in 1973, when R obert S pitzer s ided with thos e ps ychiatris ts and activists who wanted to remove homos exuality from DS M-II. T o justify the removal of homos exuality from the DS M-II, S pitzer proposed this definition of mental disorder: “In order for a mental or ps ychiatric condition to be cons idered a ps ychiatric disorder, it must either regularly cause subjective or regularly be ass ociated with generalized impairment social effectiveness or functioning.” With this definition, S pitzer argued that homosexuality per se does not the two requirements of his definition, becaus e “many homos exuals are quite satisfied with their sexual orientation and demonstrate no generalized impairment 1006 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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in social effectivenes s or functioning.” During the early years in the development of the DS MS pitzer recognized that his 1973 definition of mental disorder had ignored the concept of dysfunction. W ith help of many other colleagues, a new definition of disorder was developed, was included in DS M-III, and subs equently was modified in DS M-III-R and DS M-IV DS M-IV -T R , mental dis order is defined as a clinically significant behavioral or psychological s yndrome or pattern that occurs in an individual and that is with pres ent dis tres s (e.g., a painful s ymptom) or (i.e., impairment in one or more important areas of functioning) or with a s ignificantly increas ed risk of suffering, death, pain, dis ability, or an important loss of freedom. In addition, this syndrome or pattern must not merely an expectable and culturally sanctioned to a particular event, for example, the death of a loved Whatever its original caus e, it must currently be cons idered a manifestation of a behavioral, or biological dysfunction in the individual. Neither behavior (e.g., political, religious , or s exual) nor that are primarily between the individual and society mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as above.

Definition of Mental Dis order, Ps yc hiatric E pidemiology, and the Impairment or Dis tres s C riterion T he definition of mental dis order can potentially impact the prevalence estimates of psychiatric and s ubs tance disorders in epidemiological s tudies . C ritics of the DS M 1007 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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have sugges ted that the application of the definition of mental disorder has been too broad. One pos sible manifestation of the expans ion of the domain of mental disorder is the number of conditions identified in the S ince the publication of DS M-I, the number of identified diagnoses has increas ed by more than 300 percent 106 in DS M-I to 365 in DS M-IV -T R ). In fact, every the DS M has been accompanied by an increase in the number of diagnos es . It has been argued that the increased number of diagnos es represents a the concept of mental disorder, and behavioral, or emotional patterns that previously would not have been identified as pathological are reconceptualized as representing a dis order. However, a careful analysis of increase in diagnos tic labels s uggests that it almos t entirely repres ents greater specification of the forms of pathology, thereby allowing more homogeneous to be identified. Moreover, s ome of the highest epidemiological rates of mental disorders preceded the publication of DS M-III. S ince the publication of DS M-III, two large psychiatric epidemiological s tudies have been conducted in the United S tates —the E pidemiological C atchment Area study and the National C omorbidity S tudy (NC S ). T he res ults of these studies were reanalyzed by applying a higher threshold to define a mental dis order—the symptoms were required to cause “a lot” of interference the person's life or to result in treatment. On application the clinical significance criterion, the 1-year prevalence rate of any ps ychiatric or s ubs tance use disorder from 30.2 to 20.5 percent in the NC S and from 28.0 to percent in the E C A study. 1008 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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Impairment or Dis tres s C riterion C ons idered T he high prevalence rates of DS M-III and DS M-III-R ps ychiatric disorders in the NC S and the E C A s tudy concern that the diagnos tic criteria were overly or incorrectly applied in an overly broad manner, and they identified nondisordered individuals as disordered. P.1005 S pitzer and W akefield indicated that there were two in which the DS M diagnos tic criteria, even when correctly, might nonetheles s identify nondisordered individuals as having a mental disorder. One instance occurs when individuals experience normal reactions to stress ful environments , and the other occurs when individuals experience mild s ymptoms of a dis order are ins ufficiently s evere to be considered a disorder. S pitzer and W akefield labeled this the fals e -pos itive proble m with the DS M criteria. T o reduce the problem of potential overdiagnosis, in IV -T R , the threshold to diagnos e ps ychiatric disorders raised by explicitly adding a clinical s ignificance to approximately one-half of the criteria sets. P recedent this was found in the DS M-III-R criteria for social simple phobia, and obsess ive-compuls ive disorder T he wording of the DS M-IV -T R clinical s ignificance varies s omewhat from dis order to dis order, although most common wording is “the symptoms caus e significant distress or impairment in s ocial, or other important areas of functioning.” T he to the DS M-IV -T R manual indicates that the purpos e of 1009 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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criterion is to “help establish the thres hold for the diagnosis of a disorder in those situations in which the symptomatic presentation by itself (particularly in its milder forms) is not inherently pathological.” T his however, only address es one of the two potential of fals e positives—the labeling of mild, subthreshold conditions as dis orders . T he criterion does not addres s is sue of labeling normal reactions to stress ful events as disorders . One problem with DS M-IV -T R 's clinical s ignificance criterion is the uncertainty in how to interpret and apply Does dis tre s s refer to dis tres s about having the distress when experiencing the s ymptom? In a on S pitzer and W akefield's critique of the clinical significance criterion, K enneth S . K endler des cribed case of a 38-year-old woman who feared snakes s ince childhood. B ecause she lives in a metropolitan area, only way in which this fear impacts on her life is her to take her children into the s nake hous e at the zoo. B ecaus e it is easy for her to success fully avoid s nakes , fear does not res ult in clinically significant impairment. B ecaus e it is unclear how the distress component of clinical s ignificance criterion should be interpreted, it is unclear whether this presentation warrants a diagnos is specific phobia. T he woman is highly anxious when expos ed to the fear-inducing s timuli, much more than mos t people. Does this meet the dis tres s of the criterion? On the other hand, becaus e expos ure snakes is success fully avoided, she denies being (distress ed) by having this fear. Does this mean that does not meet the criterion? Does it mean that if s he bothered by having the fear, despite the fact that the 1010 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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degree of impairment is limited, then she does have a mental disorder? S pitzer and W akefield s uggest that distress that is intrins ic to the condition s hould be cons idered when determining dis order pres ence or absence. If distress about having a condition is a defining feature of mental disorder, then falsediagnoses might res ult (e.g., Does s omeone who is distress ed about having curly hair or being overweight have a mental disorder? ). A s econd problem with DS M-IV -T R 's clinical criterion is that it is often redundant with the s ymptom criteria. F unctional impairment is intrinsic to many disorders . F or example, the s ymptom criterion for the disorder s elective mutism is “cons istent failure to speak specific s ocial s ituations (in which there is an for speaking, e.g., at school) despite s peaking in other situations.” It is unclear how an individual can meet this criterion and not meet the additional clinical criterion that “the disturbance interferes with or occupational achievement or with s ocial communication.” T hus, the clinical significance criterion unnecess ary. A third problem with the addition of the clinical significance criterion to the s ymptom criteria s ets is that some individuals who have a mental disorder cannot diagnosed as having the disorder, becaus e the clinical significance criterion is not met. T his can be the fals e -ne gative problem with the clinical significance criterion. F or example, a child with frequent motor and vocal tics is not diagnosed with T ourette's s yndrome unles s the distress or impairment criterion is also met. alludes to the cardinal problem of diagnos ing a 1011 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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the abs ence of knowledge about underlying (T he is sue of dys function and its importance in defining disorder is described in greater detail in the following section.) T o s ay that one child with tics has a disorder, because clas smates, parents, or teachers are the symptoms and are thus res ponsible for the child's distress or impairment, whereas another child with the same symptom expres sion does not have a dis order because of a different res ponse from others , indicates the concept of mental disorder cannot s imply be bas ed the presence of impairment or dis tres s. Disorders in areas of medicine are diagnosed without explicit to concepts of distress and impairment, although one the other is us ually pres ent. However, for most medical disorders , a biological abnormality or underlying dysfunction can be identified. B y virtue of laboratory conditions s uch as cancer, liver dis ease, and cardiac disease can be diagnos ed in the absence of dis tres s or impairment (or even the manifes tation of clinical symptoms). Until underlying ps ychological and dysfunctions are identified, then the definition of mental disorder involves drawing an arbitrary line to minimize false-positive and false-negative diagnos es . Although the nature of the underlying dysfunction may currently unknown, the concept of disorder, as well as differentiation from normal variation, implies the of an underlying dis ruption of normal function. Dis tres s impairment is not s ynonymous with underlying dysfunction. T he same s ymptom presentation in two individuals may be s imilarly ass ociated with degrees of dis tres s or impairment but different degrees underlying dysfunction. C onsider, for example, the 1012 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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evaluation of depres sion. T he diagnosis of depress ive disorder poses conceptual challenges, becaus e pathways have been well es tablis hed as to their the ons et and maintenance of s ymptoms of S ome of the factors implicated in the caus e of include genetic vulnerability, s tres sful life events, and advers e child-rearing experiences. T he DS Ms explicitly recognize that individuals with s ymptoms of depres sion may or may not have a disorder. B ereavement, characterized by a full depress ive P.1006 syndrome, is not cons idered a mental disorder if the symptoms las t less than 2 months after a death and complicated by suicidal tendencies or ps ychos is . depres sive s ymptoms after a different stress ful event cons idered a dis order (unles s the s ymptoms last les s 2 weeks ). T hus, two individuals can have similar patterns, s imilar degrees of impairment, and a s imilar cours e of symptoms , yet be diagnosed differently depending on whether the stress ful event precipitating the depres sion was or was not a los s due to death different type of loss . T he clinical s ignificance criterion does not clarify how to distinguish between dis order no dis order in this instance. R ather, there is a of unknown validity, that there is a dys function in mood regulation as sociated with a depres sive s yndrome after stress ful life events other than a death. C ons ider example in which a diagnos is of depres sion does not follow from application of the clinical significance Immediately after a stress ful event, an individual who experiences a full depress ive s yndrome of brief, less 1013 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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weeks, duration is not diagnosed with major depres sive disorder. F or example, after being told unexpectedly her hus band wanted a divorce, a 35-year-old woman daily, developed insomnia, lost her appetite, had concentrating, felt res tless and agitated, and mis sed days at work. After a week, her symptoms began to improve, she returned to work, and s he thought that was coping better. A definition of disorder based on the presence of impairment and dis tres s would class ify her having a disorder. According to DS M-IV -T R , s he would be diagnosed with major depres sive dis order unles s full s yndrome lasted for at leas t 2 weeks. A mental could be diagnos ed according to DS M-IV -T R — disorder—if it was concluded that the symptoms were excess of what cons titutes a normal reaction to the stress or. T his indicates that the determination of then, is not s imply bas ed on s ymptom picture nor impairment or dis tres s, but on the presumption of the exis tence of a dys function of an underlying regulatory mechanism that is inferred from the nature, cours e, context of the s ymptoms.

C ritique of the DS M Definition of Mental Dis order from Wakefield's Harmful Dys func tion Pers pec tive E xplicit in the DS M-IV -T R definition of mental dis order the requirement of underlying dysfunction, although is sometimes not explicitly discus sed, even by F or example, in discus sing the iss ue of adding new diagnostic categories to DS M-IV -T R , the principal of DS M-IV -T R , when discuss ing the pos sible inclusion minor depress ion and mixed-anxiety/depress ive noted that “there is no inherent problem in high 1014 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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prevalences of disorders … so long as it is clear that threshold es tablis hed is as sociated with clinically significant dis tres s and/or disability and that the is us eful in predicting prognos is and guiding treatment.” Likewise, in a recent article comparing definitions of mental disorder used in different federal and s tate mandating parity coverage for mental health treatment, Marcia C . P eck and R ichard M. S cheffler indicated that DS M defines mental dis order as “a clinically s ignificant behavioral or psychological s yndrome or pattern that occurs in an individual… is as sociated with present distress … or dis ability… or with a significant increas ed of suffering.” In a paper entitled “R hinotillexomania: P sychiatric Disorder or Habit? ” J ames W. J efferson T rent D. T hompson indicated that nose picking, a universal practice in adults, should be considered a disorder when it becomes exces sive and caus es impairment or dis tres s. No reference was made to dysfunction of underlying mechanisms. It is therefore uncommon for dis cuss ions of the definition of mental disorder, or dis cuss ions of whether a behavioral or ps ychological syndrome should be characterized as a mental disorder, to focus on impairment and dis tres s to ignore the iss ue of dysfunction in underlying mechanisms. P erhaps the reason for paying les s to this component of the definition of mental dis order is the lack of knowledge of thes e dysfunctions. In a s eries of articles over the pas t 15 years, W akefield critically examined DS M's definition of mental dis order elaborated his own conceptualization of medical and mental disorder as harmful dys function. Dys function is defined as an inability of an internal mental mechanis m 1015 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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perform its intended, natural function, from an evolutionary pers pective. As noted previously, the definition of me ntal dis order already includes the of dys function. However, Wakefield critiques the way the DS M criteria operationalize the concept of merely as s tatistical deviation from normative reaction. It is for that reas on that DS M excludes a normative (expected) grief reaction, becaus e it is an “expectable and culturally s anctioned res pons e to a particular event, for example, the death of a loved one.” problem with DS M's attempt to operationalize dis order harmful s tatistical deviation is the failure to cons is tently apply this defining principle to determine what is and what is not a disorder. E xamples of conceptual inconsistency include pers istent mental or behavioral states , s uch as gullibility, lazines s, and s loppines s, that frequently unwanted, cause distress or impairment, are statis tically deviant. Although apparently meeting DS M's conceptualization of mental disorder as harmful statis tical deviation, thes e states are not considered disorders . Moreover, conceptual inconsistency is even within the DS M clas sification. DS M's V codes are heterogeneous collection of problems, such as phas e life problems , medication-induced movement dis orders, relational problems, problems related to abus e or and malingering, that may be the focus of clinical attention, are distress ing and unexpected (thereby meeting the DS M definition of mental disorder), and yet are not considered mental disorders . F ollowing this line of reas oning, W akefield critiques the criteria us ed to diagnos e adjus tment disorder, which based, in large part, on s tatistical deviation (“marked 1016 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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distress that is in exces s of what would be expected expos ure to the s tres sor”). A poss ible, literal, of the adjus tment disorder criteria is that individuals in the upper one-half of the dis tribution of dis tres s after stress ful event qualify for the diagnosis. Much of Wakefield's dis cus sion focuses on how the definition of mental disorder mus t be broad enough to include conditions that are triggered by s tres s but not broad that all environmentally induced perturbations in homeostasis are considered pathological. A definition identifies the normal reactions to stress es in everyday as disorders trivializes the concept of disorder. As Wakefield puts it, [T ]he critical distinction that to be drawn is between those situations in which an environmental s tres s caus es a breakdown of an internal mechanism such that the breakdown becomes of the original stress versus a natural res ponse that is initiated and maintained directly by the ongoing s tres s and that would subs ide if the s tres s T he former kind of reaction is a disorder but the latter is not, according to the dys function conception…. Life naturally contains a certain amount of distress , and distress that is 1017 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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cons istent with the natural functioning of the organis m is a disorder. C ons ideration of dysfunction is als o important for distinguishing between functional impairment that is indicative of disorder and impairment in functioning that instead reflects inability. C ons ider illiteracy and a reading disorder. B oth are characterized by impairment reading ability. However, illiteracy due to inadequate education is not considered a dis order, because there presumed underlying dysfunction. A reading dis order is diagnosed only when reading achievement is below expected by the individual's education and intelligence (i.e., there is a presumed dys function in the mental res ponsible for reading). Wakefield suggests that the framers of DS M-III did not incorporate the concept of dysfunction into the criteria individual dis orders , because reliability was valued highly than validity. Although the actual nature of the dysfunction may be unknown, W akefield argues that it poss ible for clinicians to judge whether symptoms are to internal dysfunction. F or example, W akefield and colleagues found that clinicians could reliably agree children growing up in violent, threatening who exhibit features of conduct dis order that are appropriate to the s ocial context s hould not be to have a mental dis order. Unfortunately, W akefield yet to s how that clinicians, for a variety of disorders , distinguish normal reactions (e.g., depres sion after a from P.1007 1018 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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harmful conditions that are the result of a dysfunction (e.g., the dysfunction of mood regulation in severe depres sion). S ome researchers have suggested that future clas sification should focus on identifying the of cognition, emotion, and motivation that underlie the signs and s ymptoms of mental disorder. S uch a would evolve simultaneous ly with the development of tes ts to evaluate these functions and to identify abnormalities in them. T his would move ps ychiatric clas sification clos er to the rest of medicine, for which laboratory testing has increas ingly as sumed identifying and class ifying pathological conditions.

Harmful Dys func tion and the Definition of Mental (and Phys ic al) Dis orders T he development of tests to identify underlying abnormalities would move ps ychiatric clas sification system primarily based on des cription clos er to one on etiology. It is s obering to realize that only 40 years during the 1960s, the failure to identify underlying abnormalities was taken as evidence that the concept mental illness was a myth. T o better appreciate a dysfunction definition of mental dis order, W akefield reviewed the arguments of the critics of psychiatric clas sification and, in doing so, illus trated that harmful dysfunction is as relevant to defining physical dis order mental disorder. T homas S . S zas z argued that a dis order requires the presence of a phys ical lesion, with a le s ion being 1019 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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an identifiable deviation in anatomical structure. T he failure to identify brain lesions in individuals with conditions was prima facie evidence that these are not dis orders. R ather, the term me ntal dis order is adopted to label behavior that deviates from societal norms and to empower the medical es tablis hment. Wakefield identified two problems with S zasz's thesis : that a lesion (i.e., a pathological anatomical s tructure) be defined solely in terms of s tatistical deviation and that phys ical dis order is defined by the presence of a T he statis tical deviation argument fails on two F irst, normal variations of anatomical s tructures , s uch webbed toes , are not synonymous with a pathological proces s (i.e., dys function or malfunction). S econd, pathological anatomical process es, such as are not statis tical deviations . T hus, the s tatistical argument fails , because infrequent variants are not neces sarily pathological, and pathological anatomical variation is not necess arily infrequent. T he second component of S zas z' argument, that physical disorder defined by the presence of a les ion, cannot account for disorders s uch as migraine headaches and trigeminal neuralgia, for which there are no known anatomical lesions . Wakefield suggests that variations in structure, whether they be anatomical structures or mental mechanisms, lesions when “the variation impairs the ability of the particular structure to accomplish the functions that it designed to perform,” and the lesion is a dis order “only the deviation in functioning of the part affects the wellbeing of the overall organism in a harmful way…. T hus, the harmful dysfunction approach to the concept of 1020 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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disorder would s eem to explain… which anatomical deviations are lesions and which lesions are disorders.”

Harmful Dys func tion and Diagnos tic C ontrovers ies In concluding his 1992 paper on the concept of mental disorder, W akefield illus trated how a lack of knowledge naturally selected mechanis ms and changes in cultural mores can influence judgments about dys function and harm, and, consequently, determination of whether a condition is a dis order. He reviewed opinions about orgasm during intercourse that were formed a century apart: According to the eminent V ictorian phys ician and William Acton (1871), the female sexual organs do not naturally function to produce orgas m during intercourse, and the occurrence of orgasm in a is a form of pathology due to an excess of s timulation beyond her body was designed to According to Mas ters and (1966, 1970, 1974), orgas m intercours e is a natural function the female sexual organs , and of orgas m in a woman is a due to inadequate stimulation of the sort to which her body was designed to respond. Acton and 1021 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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Masters and J ohnson knew that there are many women who do have orgas ms during and many women who do not. Acton interpreted these facts to mean that there are a lot of women who are disordered because they s uffer from overs timulation, whereas and J ohnson interpreted thes e facts to mean that there are a lot of women who are disordered because they s uffer from unders timulation. T he nonstatis tical nature of function and disorder, combined with ignorance of the evolutionary history of female s exual enabled these oppos ite beliefs be consistent with the s ame set data and with the same concept disorder. Wakefield indicates that facts alone do not determine disorder s tatus. T he harm component of the disorder definition is , in part, a value judgment bas ed on sociocultural s tandards . T hus , Acton and Mas ters and J ohns on could have come to an agreement on what cons titutes female orgasmic dys function based on evolutionary knowledge but might nevertheless have disagreed as to whether orgas m during intercours e is a desirable goal, thus dis agreeing regarding the 1022 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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female orgasmic disorder. T he harmful dys function definition of mental dis order does not, therefore, diagnostic controversies that are disputes based on

Problems with the Harmful Dys func tion Definition of Mental Dis order T here have been conceptual critiques of the harmful dysfunction definition of mental dis order, although have been well refuted by W akefield. T he authors with W akefield's conceptual analysis of the definition of disorder, although a weakness in W akefield's is the lack of specific details in implementation. T hat is, not clear how to operationalize and incorporate the concept of dysfunction of naturally s elected into the diagnostic criteria. Wakefield simply indicates this task needs work. Wakefield indicates that the reason that it is important define, in part, the DS M dis orders in terms of to decreas e the number of false-positive diagnoses . If concept of dysfunction is incorporated into the criteria, then s ome, perhaps many, pers ons who are currently diagnosed with a dis order will not be given a diagnos is . C ons ider the following cas e described by Wakefield: T he patient, a male profes sor in the s ocial sciences , to the cons ultation s eeking antidepress ant medication medicine for ins omnia. He had to pres ent a paper in another city as part of a job interview and was afraid he could not function adequately to do so. He reported for the pas t month, he had experienced depress ed 1023 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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and extreme feelings of sadnes s and emptiness , as lack of interest in his usual activities (in fact, when not friends , he mostly s tayed in bed or watched T V ). His appetite had diminis hed, and he laid awake long into night, unable to fall asleep becaus e of the pain of his sadness . He was fatigued and lacking in energy during day and did not have the ability to concentrate on his work. T here was no suicidal ideation or feelings of guilt worthles sness . However, there was functional T he patient was barely managing to meet minimal occupational obligations (e.g., he showed up at clas s relatively unprepared and had not attended the monthly faculty meeting or worked on his research). He als o avoided s ocial obligations , except to be with clos e to les sen his pain. When asked what event might have precipitated thes e distress ing feelings , he reported, holding back tears as spoke, that approximately a month earlier, an intens e and pass ionate 5-year love affair with a woman (the patient was s ingle) to whom he had been completely devoted had been ended by the woman she made a final decis ion that she could not leave her husband. B oth lovers had perceived this relationship as unique, once-in-a-lifetime romance in which they had their s oul mate and had experienced an extraordinary combination of emotional and intellectual intimacy. P.1008 T his individual meets the DS M-IV -T R s ymptom and impairment criteria for major depress ive disorder. However, W akefield argues that the loss res ponse is “reasonably proportional” to the nature of the los s, and 1024 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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only on cons ideration of the subjective meaning of the loss can the clinician determine whether there is a dysfunction of the loss res ponse mechanis m. He notes that s uch loss es can trigger a “genuine” disorder, and “an interesting challenge… is to try and formulate criteria that would distinguish truly cases from normal reactions to extreme loss es.” It is absence of an attempt to generate and to validate such criteria that limits the practical application of thesis.

HIS TOR Y OF C L A S S IF IC A TION K arl Menninger and colleagues presented a of clas sification from ancient times to the modern era. According to Menninger and colleagues , the firs t description of a mental illnes s appeared in 3000 bc in a depiction of s enile deterioration ascribed P rince P tah-hotep. T he syndromes of melancholia and hysteria appeared in the S umerian and E gyptian as far back as 2600 bc. In the E bers papyrus 1500 bc), s enile deterioration and alcoholism were described. In India, in approximately 1400 bc, a clas sification of psychiatric dis orders was included in medical class ification system of Ayur-V eda. Hippocrates (approximately 460 to 370 B C ) is us ually regarded as the one who introduced the concept of ps ychiatric illnes s into medicine. His writings described acute mental dis turbances with fever (perhaps acute mental dis turbances without fever (probably analogous to functional ps ychoses but called mania), chronic dis turbance without fever (called me lancholia), hysteria (broader than its later us e), and S cythian 1025 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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(s imilar to transves tis m). C aelius Aurelianus , a fifth century phys ician living in R oman E mpire, described homos exuality as an a dis eas ed mind that was found in men and women. Mental deficiency and dementia were noted by S wiss R enais sance physician F elix P latter (1536 to 1614). B efore the time of the E nglis h phys ician T homas S ydenham (1624 to 1689), all illnes s, des pite the in appearance between the different s yndromes, was attributed to a single pathogenic proces s, a disturbance the humoral balance or a dis turbance in the tensions of the solid tis sues. S ydenham, on the other hand, that each illnes s had a specific cause. He called for the study of morbid process es and likened the the s pecificity of dis eases to the botanis t's s earch for species of plants. P hilippe P inel (1745 to 1826), a F rench phys ician, the complex diagnostic s ys tems that preceded him by recognizing four fundamental clinical types : mania (conditions with acute excitement or fury), melancholia (depres sive dis orders and delus ions with limited dementia (lack of cohesion in ideas ), and idiotism and organic dementia). P inel thus reacted against the specific disease entity tradition of S ydenham and went back to a noncomplex hippocratic s ys tem of All mental illnes ses were in a category of physical called ne uros e s , which were defined as functional of the nervous system—that is , illness es that were not accompanied by fever, inflammation, hemorrhage, or anatomical les ion. B y the 19th century, mental disorder began to be 1026 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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cons istently as the manifes tation of physical pathology, and s cientis ts searched for specific lesions, parallel to inves tigation of bodily diseases. B enedict-Augustin (1809 to 1873) was the first to us e the cours e of an as a basis for clas sification. His de me nce pre core was disease entity but a particular form of the cours e of disease. K arl Ludwig K ahlbaum (1828 to 1899), a G erman descriptive ps ychiatris t who foreshadowed E mil introduced the concepts of (1) the temporary symptom complex, as oppos ed to the underlying disease, (2) the distinction between organic and nonorganic mental disorder, and (3) the cons ideration of the patient's age the time of onset and the characteris tic development of the disorder as bases for class ification. T he finding made by Antoine B ayle in 1822 that progres sive pares is was a s pecific organic dis eas e of brain and the discovery of P aul B roca (1824 to 1880) in 1861 that s ome forms of aphasia were related to lesions of the cortex increased attempts to base all clas sifications of mental disorders on demons trated lesions or disturbances in vascular and nutritional phys iology. T hose findings led W ilhelm G ries inger 1868) to coin the slogan “mental diseases are brain diseases .” B ecaus e the knowledge of brain pathology limited, he recognized the need for a provis ional functional category for mental illness es with as-yetunknown somatic pathology. In the las t two decades of the 19th century, K raepelin (1856 to 1926) synthesized three approaches : the descriptive, the somatic, and the cons ideration of the cours e of the dis order. He viewed mental illness es as 1027 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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organic disease entities that could be clas sified on the basis of knowledge about their causes, courses , and outcomes . He brought the manic and depres sive disturbances together into one illness , manicps ychos is , and distinguished it, on the basis of its of remiss ion, from the chronic deteriorating illness de me ntia prae cox, which E ugen B leuler later renamed s chizophre nia. K raepelin also recognized paranoia as distinct from dementia praecox, distinguished delirium from dementia, and, for the firs t time in a class ification system of mental disorders , included the concepts of ps ychogenic neuros es and ps ychopathic personalities “born criminal,” the “unstable,” “pathological liars and swindlers,” and “litigious paranoiacs ”). T he basic approach of K raepelin toward clas sification to search for that combination of clinical features that would best predict outcome. In contrast, B leuler (1857 1939) based his class ification s ys tem on an inferred ps ychopathological process , such as a disturbance in as sociative process in s chizophrenia. T he personality dis orders were firs t noted in the ps ychiatric literature by J . C . P richard in 1835 with his introduction of the concepts of moral ins anity and moral imbecility. In 1891, August K och coined P.1009 the phrases ps ychopathic pe rs onality and ps ychopathic cons titutional inferiority. S igmund F reud (1856 to 1939), after studying hysteria, prototypical neurosis, went on to divide the neuroses the actual ne uros e s , the result of dammed-up sexual 1028 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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excitation, and the ps ychone uros e s , the result of unconscious conflict and compromise symptom formation. As interest in the actual neuros es the term ne uros is came to be s ynonymous with ps ychone uros is . F reud recognized only the following subtypes of neurosis: anxiety neuros is, anxiety hys teria (phobia), obsess ive-compuls ive neuros is , and hysteria. was not until much later, in the American Medical Ass ociation's (AMA's) S tandard C las s ifie d Dis e as e (1935), that reactive depres sion was added as additional s ubtype of the neuros is , later to find its way, with other neurotic s ubtypes , into DS M-I and DS M-II. F reud's dynamic concepts and interest in the ps ychopathology of everyday life led to an expans ion the boundaries of what was cons idered mental illness include mild forms of pers onality deviation. As Hagop S . Akiskal and W illiam McK inney noted, the advances in the unders tanding of mental dis orders the pas t 50 years , the major categories of mental in the standard clas sification systems are based on the concepts of K raepelin and B leuler—organic disorders , affective dis orders, and schizophrenia—and F reud—neuros es and personality dis orders.

HIS TOR Y OF OF FIC IA L C L A S S IF IC A TIONS T he firs t official system for tabulating mental disorder in the United S tates was initially us ed for the decennial cens us of 1840. It contained only one category and lumped together the idiotic and the ins ane. F orty years later, in the cens us of 1880, the mentally ill were subdivided into separate categories for the firs t time 1029 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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(mania, melancholia, monomania, paresis , dementia, dipsomania, and epilepsy). It is s obering to realize that conceptual iss ues that modern clas sifiers wres tle with today were well recognized by the authors of that In the introductory remarks to the census office report, authors lamented about the difficulties of creating a clas sification system for the mentally ill: Much effort has been put forth to secure uniformity in the clas sification of the ins ane in country of the world; but it impos sible for thos e best to form an opinion to agree upon any s cheme which can be S ome clas sifications are bas ed upon s ymptoms and some upon phys ical caus es ; others are a mixture of the two; and s till take into account the complications of ins anity. F or purpos es of the cens us , it to us advisable to dis regard all minute s ubdivisions and to a s imple analysis on the poss ible outlines. In 1889, the International C ongres s of Mental S cience P aris adopted a class ification proposed by a headed by Morel that included 11 categories , including those “upon which the majority (of the commiss ion's members) was unanimous ” and omitting thos e “upon 1030 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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which opinion was divided.” T hose early clas sifications presented in T able 9.1-1.

Table 9.1-1 19th C entury C las s ific ations of Mental 1840 U.S . C ens us

1880 U.S . C ens us

1889 International C ongres s of Mental S cience

Idiocy (insanity)

Mania

Mania

 

Melancholia

Melancholia

 

Monomania

P eriodical ins anity

 

P aresis

P rogress ive systematic insanity

 

Dementia

Dementia

 

Dips omania

Organic and senile dementia

 

E pilepsy

G eneral paralys is

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Ins ane neuros es

 

 

T oxic insanity

 

 

Moral and impuls ive insanity

 

 

Idiocy, etc.

In 1923, to conduct a special cens us of patients in for mental disease, the B ureau of the C ens us used a clas sification system developed in collaboration with AP A (then the American Medico-P sychological Ass ociation) and the National C ommittee for Mental Health. T hat system, cons is ting of 22 disorders , had adopted by the AP A in 1917 and was us ed until 1935, when it was revis ed for incorporation into the first of the AMA's S tandard C las s ifie d Nome nclature of T he purpos e was to gather uniform s tatistical in mental institutions . T hat 1935 class ification was designed primarily for inpatients and, therefore, proved inadequate for us e World W ar II ps ychiatric casualties , who required clas sifications for acute dis turbances , ps ychosomatic disorders , and pers onality disorders , which were not represented in the 1935 clas sification. In addition, the system was considered anachronis tic by the increasing number of psychodynamically oriented psychiatrists were emerging from training programs and whose 1032 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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interes ts lay more in the treatment of private F or thos e reasons , shortly after W orld W ar II, the Administration and the military services developed their own systems . In 1948, the World Health Organization (W HO) the res ponsibility for revising what had previously been called the International List of C auses of Death and had been revis ed every 10 or 20 years s ince its 1900. T he s ixth revision was renamed the Manual of Inte rnational C las s ification of Dis eas e s , Injurie s , and of Death (IC D-6) and contained, for the first time, a clas sification of mental disorders , entitled “mental, ps ychoneurotic, and pers onality disorders .” It contained ten categories of psychos is, nine categories of ps ychoneurosis , and s even categories of disorders of character, behavior, and intelligence. Des pite the fact that American psychiatrists had participated in the development of the mental disorders section of IC D-6, the abs ence of such important as the dementias , many personality dis orders , and adjus tment disorders rendered it uns atis factory for use the United S tates . Other countries apparently als o the mental disorders section unsatis factory, becaus e F inland, New Zealand, P eru, T hailand, and the United K ingdom made official use of it. T he lack of wides pread international acceptance of that section of IC D-6 led the W HO to as k E rwin S tengel, a ps ychiatris t, to inves tigate the s ituation. S tengel concluded that the lack of general acceptance of the international class ification of mental disorders was due the fact that the diagnostic terms frequently had etiological implications that were at odds with various 1033 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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theoretical s chools of psychiatry. His s uggestion was to develop a clas sification in which all diagnos es should described operationally and without etiological implications in a companion gloss ary. (As the furor the elimination of neuroses in DS M-III has indicated, not so eas ily done!) In 1951, the U.S . P ublic Health S ervice commiss ioned workgroup party, with repres entation from the AP A, to develop an alternative to the mental disorders section IC D-6 for us e in this country. T hat document, prepared largely by G eorge R aines and bas ed heavily on the V eterans Administration clas sification s ys tem P.1010 developed by William Menninger, was published in by the AP A as the DS M. DS M-I included 106 T he significance of DS M-I was that it replaced the mental disorders section of the AMA's S tandard Nome nclature of Dis e as e and the s ys tems devised by military and the V eterans Administration, and, for the time, it provided a glos sary of definitions of categories. addition, for the first time, a specialty medical the AP A, developed what became the official American clas sification of mental dis orders. T he AP A is the only medical specialty that is in charge of its official clas sification of medical disorders . In the definitions of the diagnos tic categories , the us e of the term re action, as in s chizophre nic re action ps ychone urotic re action, express ed the s trong environmental orientation of Adolf Meyer, and the frequent reference to defens e mechanisms, particularly 1034 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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an explanation of the neuroses and personality reflected the wide acceptance of ps ychoanalytical concepts . Des pite its widespread influence and impact American psychiatric literature, DS M-I was not accepted as the official nomenclature throughout the country. T he New Y ork S tate Department of Mental Hygiene, for example, retained the old S tandard Nome nclature of Dis e as e until 1968. B ecaus e mos t of the other countries that used the IC D found the mental disorders section of the sixth revision unsatisfactory, the W HO s ponsored an international to develop a class ification s ys tem for mental disorders would improve on IC D-6 and would be acceptable to all member nations. T hat tas k was coordinated in this by the U.S . P ublic Health S ervice, which sent American representatives to the international committees revis ions of the mental dis orders s ection. T he eighth revis ion of the IC D (IC D-8) was approved by the W HO 1966 and became effective in 1968. (T he mental section of the s eventh revision of the IC D [IC D-7], appeared in 1955, was identical to the mental dis orders section of the s ixth revis ion of the IC D [IC D-6].) In 1965, the AP A, which had maintained clos e ties with international committees preparing IC D-8, ass igned its C ommittee on Nomenclature and S tatis tics, under the chairmanship of E rnes t M. G ruenberg, the tas k of preparing for the AP A a new diagnostic manual of disorders bas ed on the IC D-8 class ification but defining each dis order for use in the United S tates. S uch were necess ary because, when IC D-8 was first did not have an accompanying gloss ary. It was only later, in 1972, 4 years after DS M-II was adopted, that a 1035 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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gloss ary was publis hed. A draft of the second edition of the AP A's DS M was circulated in 1967 to 120 ps ychiatris ts known to have a special interes t in the area of diagnosis, and it was on the bas is of their criticisms and sugges tions. After further s tudy, the draft was adopted by the AP A in and was publis hed and officially accepted throughout country in 1968. At approximately the s ame time, the G eneral R egis ter Office in G reat B ritain publis hed its gloss ary, largely written by S ir Aubrey Lewis , which interpreted the IC D-8 clas sification. T he DS M-II clas sification cons isted of 182 disorders in ten major categories : 1. Mental retardation. T his category had been called me ntal de ficiency in DS M-I and had been limited to idiopathic or familial varieties of the disorder. In II, it was s ubdivided according to severity and 2. Organic brain syndromes. T he DS M-I distinction of acute (revers ible) vers us chronic (irrevers ible) was dropped and was replaced by the s ubdivision into ps ychos es as sociated with organic brain and nonps ychotic organic brain s yndromes. 3. P sychos es not attributed to physical conditions previous ly. T his s ection included the functional ps ychos es : schizophrenia, major affective paranoid s tates, and other ps ychos es (psychotic depres sive reaction). T he DS M-II category of schizophrenia included the latent type, not included DS M-I. T he DS M-I category of involutional reaction was s ubdivided into involutional 1036 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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and involutional paranoid s tate in DS M-II. 4. Neuroses. T his category included disorders in the chief characteristic was anxiety, whether “felt expres sed directly” or “controlled unconsciously automatically by convers ion, displacement and other psychological mechanisms.” T he DS M-I were retained with the addition in DS M-II of neuras thenic neurosis, depersonalization neurosis, hypochondriacal neuros is. 5. P ers onality disorders and certain other mental disorders . T his category included disorders , sexual deviation, alcoholism, and drug dependence. In DS M-I, all of those categories were subs umed under the rubric of pe rs onality dis orde rs . the personality disorders s ection its elf, DS M-II hysterical personality and eliminated the somewhat related DS M-I category of emotionally unstable personality. 6. P sychophys iological dis orders. T his group of was characterized by phys ical s ymptoms caused emotional factors and involving a s ingle organ us ually under autonomic nervous system T he disorders were s ubdivided by the organ involved. 7. S pecial s ymptoms. T his category was for a small symptoms occurring in the abs ence of any other mental disorder and mos t likely s een in children. II added s everal s ymptoms to the DS M-I list. 8. T ransient situational disturbances . T his category res erved for more or les s trans ient dis orders of any severity, including those of ps ychotic proportions 1037 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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occurred as acute reactions to overwhelming environmental s tres s in persons without any underlying mental disorders . T ransient situational personality dis orders in DS M-I did not s pecifically include acute reactions to stress that reached ps ychotic proportions , as did the category of situational dis turbances in DS M-II. 9. B ehavior disorders of childhood and adoles cence. category included six s pecific diagnos es . DS M-I not provided a separate category for dis orders of childhood and adolescence. 10. C onditions without manifes t ps ychiatric disorder nonspecific conditions. T his category, not pres ent DS M-I, performed the function of encompass ing “conditions of individuals who are psychiatrically normal but who nevertheles s have s evere enough problems to warrant examination by a ps ychiatris t.” T hese conditions are, therefore, not mental T his category was s ubdivided into three groups: maladjus tment without manifes t ps ychiatric nonspecific conditions, and no mental disorder. Unlike DS M-I, which discouraged multiple diagnoses, II explicitly encouraged clinicians to diagnos e every disorder that was present, even if one was caus ally to another—for example, alcoholis m s econdary to a depres sion. T he reaction to the publication of DS M-II in 1968 was mixed. T hos e who were mos t critical of DS M-II as one commentator s tated as a “giant leap into the century and a return to a kraepelinian view of mental disorders as fixed dis eas e entities”—despite the fact 1038 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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the word dis e as e was limited to certain categories in mental retardation and organic brain s yndromes and even though the word illne s s appeared only in the manic-depres sive conditions , where it was adopted to avoid the IC D term manic-de pres s ive ps ychos is . K arl Menninger summarized the view when he s aid: T his year the AP A took a great backward when it abandoned principle us ed in the s imple nosology (DS M-I) which Dr. Will (W illiam Menninger) worked s o hard to get P.1011 installed…. In the interest of uniformity, in the interes t of having s ome kind of code of designations for different kinds of human troubles , in the interes t of statis tics and computers , the American scientis ts were asked to some of the advances they had made in conceptualization and designation of mental illness . Although child ps ychiatris ts were pleas ed that DS M-II, unlike DS M-I, had a special category for children and adoles cents , many were disappointed that the G roup the Advancement of P s ychiatry's P s ychopathological Dis orde rs in C hildhood: T he ore tical C ons ide rations and 1039 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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P ropos e d C las s ification, which had been available for several years , was not us ed by the committee that developed DS M-II. Many applauded the elimination of the term re action, which had been appended to most of the DS M-I terms , an honest retreat from the position that, by adding the term re action to diagnostic labels, one thereby communicates some important knowledge about the etiology of the mental disorders . As G ruenberg T he routinizing of the word “reaction” in our standard nomenclature (DS M-I) has accomplis hed little that is positive—it has given many ps ychiatris ts the false notion that mental disorders are reactions the organis m to circums tances that tuberculosis and diabetes nephritis and measles and are “things ” independent of the patient's nature. F or all medical diseases are also reactions of organism to certain life circums tances and do not exis t independently of the people who are sick. T hose who were most enthusiastic pointed to the potential benefits that might accrue to international res earch and to communication between ps ychiatris ts different nations becaus e this country had adopted a 1040 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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system based on the IC D. Although DS M-II was the basis for the official manuals us ed in C anada, India, and several Latin countries , other national glos saries were prepared, and they defined the IC D lis t of terms in their own way. T he most influential gloss ary, other than DS M-II, was G re at B ritain's G los s ary of Me ntal Dis orders , prepared in under the direction of Aubrey Lewis. In the abs ence of an internationally accepted gloss ary, was inevitable that different countries would define categories s omewhat differently. An important example inconsistent definition occurred with s chizophrenia. II defined s chizophre nia broadly, cons is tent with the of schizophrenia held by American psychiatrists in the 1960s , and included mild cas es that most E uropean ps ychiatris ts would not have cons idered to be schizophrenia. T he B ritis h glos sary defined the more narrowly, and the differences in the reported prevalence of schizophrenia in the two countries was found to be mainly due to differences in diagnostic definition, rather than due to differences in actual rates disorder. In 1975, the ninth revision of the IC D (IC D-9) of mental disorders was publis hed, together with a gloss ary, to go into effect in 1978. Although many changes in the IC D-8 class ification and glos sary were made, thes e were not radical changes . As with IC D-8, ps ychiatris ts from the United S tates provided some input into the final document. An examination of the IC D-9 class ification reveals a difficulty in developing a class ification that is 1041 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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internationally. It is far eas ier to allow each country to introduce terms that are us ed only by that country than is to ins is t that different countries us e a single agreedterminology. T hus , as R obert E . K endell noted, the clas sification actually includes several “alternative and quite incompatible” ways of clas sifying depres sion. F or example, definitions of the categories of manicps ychos is , depres sed type, and depress ive type of nonorganic ps ychosis are not mutually exclus ive.

MODE R N HIS TOR Y OF C L A S S IF IC A TION In 1972, a group of researchers publis hed an article in Archive s of G ene ral P s ychiatry entitled “Diagnos tic for Us e in P s ychiatric R esearch.” R eferred to as the crite ria (after the lead author of the article), or the W as hington U nive rs ity crite ria (after the academic of the authors), for the first time, s pecific inclus ion and exclusion criteria for different dis orders were T he criteria were limited to the 15 dis orders that the authors cons idered to have been validated by empirical res earch. T he methods of establishing diagnos tic had been described in another paper from this group 2 years earlier and were recapitulated in the 1972 article. Was hington Univers ity five-phase approach toward es tablis hing diagnostic validity of individual categories dominated empirical psychiatry during the past 30 (T able 9.1-2).

Table 9.1-2 Was hington Approac h toward E s tablis hing 1042 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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Validity of a Ps yc hiatric C linical description

Includes symptoms of the dis order, as well as demographic features , age of onset, precipitating life events, other variables that more clearly define the clinical picture.

Delimitation from other disorders

R efers to exclusion criteria, so individuals with other disorders who share s imilar clinical are not included in the diagnos tic group.

Laboratory studies

Includes biological and ps ychological tes ts .

F ollow-up study

T he same dis order may have variable prognosis, but, until is known about the fundamental nature of the disorder, marked differences in outcome rais e questions about the validity of original diagnos is.

F amily s tudy

Includes family, adoption, and studies.

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Adapted from F eighner J P , R obins E , G uze S B , Diagnos tic criteria for us e in ps ychiatric research. Arch G e n P s ychiatry. 1972;26:57–67.

Als o in 1972, S pitzer and J os eph F leiss publis hed a article of studies examining the reliability of psychiatric diagnosis. T hey reexamined the reliability s tudies conducted during the 1950s and 1960s, and computed kappa coefficients of diagnostic agreement, which was then a relatively novel s tatistical procedure for determining the level of agreement after accounting for agreement due to chance. T hey concluded that the reliability of ps ychiatric diagnosis was poor. T his es tablis hed the groundwork for revising how ps ychiatric disorders were defined, as poor reliability limits the of a diagnostic s ys tem. As part of a longitudinal s tudy of the course of mood disorders , the R es earch Diagnostic C riteria (R DC ) developed along with a s emi-structured diagnos tic interview that evaluated these criteria. T he criteria for almos t every disorder originally defined by the Was hington Univers ity group were modified in the and s tudies were s ubs equently conducted to compare res pective reliabilities of these criteria sets (along with DS M-III criteria). As with the Was hington Univers ity only a limited number of disorders were defined in the 1044 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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R DC . DS M-III was published in 1980. S even years later, was published. Less than 1 year after the publication of DS M-III-R , P.1012 plans were announced for the publication of DS M-IV . Delayed by 2 years , DS M-IV was ultimately publis hed 1994. R obert S pitzer was the chair of the T as k F orce DS M-III and DS M-III-R , and Allen F rances the chair of T as k F orce for DS M-IV . T he publication of DS M-III was received with significant comment, as it represented a marked departure from ps ychiatric disorders had been previous ly specified and described. Although controversy surrounded s ome decis ions, such as the removal of the term ne uros is the clas sification, the achievements of DS M-III resulted widespread and continued adoption of its approach toward ps ychiatric clas sification.

A C HIE VE ME NTS OF DS M-III DS M-III was the first official diagnos tic system to inclusion and exclus ion diagnostic criteria. DS M-III thus followed the precedents s et in the W ashington criteria and R DC for defining disorders and brought the reliable diagnos tic approach used by a few research groups to the clinical community. B ecause an official clas sification system mus t be comprehensive and mus t include thos e disorders for which individuals seek treatment, DS M-III expanded the number of dis orders defined with specified criteria from the handful in the to more than 200. T his required that the criteria be 1045 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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on expert clinical consensus rather than systemic T he s pecified diagnos tic criteria of DS M-III have advantages over the prototypic descriptions of DS M-II. Diagnos tic reliability is better, and this is of benefit to res earchers attempting to replicate another findings and to clinicians who can communicate more effectively with one another. T he specification of diagnostic criteria als o enables of the boundaries between dis orders and between disorder and no disorder. T hus , the validity of the diagnostic criteria can be evaluated s cientifically. In was as sumed when DS M-III was published that would be made, and it was anticipated that thes e would follow scientific s tudy rather than ideological debate. DS M-III was the first official psychiatric clas sification to introduce a multiaxial evaluation system in which domains of information are described on five different axes . T he purpos e of multiaxial evaluation is to comprehensive, biopsychos ocial approach toward as sess ment. Axis I cons ists of all clinical disorders , for personality dis orders and mental retardation, both which are reported on Axis II. P rominent maladaptive personality traits that do not meet criteria for a s pecific disorder and defense mechanis ms are als o noted on Axis III is for general medical conditions that might be relevant to unders tanding or managing the patient's ps ychiatric disorder. Axis IV is for noting psychosocial environmental problems that are relevant to the treatment, and prognosis of Axis I and Axis II dis orders. Axis V is the global ass es sment of functioning (G AF ) a 100-point rating based on symptom severity, social 1046 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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functioning, and occupational functioning. Another major achievement of DS M-III was the of the definition of schizophrenia and the requirement that, during some point in the illness , overt psychotic features must be pres ent. T he redefinition of brought the American s ys tem closer to the E uropean approach toward diagnosing this disorder. T he descriptions of dis orders included in DS M-III were much more detailed than the des criptions provided in DS M-II. T able 9.1-3 provides the DS M-II des cription of mania as an example of the brief descriptive found in DS M-II. In contrast, the DS M-III text a manic epis ode covered s ix pages and included information on demographic characteris tics, age of familial patterns , cours e of illnes s, and differential diagnosis. (In DS M-IV -T R , this has expanded to five of text on a manic episode, another s ix pages of text to describe mixed and hypomanic episodes, and 14 more pages to des cribe the diagnosis of bipolar disorder.)

Table 9.1-3 DS M-II Des c ription of Manic -Depres s ive Dis order T hese dis orders are marked by s evere mood and a tendency to remis sion and recurrence. P atients may be given this diagnosis in the of a previous his tory of affective ps ychosis if no obvious precipitating event. T his dis order is 1047 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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divided into three major subtypes: manic type, depres sed type, and circular type.    296.1 Manic-depres sive illnes s, manic type depres sive psychosis, manic type): T his dis order cons ists exclus ively of manic epis odes. T hes e episodes are characterized by excess ive elation, irritability, talkativeness , flight of ideas, and accelerated s peech and motor activity. B rief of depress ion sometimes occur, but they are true depres sive episodes.    296.2 Manic-depres sive illnes s, depres sed type (manic-depres sive psychosis, depress ed type): disorder cons is ts exclus ively of depress ive T hese episodes are characterized by severely depres sed mood and by mental and motor retardation progress ing occas ionally to s tupor. Uneasines s, apprehens ion, perplexity, and may als o be pres ent. When illus ions, and delus ions (usually of guilt or of or paranoid ideas) occur, they are attributable to dominant mood disorder. B ecause it is a primary mood dis order, this psychosis differs from the ps ychotic depress ive reaction, which is more attributable to precipitating s tres s. C ases incompletely labeled as ps ychotic depre s s ion be clas sified here rather than under ps ychotic de pres s ive re action.

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   296.3 Manic-depres sive illnes s, circular type (manic-depres sive psychosis, circular type): T his disorder is distinguis hed by at leas t one attack of depres sive epis ode and a manic epis ode. T his phenomenon makes clear why manic and types are combined into a s ingle category.

DS M-III ass umed a descriptive approach to because it was recognized that the etiology of disorders was largely unknown. T o facilitate the us e of diagnostic class ification by clinicians with different theoretical orientations, etiological perspectives were included in DS M-III. T he bas is of the disorder was shared clinical features. DS M-III, for the first time in an official clas sification of mental disorders , included a definition of mental As noted previous ly, the definition has been debated criticized, but it at least provided a bas is for discus sing relevant iss ues .

DS M-IV-TR C L A S S IF IC A TION DS M-IV was published in the midst of the criticism that represented the third version of the DS M publis hed 14 years. T his contrasted with the 16-year interval DS M-I and DS M-II and the 12-year interval between and DS M-III. Mark Zimmerman argued that the of three DS M editions within s uch a short interval could res ult in six problems : (1) an ins ufficient amount of time between DS M editions to allow the accumulation of 1049 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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replicated res earch necess ary to justify a change in diagnostic criteria, thereby impeding progres s in the development of a valid clas sification; (2) the of resources to compare the new diagnostic criteria the old and thus divert effort toward dis covering pathophys iological mechanisms; (3) difficulties in interpreting and res olving discrepant research findings based on different criteria sets; (4) an increased diagnostic errors becaus e of the lack of time to learn nuances of frequently changing diagnos tic criteria; P.1013 (5) impeded communication among clinicians, because three diagnostic manuals will be in widespread use; frus tration from patients who have their diagnoses changed when the diagnostic manual changes . T he leaders of the T as k F orce charged with the DS M-IV acknowledged concerns about the brief between DS M editions and indicated that DS M-IV was be the mos t empirically grounded psychiatric system. T he three components of the empirical underpinning DS M-IV were comprehensive literature reviews , reanalys es of exis ting data bases, and a field trials comparing existing and propos ed criteria Along with the proliferation of DS M vers ions, the 1980s and 1990s witnes sed a proliferation of comment on the overall revis ion proces s, as well as s pecific decisions regarding behavior and cognitive patterns that were or were not included as dis orders in the DS Ms. press ures thus ass umed greater visibility (and pos sibly influence) in revising the class ification. T he ultimate political s tatement on class ification came in the form of 1050 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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referendum that was placed on the 1994 general ballot the AP A. T he referendum asked the AP A members hip vote on whether the tenth revision of the IC D (IC D-10) should be adopted as the official diagnos tic system and the DS M-IV 's publication s hould be pos tponed for 3 T he referendum was defeated; however, the fact that a petition drive was success ful in getting the iss ue on the ballot indicated that the level of dis satis faction with the frequent DS M revisions was not insignificant. DS M-IV -T R lists 365 disorders in 17 s ections (T able plus some diagnos tic criteria propos ed for further s tudy included in the appendix. T his is an increase from the disorders in 17 s ections in DS M-III and the 292 18 sections in DS M-III-R . T he DS M-IV -T R clas sification mental disorders is provided in T able 9.1-5. In the following s ection, the salient features of the disorders each section are briefly des cribed.

Table 9.1-4 G roups of C onditions DS M-IV-TR Dis orders usually firs t diagnos ed in infancy, childhood, or adoles cence Delirium, dementia, amnes tic, and other cognitive disorders Mental disorders due to a general medical 1051 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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S ubstance-related dis orders S chizophrenia and other ps ychotic dis orders Mood dis orders Anxiety disorders S omatoform dis orders F actitious disorders Dis sociative disorders S exual and gender identity disorders E ating dis orders S leep disorders Impulse-control disorders not els ewhere Adjustment disorders P ers onality disorders Other conditions that may be a focus of clinical attention

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Table 9.1-5 DS M-IV-TR C las s ific ation of Mental (With International S tatis tic al C las s ific ation of Dis eas es , Tenth R evis ion, C odes ) Dis orders us ually firs t diagnos ed in infancy, childhood, or adoles c enc e (39)    Mental retardation (41)      Note : T hese are coded on Axis II.      F 70.9 Mild mental retardation (43)      F 71.9 Moderate mental retardation (43)      F 72.9 S evere mental retardation (43)      F 73.9 P rofound mental retardation (44)      F 79.9 Mental retardation, severity uns pecified    Learning dis orders (49)      F 81.0 R eading disorder (51)      F 81.2 Mathematics disorder (53) 1053 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     F 81.8 Dis order of written express ion (54)      F 81.9 Learning dis order NOS (56)    Motor skills dis order (56)      F 82 Developmental coordination dis order (56)    C ommunication dis orders (58)      F 80.1 E xpres sive language dis order (58)      F 80.2 Mixed receptive-expres sive language disorder (62)      F 80.0 P honological disorder (65)      F 98.5 S tuttering (67)      F 80.9 C ommunication disorder NOS (69)    P ervasive developmental dis orders (69)      F 84.0 Autistic dis order (70)      F 84.2 R ett's syndrome (76)      F 84.3 C hildhood disintegrative dis order (77)      F 84.5 As perger's s yndrome (80) 1054 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     F 84.9 P ervas ive developmental dis order NOS    Attention-deficit and disruptive behavior (85)    -.- Attention-deficit/hyperactivity disorder (85)      F 90.0 C ombined type      F 98.8 P redominantly inattentive type      F 90.0 P redominantly hyperactive-impulsive      F 90.9 Attention-deficit/hyperactivity dis order (93)      F 91.8 C onduct Dis order (93)        S pe cify type: childhood-onset type or onset type      F 91.3 Oppositional defiant disorder (100)      F 91.9 Dis ruptive behavior dis order NOS (103)    F eeding and eating dis orders of infancy or early childhood (103)      F 98.3 P ica (103)

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     F 98.2 R umination disorder (105)      F 98.2 F eeding disorder of infancy or early childhood (107)    T ic dis orders (108)      F 95.2 T ourette's s yndrome (111)      F 95.1 C hronic motor or vocal tic dis order      F 95.0 T ransient tic disorder (115)        S pe cify if: single epis ode or recurrent      F 95.9 T ic dis order NOS (116)    E limination dis orders (116)      __._ E ncopresis (116)       R 15 W ith cons tipation and overflow (als o code K 59.0 cons tipation on Axis III)       F 98.1 W ithout cons tipation and overflow incontinence      F 98.0 E nures is (not due to a general medical condition) (118)

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       S pe cify type: nocturnal only, diurnal only, or nocturnal and diurnal    Other disorders of infancy, childhood, or adoles cence (121)      F 93.0 S eparation anxiety dis order (121)        S pe cify if: early ons et      F 94.0 S elective mutis m (125)      F 94.x R eactive attachment disorder of infancy early childhood (127)       .1 Inhibited type       .2 Disinhibited type      F 98.4 S tereotypic movement disorder (131)        S pe cify if: with self-injurious behavior      F 98.9 Dis order of infancy, childhood, or adoles cence NOS (134) Delirium, dementia, and amnes tic and other cognitive dis orders (135)    Delirium (136) 1057 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     F 05.0 Delirium due to… [indicate the gene ral me dical condition] (code F 05.1 if s upe rimpos e d de me ntia) (141)       __._ S ubstance intoxication delirium (re fe r to s ubs tance-re late d dis orde rs for s ubs tance code s ) (143)       __._ S ubstance withdrawal delirium (re fe r to s ubs tance-re late d dis orde rs for s ubs tance code s ) (143)       __._ Delirium due to multiple etiologies (code each of the s pecific e tiologie s ) (146)      F 05.9 Delirium NOS (147)    Dementia (147)      F 00.xx Dementia of the Alzheimer's type, with early ons et (als o code G 30.0 Alzhe ime r's early ons e t, on Axis III) (154)       .00 Uncomplicated       .01 With delus ions       .03 With depres sed mood        S pe cify if: with behavioral dis turbance 1058 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     F 00.xx Dementia of the Alzheimer's type, with onset (als o code G 30.1 Alzhe ime r's dis e as e , with ons e t, on Axis III) (154)       .10 Uncomplicated       .11 With delus ions       .13 With depres sed mood        S pe cify if: with behavioral dis turbance      F 01.xx V as cular dementia (158)       .80 Uncomplicated       .81 With delus ions       .83 With depres sed mood       S pe cify if: with behavioral dis turbance      F 02.4 Dementia due to HIV diseas e (als o B 22.0 HIV dis e as e res ulting in e nce phalopathy III) (163)      F 02.8 Dementia due to head trauma (als o S 06.9 intracranial injury on Axis III) (164)      S pe cify if: s ingle epis ode or recurrent 1059 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     F 02.3 Dementia due to P arkinson's disease code G 20 P arkins on's dis eas e on Axis III) (164)      F 02.2 Dementia due to Huntington's dis eas e code G 10 Huntington's dis e as e on Axis III) (165)      F 02.0 Dementia due to P ick's dis ease (als o G 31.0 P ick's dis e as e on Axis III) (165)      F 02.1 Dementia due to C reutzfeldt-J akob (als o code A81.0 C re utzfe ldt-J akob dis e as e on (166)      F 02.8 Dementia due to… [indicate the gene ral me dical condition not lis ted above ] (als o code the ge neral me dical condition on Axis III) (167)      __._ S ubstance-induced persisting dementia to s ubs tance -re late d dis orde rs for s ubs tancecode s ) (168)      F 02.8 Dementia due to multiple etiologies code F 00.2 for mixed Alzheimer's and vas cular de me ntia) (170)      F 03 Dementia NOS (171)    Amnestic disorders (172)      F 04 Amnestic dis order due to… [indicate the 1060 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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ge neral me dical condition] (175)        S pe cify if: transient or chronic      __._ S ubstance-induced persisting amnestic disorder (re fe r to s ubs tance -re late d dis orders for s ubs tance-s pecific code s ) (177)      R 41.3 Amnestic dis order NOS (179)    Other cognitive disorders (179)      F 06.9 C ognitive disorders NOS (179) Mental dis orders due to a general medical condition not els ewhere clas s ified (181)    F 06.1 C atatonic disorder due to… [indicate the ge neral me dical condition] (185)    F 07.0 P ers onality change due to… [indicate the ge neral me dical condition] (187)  S pe cify type: labile type, disinhibited type, aggres sive type, apathetic type, paranoid type, type, combined type, or unspecified type    F 09 Mental dis order NOS due to… [indicate the ge neral me dical condition] (190)

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S ubs tanc e-related dis orders (191)     a T he following s pecifie rs may be applie d to de pendence:      S pe cify if: with phys iological dependence or without physiological dependence    C ode cours e of depe nde nce in fifth characte r:      0 = E arly full remis sion or early partial      0 = S ustained full remis sion or sustained remis sion      1 = In a controlled environment      2 = On agonis t therapy      4 = Mild, moderate, or s evere    T he following s pe cifie rs apply to s ubs tance dis orders as note d:       IWith onset during intoxication       W With onset during withdrawal    Alcohol-related dis orders (212)

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     Alcohol us e disorders (213)       F 10.2x Alcohol dependence a (213)       F 10.1 Alcohol abus e (214)      Alcohol-induced disorders (214)       F 10.00 Alcohol intoxication (214)       F 10.3 Alcohol withdrawal (215)        S pe cify if: with perceptual dis turbances       F 10.03 Alcohol intoxication delirium (143)       F 10.4 Alcohol withdrawal delirium (143)       F 10.73 Alcohol-induced pers isting dementia       F 10.6 Alcohol-induced pers isting amnes tic disorder (177)       F 10.xx Alcohol-induced psychotic disorder       .51 With delus ions I,W       .52 With hallucinations I,W       F 10.8 Alcohol-induced mood disorderI,W (405) 1063 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      F 10.8 Alcohol-induced anxiety disorderI,W       F 10.8 Alcohol-induced s exual dysfunctionI       F 10.8 Alcohol-induced s leep disorderI,W (655)       F 10.9 Alcohol-related dis order NOS (223)    Amphetamine (or amphetamine-like)–related disorders (223)      Amphetamine use disorders (224)       F 15.2x Amphetamine dependence a (224)       F 15.1 Amphetamine abus e (225)      Amphetamine-induced disorders (226)       F 15.00 Amphetamine intoxication (226)       F 15.04 Amphetamine intoxication, with perceptual disturbances (226)       F 15.3 Amphetamine withdrawal (227)       F 15.03 Amphetamine intoxication delirium       F 15.xx Amphetamine-induced psychotic (338) 1064 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      .51 With delus ions I       .52 With hallucinations I       F 15.8 Amphetamine-induced mood (405)       F 15.8 Amphetamine-induced anxiety disorderI (479)       F 15.8 Amphetamine-induced s exual (562)       F 15.8 Amphetamine-induced s leep (655)       F 15.9 Amphetamine-related dis order NOS    C affeine-related dis orders (231)      C affeine-induced disorders (232)       F 15.00 C affeine intoxication (232)       F 15.8 C affeine-induced anxiety disorderI       F 15.8 C affeine-induced s leep disorderI (655)       F 15.9 C affeine-related dis order NOS (234)

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   C annabis -related dis orders (234)      C annabis us e disorders (236)       F 12.2x C annabis dependence a (236)       F 12.1 C annabis abus e (236)      C annabis -induced disorders (237)       F 12.00 C annabis intoxication (237)       F 12.04 C annabis intoxication, with perceptual disturbances (237)       F 12.03 C annabis intoxication delirium (143)       F 12.xx C annabis-induced psychotic disorder       .51 With delus ions I       .52 With hallucinations I       F 12.8 C annabis -induced anxiety disorderI       F 12.9 C annabis -related dis order NOS (241)    C ocaine-related dis orders (241)      C ocaine us e disorders (242) 1066 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      F 14.2x C ocaine dependence a (242)       F 14.1 C ocaine abus e (243)      C ocaine-induced disorders (244)       F 14.00 C ocaine intoxication (244)       F 14.04 C ocaine intoxication, with perceptual disturbances (244)       F 14.3 C ocaine withdrawal (245)       F 14.03 C ocaine intoxication delirium (143)       F 14.xx C ocaine-induced psychotic disorder       .51 With delus ions I       .52 With hallucinations I       F 14.8 C ocaine-induced mood disorderI,W       F 14.8 C ocaine-induced anxiety disorderI,W       F 14.8 C ocaine-induced s exual dysfunctionI       F 14.8 C ocaine-induced s leep disorderI,W       F 14.9 C ocaine-related dis order NOS (250) 1067 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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   Hallucinogen-related dis orders (250)      Hallucinogen use disorders (251)       F 16.2x Hallucinogen dependence a (251)       F 16.1 Hallucinogen abuse (252)      Hallucinogen-induced disorders (252)       F 16.00 Hallucinogen intoxication (252)       F 16.70 Hallucinogen pers is ting perception disorder (flas hbacks ) (253)       F 16.03 Hallucinogen intoxication delirium       F 16.xx Hallucinogen-induced psychotic (338)       .51 With delus ions I       .52 With hallucinations I       F 16.8 Hallucinogen-induced mood disorderI       F 19.8 P hencyclidine-induced anxiety disorderI (479)       F 16.9 Hallucinogen-related dis order NOS 1068 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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   Inhalant-related dis orders (257)       F 18.2x Inhalant dependence a (258)       F 18.1 Inhalant abus e (259)      Inhalant-induced disorders (259)       F 18.00 Inhalant intoxication (259)       F 18.03 Inhalant intoxication delirium (143)       F 18.73 Inhalant-induced pers isting dementia (168)       F 18.xx Inhalant-induced psychotic disorder       .51 With delus ions I       .52 With hallucinations I       F 18.8 Inhalant-induced mood disorderI (405)       F 18.8 Inhalant-induced anxiety disorderI (479)       F 18.9 Inhalant-related dis order NOS (263)    Nicotine-related dis orders (264)      Nicotine us e disorder (264) 1069 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      F 17.2x Nicotine dependence a (264)      Nicotine-induced disorders (265)       F 17.3 Nicotine withdrawal (265)       F 17.9 Nicotine-related dis orders NOS (269)    Opioid-related dis orders (269)      Opioid us e dis orders (270)       F 11.2x Opioid dependence a (270)       F 11.1 Opioid abus e (271)      Opioid-induced disorders (271)       F 11.00 Opioid intoxication (271)       F 11.04 Opioid intoxication, with perceptual disturbances (272)       F 11.3 Opioid withdrawal (272)       F 11.03 Opioid intoxication delirium (143)       F 11.xx Opioid-induced psychotic disorder       .51 With delus ions I 1070 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      .52 With hallucinations I       F 11.8 Opioid-induced mood disorderI (405)       F 11.8 Opioid-induced s exual dysfunctionI       F 11.8 Opioid-induced s leep disorderI,W (655)       F 11.9 Opioid-related dis order NOS (277)    P hencyclidine (or phencyclidine-like)–related disorders (278)      P hencyclidine us e disorders (279)       F 19.2x P hencyclidine dependence a (279)       F 19.1 P hencyclidine abus e (279)      P hencyclidine-induced disorders (280)       F 19.00 P hencyclidine intoxication (280)       F 19.04 P hencyclidine intoxication, with perceptual disturbances (280)       F 19.03 P hencyclidine intoxication delirium       F 19.xx P hencyclidine-induced psychotic (338) 1071 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      .51 With delus ions I       .52 With hallucinations I       F 19.8 P hencyclidine-induced mood disorderI (405)       F 19.9 P hencyclidine-related dis order NOS    S edative-, hypnotic-, or anxiolytic-related (284)      S edative, hypnotic, or anxiolytic us e disorders (285)       F 13.2x S edative, hypnotic, or anxiolytic dependence a (285)       F 16.8 Hallucinogen-induced anxiety disorderI (479)       F 13.1 S edative, hypnotic, or anxiolytic abus e      S edative-, hypnotic-, or anxiolytic-induced disorders (286)       F 13.00 S edative, hypnotic, or anxiolytic intoxication (286)      Inhalant us e disorders (258) 1072 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      F 13.3 S edative, hypnotic, or anxiolytic (287)        S pe cify if: with perceptual dis turbances       F 13.03 S edative, hypnotic, or anxiolytic intoxication delirium (143)       F 13.4 S edative, hypnotic, or anxiolytic delirium (143)       F 13.73 S edative-, hypnotic-, or anxiolyticpersis ting dementia (168)       F 13.6 S edative-, hypnotic-, or anxiolyticpersis ting amnestic disorder (177)       F 13.xx S edative-, hypnotic-, or anxiolyticps ychotic dis order (338)       .51 With delus ions I,W       .52 With hallucinations I,W       F 13.8 S edative-, hypnotic-, or anxiolyticmood dis orderI,W (405)       F 13.8 S edative-, hypnotic-, or anxiolyticanxiety dis orderW (479)

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      F 13.8 S edative-, hypnotic-, or anxiolyticsexual dys functionI (562)       F 13.8 S edative-, hypnotic-, or anxiolyticsleep dis orderI,W (655)       F 13.9 S edative-, hypnotic-, or anxiolyticdisorder NOS (293)    P olysubstance-related dis order (293)      F 19.2x P olysubstance dependence a (293)    Other (or unknown) s ubs tance-related (294)      Other (or unknown) s ubs tance use dis orders       F 19.2x Other (or unknown) s ubs tance dependence a (192)       S pe cify if: with pos tpartum ons et      Other (or unknown) s ubs tance-induced (295)       F 19.00 Other (or unknown) s ubs tance intoxication (199)       F 19.04 Other (or unknown) s ubs tance 1074 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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intoxication, with perceptual dis turbances (199)       F 19.3 Other (or unknown) s ubs tance (201)  S pe cify if: with perceptual disturbances       F 19.03 Other (or unknown) s ubs tancedelirium (code F 19.4 if ons e t during withdrawal)       F 19.73 Other (or unknown) s ubs tancepersis ting dementia (168)       F 19.6 Other (or unknown) s ubs tance-induced persis ting amnestic disorder (177)       F 19.xx Other (or unknown) s ubs tanceps ychotic dis order (338)       .51 With delus ions I,W       .52 With hallucinations I,W       F 19.8 Other (or unknown) s ubs tance-induced mood dis orderI,W (405)       F 19.8 Other (or unknown) s ubs tance-induced anxiety dis orderI,W (479)       F 19.8 Other (or unknown) s ubs tance-induced 1075 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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sexual dys functionI (562)       F 19.8 Other (or unknown) s ubs tance-induced sleep dis orderI,W (655)       F 19.9 Other (or unknown) s ubs tance-related disorder NOS (295) S chizophrenia and other ps ychotic dis orders (297)    F 20.xx S chizophrenia (298)      .0x P aranoid type (313)      .1x Dis organized type (314)      .2x C atatonic type (315)      .3x Undifferentiated type (316)      .5x R es idual type (316)    C ode cours e of s chizophre nia in fifth characte r:      2 = E pis odic with interepis ode res idual (s pecify if: with prominent negative symptoms)      3 = E pis odic with no interepis ode res idual symptoms 1076 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     0 = C ontinuous (s pecify if: with prominent negative symptoms )      4 = S ingle epis ode in partial remis sion (s pecify with prominent negative s ymptoms)      5 = S ingle epis ode in full remiss ion      8 = Other or unspecified pattern      9 = Les s than 1 year s ince onset of initial phase symptoms    F 20.8 S chizophreniform dis order (317)  S pe cify if: without good prognos tic features/with good prognostic features    F 25.x S chizoaffective dis order (319)      .0 B ipolar type      .1 Depres sive type    F 22.0 Delusional dis order (323)  S pe cify type: erotomanic type, grandios e type, jealous type, persecutory type, somatic type, type, or unspecified type

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   F 23.xx B rief psychotic disorder (329)      .81 W ith marked s tres sor(s )      .80 W ithout marked s tres sor(s )       S pe cify if: with pos tpartum ons et    F 24 S hared ps ychotic disorder (332)    F 06.x P s ychotic disorder due to… [indicate the ge neral me dical condition] (334)      .2 W ith delusions      .0 W ith hallucinations    __._ S ubs tance-induced psychotic disorder s ubs tance-re late d dis orde rs for s ubs tance code s ) (338)  S pe cify if: with ons et during intoxication/with during withdrawal    F 29 P s ychotic dis order NOS (343) Mood dis orders (345)    T he following s pe cifie rs apply (for curre nt or re cent epis ode ) to mood dis orde rs as noted: 1078 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      a S everity, ps ychotic, and remis sion s pecifiers       bC hronic       c With catatonic features       dWith melancholic features       e With atypical features       fWith postpartum onset    T he following s pe cifie rs apply to mood noted:       gWith or without full interepisode recovery       hWith s eas onal pattern       iWith rapid cycling    Depres sive dis orders (369)      F 32.x Major depres sive disorder, single episode a,b,c,d,e,f (369)      F 33.x Major depres sive disorder, recurrenta,b,c,d,e,f,g,h (369)      C ode curre nt s tate of major de pre s s ive 1079 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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fourth characte r:       0 = Mild       1 = Moderate       2 = S evere with ps ychotic features       3 = S evere with ps ychotic features       S pe cify: mood-congruent psychotic features mood-incongruent ps ychotic features       4 = In partial remis sion       5 = In full remis sion       9 = Uns pecified      F 34.1 Dysthymic disorder (376)        S pe cify if: early ons et or late onset        S pe cify: with atypical features       2 = S evere without psychotic features      F 32.9 Depress ive disorder NOS (381)    B ipolar disorders (382) 1080 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     F 30.x B ipolar I disorder, single manic (382)  S pe cify if: mixed       C ode curre nt s tate of manic e pis ode in fourth characte r:       1 = Mild, moderate, or s evere without features       2 = S evere with ps ychotic features       8 = In partial or full remis sion      F 31.0 B ipolar I disorder, mos t recent episode hypomanic g,h,i (382)      F 31.x B ipolar I disorder, mos t recent episode manic a,c,f,g,h,i (382)      C ode curre nt s tate of manic epis ode in fourth characte r:       1 = Mild, moderate, or s evere without features       2 = S evere with ps ychotic features       7 = In partial or full remiss ion 1081 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     F 31.6 B ipolar I disorder, mos t recent episode mixeda,c,f,g,h,i (382)      F 31.x B ipolar I disorder, mos t recent episode depres seda,b,c,d,e,f,g,h,i (382)      C ode curre nt s tate of major de pre s s ive fourth characte r:       3 = Mild or moderate       4 = S evere without psychotic features       5 = S evere with ps ychotic features       7 = In partial or full remiss ion      F 31.9 B ipolar I disorder, mos t recent episode unspecifiedg,h,i (382)      F 31.8 B ipolar II disordera,b,c,d,e,f,g,h,i (392)       S pe cify (curre nt or mos t re cent epis ode): or depress ed      F 34.0 C yclothymic disorder (398)      F 31.9 B ipolar disorder NOS (400)      F 06.xx Mood dis order due to… [indicate the 1082 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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ge neral me dical condition] (401)       .32 With depres sive features       .32 With major depres sive–like episode       .30 With manic features       .33 With mixed features      __._ S ubstance-induced mood dis order (re fe r s ubs tance-re late d dis orde rs for s ubs tance code s ) (405)  S pe cify type: with depress ive features , with features, or with mixed features  S pe cify if: with ons et during intoxication or with onset during withdrawal      F 39 Mood disorder NOS (410) Anxiety dis orders (429)    F 41.0 P anic dis order without agoraphobia (433)    F 40.01 P anic dis order with agoraphobia (433)    F 40.00 Agoraphobia without his tory of panic disorder (441) 1083 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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   F 40.2 S pecific phobia (443)  S pe cify type: animal type, natural environment blood-injection-injury type, situational type, or type    F 40.1 S ocial phobia (450)  S pe cify if: generalized    F 42.8 Obsess ive-compuls ive disorder (456)  S pe cify if: with poor ins ight    F 43.1 P os ttraumatic stress dis order (463)  S pe cify if: acute or chronic  S pe cify if: with delayed onset    F 43.0 Acute s tres s dis order (469)    F 41.1 G eneralized anxiety disorder (472)    F 06.4 Anxiety disorder due to… [indicate the ge neral me dical condition] (476)  S pe cify if: with generalized anxiety, with panic attacks, or with obses sive-compuls ive s ymptoms

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   __._ S ubs tance-induced anxiety disorder (re fe r s ubs tance-re late d dis orde rs for s ubs tance code s ) (479)  S pe cify if: with generalized anxiety, with panic attacks, with obs ess ive-compuls ive s ymptoms, or with phobic s ymptoms  S pe cify if: with ons et during intoxication or with onset during withdrawal    F 41.9 Anxiety disorder NOS (484) S omatoform dis orders (485)    F 45.0 S omatization dis order (486)    F 45.1 Undifferentiated somatoform disorder    F 44.x C onvers ion disorder (492)      .4 W ith motor s ymptom or deficit      .5 W ith seizures or convuls ions      .6 W ith sensory s ymptom or deficit      .7 W ith mixed presentation      F 45.4 P ain disorder (498) 1085 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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 S pe cify type: as sociated with ps ychological or ass ociated with ps ychological factors and a general medical condition  S pe cify if: acute or chronic    F 45.2 Hypochondrias is (504)  S pe cify if: with poor ins ight    F 45.2 B ody dysmorphic dis order (507)    F 45.9 S omatoform dis order NOS (511) Fac titious dis orders (513)    F 68.1 F actitious disorder (513)  S pe cify type: with predominantly ps ychological signs and s ymptoms, with predominantly physical signs and s ymptoms, or with combined ps ychological and phys ical s igns and s ymptoms    F 68.1 F actitious disorder NOS (517) Dis s ociative dis orders (519)    F 44.0 Dis sociative amnes ia (520)    F 44.1 Dis sociative fugue (523) 1086 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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   F 44.81 Dis sociative identity disorder (526)    F 48.1 Depersonalization dis order (530)    F 44.9 Dis sociative disorder NOS (532) S exual and gender identity dis orders (535)    S exual dys functions (535)      T he following s pecifie rs apply to all primary dys functions :       Lifelong type, acquired type, generalized situational type, due to ps ychological factors , or to combined factors      S exual des ire dis orders (539)       F 52.0 Hypoactive s exual des ire dis order       F 52.10 S exual avers ion dis order (541)      S exual arousal disorders (543)       F 52.2 F emale s exual arous al dis order (543)       F 52.2 Male erectile dis order (545)      Orgas mic disorders (547) 1087 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      F 52.3 F emale orgas mic disorder (547)       F 52.3 Male orgas mic disorder (550)       F 52.4 P remature ejaculation (552)      S exual pain disorders (554)       F 52.6 Dyspareunia (not due to a general condition) (554)       F 52.5 V aginismus (not due to a general condition) (556)      S exual dys function due to a general medical condition (558)       N94.8 F emale hypoactive sexual desire due to… [indicate the gene ral me dical condition] (558)       N50.8 Male hypoactive sexual desire disorder to… [indicate the gene ral me dical condition] (558)       N48.4 Male erectile dis order due to… ge neral me dical condition] (558)       N94.1 F emale dyspareunia due to… [indicate ge neral me dical condition] (558)

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      N50.8 Male dyspareunia due to… [indicate ge neral me dical condition] (558)       N94.8 Other female s exual dys function due [indicate the gene ral me dical condition] (558)       N50.8 Other male s exual dys function due [indicate the gene ral me dical condition] (558)       __._ S ubstance-induced s exual dysfunction to s ubs tance -re late d dis orders for s ubs tance code s ) (562)  S pe cify if: with impaired des ire, with impaired arousal, with impaired orgasm, or with s exual  S pe cify if: with onset during intoxication       F 52.9 S exual dysfunction NOS (565)    P araphilias (566)      F 65.2 E xhibitionis m (569)      F 65.0 F etis his m (569)      F 65.8 F rotteurism (570)      F 65.4 P edophilia (571)

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 S pe cify if: sexually attracted to males, s exually attracted to females, or s exually attracted to both    S pe cify if: limited to incest  S pe cify type: exclusive type or nonexclusive type      F 65.5 S exual masochism (572)      F 65.5 S exual s adis m (573)      F 65.1 T ransves tic fetis his m (574)  S pe cify if: with gender dys phoria      F 65.3 V oyeurism (575)      F 65.9 P araphilia NOS (576)    G ender identity disorders (576)      F 64.x G ender identity disorder (576)       .2 In children       .0 In adolescents or adults  S pe cify if: sexually attracted to males, s exually attracted to females, sexually attracted to both, or sexually attracted to neither 1090 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     F 64.9 G ender identity disorder NOS (582)      F 52.9 S exual disorder NOS (582) E ating dis orders (583)    F 50.0 Anorexia nervos a (583)  S pe cify type: res tricting type or binge-eating and purging type    F 50.2 B ulimia nervosa (589)  S pe cify type: purging type or nonpurging type    F 50.9 E ating disorder NOS (594) S leep dis orders (597)    P rimary s leep disorders (598)      Dys somnias (598)       F 51.0 P rimary insomnia (599)       F 51.1 P rimary hypersomnia (604)        S pe cify if: recurrent       G 47.4 Narcolepsy (609) 1091 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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      G 47.3 B reathing-related sleep dis order (615)       F 51.2 C ircadian rhythm s leep disorder (622)        S pe cify type: delayed s leep phase type, jet type, shift work type, or unspecified type       F 51.9 Dyss omnia NOS (629)      P aras omnias (630)       F 51.5 Nightmare disorder (631)       F 51.4 S leep terror disorder (634)       F 51.3 S leepwalking dis order (639)       F 51.8 P arasomnia NOS (644)    S leep dis orders related to another mental (645)      F 51.0 Insomnia related to… [indicate the Axis Axis II dis orde r] (645)      F 51.1 Hypers omnia related to… [indicate the or Axis II dis orde r] (645)    Other s leep disorders (651)

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     G 47.x S leep disorder due to… [indicate the me dical condition] (651)       .0 Ins omnia type       .1 Hypersomnia type       .8 P aras omnia type       .8 Mixed type      __._ S ubstance-induced s leep disorder (re fe r s ubs tance-re late d dis orde rs for s ubs tance code s ) (655)  S pe cify type: ins omnia type, hypersomnia type, parasomnia type/mixed type  S pe cify if: with ons et during intoxication or with onset during withdrawal Impuls e-control dis orders not els ewhere clas s ified (663)    F 63.8 Intermittent explosive disorder (663)    F 63.2 K leptomania (667)    F 63.1 P yromania (669)

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   F 63.0  P athological gambling (671)    F 63.3  T richotillomania (674)    F 63.9  Impulse-control disorder NOS (677) Adjus tment dis orders (679)    F 43.xx Adjus tment dis order (679)      .20 W ith depres sed mood      .28 W ith anxiety      .22 W ith mixed anxiety and depres sed mood      .24 W ith disturbance of conduct      .25 W ith mixed disturbance of emotions and conduct      .9 Unspecified  S pe cify if: acute or chronic Pers onality dis orders (685)    Note : T he s e are code d on Axis II.    F 60.0 P aranoid pers onality disorder (690) 1094 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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   F 60.1 S chizoid pers onality disorder (694)    F 21 S chizotypal personality disorder (697)    F 60.2 Antisocial personality disorder (701)    F 60.31 B orderline pers onality disorder (706)    F 60.4 His trionic pers onality disorder (711)    F 60.8 Narciss is tic pers onality disorder (714)    F 60.6 Avoidant personality dis order (718)    F 60.7 Dependent personality disorder (721)    F 60.5 Obsess ive-compuls ive personality (725)    F 60.9 P ers onality disorder NOS (729) Other c onditions that may be a foc us of attention (731)    P s ychological factors affecting medical (731)      F 54… [S pe cified ps ychological factor] [indicate the gene ral me dical condition]

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 C hoos e name bas e d on nature of factors : (731)  Mental disorder affecting medical condition  P s ychological symptoms affecting medical condition  P ers onality traits or coping style affecting condition  Maladaptive health behaviors affecting medical condition  S tress -related physiological respons e affecting medical condition  Other or unspecified ps ychological factors medical condition    Medication-induced movement disorders (734)      G 21.0 Neuroleptic-induced parkins onism      G 21.0 Neuroleptic malignant s yndrome (735)      G 24.0 Neuroleptic-induced acute dystonia      G 21.1 Neuroleptic-induced acute akathisia      G 24.0 Neuroleptic-induced tardive dys kines ia 1096 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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(736)      G 25.1 Medication-induced pos tural tremor      G 25.9 Medication-induced movement dis order NOS (736)    Other medication-induced dis order (736)      T 88.7 Advers e effects of medication NOS    R elational problems (736)      Z63.7 R elational problem related to a mental disorder or general medical condition (737)      Z63.8 P arent–child relational problem (code if focus of attention is on child) (737)      Z63.0 P artner relational problem (737)      F 93.3 S ibling relational problem (737)      Z63.9 R elational problem NOS (737)    P roblems related to abus e or neglect (738)      T 74.1 P hysical abuse of child (738)      T 74.2 S exual abuse of child (738) 1097 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     T 74.0 Neglect of child (738)      T 74.1 P hysical abuse of adult (738)      T 74.2 S exual abuse of adult (738)    Additional conditions that may be a focus of clinical attention (739)      Z91.1 Noncompliance with treatment (739)      Z76.5 Malingering (739)      Z72.8 Adult antis ocial behavior (740)      Z72.8 C hild or adolescent antisocial behavior      R 41.8 B orderline intellectual functioning (740)      R 41.8 Age-related cognitive decline (740)      Z63.4 B ereavement (740)      Z55.8 Academic problem (741)      Z56.7 Occupational problem (741)      F 93.8 Identity problem (741)      Z71.8 R eligious or s piritual problem (741) 1098 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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     Z60.3 Acculturation problem (741)      Z60.0 P hase of life problem (742) Additional c odes (743)    F 99 Unspecified mental dis order (nonps ychotic) (743)    Z03.2 No diagnosis or condition on Axis I (743)    R 69 Diagnos is or condition deferred on Axis I    Z03.2 No diagnosis on Axis II (743)    R 46.8 Diagnosis deferred on Axis II (743)

     Note: An x appearing in a diagnostic code indicates that a specific code number is required. ellipsis (…) is us ed in the names of certain to indicate that the name of a specific mental disorder or general medical condition should be inserted when recording the name (e.g., F 05.0 Delirium Due to Hypothyroidis m). Numbers in parentheses are page numbers. If criteria are currently met, one of the following s everity may be noted after the diagnos is : mild, mode rate, s e ve re . If criteria are no longer met, one of the following s pecifiers may be noted: in partial 1099 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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re mis s ion, in full re mis s ion, or prior his tory. *HIV , human immunodeficiency virus ; NOS , not otherwis e s pecified. F rom American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. T ext rev. W as hington, American P s ychiatric Ass ociation; 2000, with permis sion.

I: Dis orders Us ually Firs t Diagnos ed Infanc y, C hildhood, or Adoles c enc e T he section of disorders us ually first diagnosed in childhood, or adoles cence is unique in DS M-IV -T R , the disorders grouped here are included bas ed on the that they are usually firs t diagnos ed rather than s hared phenomenological features. DS M-IV -T R notes that this separation is for convenience only, and it does not a clear distinction between thes e disorders and the in the manual.

Mental R etardation Mental retardation is characterized by significant, average intelligence (as demonstrated by a s core on a s tandardized, individually administered, tes t) and impairment in adaptive functioning in at least two areas . Adaptive functioning refers to how effective individuals are in achieving age-appropriate common demands of life in areas such as communication, s elfand interpersonal skills. Mental retardation is one of four disorders in DS M-IV -T R in which different 1100 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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code numbers are provided for different levels of (mild, moderate, s evere, and profound).

L earning Dis orders T he three s pecific learning dis orders (reading, mathematics , and written express ion) are diagnos ed performance on standardized achievement tests are subs tantially below expectations bas ed on age, and intelligence, and these learning problems caus e significant impairment in functioning. Learning can be comorbid with mild mental retardation if the achievement is below that expected based on level. T he context of learning difficulties is cons idered insofar as learning disorders are not diagnosed if low of achievement is due to inadequate education.

Motor S kills Dis order DS M-IV -T R lists a single motor s kills disorder— developmental coordination dis order. Analogous to learning disorders , developmental coordination diagnosed when motor coordination is substantially expectations based on age and intelligence, and when coordination problem s ignificantly interferes with functioning. E xamples include delays in achieving developmental milestones s uch as crawling or walking, dropping things, and poor s ports performance. T he diagnosis is excluded if a s pecific general medical condition, s uch as cerebral palsy or mus cular accounts for the s ymptoms.

C ommunic ation Dis orders T he four specific communication dis orders (express ive 1101 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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language disorder, mixed receptive-expres sive disorder, phonological disorder, and s tuttering) are characterized by speech or language difficulties . T he diagnosis of expres sive and mixed receptivelanguage dis orders depends on s tandardized tes ting (s imilar to mental retardation and learning disorders ), whereas the two articulation dis orders do not. T he communication disorders , s imilar to the learning and motor s kills disorders , are only diagnosed when they significant impairment in functioning. T he presence of subjective dis tres s in the absence of demons trable functional impairment would not warrant the diagnosis.

P ervas ive Developmental Dis orders T he four specific pervas ive developmental dis orders (autis tic disorder, R ett's s yndrome, childhood disintegrative disorder, and Asperger's s yndrome) are characterized by severe difficulties in multiple developmental areas , including social relatedness , communication, and range of activity and interests . T he diagnostic criteria for the s ocial interaction deficits and repetitive and stereotypical patterns of behavior and interes ts are identical for autistic dis order and syndrome. T hey differ in that concurrent deficits are required to diagnose autistic dis order and absent in Asperger's syndrome. Als o, to diagnose Asperger's s yndrome, a criterion is added that the symptoms mus t caus e clinically s ignificant impairment functioning; this criterion is not s pecified for autis tic disorder. P.1014 1102 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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P.1015 P.1016 P.1017 P.1018 P.1019 P.1020

A ttention-Defic it/Hyperac tivity (A DHD) S ince the 1990s, ADHD has been one of the most discuss ed ps ychiatric disorders in the lay media the sometimes unclear line between age-appropriate normal and disordered behavior and because of the concern that nondisordered children are being and treated with medication. In fact, a lawsuit was filed agains t the AP A, charging it with being influenced by pharmaceutical industry to include the disorder in the T he central feature of the disorder is persistent or hyperactivity and impulsivity, or both, that cause clinically significant impairment in functioning in two or more s ettings . T he s ymptom criteria are polythetic— cons isting of two lis ts of nine criteria (one representing inattentive features and one repres enting the and impulsivity features) of which at least six criteria either lis t are neces sary for the diagnosis. Different 1103 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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diagnostic code numbers are provided for different subtypes (combined type, predominantly inattentive and predominantly hyperactive-impulsive type).

C onduc t Dis order C onduct dis order, the childhood precursor of antis ocial personality disorder, is characterized by a behavior in which age-appropriate s ocietal norms and rules are violated. T he broad categories of the 15 diagnos tic are aggress ion toward people and animals , destruction property, deceitfulnes s or theft, and s erious violation of rules. C onduct dis order is the only dis order in DS M-IV which s pecific guidelines are provided for rating the disorder's s everity, but the s everity distinction is not captured by different diagnos tic code numbers . T he IV -T R text indicates that the context in which the of conduct disorder are expres sed s hould be when determining if the dis order is present. T hus, a growing up in an impoverished, violent neighborhood who joins a gang and manifes ts features of conduct disorder for self-protection should not receive the diagnosis. On the other hand, the criteria thems elves not indicate that context should be cons idered.

Oppos itional Defiant Dis order Oppositional defiant disorder is characterized by an ongoing pattern of negativistic, defiant, disobedient, hostile behavior toward authority figures . B ecaus e the features of oppositional defiant dis order occur in nondis ordered children (e.g., deliberate annoyance of others and refusal to comply with adults' reques ts), IV -T R includes a note in the diagnostic criteria 1104 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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P.1021 that a criterion is met only when the behavior occurs frequently than that of other children of the same age developmental level. T he features of oppos itional disorder are us ually present in individuals with conduct disorder; thus , the diagnosis of oppos itional defiant disorder is not also made when conduct dis order criteria are met.

P ic a P ica refers to persistent eating of nonnutritive such as dirt, paint, plas ter, sand, and pebbles , that is inappropriate to developmental level and cultural P ica can be diagnosed when it is secondary to another mental disorder (e.g., delusional beliefs of a chronic ps ychotic dis order), as long as the eating behavior is enough to be an independent focus of clinical attention.

R umination Dis order T he core feature of rumination dis order is the repeated regurgitation and rechewing of food after a period of normal food cons umption. T he diagnosis is excluded if specific general medical condition, such as pyloric or esophageal reflux, accounts for the s ymptoms .

F eeding Dis order of Infanc y or E arly C hildhood F eeding disorder of infancy or early childhood, referred to as failure to thrive , is characterized by weight or a failure to make expected weight gain in an infant or young child due to inadequate food intake. T he 1105 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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excluded if a s pecific general medical condition for the symptoms .

Tic Dis orders T he three s pecific tic dis orders (T ourette's s yndrome, chronic motor or vocal tic disorder, and trans ient tic disorder) are characterized by “sudden, rapid, nonrhythmic, stereotyped motor movements or vocalization.” T he three disorders are dis tinguis hed in terms of chronicity (T ourette's s yndrome and chronic tic disorder are of at leas t 12 months in duration; trans ient disorder is of at leas t 1 month in duration but less than months in duration) and range of tics (T ourette's has motor and vocal tics , chronic tic dis order has motor vocal tics , and transient tic disorder has motor or vocal or both). F or all three dis orders, a diagnosis is only the symptoms caus e marked dis tres s or significant impairment in functioning.

E limination Dis orders T he two s pecific elimination disorders (encopresis and enures is ) are characterized by repeated inappropriate pass ing of feces or urine, whether voluntary or T o diagnos e encopres is , the child must be at least 4 of age, and the inappropriate pass age of feces mus t at least once a month for 3 months or more. F or the child must be at least 5 years of age before a can be made, and the inappropriate voiding of urine occur at leas t twice a week for 3 months or more. are provided for each (encopres is—with or without cons tipation and overflow incontinence; enures is — nocturnal only, diurnal only, and nocturnal and diurnal), 1106 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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although s eparate diagnos tic codes for the s ubtypes only provided for encopres is.

S eparation A nxiety Dis order S eparation anxiety disorder is characterized by anxiety about separation from home or attachment beyond that expected for the child's developmental DS M-IV -T R notes that clinical judgment mus t be us ed distinguish developmentally appropriate levels of separation anxiety from the excess ive and impairing or distress ing levels indicative of the disorder.

S elec tive Mutis m S elective mutis m is characterized by persistent refus al speak in s pecific s ituations in which speaking is despite the demonstration of s peaking ability in other situations. C ontext is cons idered ins ofar as the not made if the failure to speak is attributed to lack of knowledge of the spoken language (e.g., second of an immigrant).

R eac tive A ttac hment Dis order of or E arly C hildhood R eactive attachment dis order of infancy or early is characterized by one of two patterns of inappropriate s ocial relatednes s —excess ively inhibited disinhibited attachments—due to gros sly pathological caregiving.

S tereotypic Movement Dis order T he core feature of s tereotypic movement disorder is “repetitive, s eemingly driven, nonfunctional motor 1107 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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behavior,” such as body rocking, hand waving, head banging, s elf-biting, and other s elf-mutilating behaviors . T he presence of mental retardation does not exclude diagnosis if the stereotypic behavior is sufficiently to be a focus of clinical attention.

II: Delirium, Dementia, and Amnes tic and Other C ognitive Dis orders In a break from DS M-III-R , the disorders in this s ection previous ly were included in a section entitled “Organic Mental S yndromes and Dis orders.” T he term organic me ntal dis order is not us ed in DS M-IV -T R , becaus e it incorrectly implies that other dis orders in other s ections the manual do not have an organic basis. T he former III-R organic disorders section included the disorders in section, the next section (Mental Dis orders Due to a G eneral Medical C ondition Not E ls ewhere C las sified), the S ubs tance-R elated Disorders section.

Delirium Delirium is characterized by a relatively rapid onset of problems in attention ass ociated with memory impairment, dis orientation, language impairment, hallucinations , or illusions . DS M-IV -T R presents discuss ions and criteria for delirium that is due to a medical condition, s ubs tance intoxication, or s ubs tance withdrawal, although the core features of impaired attention and cognitive deficits are the s ame across disorders . Delirium s uperimposed on a preexisting vascular dementia is clas sified as dementia with

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Dementia is characterized by memory impairment and or more other cognitive impairments (aphas ia, apraxia, agnos ia, and executive functioning dys function). DS MT R distinguis hes between five types (Alzheimer's vascular, due to other general medical condition, subs tance-induced, and due to multiple etiologies). Alzheimer's dementia and dementia due to a general medical condition are s ubtyped according to the or abs ence of clinically significant behavioral (which is reflected in the fifth digit of the diagnostic Alzheimer's disease is also subtyped according to the patients' age of ons et (which is not reflected in the diagnostic code). V as cular dementia is s ubtyped to the predominant clinical characteristic (with delirium, delus ions, depress ion, or none of the prior features) this is reflected in the fifth digit coding.

A mnes tic Dis order Amnes tic dis order is characterized by clinically memory impairment, similar to dementia, but without other cognitive impairments that define dementia. T wo specific amnes tic disorders are defined—amnes tic disorder due to a general medical condition (which is subtyped as trans ient or chronic) and substancepersis ting amnestic disorder. P.1022

III: Mental Dis orders Due to a Medic al C ondition Not E ls ewhere C las s ified T his s ection of mental dis orders due to a general 1109 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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condition not elsewhere clas sified includes nine due to a general medical condition (delirium, dementia, amnes tic disorder, psychotic disorder, mood disorder, anxiety dis order, sexual dys function, s leep disorder, catatonic disorder, and pers onality change). T extual descriptions and diagnostic criteria are provided in this section only for catatonic dis order and personality T he other s even disorders are des cribed and defined in phenomenologically relevant section to facilitate differential diagnosis, although these dis orders are also listed in this s ection. F or example, the diagnos tic for mood disorder due to a general medical condition included in the mood disorders s ection to ensure that clinician cons iders this potential cause of the symptoms.

IV: S ubs tanc e-R elated Dis orders T he term s ubs tance in DS M-IV -T R includes what are commonly thought of as substances of abus e (alcohol, street drugs ), as well as medications and toxins. types of dis orders are described (dependence, abus e, intoxication with or without delirium, withdrawal with or without delirium, dementia, amnes tic disorder, mood dis order, anxiety, sexual dys function, and s leep disorder). T he s ection is organized according to the 11 specific clas ses of substances that may caus e these disorders (alcohol, amphetamines, caffeine, cannabis, cocaine, hallucinogen, inhalant, nicotine, opioid, phencyclidine [P C P ], and s edative-hypnotics). In a group of other s ubs tances is included for s ubs tances such as anabolic s teroids , nitrite inhalants , nitrous and over-the-counter and prescription drugs that are 1110 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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covered by the 11 specific clas ses. T here is also a category for polysubstance which is diagnosed when dependence criteria are met during a 1-year period during which three or more of substances are us ed without a clear predominance any one s ubs tance, and the dependence criteria are for the substances as a group but not for any specific subs tance. T he subs tance-related dis orders section begins with provis ion of general criteria for diagnos ing abuse, intoxication, and withdrawal, which can be to many of the substances, although s ubs tance is manifest in the intoxication or withdrawal syndromes . T he s ubs tance-induced dis orders (ps ychosis , mood disorder, anxiety, s exual dysfunction, and s leep are lis ted with their corres ponding diagnostic code numbers in this section but are des cribed in detail in DS M-IV -T R s ections with which they share clinically features. T he initial s ection des cribing the general diagnostic for s ubs tance dependence, abuse, intoxication, and withdrawal is followed by a discus sion of the dis orders as sociated with each of the s pecific substances. T he section is organized by s ubs tance. T hus , all of the as sociated with alcohol use are grouped together, followed by the dis orders ass ociated with amphetamine us e, then caffeine, etc. T he dis order-specific abuse and dependence refer back to the general and dependence diagnos tic criteria. In contrast, specific criteria for withdrawal and intoxication are presented separately for each substance. 1111 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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S ubs tanc e Dependenc e Dis orders E ach of the specific substances, except caffeine, can manifest a dependence s yndrome. T he s even criteria subs tance dependence (three of which are needed to make the diagnos is ) cover three major constructs : withdrawal, tolerance, and loss of control over use. tolerance nor withdrawal, s ometimes considered the hallmark of dependence, is neces sary or sufficient to the diagnostic criteria for s ubs tance dependence. However, based on the presence or absence of or tolerance, s ubs tance dependence is subtyped as without physiological dependence. S ubs tance dependence is one of the few dis orders in DS M-IV -T R which remiss ion is explicitly defined. C omple te requires the absence of all criteria for at least 1 month, whereas partial remis s ion refers to the presence of one two criteria. Unique to the substance dependence disorders , the duration of the period of remiss ion is specified. W hen the period of remiss ion is les s than 12 months, then it is s pecified as early re mis s ion. T his is contrast to s us taine d re mis s ion that has pers isted for at least 12 months.

S ubs tanc e A bus e Dis orders In contras t to DS M-III and DS M-III-R , DS M-IV -T R nonoverlapping criteria s ets for substance dependence and abuse. S ubstance abuse can be diagnosed for the specific subs tances , except caffeine and nicotine. S ubstance abuse is characterized by a maladaptive of use that res ults in recurrent psychosocial problems . S ubstance abuse is not diagnos ed if the criteria for dependence have ever been met. T he remiss ion 1112 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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for s ubs tance dependence are not also applied to subs tance abus e.

S ubs tanc e-Induc ed Dis orders T he symptoms of many Axis I dis orders can be by subs tance us e; consequently, the differential of many psychiatric disorders includes ruling out that it subs tance induced. T he criteria for diagnos ing induced dis orders are therefore placed in the phenomenologically relevant section to facilitate differential diagnosis, although these dis orders are also listed in the substance-related dis orders section. F or example, the diagnostic criteria for s ubs tance-induced mood dis order are included in the mood disorders to ens ure that the clinician considers this potential of the presenting symptoms.

V: S c hizophrenia and Other Dis orders T he section on s chizophrenia and other ps ychotic disorders includes eight specific dis orders schizophreniform disorder, s chizoaffective dis order, delus ional dis order, brief ps ychotic dis order, shared ps ychotic dis order, ps ychotic dis order due to a general medical condition, and s ubs tance-induced psychotic disorder) in which psychotic symptoms are a prominent feature of the clinical picture. T he DS M-IV -T R text that other disorders may also be characterized at times ps ychotic features (e.g., major depres sive dis order or bipolar mania with psychotic features). T he grouping of disorders in this section was made to facilitate diagnosis and not to imply etiological links amongs t the 1113 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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disorders in this section.

S c hizophrenia S chizophrenia is generally a chronic dis order in which prominent hallucinations or delusions are usually T he individual mus t be ill for at least 6 months, he or s he need not be actively psychotic during all of time. T hree phases of the dis order are defined. T he prodrome phas e refers to deterioration in function the ons et of the active psychotic phase. T he active symptoms (delusions , hallucinations , disorganized gross ly dis organized behavior, or negative s ymptoms, such as flat affect, avolition, and alogia) must be for at leas t 1 month. T he res idual phase follows the phase. T he features of the res idual and prodromal include functional impairment and abnormalities of cognition, and communication. If a manic or depress ive syndrome occurs , its duration mus t be brief relative to duration of the active phase of s chizophrenia. S chizophrenia is not diagnosed if the s ymptoms are the effects of s ubs tances or a general medical S chizophrenia is subtyped according to the mos t prominent symptoms present at the time P.1023 of the evaluation (paranoid, disorganized, catatonic, undifferentiated, and residual types ). T he subtypes different diagnostic code numbers. T he course of the disorder can als o be specified (e.g., continuous vers us episodic with or without interepisode residual although thes e are not reflected in diagnostic coding.

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S c hizophreniform Dis order S chizophreniform dis order is characterized by the active phas e s ymptoms of s chizophrenia (delusions , hallucinations , dis organized speech, gross ly behavior, or negative symptoms ) but lasts between 1 6 months, and the prodromal or residual phase social or occupational impairment are absent. S imilar schizophrenia, schizophreniform dis order is ruled out if mood epis ode, if pres ent, is not brief relative to the duration of the psychotic s ymptoms. DS M-IV -T R does indicate how s hort the mood s yndrome must be to be cons idered brie f, and, given that s chizophreniform disorder mus t be les s than 6 months duration, there is uncertainty in how often this exclus ion criterion is S chizophreniform disorder is also excluded if the symptoms are due to the effects of substances or a medical condition. T he predicted cours e of the disorder can be s pecified (with or without good prognostic features), although this is not reflected in diagnos tic coding.

S c hizoaffec tive Dis order S chizoaffective dis order is also characterized by the active phas e symptoms of s chizophrenia (delusions , hallucinations , dis organized speech, gross ly behavior, or negative symptoms ), as well as the of a manic or depres sive syndrome that is not brief to the duration of the ps ychosis . Individuals with schizoaffective disorder, in contrast to a mood disorder with ps ychotic features, have delus ions or for at leas t 2 weeks without coexis ting prominent mood symptoms. As with the other nonfunctional ps ychotic 1115 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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disorders , the symptoms are not attributable to us e or a general medical condition. S chizoaffective disorder is s ubtyped as bipolar or depress ive type, although this is not reflected in diagnostic coding.

Delus ional Dis order Delusional disorder is characterized by nonbizarre delus ions (i.e., delus ions about situations that could in real life, s uch as infidelity, being followed, or having illness ). T he pres ence of bizarre delus ions or the other active phas e ps ychotic symptoms of schizophrenia excludes the diagnosis of delus ional dis order. impairment is directly linked to the delusional s ys tem, the broad-based functional decline often as sociated schizophrenia is usually absent. If a manic or syndrome occurs , its duration mus t be brief relative to duration of the delusions . Delusional disorder is not diagnosed if the symptoms are due to the effects of subs tance us e or a general medical condition. disorder is s ubtyped according to the content of the delus ion, although this is not reflected in diagnostic coding.

B rief P s yc hotic Dis order B rief ps ychotic dis order requires the pres ence of hallucinations , dis organized speech, gross ly behavior, or catatonic behavior for at least 1 day but than 1 month. T he individual returns to his or her usual level of functioning. T he ps ychotic symptoms cannot be due to s ubs tance use or a general medical condition. ps ychotic dis order is s ubtyped based on the presence absence of markedly s tres sful life events or recent 1116 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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childbirth, although this is not reflected in diagnostic coding.

S hared P s yc hotic Dis order S hared psychotic dis order, also called folie à de ux, is characterized by a delusional belief that develops in an individual involved in a close relationship with s omeone who has an established delus ion. T he content of the delus ion is similar to the content in the pers on with the es tablis hed delusion.

P s yc hotic Dis order Due to a G eneral Medic al C ondition P sychotic disorder due to a general medical condition diagnosed when there is evidence that hallucinations delus ions are the direct cons equence of a general condition other than delirium or dementia. T he disorder subtyped according to whether delusions or predominate the s ymptom picture, and the s ubtypes coded differently.

S ubs tanc e-Induc ed P s yc hotic S ubstance-induced psychotic disorder is analogous to ps ychotic disorder due to a general medical condition, except the caus e of the hallucinations or delusions is subs tance intoxication, s ubs tance withdrawal, or a medication. T he dis order is subtyped according to the predominant s ymptom picture and the s pecific res ponsible for the s ymptoms. T he subtypes are in diagnostic coding.

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T he section on mood dis orders begins with the specification of the diagnostic criteria for mood (major depress ive epis ode, manic episode, hypomanic episode, and mixed episode). T he mood episode are the bas is for diagnosing the mood dis orders; by thems elves , the mood epis odes are not able to be T he next part of the section describes the s even mood disorders (major depress ive disorder, bipolar I disorder, bipolar II dis order, dysthymic disorder, cyclothymic dis order, mood dis order due to a general medical condition, and s ubs tance-induced mood disorder). T he final part of the mood disorders section describes the many methods of subtyping, s ome of are reflected in the diagnos tic code.

Major Depres s ive Dis order T he neces sary feature of major depres sive dis order is depres sed mood or loss of interest or pleas ure in usual activities. T he diagnos is of major depres sive dis order requires the presence of at least five of nine s ymptom criteria for at leas t 2 weeks , one of which is depress ed mood or loss of interest. All s ymptoms must be present nearly every day, except s uicidal ideation or thoughts death, which need only be recurrent. T o count toward diagnosis, the s ymptom mus t be a change from the person's us ual bas eline (e.g., chronic sleep difficulty of several years duration that did not change with the of depress ive s ymptoms 2 months ago does not make the diagnosis, the symptoms must cause significant dis tres s or impairment and mus t not be due subs tance use or a general medical condition. T he diagnosis is excluded if the symptoms are the res ult of normal bereavement and if there are ps ychotic 1118 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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in the abs ence of mood s ymptoms . T he fourth digit of five-digit diagnos tic code indicates whether the experienced a previous episode of major depress ion single epis ode vers us recurrent epis odes ). T he fifth indicates current severity, the pres ence of ps ychotic features, and, if full criteria are not met at the time of evaluation, whether the episode is in partial or full remis sion. Other methods of subtyping major which are not reflected in the diagnos tic code, are chronicity (chronic subtype indicates an epis ode of at leas t 2 years ); presence of catatonic, melancholic, atypical features ; as sociation with recent childbirth postpartum onset, if the epis ode began within 4 weeks delivery); completenes s of the recovery between for individuals with two or more epis odes (with or full interepis ode recovery); and whether there is a pattern to the onset of recurrent epis odes .

Dys thymic Dis order Dys thymic disorder is a mild, chronic form of that lasts at least 2 years , during which, on the P.1024 majority of days , the individual experiences depres sed mood for mos t of the day and at leas t two other of depress ion. During the 2-year period, the s ymptoms never get s evere enough to meet criteria for a major depres sive epis ode, although many individuals with dysthymic dis order have s uperimpos ed major disorder (called double de pres s ion). T he disorder is excluded if there is a history of mania, hypomania, or cyclothymia. T he dis order is subtyped according to age 1119 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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onset (early onset before 21 years of age, late onset 21 years of age) and the pres ence of atypical features , although neither method of s ubtyping is reflected by diagnostic coding.

B ipolar I Dis order T he neces sary feature of bipolar I disorder is a his tory manic or mixed manic and depres sive epis ode. Mania requires euphoric or irritable mood for at leas t 1 week any duration, if the individual is hos pitalized) and at three (if mood is euphoric) or four (if mood is irritable) seven s ymptom criteria. In contrast to major there is no indication that the s ymptoms mus t be nearly every day. T he diagnosis is excluded if the symptoms are the res ult of a general medical condition, subs tance use, antidepres sant medication, or if there ps ychotic symptoms in the abs ence of mood T he impairment-distress criterion for mania is different than the impairment-distress criterion for most other disorders . F or mos t disorders , s uch as major disorder, this criterion is worded “clinically significant distress or impairment.” F or a manic epis ode, there is reference to distress , and the impairment mus t be “marked.” DS M-IV -T R does not specify how “marked” differs from “clinically significant.” T he distress criterion for a manic epis ode is als o met if the neces sitate hos pitalization or if ps ychotic symptoms present. T he inclusion of these other components of impairment criterion sugges ts that marked impairment more s evere than clinically s ignificant impairment. disorder is s ubtyped in many ways : type of current (manic, hypomanic depress ed, or mixed), severity and remis sion s tatus (mild, moderate, severe without 1120 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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ps ychos is , s evere with ps ychotic features , partial or full remiss ion), the s ame symptom and cours e as major depress ion when the current epis ode is depres sion, and whether the recent cours e is by rapid cycling (at least four epis odes in 12 months ).

B ipolar II Dis order B ipolar II disorder is characterized by a his tory of hypomanic and major depress ive epis odes. T he criteria for a hypomanic episode are the s ame as that manic epis ode, although hypomania only requires a minimum duration of 4 days . T he major difference between mania and hypomania is the s everity of the impairment ass ociated with the syndrome. Hypomania the only DS M-IV -T R disorder that is excluded if the impairment is too s evere. T he DS M-IV -T R criteria refer observable changes in functioning but do not s pecify a minimum level of impairment for the diagnos is. T he subtyping of bipolar II dis order is the same as bipolar I disorder, although none of the s ubtyping methods is reflected in diagnos tic coding.

C yc lothymic Dis order T he bipolar equivalent to dysthymic dis order, disorder, is a mild, chronic mood disorder with depres sive and hypomanic episodes over the cours e of least 2 years . T he depres sive periods never meet a major depres sive epis ode, and the hypomanic never meet criteria for mania, although they may meet criteria for hypomania.

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C ondition Mood dis order due to a general medical condition is diagnosed when there is evidence that a significant disturbance is the direct cons equence of a general condition other than delirium. T he disorder is s ubtyped according to the pres ence of depress ive s ymptoms not meeting criteria for a major depress ive epis ode, symptoms meeting full major depress ion criteria, manic features, or mixed features .

S ubs tanc e-Induc ed Mood Dis order S ubstance-induced mood disorder is diagnosed when caus e of the mood dis turbance is s ubs tance withdrawal, or a medication. T he disorder is s ubtyped according to the s pecific substance res ponsible for the symptoms, which is reflected in diagnos tic coding, and type of mood s ymptoms, which is not reflected in the coding.

VII: Anxiety Dis orders T he section on anxiety dis orders includes ten s pecific disorders (panic disorder, agoraphobia, specific social phobia, OC D, posttraumatic s tres s disorder acute stress dis order, generalized anxiety disorder, disorder due to a general medical condition, and subs tance-induced anxiety dis order) in which anxious symptoms are a prominent feature of the clinical T he grouping of dis orders in this section was made to facilitate differential diagnosis and not to imply links amongst the disorders in this s ection. B ecaus e separation anxiety dis order occurs in childhood, it is included in the childhood dis orders s ection. 1122 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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P anic Dis order A panic attack is characterized by feelings of intense terror that come on out of the blue in s ituations in which there is nothing to fear and that are accompanied by at least four of a lis t of 13 features , the most common heart racing or pounding, ches t pain, shortness of or choking, dizziness , trembling or s haking, feeling faint lightheaded, s weating, and naus ea. P anic disorder is diagnosed in an individual who has experienced at two attacks as sociated with 1 month or more of concern about having another panic attack, worrying about the implications of the attack, or a change in behavior becaus e of the attacks . P anic dis order is according to the pres ence or abs ence of agoraphobia, this is reflected in the fifth digit of the diagnostic code.

A goraphobia Agoraphobia is a frequent cons equence of panic although it can occur in the abs ence of panic attacks. Individuals with agoraphobia avoid (or try to avoid) situations that they think might trigger a panic attack (or panic-like symptoms ) or situations from which they es cape might be difficult if they have a panic attack. to the precedent of diagnos ing the cooccurrence of vascular dementia and delirium as a single dis order, panic dis order and agoraphobia are present, only a diagnosis is made (panic disorder with agoraphobia).

S pec ific P hobia S pecific phobia is characterized by an excess ive, unreas onable fear of specific objects or situations that occurs almost always on exposure to the feared 1123 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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Ins ight that the fear is excess ive or unreasonable is required to make the diagnos is . T he phobic stimulus is avoided, or, when not avoided, the individual feels severely anxious or uncomfortable. T he anxiety or avoidance caus es clinically significant functional impairment or dis tres s. T he s ubtypes of specific based on the type of phobic stimulus (animal, environment, blood-injection-injury, or situation), are captured by different diagnos tic code numbers .

S oc ial P hobia S ocial phobia is characterized by the fear of being embarrass ed or humiliated in front of others . S imilar to specific phobia, insight that the fear is excess ive or unreas onable is required to make the diagnosis, and phobic s timuli are avoided, P.1025 or, when not avoided, the individual feels s everely or uncomfortable. T he anxiety res ponse or avoidance caus es clinically s ignificant functional impairment or distress . When the phobic s timuli include mos t social situations, then it is s pecified as generalized s ocial

Obs es s ive-C ompuls ive Dis order OC D is characterized by repetitive and intrus ive or images that are unwelcome (obs es sions ) or behaviors that the person feels compelled to do (compuls ions), or both. Mos t often, the compulsions done to reduce the anxiety ass ociated with the thought. S imilar to the diagnosis of s pecific and s ocial phobia, at some time during the course of the disorder, 1124 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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individual mus t exhibit s ome insight that the compuls ions are excess ive or unreasonable. If, for the cours e of the disorder the individual does not recognize that the obses sions or compulsions are excess ive, then the s pecifier with poor ins ight is added. impairment-distress criterion for OC D is s omewhat different than this criterion for other dis orders , because can also be met in the absence of evidence of clinically significant impairment or distress if the obs es sions or compuls ions are time-cons uming (pres ent for more hour per day).

P os ttraumatic S tres s Dis order P T S D occurs after the occurrence of traumatic events which the individual believes that he or she is in danger or that his or her life is in jeopardy. P T S D can occur after witness ing a violent or life-threatening event happening to s omeone else. T he symptoms of P T S D us ually occur soon after the occurrence of the event, although, in s ome cases, the s ymptoms develop months or even years after the trauma. T he symptoms P T S D are grouped into four categories : reaction to the event, reexperiencing s ymptoms, symptoms of and s ymptoms of increased arousal. P T S D is when a person reacts to the traumatic event with fear experiences at least one reexperiencing symptom, more s ymptoms of avoidance, and two or more of hyperarousal. T he s ymptoms must persist for at month and cause clinically significant impairment in functioning or dis tres s. T he cours e of the dis order (i.e., acute if less than 3 months , chronic if greater than 3 months) and timing of symptom onset in relation to the occurrence of the symptoms (i.e., with delayed ons et if 1125 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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symptoms ons et at least 6 months after the trauma) specified, although this is not reflected in diagnos tic coding.

A c ute S tres s Dis order Acute s tres s dis order occurs after the same type of stress ors that precipitate P T S D, although some of the symptom inclusion criteria are different than the ones us ed to diagnose P T S D. Acute stress dis order is not diagnosed if the s ymptoms las t beyond 1 month. Acute stress disorder is thus the third disorder in DS M-IV -T R is ruled out if the symptoms persist beyond a certain amount of time (s chizophreniform disorder and brief ps ychotic dis order are the other two). T he impairmentdistress criterion for acute stres s dis order is s omewhat different than the usual criterion, becaus e it can be met the absence of evidence of clinically significant impairment or dis tres s if the s ymptoms “impair the individual's ability to purs ue some necess ary task.”

G eneralized A nxiety Dis order G eneralized anxiety disorder is characterized by excess ive worry that occurs more days than not and is difficult to control. T he worry is as sociated with such as concentration problems, ins omnia, mus cle irritability, and physical res tles sness , and caus es significant dis tres s or impairment. G eneralized anxiety disorder is the only anxiety dis order that is not if the symptoms only occur during the cours e of depres sion.

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Medic al C ondition Anxiety disorder due to a general medical condition is diagnosed when there is evidence that s ignificant is the direct consequence of a general medical other than delirium or dementia. T he disorder is according to the pres ence of generalized anxiety, panic attacks, or obsess ive-compuls ive features, although not reflected in diagnostic coding.

S ubs tanc e-Induc ed A nxiety Dis order S ubstance-induced anxiety disorder is diagnosed when the cause of the anxiety is substance intoxication, subs tance withdrawal, or a medication. T he disorder is subtyped according to the s pecific s ubs tance for the s ymptoms, which is reflected in diagnos tic and the type of anxiety s ymptoms, which is not the coding.

VIII: S omatoform Dis orders T he section on s omatoform dis orders includes s ix disorders (s omatization disorder, undifferentiated somatoform disorder, convers ion disorder, pain hypochondriasis, and body dysmorphic dis order) in phys ical s ymptoms sugges tive of a general medical condition, but not accounted for by such a condition, prominent feature of the clinical picture. T he grouping disorders in this section was made to facilitate diagnosis (i.e., the need to rule out general medical disorders ) and not to imply etiological links amongst disorders in this section.

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S omatization dis order is characterized by multiple unexplained medical symptoms in diverse organ occurring over several years that are not explained by general medical conditions . T he s ymptoms are into four categories: pain, gastrointestinal (G I), sexual, ps eudoneurological. S ymptoms from each group must present, res ulting in functional impairment or treatment, beginning before 30 years of age.

Undifferentiated S omatoform Undifferentiated somatoform dis order is a residual category for conditions characterized by unexplained medical symptoms that are not as pervasive and longlasting as thos e of somatization dis order. T he precluded by another s omatoform dis order.

C onvers ion Dis order C onvers ion dis order is characterized by unexplained voluntary motor or sensory deficits that suggest the presence of a neurological or other general medical condition. P s ychological conflict is determined to be res ponsible for the s ymptoms. T he symptoms caus e clinically significant impairment or distress or medical evaluation. T he disorder is subtyped according to the of symptom (motor, sensory, seizure, or mixed), this is not reflected in diagnostic coding.

P ain Dis order T he core feature of pain dis order is impairing or pain that is the primary focus of attention. factors are determined to have an important role in the onset, severity, or maintenance of the pain. F ifth-digit 1128 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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coding reflects the pres ence or abs ence of a general medical condition. In addition, the cours e of the (i.e., acute if les s than 6 months, chronic if greater than months) is s pecified, although this is not reflected in diagnostic coding.

Hypoc hondrias is Hypochondrias is is a distress ing and impairing preoccupation with the belief of having a s erious illnes s based on a misinterpretation of phys ical s ymptoms. thorough medical evaluation rules out the medical the preoccupation remains. Although not a diagnostic criterion, at s ome time during the P.1026 cours e of the dis order, the individual mus t exhibit some insight that the preoccupation is excess ive or unreas onable. If there is no insight, and the belief delus ional intensity, then the diagnosis would be delus ional dis order, somatic type rather than hypochondriasis. If, for mos t of the course of the the individual does not recognize that the is excess ive, then the s pecifier with poor ins ight is

B ody Dys morphic Dis order B ody dys morphic disorder is a dis tres sing and preoccupation with an imagined or slight defect in appearance. If the belief is held with delusional then delus ional dis order, somatic type, might also be diagnosed. T his contras ts with the decision rule for hypochondriasis that cannot be codiagnosed with delus ional dis order. 1129 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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IX: Fac titious Dis order F actitious dis order refers to the deliberate feigning of phys ical or psychological symptoms to ass ume the s ick role. F actitious dis order is dis tinguished from in which s ymptoms are also fals ely reported; however, motivation in malingering is external incentives , such avoidance of res ponsibility, obtaining financial compens ation, or obtaining substances. F actitious disorder is s ubtyped according to whether the predominant s ymptoms are psychological, physical, or mixture of the two.

X: Dis s oc iative Dis orders T he section on diss ociative dis orders includes four disorders (dis sociative amnesia, diss ociative fugue, diss ociative identity disorder, and depersonalization disorder) characterized by a “disruption in the us ually integrated functions of cons cious nes s, memory, or perception.” T here is a hierarchical diagnos tic relations hip among the disorders , s uch that amnes ia is not diagnos ed when dis sociative fugue or diss ociative identity dis order is pres ent, diss ociative is not diagnosed when the criteria for diss ociative disorder are met, and depers onalization disorder is excluded when any of the other three diss ociative disorders are present. Diss ociative features, such as depers onalization, are s ometimes pres ent in other disorders and are part of the DS M-IV -T R diagnostic sets for panic attacks, P T S D, acute stress disorder, somatization disorder. DS M-IV -T R notes some in the class ification of convers ion dis order, because it cons idered to be a diss ociative phenomenon in some 1130 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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clas sification schemes but is placed in the s omatoform disorders section in DS M-IV -T R “to emphas ize the importance of considering neurological or other general medical conditions in the differential diagnosis.” T his illus trates how different principles of clas sification might influence the organization of the clas sification s ys tem.

Dis s oc iative A mnes ia Dis sociative amnes ia is characterized by memory loss important personal information that is us ually traumatic nature. T he inability to remember is not due to normal forgetfulness , substance us e, or a general medical condition; does not occur only during the course of another dis sociative disorder, P T S D, or s omatization disorder; and caus es clinically significant impairment or distress .

Dis s oc iative F ugue Dis sociative fugue is characterized by s udden travel from home as sociated with partial or complete memory loss about one's identity. At times, there is confusion personal identity, and, at times , a new identity is T he diss ociation is not due to substance us e or a medical condition and caus es clinically significant impairment or dis tres s.

Dis s oc iative Identity Dis order Multiple P ers onality Dis order) T he es sential feature of diss ociative identity dis order is presence of two or more dis tinct identities that ass ume control of the individual's behavior.

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Depers onalization Dis order T he es sential feature of depersonalization dis order is persis tent or recurrent episodes of depers onalization altered sense of one's physical being, including feeling that one is outside of one's body, phys ically cut off or distanced from people, floating, obs erving oneself from distance, like one is in a dream, or that one's body is phys ically changed in s hape or size). T he is not due to another psychiatric disorder, substance or a general medical condition, and it caus es clinically significant impairment or distress .

XI: S exual and G ender Identity Dis orders T he section on s exual and gender identity dis orders includes three groups of dis orders —sexual paraphilias, and gender identity disorder.

S exual Dys func tions T he group of sexual dys function disorders is organized the bas is of the phase of s exual respons e that is S exual pain disorders are als o included in this T he sexual dys function disorders are diagnos ed only they caus e marked dis tres s or interpers onal difficulty. two s exual desire disorders are hypoactive s exual disorder (lack of des ire for s exual activity) and sexual avers ion dis order (active avoidance of sexual contact). two s exual arousal disorders are female sexual arousal disorder (inability to attain or maintain adequate lubrication until completion of sexual activity) and male erectile dis order (inability to attain or maintain erection until completion of sexual activity). T he three 1132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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orgasmic disorders are female orgas mic disorder, male orgasmic disorder, and premature ejaculation. T he two sexual pain dis orders are dyspareunia (pain during intercours e) and vaginis mus (vaginal spasm interfering with sexual intercours e). S exual dysfunction due to a general medical condition and substance-induced dysfunction are als o included, the subtypes of which linked to the other s exual dys functions , so that these caus es of s exual dys function are ruled out as part of evaluation.

P araphilias T he characteristic features of paraphilias are recurrent, sexually arous ing fantasies, urges, or behaviors lasting least 6 months and involving nonhuman objects, or humiliation of oneself or one's partner, or children or other noncons enting partners. DS M-IV -T R includes specific paraphilias: exhibitionis m (exposure of genitals strangers), fetishism (us e of nonliving objects), (touching and rubbing agains t a noncons enting pedophilia (attraction to children), s exual mas ochis m (s uffering pain or humiliation), s exual sadis m (causing or humiliation to someone else), transves tic fetishism (cross -dress ing), and voyeuris m (observing individuals ).

G ender Identity Dis order T he characteristic feature of gender identity dis order is persis tent discomfort with one's own gender and s trong cross -gender identification. G ender identity disorder is subtyped according to the individual's current age, and the subtypes are dis tinguis hed by different diagnostic 1133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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codes .

XII: E ating Dis orders T he section on eating disorders includes two s pecific disorders —anorexia nervosa and bulimia nervosa— are characterized by abnormal eating behavior. Other disorders of eating that us ually are diagnos ed in and childhood P.1027 (i.e., pica, rumination disorder, and feeding disorder of infancy or early childhood) are included in the Usually F irst Diagnosed in Infancy, C hildhood, or Adoles cence section.

A norexia Nervos a T he core feature of anorexia nervos a is a strong fear of gaining weight or becoming fat, res ulting in deliberate maintenance of low body weight. Individuals are preoccupied with their weight and body image, and weight and perceived body shape markedly influence self-image. An additional diagnostic criterion is required for pos tmenarcheal women—amenorrhea for at leas t three cons ecutive mens trual cycles . Anorexia is based on whether the individual engages in bingeor purging behavior (binge-eating or purging type) or maintains low weight through res tricting food intake or excess ive exercise (res tricting type). T he s ubtypes are distinguished by s eparate diagnos tic codes .

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eating during which they eat an abnormally large of food over a short period of time. During the binge, person feels like he or s he cannot control his or her T o prevent weight gain from the overeating, the engages in compens atory behavior, such as s elfvomiting, excess ive exercise, laxative us e, or going on strict diets.

XIII: S leep Dis orders T he sleep dis orders are divided into four groups bas ed the presumed cause—primary, due to another mental disorder, due to a general medical condition, or due to subs tances . T he sleep dis orders are diagnosed only they caus e marked dis tres s or interpers onal difficulty. primary s leep disorders are subdivided into five dyss omnias (primary insomnia, primary hypersomnia, narcoleps y, breathing-related sleep dis order, and rhythm s leep disorder) and three paras omnias disorder, s leep terror disorder, and sleepwalking

XIV: Impuls e-C ontrol Dis orders Not E ls ewhere C las s ified F ive s pecific dis orders of impulse control are included this s ection on impuls e-control disorders not els ewhere clas sified—intermittent explosive dis order, pyromania, pathological gambling, and trichotillomania. T hese dis orders are characterized by the failure to urges to engage in behaviors that are harmful to the individual or others. T he diagnostic criteria for three disorders , kleptomania, pyromania, and are similar. T he first criterion refers to repeated performance of the harmful behavior. T he s econd 1135 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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refers to a growing feeling of tension before performing the behavior, and the third criterion refers to tension or gratification after performing the behavior. F or all disorders in this section, if the behavior is attributable another ps ychiatric disorder, then the impuls e control disorder is not diagnosed.

Intermittent E xplos ive Dis order T his dis order is characterized by recurrent, dis crete, episodes of as saultive and violent behavior that is out proportion to poss ible precipitating factors . If the can be accounted for by another ps ychiatric disorder, as antis ocial or borderline pers onality disorder, bipolar disorder, or a s ubs tance use dis order, then a separate diagnosis of intermittent explos ive dis order is not also made. T hus , intermittent explos ive disorder is only after other ps ychiatric causes of the aggress ive behavior are ruled out.

K leptomania K leptomania is characterized by repeated s tealing of that are not needed for pers onal us e or for their value. T he stealing is not done for the purpos e of expres sing anger or revenge. B efore committing the the individual experiences an increasing s ens e of that diss ipates after the behavior. If the behavior is accounted for by conduct disorder, antis ocial disorder, or a manic epis ode, then a separate kleptomania is not als o made.

P yromania P yromania is characterized by recurrent setting of fires 1136 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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because of a preoccupation or fascination with fire than being done for other purpos es such as financial political expres sion, revenge, or hiding of criminal behavior. B efore setting the fire, the individual an increasing s ense of tension that dis sipates after the behavior. If the behavior is better accounted for by conduct dis order, antisocial personality dis order, or a manic epis ode, then a s eparate diagnos is of pyromania not also made.

P athologic al G ambling P athological gambling is characterized by a pattern of gambling behavior. Although class ified as an impulse control dis order, many experts draw parallels between pathological gambling and addictive dis orders (i.e., s ubs tance use dis orders). Of the ten criteria for pathological gambling, one refers to tolerance, one to an inability to control gambling behavior, and one to withdrawal s ymptoms when cutting down on or stopping gambling. T he remaining criteria are a heterogeneous group of features , including cons equences of problem gambling, preoccupation gambling, and problematic gambling behaviors after loss es , gambling to es cape problems, or negative emotional states ).

Tric hotillomania T richotillomania is characterized by repeated hair caus ing noticeable hair los s. T he anticipatory tension criterion for trichotillomania is broader than the criterion for kleptomania and pyromania. F or trichotillomania, the criterion refers to an increasing 1137 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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of tens ion before pulling or attempts to res is t pulling. T richotillomania is the only impuls e control disorder includes an impairment-distress criterion.

XV: Adjus tment Dis orders Many ps ychiatric dis orders are precipitated or by s tres sful life events. T he adjustment disorder res idual diagnos tic category that is us ed when the ps ychiatric symptoms that follow a psychosocial do not meet the criteria for a s pecific disorder. F or example, the development of depress ive symptoms stress ful event is diagnos ed as a major depress ive if the criteria for this dis order are met (i.e., at leas t five features of major depress ion for at least 2 weeks ). Adjustment disorder with depres sed mood, rather than depres sive dis order not otherwise s pecified (NOS ), is diagnosed only if the major depress ion criteria are not met. T hus, the diagnos is of a specific disorder the diagnosis of adjus tment dis order, and the diagnosis adjus tment disorder s upersedes the diagnosis of a nototherwis e-specified condition. Adjus tment disorders are diagnosed when the pers on's dis tres s in respons e to event is in exces s of a normative reaction to the when the symptoms caus e s ignificant impairment in functioning. Adjus tment dis order is not diagnos ed if the symptoms repres ent a bereavement reaction, although the conceptual justification for the distinction between this s tres sful event and other events that frequently in ps ychiatric symptoms is not provided. T he disorders are s ubtyped according to the predominant symptom picture (depres sed mood, anxiety, mixed and depres sion, dis turbance of conduct, mixed disturbance of emotions and conduct, uns pecified), and 1138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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this is reflected in their diagnostic code. P.1028

XVI: Pers onality Dis orders P ers onality refers to an individual's characteristic affect, emotional regulation, behavior, motivation, cognition about s elf, and interactions with others that long-standing, present s ince adolescence or early adulthood. Aspects of pers onality include the way tend to think about thems elves (e.g., s elf-confident or lacking confidence), how they relate to people (e.g., friendly), how they interpret and deal with events in the environment (e.g., paranoid people believe that others out to get them and may try to attack firs t before being attacked), and how an individual reacts emotionally to situation. It is not easy to define a he althy pe rs onality, in general, it allows one to cope with the normal s tres s life and to develop and to maintain satis fying and intimate relationships . When long-standing of thinking, behaving, and emotional response are inflexible, and caus e s ignificant dis tres s or impairment functioning, then a DS M-IV -T R personality dis order present. DS M-IV -T R includes ten s pecific personality disorders that are coded on Axis II.

P aranoid P ers onality Dis order Individuals with paranoid pers onality disorder are suspicious and distrustful of others . T hey may think others do things jus t to annoy or to hurt them, and they often read hidden threats or put-downs in the of others . T hey may worry that friends or coworkers are 1139 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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really loyal or trustworthy and are often reluctant to confide in others , because they believe that there is a to pay when something pers onal is s hared. P ersons paranoid personality dis order may have problems with anger management. T hey are easily slighted and hold grudges . T hey often find that people s ay things to their character or ruin their reputation, even though it does not s eem that way to others. Individuals with paranoid personality dis order often read too much into things , take offense at things that were not meant to be critical, and often try to get back at the person they is attacking them. W hen involved in a relations hip, they often worry that their partner is unfaithful.

S c hizoid P ers onality Dis order S chizoid pers onality disorder is characterized by lack emotionality and social relations hips. Individuals with schizoid personality disorder are s ocially isolated, but does not bother them. T hey us ually prefer to work and things alone. T hey are emotionally cold and are neither bothered by criticis m from others nor joyful when complimented. Individuals with s chizoid personality disorder us ually do not get pleasure from many and often have little interes t in sexual experiences with another person.

S c hizotypal P ers onality Dis order Individuals with schizotypal pers onality disorder are and eccentric. T hey may dress , act, or speak in a manner. T hey are often s uspicious and paranoid and anxious in s ocial situations because of their distrust. B ecaus e of these beliefs , they have few friends. 1140 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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with s chizotypal personality dis order frequently feel that others are talking about them behind their back and strangers are taking s pecial notice of them. W hen into a room, they sometimes think that people start or acting differently because they are there. Individuals with schizotypal personality dis order sometimes misinterpret reality. T hey may mis take nois es for and s hadows or objects for people. T hey may believe extras ens ory perception (E S P ), hexes, telepathy, and supers titions more s trongly than most people, and their behavior may be influenced by these beliefs .

A ntis oc ial P ers onality Dis order Antisocial personality dis order, the adult manifes tation childhood conduct dis order, is characterized by selfis h, irrespons ible, unlawful, and impuls ive behavior that a lack of regard for the rights of others . Individuals with antis ocial pers onality disorder often find it easy to lie if serves their purpose. P hysical aggress ion is common. T rouble at work may be the result of not arriving on miss ing too many days, not doing the work, or not following the rules . T here is a general failure to society's rules by engaging in illegal activities or not honoring obligations . E xamples of antisocial behavior include quitting a job without other work in s ight or spending money on things that one could do without, thus being unable to pay for household neces sities , as food, rent, or the utility bill. R eckless driving, tickets, driving under the influence of drugs or alcohol, ignoring recommended s afety precautions are of a lack of regard for the s afety of oneself or others. Individuals with antisocial personality dis order us ually not feel remors eful at having hurt others but instead 1141 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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or rationalize their behavior.

B orderline P ers onality Dis order B orderline personality dis order is characterized by emotional dysregulation, unstable interpersonal relations hips , and unstable self-image. Individuals with borderline pers onality disorder have strong and intense emotions , often in reaction to how they perceive and believe others are treating them, and these emotions difficult to control. Not s urpris ingly, individuals who strong emotional reactions that are difficult to control often have problems in interpers onal relations hips and self-image. Interpersonal relations hips are affected by strong fears of being abandoned and going to keep others from leaving. At an extreme, suicide is threatened to keep someone from leaving. tend to be stormy, with many ups and downs, as the person alternates between having s trong positive and negative feelings . T he moods of the individual with borderline pers onality disorder are s trong and change. T here are often problems with controlling and anger outbursts are common. Individuals with borderline pers onality disorder frequently do not have a stable s ens e of their identity and feel empty ins ide the time. S elf-destructive behavior is common. with borderline pers onality disorder make recurrent suicide attempts, s uicide threats , or engage in s elfdamaging behavior, s uch as cutting or burning. T hey also do impuls ive things that can caus e problems , s uch gambling, spending excess ive money, s exual excess drug and alcohol use, stealing, eating binges , reckless driving. 1142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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His trionic P ers onality Dis order In contras t to some personality dis orders that are characterized by s ocial anxiety, inhibition, and individuals with his trionic personality dis order are loud, overly emotionally expres sive, and attention s eeking. act as if they are on stage. Individuals with histrionic personality dis order tend not to feel comfortable unles s they are the center of attention. T hey may be flirtatious and s exually s eductive and may us e phys ical to get people's attention. T hey often feel a close bond someone they have just met and are quick to s hare personal details of their life with new acquaintances. are often described by others as shallow.

Narc is s is tic P ers onality Dis order Individuals with narcis sis tic personality dis order have high of an opinion of thems elves and little regard for others , except as how others meet their needs. T hey thems elves as accomplishing great things that their s uperiority over others. T hey view thems elves as special and unique and that only similarly s pecial could unders tand them. T here is a s ens e of and they often feel that they have earned the right to special treatment or cons ideration because P.1029 of who they are or what they have done. Individuals narcis sistic pers onality disorder are often s o s elfthat they are intolerant of others, and they lack the capacity to understand how others feel. T he admiration others is us ually important, and they dream of attaining status . T hey may take advantage of others , if 1143 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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get what is desired. Individuals with narciss istic disorder are often envious of others who have more they do or believe that others are jealous of them, or

A voidant P ers onality Dis order Avoidant personality dis order is characterized by social inhibition related to low s elf-es teem and s ens itivity to rejection and criticism from others . Individuals with avoidant pers onality disorder have difficulty making friends and feel uncomfortable in s ocial s ituations . It is difficult to s hare personal feelings and thoughts in relations hips because of the fear of being put down. Individuals with this personality dis order usually worry about making a bad impres sion and believe that they not interes ting or fun. T heir fears of criticis m and can influence the type of career they choos e (one that does not involve a lot of contact with people) or career advancement (turning down promotions or job opportunities that would require more contact with people).

Dependent P ers onality Dis order Individuals with dependent personality dis order have difficulty with self-sufficiency and have a s trong need to taken care of by others. E veryday decis ions often are made without the input of others , and others frequently make decis ions about important areas of their life. Individuals with dependent pers onality disorder may over backward to the point of doing unpleasant tasks others to get s upport and gratitude. It is difficult for the person with dependent personality dis order to start projects on their own, because they do not feel 1144 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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in their own abilities , and it is hard to disagree with for fear of losing s upport or approval. Individuals with dependent pers onality disorder do not like being alone. T hey often believe that they cannot care for and, if a clos e relations hip ends, they may be get into another relationship right away, even if it is not the best pers on for them.

Obs es s ive-C ompuls ive P ers onality Dis order Obsess ive-compuls ive personality dis order is by a pattern of perfectionis m, stingines s, stubbornnes s, orderlines s, and inflexibility. Individuals with obsess ivecompuls ive personality dis order often s pend so much on small details that they los e s ight of the main thing were trying to do. T hey frequently are workaholics, who spend so much time working that they have little time family activities , friends hips, or entertainment. T hey are often interpers onally controlling because of their Individuals with obs ess ive-compuls ive personality have difficulty delegating tasks or working with others unles s things are done their way. Others often that they are too s trict about moral is sues and that they are cheap. Individuals with obsess ive-compuls ive personality dis order frequently find it difficult to throw things away, even when the object is old and worn and no sentimental value.

XVII: Other C onditions That May B e Foc us of C linic al Attention T he conditions included in the section on other that may be a focus of clinical attention are not 1145 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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mental disorders but are included because they may the focus of clinical attention. T he reasons that these conditions fail to meet the DS M-IV -T R definition for a mental disorder are not s pecified. T wenty-nine s pecific problems are lis ted in s ix groups : ps ychological factors affecting medical conditions , medication-induced movement disorders , other medication-induced relational problems, problems related to abus e or and others . T hese problems are coded on Axis I.

P s yc hologic al P roblems A ffec ting Medic al C onditions T he category of ps ychological problems affecting conditions refers to those situations in which ps ychological factors negatively affect the cours e or outcome of a general medical condition or significantly increase the risk of an advers e outcome. T he and behavioral factors that may negatively impact on cours e and outcome of a medical condition include subthreshold symptoms and personality traits that do meet criteria for a s pecific mental disorder diagnos is , personality traits that undermine a therapeutic collaboration with health providers, and maladaptive behaviors , s uch as overeating and s edentary lifestyle.

Medic ation-Induc ed Movement Dis orders T he category of medication-induced movement is included because of its clinical importance in and differential diagnosis. F ive of the six s pecific movement disorders des cribed are related to the us e of neuroleptics (neuroleptic-induced parkins onism, acute 1146 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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dystonia, acute akathisia, tardive dys kinesia, and neuroleptic malignant s yndrome). T he s ixth disorder is medication-induced pos tural tremor, which is most as sociated with antidepres sants and mood s tabilizers . DS M-IV -T R text includes brief descriptions of thes e disorders , with reference to DS M-IV -T R 's appendix for more detailed des cription of sugges ted diagnostic

Other Medic ation-Induc ed Dis orders T he category of other medication-induced dis orders is included so that clinicians could code medication side effects that are a focus of clinical attention (e.g., severe hypotens ion, priapis m, weight gain, and sexual dysfunction).

R elational P roblems R elational problems that caus e s ignificant s ymptoms or functional impairment are frequently the focus of attention. T hes e problems may be as sociated with a mental or general medical disorder in one of the of the relational unit. W hen the relations hip problem is primary focus of treatment, then the problem is coded Axis I. If not the primary focus of treatment, the can be listed on Axis IV .

P roblems R elated to A bus e or T he category of problems related to abus e or neglect includes five problems (physical abuse of child, sexual abuse of child, neglect of child, phys ical abus e of adult, and s exual abus e of adult) that frequently are the focus clinical attention. S eparate diagnos tic codes are used when the patient is the perpetrator or victim of the 1147 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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or neglect.

Other C onditions That May B e a C linic al A ttention T he last group in this clas s of problems includes a heterogeneous collection of 13 problems that may the focus of treatment (noncompliance with treatment, malingering, adult antis ocial behavior, child or antis ocial behavior, borderline intellectual functioning, age-related cognitive decline, bereavement, academic problem, occupational problem, identity problem, religious or s piritual problem, acculturation problem, phase of life problem). E ach of thes e problems has its diagnostic code.

XVIII: Appendix Diagnos es DS M-IV -T R contains propos ed criteria for 20 specific disorders that were not included in the official clas sification but are included in an appendix, s o that P.1030 res earch can be conducted on their reliability, validity, potential clinical usefulnes s (T able 9.1-6). Many of disorders are currently captured by the clas sification not-otherwis e-specified designations (e.g., depress ive disorder NOS for minor depres sive dis order or premenstrual dys phoric disorder).

Table 9.1-6 Appendix Diagnos es the DS M-IV-TR 1148 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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P os tconcuss ional dis order Mild neurocognitive disorder C affeine withdrawal P os tps ychotic depress ive disorder of S imple deteriorative disorder Minor depress ive disorder R ecurrent brief depres sive dis order P remens trual dysphoric disorder Mixed anxiety depress ive disorder F actitious disorder by proxy Dis sociative trance dis order B inge-eating dis order Depress ive personality dis order P as sive-aggres sive pers onality disorder personality dis order)

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US ING DS M-IV-TR An 11-page introduction to DS M-IV -T R describes its history, methods of the revision process , definition of mental disorder, and iss ues in us ing a clas sification of mental disorders . T his is followed by a cautionary statement warning agains t reifying the diagnos tic and the clas sification. It is noted that the specified diagnostic criteria repres ent guidelines for making diagnoses based on consensus opinion of current knowledge. Als o, the clas sification may not cover all conditions for which pers ons seek treatment, and the inclusion of a diagnos tic category in the clas sification not have implications for legal decis ions. After the cautionary s tatement, an 11-page s ection des cribes us e of the manual, and a 7-page s ection des cribes T R 's multiaxial diagnostic approach. T he inclusion of latter two s ections is indicative of the complexity of the DS M-IV -T R clas sification and the potential difficulty in us ing it.

Multiaxial E valuation 1150 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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T he DS M-IV -T R multiaxial system of evaluation, in different domains of information are described on five different axes , was introduced in DS M-III. P roper us e DS M-IV -T R does not require the use of the multiaxial format. T he purpose of multiaxial evaluation is to a comprehens ive, biops ychos ocial approach toward clinical as sess ment. Axis I cons ists of all clinical except for the pers onality disorders and mental retardation, both of which are reported on Axis II. P rominent maladaptive personality traits that do not criteria for a s pecific disorder and defense mechanis ms also noted on Axis II. Axis III is for general medical conditions that might be relevant to unders tanding or managing the patient's ps ychiatric dis order. In those in which the medical dis order caus es the mental then the medical disorder is listed on Axis III, and the mental disorder is listed on Axis I as due to a ge neral me dical condition. Axis IV is for noting psychosocial environmental problems that are relevant to the treatment, and prognos is of Axis I and Axis II disorders. When a ps ychosocial problem is the primary focus of treatment, then it is lis ted on Axis I as a condition that be the focus of clinical attention, although this is not cons idered a mental dis order. T he problem is also Axis IV . Axis V is the G AF s cale, a 100-point rating symptom severity, social functioning, and occupational functioning (s ee T able 7.9-2).

Multiple Dis orders Many patients have more than one psychiatric When more than one dis order is pres ent in a patient presenting for treatment, the clinician denotes one disorder as the principal diagnos is . S everal methods 1151 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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been used by res earchers in identifying principal in patients with multiple ps ychiatric dis orders. S ome of factors us ed to designate a principal dis order include of ons et (i.e., the principal disorder is the one that first), relative degree of impairment (i.e., the principal disorder is the one res ponsible for the greatest degree ps ychos ocial dysfunction), and reas on for s eeking treatment (i.e., the principal disorder is the one that is chiefly respons ible for the treatment s eeking). In DS MT R , the determination of the principal diagnos is is on the reas on for the clinical service. W hen two are nearly equally res ponsible for the clinical s ervice, IV -T R acknowledges that the identification of one as the principal dis order is somewhat arbitrary.

Dis order S everity When the full criteria for a dis order are met, its s everity be s pecified as mild, moderate, or s evere. S everity are bas ed on the number and intensity of the the disorder and the impairment in occupational or functioning caus ed by the symptoms . Although the severity specifier can be applied to all disorders , guidelines for making this rating are provided only for mental retardation, conduct disorder, mania, mixed depres sive epis odes, and major depres sion. F or each these dis orders, except conduct dis order, the disorder's severity is captured by the diagnostic code.

R emis s ion S tatus When the s ymptoms of a dis order are pres ent, but the criteria of the dis order are no longer met, then the is cons idered in partial remis sion. According to DS M1152 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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a dis order is in full remiss ion when no s ymptoms or of the dis order are pres ent. Although this s pecifier, to dis order severity, can be applied to all dis orders, guidelines for making this distinction are provided only manic and major depress ive epis odes and s ubs tance dependence. F or s ubs tance dependence, full requires that none of the diagnostic criteria has been for at leas t 1 month. T he definition of remiss ion from a manic and depres sive episode differs from the dependence remis sion definition in two ways . F irst, in contrast to a complete absence of diagnos tic criteria, DS M-IV -T R remis sion definition for mania and requires the absence of “s ignificant (italics added) symptoms of the disturbance.” No guidelines are for interpreting the meaning of “significant.” It is unclear if the pres ence of one or two mild s ymptoms is inconsistent with the definition of remiss ion. S econd, duration of the symptom-free interval mus t last at least months for depres sion and mania, in contrast to 1 for substance dependence. B ecause of the differences defining remiss ion for the mood and substance dependence disorders , it is unclear how to define remis sion for other disorders . F or example, to anorexia as being in remis sion, how much residual concern, if any, about body image can remain in a who has regained lost weight? Or, how much any, can remain in a patient with a public s peaking phobia who no longer avoids public pres entations? T he threshold used to determine dis order remis sion has important implications for characterizing the P.1031

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longitudinal course of disorders and the effectivenes s treatment efforts and will hopefully be given more cons ideration in the next DS M revision. DS M-IV -T R also differentiates between full remiss ion recovery. A disorder in full remiss ion is listed as a disorder, becaus e it remains clinically relevant. After an unspecified period of time, bas ed on factors s uch as duration of the symptoms , the duration of the symptomfree interval, and the need for continued monitoring prophylactic treatment, the clinician might cons ider the patient as having recovered from the dis order, and the disorder is no longer class ified a current condition. In cases, the clinician can lis t the disorder by using the specifier prior his tory.

Diagnos tic Unc ertainty T here are s everal ways of coding diagnos tic DS M-IV -T R . T he diagnos is can be deferred, or a diagnosis can be rendered and identified as When s ome information is available, not enough to diagnose a s pecific disorder but enough to know which clas s of disorder is present, then the diagnos is is NO S .

C linic al C onditions Not Meeting S pec ified Diagnos tic C riteria C linically s ignificant presentations sometimes do not the threshold for a diagnosis . T his is particularly true disorders that are defined polythetically, whereby a minimum number of features from a list are needed to make a diagnosis. T o account for this , every DS M-IV diagnostic clas s has an NOS category. F or example, patients who present with fewer than five clinically 1154 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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significant depress ive s ymptoms would be diagnos ed depres sive dis order NOS . B ecaus e the definition of mental dis order is based, in on impairment and dis tres s, and knowledge of dysfunction and etiological mechanisms is largely unknown, the DS M-IV -T R phenomenologically based clas sification system is unable to account for the wide divers ity of clinical presentations . S imilar to patients fall below s pecified diagnos tic thresholds, patients with atypical symptom pres entations are given an NOS diagnosis in the diagnostic class that most closely res embles the clinical picture. F or s ome NOS DS M-IV -T R provides specific examples of such presentations , and, in s ome ins tances , these symptom patterns have corres ponding res earch diagnos tic that are pres ented in the appendix.

P S YC HIA TR IC DIA G NOS IS IN P R A C TIC E Multiple opinions about the us e of the DS M s ys tem in clinical practice have been offered, two of which are described in this s ection. S ome authors have rais ed concerns that clinicians have become preoccupied with eliciting s igns and s ymptoms to make DS M psychiatric diagnoses to the exclusion of evaluating the and ps ychodynamic perspectives of the patient's In contras t, s ome res earchers have sugges ted that adherence to the DS M s ys tem is clinically important, they have raised concerns related to clinicians ' high diagnostic error rate. In their review of DS M-III, Arnold C ooper and R obert Michels s peculated that the antitheoretical approach 1155 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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toward clas sification, without s uperordinate principles integrate biops ychosocial information with DS M diagnoses, would result in an overly narrow focus on determining whether diagnostic criteria are met. In their review of DS M-III-R 7 years later, they concluded that initial concern had been realized, particularly in the as sess ments done by the new generation of trainees . S imilarly, G ary J . T ucker s uggested that the improved diagnostic precision offered in the modern DS M era res ulted in narrowly focus ed evaluations of DS M that rule in or out diagnos es but neglect the patient's story. S igns and s ymptoms are accorded greater significance than coping style. T hese authors acknowledged that the multiaxial system of encourages a pers pective beyond the s igns and of Axis I dis orders but found, in their experience, that broader pers pective is not actually taken in clinical practice. T homas A. W idiger and S pitzer, res ponding to concerns expres sed in C ooper's and Michels ' review of DS M-III-R , indicated that the problem lies with the of the new generation of clinicians rather than the T hey reiterated the cautionary s tatement in DS M-III-R a diagnos is represents only one component of a comprehensive evaluation. Moreover, they added that their anecdotal experience in us ing DS M-III-R with was that it stimulated a broader perspective of ps ychopathology, becaus e its antitheoretical approach encouraged cons ideration of different models of and treatment. In contras t to concerns regarding an overly narrow on diagnosis, in the past few years , res earch by independent research groups has raised concerns 1156 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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the adequacy of psychiatric diagnos tic evaluations conducted in routine clinical practice, becaus e the diagnostic as sess ment is not s ufficiently F or example, M. K atherine S hear and colleagues diagnostic accuracy in two community mental health centers, one in urban P itts burgh and the other in rural wes tern P enns ylvania. T hey found poor agreement between clinical ass es sments and evaluations by trained raters adminis tering the S tructured C linical Interview for DS M-IV (S C ID), a semi-structured interview commonly used by res earchers to make ps ychiatric diagnoses . In particular, they found that, whereas clinicians frequently diagnosed adjus tment disorder, the S C ID interviewers made specific mood or anxiety dis order diagnoses . T hey als o reported that diagnostic comorbidity was identified on the S C ID. In discuss ing their findings , S hear and colleagues whether patients ' outcomes were compromised by the failure to detect and to diagnos e correctly treatable conditions. In another s tudy of community mental health patients , one conducted in T exas , Monica R . B asco and adminis tered the S C ID to patients as a tes t of the us efulnes s of research diagnos tic procedures in clinical practice. T hey found that supplementing information the patients' charts with the information from the S C ID res ulted in more than five times as many comorbid conditions being diagnosed. A gold standard, all information, diagnos is was made for all patients, and level of agreement with this s tandard was higher for the S C ID than the clinical diagnoses. After feedback from S C ID interview was presented to the clinicians , a 1157 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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patient care occurred in one-half of the cases . T he res ults of these two studies are cons is tent with the findings from the R hode Island Methods to Improve Diagnos tic Ass es sment and S ervices (MIDAS ) project, which diagnos tic frequencies were compared in two samples —one interviewed with the S C ID and the other interviewed by ps ychiatrists us ing an uns tructured interview. C onsistent with the findings of the T exas and P ittsburgh groups, it was found that many more were diagnos ed with two or more DS M-IV -T R Axis I disorders when research interviews were conducted when diagnoses were bas ed on the routine clinical evaluation. More than one-third of patients interviewed with S C ID received three or more diagnoses in contrast fewer than 10 percent of the patients ass es sed with an unstructured interview. F ifteen dis orders were more frequently diagnosed when the S C ID was us ed, and differences cut across mood, anxiety, eating, and impulse control dis order categories . Importantly, patients often desired treatment for the comorbid Axis I disorders that were P.1032 not the primary reason for s eeking treatment. T hus , detecting diagnostic comorbidity was important from a cons umer and patient perspective. Another report from the MIDAS project examined the is sue of diagnosing borderline pers onality disorder and found that res earch interviewers us ing the S tructured Interview for DS M-IV P ers onality were much more likely to diagnos e personality dis order than clinicians . Moreover, when information from the research interview was provided 1158 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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the clinician, clinicians diagnos ed borderline disorder more frequently; thus, it was not simply a of clinicians being reluctant to diagnos e borderline personality dis order during the initial diagnos tic evaluation. Are thes e findings any caus e for alarm? T hat is hard to because no research has demonstrated the clinical significance of the gap between res earchers ' and diagnostic practices. S pecifically, there are currently no studies that have examined the important ques tion of whether the more accurate and comprehensive diagnostic evaluations improve outcomes. In fact, one could argue that patients ' outcomes are not more likely be worse, even if diagnoses are mis sed. C linicians currently have at their disposal agents with broad-based efficacy; consequently, diagnostic error might not be important. T he new generation of medications, s uch as s elective serotonin reuptake inhibitors (S S R Is ), have been found to be for depress ion, almost all anxiety disorders , eating disorders , impulse control dis orders, s ubs tance use disorders , attention deficit dis order, and some disorders . In s hort, most of the disorders for which individuals seek outpatient care have been found to be res ponsive to at least one of the new generation of antidepres sant medications . T hus , it is pos sible that accurate and comprehens ive DS M-IV -T R diagnoses critical after gros s diagnos tic clas s distinctions (e.g., ps ychotic dis order vs . mood dis order) are made. T his would be cons istent with the res ults of a s urvey of ps ychiatris ts' attitudes about DS M-III and DS M-III-R conducted 10 years ago that found that only a minority 1159 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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ps ychiatris ts rated the DS Ms as being important for treatment planning, determining prognosis, patient management, and understanding patients ' problems . Whether or not improved diagnostic practice would in improved outcome, it is important to recall from the beginning of this chapter that diagnos is has more than one clinically relevant function. In addition to optimizing outcome, diagnos is is important for predicting outcome. It is the opinion of the authors of this chapter that a greater percentage of the variance in outcome would be predicted by comprehens ive evaluations than clinical diagnoses. Again, this is an unstudied question.

C L A S S IF IC A TION Dimens ional Vers us C ategoric al Approac hes toward C las s ific ation T he introduction to DS M-IV -T R makes it clear that, although a categorical class ification is des cribed in the manual, this should not be interpreted as sugges ting the categorical approach is more reliable or valid than dimensional approach toward class ification. P ut s imply, categorical s ys tem posits that there are clear between diagnos tic entities or between dis order and absence of disorder, whereas a dimens ional model lack of clear demarcation. Discus sions of the relative of categorical and dimens ional approaches toward the clas sification of mental disorders have persisted throughout the 20th century. F or example, in the E dward Mapother ques tioned the usefulness of depres sed patients as endogenous or neurotic the difficulty in placing many patients into one group or 1160 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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the other. T hrough the years , several s tatistical have been used to evaluate the categorical vers us dimensional approaches toward clas sification. T hes e include plotting scores of symptom characteris tics and determining whether the plots were consistent with a bimodal or unimodal distribution or determining linear nonlinear relationships between s ymptom s cores and independent variables, s uch as laboratory tes ts, family history, or treatment respons e. More recently, interest grown in using P aul Meehl's taxometric methods to test latent categories . At present, the research community not unified in its opinion regarding the categoricaldimensional debate. Although it is apparent that there no clearly defined boundaries distinguishing dis orders from each other and from normality, much of the taxometric research is consistent with the categorical model. DS M-IV -T R 's categorical approach, which is the traditional method of medical clas sification, s eems appropriate at this time, becaus e it is more us eful in practice.

S eparate Dis orders Vers us Arthur C . Houts has been highly critical of the number of dis orders lis ted in each success ive edition of DS M and has sugges ted that this was indicative of a scientific progress . Moreover, he s ugges ted that were being created that had previous ly not been recognized as pathology. W akefield carefully examined caus es of diagnostic proliferation and concluded that greater number of diagnoses listed in s ucces sive represented greater s pecification rather than diagnos tic discoveries . In fact, he found that the increas e in the number of diagnos es paralleled the increas es found in 1161 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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IC D clas sification of cardiac and G I diseases during the 30 years . Although the increased number of coded diagnos tic entities does not generally represent the discovery of diagnostic entities , this iss ue nonetheless warrants cons ideration, because it has generated debate within field between the s o-called lumpers, who favor broader categories , and the s plitters , who favor R es earchers are more likely to benefit from embracing splitters ' approach, as it is eas ier to publish findings demonstrating that a method of s ubclas sification is as sociated with s tatistically significant differences than to publis h null findings. T hus , there are many res earch articles sugges ting the validity of diagnos tic and (s ub) clas sification distinctions . However, the principles the incorporation of thes e distinctions into a of dis orders are unwritten. S ome resulting questions include the following: When is a syndrome s ufficiently distinct from its near neighbors to warrant being cons idered a s eparate dis order? When is the amongst members of a disorder s ufficient to warrant subdividing the group into more homogeneous subgroups (i.e., s ubtyping)? Is there a conceptual difference between dis tinguis hing between dis orders distinguishing between s ubtypes of a disorder? T he introduction to DS M-IV -T R does not dis cuss thes e questions . S ome examples illustrate the lack of conceptual in making thes e distinctions. T he dis tinctions between bipolar and unipolar depres sion and psychotic and nonps ychotic depress ion have been demons trated in multiple domains. Y et, unipolar and bipolar depress ion 1162 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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cons idered different disorders , whereas determination the presence of ps ychotic features is a method of subtyping depres sion. B ody dysmorphic dis order is clas sified as a s omatoform dis order. It has been conceptualized as an obs ess ive-compuls ive s pectrum disorder, and research sugges ts that there are many similarities and few differences between patients with body dys morphic disorder and patients with OC D. C ons ider individuals with OC D who obs es sively was h hands and shower. S uch individuals are not clas sified body cleaning disorder. It is reasonable to sugges t that body dys morphic disorder is as repres entative of OC D body cleaning disorder. P.1033

Financ ial Implic ations of R evis ing C las s ific ation S ince DS M-III, the AP A has made millions of dollars the DS Ms . W hen plans were announced to publis h 5 years after DS M-III-R was published, concern was that profit motives were res ponsible, at leas t in part, for the short interval between DS M editions. reviews of DS M-III-R also rais ed s uch ques tions. It is disconcerting that financial cons iderations might have significantly influenced the timing of revis ions of the clas sification. P erhaps as a result of thes e criticisms, pace of DS M revis ions has slowed. At the time of the writing of this chapter, it has been 8 years since the publication of DS M-IV , and DS M-V is not anticipated the end of the decade. However, the iss ue of profiting from revising the DS M 1163 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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manual renewed its elf with the publication of the DS MT R . On the one hand, the principal architects of the have ass erted that the manual is not a textbook. this caveat, the detailed clinical descriptions and discuss ions of differential diagnos is along with up-tosummaries of prevalence data, demographic familial patterns , and cours e of illness , give the DS Ms feel of a textbook, which has undoubtedly contributed their s ucces s. S eemingly incons is tent with the that the DS M s hould not be considered to be a the most recent vers ion of the DS M, DS M-IV -T R , is updating of the text without changes to the diagnostic criteria. T his follows the typical pattern of publishing editions of academic textbooks, such as the present every few years to have up-to-date s ummaries of knowledge. T hus , despite the declaration that the DS M not a textbook, the publication schedule sugges ts otherwis e. T he integrity of the revis ion proces s can be compromised by a conflict of interes t between the scientific jus tification for revising and updating the manual's text and nomenclature versus fiscal gains to AP A. A potential method of reducing the tension scientific and economic forces is to develop scientific guidelines regarding the level of s ignificant change needed in the clas sification s ys tem that should trigger revis ion.

S UG G E S TE D C R OS S T he ps ychiatric report is discuss ed in S ection 7.3, signs and s ymptoms are discus sed in S ection 7.4, neurops ychological as sess ment is discus sed in clinical manifestations of psychiatric disorders are discuss ed in C hapter 8, and international pers pectives 1164 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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ps ychiatric diagnosis are discus sed in S ection 9.2.

R E F E R E NC E S Akiskal HS , McK inney W : P s ychiatry and ps eudops ychiatry. Arch G e n P s ychiatry. American Medical As sociation. S tandard C las s ifie d Nome nclature of Dis e as e . C hicago: American Ass ociation; 1935. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 1s t ed. Was hington, DC : American P s ychiatric Ass ociation; 1952. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 2nd ed. Was hington, DC : American P s ychiatric Ass ociation; 1968. *American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 3rd ed. Was hington, DC : American P s ychiatric Ass ociation; 1980. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 3rd revis ed Was hington, DC : American P sychiatric As sociation; 1987. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed, text 1165 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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revis ion. W ashington, DC : American P sychiatric Ass ociation; 2000. B as co MR , B ostic J Q, Davies D, R us h AJ , W itte B , Hendricks e W , B arnett V : Methods to improve diagnostic accuracy in a community mental health setting. Am J P s ychiatry. 2000;157:1599–1605. B rill H. Nos ology. In: F reedman AM, K aplan HI, HS , eds. C omprehe ns ive T e xtbook of P s ychiatry. B altimore: W illiams & W ilkins ; 1967:581–589. C ooper A, Michels R : B ook review of Diagnos tic and S tatistical Manual of Mental Dis orders, 3rd ed, (DS M-III-R ). Am J P s ychiatry. 1988;145:1300–1301. C ooper J E , K endell R E , G urland B J , S harpe L, J R M, S imon R . P s ychiatric Diagnos is in Ne w Y ork L ondon. London: Oxford University P res s; 1972. E ndicott J , S pitzer R L: A diagnos tic interview: T he S chedule for Affective Disorders and S chizophrenia. Arch G e n P s ychiatry. 1978;35:837–844. *F eighner J P , R obins E , G uze S B , Woodruff R A, G , Munoz R : Diagnostic criteria for us e in ps ychiatric res earch. Arch G e n P s ychiatry. 1972;26:57–67. F irst MB , P incus HA: T he DS M-IV text revision: and potential impact on clinical practice. P s ychiatr 2002;53:288–292.

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F irst MB , S pitzer R L, W illiams J B W, G ibbon M. C linical Inte rvie w for DS M-IV (S C ID). W ashington, American P s ychiatric Ass ociation; 1997. F ollette W C , Houts AC : Models of scientific progress the role of theory in taxonomy development: A case study of the DS M. J C ons ult C lin P s ychol. 1132. F rances AJ , W idiger T A, P incus HA: T he DS M-IV . Arch G e n P s ychiatry. 1989;46:373–375. F reud S . Introductory L e cture s on P s ycho-analys is . London: Hogarth P ress ; 1963. F ulford K W M: Nine variations and a coda on the of an evolutionary definition of dys function. J P s ychol. 1999;108:412–420. G ottesman II, G ould T D: T he endophenotype ps ychiatry: E tymology and strategic intentions. Am J P s ychiatry. 2003;160:636–645. G roup for the Advancement of P s ychiatry. P s ychopathological Dis orde rs in C hildhood: C ons ide rations and a P ropos ed C las s ification. New G roup for the Advancement of P s ychiatry; 1966. G ruenberg E M: How can the new diagnos tic manual help? Int J P s ychiatry. 1969;7:368. Houts AC : T he diagnos tic and statis tical manual's 1167 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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white coat and circularity of plausible dys functions : R es pons e to W akefield, part 1. B ehav R e s T her. 2001;39:315–345. J effers on J W , T homps on T D: R hinotillexomania: P sychiatric dis order or habit? J C lin P s ychiatry. 1995;56:56–59. K endell R E . T he R ole of Diagnos is in P s ychiatry. B lackwell; 1975. K endell R , J ablens ky A: Dis tinguis hing between the validity and utility of ps ychiatric diagnoses . Am J P s ychiatry. 2003;160:4–12. K endler K S : S etting boundaries for psychiatric Am J P s ychiatry. 1999;156:1845–1848. K ihlstrom J F . T o honor K raepelin: F rom s ymptoms pathology in the diagnosis of mental illness . In: LE , Malik ML, eds . R ethinking the DS M. American P s ychological As sociation; 2002:279–303. K lerman G L, V aillant G E , S pitzer R L, Michels R : A on DS M-III. Am J P s ychiatry. 1984;141:539–542. K ramer M. T he history of the efforts to agree on an international clas sification of mental dis orders. In: American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 2nd ed. Was hington, DC : American P sychiatric As sociation; 1973. 1168 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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Lilienfeld S O, Marino L: Mental dis order as a concept: A critique of W akefield's “harmful analysis. J Abnorm P s ychol. 1995;104:411–420. Lilienfeld S O, Marino L: E ss entialism revisited: E volutionary theory and the concept of mental disorder. J Abnorm P s ychol. 1999;108:400–411. Mapother E : Discus sion on manic-depres sive B r J P s ychiatry. 1926;2:872–876. Meehl P E : B ootstrap taxometrics . Am P s ychol. 1995;50:266–275. Menninger K : S heer verbal Mickey Mouse. Int J P s ychiatry. 1969;7:415. Menninger K , Mayman M, P ruys er P . T he V ital T he L ife P roces s in Mental He alth and Illnes s . New V iking P res s; 1963. Merikangas K R , R isch N: W ill the genomics revolutionize ps ychiatry? Am J P s ychiatry. 635. Narrow W E , R ae DS , R obins LN, R egier DA: prevalence estimates of mental disorders in the S tates. Arch G e n P s ychiatry. 2002;59:115–123. Office of G eneral R egister. A G los s ary of Me ntal London: Her Majesty's S tationery Office; 1968. 1169 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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P eck MC , S cheffler R M: An analys is of the mental illness us ed in s tate parity laws. P s ychiatr 2002;53:1089–1095. P incus HA, F rances A, Davis WW, F irst MB , Widiger DS M-IV and new diagnostic categories: Holding the on proliferation. Am J P s ychiatry. 1992;149:112– R obins E , G uze S B . E s tablis hment of diagnostic in ps ychiatric illnes s: Its application to Am J P s ychiatry. 1970;126:983–987. R obins LN, Locke B Z, R egier DA. An overview of ps ychiatric disorders in America. In: R obins LN, DA, eds. P s ychiatric Dis orde rs in Ame rica: T he E pidemiologic C atchment S tudy. New Y ork: T he P res s; 1991. S hear MK , G reeno C , K ang J , Ludewig D, F rank E , HA, Hanekamp M: Diagnosis of nonps ychotic community clinics. Am J P s ychiatry. 2000;157:581– S pitzer R L: A proposal about homosexuality and the AP A nomenclature: Homosexuality as an irregular of sexual behavior and s exual orientation as a psychiatric disorder. A symposium: S hould homos exuality be in the AP A nomenclature? Am J P s ychiatry. 1973;130:1207–1216. S pitzer R L, E ndicott J , R obins E : R es earch criteria: R ationale and reliability. Arch G e n 1170 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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1978;35:773–782. S pitzer R L, F leis s J : A re-analysis of the reliability of ps ychiatric diagnosis. B r J P s ychiatry. *S pitzer R L, W akefield J C : DS M-IV diagnos tic for clinical significance: Does it help s olve the fals e positives problem? Am J P s ychiatry. 1864. S role L, Langner T S , Michael S T , Opler MK , R ennie Me ntal H ealth in the Me tropolis . V ol 1. T he Midtown Manhattan S tudy. New Y ork: McG raw-Hill; 1962. S tengel E : C lass ification of mental disorders . B ull 1959;21:601. S zasz T S . T he Myth of Me ntal Illne s s : F oundations T he ory of P e rs onal C onduct. New Y ork: Harper & 1974. T ucker G J : P utting DS M-IV in perspective. Am J P s ychiatry. 1998;155:159–161. T uke H: F rench retros pective. J Me nt S ci. *Wakefield J C : Disorder as harmful dysfunction: A conceptual critique of DS M-III-R 's definition of disorder. P s ychol R e v. 1992;99:232–247. P.1034

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Wakefield J C : Diagnosing DS M-IV part I: DS M-IV concept of disorder. B ehav R e s T her. 1997;35:633– Wakefield J C : W hen is development dis ordered? Developmental ps ychopathology and the harmful dysfunction analys is of mental disorder. Dev P s ychopathol. 1997;9:269–290. Wakefield J C . Meaning and melancholia: W hy the IV cannot (entirely) ignore the patient's intentional system. In: B arren J , ed. Making Diagnos is E nhancing E valuation and T reatme nt of Dis orde rs . W ashington, DC : American P sychological Ass ociation; 1998:29–72. Wakefield J C : E volutionary versus prototype the concept of disorder. J Abnorm P s ychol. 1999;108:374–399. Wakefield J C : T he myth of DS M's invention of new categories of dis order: Houts' diagnostic theses disconfirmed. B ehav R e s T her. Wakefield J C , P ottick K J , K irk S A: S hould the DS Mdiagnostic criteria for conduct dis order consider context? Am J P s ychiatry. 2002;159:380–386. Widiger T A, S pitzer R L: C riticis ms of DS M-III-R . Am P s ychiatry. 1989;146:566–567. World Health Organization. Manual of the C las s ification of Dis e as e s , Injurie s , and C aus e s of 1172 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/9.1.htm

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G eneva: W orld Health Organization; 1948. *Zimmerman M: Why are we rus hing to publis h IV ? Arch G e n P s ychiatry. 1988;45:1135–1138. Zimmerman M, J ampala V C , S ierles F S , T aylor MA: III and DS M-IIIR : W hat are American ps ychiatris ts and why? C ompr P s ychiatry. 1993;181:360–364. Zimmerman M, Mattia J I: Differences between and res earch practice in diagnosing borderline personality dis order. Am J P s ychiatry. 1574. Zimmerman M, Mattia J I: P sychiatric diagnos is in practice: Is comorbidity being miss ed? C ompr P s ychiatry. 1999;40:182–191. Zimmerman M, Mattia J I: P rincipal and additional IV disorders for which outpatients s eek treatment. P s ychiatr S erv. 2000;51:1299–1304.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 10 - Delirium, Dementia, and Amnes tic and O ther C ognitive and Mental Dis orders Due to a G eneral Medical C ondition > 10.1: C ognitive Dis orders : Introduction Overview

10.1: C ognitive Dis orders : Introduc tion and Overview K enneth L . Davis M.D. P art of "10 - Delirium, Dementia, and Amnestic and C ognitive Disorders and Mental Disorders Due to a Medical C ondition" C ognition includes memory, language, orientation, judgment, conducting interpers onal relations hips, and problem s olving. C ognitive dis orders not only reflect disruption in one or more of the above domains but are also frequently complicated by behavioral symptoms. C ognitive dis orders exemplify the complex interface between neurology, medicine, and ps ychiatry in that medical or neurological conditions often lead to disorders that are, in turn, as sociated with behavioral symptoms. It can be argued that of all psychiatric conditions, cognitive dis orders bes t demonstrate how biological ins ults res ult in behavioral s ymptomatology. phys ician mus t carefully as sess the his tory and context the presentation of these dis orders before arriving at a diagnosis and treatment plan. F ortunately, advances in molecular biology, diagnostic techniques , and management have significantly improved the ability to recognize and to treat cognitive dis orders. T he aging population has res ulted in a public health 1174 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

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regarding the diagnosis and management of dementia. More than 14 million Americans will develop dementia the year 2050. W ith illnes s progress ion, dementia eventually dis rupts all domains of cognition, thereby significantly impairing an individual's ability to function the most bas ic level. Although not included in the criteria, dementia is frequently complicated by symptoms, including agitation, delusions , and hallucinations . Not s urprisingly, a tremendous amount res earch has focused on the molecular biology, pathophys iology, epidemiology, phenomenology, and treatment of dementia. J udith Neugroschl and focus their review on Alzheimer's disease, the most common cause of dementia. Much progress has been made in the area of res earch that investigates the cognitive deficits as sociated with Alzheimer's disease. Many studies have elucidated the role of amyloid and neurofibrillary tangles, the pathological changes by Alois Alzheimer more than a century ago, in the pathophys iology of Alzheimer's dis eas e. Neuroimaging techniques have permitted vis ualization of the earlies t structural and functional correlates of cognitive decline. Molecular biology advances have identified at least genes that are ass ociated with Alzheimer's disease. F ood and Drug Administration (F DA) approval of cholines terase inhibitors has trans formed Alzheimer's disease from an untreatable illnes s less than 10 years to a condition for which there are effective pharmacological interventions . T he ability to better identify risk factors for the subsequent development of dementia will undoubtedly provide opportunities for interventions that could delay onset and perhaps 1175 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

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the development of this devas tating illness . Although cognitive disorders may cros s -sectionally present with s imilar symptoms , this heterogeneous of illnes ses may significantly differ in their etiologies, cours es, and treatments. As a case in point, delirium Alzheimer's disease may present with impaired recall, the former condition is epis odic and revers ible, the latter illness is a neurodegenerative process for there are only symptomatic treatments. S teven S amuels and Neugros chl review the pathophys iology, and management of delirium. Of the cognitive disorders , delirium can be particularly difficult diagnose becaus e of its waxing and waning symptomatology. G iven the high prevalence of delirium the acutely ill medical patient, it behooves the clinician anticipate the development of this condition and to aggres sively for the underlying etiology. However, a relative paucity of res earch regarding the pathophys iology and pharmacological management of delirium. In part, this fact is due to the difficulty in obtaining informed cons ent from delirious patients and the urgency to treat in an expedient fashion. with adequate recognition of the disorder, clinicians treat the caus ative factors and can appropriately the behavioral complications . Martin Allan Drooker reviews cognitive dis orders due to general medical condition and substances. T his extends previous chapters in this s ection through discuss ion of additional medical, neurological, or subs tance-induced causes of dementia and delirium. In contrast to other cognitive disorders , amnestic are characterized by a s ingle cognitive deficit, impaired 1176 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

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memory. However, these syndromes are commonly as sociated with s ocial and occupational functioning. G ross man reviews the range of illness es and that can result in amnes tic disorders. K ors akoff's provides a paradigm for recognizing how exposure to a subs tance (e.g., alcohol) results in focal brain injury turn, caus es an amnestic disorder. P atients often develop or are evaluated for cognitive disorders in the medical setting and are not evaluated ps ychiatris t unles s P.1054 there are significant behavioral disturbances that with day-to-day patient management. T he high prevalence of ps ychiatric symptoms and s yndromes in medically ill patients without prior ps ychiatric his tories saliently demonstrates the physician's obligation to anticipate cognitive complications in the medical or surgical s etting. Optimum treatment for cognitive disorders res ults from a collaborative effort between patient's primary phys ician and a psychiatrist.

S UG G E S TE D C R OS S P sychiatric clinical manifestations of specific and s ys temic dis orders are discus sed in C hapter 2. Neurops ychological and intellectual ass es sment of is presented in S ection 7.5, ass ess ment of children in S ection 7.7, and medical as sess ment and laboratory tes ting in S ection 7.8. Dis cuss ion of s ubstance-related disorders appears in C hapter 11, s chizophrenia in 12, psychotic dis orders in S ection 12.16, anxiety in C hapter 14, factitious dis orders in C hapter 16, 1177 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

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diss ociative dis orders (including diss ociative amnesia) C hapter 17, s exual dys functions in S ection 18.1a, disorders in C hapter 20, and personality dis orders in C hapter 23. T he ps ychiatric as pects of human immunodeficiency virus (HIV ) infection and acquired immune deficiency s yndrome (AIDS ) are pres ented in S ection 2.8. P s ychological changes in normal aging (including age-related cognitive decline) are dis cuss ed S ection 51.2c, and dementia of the Alzheimer's type other dementing disorders of late life are discus sed in S ection 51.3e.

R E F E R E NC E S *F ick DM, Agostini J V , Inouye S K : Delirium superimposed on dementia: A systematic review. J G e riatr S oc. 2002;50:1723–1732. *Hardy J , S elkoe DJ : T he amyloid hypothes is of Alzheimer's disease: P rogress and problems on the to therapeutics. S cience . 2002;297:353–356. *Helmes E , B owler J V , Merskey H, Munoz DG , V C : R ates of vognitive decline in Alzheimer's and dementia with Lewy bodies. Deme nt G e riatr Dis ord. 2003;15:67–71. *Morita T , T ei Y , Inoue S : Agitated terminal delirium as sociations with partial opioid s ubs titution and hydration. J P alliat Me d. 2003;6:557–563. *Wild R , P ettit T , B urns A: C holines terase inhibitors dementia with Lewy bodies. C ochrane Databas e 1178 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/10.1.htm

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R ev. 2003;3:C D003672.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 11 - S ubstance-R elated Dis orders > 11.1: S ubs ta nce-R elated Introduction and O verview

11.1: S ubs tanc e-R elated Dis orders : Introduc tion and Overview J erome H. J affe M.D. J ames C . Anthony Ph.D., S C .M. P art of "11 - S ubstance-R elated Disorders " T his chapter on the s ubs tance-related dis orders is up of s eparate s ections organized around the as sociated with the use of each of the major groups of pharmacological agents that are commonly mis used (abused). T his section deals with is sues that are acros s categories of drugs : the nomenclature and diagnostic s chemes of the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs IV -T R ) and the tenth edition of the Inte rnational C las s ification of Dis e as e s and R e late d He alth 10), the his tory of substance us e and dependence, epidemiology, and the etiological factors and treatment principles that appear to be common to thes e

S UB S TA NC E -R E L A TE D DS M-IV, DS M-IV-TR , A ND IC D-10 DS M-IV -T R does not differ from DS M-IV in the us e disorders sections . DS M-IV -T R includes two broad categories of substance-related disorders : s ubs tance 1180 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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disorders (substance dependence and s ubs tance and a diverse grouping of substance-induced dis orders (s uch as intoxication, withdrawal, ps ychotic dis order, mood dis orders). T hus , in DS M-IV -T R , the topic of subs tance-related dis orders goes beyond s ubs tance dependence and abus e and clos ely related problems include a wide variety of advers e reactions not only to subs tances of abus e but also to medications and T he medications as sociated with substance-induced disorders range from anes thetics to over-the-counter medications and include s uch diverse drug categories anticholinergics, antidepress ants , anticonvuls ants, antimicrobial drugs , antihypertens ive agents , corticos teroids, antiparkinsonian agents , chemotherapeutic agents , nonsteroidal drugs (NS AIDs ), and disulfiram (Antabuse). In addition, several categories of s ubs tance-induced disorders can as sociated with a wide range of nonmedicinal toxic materials , ranging from heavy metals and industrial solvents to ins ecticides and hous ehold cleaning DS M-IV -T R groups the diagnostic criteria for s ubs tance dependence, abus e, intoxication, hallucinogen perception disorder, and withdrawal s yndromes in a section titled s ubs tance -re late d dis orde rs , whereas the other s ubs tance-related dis orders (e.g., substancemood dis orders and s ubs tance-induced delusional disorders ) are des cribed in the s ections covering and other psychiatric s yndromes that they most closely res emble phenomenologically (T able 11.1-1).

Table 11.1-1 S ubs tanc e-Induc ed 1181 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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Mental Dis orders Inc luded E ls ewhere in the Textbook S ubstance-induced dis orders caus e a variety of symptoms that are characteristic of other mental disorders . T o facilitate differential diagnos is, the and criteria for these other s ubs tance-induced disorders are included in the sections of DS M-IV and this textbook with disorders with which they share phenomenology.    S ubs tance-induced delirium (C hapter 10) is included in the “Delirium, Dementia, and and Other C ognitive Dis orders” section of DS MTR .    S ubs tance-induced pers isting dementia 10) is included in the “Delirium, Dementia, and Amnes tic and Other C ognitive Dis orders ” section.    S ubs tance-induced pers isting amnestic (C hapter 10) is included in the “Delirium, and Amnes tic and Other C ognitive Dis orders ” section.    S ubs tance-induced psychotic disorder is in the “Other P sychotic Disorders ” section 12.16). (In DS M-III-R , these dis orders were as organic hallucinos is and organic delusional 1182 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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disorder.)    S ubs tance-induced mood disorder is included the “Mood Disorders ” chapter (C hapter 13).    S ubs tance-induced anxiety disorder is included the “Anxiety Dis orders” chapter (C hapter 14).    S ubs tance-induced s exual dysfunction is in the “Normal S exuality and S exual and G ender Identity Disorders” chapter (C hapter 18).    S ubs tance-induced s leep disorder (C hapter 20) included in the “S leep Dis orders ” section.    In addition, hallucinogen persisting perception disorder (flas hbacks ) (S ection 11.7) is included hallucinogen-related dis order.

Adapted from Diagnos tic and S tatis tical Manual Me ntal Dis orde rs . 4th ed. T ext rev. W as hington, American P s ychiatric Ass ociation; 2000. T he section dealing with substance dependence and subs tance abus e presents des criptions of the clinical phenomena as sociated with the use of 11 designated clas ses of pharmacological agents : alcohol; or s imilarly acting agents; caffeine; cannabis ; cocaine; hallucinogens; inhalants; nicotine; opioids; 1183 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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(P C P ) or s imilar agents ; and a group that includes sedatives, hypnotics , and anxiolytics. A residual 12th category includes a variety of agents not in the 11 designated clas ses, s uch as anabolic steroids and oxide. IC D-10 considers the dis orders due to ps ychoactive subs tance use within the confines of an alphanumeric system that allows only nine categories of pharmacological agents , with one res idual category to cover both multiple drug use and use of psychoactive subs tances not included in the nine des ignated DS M-IV -T R and IC D-10 categorize substances with the following exceptions . C affeine and P C P are cons idered distinct categories in DS M-IV -T R , whereas 10 includes problems related to caffeine in the category other s timulants , such as amphetamine, and P C P mus t included with hallucinogens or in the res idual category. Als o, IC D-10 has a s pecial category for abuse of non– dependence-producing substances (T able 11.1-2). S pecifically mentioned are antidepress ants, antacids , vitamins , and s teroids or hormones .

Table 11.1-2 IC D-10 Diagnos tic C riteria for Abus e of NonDependenc e-Produc ing S ubs tanc es A wide variety of medicaments and folk remedies 1184 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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may be involved, but the particularly important groups are: ps ychotropic drugs that do not dependence, s uch as antidepres sants , and and analgesics that may be purchased without medical prescription such as aspirin and paracetamol. Although the medication may have been medically pres cribed or recommended in first instance, prolonged, unnecess ary, and often excess ive dos age develops , which is facilitated the availability of the substances without medical prescription. P ers is tent and unjustified us e of these us ually ass ociated with unneces sary expense, involves unneces sary contacts with medical profes sionals or supporting staff, and is marked by the harmful phys ical effects of the subs tances . Attempts to dis courage or forbid the of the s ubs tance are often met with resistance; laxatives and analgesics , this may be in spite of warnings about (or even the development of) phys ical harm s uch as renal dys function or electrolyte disturbances. Although it is us ually that the patient has a strong motivation to take subs tance, no dependence or withdrawal develop, as in the cas e of the psychoactive subs tances specified in mental and behavioral disorders due to ps ychoactive substance us e. Identify the type of s ubs tance involved:

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   Antidepres sants (such as tricyclic and antidepres sants and monoamine oxidase    Laxatives    Analgesics (such as aspirin, paracetamol, phenacetin, not s pecified as psychoactive mental and behavioral disorders due to psychoactive subs tance use)    Antacids    V itamins    S teroids or hormones    S pecific herbal or folk remedies    Other s ubs tances that do not produce (s uch as diuretics)    Unspecified

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion.

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DE F INITIONS A ND DIA G NOS IS S ubs tanc e Dependenc e DS M-IV , DS M-IV -T R , and IC D-10 formulations for abuse and dependence closely follow the concepts and terminology developed in 1980 by an International Working G roup spons ored by the W orld Health Organization (WHO) and the Alcohol, Drug Abuse, and Mental Health Adminis tration (ADAMHA) of the United S tates, which defined s ubs tance dependence as A s yndrome manifested by a behavioral pattern in which the us e of a given ps ychoactive or class of drugs , is given a higher priority than other behaviors that once had higher value. T he term “syndrome” is taken to mean no more than a clus tering of phenomena so that not all the components need always be pres ent or not always present with the same T he dependence s yndrome is absolute, but is a quantitative phenomenon that exis ts in different degrees. T he intensity the syndrome is measured by behaviors that are elicited in relation to us ing the drug and by the other behaviors that are secondary to drug us e…. No 1187 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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cut-off point can be identified for distinguishing drug dependence P.1138 from non-dependent but recurrent drug us e. At the extreme, the dependence syndrome is as sociated with “compuls ive drug-us ing T hat central notion is continued in DS M-IV and DS Mwhich s tate: T he es sential feature of dependence is a cluster of cognitive, behavioral, and phys iological symptoms that the individual continues subs tance use des pite subs tance-related problems. T he central notion in IC D-10 is virtually the same: … a cluster of behavioural, cognitive, and phys iological phenomena that develop after repeated s ubs tance use and typically include a s trong desire take the drug, difficulties in controlling its use, pers is ting in us e despite harmful cons equences, a higher priority 1188 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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given to drug use than to other activities and obligations, increased tolerance, and sometimes a phys ical state. Diagnos tic criteria for substance dependence are T able 11.1-3 (for DS M-IV -T R ) and T able 11.1-4 (for DS M-IV -T R us es seven criteria to des cribe a generic concept of dependence that applies acros s 11 clas ses pharmacological agents and requires three of s even criteria to be met if dependence is to be diagnosed. is based on a more dimens ional concept of the dependence s yndrome, but it s tates that a definite diagnosis of dependence s hould usually be made only three or more of six criteria have been met within the previous year. B oth s ys tems use a polythetic s yndrome definition in which no one specific criterion is required long as three or more are present. However, DS M-IV as ks the clinician to s pecify whether phys iological dependence—evidence of C riterion 1 (tolerance) or C riterion 2 (withdrawal)—is present or abs ent. indicates that phys iological dependence is ass ociated a more severe form of the disorder.

Table 11.1-3 DS M-IV-TR C riteria for S ubs tanc e

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A maladaptive pattern of s ubs tance use, leading clinically significant impairment or distress , as manifested by three (or more) of the following, occurring at any time in the same 12-month    (1) T olerance, as defined by either of the       (a) A need for markedly increased amounts of subs tance to achieve intoxication or des ired       (b) Markedly diminis hed effect with continued us e of the same amount of the s ubs tance    (2) Withdrawal, as manifes ted by either of the following:       (a) T he characteristic withdrawal s yndrome the substance (refer to C riteria A and B of the sets for withdrawal from the s pecific s ubs tances )       (b) T he s ame (or clos ely related) subs tance is taken to relieve or avoid withdrawal s ymptoms    (3) T he substance is often taken in larger or over a longer period than was intended.    (4) T here is a pers is tent des ire or unsuccess ful effort to cut down or control s ubs tance use.    (5) A great deal of time is spent in activities 1190 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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neces sary to obtain the substance (e.g., vis iting multiple doctors or driving long distances), use subs tance (e.g., chain s moking), or recover from effects.    (6) Important s ocial, occupational, or activities are given up or reduced becaus e of subs tance use.    (7) T he substance us e is continued despite knowledge of having a pers is tent or recurrent phys ical or ps ychological problem that is likely to have been caused or exacerbated by the (e.g., current cocaine use des pite recognition of cocaine-induced depress ion or continued drinking despite recognition that an ulcer was made wors e alcohol cons umption). S pe cify if:    With phys iological dependence: evidence of tolerance or withdrawal (i.e., either item 1 or 2 is present)    Without phys iologic al dependence: no of tolerance or withdrawal (i.e., neither item 1 nor is present) C ours e s pe cifiers :

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   E arly full remis sion    E arly partial remiss ion    S ustained full remiss ion    S ustained partial remis sion    On agonis t therapy    In a controlled environment

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 11.1-4 IC D-10 Diagnos tic C riteria for Mental and Dis orders Due to Ps yc hoac tive S ubs tanc e Us e Mental and behavioral dis orders due to us e of alc ohol

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Mental and behavioral dis orders due to us e of opioids Mental and behavioral dis orders due to us e of cannabinoids Mental and behavioral dis orders due to us e of s edatives or hypnotic s Mental and behavioral dis orders due to us e of coc aine Mental and behavioral dis orders due to us e of other s timulants , inc luding caffeine Mental and behavioral dis orders due to us e of hallucinogens Mental and behavioral dis orders due to us e of tobac co Mental and behavioral dis orders due to us e of volatile s olvents Mental and behavioral dis orders due to drug us e and us e of other ps yc hoactive s ubs tanc es Acute intoxication

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G 1. T here mus t be clear evidence of recent us e ps ychoactive substance (or s ubs tances ) at sufficiently high dose levels to be cons istent with intoxication. G 2. T here mus t be symptoms or signs of compatible with the known actions of the subs tance (or s ubs tances ), as s pecified below, sufficient s everity to produce disturbances in the level of consciousness cognition, perception, or behavior that are of clinical importance. G 3. T he s ymptoms or s igns present cannot be accounted for by a medical disorder unrelated to subs tance use, and are not better accounted for another mental or behavioral dis order. Acute intoxication frequently occurs in persons have more pers is tent alcohol- or drug-related problems in addition. W here there are s uch problems , e.g., harmful us e, dependence or psychotic disorder, they should also be T he following may be used to indicate whether acute intoxication was as sociated with any complications :       Uncomplicated          S ymptoms are of varying severity, us ually dependent 1194 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      With trauma or other bodily injury       With other medical complications          E xamples are hematemesis , inhalation of       With delirium       With perceptual distortions       With coma       With convuls ions       P athological intoxication          Applies only to alcohol Acute intoxication due to us e of alc ohol A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior, as evidenced by at least one of the following:       (1) disinhibition       (2) argumentativenes s

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      (3) aggres sion       (4) lability of mood       (5) impaired attention       (6) impaired judgment       (7) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) uns teady gait       (2) difficulty in s tanding       (3) s lurred s peech       (4) nystagmus       (5) decreas ed level of consciousness (e.g., coma)       (6) flus hed face       (7) conjunctival injection C omment

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When s evere, acute alcohol intoxication may be accompanied by hypotens ion, hypothermia, and depres sion of the gag reflex. If des ired, the blood alcohol level may be specified. Pathologic al alcohol intoxication Note . T he s tatus of this condition is being T hese res earch criteria mus t be regarded as tentative. A. T he general criteria for acute intoxication mus t met, with the exception that pathological intoxication occurs after drinking amounts of insufficient to cause intoxication in most people. B . T here is verbally aggres sive or phys ically behavior that is not typical of the pers on when sober. C . T he intoxication occurs very soon (usually a minutes) after consumption of alcohol. D. T here is no evidence of organic cerebral or other mental dis orders. C omment T his is an uncommon condition. T he blood levels found in this disorder are lower than those 1197 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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that would caus e acute intoxication in mos t (i.e., below 40 mg/100 mL). Acute intoxication due to us e of opioids A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior, as evidenced by at least one of the following:       (1) apathy and s edation       (2) disinhibition       (3) psychomotor retardation       (4) impaired attention       (5) impaired judgment       (6) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) drowsines s       (2) s lurred s peech

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      (3) pupillary cons triction (except in anoxia severe overdose, when pupillary dilatation       (4) decreas ed level of consciousness (e.g., coma) C omment When s evere, acute opioid intoxication may be accompanied by res piratory depres sion (and hypoxia), hypotension, and hypothermia. Acute intoxication due to us e of c annabinoids A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, including at leas t one of the following:       (1) euphoria and disinhibition       (2) anxiety or agitation       (3) s uspicious ness or paranoid ideation       (4) temporal s lowing (a sense that time is very s lowly, and/or the person is experiencing a rapid flow of ideas) 1199 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      (5) impaired judgment       (6) impaired attention       (7) impaired reaction time       (8) auditory, visual, or tactile illusions       (9) hallucinations with pres erved orientation    (10) depers onalization    (11) derealization    (12) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) increas ed appetite       (2) dry mouth       (3) conjunctival injection       (4) tachycardia Acute intoxication due to us e of s edatives or hypnotic s

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A. T he general criteria for acute intoxication mus t met. B . T here is dys functional behavior, as evidenced at least one of the following:       (1) euphoria and disinhibition       (2) apathy and s edation       (3) abus iveness or aggress ion       (4) lability of mood       (5) impaired attention       (6) anterograde amnesia       (7) impaired ps ychomotor performance       (8) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) uns teady gait       (2) difficulty in s tanding       (3) s lurred s peech 1201 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      (4) nystagmus       (5) decreas ed level of consciousness (e.g., coma)       (6) erythematous s kin lesions or blis ters C omment When s evere, acute intoxication from s edative or hypnotic drugs may be accompanied by hypotens ion, hypothermia, and depres sion of the gag reflex. Acute intoxication due to us e of c oc aine A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, as evidenced by at one of the following:       (1) euphoria and s ens ation of increased       (2) hypervigilance       (3) grandios e beliefs or actions       (4) abus iveness or aggress ion 1202 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      (5) argumentativenes s       (6) lability of mood       (7) repetitive s tereotyped behaviors       (8) auditory, visual, or tactile illusions       (9) hallucinations , us ually with intact    (10) paranoid ideation    (11) interference with personal functioning C . At leas t two of the following s igns mus t be present:       (1) tachycardia (s ometimes bradycardia)       (2) cardiac arrhythmias       (3) hypertension (s ometimes hypotension)       (4) s weating and chills       (5) naus ea or vomiting       (6) evidence of weight los s       (7) pupillary dilatation 1203 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      (8) psychomotor agitation (sometimes retardation)       (9) mus cular weakness    (10) ches t pain    (11) convuls ions C omment Interference with pers onal functioning is mos t readily apparent from the s ocial interactions of cocaine users, which range from extreme gregarious nes s to social withdrawal. Acute intoxication due to us e of other inc luding caffeine A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, as evidenced by at one of the following:       (1) euphoria and s ens ation of increased       (2) hypervigilance

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      (3) grandios e beliefs or actions       (4) abus iveness or aggress ion       (5) argumentativenes s       (6) lability of mood       (7) repetitive s tereotyped behaviors       (8) auditory, visual, or tactile illusions       (9) hallucinations , us ually with intact    (10) paranoid ideation    (11) interference with personal functioning C . At leas t two of the following s igns mus t be present:       (1) tachycardia (s ometimes bradycardia)       (2) cardiac arrhythmias       (3) hypertension (s ometimes hypotension)       (4) s weating and chills       (5) naus ea or vomiting 1205 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      (6) evidence of weight los s       (7) pupillary dilatation       (8) psychomotor agitation (sometimes retardation)       (9) mus cular weakness    (10) ches t pain    (11) convuls ions C omment Interference with pers onal functioning is mos t readily apparent from the s ocial interactions of subs tance us ers , which range from extreme gregarious nes s to social withdrawal. Acute intoxication due to us e of A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, as evidenced by at one of the following:       (1) anxiety and fearfulnes s 1206 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      (2) auditory, visual, or tactile illusions or hallucinations occurring in a state of full and alertness    (3) depers onalization    (4) derealization    (5) paranoid ideation    (6) ideas of reference    (7) lability of mood    (8) hyperactivity    (9) impulsive acts    (10) impaired attention    (11) interference with personal functioning C . At leas t two of the following s igns mus t be present:       (1) tachycardia       (2) palpitations       (3) s weating and chills 1207 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      (4) tremor       (5) blurring of vision       (6) pupillary dilatation       (7) incoordination Acute intoxication due to us e of tobac c o nic otine intoxic ation] A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior or perceptual abnormalities, as evidenced by at one of the following:       (1) insomnia       (2) bizarre dreams       (3) lability of mood       (4) derealization       (5) interference with personal functioning C . At leas t one of the following s igns must be present: 1208 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      (1) naus ea or vomiting       (2) s weating       (3) tachycardia       (4) cardiac arrhythmias Acute intoxication due to us e of volatile A. T he general criteria for acute intoxication mus t met. B . T here mus t be dysfunctional behavior, by at least one of the following:       (1) apathy and lethargy       (2) argumentativenes s       (3) abus iveness or aggress ion       (4) lability of mood       (5) impaired judgment       (6) impaired attention and memory       (7) psychomotor retardation

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      (8) interference with personal functioning C . At leas t one of the following s igns must be present:       (1) uns teady gait       (2) difficulty in s tanding       (3) s lurred s peech       (4) nystagmus       (5) decreas ed level of consciousness (e.g., coma)       (6) mus cle weakness       (7) blurred vision or diplopia C omment Acute intoxication from inhalation of s ubs tances other than s olvents s hould als o be coded here. When s evere, acute intoxication from volatile solvents may be accompanied by hypotens ion, hypothermia, and depres sion of the gag reflex. Acute intoxication due to multiple drug us e 1210 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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us e of other ps ychoac tive s ubs tanc es T his category should be us ed when there is of intoxication caused by recent use of other ps ychoactive s ubs tances (e.g., phencyclidine) or multiple ps ychoactive s ubs tances where it is uncertain which s ubs tance has predominated. Harmful us e A. T here mus t be clear evidence that the us e was res ponsible for (or substantially to) physical or psychological harm, including impaired judgment or dys functional behavior, may lead to dis ability or have advers e for interpers onal relations hips. B . T he nature of the harm should be clearly identifiable (and specified). C . T he pattern of use has pers is ted for at least 1 month or has occurred repeatedly within a 12month period. D. T he disorder does not meet the criteria for any other mental or behavioral dis order related to the same drug in the s ame time period (except for intoxication). Dependenc e s yndrome 1211 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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A. T hree or more of the following manifes tations should have occurred together for at leas t 1 or, if persisting for periods of les s than 1 month, should have occurred together repeatedly within 12-month period:       (1) a strong desire or sense of compuls ion to the substance       (2) impaired capacity to control substancebehavior in terms of its ons et, termination, or of use, as evidenced by: the s ubs tance being taken in larger amounts or over a longer period intended; or by a persis tent desire or efforts to reduce or control s ubs tance use       (3) a phys iological withdrawal state when subs tance use is reduced or ceas ed, as the characteristic withdrawal s yndrome for the subs tance, or by us e of the same (or clos ely subs tance with the intention of relieving or withdrawal s ymptoms       (4) evidence of tolerance to the effects of the subs tance, s uch that there is a need for increased amounts of the subs tance to achieve intoxication or the desired effect, or a marked diminis hed effect with continued us e of the same amount of the substance

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      (5) preoccupation with subs tance use, as manifested by important alternative pleas ures or interes ts being given up or reduced becaus e of subs tance use; or a great deal of time being activities necess ary to obtain, take, or recover the effects of the substance       (6) pers istent s ubs tance use des pite clear evidence of harmful consequences , as evidenced continued us e when the individual is actually or may be expected to be aware, of the nature extent of harm Diagnos is of the dependence syndrome may be further s pecified by the following: C urrently abs tinent    E arly remiss ion    P artial remis sion    F ull remiss ion C urrently abs tinent but in a protected (e.g., in a hos pital, in a therapeutic community, in prison, etc.) C urrently on a clinically s upervis ed maintenance replacement regime (controlled dependence) 1213 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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with methadone; nicotine gum or nicotine patch) C urrently abs tinent, but receiving treatment with avers ive or blocking drugs (e.g., naltrexone or disulfiram) C urrently us ing the substance (active    W ithout phys ical features    W ith physical features T he cours e of the dependence may be further specified, if desired, as follows: C ontinuous us e E pisodic use (dipsomania) Withdrawal s tate G 1. T here mus t be clear evidence of recent or reduction of substance us e after repeated, and us ually prolonged and/or high-dose, use of that subs tance. G 2. S ymptoms and s igns are compatible with the known features of a withdrawal s tate from the particular substance or s ubs tances (see below).

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G 3. S ymptoms and s igns are not accounted for medical dis order unrelated to subs tance use, and not better accounted for by another mental or behavioral disorder. T he diagnosis of withdrawal state may be further specified by us ing the following: Uncomplicated With convuls ions Alcohol withdrawal s tate A. T he general criteria for withdrawal state mus t met. B . Any three of the following s igns mus t be       (1) tremor of the tongue, eyelids , or hands       (2) s weating       (3) naus ea, retching, or vomiting       (4) tachycardia or hypertension       (5) psychomotor agitation

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      (6) headache       (7) insomnia       (8) malais e or weakness       (9) trans ient visual, tactile, or auditory hallucinations or illus ions    (10) grand mal convuls ions C omment If delirium is present, the diagnosis s hould be alcohol withdrawal s tate with delirium (delirium tremens). A. T he general criteria for withdrawal state mus t met. (Note that an opioid withdrawal state may be induced by adminis tration of an opioid antagonis t after a brief period of opioid us e.) B . Any three of the following s igns mus t be       (1) craving for an opioid drug       (2) rhinorrhea or s neezing       (3) lacrimation

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      (4) mus cle aches or cramps       (5) abdominal cramps       (6) naus ea or vomiting       (7) diarrhea       (8) pupillary dilatation       (9) piloerection, or recurrent chills    (10) tachycardia or hypertens ion    (11) yawning    (12) restless s leep C annabinoid withdrawal s tate Note . T his is an ill-defined s yndrome for which definitive diagnostic criteria cannot be established the present time. It occurs following cess ation of prolonged high-dose us e of cannabis . It has been reported variously as lasting from s everal hours up to 7 days. S ymptoms and signs include anxiety, irritability, tremor of the outstretched hands, s weating, and muscle aches. 1217 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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S edative or hypnotic withdrawal s tate A. T he general criteria for withdrawal state mus t met. B . Any three of the following s igns mus t be       (1) tremor of the tongue, eyelids , or hands       (2) naus ea or vomiting       (3) tachycardia       (4) pos tural hypotens ion       (5) psychomotor agitation       (6) headache       (7) insomnia       (8) malais e or weakness       (9) trans ient visual, tactile, or auditory hallucinations or illus ions    (10) paranoid ideation    (11) grand mal convuls ions 1218 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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C omment If delirium is present, the diagnosis s hould be sedative or hypnotic withdrawal state with C oc aine withdrawal s tate A. T he general criteria for withdrawal state mus t met. B . T here is dys phoric mood (e.g., sadnes s or anhedonia). C . Any two of the following s igns mus t be       (1) lethargy and fatigue       (2) psychomotor retardation or agitation       (3) craving for cocaine       (4) increas ed appetite       (5) ins omnia or hypersomnia       (6) bizarre or unpleasant dreams Withdrawal s tate from other s timulants , inc luding c affeine

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A. T he general criteria for withdrawal state mus t met. B . T here is dys phoric mood (e.g., sadnes s or anhedonia). C . Any two of the following s igns mus t be       (1) lethargy and fatigue       (2) psychomotor retardation or agitation       (3) craving for s timulant drugs       (4) increas ed appetite       (5) ins omnia or hypersomnia       (6) bizarre or unpleasant dreams Halluc inogen withdrawal s tate Note : T here is no recognized hallucinogen withdrawal state. Tobacc o withdrawal s tate A. T he general criteria for withdrawal state mus t met.

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B . Any two of the following signs mus t be       (1) craving for tobacco (or other nicotinecontaining products )       (2) malais e or weakness       (3) anxiety       (4) dys phoric mood       (5) irritability or restles sness       (6) insomnia       (7) increas ed appetite       (8) increas ed cough       (9) mouth ulceration    (10) difficulty in concentrating Volatile s olvents withdrawal s tate Note : T here is inadequate information on states from volatile solvents for research to be formulated. Multiple drug withdrawal s tate 1221 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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Withdrawal s tate with delirium A. T he general criteria for withdrawal state mus t met. B . T he criteria for delirium mus t be met. T he diagnosis of withdrawal state with delirium be further s pecified by using the following: Without convuls ions With convuls ions Ps yc hotic dis order A. Ons et of ps ychotic symptoms must occur or within 2 weeks of s ubs tance use. B . T he psychotic symptoms mus t pers is t for more than 48 hours. C . Duration of the disorder mus t not exceed 6 months. T he diagnosis of ps ychotic disorder may be specified by us ing the following: S chizophrenia-like

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P redominantly delusional P redominantly hallucinatory P redominantly polymorphic P redominantly depress ive s ymptoms P redominantly manic symptoms Mixed F or research purpos es it is recommended that change of the dis order from a nonpsychotic to a clearly psychotic state be further specified as abrupt (ons et within 48 hours ) or acute (onset in more than 48 hours but les s than 2 weeks ). Amnes ic s yndrome A. Memory impairment is manifest in both:    (1) a defect of recent memory (impaired new material) to a degree sufficient to interfere daily living    (2) a reduced ability to recall past experiences B . All of the following are abs ent (or relatively absent): 1223 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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   (1) defect in immediate recall (as tested, for example, by the digit s pan)    (2) clouding of cons cious nes s and disturbance attention, as defined in delirium, not induced by alcohol and other ps ychoactive s ubs tances , A    (3) global intellectual decline (dementia) C . T here is no objective evidence from phys ical neurological examination, laboratory tests , or of a disorder or dis eas e of the brain (especially involving bilaterally the diencephalic and medial temporal s tructures), other than that related to subs tance use, that can reasonably be presumed be res ponsible for the clinical manifes tations described under C riterion A. R es idual and late-ons et ps ychotic dis order A. C onditions and disorders meeting the criteria the individual s yndromes lis ted below s hould be clearly related to s ubs tance use. Where onset of condition or dis order occurs s ubs equent to us e of ps ychoactive substances, strong evidence s hould provided to demonstrate a link. C omments

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In view of the cons iderable variation in this the characteristics of s uch res idual states or conditions s hould be clearly documented in terms their type, severity, and duration. F or res earch purpos es full des criptive details should be If required, use as follows : F lashbacks P ers onality or behavior disorder B . T he general criteria for personality and disorder due to brain disease, damage and dysfunction must be met. R es idual affective disorder B . T he criteria for organic mood (affective) must be met. Dementia B . T he general criteria for dementia mus t be met. Other pers is ting cognitive impairment B . T he criteria for mild cognitive dis order must be met, except for the exclusion of ps ychoactive subs tance use in C riterion D. 1225 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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Late-onset psychotic disorder B . T he general criteria for ps ychotic dis order met, except with regard to the onset of the which is more than 2 weeks but not more than 6 weeks after substance us e. Other mental and behavioral dis orders Uns pecified mental and behavioral dis order

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. C opyright, Health Organization, G eneva; 1993, with In addition to requiring the clus tering of three criteria in 12-month period, DS M-IV -T R includes a few other qualifications. It s tates s pecifically that the diagnos is of dependence can be applied to every clas s of except caffeine. T his point is admittedly controversial, some res earchers (including thos e who authored the section in this chapter) believe, on the bas is of the DS M-IV -T R generic criteria, that caffeine produces a distinct form of dependence, although it is us ually relatively benign. S ome people cons ume s everal categories of drugs concurrently and are clearly drug dependent according the generic criteria, but it may not be poss ible to 1226 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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whether they are dependent on any one s pecific clas s drugs. W hen at leas t three groups of drugs are DS M-IV -T R calls the condition polys ubs tance (T able 11.1-5). DS M-IV -T R also makes provis ion for clas sifying s ubs tance-related dis orders that cannot be clas sified in any of the previous categories (e.g., oxide, anticholinergics, anabolic-androgenic P.1139 steroids) or for an initial diagnos is of dependence or when the specific drug is not known. A s imilar res idual category is included in IC D-10, but steroids are given a distinct code. T he DS M-IV -T R diagnostic criteria for (or unknown) s ubstance-related dis orders are listed in T able 11.1-6.

Table 11.1-5 DS M-IV-TR C riteria for Polys ubs tanc e Dependenc e T his diagnos is is res erved for behavior during the same 12-month period in which the pers on was repeatedly us ing at leas t three groups of (not including caffeine and nicotine), but no single subs tance predominated. F urther, during this period, the dependence criteria were met for subs tances as a group but not for any s pecific subs tance. 1227 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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F rom Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. T ext rev. W as hington, DC : American P s ychiatric Ass ociation; 2000, with permis sion.

Table 11.1-6 DS M-IV-TR C riteria for Other (or Unknown) S ubs tanc e-R elated Dis orders T he other (or unknown) substance-related category is for clas sifying s ubs tance-related disorders ass ociated with subs tances not shown T able 11.1-4. E xamples of thes e s ubs tances , are des cribed in more detail below, include steroids, nitrite inhalants (“poppers ”), nitrous over-the-counter and prescription medications not otherwis e covered by the 11 categories (e.g., antihistamines , benztropine), and other that have ps ychoactive effects . In addition, this category may be us ed when the s pecific unknown (e.g., an intoxication after taking a bottle unlabeled pills ).

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Anabolic s teroids s ometimes produce an initial of enhanced well-being (or even euphoria), which replaced after repeated use by lack of energy, irritability, and other forms of dysphoria. us e of these substances may lead to more symptoms (e.g., depress ive s ymptomatology) general medical conditions (liver disease). Nitrite inhalants (“poppers ”—forms of amyl, butyl, and is obutyl nitrite) produce an intoxication that is characterized by a feeling of fullnes s in the head, mild euphoria, a change in the perception of time, relaxation of smooth muscles , and a pos sible increase in s exual feelings. In addition to poss ible compuls ive us e, these substances carry dangers potential impairment of immune functioning, irritation of the res piratory system, a decrease in oxygen-carrying capacity of the blood, and a toxic reaction that can include vomiting, severe hypotens ion, and dizzines s. Nitrous oxide (“laughing gas ”) caus es rapid ons et an intoxication that is characterized by lightheadedness and a floating s ensation that in a matter of minutes after adminis tration is stopped. T here are reports of temporary but clinically relevant confusion and reversible states when nitrous oxide is us ed regularly. Other substances that are capable of producing

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intoxication include catnip, which can produce states s imilar to those obs erved with marijuana which in high dos es is reported to res ult in acid diethylamide–type perceptions ; betel nut, which is chewed in many cultures to produce a euphoria and floating s ensation; and kava (a subs tance derived from the S outh P acific pepper plant), which produces sedation, incoordination, weight loss , mild forms of hepatitis , and lung abnormalities . In addition, individuals can develop dependence and impairment through repeated adminis tration of over-the-counter and drugs, including cortis ol, antiparkins onian agents that have anticholinergic properties, and antihistamines . T exts and criteria sets have already been define the generic as pects of s ubs tance dependence, s ubs tance abuse, s ubs tance intoxication, and s ubs tance withdrawal that are applicable acros s class es of s ubs tances . T he unknown) s ubs tance-induced dis orders are described in the sections of the manual with disorders with which they s hare phenomenology (e.g., other [or unknown] s ubs tance-induced disorder is included in the mood dis orders Listed below are the other (or unknown) us e disorders and the other (or unknown) induced disorders .

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Other (or unknown) s ubs tance us e dis orders Other (or unknown) s ubs tance dependenc e Other (or unknown) s ubs tance abus e Other (or unknown) s ubs tance-induced Other (or unknown) s ubs tance intoxic ation    S pe cify if:       With perceptual disturbances Other (or unknown) s ubs tance withdrawal    S pe cify if:       With perceptual disturbances Other (or unknown) s ubs tance-induced Other (or unknown) s ubs tance-induced pers is ting dementia Other (or unknown) s ubs tance-induced pers is ting amnes tic dis order Other (or unknown) s ubs tance ps yc hotic with delus ions 1231 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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   S pe cify if:       With onset during intoxication       With onset during withdrawal Other (or unknown) s ubs tance-induced dis order with halluc inations    S pe cify if:       With onset during intoxication       With onset during withdrawal Other (or unknown) s ubs tance-induced mood dis order    S pe cify if:       With onset during intoxication       With onset during withdrawal Other (or unknown) s ubs tance-induced dis order    S pe cify if:       With onset during intoxication 1232 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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      With onset during withdrawal Other (or unknown) s ubs tance-induced dys func tion    S pe cify if:       With onset during intoxication Other (or unknown) s ubs tance-induced s leep dis order    S pe cify if:       With onset during intoxication Other (or unknown) s ubs tance-related not otherwis e s pecified

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

P atterns of R emis s ion and C ours e S pec ifiers B oth systems deal with remis sion by providing distinct modifying terms that can be appended to a diagnos is 1233 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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subs tance dependence. DS M-IV -T R terms are more than those of IC D-10 (T able 11.1-7). T he DS M-IV -T R specifiers for remis sion require a period of at leas t 1 month, after a period of active dependence, during no criteria of dependence are present. If a patient has met any criteria for dependence for at least 1 month fewer than 12 months , the cours e s pecifier is early full remis sion. If the period during which no criteria of dependence are met exceeds 12 months , the s pecifier s us taine d full remis sion can be used. If the full criteria dependence or abuse have not been met for less than year, but one or more criteria have been present, early partial remis sion may be des ignated. If the period 12 months , s us taine d partial remis sion may be us ed. additional remis sion s pecifiers should be used when appropriate: on agonis t the rapy (includes partial and in a controlle d e nvironment. T hus , a heroinpatient or client success fully enrolled in a methadone maintenance program for 12 months is described as in remis sion on agonis t therapy, as are those maintained succes sfully on buprenorphine, a partial agonis t.

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S everal factors , s uch as duration of remiss ion and of a period of dependence, must be cons idered when deciding that a person has fully recovered and no warrants a diagnosis of dependence. T he modifiers describe the course of dependence in IC D-10 are but specific criteria for selecting them are not provided (T able 11.1-4). T he DS M-IV -T R does not use the term “in recovery” to describe any part of the course of remis sion from subs tance use dis orders. It is a term commonly used among patients who are currently abstinent while participating in 12-step programs . Many profess ionals are interacting with such patients also us e it. who were formerly dependent on drugs or alcohol and 1235 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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have been s tably abs tinent for many years may also to themselves as being “in recovery,” typically to the idea that they are vulnerable to relaps e.

S ubs tanc e Abus e DS M-IV -T R defines the ess ential features of s ubs tance abuse as follows : A maladaptive pattern of subs tance use manifes ted by recurrent and s ignificant advers e cons equences related to the repeated us e of subs tances …. T hese problems mus t occur recurrently during the s ame 12month period…. [T ]he criteria for S ubstance Abus e do not include tolerance, withdrawal, or a of compulsive use and instead include only the harmful cons equences of repeated us e. diagnosis of S ubs tance Abus e is preempted by the diagnos is of S ubstance Dependence if the individual's pattern of substance us e has ever met the criteria for Dependence for that class of subs tances . E xpert committees of the W HO have rejected the term “abuse” when applied to drug problems . However, IV -T R task panels have chosen to retain the concept of 1236 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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“subs tance abus e” to des cribe s ocially maladaptive behavior in connection with drug use in the absence of history of drug dependence. T hat is , the progres sion toward drug dependence is defined by DS M-IV -T R to include the poss ibility of drug abuse, but once a pers on meets criteria for drug dependence, the pos sibility of abuse is abs ent with respect to each drug clas s by the DS M-IV -T R . T he DS M-IV -T R criteria for abuse are shown in T able 11.1-8.

Table 11.1-8 DS M-IV-TR C riteria for S ubs tanc e Abus e A. A maladaptive pattern of s ubstance us e clinically significant impairment or distress , as manifested by one (or more) of the following, occurring within a 12-month period:    (1) R ecurrent substance us e res ulting in an to fulfill major role obligations at work, s chool, or home (e.g., repeated abs ences or poor work performance related to substance us e; related abs ences , s uspens ions, or expuls ions school; neglect of children or hous ehold)    (2) R ecurrent substance us e in s ituations in is phys ically hazardous (e.g., driving an or operating a machine when impaired by us e) 1237 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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   (3) R ecurrent substance-related legal problems (e.g., arrests for substance-related dis orderly conduct)    (4) C ontinued s ubs tance use des pite having persis tent or recurrent social or interpers onal problems caus ed or exacerbated by the effects of the substance (e.g., arguments with spous e cons equences of intoxication, phys ical fights ) B . T he s ymptoms above never met the criteria for subs tance dependence for this class of

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. Although rejecting the concept of drug “abuse,” the 10 includes a category of harmful us e, which differs from the DS M-IV -T R concept of “abuse.” T he concept of “harmful us e” is limited to mental and health (e.g., hepatitis and overdose or episodes of depres sive dis order res ulting from heavy alcohol use). concept s pecifically excludes s ocial impairment, “T he fact that a pattern of us e of a particular s ubs tance disapproved of… or may have led to s ocially negative cons equences s uch as arrest or marital arguments is its elf evidence of harmful use.” F our diagnostic criteria 1238 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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must be met to make the IC D-10 diagnosis of harmful P.1140 P.1141 P.1142 P.1143 P.1144

S ubs tanc e Withdrawal S ubstance withdrawal, as used in DS M-IV -T R , is a diagnostic term rather than a technical one. T hus , symptoms that technically are due to cess ation of the of a drug (e.g., the coffee drinker's early morning lethargy or minor headache) do not by thems elves fulfill the criteria for substance withdrawal unles s they are accompanied by a maladaptive behavior change and caus e s ome clinically significant distress or impairment social, occupational, or other important areas of functioning. DS M-IV -T R does not recognize withdrawal from caffeine, cannabis , or P C P , although some believe that specific signs and symptoms can be when those agents are abruptly dis continued after a period of heavy use. IC D-10 does describe a withdrawal state; accumulating evidence sugges ts that cannabis withdrawal s yndrome will be recognized in future revisions of the DS M-IV -T R . Withdrawal is commonly, but not invariably, as sociated 1239 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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with the dependence s yndrome. T he s igns and of withdrawal vary with the specific clas s of drug. In general, the s everity of withdrawal is related to the amount of the substance us ed and the duration and patterns of us e. W ithdrawal is s een not only when the of the substance is stopped but also when reduced change in metabolis m, or the adminis tration of an antagonis t res ults in lower levels of the drug at the relevant s ites of action. T able 11.1-9 s hows the DS Mgeneric criteria for subs tance withdrawal; the IC D-10 general criteria are shown in T able 11.1-4. S pecific diagnostic criteria for withdrawal from each category of drugs, to be us ed when the general criteria have been are als o s hown.

Table 11.1-9 DS M-IV-TR C riteria for S ubs tanc e A. T he development of a subs tance-specific syndrome due to the ces sation of (or reduction in) subs tance use that has been heavy and B . T he s ubs tance-specific s yndrome caus es significant dis tres s or impairment in social, occupational, or other important areas of functioning. C . T he s ymptoms are not due to a general condition and are not better accounted for by 1240 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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another mental disorder.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. Was hington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

S ubs tanc e Intoxic ation Intoxication is defined more narrowly in DS M-IV -T R might be in a pharmacology text. A variety of drugs produce unwanted phys iological or ps ychological that could be construed as intoxication (e.g., exces sive sleepiness after the us e of an antihis tamine), but they are as sociated with maladaptive behavior, thos e effects do not constitute s ubs tance-induced intoxication as DS M-IV -T R defines it. F urthermore, whether a effect is maladaptive depends on the social and environmental context in which it occurs. W hen alcohol makes a pers on unus ually sociable, a bit garrulous , little uncoordinated at a family celebration, it may not maladaptive drinking behavior; the same behavior at a formal bus iness meeting probably is . S imilarly, IC D-10 specifies that intoxication mus t produce disturbances in the level of cons cious nes s, cognition, perception, behavior that are of clinical importance. However, clinicians are to further specify which of s everal complications of intoxication (e.g., trauma, delirium, convuls ions) are also present. In addition, IC D-10 1241 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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specific s ets of diagnos tic criteria for each of the drug categories and for multiple drugs to be used once the generic criteria for intoxication have been met. T he IV -T R general criteria for s ubs tance intoxication are in T able 11.1-10. Also s ee T able 11.1-4 for the IC D-10 additional s pecifiers for complications of intoxication.

Table 11.1-10 DS M-IV-TR Diagnos tic C riteria for Intoxic ation A. T he development of a revers ible s ubs tancespecific s yndrome due to recent ingestion of (or expos ure to) a substance. Note: Different may produce similar or identical s yndromes. B . C linically significant maladaptive behavioral or ps ychological changes that are due to the effect the substance on the central nervous s ys tem belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or functioning) and develop during or s hortly after of the s ubs tance. C . T he s ymptoms are not due to a general condition and are not better accounted for by another mental disorder.

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F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

S ubs tanc e-Induc ed Dis orders In addition to dependence, abuse, intoxication, and withdrawal, certain psychoactive P.1145 drugs can induce syndromes that used to be called me ntal dis orders . T o avoid implying that other disorders do not have an organic bas is , DS M-IV -T R designates thes e s yndromes as s ubs tance -induce d and recognizes the following categories : s ubs tance intoxication, s ubs tance withdrawal, s ubs tance-induced withdrawal delirium, s ubs tance-induced intoxication delirium, substance-induced pers isting dementia, subs tance-induced pers isting amnes tic dis order, subs tance-induced mood disorder, s ubs tance-induced anxiety dis order, substance-induced psychotic subs tance-induced s exual dysfunction, and substanceinduced s leep disorder. When recording a diagnosis of s ubs tance-related the clinician should indicate the s pecific agent causing disorder, if known, rather than the broad drug category. 1243 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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F or example, the diagnos is should be s ubs tanceintoxication, pentobarbital (Nembutal), rather than subs tance-induced intoxication, sedative-hypnotics. However, the diagnos tic code s hould be s elected from list of clas ses of substances provided in sets of criteria the substance-induced dis order being recorded. F or of the s ubs tance-induced dis orders (other than intoxication and withdrawal), the clinician should whether the onset occurred during intoxication or withdrawal. T hus, a s pecific s ubs tance-induced has a three-part name delineating (1) the specific subs tance, (2) the context (whether the dis order during intoxication or during withdrawal or occurs or persis ts beyond those stages ), and (3) the phenomenological presentation (e.g., diazepam induced anxiety disorder with onset during withdrawal). P.1146 T able 11.1-11 s hows the various disorders induced by major categories of drugs recognized by DS M-IV -T R indicates which dis orders are s een during intoxication which during withdrawal. Although they are not specifically in the table, anabolic-adrenergic s teroids also induce ps ychotic mood, anxiety, and sleep and disorders , and their withdrawal can also be ass ociated mood and sleep disorders . Although the current the table in DS M-IV (DS M-IV -T R ) does not s how a withdrawal syndrome, future revis ions may do so.

Table 11.1 1244 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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  Dependenc e Abus e

Intoxic ation

Alcohol

X

X

X

Amphetamines

X

X

X

C affeine

 

 

X

C annabis

X

X

X

C ocaine

X

X

X

Hallucinogens

X

X

X

Inhalants

X

X

X

Nicotine

X

 

 

Opioids

X

X

X

P hencyclidine

X

X

X

S edatives , hypnotics, or anxiolytics

X

X

X

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P olys ubs tance

X

 

 

Other

X

X

X

Note: X, I, W , I/W , or P indicates that the category is rec Delirium); W indicates that the s pecifier With Ons et Duri With Ons et During W ithdrawal may be noted for the cate aAls o

hallucinogen persisting perception disorder (flas hb

F rom American P sychiatric As sociation. Diagnos tic and IC D-10 takes a distinctly different approach to these drug-related dis orders. W ith the firs t and s econd digits after the letter committed to designating the drug category, additional ps ychiatric syndromes are by the us e of the third and fourth digits. F or example, persis tent mood (affective) dis order as sociated with hallucinogens is des ignated F 16.72. F or the diagnosis made, the mood disorder needs to meet the criteria for mood disorders .

E volving Terminology T he terminology used to des cribe the s ubs tancedisorders has been repeatedly revised as concepts the nature of drug-us ing behavior have evolved. In the 1980 third edition of the DS M (DS M-III), drug us e were divided into two major categories, drug abuse and drug dependence, and s pecific criteria for diagnosis 1246 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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provided. In DS M-III-T R , adopted in 1987, the two categories were retained, P.1147 but the diagnostic criteria were modified. F urther were made for DS M-IV -T R , which adopted the terms “subs tance abus e” and “subs tance dependence,” to eliminate the use of the more cumbers ome term “alcohol and drug dependence including tobacco.” F or similar reasons, IC D-10 adopted the term subs tance dependence.” In much of the world literature on drug dependence, term “dependence” is us ed to convey two distinct (1) a behavioral s yndrome, and (2) physical or dependence. P hys iological de pe ndence can be defined an alteration in neural systems that is manifes ted by tolerance and the appearance of withdrawal when a chronically adminis tered drug is dis continued displaced from its receptor. B ecause the dual us e of word causes confusion, a 1980 ADAMHA-WHO group recommended us ing “dependence” only to the behavioral syndrome and s ubs tituting the term “neuroadaptation” for physical dependence. S uch a subs titution would have emphas ized s everal points . the continued us e of many drugs, including some antidepres sants, some selective serotonin uptake inhibitors (S S R Is), and β-adrenergic receptor caus es neuroadaptive changes followed by withdrawal phenomena but not by drug-seeking behavior when are dis continued. S econd, neuroadaptive changes with the first dose of an opioid or sedative drug, and, therefore, s uch changes in and of thems elves are not a 1247 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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sufficient caus e (or definition) of drug dependence as a behavioral s yndrome.

Why Us e “A ddic tion”? T he words “addict” and “addiction” often have connotations . Often, they are trivialized and are used to refer to frequently engaging in ordinary activities s uch exercising or solving cross word puzzles . However, “addiction” continues to have the core connotation of decreased control, and s ome chapters in this book retained s uch terms as “opioid addict” simply becaus e are les s awkward than “severely opioid-dependent person.” Here, the word “dependent,” unmodified, is to mean behaviorally dependent. T he term de pendence or phys ical de pe ndence is us ed to refer to phys iological changes that res ult in withdrawal when drugs are discontinued.

C OMP A R A TIVE NOS OL OG Y DS M-IV-TR and IC D-10 T he generic concept of dependence is virtually DS M-IV -T R and IC D-10. B y requiring the clinician to whether tolerance and withdrawal are pres ent, DS Mappears to recognize a s pecial s ignificance for and phys iological dependence. S ome data indicate among alcoholics , the pres ence of phys ical and, to a less er degree, tolerance, is as sociated with a severe variety of the syndrome. In practice, however, requiring evidence of these criteria does not reduce the number of cas es meeting the criteria for dependence in most drug categories, with the of hallucinogens , a class of drugs for which DS M-IV -T R 1248 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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does not lis t phys iological dependence as a criterion. T here is generally a high level of agreement between IV -T R and IC D-10 for making a diagnosis of although the descriptions of the criteria for determining the presence and severity of the syndrome differ. T hey both require that three elements of the syndrome have been present in a 12-month period. T he DS M-IV -T R categorization of drug class es differs somewhat from one us ed by IC D-10, which, constrained by a new alphanumeric system, uses only nine drug categories including caffeine with amphetamine-like stimulants P C P with other psychoactive agents . T he word abus e is also commonly us ed in ways that significantly from the definitions developed for use in DS M-IV -T R . In popular and legis lative contexts, drug means any use of an illegal s ubs tance or any nonpres cribed us e of a drug intended as a medicine as well as the harmful or excess ive use of legally available subs tances such as alcohol and tobacco. In this the authors have chosen to use the term ille gal in lieu illicit wherever pos sible because illicit carries with it a moral connotation that is not carried by the term illegal. S ome exceptions appear in figures taken from works. Des pite the reliability of DS M-IV -T R and IC D-10 criteria dependence in many E uropean and Anglo-American cultures, several criteria (e.g., narrowing of drinking repertoire, time spent obtaining the drug, and even tolerance for the drug) have pos ed difficulties in other cultures, es pecially when dealing with alcohol. often mis understood when applied to alcohol; in some cultures, holding one's liquor is a s ign of manhood. 1249 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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C linicians are more likely to make a diagnos is of drug dependence than alcohol dependence even when behavioral s igns are comparable. In several cultures , or no distinction is recognized among us e, abus e, and harmful us e of illegal drugs .

Other Pers pec tives T he criteria for diagnos is in DS M-IV -T R and IC D-10 developed from what is es sentially a biopsychosocial model of drug dependence. In such a model, multiple factors —genetic, psychological, sociological, and pharmacological—contribute to the observed clinical syndromes. S uch apparent unanimity about drug dependence s hould not obscure the existence of diss enting perspectives, which take s everal forms. In the biops ychos ocial model is criticized as giving too weight to biological factors and too little recognition to the notion of human will and responsibility, of medicalizing deviant behavior for the benefit of profes sionals, and of creating universal exculpation for those who do not live up to reas onable societal expectations . B ut some profess ionals have implicitly criticized the P.1148 P.1149 same biopsychos ocial model for not giving s ufficient weight to the ideas that substance dependence is a specific primary disease (i.e., not a s ymptom of other ps ychiatric difficulties ), that those who develop the have no control over their intake of certain substances, 1250 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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and that denial of the pres ence of a problem can be a major characteris tic of the disease. C oncepts about substance dependence can be along several dimensions that are not entirely independent or orthogonal: broad versus narrow, versus learned behavior, and social vers us medical. narrow concept of substance dependence accepts as disorders thos e maladaptive behaviors as sociated primarily, if not exclus ively, with the inges tion of subs tances generally accepted as pharmacological C ompulsive eating, gambling, running, hair pulling, and repetitive exces sive sexual activities are not included among the dependence disorders , although thos e problems may s hare certain features that resemble a decreased ability to choos e and are s ometimes ameliorated by participation in support groups founded on principles s imilar to those of Alcoholics Anonymous (AA). A broad approach creates a superclas s of that include a number of s uch behaviors not involving pharmacological agents . At the disease end of the dis eas e-versus -behavioral syndrome dimension is a belief that dependence is not learned behavior that can be modified or ameliorated relearning but is a primary disorder caus ed by an interaction between a drug and a pers on with s ome genetic vulnerability and that only total abstinence can arrest the progress ion of the disease. T he medicalsocial dimens ion typically describes a range of views how bes t to res pond to problems with s ubs tances , than differences about the es sential nature of the problems . T he medical model s tres ses iss ues of as sess ment—treatment, planning, and record 1251 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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and s ometimes treatment that can be rendered only by those with profess ional training (not necess arily phys icians ). T he s ocial model emphas izes the of social s upports and integrating the person with a problem into a network of recovering people who can offer continuing s upport. T he ass ess ment and progres s and outcome as generally practiced by credentialed profess ionals are minimized.

HIS TOR Y T he most commonly us ed drugs have been part of exis tence for thous ands of years. F or example, opium been used for medicinal purpos es for at least 3,500 references to cannabis (marijuana) as a medicinal can found in ancient C hinese herbals , wine is mentioned frequently in the B ible, and the indigenous people of Wes tern Hemisphere were s moking tobacco and coca leaves generations before the arrival of the S ome of the problems caused by alcohol and other such as drunkennes s, are described in the B ible and in writings of the ancient G reeks and R omans . As new more concentrated forms of drugs were discovered or invented or new routes of adminis tering them were developed, new problems related to their us e emerged. 18th-century E ngland, for example, the alcohol-related problems seen after the introduction of cheap gin were cons idered more serious than those as sociated with and wine. Although, in As ia, opium s moking was a problem in the 18th and 19th centuries, new problems related to opium were seen there and in other parts of world after morphine, its most active alkaloid, was in 1806. W ith the introduction of the hypodermic needle the mid-19th century, morphine could be injected and 1252 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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became s ubject to mis us e by that route. Intravenous morphine and heroin us e began to spread in the early of the 20th century. T echnology also influenced the us e tobacco and the problems related to it. Although us e was common by the 19th century, the serious medical consequences as sociated with it did not until the 20th century, when new methods of curing the leaves produced a mild smoking tobacco, and were introduced. C igarettes made common the inhaling tobacco smoke deeply into the lungs . B y the 20th century, cigarette s moking was a popular practice, and lung cancer was recognized as a consequence of cigarette use. It took an additional 20 years for it to become generally accepted that tobacco has the to induce dependence.

Medic alizing E xc es s ive Drug Us e In 1810, B enjamin R ush, who is often credited as the American phys ician to s uggest that exces sive use of alcohol was a dis eas e rather than exclus ively a moral defect, propos ed the establishment of a sober hous e; 1835, S amuel W oodward, a pioneer in the as ylums for the ins ane, advocated s imilar as ylums for inebriates . C ontemporaneous with those early moves involve medicine in dealing with exces sive alcohol us e the emergence of the temperance movement and the Was hingtonians—groups of reformed drunkards concerned with helping others to adopt and maintain sobriety. In the process , the W ashingtonians many of the principles of s elf-help that were by AA almost a century later. W hen the ideas of voluntarism and s elf-help, as exemplified by Was hingtonian s ocieties, failed to eliminate the 1253 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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drunkenness , physicians began to debate more the idea of coerced treatment in inebriate as ylums supported by public funds. In 1870, advocates of the approach established the American As sociation for the C ure of Inebriates (AAC I), dedicated to setting up for such people, conducting res earch, and teaching medical students and phys icians how to treat inebriety. first, thos e phys icians who believed in a more s piritual, voluntary approach to the problem (neowere part of the AAC I, but, gradually, the more oriented factions , which advocated medically as ylums (and compuls ory treatment when needed), gained as cendancy. F urthermore, the focus of concern no longer limited to thos e who abused alcohol. T homas C rothers, the secretary of AAC I, s aw inebriate asylums places to treat all those who used any variety of or narcotic to exces s. However, very few publicly supported inebriate as ylums ever opened.

E arly Attitudes T he clos ing years of the 19th century s aw growing about the excess ive and inappropriate use of drugs , including alcohol and tobacco, as well as opiates and cocaine. F irs t isolated from the coca leaf in 1860, came into wides pread us e in 1885 when companies began s elling it in the United S tates and E urope. In 1884, S igmund F reud published a review of potential therapeutic uses of cocaine. S ome medical authorities in the United S tates shared his enthus ias m, cocaine was recommended by the Hay F ever as a remedy for that malady. W ithin a few years, it was recognized that cocaine had the capacity to toxic ps ychos is as well as “habitual” or compulsive use 1254 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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other features of a dependence syndrome. It was also recognized that long-term opiate us e had dependenceinducing effects . Nevertheles s, in the United S tates, the beginning of the 20th century, the opium alkaloids cocaine were s till found in patent medicines that were over the counter without pres cription for a wide variety indications , and their labeling often did not reveal their contents. Although achieving long-term cure of morphinis m was reported to be exceedingly difficult, neither the public the medical profess ion viewed the habitual user of or morphine as invariably having a moral deficit. T hose who had developed the morphine habit repres ented the entire socioeconomic s pectrum, with women outnumbering men by approximately two to one. political and literary figures were known to us e opiates to lead otherwis e productive and exemplary lives. with emotional problems and thos e who had formerly us ed alcohol to exces s were probably als o overrepres ented among opium us ers because it was unusual at the time for phys icians to pres cribe opiates control emotional problems and alcoholis m. However, cocaine use and the morphine habit were als o common among gamblers, petty thieves , prostitutes , and other disreputable members of society. T he problem of us ing the same institution for the treatment of drug us ers who had antisocial tendencies those who led more conventional lives P.1150 was jus t as vexing to early advocates of medical as it is to present-day practitioners . Many proponents 1255 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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inebriate asylums did not want to take responsibility for people who had frequent or serious encounters with police because it was believed that s uch people made impos sible to create an atmos phere conducive to recovery. P artly to cope with the problem, even some the proponents of a dis ease model of inebriety the distinction between “inebriety the dis eas e” and “intemperance the vice.”

E arly C ontrol E fforts : E volution of C riminal Model B y the late 1890s, the public and the medical were no longer indifferent to drug use and habituation. 1893, the Anti-S aloon League was founded, a temperance movement that advocated the total prohibition of alcohol. Medical texts in E ngland, and the United S tates contained descriptions of morphinis m, theories of its causation, and recommendations for withdrawal and pos twithdrawal treatment. S ome texts als o described problems of cocainism. Medical authorities in the United S tates cautioned agains t overly liberal prescribing of cocaine opiates by phys icians and express ed great concern the presence of those drugs in unlabeled proprietary the-counter medicines. S tate laws were pas sed that at controlling the sale of opiates and cocaine, patent medicines . In 1903, the cocaine in C oca-C ola replaced by caffeine. P artly to s upport the efforts of the C hines e government control opium us e in C hina, repres entatives of the S tates government led the movement to negotiate an international treaty to control traffic in opium, cocaine, 1256 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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and related drugs. T he firs t such treaty was signed in Hague in 1912. Negotiators from the United S tates also interested in the international control of cannabis could not get other nations to view the s ubs tance as sufficiently problematic to warrant it. (S uch control was achieved in 1925 at the S econd G eneva C onvention.) Hague C onvention required the s ignatories to pass domes tic legis lation controlling opiates and cocaine. Harrison Act of 1914, the firs t federal legislation to opiates and cocaine in the United S tates, was res trict access to opiates and cocaine to doctors, pharmacists , and legitimate importers and it brought the United S tates into compliance with the convention. Within the United S tates, state regulations concerning sale of opiates and cocaine, the introduction of aspirin the barbiturates , and the P ure F ood and Drug Act of which required labeling of patent medicines , were having an impact on the us e of opiates in medicine the Harrison Act was pas sed in 1914. Although many medical and political leaders in the United S tates that much of the problem of drug dependence resulted from careless prescribing by phys icians, the Harrison was not originally intended to interfere with the practice of medicine or to caus e s pecial hardship for already dependent on opiates . F or several years after Harrison Act was pass ed, a few cities operated clinics prescribed morphine to people with es tablis hed habits . Mos t of thos e dependent on opiates before the Harrison Act became abs tinent within a few years after was pass ed, although generally not as a res ult of at the clinics . 1257 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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Fluc tuating Attitudes Major changes had taken place in American attitudes practices by the 1920s . T he 18th Amendment to the C ons titution, which prohibited the s ale of alcohol, law in 1920 and radically changed drinking behavior in United S tates . W ithin a year after alcohol prohibition enacted, 14 s tates also pas sed cigarette prohibition E ven less popular than alcohol prohibition, thos e antitobacco laws were all repealed by 1927, and by the 1920s , Americans were s moking 80 billion cigarettes a year. However, cocaine us e, so prevalent at the turn of century, was no longer wides pread. Dis illusioned by the reluctance of morphine addicts at clinics to detoxify and by repeated relaps es among who did, doctors began to recommend (not for the firs t time) compulsory treatment with confinement until cure. As the new laws curtailed legitimate s upplies of illegal traffic developed to provide them to morphine addicts who could not or would not us e the clinics. Increasingly, the drug s old was heroin, which had been introduced for medical use in 1898 but was quickly by drug us ers to have effects quite similar to those of morphine. Many who patronized the illegal traffickers us ed the clinics had his tories of delinquency and activity, and, eventually, that subgroup came to predominate. R eformers, moralists, and the popular found in the opiate habit, and in the reputation of thos e who continued to us e morphine, proof of the evils inherent in those drugs. Negative publicity, lurid stories, medical and press ure from law enforcement agents combined 1258 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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label the morphine clinics as medical folly and brought about their closing, the las t in 1923. At the s ame time, series of U.S . S upreme C ourt decis ions implied that prescribing even s mall amounts of opiates or cocaine addict for treatment of addiction was not proper practice and was thus an illegal sale of narcotic drugs. S everal physicians were imprisoned, and numerous were tried, reprimanded, or otherwise harass ed. B y the early 1920s, people addicted to opiates were not in doctor's offices , and they were often refus ed at hos pitals . Dope addict and dope fiend had become common terms, and the average laypers on, as well as some otherwise well-informed members of the medical profes sion, appeared to believe that the opiate was inherently evil. In the late 1930s , cannabis similar reputation, and in 1937, the U.S . C ongress tax legis lation prescribing criminal penalties for its us e, sale, or poss es sion. Alcohol prohibition had been in 1933.

New Drug Problems T he firs t of the barbiturate s edatives , barbital, was introduced into clinical medicine in 1903, followed over the next 30 years by scores of congeners that differed primarily in their duration of action. Within a few years after the introduction of each new compound, the first case reports of mis use, dependence, and withdrawal appeared in the medical journals , a pattern that was repeated with the nonbarbiturate s edatives, such as glutethimide (Doriden), ethchlorvynol (P lacidyl), and meprobamate (Miltown), in the 1950s . Amphetamine, firs t synthesized in 1887, was put into 1259 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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clinical us e in 1932 as a drug to s hrink mucous membranes. B y 1935, its central stimulant effects had recognized and found us eful for treating narcolepsy, dozens of other suggested us es soon followed. that amphetamine was being used as a euphoriant to appear in the late 1930s , but the full s ignificance of potential to caus e harm was not appreciated until the post–World W ar II epidemic of IV methamphetamine addiction in J apan. T hat epidemic, precipitated by the of surplus methamphetamine tablets intended for troops , involved millions of people. Other like drugs, which have also been s ubject to mis use, introduced during the 1950s and early 1960s . T he ps ychological effects of mes caline were already known and written about at the end of the 19th century. However, public concern about hallucinogens did not reach a high level until the 1960s, when the use of a discovered and exceedingly potent compound, lys ergic acid diethylamide (LS D), evolved from experimentation the intellectual elite and a few college s tudents to more widespread use by even younger people. P C P , a anesthetic developed in the 1950s , also became a drug abuse in the 1960s and 1970s . Des pite repeated reports of abus e and dependence as sociated with barbiturates, barbiturate-like sedatives , and amphetamines and related s timulants and in spite concerns about experimentation with LS D and related hallucinogens, there were no federal criminal sanctions related to thes e drugs until 1964, when authority for control was as signed to the F ood and Drug (F DA). In contrast, in the 1950s , concern about heroin addiction had led to ever harsher criminal penalties for 1260 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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sale or poss ess ion. Although law enforcement efforts aimed at controlling heroin use were increas ed, both number of new heroin us ers and the crime rates to increas e throughout the late 1960s . At about that there was also a s harp increas e in the nonmedical us e other s ubs tances , s uch as cannabis and LS D, and a epidemic of amphetamine mis us e and dependence. In addition to amphetamines diverted from medical channels , s upplies came P.1151 from clandes tine laboratories. Drug us e, es pecially cannabis , became linked to antiestablishment attitudes, politics , and lifes tyles . T hrough the mid-1970s in the United S tates, there was subs tantial increase in experimentation with cocaine followed by increases in heavy cocaine us e. S tarting in late 1980s , there was an upsurge in methamphetamine us e that was driven by a proliferation of illegal laboratories. S ubsequently, there has been an increas e the popularity of drugs s uch as 3,4methylenedioxymethamphetamine (MDMA) and γhydroxybutyrate (G HB ), now often referred to as club because they are typically us ed at marathon-like dance parties (“raves ”).

E volving Treatment Approac hes T reatment for drug- and alcohol-related problems underwent several dramatic changes during the 20th century. T he large specialized as ylums that were advocated in the 19th century never materialized. the end of the 19th century, physicians were primarily 1261 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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concerned with how to manage withdrawal s yndromes and whether longer compuls ory treatment was needed. With the advent of prohibition, the impetus to develop treatments for alcoholis m declined s harply. Interes t in treating opioid-dependent patients also declined as phys icians became dis couraged by their patients ' tendency to relapse after being detoxified and as opioid us e and dependence came to be seen more as behaviors than as medical dis orders. A few private sanatoriums continued to provide treatment for opioid dependence. B y 1930, after a change in federal policy drug-addicted pris oners began to fill the penitentiaries , the federal government es tablis hed two hospitals, at Lexington, K entucky, and F ort W orth, T exas , to provide treatment for that population and also to conduct on opiates and opiate addiction. T reatment for and amphetamine dependence took place largely in mains tream of medical practice and in s tate hos pitals , there was no consensus on what constituted effective posthospital care. In the mid-1930s , two recovering alcoholics the principles of the W ashingtonians, added s ome new principles, and initiated the s elf-help movement now known as AA. B y the 1950s , this movement had begun inspire analogous s elf-help efforts among other types drug us ers . T he situation changed again in the early 1960s . W ith outbreaks of heroin use by young people and crime, the federal government and individual states attempted to respond to the problem. C alifornia civil commitment program for addicts under the adminis trative control of the Department of C orrections ; 1262 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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New Y ork C ity reopened R ivers ide Hospital to treat heroin addicts. T he first follow-up studies of patients treated at the federal hospital at Lexington, K entucky, revealed exceedingly high rates of relaps e after B oth the medical community and the general public demanded new ideas and s olutions, including a recons ideration of providing opiate addicts with opioids through medical channels . F rom 1958 to 1967, several major new approaches to treating opioid dependence were developed. S ynanon, prototype therapeutic community for treatment of drug dependence, was s tarted in C alifornia in 1958 and was s oon replicated in New Y ork with the Daytop V illage and P hoenix House. V incent Dole and Nys wander s howed that maintaining s elected longheroin addicts on large daily doses of methadone (Dolophine) was effective in reducing crime and heroin us e. S everal research groups demons trated that heroin addicts voluntarily tried treatment with narcotic antagonis ts. In the mid-1960s , New Y ork S tate and the federal government legis lated civil commitment modeled after the program in C alifornia, with an initial period of prolonged ins titutional care as a key element. Although many treatment programs initiated in the 1960s continued to focus on the treatment of opioid dependence, others , especially the therapeutic communities, viewed all nonmedical drug us e as stemming from s imilar defects in character s tructure offered a generic approach to treating drug E ach of these general approaches has evolved and incorporated findings from an unprecedented of government-funded res earch on treatment methods 1263 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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and outcome. Among the methods that found their way into both publicly s upported programs and individual practices was the us e of cognitive-behavioral and prevention techniques.

A lc ohol and Nic otine In the 1950s, clinicians at Wilmar S tate Hos pital in Minnesota developed a treatment program for built on a synthesis of the medical model and the experiences of individuals recovering from alcohol dependence us ing the 12-step principles of AA. T hat treatment approach was refined and expanded at the J ohns on Ins titute and Hazelden F oundation, als o in Minnesota. T he modified programs , widely adopted by others , are often referred to as 28-day programs , 12programs , or the Minne s ota mode l. In the early 1970s, effort to recognize alcoholism as a dis eas e gained momentum, and the decision of medical ins urance to provide coverage for detoxification and inpatient treatment fueled an unprecedented growth of privatesector facilities offering treatment for alcoholism. without exception, they were res idential programs the Minnesota model. T he decriminalization of public intoxication spurred a parallel increase in alcohol treatment programs supported by the public s ector. T he S urgeon G eneral's R eport of 1964 linked cigarette smoking to lung cancer and concluded that tobacco smoking was a form of dependence, although not an addiction. B y the 1970s, tobacco dependence was widely accepted as a valid clinical entity, and various treatments for it were developed. B y the late 1980s , as smoking was becoming socially unacceptable, many 1264 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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buildings were declared s moke free, smoking was on most airplane flights and in many hospitals , and pharmaceutical companies began to market new for delivering nicotine (e.g., nicotine chewing gum and transdermal patches) as aids for smoking cess ation. B y late 1990s , the tobacco companies were negotiating settlements in multiple civil lawsuits by states and by individuals who had been injured by their tobacco use, and C ongres s had debated major tax increases on and regulation by the F DA.

Two-Tiered S ys tem As the cocaine epidemic of the 1970s and 1980s s truck middle clas s, much of the large, private-sector system treating alcoholism evolved into chemical dependency units offering similar treatments to people with alcohol problems and thos e with other varieties of subs tance dependence. B y 1990, it was es timated that more than 8,000 recognized programs exis ted that dealt with alcoholism and other s ubs tance dependence. (T he es timate at the turn of the 21s t century was 12,000.) treatment methods us ed varied widely in terms of costs , philosophical underpinnings , and populations served. New categories of drug treatment profes sionals had emerged, and psychiatrists who once had the problems to be a low-status area s ucces sfully for the creation of a recognized s ubs pecialty in ps ychiatry. T reatment capacity was described as a tiered system with private and public s ectors in which private s ector served 40 percent of the population but received 60 percent of the total expenditures for treatment. One res ponse to the es calating cos t of drug treatment s ervices among thos e with private medical 1265 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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insurance was the ris e of a managed care industry to control cos ts on behalf of employers who pay for insurance, generally by severely limiting the length of in hos pital s ettings . Managed care, by refusing to recognize (and pay for) the medical neces sity of treatment for most cas es of drug or alcohol largely dismantled the “28-day” inpatient alcohol and treatment programs that had serviced patients with insurance. B y the mid-1990s , managed care principles were routine in the public s ector as well, and little remained of the res idential component of the two-tiered system. T here are s till two tiers of treatment in that some individuals with private res ources or insurance have to a wider variety of treatment opportunities . T hose do have insurance or their own funds mus t rely on the availability of publicly supported programs . T hese programs are often unable to accept new patients in a timely way. T he 1990s s aw increased effort to provide treatment to incarcerated individuals with drug dependence problems . Als o, there was subs tantial expansion of “drug courts ” in which judges with s pecial interes t us ed their authority to motivate (or coerce) us ing offenders to P.1152 accept treatment. In s ome cases, the treatment was coerced abstinence in which the court mandated drug testing (usually urine tests ) and s pecified periods of incarceration for continued drug use.

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In 1969, C ongres s recognized the need to give greater attention to the problem of alcoholism and es tablished National Ins titute on Alcohol Abuse and Alcoholis m (NIAAA) in the National Ins titute of Mental Health In 1970, new federal controlled s ubstances legis lation pass ed, reorganizing the jumble of drug regulatory statutes that had evolved s ince the pass age of the Act, increasing the res ources for controlling the of illegal drugs . S hortly thereafter, the task of was given to a new agency, the Drug E nforcement (DE A), which incorporated elements of the F DA and B ureau of Narcotic and Dangerous Drugs. All drugs to special controls were included in one of several categories of the C ontrolled S ubstances Act (C S A). In 1971, when U.S . troops in V ietnam were reported to us ing heroin heavily, the S pecial Action Office for Drug Abuse P revention (S AODAP ) was es tablis hed in the executive office of the pres ident to coordinate government activities and policies relating to drug and to develop and publish an overall national drug strategy. T he creation of that office and the ass ociated legis lation marked a turning point in U.S . drug policy. notion that opioid dependence was an incurable which jus tified the harshest of penalties in the name of prevention, was supers eded by a policy that that a s ubs tantial proportion of drug-dependent individuals could eventually reenter the mainstream of society. New commitments were made to basic epidemiology, development of new treatment methods , and evaluation of existing treatment approaches . Methadone maintenance was moved, by executive fiat, from the legal limbo of experimental s tatus to a 1267 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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that recognized its legitimacy. R egulations intended to prevent inappropriate prescribing of opioids were developed. F ederal s upport for the expans ion of community treatment programs was also greatly increased. T he legis lation that es tablished S AODAP provided the legislative framework for the National Ins titute on Drug Abus e (NIDA) in the Department of Health, E ducation, and W elfare (HE W). W hen it was es tablis hed in 1974, NIDA became the lead agency for implementing federal policy on treatment, research, prevention. S AODAP was ended in 1974 but was succeeded by s everal similar drug policy coordinating offices (currently the Office of National Drug C ontrol [ONDC P ]) located within the executive office of the president. B y the early 1980s , treatment for opioid dependence generally accepted to have demonstrable impact. However, for most patients in treatment programs, the primary drugs of choice were no longer opioids but, typically, cannabis, stimulants, or sedatives. In the and mid-1970s , some groups had argued for the decriminalization or legalization of cannabis. T he arguments los t much of their force when it was found in 1979 almost 10 percent of high s chool students were us ing cannabis on a daily bas is . In res ponse to what perceived as tolerance toward cannabis use, a number parents ' organizations were formed that were to making all drug us e unacceptable. T hos e groups NIDA to review and remove from all its publications any statements that could be interpreted as tolerating drug us e. T his decreas ed tolerance for drug us e grew in with a more general cons ervative s hift in public 1268 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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F or example, in the 1970s , the public and the courts rejected the use of urine testing as a means of drug us e in an effort to interrupt the heroin epidemic; starting in 1986, federal employees were required by presidential order to undergo s uch tes ts . S imilar drug tes ting was encouraged in private indus try, giving ris e new indus tries for detecting the pres ence of drugs, interpreting tes t results, and placing drug users in treatment. B y the 1970s, it was obvious that the major drug in the United S tates in terms of s ocial and economic impact and health costs were alcoholism and tobacco dependence. Although the S urgeon G eneral's R eport 1964 linking cigarettes to cancer had not produced any dramatic immediate decreas e in s moking, the rate of increase in cigarette cons umption among men had to level out. In 1988, the S urge on G e neral's R eport on Health C ons e que nce s of S moking officially defined dependence as analogous to other varieties of drug dependence. In 1994, the F DA held hearings on the appropriatenes s of regulating the nicotine in tobacco as addictive drug. S hortly thereafter, with backing from the president, the F DA as sumed authority to regulate advertising of tobacco products ; the W hite House C ongres s to pas s legislation that would limit advertis ing and increase federal taxes on tobacco. Legislation was pass ed. T he U.S . S upreme C ourt rejected the F DA's as sertion of authority, s tating that s pecific authority to regulate tobacco would be required. In the major tobacco manufacturers negotiated a with 46 of the 50 states (the Master S ettlement Agreement), which awarded the s tates more than $200 1269 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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billion over 20 years , provided that they pass legis lation that prevents any tobacco manufacturers that did not the agreement from selling cigarettes without paying a special tariff. T his allowed the major tobacco increase their prices to pay the s tates the agreed-on B y the mid-1980s , increasing demand for the treatment cocaine dependence, the s udden cocaine-induced of several prominent athletes , and concern about the spread of human immunodeficiency virus (HIV ) and acquired immune deficiency s yndrome (AIDS ) among drug us ers led to additional legis lation that authorized government to spend nearly $4 billion to intensify agains t drugs and drug problems. Although most of money was allocated to law enforcement activities , res ources for the treatment of drug dependence and res earch were also substantially increased. T hereafter, federal government created a s eries of offices that into the S ubstance Abus e and Mental Health S ervices Administration (S AMHS A) with s everal cons tituent including the C enter for S ubs tance Abus e T reatment (C S AT ) and the C enter for S ubs tance Abus e (C S AP ). C ritics of the emphas is on s upply control public attention when they were supported by s everal prominent conservative writers and economists and garnered the financial support of several well-endowed foundations. Although the more thoughtful of these have stopped calling for outright legalization of drugs , they have called for greater emphas is on reducing the harm related to drug us e by medically pres cribing and other psychoactive drugs and more support for needle-exchange programs. Despite s ome evidence suggesting that availability of s terile needles can 1270 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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HIV transmis sion, the federal government continues to the us e of federal money for s uch programs. Although largely rejected at the federal level, the thrust toward harm reduction has gained s ome momentum in some states in which penalties for poss ess ion of cannabis have been reduced, and its medical purposes has been approved. In 2000, C ongres s pass ed legislation that allows with s pecial training to provide office-based treatment to pres cribe an opioid for opioid-dependent patients . C urrently, the only opioid that meets the legis latively specified criteria is buprenorphine, a partial opioid

E P IDE MIOL OG Y Most of epidemiology's contributions to the unders tanding of the drug dependence s yndromes can sorted in relation to five main s ubs tantive rubrics plus a separate rubric for theoretical and methodological res earch on core concepts, measurements , and other details of res earch approach. T he five main substantive rubrics and examples of the as sociated research are s hown in T able 11.1-12.

Table 11.1-12 E pidemiology's R ubric s F ive main s ubject matter rubrics and examples of res earch ques tions 1271 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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   Quantity: How many in the population are becoming drug dependent for the first time each year?    Location: W here, within the population, are we more and less likely to find people becoming drug dependent?    C auses: W hat accounts for s ome people drug dependent, whereas others remain    Mechanis ms : What is the pathogenesis , natural history, and clinical course of drug dependence observed in drug-dependent people identified in community, compared with those identified when they are incarcerated for drug-related crimes or when they otherwis e come to official attention?    P revention and control: W hat can be done to prevent or delay the onset of drug dependence to shorten or ameliorate the burden of drug dependence when it occurs ?

Adapted from Anthony J H, V an E tten ML. E pidemiology and its rubrics. In: B ellack A, eds. C omprehe ns ive C linical P s ychology. Oxford, E ls evier; 1998. In the field of drug dependence res earch, epidemiology 1272 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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may be known best for contributions under the rubric of quantity.” E pidemiological field s urveys to quantify the burden of inebriety and habitual use of opiate drugs added to community surveys of mental illness in the quarter of the 19th century during the era of P.1153 increasing concern about drunken behavior and the misuse of over-the-counter patent medicines opiates and cocaine. B eginning in the 1960s , a number of distinct methods designed to gauge the extent and consequences of subs tance use, abuse, and dependence have been developed and have been progres sively improved. C urrently, the major recurring s urveillance ins truments the United S tates are the National Household S urvey Drug Abus e (NHS DA), the Drug Abuse Warning (DAWN), Arres tee Drug Abus e Monitoring S ys tem formerly known as the Drug Us e F orecas ting [DUF ] program), and the Monitoring the F uture S tudy (MT F ), known as the High S chool S urvey. In addition, data on availability and purity of illegal drugs , drug seizures , arrests for drug offenses are collected nationally from DE A and the F ederal B ureau of Investigation (F B I) and locally from municipal police departments . E ach of data s ources has strengths and limitations . T he (recently renamed the National H ous e hold S urve y on Us e and He alth) annually interviews a repres entative sample of individuals aged 12 years and older living in households, college dormitories, homeless shelters, rooming hous es. It overs amples minority populations certain large urban areas and focuses in detail on drug1273 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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us ing behaviors . It does not interview military individuals who are living on the s treet or in institutions (jails or hospitals). S ince 2000, it has als o included questions designed to measure s ubs tance dependence and abuse bas ed on DS M-IV criteria and to determine whether res pondents believe they need treatment, and as ks what type of treatment, if any, they have received the pas t year. Other developments have included an increase in s ample size, from less than 8,000 in the survey in the 1970s to more than 50,000 in more years , and the deliberate probabilis tic overs ampling of certain metropolitan areas and disadvantaged minority groups . B ecause of the new sample sizes and NHS DA can now produce remarkably precise some years, there has been ass es sment of s uspected determinants or cons equences of drug taking, s uch as major depres sion. Analys is of the 2001 NHS DA indicates that 16.6 million people in the United S tates aged 12 years or older (7.3 percent of the population) could be considered to be abusing or dependent on alcohol (but not illegal drugs); 2.4 million, abusing or dependent on both alcohol and illegal drugs ; and 3.2 million, abusing or dependent on illegal drug (but not alcohol). T hese es timates are illus trated in F igure 11.1-1. Approximately one-half of 16.6 million people (8.2 million) were considered subs tance dependent. Of those, 4.5 million were dependent on alcohol only, 2.7 million were dependent illegal drugs but not alcohol, and 0.9 million were dependent on both alcohol and illegal drugs. W hen the analysis is limited to those who have used a given drug the pas t year, the proportion with dependence or abus e 1274 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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increases. F or example, 9.3 percent of past-year users alcohol, approximately 50 percent of pas t-year heroin us ers , and 25 percent of past-year cocaine us ers are clas sified with dependence or abus e of thos e drugs . past-year users of marijuana, dependence or abuse is cons idered present in only 16.5 percent, but because the total number of marijuana users, the number of with cannabis dependence or abuse (3.5 million) the number dependent on heroin and cocaine

FIGUR E 11.1-1 E s timates of past-year s ubs tance dependence or abuse among people 12 years of age or older in the United S tates , 2000 and 2001. (F rom Hous ehold S urvey of Drug Abuse; 2001, with

C orrelates of G ender, E duc ation, 1275 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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E mployment, and Age of Firs t Us e Men are twice as likely as women to be considered dependent on or abus ers of alcohol or illegal drugs , 10 percent; women, 4.9 percent). T here is little gender difference with respect to tobacco dependence. Adults who did not complete high s chool are more likely than college graduates to have become dependent on illegal drugs (3.7 percent for those with les s than a high education, 0.9 percent for college graduates ), although alcohol dependence or abuse is not particularly with educational level. T he unemployed are almost as likely as thos e employed full time to be categorized dependent on illegal drugs or alcohol (15.4 percent, compared with 7.9 percent). Adults who first used a younger age are more likely to have developed dependence or abuse than thos e who s tarted later. F or example, 12 percent of thos e who tried marijuana by years of age are clas sified as dependent on or abusers an illegal drug, compared with 2 percent of those who us ed at 18 years of age or older. T he Monitoring the F uture s urvey has obtained information each year s ince 1975 from selfforms returned anonymous ly by high s chool s eniors. It includes former s eniors now in college and students in eighth and tenth grades. In addition to drug use, the survey taps sus pected caus es and cons equences of such as perceived availability of drugs and perceived harmfulnes s. Although the survey depends on s elfthe trend information it provides is useful. F igure 11.1-2 shows the changes in annual us e of illegal drugs by , tenth-, and 12th-grade s tudents through 2002. 1276 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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FIGUR E 11.1-2 T rends in annual prevalence of an drug us e index for eighth, tenth, and 12th graders : percentage of s tudents who reported use. (C ourtesy of J ohns ton LD, O'Malley P M, B achman J G . Monitoring F uture N ational R es ults on Drug Us e: O ve rview of K ey F indings , 2002. [NIH P ubl. No. 03-5374]. B ethesda, National Ins titute on Drug Abus e; 2003.) T he ADAM s ys tem interviews and obtains anonymous urine s pecimens from a sample of arres tees in 1277 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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sized cities in the United S tates . B y design, people with sale or pos sess ion of drugs cannot make up P.1154 more than 25 percent of the sample. Although it does depend on self-reports to meas ure us e, the ADAM cannot be eas ily extrapolated to a national population, and the information that can be derived from a single urine test is limited. Nevertheless , the system obtains from a population in which illegal drug use is high and thus provides trend data not readily available from sources. In general, current drug us e among arrestees several times higher than among those s ampled and as sess ed in s elf-reports for the national surveys. F ield survey approaches of nationally representative samples tend to be more us eful and informative than incident or event reporting approaches s uch as DAW N. T he DAW N system involves abs tracting and reporting drug-related emergency room and medical examiner death event data each month of the calendar year. T he DAWN s ys tem is now designed so that the reporting emergency rooms cons titute a representative sample such facilities in the continental United S tates . T he data provide useful information on trends in the as sociated with various illegal drugs ; but these data to be interpreted with caution because the DAW N reports only epis odes in which a drug is part of the presenting clinical picture. F or example, an increas ing number of emergency room episodes ass ociated with heroin could mean that more heroin us ers with AIDS related problems are s eeking primary medical care in emergency department facilities rather than that more 1278 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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individuals are us ing heroin. S imilarly, reports by examiners of more violent deaths ass ociated with may s ignal an escalation of competition among drug dealers rather than more people using cocaine. T he analytical methods do not reveal the nature of the between drug use and the pres enting problem, which drugs (if any) played a causal role in the episode, or whether the user was a novice or a chronic user.

C omorbidity S urveys In addition to the recurring data-gathering efforts, important epidemiological information is available from two national studies that s ys tematically interviewed representative samples of the population and used or DS M-III-R criteria to develop es timates of current lifetime prevalence of ps ychiatric disorders, including subs tance abus e and s ubs tance dependence. T hes e studies are the NIMH E pidemiological C atchment Area (E C A) S tudy, conducted in the early 1980s , and the National C omorbidity S urvey (NC S ), conducted 1990 and 1992. T he E C A interviews in five areas of the United S tates included individuals in institutions hospitals , jails, nurs ing homes, and s o forth) and used DS M-III criteria to develop es timates of prevalence. NC S interviews of a nationally representative sample of people not res iding in institutions us ed DS M-III-R Although the E C A was conducted before the cocaine epidemic of the 1980s cres ted, and criteria for us ed were altered somewhat in DS M-III-R , it remains a landmark study of the extent of drug abuse dependence and cooccurring ps ychiatric disorders . T he E C A study found that 16.7 percent of the U.S . 1279 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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population aged 18 years and older met the DS M-III for a lifetime diagnos is of either abus e or dependence some substance, with 13.8 percent meeting the criteria an alcohol-related dis order, and 6.2 percent meeting criteria for abuse or dependence of a drug other than alcohol or tobacco. T he NC S found a 26.6 percent prevalence of substance abus e and dependence, subs tantially higher than the 16.7 percent found in the E C A. S ome of this is probably due to ques tions in the about pres cription drugs that were posed when a reported symptoms of dependence and on differences criteria (DS M-III vs . DS M-III-R ). However, there may have been real increases in prevalence. F or illegal and the nonmedical use of prescription drugs, the history of dependence in the NC S was 7.9 percent, a much closer to the 6.2 percent found for s uch drugs in E C A study. T he NC S found a 12-month prevalence for any drug us e disorder (including dependence and abuse) of 8.2 percent, 4.5 percent alcohol dependence, and 1.8 percent drug dependence. E xcept for tobacco, men are far more likely than women to use drugs and alcohol and are corres pondingly more likely to have developed dependence. F or example, lifetime and 12month prevalence of alcohol dependence is 20.1 and percent for men but only 8.2 and 2.2 percent for res pectively. Among the major achievements of the NC S analyses the findings on the proportions of people who had us ed drugs at any time in their lives (lifetime us ers) who dependent (overall and for each drug category); the demographic factors ass ociated with us e, dependence, and persis tence of dependence; and the prevalence 1280 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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significance of multiple psychiatric diagnoses. Dependence cannot develop if a drug is never us ed; presenting data on the prevalence of dependence in population as whole, including thos e who never used, obscure the likelihood of dependence developing those who do use a particular drug. In the NC S , of lifetime dependence on the broad range of illegal nonpres cribed medications was 14.7 percent, with us ers only s lightly more likely (16.4 percent) than us ers (12.6 percent) to develop dependence. In a analysis of the 12-month prevalence of dependence on these drugs, the rate for the population as a whole was percent. However, the 12-month prevalence was 3.5 percent for thos e who had us ed any of these drugs at time in their lives, 10.3 percent for thos e who had us ed them in the past 12 months, and 23.8 percent among those who had a lifetime history of dependence. T he likelihood of being drug dependent within the pas t 12 months, given a lifetime history of dependence, was similar for men (24.9 percent) and women (22.2 Lower educational and income levels predicted a history of dependence (odds ratios greater than 2), but race, ethnicity, or living in an urban environment did T here were als o differences in the likelihood that users particular drug would become dependent on it. F or example, for heroin, the estimated probability of having developed opioid dependence was 23 percent; for tobacco, 32 percent; for cocaine, 16.7 percent; for P.1155 15.4 percent; but only 4.9 percent for ps ychedelics . who used alcohol were more likely to have become 1281 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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dependent (21.4 percent) than women (9.2 percent), poss ibly because they drink more than women, but genetics may also play a role. A comparable comorbidity s tudy conducted in E ngland and W ales in the 1990s found, like s tudies in the S tates, that substance-related disorders are among the most common psychiatric disorders . Alcohol was found in 5 percent of the household s ample (8 of men, 2 percent of women), in 7 percent of an institutional sample, and in 21 percent of the homeles s sample. S ubs tance use was s ignificantly as sociated higher rates of ps ychological morbidity. Among thos e dependent on any substance, 12 percent were having a psychiatric dis order. Among thos e dependent nicotine, 22 percent were as sess ed as having another ps ychiatric disorder. T he rates for psychiatric were 30 percent and 45 percent for thos e dependent alcohol and other drugs, respectively. T he newest vers ions of NHS DA now provide s ome comorbidity and confirm the findings of the NC S that serious mental illnes s is s trongly correlated with illegal drug us e and cigarette us e. Individuals with a s erious mental illness are more than twice as likely to have illegal drug and to have been cigarette smokers. mental illness is even more strongly correlated with the presence of drug abus e or dependence. T his illus trated in F igure 11.1-3. In 2001, it was es timated million adults had both a s erious mental illnes s and subs tance dependence or abuse in the past year. Of million, 1.6 million met criteria for abus e of or on alcohol alone; 0.7 million for abus e of or on both drugs and alcohol; and 0.7 million for abuse of 1282 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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dependence on an illegal drug.

FIGUR E 11.1-3 S ubstance dependence or abuse adults by serious mental illnes s, 2001. (F rom National Hous ehold S urvey of Drug Abus e; 2001, with C omorbidity is also considered below as an etiological factor in the development of s ubs tance abuse and dependence.

E pidemic s S everal major overlapping drug epidemics have over the past 30 years , affecting somewhat different populations. C annabis us e, which had been endemic among certain minority groups and jazz musicians , to increas e in the 1960s , es pecially among young and then s pread to other segments of the population. its peak in the mid- to late 1970s , 10 percent of high seniors were us ing marijuana on a daily bas is . Daily 1283 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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declined to 5 percent by 1984, to 2 percent by 1991, then revers ed direction and again increased, according the Monitoring the F uture s urvey. S imilar changes in rates were reflected in the NHS DA. An epidemic of heroin us e also began in the early and incidence peaked between 1969 and 1971. T he population of active heroin users reached its highest in the early 1970s , but periodic ups urges have supplies became more available, law enforcement waxed and waned, and relapse rates increased among former users. In 1977, the U.S . government estimated there were 500,000 opioid abusers and dependent and more recently, it revised the es timate to 320,000 occasional us ers and 810,000 chronic users. In heroin-us ing population is an aging one, with a high still growing prevalence of HIV in s ome areas. In 1996, NHS DA estimated that approximately 2.3 million had tried heroin at leas t once and that 245,000 had in the pas t year. However, it was believed that a large percentage of heroin us ers were outs ide the population interviewed by the s urvey. Data from the more recent NHS DA indicate that heroin us e increased during the 1990s to levels nearly as high as those of the 1970s . annual number of new us ers was estimated to range 55,000 to 69,000 between 1989 and 1992. B y 2000, number of new heroin us ers per year appeared to have increased to 146,000. T he cocaine epidemic that began in the late 1960s to have reached its peak by 1980. In the early 1980s, according to the NHS DA, an es timated 5.8 million in the United S tates (2.9 percent of the population) had us ed cocaine in the month before the survey. T here 1284 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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an es timated 1.5 million new users in 1983. T he pass ed its peak in most s egments of society by the 1980s , with the number of new us ers declining s teadily until 1992. Among the heavies t users (weekly or almost weekly), us e did not decline significantly, although among arres tees decreas ed in 1995. F or the a whole, the number of new us ers has been increasing modes tly s ince 1992. T here were approximately 0.9 new users in 2000. In the early 1990s , fueled by abundant s upplies of methamphetamine produced illegally in many s mall laboratories, methamphetamine us e began to increas e number of cities in the west, southwes t, and northwes t the United S tates . F or the country as a whole, the of new us ers increased from 164,000 per year at that to 344,000 in 2000. C hanges in the annual rate of new users of various over the past 30 years as deduced from the NHS DA database are s hown in F igure 11.1-4.

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FIGUR E 11.1-4 Annual number of new us ers (in of various drugs, 1965 to 2000. A: Marijuana. B : lysergic acid diethylamide (LS D), and phencyclidine C : Nonmedical users of psychotherapeutics. D: (Adapted from National Hous ehold S urvey of Drug 2001.)

E TIOL OG Y T he model of drug dependence from which the DS Mand IC D-10 criteria were derived conceptualizes dependence as a result of a process in which multiple interacting factors influence drug-us ing behavior and loss of flexibility with res pect to decisions about using a given drug. Although the actions of a given drug are critical in the process , it is not ass umed that all people become dependent on the same drug P.1156 experience its effects in the s ame way or are motivated the same set of factors. F urthermore, it is postulated different factors may be more or less important at stages of the process . T hus, drug availability, social acceptability, and peer pres sures may be the major determinants of initial experimentation with a drug, but other factors, s uch as personality and individual probably are more important in how the effects of a drug are perceived and the degree to which repeated us e produces changes in the central nervous system S till other factors, including the particular actions of the drug, may be primary determinants of whether drug 1286 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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progres ses to drug dependence, whereas still others be important influences on the likelihood that drug us e leads to adverse effects or the likelihood of s ucces sful recovery from dependence. It has been as serted that addiction is a “brain dis eas e,” the critical proces ses that transform voluntary drugbehavior to compuls ive drug use are changes in the structure and neurochemistry of the brain of the drug T here is now more than enough evidence that s uch changes in relevant parts of the brain do occur. T he perplexing and unans wered question is whether these changes are both necess ary and sufficient to account the drug-us ing behavior. Many argue that they are not, that the capacity of drug-dependent individuals to their drug-us ing behavior in res ponse to positive reinforcers or avers ive contingencies indicates that the nature of addiction is more complex and requires the interaction of multiple factors. F igure 11.1-5 illus trates how various factors might in the development of drug dependence. T he central element is the drug-us ing behavior itself. T he decision us e a drug is influenced by immediate s ocial and ps ychological situations as well as by the person's remote his tory. Us e of the drug initiates a sequence of cons equences that can be rewarding or aversive and which, through a proces s of learning, can res ult in a greater or less er likelihood that the drug-us ing behavior will be repeated. F or s ome drugs, use also initiates the biological process es as sociated with tolerance, dependence, and (not s hown in the figure) turn, tolerance can reduce some of the advers e effects the drug, permitting or requiring the us e of larger 1287 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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which then can accelerate or intensify the development phys ical dependence. Above a certain thres hold, the avers ive qualities of a withdrawal s yndrome provide a distinct recurrent motive for further drug use. of motivational systems may increase the s alience of related stimuli.

FIGUR E 11.1-5 W orld Health Organization s chematic model of drug use and dependence. (F rom E dwards G , A, Hodgs on R : Nomenclature and class ification of drugalcohol-related problems. A WHO memorandum. B ull 1981;99:225, with permiss ion.) F or simplicity, F igure 11.1-5 s hows drug us e alone as initiating that chain of consequences , but the choices a person makes over and over again are more complex. decis ion is whether to us e one drug or another or to engage in some behavior that does not involve drug 1288 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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E ach of those decis ions can initiate positive and cons equences. C hanges in the availability, cos ts, and cons equences of alternative behaviors can als o what appears to be compuls ive use of a agent. F or example, patients in a methadone program who were us ing cocaine despite negative cons equences (no take-home methadone) reduced cocaine use when vouchers for goods and s ervices awarded for clean (negative for cocaine) urine

S oc ial and E nvironmental Fac tors C ultural factors , social attitudes , peer behaviors, laws, drug cost and availability all influence initial experimentation with s ubs tances , including alcohol and tobacco. T hes e factors als o influence initial use of socially disapproved drugs, such as cocaine and but personality factors as sume a more important role. S ocial and environmental factors also influence us e, although individual vulnerability and ps ychopathology are probably more important determinants of the P.1157 development of dependence. In general, the us e of the less socially disapproved substances (alcohol, tobacco, cannabis ) precedes the use of opioids and cocaine, those antecedent substances are s ometimes referred gateway drugs .

A lc ohol and Tobac c o S ubstantial evidence indicates that changes in price availability can alter the consumption of alcohol and 1289 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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tobacco. W hen an increas e in sales outlets or an of sales hours increases the availability of alcohol, cons umption tends to increase. W hen the cost of either alcohol or tobacco is increas ed in relation to disposable income (e.g., by increas ed taxes ), cons umption T hese factors even influence the behavior of people, although perhaps not to the s ame degree as those who are not dependent. Availability can be independently of cos t, and alterations can be limited to selected populations (e.g., prohibiting sale of alcohol tobacco to those younger than a specific age). S ocial, cultural, and economic factors do not always operate s ynergis tically but may sometimes influence cons umption in opposite directions. F or example, in the late 1980s , increased public awareness of how alcohol advers ely affects health resulted in a decline in its cons umption. T hat decline occurred even though was more freely available, its cos t relative to income remained constant or actually decreas ed, and social press ures agains t women drinking (unles s pregnant) decreased.

Illegal Drugs S ocial and cultural factors, including beliefs about the effects of a drug, frequently exert more influence on us e patterns than the laws that s upposedly reflect such factors . F or example, cannabis use increased among school s tudents from the early 1970s to 1979 and then decreased steadily over the next decade, although us e poss ess ion were illegal throughout the entire 18-year period, and nothing indicates that it became more expensive or less available during the 1980s (F ig. 11.11290 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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An upward trend in us e was noted from 1993 to 1997, although perhaps the values never reached the peak of 1979. S ome experts believe the decline in use s een during the 1980s was linked to changing perceptions about the toxic effects of cannabis on health. T he beginning in the 1990s was correlated with a decline in perception of the risk of harm from regular us e. cocaine use increased in the 1970s des pite high prices the drug and high risk of criminal penalties ; but after several well-publicized deaths from cocaine in the mid1980s , prevalence of active cocaine us e declined high s chool seniors and in the general population even the price of the drug declined. S ocial and cultural factors profoundly influence the availability of illegal drugs ; availability, in turn, which groups within a s ociety are mos t likely to us ers . C urrently, illegal opioids and cocaine are more available in the inner cities of large urban areas than in other parts of the country. S uch availability influences only initial and continued drug us e but also affects the relaps e rates after treatment of thos e who live in highavailability areas . When a significant number of users illegal drugs live in one area, a s ubculture evolves that supports experimentation and continued us e. Many of areas in which illegal drugs are readily available are characterized by a high crime rate, high and demoralized s chool systems —all of which s erve to reduce the sense of hope and sense of s elf-es teem as sociated with resistance to use. S ocial and factors also affect the likelihood for s uccess ful recovery from drug dependence; thos e who find satis fying alternatives are more likely to abs tain from drug use. 1291 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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VIE TNAM T he experience of U.S . s ervice pers onnel who us ed in V ietnam provided a unique natural experiment in the influences of availability, vulnerability, and s ocial norms could be observed. F rom 1970 to P.1158 1972, high-grade heroin at very low cost was readily available to young people in V ietnam s eparated from families and us ual s ocial norms. Among army enlisted personnel, approximately one-half of those who tried heroin became dependent (at leas t they developed withdrawal s ymptoms when they attempted to s top heroin). Of those who us ed heroin at leas t five times, percent became dependent. T he background factors predicted heroin use in the general civilian early deviant behavior, s uch as fighting, drunkenness , arrest, and school expulsion—also predicted drug us e V ietnam, but they were not the bes t predictors of after the s oldiers returned to the United S tates . was related to being white, being older, and having parents who had criminal his tories or were alcoholic.

A vailability and Health P rofes s ionals T he important role of availability is also illus trated by repeated observation that physicians, dentis ts, and have far higher rates of dependence on DE A-controlled subs tances , such as opioids , s timulants , and than other profes sionals of comparable educational achievement (e.g., accountants or lawyers) who do not have such easy access to the drugs . C ompared with controls, physicians appear to be four to five times as 1292 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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to take s edatives and minor tranquilizers without supervis ion by a profes sional other than themselves. even in that s ituation, other factors play a role. who had unhappy childhoods are more likely to selfprescribe than those who are healthier psychologically.

Drugs as R einforc ers Different drugs produce dis tinctive s ubjective states , extensive laboratory evidence shows that people with experience can dis tinguis h one drug clas s from another and can even rank different clas ses and doses on the of how much they like the effects . Y et, the hold that can eventually exert on a us er's behavior is not entirely function of its initial likable or euphorigenic actions. F or example, the effects of cocaine are typically described most users as powerfully euphorigenic, producing increased s elf-es teem, alertnes s, energy, and wellT he effects of nicotine, as described by many tobacco us ers , are more subtle, producing some mixture of and relaxing. T he subjective effects of alcohol are more likely to be described as relaxing, but are more and appear to be more dependent on personality and underlying genetic variability traits and genetically influenced ethanol metabolism. Des pite those dependence (or addiction) can occur with each, and appear to have shared or overlapping neural their reinforcing properties . Almos t all of the drugs that are us ed for their s ubjective effects and are as sociated with the development of dependence induce s ome degree of tolerance. In some cases, the tolerance to the toxic and aversive effects is more pronounced than the tolerance to the reinforcing 1293 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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and mood-elevating effects. F or example, most opioid us ers quickly develop tolerance to opioid-induced and vomiting. T his may allow users to increas e the and thus experience greater euphoric effects . those who continue to experience aversive drug effects (s uch as severe flushing with alcohol) may be less persis t in us ing the drug and are at lower risk for developing dependence. T olerant opioid users do not continue to s elf-adminis ter opioids s olely to prevent the highly avers ive withdrawal phenomena. Interviews with heroin users have indicated that, despite s ome to many of the drug's effects, they continue to a brief euphoric effect immediately after an IV injection. Among nonalcoholic sons of alcoholic fathers, intrinsic tolerance may be a marker of biological vulnerability to developing alcohol dependence. S ons of alcoholic who were more tolerant to a test dos e of alcohol were more likely to have developed alcohol dependence at 8 years ' follow-up than those who were les s tolerant. With a few notable exceptions , animals in experimental situations s elf-adminis ter mos t of the drugs that tend to us e and abuse. Included among the drugs are and δ-opioid agonis ts , cocaine, amphetamine and amphetamine-like agents, substituted amphetamines, such as MDMA, alcohol, barbiturates, many benzodiazepines, a number of volatile gases and (e.g., nitrous oxide and ether), P C P , and nicotine. C annabinoid self-adminis tration, which has been to demons trate with natural cannabinoids, has been shown with s ome synthetics. LS D-like drugs are not generally found to be reinforcing in preclinical studies. 1294 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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B iologic al S ubs trates K nowledge about the neurobiology of drug and the mechanisms underlying tolerance and dependence has continued to increase. P athways and structures critical for the reinforcing actions of a dependence-producing drugs, s uch as opioids, amphetamine, cocaine, and, to some degree, nicotine alcohol, have their origins in dopaminergic neurons cell bodies in the ventral tegmental area (V T A) and projections to the nucleus accumbens and the related structures that make up the “extended amygdala.” T he extended amygdala compris es several neural structures , including the central nucleus of amygdala, bed nucleus of the s tria terminalis, as well as the s hell of the nucleus accumbens . T he extended amygdala receives input from the limbic cortex, hippocampus , basolateral amygdala, midbrain, and lateral and projects axons to the ventral pallidum, the medial and the lateral hypothalamus . T he medial part of the nucleus accumbens (shell) is a particularly important site; dopamine releas e here is for the reinforcing effects of cocaine and is also important for the reinforcing effects of opioids, there are opioid receptors on neurons in the nucleus accumbens, and opioids can exert reinforcing effects at that s ite even when the dopaminergic terminals are destroyed. S ome researchers have propos ed that all positive reinforcement, including the reinforcement as sociated with food reward and sex, critically depends this dopaminergic circuit. Dopamine release from mes olimbic dopaminergic 1295 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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may play more than one role in the genes is of drug seeking and drug dependence. Dopamine releas e has been postulated to facilitate learning what events and behaviors lead to important consequences for the organism and to alert the organis m to pay greater attention to s uch events . In this way, drug-induced dopamine release leads to a greater salience of drugopportunities and is linked to wanting and craving. However, the diverse categories of drugs that activate mesolimbic dopaminergic system do s o by distinct mechanisms, and mos t have actions on many other systems . R einforcing mechanisms are also briefly in the chapters devoted to s pecific drugs . Only a few examples are given here. T he V T A dopaminergic have both nicotinic and γ-aminobutyric acid (G AB A) receptors. T hes e neurons normally are inhibited by G AB Aergic activity. T he G AB Aergic neurons acting on V T A express μ and δ-opioid receptors . When these receptors are activated by μ opioids, G AB Aergic transmis sion is inhibited, and the dopaminergic V T A neurons become more active and releas e dopamine in nucleus accumbens. However, opioids can als o act on neurons in the nucleus accumbens , independent of dopamine action. As a reinforcing drug, cocaine acts primarily at the endings of the serotonergic, dopaminergic, and noradrenergic neurons. W hen transmitters are from those neurons into the s ynapse, they are back into the nerve endings by transporter proteins . B y occupying thes e transporter sites, cocaine prevents the reuptake of the transmitters, thus increasing their concentration in the synaps e. C ocaine's binding to the 1296 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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dopamine transporter is primarily res ponsible for its reinforcing effects, but the actions on other neurotransmitters als o influence its s ubjective effects. C ocaine adminis tration P.1159 also produces glutamate releas e within the mesolimbic accumbens system, an action that is probably relevant its capacity to change behavior becaus e glutamate antagonis ts interfere with learning to as sociate cocaine effects to environmental stimuli. Amphetamine als o increases dopamine levels at the synapse and binds to the dopamine trans porter to degree. B ut amphetamine actions at the dopamine transporter are not as important as its major action, is to displace dopamine and norepinephrine from their storage s ites in the neuron and thereby lead to their releas e. Alcohol, at clinically relevant concentrations, exerts its actions relatively s electively on s pecific receptors and neurotransmitter s ys tems. T hes e actions include enhancing the inhibitory action of G AB Aergic neurotransmitters (by increasing the s ens itivity of the G AB A receptor) and reducing the excitatory actions of glutamatergic neurotransmitters (by altering the of the N-methyl-D-as partate [NMDA] receptors). B y its blocking actions at the NMDA receptor, ethanol can indirectly alter the release of other neurotransmitters serotonin, dopamine, norepinephrine, glutamate, as partate, and G AB A). Low doses of alcohol increas e dopamine levels in the nucleus accumbens and elevate brain s erotonin concentration. V arious regions of the 1297 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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differ in their s ensitivity to these actions of ethanol. T he endogenous opioid s ys tem may be involved in some as pects of the mood-elevating effects of alcohol the opioid antagonis t naloxone reduces alcohol selfadminis tration in animals , and the antagonis t (R eV ia) reduces relapse rates in treated alcoholics. Mesolimbic dopaminergic neurons have multiple cholinergic receptors on their cell bodies and terminals the nucleus accumbens. W hen activated, thes e increase dopamine release. Nicotine also increas es glutamatergic activity, thereby tending to increase the activity of V T A dopaminergic neurons. T his action las ts longer than nicotine's G AB Aergic effects, which mesolimbic dopaminergic activity. Interes tingly, regular expos ure to nicotine-containing tobacco smoke may be more reinforcing than nicotine its elf becaus e other chemical entities in tobacco inhibit brain monoamine oxidase type A (MAO A ) and MAO B , which are involved the regulation of intraneuronal stores of dopamine. P res umably, this inhibition increas es the amount of dopamine available for release when the dopaminergic neurons are activated. Drugs can also act as reinforcers by terminating states . S ome of these actions involve dopaminergic systems , but others do not. S ome res earchers argue compuls ive drug us e can be explained on the basis of positive reinforcing effects of drugs without any need to invoke alleviation of withdrawal distress or any obvious source of antecedent pain or dys phoria. F urthermore, argue, craving is primarily as sociated not with cues that evoke withdrawal but with thos e that evoke memories positive reinforcement (euphoria). However, evidence 1298 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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indicates that even when there are no obvious and dramatic withdrawal s ymptoms (e.g., cocaine, nicotine) adaptive changes in the reward system result in a dopaminergic deficiency state (meas urable as dopamine levels in the nucleus accumbens ) when drug us e is s topped or its action ceases. T his deficiency experienced as dys phoria or anhedonia. Quite often, same drug-us ing behavior that terminates this moves the s ys tem to a hyperdopaminergic s tate as sociated with positive reinforcement (euphoria). In the behaviors as sociated with chronic drug us e are typically driven by both the avoidance of dysphoria (negative reinforcement) and the purs uit of euphoria (positive reinforcement). In animal models, s uch as the rat, the sensitivity of systems to reinforcing drugs, s uch as cocaine and is enhanced by corticos teroids . In animal models, a of stress es acting through release of corticotropinreleas ing factor (C R F ) and the hypothalamic-pituitaryadrenal axis can s ens itize neural s ys tems and trigger reinitiation of drug taking. T here is ample clinical that s uch stress es can act s imilarly in drug-dependent individuals immediately after withdrawal and for long periods thereafter. In addition, some drugs may neural systems to the reinforcing effects of the drug.

L earning and C onditioning Drug use, whether occasional or compulsive, can be viewed as behavior maintained by its cons equences. event that strengthens an antecedent behavior pattern can be cons idered a reinforcer of that behavior. In that sens e, certain drugs reinforce drug-taking behavior. 1299 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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can also reinforce antecedent behaviors by terminating some noxious or aversive state s uch as pain, anxiety, depres sion. In s ome social s ituations, the use of the quite apart from its pharmacological effects, can be reinforcing if it res ults in s pecial status or the approval friends . S ocial reinforcement can maintain drug us e the effects of primary reinforcement or reinforcement alleviation of withdrawal s ymptoms come into play. us e of the drug evokes rapid pos itive reinforcement, as a result of the rush (the drug-induced euphoria), alleviation of disturbed affects , alleviation of withdrawal symptoms, or any combination of these effects. In addition, some drugs may s ens itize neural systems to reinforcing effects of the drug. With s hort-acting subs tances , such as heroin, cocaine, nicotine, and such reinforcement occurs s everal times a day, day in day out, creating powerfully reinforced habit patterns . E ventually, the paraphernalia (needles , bottles, packs) and behaviors ass ociated with substance us e become s econdary reinforcers , as well as cues availability of the substance, and in their pres ence, or a desire to experience the effects increases . W ith acceptable s ubs tances , s uch as tobacco, use becomes woven into the matrix of daily functioning that s ome are reminded of the substances when performing tas ks . S tress es can also act as cues that induce drug particularly in the postwithdrawal period. R es earchers have used positron emiss ion tomography (P E T ) and functional magnetic res onance imaging study brain activity in both drug users and controls presented with drug-related stimuli (paraphernalia or video tapes). Drug users res pond to the drug-related 1300 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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stimuli with increas ed activity in limbic regions, the amygdala and the anterior cingulate, but do not res pond this way to neutral stimuli. C ontrol s ubjects res pond minimally to both types of s timuli. S uch drugrelated activation of limbic areas has been with a variety of drugs , including cocaine, opioids, and cigarettes (nicotine). Interes tingly, the same regions activated by cocaine-related stimuli in cocaine us ers activated by sexual s timuli in both normal controls and cocaine users.

C las s ic al C onditioning In addition to the operant reinforcement of drug-us ing and drug-seeking behaviors, other learning probably play a role in dependence and relapse. Opioid and alcohol withdrawal phenomena can be conditioned (in the P avlovian or clas sical sense) to environmental interoceptive stimuli. S uch conditioning has been demonstrated in both laboratory animals and abs tinent and methadone-dependent human volunteers. F or a time after withdrawal (from opioids , nicotine, or the addict exposed to environmental s timuli previous ly linked with subs tance use or withdrawal may conditioned withdrawal, conditioned craving, or both. increased feelings of craving are not necess arily accompanied by symptoms of withdrawal. T he most intens e craving is elicited by conditions as sociated with the availability or use of the s ubs tance, such as someone els e us e heroin or light a cigarette or being offered some drug by a friend. S ome workers now that the cues that induce memories of P.1160 1301 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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drug-induced euphoria are more important for craving and in predis posing to relapse than either protracted or conditioned withdrawal. T hos e learning conditioning phenomena can be s uperimposed on any preexisting psychopathology, but preexisting difficulties are not required for the development of powerfully reinforced substance-seeking behavior.

Withdrawal S yndromes and R einforc ement Although positive reinforcement is a powerful factor in the genes is of cocaine, amphetamine, and (in some cases ) opioid dependence, for a number of other drugs, aversive withdrawal phenomena and negative reinforcement may be equally important, or even dominant, factors . F or example, in people who become dependent on benzodiazepines in the cours e of for anxiety syndromes , when drug us e is interrupted, seem to experience a reappearance of the original symptoms, whereas others have new distress ing symptoms indicating withdrawal. T he use of benzodiazepines alleviates both kinds of aversive either cas e, the drug is acting as a negative reinforcer perpetuating drug us e. B enzodiazepines can induce euphoria in alcoholic patients or in people with his tories sedative abuse, but they are not reliably euphorigenic normal, nonalcoholic people. B enzodiazepine anxiolytic agents may induce euphoria in people who are not dependent and not anxious, but s uch instances are relative to the number who experience only relief of anxiety. 1302 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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In mos t clinical s ituations, even among us ers of highly euphorigenic illegal drugs, the dis tinction between positive and negative reinforcing effects does not exist. T he alcoholic, the heavy s moker, and the heroin us er experience, s imultaneous ly or sequentially, relief of withdrawal, a s ense of ease, and perhaps alleviation of dysphoria and depres sion. S ome of the dys phoria may res ult of long-lasting dys function in s ys tems s ubs erving hedonic tone. With IV drugs , there may als o be a rus h of intens e pleas ure.

L ong-L as ting C hanges A s s oc iated C hronic Drug Us e After long-term us e, mos t drugs of abus e produce adaptive changes in the brain that are manifested as and chronic withdrawal s yndromes when drug use Other drug-induced changes in the brain appear to be related to the proces ses by which the memories of action are stored and by which drug-related stimuli acquire and retain salience. How these changes are produced, how long they persis t after ces sation of drug us e, and how they contribute to relapse are still being explored. B ut much progres s has occurred, as is by the example of recent changes found with chronic opioids.

OPIOIDS T olerance and dependence on opioids involve several mechanisms. Opioid agonis t binding to the opioid receptors results in an inhibition of adenylyl cyclas e lower intracellular cyclic adenosine monophosphate (cAMP ) concentrations. Long-term exposure elicits 1303 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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compens atory upregulation of the cAMP pathway, internalization of μ and δ receptors, and a decrease in number of G proteins, which couple the receptors to second mes sengers and ion channels . Upregulation of adenylyl cyclas e is mediated by the trans cription factor C R E B (cAMP respons e element–binding protein), also plays a role in the generation of dis tinct and F os -like proteins . T hese are believed to be involved in tolerance and sensitization. T he s ens itization may F os -like proteins that alter the s ens itivity of an α-aminohydroxy-5-methyl-4-is oxazolepropionic acid (AMP A) glutamate receptor s ubunit. As a res ult of upregulation cAMP , G AB Aergic neurons innervating the V T A hyperactive when opioids are withdrawn, thus inhibiting dopaminergic neurons. S uch a mechanism may part, for the dys phoria and anhedonia of opioid withdrawal. In addition, chronic opioid use reduces the size of dopamine neurons in the V T A; increased production of dynorphin may als o s erve to inhibit dopaminergic activity at the V T A and nucleus T he glutamatergic s ys tem is als o involved in opioid adaptation becaus e NMDA receptor s ens itivity is by opioids, and NMDA antagonis ts can alter the development of opioid tolerance and phys ical dependence. T he opioid-induced changes des cribed believed to be only a s ubs et of a wide range of cellular molecular changes induced by chronic drug use.

C onditioned Withdrawal and S tres s S ens itivity In addition to the direct contribution of withdrawal phenomena to the perpetuation of drug us e are the indirect effects exerted through learning mechanisms. 1304 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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regular recurrence of withdrawal-induced aversive provides ample opportunity for thos e states to become linked through learning to environmental cues and mood states, and the rapid relief of withdrawal by drug res ults in repeated reinforcement of drug-taking Long after there are meas urable manifes tations of withdrawal, certain moods or environmental cues can evoke components of the original withdrawal s tate with urges to us e the drug again. C ons iderable shows that in former opioid addicts , stress can trigger craving and relapse, and dysregulation of the hypothalamic-pituitary-adrenal axis pers is ts for long periods after drug cess ation. How long withdrawal phenomena, stres s sensitivity, or both continue to contribute to risk of relapse is not S ubstantial evidence s upports a withdrawal s yndrome period for alcohol, opioids, and certain sedatives with subtle disturbances of mood, s leep, and cognition that persis ts for many weeks or months after the acute syndrome subsides . W hether the dysregulation of the hypothalamic-pituitary-adrenal axis is causally related protracted withdrawal or has a s imilar time cours e is uncertain.

Integrating Neurobiology and S everal res earch groups have attempted to integrate most recent findings from neurobiology and the role of learning to better explain how drugs gain control of behavior to produce compuls ive drug use and the tendency to relaps e after withdrawal. G eorge K oob and Michel LeMoal des cribe the proces s as a “cycle of spiraling dysregulation of brain 1305 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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reward systems .” T hey des cribe in detail the of the hedonic regulatory system of the brain and its interaction with systems regulating res pons e to the pituitary-adrenal axis and extrahypothalamic C R F system. T he adaptive changes to chronic drug us e are believed to lead to deviations in hedonic homeostasis such magnitude that the s ys tem cannot be maintained within the normal range. C ontinued apparent reward function requires the mobilization of different systems, and in this s ens e, the s ys tem functions at a new setwhich thes e res earchers describe as an allos tatic s tate. C entral to this pers pective is the dysregulation of tone that results from a counter-adaptive respons e to drug-induced excess ive activation of the reward When drug action is withdrawn, prolonged hypoactivity follows . F ailed efforts to cope with this dysregulation to emotional dis tres s, which brings further negative and (mediated by increased levels of glucocorticoids) increased sens itivity to the rewarding effects of the At the s ame time, drug use alleviates the dys phoric of the hypofunction of the reward system. A strength of this des cription of the addictive proces s is the the interaction of various neural s ys tems s ubs erving reinforcement, motivation effects of withdrawal, learned as sociations with drug effects, thos e s ys tems (such as cortico-striatal-thalamic circuits ) involved in reinforcer evaluation, cognitive functioning and active inhibitory mechanisms, and the hypothalamic-pituitary-adrenal P.1161 Another important contribution is the role as signed to extrahypothalamic C R F system as well as other 1306 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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neuropeptide transmitters such as neuropeptide Y During opiate, cocaine, or alcohol withdrawal, C R F increases in the central nucleus of the amygdala; microinjection of a C R F antagonis t revers es the effects of opioid or alcohol withdrawal. K oob and point out that, although adrenocorticotropic hormone (AC T H)–stimulated high levels of glucocorticoids the synthesis of C R F at the paraventricular nucleus, can actually increase C R F activity at the level of the nucleus of the amygdala. T erry R obins on and K ent B erridge have elaborated on role of drug-induced s ensitization and alteration of structure in the development of addiction. T he major points that form this general thes is are that addictive drugs share the ability to alter brain organization, particularly the organization of s ys tems that subserve incentive motivation and reward. T he alteration critical the development of addiction is the s ens itization of reward systems to drugs and drug-related stimuli. T his hypers ens itivity develops in those subcomponents of brain reward s ys tem involved with as signing s alience (drug wanting) to drugs to related s timuli rather than those more directly mediating drug reward or euphoria. Within this incentive-sens itization pers pective, drug-seeking behavior does not require the pres ence subs tantial or even subtle withdrawal dys phoria or the desire to obtain drug-induced euphoria. R ather, with repeated expos ure, drug-related stimuli become more attractive, acquiring greater incentive value, and “grab attention” of the drug user. In animals, drug-induced neural s ens itization can be long lasting and has the long-lasting drug-seeking behavior that outlasts 1307 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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observable withdrawal phenomena. S ensitization (like development of drug-dependent behavior) is not a cons equence of drug administration but is powerfully influenced by learning and environmental context. T his view helps to explain the waxing and waning long persis tence of drug craving or wanting among drugdependent individuals attempting to function in their home environments. It does not explain why the so often leads to behavior even in the face of highly probably adverse cons equences. T he case for inhibitory control is better put by R ita G oldstein and V olkow. G oldstein and V olkow elaborate a pers pective that cons iderable us e of data from s tudies of neuroimaging. T his effort goes beyond the now generally accepted the mesolimbic dopaminergic system in accounting for the hedonic effects of addicting drugs , the role of the hippocampus and amygdala in the organization and storage of the drug experience, the hedonic deficiency (dysthymia) states that ens ue after drug ces sation, the biochemical and morphological dendritic changes to result from repeated drug adminis tration, and the res ulting salience of drug-related stimuli. W hat they these elements of addictive neurobiology are the importance of the activation of the thalamo-orbitofrontal circuit and the anterior cingulate in the experience of craving and the decreased inhibitory control over drug salient s timuli (impulsivity) due to inherent or druginduced impairment of function of the frontal cortex, particularly the anterior cingulate.

B iologic al Fac tors —Vulnerability 1308 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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T he children of alcoholic parents are at higher risk for developing alcoholism and drug dependence than are children of nonalcoholic parents. T he higher ris k for alcoholism manifests itself even when children are adopted by nonalcoholic families s oon after birth. Dependence on other drugs also shows a familial T he increased ris k is partly due to early environmental factors (parental modeling, neglect, early child abus e) later exposure to drugs , but genetic factors also play important role. Numerous studies of laboratory animals have revealed genetically transmitted differences in the reinforcing effects of alcohol and various drugs, s uch cocaine and opioids, and s how that genetic factors powerfully influence s ensitivity to toxic effects. T he evidence for genetic factors in human vulnerability to alcoholism and other drug dependence is derived mos t convincingly from twin and adoption studies, but family studies are also revealing. S everal studies of twins found a higher concordance rate for alcoholis m among identical twins than among fraternal twins. Although identical twins are generally believed to have more contact than fraternal twins , when the effects of environmental factors are adjus ted statis tically, genetic factors are still found to have a major influence on the likelihood of becoming dependent. In one populationbased twin s tudy, 48 to 58 percent of the variation in liability to dependence was attributable to genetic the remainder was due to general environmental influences not s hared by family members . All of the twin s tudies have found that genetically vulnerability contributes s ubstantially to the likelihood us ing drugs and to becoming drug or alcohol 1309 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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including dependence on nicotine and caffeine. One that has not been entirely settled is whether the genetic vulnerability is a general, nonspecific vulnerability or is subs tance s pecific. A s tudy of male twins in V irginia only a nonspecific genetic vulnerability. However, a of V ietnam–era veteran twin pairs us ing a s omewhat different analytical approach identified both common drug-specific genetic vulnerability factors . In that study, the importance of the nons pecific factors vers us the specific factors varied cons iderably for different drug categories . F or most drugs , the variance was mos tly a nons pecific vulnerability factor. B ut in the cas e of 54 percent of total variance was due to genetic factors , 70 percent of this genetic variance was due to drugspecific factors. T he differences concerning drug between thes e twin studies may be due to differences method or to the unusual experiences with heroin in V ietnam of that study population. T he C ollaborative on the G enetics of Alcoholis m als o found some in transmiss ion of cocaine and marijuana dependence. seems that the exis tence of nons pecific genetic vulnerability factors is well es tablis hed, but the role, if of drug-specific genetic vulnerability requires further study. S tudies of boys adopted s oon after birth have shown higher rates of alcoholism among those whose fathers were alcoholics than among thos e whose biological fathers were not. S ome adoption studies toward s ubtypes of alcoholis m among men: One is a onset dis order that is less severe and far more environmental factors (type I), and the other is with early-onset, antisocial behavior and criminality in 1310 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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biological fathers and a stronger genetic basis for the increased vulnerability (type II). T he hypothes is that genetically dis tinct types of alcoholism (type I and type exis t has been criticized on the grounds that it is es sentially a relabeling of the older primary-secondary categorization. In the latter, alcohol-dependent people who do not have antisocial personality dis order are designated as having primary alcoholis m; thos e who exhibit antis ocial pers onality disorder and later develop alcoholism are designated antis ocial pers onality with s e condary alcoholis m. More recent s tudies of have shown that, compared with adoptees who have biological risk or a parent with only alcoholis m or only antis ocial pers onality disorder, risk for both drug abuse dependence is increased when subs tance abus e and antis ocial pers onality disorder are present in the same biological parent. Although s everal research groups been unable to us e the type I and type II criteria to categorize patients with alcohol dependence accurately clinical s tudies, arguments about the validity of the type I/type II categorization do not diminis h the importance genetic factors in vulnerability to developing alcohol dependence. As many as one-third of people with alcohol have no family his tory of the disorder. Men are more than women to develop alcoholism (four- to fivefold in United S tates ). T his is true across every culture probably reflecting in part s tronger s ocial s anctions on drug us e and deviant behavior by women. B ut it P.1162 is also pos tulated that women are les s likely to drink 1311 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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heavily becaus e they are les s tolerant to alcohol. who do drink heavily run the s ame ris k as men of developing alcoholis m, and women who us e illegal are about as likely as men to become dependent. S ome s tudies have found that alcohol-dependent are at far greater ris k for developing other varieties of dependence. A more cons is tent finding is that drugdependent people are at high risk for alcoholis m and have a family history of alcoholism. S uch findings are cons istent with data from the twin s tudies that have general vulnerability factors. Most researchers believe that no s ingle gene will be to account for the complexities of inherited ris k for drug and alcohol dependence. S ome genetic factors may increase vulnerability to alcoholis m but decrease it. A genetically determined variation in the activity of that metabolize alcohol (alcohol dehydrogenase and aldehyde dehydrogenase [ALDH]), common among Asian groups, results in high levels of acetaldehyde in res ponse to alcohol ingestion. T he effect is to caus e alcohol flus h reaction and to exert s ome deterrent on alcohol inges tion. Alcoholism is lower among many Asian groups than among whites . F urther, Asians with alcoholism are much less likely to have the inactive the ALDH enzyme. Als o, genetically determined differences in nicotine metabolis m can influence the likelihood of becoming a smoker.

B iologic al and B ehavioral S tudies exploring how people with and without family histories of alcoholism might differ have involved meas ures of pers onality, drug and alcohol us e 1312 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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ps ychomotor and cognitive performance, electrical of the brain, and endocrine respons es to challenges alcohol and other substances as well as meas ures of receptor numbers and affinities and enzyme activities MAO) in peripheral tis sues (e.g., blood platelets and lymphocytes). S imilar s tudies have been conducted offspring of men with histories of other s ubs tance use disorders . One finding that has been replicated is that, under s ome conditions, the electrical res ponse of the that occurs approximately 300 millis econds after a stimulus (the P 300 wave) has a s maller amplitude in nondrinking s ons and daughters of alcoholic fathers in control s ubjects without family histories of T he decreased amplitude is believed to reflect a capacity to recognize and interpret complex environmental s timuli. It has als o been considered an indicator of low phys iological inhibition and reflective of maturational lag. Mos t s tudies have found no in intelligence among subjects with and without family histories of alcoholis m. However, the res ults of studies are conflicting; some find no differences , and others find greater impuls ivity, adventurousness , and sens ation s eeking among thos e with a pos itive family history. S tudies of offspring of fathers with substance dependence have found, in addition, irritability, affect, and a difficult temperament. S tudies of the patterns of adoles cent and young adult sons of people also have not yielded consistent res ults; some not all) s tudies show that s ons of alcoholic parents are heavier drinkers. Other s tudies have compared the subjective, motoric, and endocrine res ponses of young men with and without family his tories of alcoholism challenge expos ures to alcohol and other potentially 1313 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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euphoriant drugs (s uch as benzodiazepines). S ons of alcoholic fathers s eem to be more tolerant to the intoxicating effects of modes t doses of alcohol, and in some (but not all) studies, higher doses of alcohol produced s maller changes in their prolactin and cortis ol concentrations. F urthermore, one s tudy found that who had smaller res ponses to tes t doses of alcohol at years of age (i.e., were more tolerant) were fourfold likely to have developed alcoholism 8 years later. study of sons of alcoholic parents found that thos e who had exhibited smaller electroencephalographic (E E G ) alpha frequency res ponses to alcohol were more likely be alcohol dependent at 10 years ' follow-up. T he res ults of studies using benzodiazepine challenges also not cons is tent; one showed a greater euphoric res ponse to alprazolam (Xanax) in sons of alcoholic parents , and another showed no difference between positive and negative family history groups after a dos e diazepam. A number of studies have shown that conduct dis order and early childhood aggres sion are ass ociated with a subs tantial increas e in the likelihood of early with illegal drug use and development of dependence alcohol and illegal drugs. C ons iderable evidence a role for both genetics and environmental factors in development of conduct disorder. Antis ocial pers onality disorder repres ents an independent additional risk for addictive dis orders. T he effects of antisocial disorder and family his tory of a substance-related appear to be additive rather than s ynergis tic. It seems poss ible that, in s ome of the s tudies of children and people at high ris k for later drug dependence, the 1314 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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electrophysiological differences , cognitive deficits , and personality differences reflect the presence of conduct disorder or antisocial personality disorder rather than a family history of alcoholism per se. In a s tudy of offs pring of fathers with s ubs tance use disorders , a high compos ite score of neurobehavioral disinhibition (derived from measures of affect, and cognition) when measured at 10 to 12 years of age was a predictor of s ubs tance use dis order at 19 years age. A high score at 16 years of age was a better of substance us e disorder than frequency of s ubs tance cons umption. Interes tingly, it was the presence of indicators of neurobehavioral dis inhibition that was predictive and not s ocioeconomic s tatus or being the of a father with a substance us e disorder.

Ps yc hodynamic Fac tors and Ps yc hopathology E arly psychoanalytical formulations pos tulated that us ers , in general, had either a s pecial form of affective dysregulation (tense depress ion) that was alleviated by drug us e or a disorder of impulse control in which the search for pleasure was dominant. More recent formulations pos tulate ego defects, which are evinced the addict's inability to manage painful affects (guilt, anger, anxiety) and to avoid preventable medical, legal, and financial problems . T he newer formulations postulating ego defects are to s ome degree the older formulations with a modes t change in terminology that gives greater weight to the inability to cope with painful affects than to the intens ity or abnormality of the affects per se. It is postulated that s ome s ubs tances 1315 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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pharmacologically and symbolically aid the ego in controlling thos e affects and that their use can be as a form of s elf-medication. F or example, it has been suggested that opioids help us ers control painful anger, that alcohol helps alcoholics control panic, and that nicotine may help s ome cigarette smokers control symptoms of depres sion. Although it is conceded that some of thos e observations may reflect problems produced by long-term us e, the psychodynamic perspective is that the psychopathology is the motivation for initial us e, dependent us e, and relapse a period of abs tinence. However, traditions of pas sivity uncovering techniques derived from the neuros is are poorly s uited to the treatment of most addicts. F urther, s ome addicts have great difficulty differentiating and describing what they feel, a difficulty that has been called ale xithymia (i.e., no words for feelings). P.1163

F amily Dynamic s One family member's subs tance abus e is often by s ubs tance-us ing behaviors of others in the family, these complex interrelations hips can profoundly affect their lives. An unders tanding of the relations hips subs tance-us ing patients and their families is relevant unders tanding the etiology of subs tance dependence its treatment and for helping other family members to cope with problems as sociated with the s ubs tancebehavior. More has been written about the families of alcohol1316 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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dependent people and heroin us ers than about families affected by users of other drugs. S imilarities between family dynamics in thes e two prototypical have led researchers and clinicians to ass ume that general principles apply to all varieties of s ubs tance dependence. T he observation that alcoholis m is commonly found in the families of those seeking treatment for other types of dependence, that alcoholdependent people are often dependent on other subs tances as well, and that those addicted to illegal are often alcoholic s uggests that there are common features among families with an addicted member. However, there are few data to sugges t that the those dependent on tobacco or benzodiazepines are dysfunctional as thos e affected by alcohol, opioids, or cocaine. It is not always clear to what degree one family behavior is the caus e of the substance-us ing behavior another or is primarily a res ponse to that behavior. writers emphas ize that the addiction is a s ymptom that provides a displaced focus for conflict among other members and that the us er (the designated patient) be playing a role in maintaining the homeostasis of a dysfunctional family. At the s ame time, addiction often arises in families in which one or both parents (and sometimes grandparents ) have drug or alcohol and other psychopathology. S ome characteristics commonly observed both in families of people who are alcohol dependent and of those addicted to illegal are multigenerational drug dependence; a high of parental los s through divorce, death, abandonment, incarceration; overprotection or overcontrol by one 1317 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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(us ually the mother) whose life is inordinately on the behavior of the addicted offspring (s ymbiotic relations hips ); distant, cold, disengaged, or absent (when the father is alive); and defiant drug-us ing child appears to be engaged with peers but remains dependent on the family well into adult life (ps eudoindependence). T he actual family dynamics difficult to characterize because the family members' reports about their relations hips do not reliably corres pond to what outs iders observe. S uch families typically do not describe thems elves in the way that therapists s ee them. S ome workers have proposed that unresolved family grief plays a role in the genes is of addiction in a family member and that such families cannot deal effectively with s eparation because of previous los ses. Despite the pathological between the addict and other family members , the is often described as pass ive, dependent, withdrawn, unable to form close relationships . Des pite all the apparent pathology found in families , in many instances, the family brings the substance us er treatment, and the patient often believes that it is the family that is mos t likely to be helpful in recovery. F urthermore, clinicians now generally believe that involving families in treatment is important, if not es sential, to effective intervention. One as pect of families is dealing with the tendency of s ome members shield the patients from the consequences of their subs tance use, a behavior us ually labeled by clinicians enabling but us ually experienced by the family member loving, s upporting, accepting, and protecting. A on family therapy, s ometimes called ne twork the rapy, 1318 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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involves enlis ting family members and clos e friends as allies of the therapis t to provide s ocial s upport and reinforcement of drug-abstaining behaviors. T he selected to fulfill this role function as part of a treatment team rather than as patients.

C ODE PE NDE NC E T he term code pe nde nce came into vogue to describe behavioral patterns of family members who have been significantly affected by another family member's subs tance use or addiction. T he term has been used in various ways , and there are no established criteria for codependence, a concept that s ome writers have expanded far beyond its origins to encompas s any personality trait that involves difficulty in expres sing emotions . However, many have criticized the expanded concept of codependence as a largely invalid notion solely on anecdote. T he following s ummary of some characteristics frequently des cribed as aspects of codependence is not meant to imply the validity of a unitary s yndrome. One of the more agreed-on characteris tics of codependence is enabling behavior. F amily members sometimes feel that they have little or no control over enabling acts. E ither becaus e of social press ure to and s upport family members or becaus e of interdependencies, or both, enabling behavior often res is ts modification. Other characteristics of codependence include an unwillingnes s to accept the notion of addiction as a disease. F amily members to behave as if the s ubs tance-us ing behavior were voluntary and willful (if not actually s piteful), and the 1319 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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cares more for alcohol and drugs than for the members the family. T his res ults in feelings of anger, rejection, failure. In addition to thos e feelings , the family may feel guilty and depress ed becaus e the addict, in effort to deny los s of control over drugs and to shift the focus of concern away from their use, often tries to the res ponsibility for s uch us e on the other family members who often seem willing to accept s ome or all it. Like the s ubstance us ers themselves, family members often behave as if the substance us e that is caus ing obvious problems is not really a problem—that is , they engage in denial. T he reas ons for the unwillingness to accept the obvious vary. S ometimes denial is s elfprotecting in that the family members believe that, if is a drug or alcohol problem, then they are res ponsible. Like the addicts thems elves , codependent family seem unwilling to accept the notion that outside intervention is needed and, des pite repeated failures, continue to believe that greater willpower and greater efforts at control can restore tranquility. W hen efforts at control fail, they often attribute the failure to thems elves rather than to the addict or the dis eas e proces s, and along with failure come feelings of anger, lowered s elf-es teem, and depress ion.

Other Fac tors T here are other factors that influence the pattern of use and cess ation of any given s ubs tance. F or example, decis ion not to use a s ubs tance als o has that can be avers ive or reinforcing, and evidence that when the rewards of not us ing the substance are 1320 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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the likelihood of us e is reduced. In addition, many of subs tances as sociated with dependence act directly on systems that s ubs erve both motivation and decision making, rais ing questions about whether use is always influenced s olely by its cons equences (learning T he cognitive proces ses and s kills that ordinarily decis ion making appear to be impaired by alcohol, barbiturates , cannabis, and s everal other categories of adminis tered agents . T hus , whereas substance us e is influenced by learning, the substances also alter the its elf. T his sugges ts additional problems and for intervention. E vidence is accumulating that limited cognitive s kills reduce the likelihood of s ucces sful from s ubs tance use and that coping skills can help a person avoid or deal with avers ive affective s tates , environmental s tres ses , and s ituations that are with a high risk for substance us e. T he presence of ps ychiatric disorders has a powerful influence on both development and course of s ubs tance use disorders discuss ed separately below. Other factors that influence the course of s ubs tance and dependence are difficult to operationalize or teach prescribe, but they deserve mention. S tudies of the history of substance us e P.1164 indicate that recovery is powerfully influenced by the support of family and friends . Many people report that hope, faith, formal religious affiliation, or the s ustaining love of s ome significant person are more important to their recovery than any s pecific treatment. 1321 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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C omorbidity C omorbidity is the cooccurrence of two or more disorders in a single patient. As noted earlier, a high prevalence of additional ps ychiatric dis orders is found among people seeking treatment for alcohol, cocaine, opioid dependence. Although opioid, cocaine, and abusers with current ps ychiatric problems are more to seek treatment, it s hould not be as sumed that those who do not s eek treatment are free of comorbid ps ychiatric problems; such people may have s ocial supports that enable them to deny the impact that drug us e is having on their lives. T wo large epidemiological studies have s hown that even among representative samples of the population, thos e who meet the criteria alcohol or drug abuse and dependence (excluding tobacco dependence) are far more likely to meet the criteria for other psychiatric disorders also. In the NC S , percent of thos e who met the criteria for a lifetime addictive disorder received at least one additional disorder diagnosis; in the earlier E C A s tudy, the comparable figure was 38 percent. In the E C A study, among those diagnos ed with drug dependence, the common additional diagnos is was alcohol abuse/dependence, followed in frequency by antisocial personality dis order, phobic disorders , and major depres sion for men and phobic disorders , major depres sion, and dys thymia for women. Almost every ps ychiatric diagnosis was more common among thos e who met the criteria for drug dependence, with notable increases in odds ratios for alcoholism, antis ocial personality dis order, and mania among women and for mania, antis ocial pers onality disorder, and dys thymia 1322 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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among men. B oth men and women with drug abus e dependence are at a s ubs tantially higher risk for schizophrenia. In general, the probability of comorbidity is higher for those with a lifetime diagnosis of an opioid or cocaine disorder than for those with a diagnosis of cannabis Among people in prison, the comorbidity rates were higher than in the general population; addictive were found in 92 percent of pris oners with 90 percent of thos e with antisocial personality dis order, and 89 percent of thos e with bipolar disorders. Among people with mental dis orders s eeking treatment in ps ychiatric specialty s ettings , 20 percent have a subs tance abus e disorder diagnos is. More recently, it become apparent that cigarette smoking is as sociated with higher probability of additional ps ychiatric es pecially mood disorders . T he findings from the NC S largely confirm the observations of the E C A s tudy that those with us e disorders are substantially more likely to other mental disorders and that those with other mental disorders are far more likely to develop s ubs tance use disorders . T he NC S als o unders cored the finding that, although 52 percent of res pondents had never experienced any DS M-III-R disorder and 21 percent one s uch dis order, 13 percent had two disorders , and percent had three or more disorders . F urthermore, the month prevalence of a dis order was more likely among those with more than one disorder: 59 percent of all of month dis orders occurred in the 14 percent with a history of three or more dis orders, and 89 percent of severe 12-month dis orders occurred in the s ame 1323 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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T hese findings describe rather than explain T hey do not s hed much light on the ques tion of or in which cas es , drug us e is at least initially an effort at self-medication or whether thos e with a variety ps ychiatric disorders are less able to cope with the of s ubs tance use and so are more likely to become dependent. It is also not clear whether psychiatric disorders increas e the vulnerability to drug abuse and drug dependence or whether s ome common factor contributes to both. In some cas es , however, there appear to be a causal link between drug us e and s ome ps ychiatric disorders. F or example, evidence indicates subs tance abus e (es pecially alcohol) can cause or the ris k for depres sive dis order; cocaine can increase frequency of panic disorder; and cannabis, cocaine, amphetamine us e can aggravate or precipitate schizophrenic symptomatology. S ome of these are induced dis orders (particularly some of the depres sive symptoms s een in alcoholics) and clear with cess ation alcohol use. However, s ome ps ychiatric dis orders (e.g., mood dis order and antisocial personality disorder) antedate s ubs tance use and can be viewed as risk or predictors for substance abuse and dependence. particularly true of conduct dis order and adult antis ocial behavior, in which the symptoms often begin before the onset of problematic drug us e. T he NC S found that the odds of developing alcohol or drug dependence fivefold in the presence of conduct dis order without antis ocial behavior and 10- to 14-fold if only adult antis ocial behavior or both conduct disorder and behavior were present. Of the Axis I disorders , bipolar I disorder is more s trongly related to dependence on alcohol or drugs than any other mood or anxiety 1324 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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In general, approximately 24.5 percent of thos e with a month addictive dis order had a mood disorder as well, 35.6 percent had an anxiety dis order. Overall, 42.7 of thos e with a 12-month addictive dis order had at least one 12-month Axis I mental dis order. In terms of disorders , 41.0 to 65.5 percent of those with a lifetime addictive disorder have a lifetime history of at least one Axis I mental dis order, whereas 51 percent of those one or more lifetime mental disorders (Axis I or II) have history of one or more addictive disorders . F or lifetime conduct dis order or adult antisocial behavior, the rate lifetime substance us e disorder increas es to 82 Although the poss ibility of recall bias exis ts, those with both an affective and an addictive disorder us ually that depres sion began earlier than s ubs tance use. However, temporal relationship between two dis orders does not prove causality, even when the development the firs t disorder is a predictor of both the likelihood cours e of the subsequent disorder. T here is the as has been sugges ted for s moking and depres sion, both disorders are linked to s ome third common factor. the NC S , a more chronic cours e of an addictive was found for those who reported earlier development primary anxiety dis order, conduct dis order, or adult antis ocial behavior but was not found with earlier onset other mental disorders . As noted above, several views of the etiology of drug dependence place on preexis ting (genetically determined) or s ubstanceinduced deficits in the function of the prefrontal cortex only in inhibiting respons es to drug-related stimuli but impulsivity in general. In the NC S , cooccurring mental disorders als o 1325 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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likelihood of s eeking treatment and the treatment from which service is s ought. As mentioned, those who had a s ubstance dependence problem were far more to seek and receive treatment if they also had a cooccurring mental disorder. Approximately one-third people with a 12-month his tory of affective disorder received some treatment; but those who also had an addictive disorder were more likely to have received it specialty addiction treatment program. A collaborative s tudy of the genetics of alcoholism extensive s tructured interviews to s eparate mood and anxiety disorders from those that occurred within the context of active P.1165 drinking or withdrawal. T his s tudy found that over a lifetime, independent mood dis order was les s common alcoholics (14 percent) than in controls (17.1 percent), although more than twice as many alcoholics (2.3 as controls (1 percent) met criteria for bipolar disorder. P anic dis order and social phobia were als o more common as independent disorders among alcoholics . In general, in this study, the large majority alcohol-dependent men and women did not have independent mood or anxiety dis orders. T his s uggests the higher rates of cooccurrence of most anxiety and affective dis orders found in epidemiological s tudies or clinical populations probably reflect s ubs tance induced anxiety and mood disorders that res olve special intervention once drug use ceas es .

Multiple Fac tors 1326 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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T he biops ychos ocial general model of s ubs tance dependence presented here does not attempt to ass ign weight or special significance to any one factor or interaction. T he implication is that for different of drugs , different factors may play more or less caus al roles in perpetuating s ubs tance use or relaps e. F or example, pos itive reinforcing effects may more important for the development of cocaine dependence, whereas acute and protracted withdrawal phenomena may be more important in the return to opioid us e after withdrawal. E ven with the s ame subs tance, different factors may be more or les s for different people. T hus, the emergence of symptoms may make it difficult for some cigarette to quit, particularly thos e with a his tory of major depres sive disorder, and thos e people may be helped antidepres sants. S uch a multifactorial model implies certain treatments or interventions may be more for one substance category than another and that, among people us ing the same substances, different treatments may be indicated. F igure 11.1-5 implies that the notion of dependence is a property of any one element but, rather, an inferred from the relations among the elements of the system. Although it is convenient (and required by IV -T R ) to see dependence as a dis order located within person, any interpretation that overemphas izes one the system, whether the biology of the pers on, changes the brain, s ocial influences, or behavior, is miss ing part the nature of dependence.

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Many people who develop substance-related problems recover without formal treatment. F or those who do help or advice, particularly those patients with les s disorders , relatively brief interventions are often as effective as more intens ive treatments . B ecause thes e interventions do not change the environment, alter induced brain changes, or provide new skills, a change the patient's motivation (cognitive change) probably explains their impact on the drug-us ing behavior. F or those individuals who do not res pond or whos e dependence is more severe, a variety of interventions appear to be effective. Although each section in this chapter discuss es treatment relevant to the particular subs tance use dis order, the clinician s ees few drugdependent people who use only one drug. (Nicotine dependence may be an exception.) F or example, patients using an illegal drug, the mos t common additional diagnosis is alcohol dependence. It is useful to distinguish among specific procedures or techniques (e.g., individual cognitive-behavioral family therapy, group therapy, relaps e prevention, and pharmacotherapy) and treatment programs. Mos t programs us e a number of s pecific procedures and several profes sional disciplines as well as who have s pecial skills or personal experience with the subs tance problem being treated. T he bes t treatment programs combine s pecific procedures and disciplines meet the needs of the individual patient after a careful as sess ment. However, there is no generally accepted clas sification either for the s pecific procedures us ed in treatment or for programs making us e of various combinations of procedures . T his lack of s tandardized 1328 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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terminology for categorizing procedures and programs presents a problem, even when the field of interes t is narrowed from substance problems in general to treatment for a s ingle substance such as alcohol, or cocaine. E xcept in carefully monitored research even the definitions of specific procedures (e.g., couns eling, group therapy, and methadone tend to be so imprecise that one us ually cannot infer what transactions are s upposed to occur. descriptive purpos es , programs are often broadly on the bas is of one or more of their s alient whether the program is aimed at merely controlling withdrawal and consequences of recent drug us e (detoxification) or is focus ed on longer-term behavioral change; whether the program makes extensive use of pharmacological interventions ; and the degree to which the program is bas ed on individual ps ychotherapy, AA, other 12-step principles or therapeutic community principles. B road program des criptions mas k as much they reveal, tend to confuse the setting with the procedures , and obscure differences in the etiological models underlying the treatments used in different programs. F urther, s ervices actually provided by the types of programs can vary greatly in intens ity and in specific problems (legal, medical, vocational) they are intended to ameliorate. B as ed on the NHS DA, approximately 3.1 million people years of age or older reported receiving some form of treatment for a drug- or alcohol-related problem in S ome reported treatment at more than one location. most common treatment reported was participation in a self-help group (1.6 million). T he next mos t frequent 1329 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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setting was treatment at an outpatient rehabilitation facility (1.2 million). T hen, in des cending order, were inpatient rehabilitation (0.87 million), mental health (0.73 million), hospital inpatient (0.71 million), private doctor's office (0.44 million), an emergency room (0.38 million), and pris on or jail (0.18 million). F igure 11.1-6 shows the drug for which people reported receiving treatment. S ome of the treatments received were for induced conditions other than dependence.

FIGUR E 11.1-6 Number of U.S . community res idents received services for treatment of alcohol and other problems in the year before as sess ment, as estimated each drug category under s tudy. (Data from U.S . Hous ehold S urvey of Drug Abus e, 2001, with Not all interventions are applicable to all varieties of subs tance us e or dependence, and s ome of the more coercive interventions us ed for illegal drugs are not applicable to s ubs tances that are legally available, 1330 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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tobacco. C hanges in addictive behaviors do not occur abruptly but rather through a series of s tages. F ive in this gradual process have been proposed: precontemplation, contemplation, preparation, action, and maintenance. F or some types of addiction, the therapeutic alliance is enhanced when the treatment approach is tailored to the patient's s tage or readines s change. F or some drug use dis orders , a specific pharmacological agent may be an important of an intervention—for example, dis ulfiram, naltrexone, acampros ate (C ampral) for alcoholis m; methadone, levomethadyl acetate (Orlaam) (als o called L- αacetylmethadol [LAAM]), or buprenorphine (B uprenex, S ubutex) for heroin addiction; nicotine delivery devices bupropion (Zyban) for tobacco dependence. Not all interventions are likely to be useful as res ources for care profes sionals. F or example, young offenders with histories of drug use or dependence may be remanded special facilities under the juris diction of the criminal justice system. S ome P.1166 programs for offenders (and sometimes for employees) rely almost exclus ively on the deterrent effect of urine testing. In contrast to the numerous studies suggesting s ome value for brief interventions for and for problem drinking, there are few controlled of brief interventions for thos e s eeking treatment for dependence on illegal drugs . In general, for people who are severely dependent on illegal opioids, brief interventions (s uch as a few weeks detoxification, whether in or out of a hos pital) have 1331 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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effect on outcome meas ured a few months later. F or dependent on cocaine or heroin, treatment las ting as 3 months is much more likely to result in s ubs tantial reductions in illegal drug us e, antisocial behaviors , and ps ychiatric distres s. S uch a time-in-treatment effect is acros s very different modalities, from res idential therapeutic communities to ambulatory methadone maintenance programs . Although s ome patients benefit from a few days or weeks of treatment, a subs tantial percentage of users of illegal drugs drop (or are dropped) from treatment before they have achieved significant benefits . S ome of the variance in outcome of treatment can be attributed to differences in the characteristics of patients entering treatment and events and conditions after treatment. However, based on similar philosophical principles and us ing seem to be s imilar therapeutic procedures vary greatly effectivenes s. S ome of the differences among that s eem to be s imilar reflect the range and intensity services offered. P rograms with profess ionally trained staffs that provide more comprehens ive s ervices to patients with more severe psychiatric difficulties are likely to be able to retain thos e patients in treatment to help them to make pos itive changes. Differences in skills of individual counselors and profes sionals can powerfully affect outcomes. P atients who have low of psychiatric problems tend to do well in mos t and for thes e patients , the impact of specialized skills services is more difficult to demons trate. S uch generalizations concerning programs s erving illegal us ers may not hold for programs dealing with thos e seeking treatment for alcohol or tobacco or even problems uncomplicated by heavy us e of illegal drugs . 1332 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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such cases , relatively brief periods of individual or couns eling can produce long-lasting reductions in drug us e. T he outcomes us ually considered in programs with illegal drugs have typically included meas ures of social functioning, employment, and criminal activity as well as decreases in drug-us ing behavior. T reatment alcoholism and other mental health problems generally has more limited expectations (e.g., reduction in us e and s ymptoms of psychiatric disorders ), although reduced us e of health care res ources subs equent to treatment is s ometimes an additional meas ure of treatment effectiveness .

Meas uring Treatment Outc ome In a large multis ite study of treatment, the Drug Abuse T reatment Outcome S tudy (DAT OS ; carried out from to 1993) patients were interviewed at intake and 1, 3, 12 months after treatment. (F or s ome types of drug data are now available for outcomes 5 years after treatment entry.) As in previous multis ite studies, s ites selected were s table repres entatives of four major program types : drug-free outpatient, methadone maintenance, s hort-term res idential (chemical dependency), and long-term res idential (therapeutic community). E xcept at the methadone programs, which us ed group and individual counseling approximately equally, group couns eling was the common element of other treatments . S ome antidepress ant and agents were us ed in the nonmethadone programs , but they were incidental. T his s tudy found a lower level of services available to patients s eeking treatment than a decade earlier. Als o, 1333 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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patients were older and more likely to have a variety of special medical problems (HIV , psychiatric disorders ) social needs (homeles sness ). T reatment outcomes generally cons is tent with thos e of previous s tudies of treatment in the public s ector. One year after there were substantial decreas es in drug use. Levels of weekly or daily cocaine us e at 1 year were, on approximately 50 percent of pretreatment levels , with greater reduction for those who participated in for 3 months or more. Daily heroin use was lower patients who remained in methadone maintenance treatment than among thos e who left. Although cocaine us e among patients treated with methadone was somewhat lower, the reduction could not be attributed treatment. Alcohol and marijuana us e did not decline significantly. T here was als o no apparent decrease in suicidal thoughts or increase in employment, and, in contrast to a number of previous multis ite studies, multivariate analys is in this s tudy did not confirm the widely reported reduction in predatory or high-ris k behaviors , or both, for those in methadone programs . T hose who s tayed in long-term res idential treatment for months or more showed a major decreas e in drug us e from preadmis sion levels for all categories of drugs — to 22.0 percent for cocaine; 17.2 to 5.8 percent for alcohol and marijuana use reduced by more than oneT hese individuals als o reported a 50 percent decrease illegal activities and approximately a 10 percent full-time employment. T he outpatient drug-free and short-term inpatient programs s urveyed by DAT OS had very few which heroin was the major drug problem; the most 1334 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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common pres enting drug problem for both was P.1167 cocaine, followed by alcohol and marijuana. in the outpatient drug-free programs for 3 months or was as sociated with a greater decreas e in cocaine use year (approximately 50 percent, compared with those stayed 3 months or less ). B ut even 58 percent of those stayed less than 3 months reported some decreas e in cocaine use over preadmis sion levels . P atients who entered short-term inpatient programs also reported major decreas es in drug use at 1 year, but there was difference between those who s tayed more than 2 and those who s tayed les s than 2 weeks . G enerally, level of drug use at 1 year was predictive of drug us e at 5-year follow-up. T his s us tained improvement at 4 to 5 years was als o noted in a follow-up of treatment in the United K ingdom. Although adolescents are generally reluctant to seek treatment without some external or family press ure, follow-up studies of specializing in adolescent treatment have found subs tantial and sus tained decreas es in drug use. B ecaus e the decision to enter any of the programs in DAT OS is made by the patient, the study does not much guidance to a clinician weighing a for a s pecific patient. More guidance comes from a scale, random-as signment study of the treatment of alcoholics , which found that three dis tinct methods of delivering individual therapy over a 12-week period— step facilitation, cognitive-behavioral coping s kills , and motivational enhancement (four ses sions only)— produced comparable and generally quite favorable 1335 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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outcomes . P atient characteristics interacted with the treatment in only one area, alcoholics with lowlevel ps ychiatric problems had better outcomes in days of abstinence if ass igned to 12-step facilitation than cognitive-behavioral therapy. P atients who individual therapy after a brief period of inpatient and intens ive day care treatment (aftercare) had better 1outcomes than those who began individual treatment outpatients, even though their problem level at bas eline was more s evere. C urrently, entry into treatment rarely reflects a truly informed choice aimed at matching the characteris tics needs of the patient with the capacities and skills of a provider. F indings from s tudies of public sector serving drug users with relatively few social s upports that more intensive s ervices, such as vocational, and mental health services , increase retention and produce better outcomes at follow-up. P atients who expres s more satis faction with the treatment received to remain in treatment longer. In general, acros s drug categories , participation in self-help groups s uch as AA correlates with better s hort-term and long-term

Influenc e of P hilos ophic al T he kinds of therapeutic procedures that treatment profes sionals deem valuable or es sential are affected by philosophical orientation. F or example, one study found that many profes sionals who adhere to a “disease model” of substance dependence view of denial, acceptance of disease, need for lifelong abstinence, commitment to recovery, and affiliation AA as the most important elements of intervention. In 1336 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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contrast, dealing with res ponsibility, instilling motivation and confidence, teaching relaps e prevention, and high-ris k situations were rated highes t by ps ychologists es pousing a behavioral model of dependence. Until recently, even physicians were unlikely to view pharmacological interventions as having s ignificant in treating alcoholis m or most other forms of drug dependence, although some phys icians did prescribe various forms of nicotine for tobacco dependence. Many controlled studies over many years have shown the us e of illegal opioids (heroin) can be markedly by supervis ed adminis tration of oral opioid agonists (methadone or LAAM) or partial agonis ts B ecaus e of government regulations, the use of full agonis ts is limited to practitioners and programs that obtained s pecial licenses. Data also show that can reduce relaps e rates for alcoholics after C ontrolled s tudies conducted in E urope show that acampros ate, a drug believed to act via actions on the glutamatergic system, can also reduce alcoholis m rates. At pres ent, however, there s eems to be only a modes t correlation between the evidence s howing that given intervention or procedure is effective and the likelihood that it will be widely used.

Treatment of C omorbidity— vers us C onc urrent T he treatment of the severely mentally ill (primarily with s chizophrenia and schizoaffective dis orders) who also drug dependent continues to pos e problems for clinicians . Although s ome special facilities have been developed that us e both antipsychotic drugs and 1337 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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therapeutic community principles, for the mos t part, specialized addiction agencies have difficulty treating these patients. G enerally, integrated treatment in which the same staff can treat both the psychiatric dis order the addiction is more effective than either parallel treatment (a mental health and a s pecialty addiction program providing care concurrently) or s equential treatment (treating either the addiction or the disorder first and then dealing with the comorbid condition).

S ervic es and Outc ome T he extens ion of managed care into the public sector produced a major reduction in the us e of hospitaldetoxification and virtual disappearance of longer-term res idential rehabilitation programs for alcoholics . However, s ome managed care organizations tend to as sume that the relatively brief courses of outpatient couns eling that are effective with private s ector patients are also effective with patients who are dependent on illegal drugs and who have minimal supports. F or the present, the trend is to provide the that costs leas t over the s hort term and to ignore showing that, for some patients , more services can produce better long-term outcomes. T reatment is often a worthwhile s ocial expenditure. F or example, treatment of antis ocial illegal drug us ers in outpatient settings can produce decreases in antis ocial behavior and reductions in rates of HIV seroconversion that more than offs et the treatment cos t. T reatment in a prison setting can produce favorable decreases in postreleas e cos ts ass ociated with drug us e and 1338 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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Des pite such evidence, there are problems maintaining public s upport for treatment of substance dependence, both in the public and private s ectors. T his lack of suggests that these problems continue to be viewed, at least in part, as moral failings rather than as medical disorders .

S UG G E S TE D C R OS S Individual s ections discus s in detail the relevant subs tances and treatment for their related disorders : alcohol-related dis orders in S ection 11.2; related dis orders, S ection 11.3; caffeine-related S ection 11.4; cannabis -related dis orders, S ection 11.5; cocaine-related dis orders, S ection 11.6; hallucinogenrelated dis orders, S ection 11.7; inhalant-related S ection 11.8; nicotine-related disorders , S ection 11.9; opioid-related dis orders, S ection 11.10; P C P -related disorders , S ection 11.11; s edative-hypnotic–related disorders , S ection 11.12; and anabolic-androgenic abuse, S ection 11.13. B rief psychotherapy is covered S ection 30.9; alternative therapies , in S ection 30.10; methadone (and other maintenance therapies) in 31.22. Drug and alcohol abus e among elderly people is discuss ed in S ection 51.3i.

R E F E R E NC E S Anthony J C . E pidemiology of drug dependence. In: G alanter M, K leber HD, eds. T e xtbook of S ubs tance T re atme nt. 3rd ed. W ashington, DC : T he American P sychiatric P ress , Inc.; 2003. P.1168 1339 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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R egier DA, F armer ME , R ae DS , Locke B Z, K eith LL, G oodwin F K : C omorbidity of mental disorders alcohol and other drug abus e. J AMA. R obins on T W , B erridge K C : Incentive-sens itization addiction. Addiction. 2001;96:103. R ounsaville B J , B ryant K , B abor R , K ranzler H, C ros s s ys tem agreement for s ubs tance use DS M-III-R , DS M-IV and IC D-10. Addiction. S chuckit MA, S mith T L: An 8-year follow-up of 450 of alcoholic and control s ubjects . Arch G e n 1996;53:202. S chuckit MA, T ipp J E , B ucholz K K , Nurnberger J I J r, Hes selbrock V M, C rowe R R , K ramer J : T he life-time of three major mood disorders and four major disorders in alcoholics and controls . Addiction. 1997;92:1289. *S impson DD, J oe G W , B roome K M: A national 5follow-up of treatment outcomes for cocaine dependence. Arch G en P s ychiatry. 2002;59:538. S imps on DD, J oe G W , B rown B S : T reatment and follow-up outcomes in the Drug Abuse Outcome S tudy (DAT OS ). P s ychol Addict B e hav. 1997;11:294. T arter R E , K irisci L, Mezzich A, C ornelius J R , P ajer V anyukov M, G ardner W , B lackson T , C lark D: 1345 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/11.1.htm

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Neurobehavioral dis inhibition in childhood predicts early age at onset of substance us e disorder. Am J P s ychiatry. 2003;160:1078. T s ai G E , R agan P , C hang R , C hen S , Linnoila MI, Increased glutamatergic neurotransmis sion and oxidative s tres s after alcohol withdrawal. Am J P s ychiatry. 1998;155:726. T s uang MT , Lyons MJ , Meyer J M, Doyle T , E isen G oldberg J , T rue W , Lin N, T oomey R , E aves L: C ooccurrence of abuse of different drugs in men. Arch P s ychiatry. 1998;55:967. Weisner C , Matzger H, K askutas LA: How important treatment? One-year outcomes of treated and untreated alcohol-dependent individuals . Addiction. 2003;98:901.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 12 - S chizophrenia and O ther P s ychotic Dis orders > 12.1 S chizophrenia

12.1 C onc ept of S c hizophrenia R obert W. B uc hanan M.D. William T. C arpenter J r. M.D. P art of "12 - S chizophrenia and Other P s ychotic S chizophrenia is a clinical s yndrome of variable, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. T he express ion of thes e manifes tations acros s patients and over time, but the effect of the always severe and is us ually long-lasting.

HIS TOR Y Written des criptions of s ymptoms commonly observed today in patients with s chizophrenia are found recorded history. E arly G reek phys icians described delus ions of grandeur and paranoia and deterioration cognitive functions and personality. B ecaus e these symptoms are not unique to s chizophrenia, it is whether thes e behaviors were ass ociated with what is currently called schizophrenia. Indeed, s everal have argued that s chizophrenia is of relatively recent origin. S chizophrenia emerged as a medical condition worthy study and treatment in the 18th century. B y the 19th 1347 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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century, the various psychotic disorders were generally viewed as ins anity or madness , and the movement to conceptualize thes e disorders as regrettable afflictions replaced the view of insanity as a reprehens ible Many clinical categories were des cribed during the to late 19th century, but a general approach capable of integrating the divers e manifes tations of mental illnes s into distinguis hable clinical s yndromes was lacking. A major impediment to dis tinguishing schizophrenia other forms of ps ychos es was the exis tence of another common illnes s, general pares is of the insane. T he manifestations of general pares is were quite divers e overlapped extensively with schizophrenic symptomatology. T he caus e of s yphilitic insanity was subs equently traced to a spirochetal infestation, and malaria-induced fever therapy proved partially Antibiotics were eventually found to provide effective treatment and prevention. T he identification and treatment of general paresis is one of the great s tories medical science. T he identification of syphilitic insanity reduced the heterogeneity of madnes s and enabled K raepelin to delineate the two other major patterns of insanity—manic-depres sive psychosis and dementia praecox (or dementia of the young)—and to group together under the diagnostic category of dementia praecox the previous ly dis parate categories of insanity, such as hebephrenia, paranoia, and catatonia. In differentiating dementia praecox from manicdisorder, K raepelin emphas ized what he believed to be characteristic poor long-term prognosis of dementia praecox, as compared to the relatively nondeteriorating cours e of manic-depres sive illnes s. K raepelin went on 1348 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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describe the two principal pathophys iological or proces ses occurring in dementia praecox (Deme ntia P rae cox and P araphre nia, 1919): On the one hand we obs erve a weakening of those emotional activities which permanently the mains prings of volition. In connection with this, mental activity and instinct for become mute. T he res ult of this part of the process is emotional dullness , failure of mental activities, loss of mas tery over volition, of endeavor, and of for independent action. T he es sence of pers onality is destroyed, the bes t and mos t precious part of its being, as G ries inger once expres sed it, from her.… T he second group of disorders , which gives dementia praecox peculiar stamp… cons ists in the loss of the inner unity of the activities of intellect, emotion, volition in themselves and one another. S transky speaks of annihilation of the “intraps ychic co-ordination”… this annihilation presents its elf to us in the disorders of ass ociation 1349 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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by B leuler, in incoherence of the train of thought, in the sharp change of moods as well as in desultorines s and derailments in practical work. B ut further, the near connections between thinking and feeling, between deliberation and emotional activity on the one hand, and practical work on the other is or les s lost. E motions do not corres pond to ideas. T he description of the des truction of the pers onality provides a conceptual framework for the avolitional or negative symptom component of the illness , and the description of “the loss of the inner unity of activities” proces s provides a conceptual framework for the symptoms of s chizophrenia. In 1911, E ugen B leuler, recognizing that dementia was a usual characteristic of dementia praecox, s uggested term s chizophre nia (s plitting of the mind) for the B leuler introduced the concept of primary and schizophrenic symptoms ; his four primary symptoms four As) were abnormal ass ociations , autis tic behavior thinking, abnormal affect, and ambivalence. Of thes e symptoms, B leuler viewed as central to the illness the of ass ociation between thought process es and among thought, emotion, and behavior. E xamples of thes e of as sociations are a P.1330 1350 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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patient laughing on receiving news of the death of a one, the introduction of magical thinking and peculiar concepts into an ordinary discus sion, and the s udden display of angry behavior without experiencing anger an understandable provocation). B leuler's view that a dis sociative proces s is schizophrenia and that this proces s underlies a wide variety of the symptom manifes tations of s chizophrenia has provided a major paradigm for conceptualizing the illness , that is , that in spite of its various schizophrenia is a single disease entity in which there extensive s imilarity in etiology (caus e) and pathophys iology (mechanism) across all patients with disorder. In this view, a neurophys iological disturbance indeterminate origin and nature occurs that is as diss ociative process es adversely influencing the development of mental capacities in the areas of emotion, and behavior. Depending on the individual's adaptive capacity and environmental circums tances , fundamental process could lead to s econdary disease manifestations, such as hallucinations , delus ions, withdrawal, and diminis hed drive. T here are many parallels in medicine for the previously mentioned s ingle-disease model. P atients with type I diabetes mellitus share an impairment in insulin metabolism, but the secondary manifestations may cons iderably, depending on which organ s ys tems are involved. S imilarly, patients with temporal lobe epileps y share a common pathophysiological mechanis m but present with a myriad of different s igns and s ymptoms. T he divers e manifes tations of syphilitic insanity best illustrate the us efulness of this dis ease entity 1351 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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approach for schizophrenia. T he major alternative etiopathophys iological model conceptualizes s chizophrenia as a clinical s yndrome than as a single dis eas e entity. T his view holds that, although patients with schizophrenia s hare a s ufficient commonality of signs and symptoms to validly differentiate them from patients with other forms of ps ychos is (e.g., affective disorders and toxic more than one dis eas e entity is eventually found within this s yndrome. T his view is s upported by the existence numerous ris k factors, the implication of multiple and the heterogeneity in clinical pres entation, res ponse, and clinical cours e. T he demonstration over past 50 years that mental retardation is a clinical comprised of multiple dis eas e entities rather than a disease entity bes t illus trates this construct. currently maintains the status of a clinical syndrome in absence of evidence for the existence of a s ingle entity. T here are other competing models for conceptualizing schizophrenia, that, although seriously debated in the past, are presently dismis sed as demonstrably invalid seriously reductionis tic as to not account for major observations as sociated with the illness . Nondis eas e models, such as the s ocietal reaction theory (a sane reaction to an ins ane world) or T homas S zas z's theory schizophrenia is a myth enabling s ociety to manage deviant behavior, cannot adequately account for the distribution of s chizophrenia among biological relatives , the range of early developmental ris k factors, the as sociated functional and s tructural brain the normalizing effects of drug treatment, or the 1352 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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similarity and lifetime prevalence and clinical manifestations of s chizophrenia across widely cultures. Narrow framework disease models that to account for the illnes s s olely at the level of ps ychological mechanis ms are als o demons trably inadequate in accommodating the known facts of the illness . G enetic or immunovirological caus al factors be address ed by reductionis tic theories operating at ps ychological or s ocial levels. T he many biological, ps ychological, and s ocial factors relevant to the unders tanding and treatment of the pers on with schizophrenia requires a broad medical model and es chews reduction to any single level of the functioning organism. R ecent scientific advances have confirmed current concepts of s chizophrenia and sugges ted that the nosology of psychotic illness will continue to evolve. F amily s tudies have provided an important validation of K raepelin's original formulation of dementia praecox manic-depres sive psychosis as s eparate dis orders . studies have repeatedly shown that biological relatives patients with s chizophrenia have an increased ris k of schizophrenia and s chizophrenia spectrum disorders , whereas biological relatives of patients with a major affective dis order have an increas ed risk for affective disorders . T he s eparation is not complete, but it is supportive of the two disorders as independent dis eas e entities. T win studies indicate that the genetic between schizophrenia and major affective dis orders is even more robust when cons idering concordance rates among monozygotic twins. T here is als o evidence that presence of the deficit form of s chizophrenia (i.e., 1353 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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schizophrenia with primary negative symptoms) the relative risk of s chizophrenia and decreases the ris k for other mental illnes s in biological relatives. res ults s uggest that some subtypes of s chizophrenia breed true. In contrast, there are emerging data from linkage analys es conducted in families s elected for the presence of bipolar disorder, other major affective disorders , or schizophrenia that s uggest that there is remarkable overlap of chromosomal areas suspected the location of genes contributing to disease liability. It now appears likely that a number of genes confer for major ps ychiatric disorders and that these genes overlap acros s current diagnostic boundaries. Initial expres sion findings from postmortem tiss ue als o this overlap, and nos ologis ts will soon be challenged to reconceptualize clas sification of these illnes s In summary, schizophrenia is appropriately and conceptualized as a disease proces s. Although it is that a unifying etiology and pathophys iology will eventually be uncovered that will account for all, or all, cas es, it s eems more likely that more than one entity exis ts within the clinical syndrome of with each having a distinguishable etiology and pathophys iology. Any reductionistic approach to the description or explanation of the disorder cannot adequately account for the range of relevant and facts . A broad medical model that integrates ranging from the molecular to the psychosocial level of organization is necess ary to describe schizophrenia, to account for the range of pathogenic influences, and to provide for treatment and rehabilitation. W ith of extensive overlap in genetic vulnerability acros s 1354 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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schizophrenia and affective disorder disease class es , a remarkable reconceptualization of nos ology may be required in the near future.

E P IDE MIOL OG Y S chizophrenia is a leading worldwide public health problem that exacts enormous personal and economic costs . S chizophrenia affects just les s than 1 percent of world's population. If schizophrenia s pectrum disorders are included in the prevalence estimates , then the of affected individuals increases to approximately 5 percent. T he concept of s chizophrenia s pectrum is derived from observations of ps ychopathological manifestations in the biological relatives of patients schizophrenia. Diagnos es (and approximate lifetime prevalence rates [percent of population]) for these disorders are s chizoid pers onality disorder (fractional percentage), s chizotypal personality dis order (1 to 4 percent), s chizoaffective psychosis (<1 percent), and delus ional dis order (fractional percentage). T he relations hip of these disorders to s chizophrenia in the general population is unclear, but in family pedigree studies, the pres ence of a proband with s chizophrenia significantly increas es the prevalence of thes e among biological relatives. P.1331 S chizophrenia is found in all s ocieties and areas. Although comparable data are difficult to obtain, incidence and lifetime prevalence rates are roughly worldwide. T here is a slightly greater incidence of schizophrenia in men than women. T here is a greater 1355 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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incidence of s chizophrenia in urban vers us rural areas. difference had previously been attributed to the s ocial phenomenon, in which afflicted or vulnerable tend to los e their occupation and s ocial niche and drift toward pockets of poverty and inner city areas. recent s tudies have confirmed the increased incidence urban areas , with the relative risk for s chizophrenia to the degree of urbanization. S chizophrenia also tends be more s evere in developed versus developing Occasional geographic areas of increas ed prevalence schizophrenia are interesting in terms of illnes s F or example, a northern S candinavian, is olated appears to have a gene pool enriched for vulnerability, probably brought to the region ago by two immigrating families . P atients with schizophrenia are at increas ed ris k for subs tance abus e, es pecially nicotine dependence. As much as 90 percent of patients may be dependent on nicotine. P atients with schizophrenia are also at ris k for suicidal and as saulting behavior. S uicide is a caus e of death of patients with s chizophrenia, and approximately 10 percent of patients commit s uicide. B ecaus e s chizophrenia begins early in life, causes significant and long-lasting impairments , makes heavy demands for hospital care, and requires ongoing care, rehabilitation, and s upport services, the financial of the illnes s in the United S tates is es timated to that of all cancers combined. In 1990, the direct and indirect cos ts of s chizophrenia were es timated at $33 billion. T he locus of care has shifted dramatically over last 50 years from long-term hospital-based care to hospital care and community-based services . In 1955, 1356 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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approximately 500,000 hospital beds in the United were occupied by the mentally ill—the majority of these with a diagnosis of s chizophrenia. T he figure is now than 250,000 hospital beds . Deinstitutionalization has dramatically reduced the number of beds in custodial facilities, but an overall evaluation of its cons equences is disheartening. Many patients have s imply been transferred to alternative of cus todial care (in contras t to treatment or services ), including nursing home care and poorly supervis ed s helter arrangements . Others have been releas ed to communities often unable or unwilling to provide the minimal requirements for clinical care or humane s upport. F or more fortunate patients, the of care has s hifted to the family, creating an extremely difficult hardship for large numbers of families in this country. T he estimate of the overall financial burden to these families is in the billions of dollars . T he less patient may have no place to live, may be forced to live circums tances of isolation and hopeles sness , or may up in jail. P atients with a diagnos is of s chizophrenia are reported to account for 15 to 45 percent of homeless Americans . Modern-day managed care and other economic factors place further pres sure to reduce bed with still marginally prepared communities and a dearth of alternative care systems. C ontinuity-of-care systems that include as sertive outreach programs and supervis ed hous ing and emergency care provide an effective alternative to hos pital-based care for many patients, but costs are subs tantial, and it has not feasible to s imply shift cos t from impoverished public hospital sectors . 1357 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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E TIOL OG Y T he etiological process or process es by which a causal agent creates the pathophysiology of schizophrenia are not yet known. However, there is cons iderable from family, twin, and adoptive s tudies that genetic make a robus t contribution to the etiology of schizophrenia, with genetic factors established as to some, perhaps all, cases. Linkage and as sociation genetic s tudies have been used to delineate thes e and have provided strong evidence for eight linkage 1q21-22, 6p22-24, 6p21-22, 8p21-22, 10p11-15, 15q13-15, and 22q11-13. F urther analys es of these chromosomal s ites have led to the identification of candidate genes , and the best current candidates are alpha-7 nicotinic receptor, DIS C 1, G R M 3, dys bindin, NR G 1, R G S 4, and G 72. E ach of these genes make a s mall contribution to s chizophrenia What other genes are involved and what combinations neces sary for disease are not known. It is also not yet determined how the proteins they produce contribute to the pathophys iology of schizophrenia. R is k factor studies have also identified a number of potential environmental factors that may contribute to development of s chizophrenia. T hese include and birth complications , exposure to influenza or maternal starvation during pregnancy, R hes us (R h) factor incompatibility, and an excess of winter births. nature of these factors further sugges ts a neurodevelopmental pathological process in schizophrenia, but the exact pathophys iological mechanisms as sociated with thes e risk factors is not known. T here are interesting reports that a subgroup of 1358 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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patients with the avolitional component of the illness , defined by criteria for the deficit s yndrome, do not the winter birth excess but rather s how a summer birth excess , suggesting the poss ibility of a s eparate entity within the s chizophrenia syndrome. A number of speculations regarding viral and immune mechanisms, sometimes pos ited as an explanation of the season of ris k factor, are plausible, but no virus or immune mechanism has yet been established as an etiological factor in s chizophrenia. F inally, substance abuse has identified as a risk factor for developing s chizophrenia. A central conceptual iss ue in the investigation of the etiology of s chizophrenia is whether schizophrenia is a neurodevelopmental or a neurodegenerative dis order. the cause of schizophrenia to be found in the failure of normal development of the brain, or is it to be found in disease proces s that alters a normally developed B oth, of course, may be true, because the syndrome probably repres ents more than one disease proces s, or a developmental abnormality may increase ris k for the s ubs equent occurrence of a disorder. Although K raepelin believed that had an early onset and was a chronic deteriorating disorder, the examination of the clinical course of the illness has not been helpful in clarifying this is sue. K raepelin eventually came to believe that there were multiple pos sible outcome types . T his has been verified E uropean and North American long-term follow-up studies, in which as many as eight cours e types are typically described. F urthermore, s ubtle neurological manifestations, cognitive dys function, and disturbances affect are often pres ent early in the cours e of illnes s, 1359 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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us ually before the onset of hallucinations and and perhaps from birth. However, it is not clear these abnormalities reflect abnormal brain or are the cons equences of an early les ion to a normal brain, nor is it clear whether the early morbid picture progres ses into the full manifes tation of ps ychos is or whether early morbidity represents a vulnerability s tate susceptible to express ing ps ychos is in the context of a later lesion or stress ful new demands on cognition and interpersonal skills later in adolescence and early adulthood, or both. In any cas e, it is clear that the proces s usually plateaus within the first 5 to 10 years of ps ychos is and does not manifest progress ive throughout the course. Late life improvement, perhaps based on les sened P.1332 intens ity of the psychotic component of the illness , is typical than continued progress ion. T he neuropathological inves tigation of schizophrenia produced s omewhat les s ambiguous results . Although there are sporadic reports of glios is in schizophrenic brains , which may indicate the pres ence of a neurodegenerative disease proces s and s ubs equent neuropathological res ponse, the majority of s tudies failed to document the presence of gliosis. T he glios is does not necess arily preclude a proces s, becaus e an apoptotic pathology in early development might not be as sociated with gliosis. However, in combination with reports of abnormal cell migration and other markers of abnormal development, the preponderance of postmortem evidence is 1360 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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with the neurodevelopmental hypothes is of schizophrenia. F urther support for a pathophys iology comes from neuropsychological, cognitive ps ychological, and neuroimaging findings in first-episode cas es , which tend to be similar to findings more chronic cas es , although longitudinal imaging have sugges ted that patients with schizophrenia may exhibit accelerated cortical or s ubcortical tis sue loss . P erhaps even more decis ive are abnormalities in morphological features, which are believed to be developmental in nature and are ass ociated with at some forms of s chizophrenia. S uch findings range from abnormalities in peripheral development, s uch as finger ridge formation, to abnormal cell migration to of abnormal brain development, s uch as as ymmetry of planum temporale. T he consistency with which the data point to early deviations in the development of the central nervous system (C NS ) has been useful in theory and inves tigative work. T he explosion of information on the neurobiology of development has led to considerable new knowledge the potential mechanis ms of pathogenic influences . It is now clear that s ubtle deviations in the development of brain could create dysfunctions ass ociated with specific behaviors . P os tmortem findings of abnormalities in plate formation, which sugges t a deviation in cell migration or reduced cell dens ity, provide intriguing support for the proposition that the developmental proces s that es tablis hes normal brain cytoarchitecture have gone awry in s chizophrenia. Another view is that brain has established extensive redundancy during the developing years and that the fine-tuning that is 1361 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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for efficient functioning involves eliminating certain cells and many of the s ynaps es connecting cells . A to adequately prune nerve cells and synapses or to err selection for pruning could, in theory, underlie dysfunctions that later lead to s chizophrenia Altered nerve cell migration or pruning is s peculative illus trates plausible mechanis ms by which ris k factors could alter normal brain development in s chizophrenia. P rincipal hypotheses regarding caus ation include genes , neuroimmunovirology factors, and hypoxic or neurotoxic damage during gestation and birth.

Altered E xpres s ion of G enes S chizophrenia and schizophrenia-related dis orders schizotypal, s chizoid, and paranoid personality schizophreniform disorder; and other nonaffective ps ychotic dis orders) occur at an increas ed rate among biological relatives of patients with s chizophrenia. T his increased rate is most dramatically illus trated in the monozygotic twins, who have identical genetic endowment and an approximately 50-percent concordance rate for s chizophrenia. T his rate is four to times the concordance rate in dizygotic twins or the occurrence found in other firs t-degree relatives (i.e., siblings , parents, or offs pring). T he role of genetic further reflected in the drop-off in the occurrence of schizophrenia among s econd- and third-degree in whom one would hypothes ize a decreas ed genetic loading. T he finding of a higher rate of schizophrenia among the biological relatives of an adopted-away who develops schizophrenia, as compared to the nonbiological relatives who rear the patient, has 1362 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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further s upport to the overwhelming pedigree and twin study evidence sugges ting a s ignificant genetic contribution to the etiology of s chizophrenia. However, the monozygotic twin data clearly demons trate the fact that individuals who are genetically vulnerable to schizophrenia do not inevitably develop schizophrenia; environmental factors must be involved in determining schizophrenia outcome. If a vulnerability-liability model schizophrenia is correct in its postulation of an environmental influence, then other biological or ps ychos ocial environmental factors may prevent or schizophrenia in the genetically vulnerable individual. A major obs tacle to delineating which genes are in s chizophrenia is the fact that the modes of genetic transmis sion in s chizophrenia are unknown. No current model (e.g., s ingle-gene dominant or reces sive, polygenetic, multifactorial, or latent trait) satisfactorily accounts for the data. Determining the mode of transmis sion in a putative genetic disorder requires a known phenotype and genetic homogeneity acros s the pedigrees . Neither of these conditions is met in schizophrenia. Nonetheless , to unders tand the etiology schizophrenia, it will eventually be necess ary to identify the actual genes and their products and to determine molecular and neurobiological consequences that lead schizophrenia pathophysiology. P os tgenomic era technologies provide an opportunity accelerate discovery of molecular mechanisms. T he application of gene express ion methods, gene techniques, and proteomic technology to pos tmortem brain tiss ue has the potential to identify s pecific cell genes , and proteins involved in the molecular cascade. 1363 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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early in development, these approaches offer s olid potential for discovery of molecular targets as for etiology and for drug development. S ubs tantial technological and data analytical problems remain to res olved. T he delineation of the different phenotypic manifestations of the s chizophrenic genes or markers the phenotypes is critically important, for case as certainment and in moving genetic inquiry clos er to neuronal effects of s chizophrenia-related genes. of oculomotor phys iology (e.g., s mooth purs uit eye movements), information process ing (e.g., the performance task and forced s pan-of-apprehens ion and s ens ory gating (e.g., P 50) are prominent candidate markers. T hes e meas ures have been found to patients with s chizophrenia and their biological from control groups . T he P 50 s ens ory gating marker is of particular interest, becaus e it captures a neuronal property, whose dysfunction could be explanatory of s chizophrenia pathophysiology. In studies, the P 50 meas ure has been used to define the schizophrenia phenotype, and positive linkage has found on an area of chromos ome 15 near the site of gene for the α7 nicotinic receptor. T his receptor is to mediate the normal P 50 s ensory gating mechanis m. It has proven exceedingly difficult to progres s from evidence confirming a genetic contribution to the of schizophrenia to evidence implicating s pecific genes the disease. Nonetheless , the area of genetic is highly promising, becaus e there is unequivocal for a genetic contribution to some, perhaps all, forms of the illnes s, and there is presently an explos ion of knowledge and techniques relevant to discovering the 1364 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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genetic basis for human dis ease. Linkage analysis has quickly moved from a few marker probes to banks of hundreds, which enables the entire genome to be examined with probes spaced along all chromosomes . Analytical techniques have been developed to evaluate polygenetic dis orders, and gene subs tructure now enable investigators P.1333 to focus on candidate genes found to distinguish schizophrenia and normal control brains.

Neuroimmunovirology Immune and viral hypothes es of s chizophrenia are as as s cientific knowledge in these areas. Louis P asteur confirmed that a virus could caus e a neurops ychiatric disease when he isolated the rabies virus in 1881. However, s chizophrenia is not an acute encephalitis or fulminating infection. More s ubtle pathophysiological mechanisms are involved that make it more difficult to es tablis h etiology. F urthermore, the epidemiological supporting an infectious theory, although interesting, weak. S chizophrenia may have a north to s outh gradient (s outh to north in the S outhern hemisphere), be endemic to a few areas (e.g., northern S weden), winter birth exces s, and, similar to multiple s cleros is has monozygotic twin discordance. However, it has difficult to conduct definitive studies of hypothes es becaus e any potential marker of an viral process as sociated with s chizophrenia is only some cas es of s chizophrenia and is subject to interpretation as being secondary to conditions 1365 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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with the dis eas e (e.g., crowding of chronically patients, expos ure of chronic patients living in low socioeconomic circums tances , and poor health habits ). V iral theories remain popular, des pite the difficulty in validating any particular version. T heir popularity stems from the fact that s everal s pecific viral theories have power to explain the particular localization of pathology neces sary to account for a range of manifes tations in schizophrenia without overt febrile encephalitis . T here six general pathogenic models of viral and immune pathophys iology relevant to s chizophrenia. T hes e are retroviral infection, current or active viral infection, past viral infection, virally activated immunopathology, autoimmune pathology, and secondary influences (i.e., utero exposure to maternal infection).

R etroviral Infec tion A retrovirus can insert its elf into the genome and alter the expres sion of the host's own genes and the of the hos t's offspring toward the development of schizophrenia (the virogene hypothesis). T here is conflicting evidence for the hypothes is . R etroviral sequences have been identified in pos tmortem brain tis sue from patients with schizophrenia. In contrast, retrovirus-as sociated enzymes that would be pres ent in active infection but not in a virogene s cenario have not been s ucces sfully identified.

C urrent or A c tive Viral Infec tion V iruses with an affinity for the C NS have been to be involved in the etiology of s chizophrenia. It is envis ioned that a neurotropic virus infects nerve cells in 1366 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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discrete parts of the brain and causes s us tained in the functioning of the involved neural s ys tems or that byproducts of a viral infection have direct toxic effects nerve cell functioning. An alternative formulation of this hypothes is is bas ed on the observation that virus es infect the brain, with s ubs tantive disease only s howing up many years later. In theory, this could account for the s ubtle early manifes tations frequently observed in s chizophrenic patients that are followed by more intense symptom manifes tations 10 to 30 years A s ubs tantial challenge to either formulation of the or active viral infection hypothesis is the absence of evidence s ubs tantiating a viral etiology, including the of physical signs of encephalitis (e.g., lymphocytic infiltrate) in postmortem tis sue and the failure to or to is olate a putative agent.

P as t Viral Infec tion T he past viral infection hypothesis posits a virus certain brain tiss ues early in life to create a vulnerability schizophrenia or as a caus al mechanism for the initial illness proces ses that later lead to the picture of schizophrenia. T he resulting tiss ue damage produces lasting alterations in neural systems , leading to schizophrenia manifes tations without persistent viral infection.

Virally A c tivated Immunopathology One of two general mechanisms is proposed in the category of virally activated immunopathology. T he firs t based on the obs ervation that virus es are normally endogenous to the human brain and have a 1367 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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or focal distribution in the brain. P eriodic viral of thes e foci normally does not result in ps ychotic symptoms. However, in an individual with a genetically environmentally determined abnormal immune to viruses, it is hypothesized that viral reactivation res ult in an induction of s chizophrenic T his theory regards the products of immunoreactivity the mediators of the pathogenic influence. T he s econd mechanism in this category is that the virus may induce the hos t to fail to recognize its own tis sues as “self” a consequence, to mount a destructive immune T he virus may do this by altering some cellular such as normally cryptic neural cell s urface proteins , caus ing it to s timulate a hos t res ponse. A cytotoxic or antibody respons e would cause direct interference of nerve cell function by des truction of the cells or, in the case of receptor proteins , altered neurotrans mis sion.

A utoimmune P athology S chizophrenia has been hypothesized to be an autoimmune disease, such as rheumatoid arthritis or systemic lupus erythematos us, wherein, for reas ons entirely clear but probably involving genetics, some tis sues are not recognized as s elf and become the immune respons e.

S ec ondary Influenc es : In Utero to Maternal Infec tion A number of epidemiological studies have reported that women who are expos ed to influenza epidemics during the second trimester of pregnancy are more likely to birth to offs pring at increased ris k for s chizophrenia. 1368 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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observation rais es the poss ibility that some attribute of maternal infection, s uch as fever or cytokine activation, perturbs normal brain development during the period of active neural cell migration. T his interes ting etiological lead has been challenged by s tudies that have to ass es s whether the mother was actually infected, than s imply being exposed to an epidemic. T here is evidence that prenatal rubella infection may increas e ris k for development of s chizophrenia and other nonaffective ps ychotic disorders .

B irth and Pregnanc y C omplic ations S tudies , acros s a broad range of methodological approaches, have repeatedly demonstrated an between obs tetrical complications and an increased schizophrenia. P rospective, population-based studies suggest three major clas ses of complications that are as sociated with s chizophrenia: (1) pregnancy complications (i.e., bleeding, diabetes, preeclamps ia, R h incompatibility), (2) abnormal fetal growth and development (i.e., low birth weight, congenital malformations, and reduced head circumference), and delivery complications (i.e., as phyxia, emergency section, and uterine atony). However, the mechanisms underlying these as sociations have not been T he following plaus ible explanations, which are not mutually exclus ive, guide pres ent-day research. [black right-pointing arrowhead] T he genes that vulnerability for schizophrenia may als o alter early embryonic development in a manner that leads to increased likelihood of birth and pregnancy 1369 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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complications . P.1334 [black right-pointing arrowhead] E arly ges tational advers e events influence the developing brain and create an increas ed risk for birth complications and schizophrenia. T he potential role of R h as a risk factor for schizophrenia is an interes ting example of this propos ition. [black right-pointing arrowhead] G es tational or birth complications may caus e hypoxic damage. B rain regions most frequently implicated as deviant in schizophrenia (e.g., hippocampus ) are among the most s ens itive areas in the developing brain to hypoxia.

P A THOP HYS IOL OG Y B ecaus e s chizophrenia represents a disturbance in but not all, brain functions , it is reas onable to s uppose specific brain regions or neural circuits are involved that the manifestations of s chizophrenia mus t involve altered process ing of physiological information; this altered proces sing would be, in turn, dependent on disturbances of cytoarchitectural, biochemical, or electrophysiological properties of the neural s ys tems, combination of thes e. T hroughout mos t of this century, examination of postmortem brain tiss ue has been the principal source data bearing on the neuroanatomy of s chizophrenia. reference to schizophrenia as “the graveyard of neuropathology” was not becaus e of a lack of 1370 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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neuropathological findings but rather becaus e of the of a discernible pattern in the frequently obs erved pathological findings and the pos sibility that deviations were artifactual in nature or were a cons equence, than a cause, of the diseas e. F or example, head viral infections affecting the brain would be more in crowded custodial hospitals than in typical groups . Moreover, the widespread us e of antipsychotic drugs in the treatment of s chizophrenia introduced additional artifacts in the investigation of brain pathophys iology. F inally, knowledge of brain and behavioral relations hips was not sufficiently detailed to guide neuropathological inquiry during much of this century. S cientists have long been keenly aware of the the development of noninvasive techniques to study structure and function in living patients . T his is important in the absence of valid animal models. the middle one-third of the 20th century, pneumoencephalography (P E G ) provided s ubstantial evidence for enlarged brain ventricles, sugges ting diminis hed tis sue in schizophrenia compared to E lectroencephalography (E E G ) provided information cortical surface electrical activity, but neither P E G nor techniques could provide a comprehensive evaluation human brain s tructure or function. T he development of s tructural (e.g., computerized axial tomography [C AT ] and magnetic resonance imaging and functional (e.g., positron emis sion tomography single photon emis sion computed tomography functional MR I, magnetoencephalography, and res onance spectroscopy) in vivo imaging techniques 1371 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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made pos sible a more detailed view of brain s tructure phys iology. T hese techniques have become available time when a better unders tanding of the between cortical and s ubcortical s tructures and their implications for brain and behavior relations is from preclinical studies of the brain. C AT studies have replicated the P E G observation of enlarged ventricles have further shown that a substantial proportion of patients with s chizophrenia, in comparison to normal controls, exhibits increased sulcal widening. T hes e suggest that patients with s chizophrenia may have relatively less brain tiss ue, a condition that could a failure to develop or a s ubs equent los s of tiss ue. with its enhanced gray and white matter res olution, is to provide a far more detailed ass es sment of s pecific structures . S tudies us ing MR I have found evidence in patients with s chizophrenia for decreased cortical gray matter in the prefrontal and temporal cortex; cerebral white matter fiber tract alterations; decreas ed volume limbic s ys tem s tructures , for example, the amygdala, hippocampus , and entorhinal cortex and the thalamus ; and increased volume of basal ganglia nuclei. T hes e findings are cons is tent with the findings of neuropathological examinations of pos tmortem tiss ue, including ultras tructural examination, which, in s ome cases, indicate cell los s, mis alignment of cells, altered membrane and intracellular s tructure and protein expres sion, or a combination of these. S tructural findings may help clarify the meaning of patterns of function. F unctional imaging s tudies have documented abnormal patterns of glucose metabolis m blood flow during performance of specific cognitive 1372 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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T hese techniques are als o able to provide ins ights into functional neuroanatomy of the various symptom complexes that characterize patients with F unctional imaging studies of actively hallucinating patients have implicated components of the language anterior cingulate basal ganglia thalamocortical neural circuits (F ig. 12.1-1). In contrast, several studies have demonstrated an ass ociation of primary, enduring negative symptoms and decreased glucose blood flow of the dors olateral prefrontal and the inferior parietal cortices (F ig. 12.1-2).

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FIGUR E 12.1-1 Axial sections demonstrating brain areas with s ignificantly increased activity during auditory verbal hallucinations in the group study. F unctional positron emis sion tomography results (threshold at Z >3.09, P <.001, by reference to the normal distribution) are dis played, superimposed on single s tructural T 1-weighted magnetic res onance imaging scan that has been transformed into the T alairach space for anatomical reference. S ection numbers refer to the distance from the anterior commis sure-posterior commiss ure line, with positive numbers being s uperior to the line. T he areas of activation extend into the amygdala bilaterally and the right orbitofrontal cortex. Although thes e regions extension are consistent with the limbic paralimbic component of activity during hallucinations and may contribute to drive and affect in this context, statements cannot be made in the abs ence of maxima. (S ee C olor P late.) (F rom S ilbersweig DA, E , F rith C , et al.: A functional neuroanatomy of hallucinations in s chizophrenia. Nature . with permiss ion.)

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FIGUR E 12.1-2 B rain regions activated more in ten schizophrenic patients without primary negative symptoms than in eight patients with primary negative symptoms deficit s chizophrenia during a sensory-motor control task and a decision task. As s hown in the left the regions s ignificantly more activated in nondeficit deficit patients during the control task were the right and left middle frontal cortex. R ight clus ter s ize: 104 voxels a maximum Z score of 2.61. Left cluster s ize: 316 a maximum Z score of 3.98. As s hown in the right the regions s ignificantly more activated in the nondeficit patients during the decis ion task were the right middle frontal two clus ters and inferior parietal cortices . R ight frontal cluster s izes: 299 voxels with a maximum Z 4.81 and 138 voxels with a maximum Z score of 3.28. inferior parietal clus ter s ize: 185 voxels with a maximum score of 3.32. (F rom Lahti AC , Holcomb HH, Medoff Abnormal patterns of regional cerebral blood flow in schizophrenia with primary negative symptoms during effortful auditory recognition tas k. Am J P s ychiatry. 2001;158:1797-1808, with permiss ion.) P res ent-day knowledge of the pathophysiology of schizophrenia is acquired from the study of living by us ing structural and functional imaging and anatomically relevant symptom and neurocognitive as sess ment techniques. T hes e technologies are supplemented by advances in pos tmortem molecular, and P.1335 1375 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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structural evaluations to test increas ingly s ophisticated neuroanatomical and biochemical theories of schizophrenia.

Major Neuroanatomic al Theories Over the las t 25 years, there has been a gradual from conceptualizing s chizophrenia as a disorder that involves discrete areas of the brain to a pers pective views schizophrenia as a dis order of brain neural T hese neural circuit models of the pathophys iology of schizophrenia posit that a s tructural or functional les ion disrupts the functional integrity of the entire circuit. are several factors that have contributed to this change perspective. F irs t, the delineation of the neuroanatomy the different neurotrans mitter pathways has led to an increased appreciation of how different brain regions connected with each other and how cortical and subcortical structures are able to reciprocally regulate function of each other. F or example, the identification the mesolimbic and mesocortical dopaminergic contributed to the development of neuroanatomical hypothes es implicating the prefrontal cortex or limbic system, or both, in the pathophysiology of T he further delineation of the reciprocal regulatory pathways between the prefrontal cortex and the limbic system, particularly the hippocampus, led to more formulations of thes e hypothes es , in which limbic and prefrontal neuroanatomical models of s chizophrenia been integrated into a single unifying neurodevelopmental theory of s chizophrenia. T hese hypothes es propose that an early developmental lesion the dopaminergic tracts to the prefrontal cortex results the disturbance of prefrontal and limbic s ys tem function 1376 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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and leads to the positive and negative symptoms and cognitive impairments obs erved in patients with schizophrenia. P refrontal cortex and limbic s ys tem hypothes es are the predominant neuroanatomical hypotheses of schizophrenia. T he demons tration of decreased gray or white matter volumes, or both; prefrontal interneuron abnormalities ; disturbed prefrontal metabolism and blood flow; decreased hippocampal entorhinal cortex volume; disarray or abnormal of hippocampal and entorhinal neurons, or both, strong s upport for the involvement of thes e brain in the pathophys iology of s chizophrenia. Of particular interes t in the context of neural circuit hypothes es the prefrontal cortex and limbic system are s tudies demonstrating a relations hip between hippocampal morphological abnormalities and disturbances in prefrontal cortex metabolism or function, or both. A s econd contributing factor to the adoption of a neural circuit conceptual framework has been the increased unders tanding of how the brain is organized into local microcircuits, consisting of the connections among afferent and efferent neurons and interneurons (F ig. 3), and macrocircuits. An example of the latter are the segregated parallel basal ganglia thalamocortical circuits , which connect the cerebral cortex, through the basal ganglia, with the thalamus (F ig. 12.1-4). E ach of circuits is hypothesized to subserve a discrete range of functions . A number of inves tigators have used these circuits as a s tarting point for their hypotheses of schizophrenic pathophysiology. T hese hypothes es primarily differ from each other on their point of 1377 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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F or example, integrating data from animal studies and neurobehavioral and functional and s tructural imaging studies in humans, it has been hypothes ized that dysfunction of the anterior cingulate basal ganglia thalamocortical circuit underlies the production of ps ychotic symptoms , whereas dysfunction of the dorsolateral prefrontal circuit underlies the production primary, enduring, negative or deficit symptoms.

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FIGUR E 12.1-3 C ortical circuitry in s chizophrenia. S chematic diagram s ummarizing disturbances in the connectivity between the mediodors al (MD) thalamic nucleus and the dors al prefrontal cortex in P os tmortem studies have reported that s ubjects with schizophrenia have (1) decreas ed number of neurons in MD thalamic nucleus ; (2) diminis hed density of parvalbumin-positive varicos ities, a putative marker of thalamic axon terminals, s electively in deep layers 3 the termination zone of MD projections to the prefrontal cortex; (3) preferential reduction in spine density on the basilar dendrites of deep layer 3 pyramidal neurons , a principal synaptic target of the excitatory projections the MD; (4) reduced express ion of the mes senger ribonucleic acid (mR NA) for glutamic acid (G AD 67 ), the s ynthes izing enzyme for γ-aminobutyric (G AB A), in a s ubs et of prefrontal cortex G AB A neurons ; decreased dens ity of G AB A transporter (G AT -1)– immunoreactive axon cartridges, the distinctive, arrayed axon terminals of G AB Aergic chandelier which s ynaps e exclus ively on the axon initial s egment pyramidal neurons; and (6) decreased dopamine (DA) innervation of layer 6, the principal location of pyramidal neurons that provide corticothalamic feedback (F rom Lewis DA, Lieberman J A: C atching up on schizophrenia: Natural history and neurobiology. 2000;28:325, with permis sion. S ee this article for details and references .)

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FIGUR E 12.1-4 A tentative scheme of interactions glutamate (G lu) and dopamine (DA) in the bas al T he cholinergic interneuron in the striatum is a large, cell with a rich collateral network that can be as sumed make synaptic contacts with a large number of other striatal cells. T he cholinergic interneuron receives a glutamatergic input on its s oma, while its axon terminals are in synaptic contact with medium-sized, s piny γaminobutyric acid (G AB A)ergic output neurons. Only such G AB A neurons are shown, but, in reality, it is reasonable to ass ume that one cholinergic neuron innervates many G AB Aergic neurons. T he cholinergic interneuron als o makes contact (although perhaps not 1380 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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forming a real s ynaps e) with dopaminergic nerve F rom the way in which the s ynaps es are drawn here, cortex would be able to control the activity in the G AB Aergic output neurons projecting to the thalamus the medial s egment of the globus pallidus (partly via the subthalamic nucleus [S T N] and s ubs tantia nigra pars reticulata [S Nr]). In this manner, the cortex can suppress impulse flow in one s ubpopulation of projection neurons while facilitating impulse flow in another s ubpopulation, thus pres umably enabling a meaningful behavior by s uppress ing irrelevant programs. T he importance of glutamatergic pathways maintaining a purpos eful behavior is revealed by the primitive locomotor pattern that results from treatment with the N-methyl-D-as partate antagonist MK -801. F or the sake of simplification, the different thalamic are not shown. C onceivably, striatopallidothalamic can influence the entire thalamus via, for example, the reticular nucleus , which communicates with all other thalamic nuclei. Apart from the corticos triatal glutamatergic pathway, there are at leas t three other corticifugal systems that the cortex can us e to protect from overs timulation: (1) the corticonigral projection; (2) the corticothalamic projection, which terminates in the thalamic intralaminar nuclei, from which a projection originates ; and (3) the corticos ubthalamic projection. AC h, acetylcholine; S N, s ubstantia nigra; subs tantia nigra pars compacta; V T A, ventral tegmental area. (F rom C arlss on M, C arlss on A: Interactions glutamatergic and monoaminergic s ys tems within the basal ganglia-implications for s chizophrenia and 1381 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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P arkins on's dis ease. T re nds N euros ci. 1990;13:896, permis sion.) A third factor has been the elucidation of the neural of cognitive functions observed to be impaired in with schizophrenia. T he observation of the relations hip among impaired working memory performance; prefrontal neuronal integrity; altered prefrontal, and inferior parietal cortex; and hippocampal blood flow provides strong s upport for disruption of the normal working memory neural circuit in patients with schizophrenia. S imilarly, the delineation of the neural circuits for language and attention and information proces sing has influenced the conceptualization of schizophrenia pathophysiology. T he class ical language circuit, which includes B roca's and W ernicke's areas as sociated cortical and s ubcortical structures , has hypothes ized to be involved in the production of hallucinations , delus ions, and pos itive formal thought disorder. T his hypothesis is the mos t important to the anterior cingulate hypothes is for pos itive symptoms. T he involvement of this circuit, at least for auditory hallucinations , has been documented in a number of functional imaging s tudies contrasting hallucinating vers us nonhallucinating patients . S ensory proces sing abnormalities are routinely in patients with schizophrenia. T he type of range from dis turbances in s ens ory gating to in visual information process ing. T he latter impairments have been argued to be selectively P.1336 1382 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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related to negative s ymptoms. T he overlap between regions that have been implicated in the production of negative s ymptoms and the vis ual information neural circuit, which includes inferior and s uperior and prefrontal cortices , caudate and thalamic nuclei, the reticular activating system, provides a neuroanatomical rationale for the relations hip between these two dimensions of schizophrenia and a framework for future s tudies of the neuroanatomy of negative s ymptoms. T he development of neural circuit hypothes es offers tremendous advantages to the inves tigation of the neuroanatomy of s chizophrenia. F irs t, these more accurately reflect the actual organization of the brain. S econd, computational models of neural circuit hypothes es can be developed to investigate how perturbations of circuit function can lead to s igns and symptoms of schizophrenia. Neural circuit models have been created for the cognitive and s ymptom manifestations of s chizophrenia. T hird, neural circuit hypothes es provide a conceptual framework for hypothes is-tes ting s tudies and optimize the of information derived from current brain imaging and postmortem s tudies . F inally, the use of neural circuit models implicates brain regions not typically conceptualized as being central to the neuroanatomy schizophrenia. T he thalamus and cerebellum are but examples of this iss ue.

Major B ioc hemic al Theories Information is proces sed in neural circuits through the 1383 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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transmis sion of an electrical signal through a nerve cell axon and across s ynaps es to posts ynaptic receptors other nerve cell components . Nerve cells generally proces s, and send s ignals to and from thousands of cells . T he transmis sion of the signal acros s the the proces sing of the s ignal within a cell require a series of biochemical events . T he entire operation a number of steps requiring large amounts of energy involving gene expres sion and the s ynthes is and degradation of proteins . It is evident that physiological function in any brain system involves the chemis try of system and that dysfunction can emanate from these biochemical process es. It is , therefore, natural to that the biochemistry of the brain plays a fundamental in the dis ruptions of brain function involved in schizophrenia. T he move from a general concept of the biochemistry of s chizophrenia to s pecific theories is on three principal sources of knowledge. T he firs t an ever-increasing unders tanding of intracellular communication from the cell membrane to the genetic material of the nucleus and of intercellular through the various neurotrans mitter s ys tems of the T he second is increased knowledge of the basic pharmacology of behavior and cognitive functions . T he third is knowledge of the mechanism of action of drugs that can induce s chizophrenia-like behaviors or that symptom expres sion in patients with s chizophrenia. three s ources of knowledge have led to biochemical hypothes es involving dopamine, noradrenaline, acetylcholine, glutamate, and several neuromodulatory peptides or their receptors . B ecaus e there are many poss ibilities , it is important to unders tand the general development of a biochemical hypothes is of 1384 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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schizophrenia. T he dopamine hypothesis is the mos t prominent and enduring hypothes is.

Dopamine and S c hizophrenia T he hyperdopaminergic hypothes is of s chizophrenia from two s ets of observations of drug action on the dopaminergic system. Drugs that increase dopamine system activity, such as amphetamine, cocaine, Land methylphenidate (R italin), can induce a paranoid ps ychos is that is P.1337 similar to s ome as pects of s chizophrenia. W hen adminis tered to patients with schizophrenia, these compounds may produce a transitory wors ening of hallucinations , delus ions , and thought disturbance. In contrast, drugs that have the capacity to block posts ynaptic dopamine receptors reduce the symptoms schizophrenia. S ubs tantial evidence supports the role posts ynaptic dopamine blockade as an initiating factor cascade of events res ponsible for the therapeutic antips ychotic drugs . Other mechanis ms , s uch as depolarization blockade, have been implicated as plaus ible explanations for long-term antipsychotic T hat these actions are actually corrective for the pathophys iological disturbance in s chizophrenia is suggested by the capacity of dopamine-stimulating to worsen s ymptoms of s chizophrenia or to induce ps ychos is . T his rationale for the role of dopamine particularly for the pos itive symptom aspect of schizophrenia, is compelling. However, despite the compelling rationale for the role 1385 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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dopamine in schizophrenia, testing the hypothesis has proven problematic. In general, clinical s tudies , acros s broad range of indices of dopamine metabolism, have been characterized by marked variability in results . aimed at measuring abnormal concentrations of dopamine or its metabolites in blood, urine, and s pinal fluid are confronted by problems that are almos t insurmountable. In large fluid compartments , dopamine metabolis m ass ociated with s chizophrenia represent only a minor contribution to the particular of dopamine metabolis m; spinal fluid necess arily a s ummation of total brain activity, mos t of which is not cons idered germane to s chizophrenia, and blood and urine provide even more indirect indices. Imaging s tudies have produced more compelling for dopamine involvement. S everal s tudies have used following paradigm to investigate abnormal dopamine metabolism: P atients with schizophrenia are infus ed an indirect dopamine agonist (e.g., amphetamine), and then the extent to which radioligand occupancy of posts ynaptic dopamine receptors is reduced by competition with endogenous dopamine is determined. T he comparis on of pre- and postinfus ion radioligand occupancy provides an index of dopamine releas e and reuptake rates . T hese studies have demons trated dopamine release in patients with s chizophrenia, which may be related to the severity of their positive symptoms. P E T studies of dopamine receptor and the density of receptor express ion offer an approach for examining the dopamine hypothesis. T his approach has been us ed to document an increas e in dopamine type 2 (D 2 ) receptors in the caudate nucleus 1386 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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drug-free patients with s chizophrenia and has been applied to other dopamine receptors (i.e., D 1 receptor) brain regions, including the prefrontal and anterior cingulate cortices . T here is evidence of altered D 1 and receptor distribution in thes e areas, but replication of these preliminary results is required. F inally, there is the potential for the relatively precise biochemical s tudy of dopamine in postmortem tiss ue, here, as with the us e of body fluids , sources of artifact imprecis ion have been difficult to manage. T he concentration of a neurotransmitter in any tiss ue is as cellular components break down after death and as small differences in diss ection from brain to brain take place. T he adminis tration of antips ychotic drugs during almos t always confounds the biochemistry of tis sue, and one can rarely be sure of the extent to any biochemical finding is directly related to the schizophrenic dis eas e process . In addition, there are a large number of candidate areas for brain dysfunction, that one may eas ily examine the wrong location. It is quite pos sible that brain areas may exhibit biochemical dysfunction during dis crete periods of development but that these abnormalities are no longer pres ent at the of death or that the biochemis try of death may obscure the biochemistry of life. Des pite these methodological limitations , pos tmortem s tudies have confirmed the elevation of s triatal D 2 posts ynaptic receptors observed P E T s tudies . T here have als o been reports of dopamine concentrations in the amygdala, decreased density of the dopamine transporter, and increas ed numbers of dopamine type 4 (D 4 ) receptors in cortex. 1387 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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Although conclus ive evidence for the hypothes is has been elusive, the hypothesis remains a viable explanation for the positive s ymptoms of schizophrenia. It is a particularly robust proposition for explaining the effect of antips ychotic drugs . in the context of the inves tigation of the hypothesis, P.1338 recent studies have sugges ted the poss ibility that a dopamine deficiency may also occur in patients with schizophrenia. F or example, s everal s tudies have that patients with negative symptoms have lower or cerebros pinal fluid (C S F ) homovanillic acid (HV A) concentrations. Also, patients with influenza who were mis taken for having s chizophrenia, tended to have emotional dullnes s and low drive. S imilarities in cases with as pects of P arkinson's disease (which is to involve loss of dopamine neurons) and the fact that some of thes e postencephalitic patients developed P arkins on's dis ease lend support to a dopamine hypothes is for the negative symptom aspect of schizophrenia. In addition, antipsychotic drugs, which dopamine antagonists, produce behaviors s uggestive negative symptoms of schizophrenia in animals and humans free of mental illnes s. T hes e observations to a reformulation of the dopamine hypothes is, which incorporates the poss ibility of concomitant dopamine excess and deficiency. Dopamine exces s would be res tricted to the dopaminergic pathways projecting to basal ganglia and limbic system and would account for positive ps ychotic s ymptoms , whereas dopamine deficiency would be restricted to the mes ocortical 1388 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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pathways and would account for the negative of s chizophrenia.

G lutamate and S c hizophrenia G lutamate is the major excitatory neurotransmitter in brain and mediates cortical–cortical, cortical– and thalamic–cortical transmis sion. G lutamate binds to ionotropic and metabotropic receptors . T he ionotropic receptors include the N-methyl-D-as partate (NMDA) receptor complex, kainate, and α-amino-3-hydroxy-5methyl-4-is oxazolepropionic acid (AMP A). Interest in poss ible role of glutamate in the pathophysiology of schizophrenia has emerged from an increased unders tanding of the role of NMDA in the regulation of behavior and cognition; an increas ed unders tanding of interactions between glutamatergic and dopaminergic, cholinergic, and γ-aminobutyric acid (G AB A)ergic observations of abnormal NMDA receptor binding in prefrontal cortex and abnormal NMDA mess enger ribonucleic acid (mR NA) express ion in the patients with s chizophrenia; and obs ervations of the and chronic effects of phencyclidine (P C P ) and related compounds. Acute adminis tration of P C P produces symptoms that have been argued to mimic the positive and negative symptoms of schizophrenia. C hronic P C P adminis tration produces a hypodopaminergic state in prefrontal cortex; a state that has been argued to res ult negative symptoms . P C P occupies receptors within the open calcium channels of the NMDA receptor complex, thereby blocking ion flow. P C P and its analog, interfere with glutamatergic transmiss ion. In addition to the obs ervation of schizophrenia-like symptomatology humans abus ing P C P , ketamine has been us ed in the 1389 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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experimental laboratory and has been observed to produce transitory mild manifes tations of pos itive and negative s ymptoms in normal volunteers and a and mild worsening of pos itive s ymptoms in patients schizophrenia. Activation of dopamine receptors glutamatergic neurons or decreas ed NMDA-mediated inhibition of dopamine neurons , directly or through the actions of G AB Aergic interneurons, could be with a dopamine-excess ps ychos is. T here is also evidence to support the involvement of the other two ionotropic receptors. P os tmortem s tudies have documented abnormal kainate and AMP A receptor binding in the cerebral cortex and abnormal AMP A expres sion in the hippocampus of patients with schizophrenia. T hes e cons iderations support a hypoglutamatergic hypothes is for s chizophrenia pathophys iology and predict a therapeutic effect for compounds activating the NMDA receptor complex. a difficult s trategy to implement, because exces sive glutamatergic activity is neurotoxic; however, activation the NMDA receptor complex via the glycine s ite with glycine, D-cyclos erine, or D-serine has been reported alleviate negative symptoms in patients with schizophrenia.

A c etylc holine and S c hizophrenia Acetylcholine acts at mus carinic and nicotinic receptors. T hes e receptors are broadly distributed throughout the brain, including the neocortex, hippocampus , and basal ganglia. C holinergic have been implicated in the regulation of attention, memory, process ing speed, working memory, and gating proces ses —proces ses that are impaired in 1390 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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with schizophrenia. T here are s everal lines of evidence suggest that acetylcholine abnormalities may play a the pathophys iology of s chizophrenia. P atients with schizophrenia are more likely to smoke cigarettes than patients with other psychiatric disorders or the general population. P os tmortem s tudies have demonstrated decreased M1 and M4 muscarinic receptors in the putamen, hippocampus, and selected regions of the prefrontal cortex. P atients with s chizophrenia are characterized by impaired s ensory gating, including impaired performance on the P 50 s ens ory gating paradigm. T he α7 nicotinic receptor plays an important role in normal sensory gating function, s moking P 50 impairments in patients with s chizophrenia, and, in families with patients with schizophrenia, impaired P 50 performance is linked with the chromosome 15 region contains the gene for the α7 nicotinic receptor. P atients with schizophrenia have been s hown to have nicotinic receptors in the hippocampus. T he α4β2 receptor has been s hown to regulate dopamine, G AB A, and glutamate release, which s uggests that this receptor may play a pivotal role in the regulation of neurotransmitter s ys tems that are involved in cognition. P os tmortem studies have demonstrated abnormal regulation of thes e receptors in patients with schizophrenia. T he glutamatergic and cholinergic hypotheses major transition that has occurred recently in the biochemistry of schizophrenia. B efore this transition, observations of drug actions in schizophrenia first led clinical treatment and then to the advancement of the pathophys iological theory of s chizophrenia. W ith the 1391 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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increasing knowledge of the neural organization of the brain and of the various properties and receptor s ites of neurotransmitters, it is now poss ible to pos tulate pathophys iological theory first and then attempt to new clinical treatment from theory. T here is now subs tantial optimism that new treatment approaches be developed more rapidly in the future, based on a broader range of pathophysiological hypothes es and availability of animal models for as pects of the illnes s therapeutically respons ive to dopamine blockade– medications .

Other Neurotrans mitters and Neuromodulators Any neurotransmitter involved in neural s ys tems subs erving behaviors whose dis ruption could result in symptoms of s chizophrenia is naturally of interest in schizophrenia theory and res earch. T he rich the frontal cortex and limbic s ys tem with s erotonergic neurons , the modulatory effect of thes e neurons on dopaminergic neurons , and the involvement of these pathways in the regulation of a broad range of complex functions have led s everal inves tigators to posit a pathophys iological role for serotonin in s chizophrenia. T hese hypotheses have taken various forms over the cours e of the last five decades . In the early 1950s , a serotonergic deficiency hypothes is was propos ed for schizophrenia. Obs ervations of hallucinations in who had inges ted lysergic acid diethylamide (LS D), a compound that is chemically s imilar to serotonin and blocks serotonin receptor s ites, furthered the hypos erotonin hypothes is . However, 1392 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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P.1339 drugs that decreas e s erotonin activity tend to reduce schizophrenic symptoms (e.g., reserpine [S erpalan] and clozapine [C lozaril]) and have diminis hed interes t in the deficiency hypothesis. Of greater current interest are hypothes es pos iting a serotonin excess as caus ative of positive and negative s ymptomatology. T he robust serotonergic antagonist activity of clozapine and other or s econd-generation antips ychotics , coupled with the demonstrated effectiveness of clozapine for pos itive symptoms in chronic, treatment-res is tant patients, has contributed to the current emphas is on this proposition. However, s everal studies have rais ed questions about efficacy of serotonin antagonis ts for negative symptoms broadly defined or persistent, primary negative Moreover, pharmacological modification of s erotonin systems with specific s erotonergic agents has not impres sive clinical results. A s imilar rationale can be applied to cons truct implicating norepinephrine in the psychopathology of schizophrenia. Anhedonia, that is, the impaired capacity emotional gratification and the decreas ed ability to experience pleas ure, has long been noted to be a prominent feature of s chizophrenia. A selective degeneration within the norepinephrine reward neural system could account for this as pect of schizophrenic symptomatology. However, biochemical and pharmacological data bearing on this propos al are inconclusive. As with dopamine and serotonin, there been noradrenergic exces s and deficiency pathophys iological hypothes es. 1393 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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G AB A is the major inhibitory neurotrans mitter. T here been s everal studies that have documented interneuron abnormalities in the prefrontal cortex of patients with s chizophrenia. G AB Aergic interneurons regulate glutamatergic activity and are als o involved in hippocampal sensory gating neural circuits. B enzodiazepines have been shown to have a modes t antips ychotic effect. T hes e cons iderations provide a rationale for a G AB Aergic role in the pathophysiology schizophrenia. Neuromodulatory hypotheses focus on the fact that neuropeptides , s uch as substance P and neurotens in, colocalized with the catecholamine and indolamine neurotransmitters and influence the action of these neurotransmitters. Alterations in neuromodulatory mechanisms could facilitate, inhibit, or otherwis e alter pattern of firing in thes e neuronal systems . neuromodulator hypotheses are preliminary and inconclusive.

Integrative Hypothes es T he natural evolution of pathophysiological hypothes es schizophrenia is the development of comprehens ive models that integrate neuroanatomical and biochemical hypothes es. T he superimpos ition of the involved in the connections among cortical, basal and thalamic s tructures that comprise the bas al ganglia thalamocortical neural circuits is a prime example of approach (F ig. 12.1-3). T he cerebral cortex, through glutamate projections from the cortex to the bas al facilitates the performance of s elected behaviors while inhibiting others . T he excitatory glutamatergic neurons 1394 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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terminate on G AB Aergic and cholinergic neurons that, turn, provide a feedback mechanis m for glutamatergic excitation and s uppres s or excite dopaminergic and other neurons. T his regulatory activity can enable cortex to protect itself from overs timulation from thalamocortical neurons . T he elucidation of the neuroanatomy and biochemistry of cortical has also served as a s tarting point for the articulation of pathophys iological hypothes es of s chizophrenia. T hes e integrative models provide a framework for identifying potential neurotransmitter targets for drug as well as providing explanatory models for the effects of pharmacological agents in patients with schizophrenia, for example, P C P -induced psychotic symptoms mediated through the interactions of glutamate and other neurotransmitter s ys tems in the neocortex, basal ganglia, or limbic s ys tem structures , combination of thes e.

DIA G NOS IS Is sues relating to the validity and reliability of schizophrenia diagnoses are a dis tant echo in of class ification. C urrent attention is conceptual and theoretical. Is s chizophrenia one dis eas e or many? are the endophenotypes? Where will future boundaries between schizophrenia and affective ps ychos es be Will the various functional ps ychos es of the last century turn out to be one ps ychotic illnes s on a severity continuum? W hat are the implications of multigenetic multifactorial etiological cons tructs? Although 20th century views of schizophrenia varied subs tantially acros s time and diagnostic s chools, there 1395 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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been s ubs tantial agreement among diagnosticians throughout the world and between s eemingly divergent diagnostic approaches in the recognition of typical of schizophrenia, at least where the presence of ps ychotic symptoms was required. Although many pathological manifestations can be viewed on a continuum with normal behavior, there is little difficulty distinguishing schizophrenia from normality and validating the presence of a disease. In the past, major areas of disagreement between diagnostic approaches involved broad vers us narrow concepts, whether ps ychotic symptoms were required, whether thought disorder was required in all cases , and which symptoms could be cons idered of firs t rank in diagnosis. In general, s ys tems with broad criteria and emphasis on ps ychos ocial pathology included more cases with greater likelihood of diagnostic but also increas ed validity for genetic s tudies us ing pedigree data. T he concept of schizophrenia s pectrum pathology was introduced in this regard and led to the development of s chizoid and schizotypal personality disorder cons tructs. T he importance of operationalized diagnostic criteria differential diagnosis increas ed with the development specific pharmacological interventions . T he variability diagnostic criteria was unders cored in the 1960s , when was convincingly demons trated that U.S . us ed a much broader and les s defined cons truct of schizophrenia than their U.K . counterparts. Application reliable research diagnos tic criteria s uggested greater validity for the U.K . clinical diagnoses , prompting the concern that a broad cons truct of schizophrenia 1396 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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inadvertently included two categories of patients illfor antips ychotic drug therapy. T he first category was patients with bipolar or major depress ive dis orders with ps ychotic features, who, if erroneously cons idered to schizophrenia, were adminis tered antips ychotic medication rather than the more s pecific and effective treatments available for patients with these dis orders antidepres sant drugs , lithium [E s kalith], and electroconvuls ive therapy [E C T ]). T he s econd category included patients with s chizophrenia s pectrum disorders . T hese patients were sometimes as having s chizophrenia and, as a consequence, were to be adminis tered drug treatments designed for the positive symptoms of schizophrenia that provided little benefit and s ubjected them to s ubs tantial ris k. A cons iderable body of res earch during the 1960s and 1970s clarified many diagnos tic is sues and set the the development of a diagnostic system implemented the American P s ychiatric Ass ociation's third edition of Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs III). T he DS M-III approach, with s pecified s ymptomdiagnostic criteria and demons trated P.1340 reliability, is now the accepted diagnostic s ys tem in America and throughout the international res earch community. T he us e of this approach has led to the reliable and cons is tent differential diagnosis of schizophrenia, which has enhanced scientific and communication and has s ubs tantially increas ed the likelihood of the effective us e of diagnostically specific treatments . T he current revised fourth edition of the 1397 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs IV -T R ) and the tenth edition of the Inte rnational C las s ification of Dis e as e s (IC D-10) diagnostic are extens ions of this approach. T he clos e connection of diagnosis and drug treatment been the dominant paradigm in drug development and regarded as es sential in regis tration s tudies seeking U. F ood and Drug Administration (F DA) approval of new drugs and new indications . S chizophrenia and bipolar patients are s tudied s eparately to determine efficacy, and an approved drug indication is s pecifically related to the diagnos tic class in which it is tes ted. T his paradigm is about to shift. An early indication of the limitation of this paradigm was a little-noted of the influential 1960s U.S .–U.K . s tudy. In the United S tates, the broad application of a schizophrenia was as sociated with an increased rate of drug therapy in patients with schizophrenia. A patient with schizophrenia and a patient with ps ychotic depres sion are both potential candidates for and antidepres sant therapy. B eginning with in the 1970s, which s uggested that s chizophrenia is conceptualized as a s yndrome compris ed of three independent domains of psychopathology, an paradigm has been introduced requiring understanding treatment effects on s pecific ps ychopathological Drug and psychosocial therapies have turned out not to antis chizophrenic but antipsychotic. F or this reas on, data relating to endophenotypes and neuroanatomy, field is moving beyond diagnosis in characterizing and grouping patients .

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B eyond Diagnos is A valid diagnostic s ys tem is es sential for clinical and epidemiological purpos es and is an important initial cons ideration in treatment, es pecially in longer-term relaps e prevention and maintenance therapy. diagnosis at the syndrome level is not adequate for the scientific study of the multiple etiopathophys iologies of schizophrenia. T he dis eas e clas s paradigm has led to development of treatment for psychosis but has limited treatment discovery for other key features of the T he traditional approach to reducing the heterogeneity the s chizophrenia syndrome has been to delineate subtypes and to attempt to confirm or to disprove their validity. T he clas sical subtypes , disorganized (DS M-IV or hebephrenia (IC D-10), paranoid, catatonic, and schizophrenia, repres ent the mos t frequently us ed approach for reducing heterogeneity. Although differences, s uch as age of ons et and pattern of development, validate thes e s ubtypes, the clas sical subtypes have not provided a s trong heuris tic for the study of etiology and pathophysiology. An alternative approach to syndromic heterogeneity is domains of ps ychopathology cons truct. In this important clinical features of the s yndrome are defined, and those that are relatively independent from other features are selected as domains forming the basic unit study. S ymptoms of s chizophrenia usually s egregate three s emi-independent s ymptom complexes : (1) hallucinations and delusions ; (2) dis organized including positive formal thought disorder, bizarre behavior, and inappropriate affect; and (3) negative 1399 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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symptoms, including res tricted affective experience expres sion, diminis hed drive, and poverty of s peech. Longitudinal studies provide s upport for the independence and stability of thes e domains , at least when negative s ymptoms are primary to the disease proces s. T hes e results support a paradigm s hift. T he neuroanatomy of s chizophrenia becomes the neuroanatomy of each domain, for example, and treatment efficacy has to be evaluated domain by T he domains of psychopathology approach has been extensively applied to the inves tigation of primary negative symptoms . T hese symptoms differ from other domains with respect to their familial heritability; neuroanatomy, as evidenced in s tructural and neuroimaging studies; and respons e to antipsychotic treatment. Long-term outcome, season of birth, and onset are also dis tinctive. T hes e results provide strong support for the heuristic value of this approach and the hope that this approach to heterogeneity reduction will provide more decisive data in studies of etiopathophys iology and neuroanatomy and explicit information regarding the efficacy profile of pharmacological treatments . In this approach, an interes ting challenge relates to the question of why domains , semi-independent within individuals with schizophrenia, cooccur in the syndrome. One outcome is the poss ibility that s ome domains may help define specific disease entities within the s yndrome. S ubstantial evidence exis ts that this is the case when patients with the deficit form of schizophrenia, which is defined by the presence of enduring, primary, negative symptoms, are dis tinguis hed from those with the 1400 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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nondeficit form of schizophrenia.

C ognitive Impairment F or diagnos is , the three s ymptom domains constitute principal diagnostic considerations . However, schizophrenia is ass ociated with a broad array of impairments , including impaired attention/information proces sing, reas oning and problem-solving, social cognition, proces sing speed, verbal and visual learning and memory, and working memory functions. Attention, language, memory, and process ing speed impairments critically important and account for much of the in poor social and occupational functional outcomes. theoretical level, attention, working memory, and, poss ibly, verbal memory impairments may be liability vulnerability markers and may be us ed to define schizophrenia phenotypes . C ognitive impairments may us eful in the early detection of individuals at high ris k the future development of s chizophrenia. T hey may provide a bas is for creating new models for treatment development. Moreover, the neuropsychological as sess ment of cognitive impairments permits anatomical inferences, and the use of cognitive tasks as sess thes e impairments have become increasingly important in guiding functional neuroimaging s tudies. T he relationship among cognitive impairments and the symptoms of s chizophrenia is unclear. F or many years , cognitive impairments were conceptualized as the ps ychological foundations of symptom manifestations. However, there is a large body of evidence that has documented the relative independence of cognitive impairments and pos itive psychotic s ymptoms. F or 1401 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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example, clinical trials have repeatedly demonstrated large changes in positive s ymptom status can occur without a corres ponding improvement in cognitive function reflected in cognitive or neuropsychological performance. T he use of the three s ymptom complex model and less complicated cognitive paradigms may to the elucidation of pos sible relationships between the various cognitive impairments and the s ymptom complexes . In summary, the clinical manifes tations of are well known. T he conceptualization of schizophrenia a clinical syndrome, which is importantly dis tinguis hed from bipolar affective and other psychotic dis orders, been validated. Diagnostic research P.1341 has produced some modification in clas sification and demonstrated the adequacy of the reliability and of current approaches. It has als o produced a degree of uniformity in international usage that serves clinical and s cientific purposes. B ecause the clinical syndrome of s chizophrenia probably repres ents more one pathological proces s, specifically addres sing the etiology, pathophys iology, and treatment of s pecific symptom domains offers important new power to designs. T he future may bring a more dramatic of the concept, as the basis for genetic and ps ychopathological overlap between major class es is unders tood.

C OUR S E , P R OG NOS IS , A ND In his pioneering des cription of schizophrenia, 1402 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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argued that s chizophrenia was characterized by an onset followed by a chronic and deteriorating cours e a defect end s tate. B leuler sugges ted that a chronic deteriorating cours e was a frequent, but not a outcome. He rejected dementia as the defect end However, neither of these early workers took into the extent to which these obs ervations were based on chronic, institutionalized patient populations . T here are now extens ive longitudinal outcome data on patients were treated before and after the introduction of antips ychotic medication, which support a more prognos tic picture. Although s chizophrenia is always a serious dis eas e, it is now clear that patients with the disorder may follow a variety of courses over the long term, including s ome that are relatively benign. it remains true that, although the dis eas e does not progres s to a deteriorated end s tate, there are and enduring adverse consequences for most patients . T he cours e of illnes s is s ometimes more benign in patients with schizophrenia. P oss ible reasons include following: (1) E strogen may modify dopamine pathophys iology; (2) female patients may have a better res ponse to antips ychotic drugs ; (3) the deficit form of schizophrenia is a predominantly male dis eas e; and (4) egocentric cultures are traditionally more stress ful for T he cours e of illnes s can be divided into four major epochs: premorbid, ons et of illness , middle cours e, and late cours e.

Premorbid E poc h T he pre morbid e poch refers to s ymptom manifes tations before the onset of overt, positive ps ychotic symptoms . 1403 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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T wenty-five to 50 percent of patients with exhibit impaired behavior or s ubtle s ymptom manifestations. T hese abnormalities may present as diminis hed social drive; decreas ed emotional withdrawn, introverted, s uspicious , or impulsive idios yncratic respons es to ordinary events or circums tances ; and s hort attention span, delayed developmental milestones , or poor motor and sens orimotor coordination, or a combination of thes e. presence of s ocial behavior disturbances have been up as early as infancy by workers who have noticed a of res ponsivenes s and emotional express ion in infants later developed s chizophrenia. C hildhood as ociality, a that has previous ly been referred to as a poor indicator, is probably more appropriately as the early morbid manifes tations of negative or deficit symptomatology. C ognitive difficulties are observed during preteen and teenage years in children at high for developing schizophrenia. P atients may als o exhibit impaired premorbid s cholas tic and occupational development or poor premorbid adjustment in these domains . T hese functional impairments may reflect morbid features related to negative s ymptom and cognitive impairments , the effect of s ubtle or reality dis tortion pathology, or developmental or weakness that interacts with dis eas e pathology to determine course. T heir presence is as sociated with prognos is .

Ons et of Illnes s T he s e cond e poch, onset of illnes s, typically refers to onset of positive ps ychotic symptoms (i.e., and delus ions, formal thought disorder, and 1404 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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disorganization). T he onset of pos itive psychotic symptoms is ins idious in approximately one-half of the patients, with the earliest signs of psychotic illness occurring years before the florid or overt manifestation ps ychos is . In other cases , onset is relatively acute, with onset of positive ps ychotic symptoms marking a s harp deviation in life trajectory. P atients with the ins idious of ons et are likely to have a poor intermediate course poor long-term cours e. In contrast, patients with normal development and ordinary personality attributes , who experience a relatively sudden appearance of hallucinations , delus ions , and disorganized thought, widely in terms of intermediate and long-term outcome the disorder, s ome having good long-term outcomes others having poor long-term outcomes. Duration of untreated psychosis (DUP ) is now a focus of early intervention research. T he hypothesis that longer DUP caus es a wors e outcome (i.e., positive ps ychotic are toxic hypothesis) is difficult to evaluate, because insidious onset is a robus t poor prognostic factor, and insidious onset cases routinely come to diagnos is and treatment later in the ps ychotic course than acute cases. T here is a gender difference in age of ons et. In men, is a unimodal onset of positive s ymptoms, with peak incidence from 18 to 25 years of age. In contrast, exhibit a bimodal distribution in the ons et of pos itive symptoms. T he firs t peak occurs between 20 and 35 of age, and the second peak occurs after 40 years of

Middle C ours e T he middle cours e -of-illne s s epoch may be s ubdivided 1405 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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two s ubepochs . T he firs t 5 to 10 years of illnes s is frequently characterized by multiple exacerbations of positive ps ychotic s ymptoms , during which a patient return to an asymptomatic baseline between epis odes may remain actively ps ychotic without achieving full recovery. T his s ubepoch is followed by a plateau which patients experience a stabilization of their symptoms, and the number of exacerbations R ecent studies have made it evident that the deterioration ass ociated with schizophrenia principally occurs during the ons et of illnes s and the first half of middle phas e, rather than over the remaining cours e of illness . However, complications caus ed by the illness to ever-increasing impediments to normal existence, s o that s econdary effects may be progress ive, even the primary ps ychopathology has reached a plateau. example, patients who live in unders timulating environments lose s ocial skills and work capabilities, if their symptom levels improve. E ffective treatment late the cours e of a chronic dis eas e diminis hes illness , but does not restore lost experience and opportunity—nor does it overcome s tigma. A his tory of dis abling schizophrenia is a serious s ocial and occupational regardless of the degree of recovery.

L ate C ours e In the late cours e -of-illne s s epoch, there is a tendency the intens ity of pos itive psychotic symptoms to diminis h with age, and many patients with long-term regain some degree of s ocial and occupational competence. Although the illnes s becomes less and easier to manage, the effects of years of 1406 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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are rarely overcome. It would be highly unusual for an individual with a chronic form of the illnes s to gain the niche in society and the quality of personal life that have been pos sible had the illness not been present. typically, patients continue to manifes t P.1342 direct signs of the illness proces s throughout their life. T wenty- to 40-year follow-up studies provide a bas is for es timating that approximately 55 percent of patients schizophrenia have moderately good outcomes, and percent have more severe outcomes . T hese figures more optimis tic than earlier views for at least two F irst, s ample selection was broader and more representative. S econd, effective treatments , which cons iderable difference in the s hort-term cours e, als o a modest impact on the long-term cours e. Although no pres ent treatment approach can prevent cure s chizophrenia, some approaches have had remarkable remedial effects on course. Although not subject to s cientific verification, there is considerable evidence from a large body of clinical experience that a form of schizophrenia referred to as de vas tating s chizophre nia, which represented approximately 15 percent of the cas es before the introduction of antips ychotic medication, now repres ents less than 5 percent of the cas es . T his form of the illness had an rather than ins idious , ons et but paradoxically led to an unrelenting cours e. T here is another line of evidence, difficult to s ubs tantiate empirically, which s ugges ts that the earlier the antipsychotic medication is initially adminis tered in the course of s chizophrenia, the more 1407 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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benign the course. In patients with es tablis hed of schizophrenia, clinicians cons ider it prudent to detect and to initiate treatment as early as poss ible during an acute symptom exacerbation. Us ing the same the initial treatment should also be undertaken as early the initial detection of the disease proces s permits. of firs t-episode patients suggest that the onset of ps ychos is may, on the average, precede diagnos is and treatment by almost 2 years, and the ons et of negative symptoms can be traced back even further. T hes e also sugges t that earlier initiation of pharmacological treatment improves outcome in firs t-episode patients . However, as noted previous ly, the as sociation of onset with poor prognosis confounds the interpretation the benefits of decreased length of DUP on future of illness . T here is now increasing interest in es tablis hing reliable methodology for the detection and treatment of individuals who are at immediate risk for having an episode of s chizophrenia but who have not yet overt pos itive psychotic symptoms, to as certain future cours e is thereby s ubs tantially affected. T he manifestations of illness are us ually nonspecific, and it would be difficult to initiate antips ychotic drug treatment in the large population of young people manifes ting suspicious nes s, eccentric behavior, social withdrawal, motivation, magical ideation, and the like. S econdgeneration antips ychotic medications have a reduced extrapyramidal and dysphoric adverse effect profile, lending impetus to the early intervention approach on pres umptions of increas ed s afety and tolerability. P reliminary s tudies sugges t that early intervention 1408 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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approaches can have a beneficial impact on the early cours e of illnes s. T he long-term impact of these interventions is not known. Moreover, early intervention often initiates long-term treatment, and s ome secondgeneration antips ychotics may increas e cardiovas cular diabetic risk factors —an important cons ideration when treating young patients. T here is cons iderable evidence s uggesting that the prophylactic us e of antips ychotic medication reduces relaps e rate by more than one-half. T his fact is largely res ponsible for the s ubs tantial reduction in inpatient and the transition to community-based treatment. T he level of success as sociated with this major s hift in the setting in which s chizophrenia is treated and the shortcomings as sociated with shifting care to communities are noted in the discus sion on treatment rehabilitation. T here are s ocial determinants of outcome that are best unders tood in a cultural context. T he cours e of schizophrenia tends to be more benign in developing countries than in developed countries . T his difference cours e is generally unders tood as representing a ps ychos ocial influence on course rather than cultural differences in the caus es of s chizophrenia. T he and lifetime prevalence of the dis eas e appear to be relatively comparable across cultures and societies . compelling construct is that the s ociocentric s tructures developing countries place less demand on individual performance and provide a more broadly s upportive interpersonal environment than do the egocentric of the more developed nations . T he latter nations , with their marked emphas is on individual accomplishment 1409 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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productivity, are more demanding and s tres sful for with impaired drive or impaired mental functioning. R ather than finding an appropriate, us ually reduced of functioning, the patient with s chizophrenia in indus trialized s ocieties tends to be isolated, with reduced opportunities for work and meaningful s ocial contacts . Indicative of this lack of involvement, unemployment rates for patients with s chizophrenia are upward of 80 percent in the United S tates .

TR E A TME NT A ND T he history of the care and treatment of patients with schizophrenia is replete with instances of humane and inhumane approaches . F rom a practical and moral standpoint, the value of humane care is intrins ic and not res t on scientific evaluation of efficacy. T here is a body of literature and scientific data regarding the pharmacological and ps ychos ocial treatment and rehabilitation of patients with schizophrenia. T he conclus ions of this accumulated information are in the following discus sion.

Pharmac ologic al Interventions B efore 1952, there were no generally applicable treatments of demonstrated effectiveness . R es erpine been used with some limited success , and electroconvuls ive treatment was important in reducing symptoms in the most acutely dis turbed cas es. was not until the introduction of chlorpromazine (T horazine) in F rance in 1952 and in North America in that the modern era of effective pharmacological therapeutics for s chizophrenia began. 1410 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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T he antips ychotic drugs us ed to treat s chizophrenia wide variety of pharmacological properties , but all the capacity to antagonize posts ynaptic dopamine receptors in the brain. C onventional antips ychotics are often referred to as ne urole ptics because of their neurological side effects. New or s econd-generation antips ychotics are les s likely to exhibit thes e effects, they have been referred to as atypical antips ychotics . generally recognized clinical effect of antipsychotics is diminis h positive ps ychotic s ymptom express ion and to reduce relaps e rates. Although sedation may be a side effect, and diminis hed anxiety may be a clinical effect, primary value of thes e drugs is for their remedial effect positive ps ychotic s ymptoms and not for their s edating tranquilizing properties. In fact, their antips ychotic extends beyond schizophrenia to include positive ps ychotic symptoms as sociated with illness es other schizophrenia. In contrast to positive ps ychotic conventional antips ychotics have not been shown to be effective for primary, enduring, negative or deficit symptoms or the cognitive impairments observed in patients with s chizophrenia. Antips ychotic drugs are used throughout the world for four primary clinical purpos es : (1) to manage acute positive ps ychotic s ymptom disturbances, (2) to induce remis sion from positive psychotic symptom (3) to maintain the achieved clinical effect over periods of time (maintenance therapy), and (4) to relaps es or new episodes of positive ps ychotic expres sion (prophylactic therapy). T he clinical intent is adminis ter the drugs in a manner that increases patient compliance and avoids illness exacerbations due to 1411 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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patients dis continuing their medication. It is now P.1343 recognized that optimal treatment involves the of antipsychotic drug treatment with psychosocial treatment approaches and rehabilitation techniques . T he firs t s econd-generation antips ychotic to be for clinical use was clozapine. C lozapine has a unique mechanism of action and was s hown during the 1970s have a differential effect on patients res is tant to the therapeutic effects of conventional antips ychotics . However, there is an approximately 1 percent ris k of agranulocytosis as sociated with the use of clozapine. potentially lethal ces sation in the production of white blood cells was as sociated with a series of deaths in F inland during the mid-1970s and led to a decreased of clozapine in E urope and failure to market the drug in the United S tates . Interes t in clozapine was rekindled the res ults of a large-scale multicenter s tudy in chronic, treatment-res is tant inpatients with s chizophrenia. T he study yielded convincing evidence of the superior of clozapine for ameliorating pos itive psychotic in treatment-res is tant patients. C ons is tent with the worldwide experience in the late 1970s and early the study als o s howed that clozapine can be used with relative s afety within the context of careful monitoring agranulocytosis . T he development of clozapine represented the firs t incremental gain in the of the pharmacological agents us ed to treat since the original introduction of chlorpromazine. T he demonstration that clozapine can be effective in patients for whom conventional antips ychotics are not 1412 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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spawned cons iderable interes t in the development of antips ychotics for the treatment of schizophrenia. Over last decade, five new antips ychotics have been ris peridone (R is perdal), olanzapine (Zyprexa), (S eroquel), ziprasidone (G eodon), and aripiprazole T hese new drugs were introduced in the hope that they would s hare the superior efficacy of clozapine, but the ris k of agranulocytosis and the other s ide effects have limited the us e of clozapine. However, although these new medications appear to be as effective for positive ps ychotic s ymptoms as the conventional antips ychotics , none of them has been proven to have superior efficacy for this as pect of the illnes s. T heir advantage over the conventional antips ychotics is their subs tantially decreas ed extrapyramidal s ide effect T his decreas ed s ide effect burden may res ult in their apparently greater effectiveness and appears to have reduced the incidence of long-lasting motoric side (i.e., persistent dys tonia and tardive dys kinesia). the second-generation antips ychotics als o appear to greater benefit than the conventional antipsychotics for the treatment of depress ive s ymptoms and the of relapse and rehospitalization. T hese considerations led to the second-generation antips ychotics replacing conventional antips ychotics as the first line of pharmacological treatment for first-episode and chronic patients with s chizophrenia. T he second-generation antips ychotics are not without their limitations . S everal of thes e agents have been as sociated with the development of clinically significant metabolic disturbances , including weight gain, hyperlipidemias , and new-onset type II diabetes 1413 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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P atients with s chizophrenia are already at increased cardiovascular dis eas e because of their lifes tyle, and occurrence of these s ide effects only places these at greater risk for adverse cardiovas cular events. Longterm s tudies will eventually clarify whether the ris k of extrapyramidal s ide effects, including tardive dyskinesia, warrants the increas ed risk of thes e side effects . T here is cons iderable interest in whether the novel pharmacological properties of the s econd-generation antips ychotics will lead to increased efficacy for the negative symptom and cognitive impairment illness components. A number of studies have indicated that second-generation antips ychotics are more effective conventional antips ychotics for negative s ymptoms , but differences are us ually related to concurrent changes extrapyramidal or depres sive symptoms or exces sive dosages of the conventional antipsychotic comparator drug. In studies that have controlled for thes e potential sources of artifact, the apparently s uperior efficacy of second-generation antipsychotics disappears. A similar story is emerging for the comparative efficacy of generation and conventional antips ychotics for impairments . C onventional antipsychotics have been observed to have little impact on cognitive function, when their us e has resulted in significant improvement the pos itive ps ychotic s ymptom component of the T his lack of benefit sugges ts that thes e agents may inherent toxic effects on cognition, especially when in higher dos ages . S econd-generation antipsychotics improve performance on neuropsychological meas ures cognitive functions , but the effect is relatively modes t, 1414 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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patients continue to exhibit cons iderable cognitive impairments in comparison to normal controls . T he differential cognitive effect between second-generation and conventional antipsychotics is less pronounced second-generation antips ychotics are compared to doses of conventional antips ychotics . T he limitations of conventional and s econd-generation antips ychotics for the negative s ymptoms and cognitive impairment components of s chizophrenia have led to inves tigation of the us efulnes s of pharmacological augmentation strategies for thes e components. A studies have s upported the potential usefulnes s of glutamatergic agents that bind to the glycine site of the NMDA glutamatergic receptor for the treatment of primary, enduring, negative or deficit s ymptoms . D-cyclos erine, and D-serine have produced res ults in preliminary controlled clinical trials. Other augmentation strategies for thes e symptoms include us e of dopamine and s erotonergic and noradrenergic agents . T he delineation of the pharmacology of normal has also led to the inves tigation of augmentation strategies in the treatment of cognitive impairments . potential usefulnes s of cholinergic and dopaminergic other pharmacological agents is currently being inves tigated. Augmentation s trategies have also been us ed to treat positive ps ychotic symptoms that fail to res pond to antips ychotic treatment, including clozapine. However, lithium, antiepileptics, antidepress ants , and antianxiety agents have not been shown to substantially reduce symptoms. S ome small patient s ubgroups may be 1415 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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differentially res ponsive to a class of drugs other than antips ychotics , but, in the absence of the capacity to identify in advance which patients res pond favorably, it difficult to prove or to disprove this propos ition. In contrast, thes e drugs may be effective for cooccurring anxiety, depres sive, manic, and aggres sive symptoms . emerging trend for patients with persistent positive ps ychotic symptoms is to treat thes e patients with multiple antipsychotic drugs. T here is currently no empirical basis for this treatment s trategy. E C T was frequently us ed in the treatment of patients schizophrenia before the introduction of antips ychotic drugs. E C T is particularly effective in the treatment of catatonic stupor and excitement but generally produces res ults s imilar to thos e obtained with antipsychotics, is , a reduction of pos itive symptoms rather than a of long-term functional impairments . Although E C T is and painless , its use is res tricted, in part by litigation societal attitudes, but als o because any therapeutic advantage gained in an initial series of treatments is easily maintained. Also, there is currently no evidence that E C T is effective in antips ychotic-res is tant patients. F or all of these reas ons , drug treatment approaches are generally preferred.

Ps yc hos oc ial Interventions T he debate over whether patients should be treated pharmacological or psychosocial treatments has given to the search for how these treatments P.1344 should be optimally integrated. C ontrolled clinical trials 1416 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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have conclusively demons trated that intens ive ps ychotherapy is less effective than pharmacological treatment, that it is not s uperior to less expensive, les s ambitious ps ychosocial forms of psychotherapy, and should no longer be cons idered as an alternative to the us e of antips ychotic drugs . In addition, s tudies have repeatedly demonstrated that supportive forms of ps ychos ocial treatment are entirely compatible with treatment and can increase the effectivenes s of overall treatment, reduce the amount of medication necess ary, enhance patient participation in the full range of treatment, and optimize s ocial and occupational functioning. E specially impress ive are studies documenting the considerable additional benefit in reducing relaps e and hospitalization rates when therapy and education programs are added to maintenance pharmacological treatment. T hes e make clear that ps ychosocial and rehabilitative interventions have become es sential components of comprehensive treatment of patients with P sychos ocial and rehabilitation interventions include cognitive behavior therapy for treatment-res is tant ps ychotic symptoms ; s upportive, problem-solving, educationally oriented psychotherapy; family therapy education programs aimed at helping patients and their families unders tand the patient's illness , reduce stress , enhance coping capabilities; s ocial and living s kills training; s upported employment programs ; and the provis ion of supervised res idential living arrangements . T he development and increased us e of ps ychos ocial services have been complemented by the evolution of services designed to decreas e the us e of inpatient 1417 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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services and to maintain the patient in the community. Ass ertive community treatment teams are designed to provide intensive outreach services to patients who are unable to be maintained in the community with outpatient clinical treatment. C risis management including 24-hour crisis beds and partial hospitalization programs, repres ent alternatives to hospitalization periods of symptom exacerbation. T he development of these services reflects the ongoing shift in the treatment of the patient with schizophrenia from a hos pital-based to a community-based system of care. W hen optimal treatment with these services is provided, the rewards of therapeutic accomplishment, reduction in morbidity, and economic cos t benefits are profound and rival therapeutic accomplishments found anywhere in medicine. T he demonstrated benefits of services challenge the field to establish an adequate community-based treatment approach prepared to the challenges and demands of broad-based integrated treatment. S ociety has failed to meet the challenge of providing evidence-based treatment to most people have schizophrenia. A new and future challenge is the organization of intervention in the prepsychotic and early ps ychotic phases of illness . C linical prudence requires early identification and treatment, but the earlies t indicators us ually not psychotic features. P s ychosocial treatment nonps ychotic illness manifes tations needs to be developed, just as pharmacological treatments for cognitive impairments and negative psychopathology required if prepsychotic treatment is to addres s early morbid features in patients at high risk for ps ychosis . 1418 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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FUTUR E DIR E C TIONS T he field is at the beginning of a new century of opportunity for major breakthroughs in the treatment prevention of schizophrenia. T he 20th century closed subs tantial progress in defining brain anatomy and function as sociated with this illness syndrome. diseases within the s yndrome were hypothesized, and postmortem findings ranged from the microanatomical gene express ion candidates for pathophys iology. C hromos ome locations and candidate genes were identified, and new methodologies based in technology were put into place. P rogres s with phys iological and cellular phenotypes has pos itioned field for more sure-footed and rapid advance on discovery in s chizophrenia. Although the multifactorial and multigenetic etiology of the s yndrome is certain, paradigms providing heuris tic advantage in the clas sification of psychopathological phenomena means of address ing the problem of syndromic heterogeneity. Multidis ciplinary work has become and the schizophrenia investigator of today is likely to engaged in translational res earch us ing postgenomic technology and bioinformatics . Although opportunities are great, so are the remaining challenges. C ognitive impairments and primary symptoms are largely respons ible for the poor outcome and low quality of life of most pers ons with schizophrenia. W ill new molecular targets result in the efficacious treatments for thes e illness components ? knowledge of etiopathophysiology is required to primary and s econdary prevention interventions ? W ill multiple genes involved in risk so overlap with affective 1419 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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and other disorders that current clas sification of will be invalidated? W ill the many common and small contributors to ris k and the many and varied pathophys iological res ults require a new disease paradigm? T he sections in C hapter 12 s how the clinical progres s and future scientific promise relating schizophrenia. T he complexity of this mos t distinctively human disease syndrome, however, ass ures that the conquest of s chizophrenia will be one of medicine's difficult challenges.

S UG G E S TE D C R OS S A more detailed dis cuss ion of etiology, brain structure function, clinical features , and s omatic and treatments are presented in other sections of C hapter detailed introduction to areas of neuroscience and cognitive s cience relevant to s chizophrenia is provided S ection 1.2 on functional neuroanatomy, S ection 1.3 neuronal development and plas ticity, S ections 1.15 and 1.16 on brain imaging, S ection 1.17 on bas ic molecular genetic neuros cience, and S ection 3.1 on perception cognition.

R E F E R E NC E S B lyler C R , G old J M. C ognitive effects of typical antips ychotic treatment: Another look. In: S harma T , Harvey P , eds . C ognition in S chizophre nia. New Oxford Univers ity P res s; 2000. B reier A, S u T -P , S aunders R , C arson R E , De B artolomeis A, W einberger DR , W eis enfeld N, Malhotra AK , E ckelman W D, P ickar D: 1420 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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as sociated with elevated amphetamine-induced synaptic dopamine concentrations: E vidence from a novel pos itron emis sion tomography method. P roc Acad S ci U S A. 1997;94: 2569. *B uchanan R W , B reier A, K irkpatrick B , B all P , WT J r: P ositive and negative symptom respons e to clozapine in s chizophrenic patients with and without the deficit s yndrome. Am J P s ychiatry. C ahn W, P ol HE , Lems E B , van Haren NE , S chnack van der Linden J A, S chothors t P F , van E ngeland H, R S : B rain volume changes in first-episode schizophrenia: A 1-year follow-up study. Arch G en P s ychiatry. 2002;59:1002. C annon M, J ones P B , Murray R M: Obs tetric complications and s chizophrenia: Historical and analytic review. Am J P s ychiatry. 2002;159:1080. C arls son A: Neurocircuitries and neurotransmitter interactions in s chizophrenia. Int C lin 1995;3:21. *C arpenter W T , B uchanan R W , K irkpatrick B , C , W ood F : S trong inference, theory tes ting, and the neuroanatomy of s chizophrenia. Arch G e n 1993;50:825. C sernansky J G , Mahmoud R , B renner R : T he R is peridone-US A-79 S tudy G roup: A comparis on of ris peridone and haloperidol for the prevention of 1421 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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relaps e in patients with s chizophrenia. N E ngl J 2002;346:16. Davis J M, C hen N, G lick ID: A meta-analysis of the efficacy of second-generation antips ychotics . Arch P s ychiatry. 2003;60:553. *E gan MF , G oldberg T E , K olachana B S , C allicott Mazzanti C M, S traub R E , G oldman D, W einberger E ffect of C OMT V al108/158 Met genotype on frontal lobe function and ris k for s chizophrenia. P roc Natl S ci U S A. 2001;98:6917. F reedman R : S chizophrenia. N E ngl J Me d. 2003;349:1739. P.1345 F reedman R , C oon H, Myles -Worsley M, OrrOlincy A, Davis A, P olymeropoulos M, Holik J , Hoff M, R osenthal J , W aldo MC , R eimherr F , Y aw J , Y oung DA, B rees e C R , Adams C , P atterson Adler LE , K ruglyak L, Leonard S , B yerley W: neurophys iological deficit in s chizophrenia to a chromosome 15 locus. P roc Natl Acad S ci U S A. 1997;94:587. G ao W J , G oldman-R akic P S : S elective modulation excitatory and inhibitory microcircuits by dopamine. P roc N atl Acad S ci U S A. 2003;100:2836. G off DC , T sai G , Levitt J , Amico E , Manoach D, 1422 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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S choenfeld DA, Hayden DL, McC arley R , C oyle J T : placebo-controlled trial of D-cyclos erine added to conventional neuroleptics in patients with schizophrenia. Arch G e n P s ychiatry. 1999;56:21. G oldberg T E , E gan MF , G scheidle T , C oppola R , T , K olachana B S , G oldman D, W einberger DR : subproces ses in working memory: R elations hip to catechol-O -methyltransferas e V al158Met genotype schizophrenia. Arch G e n P s ychiatry. 2003;60:889. G reen MF , Marder S R , G lynn S M, McG urk S R , WC , W irshing DA, Liberman R P , Mintz J : T he neurocognitive effects of low-dose haloperidol: A year comparison with risperidone. B iol P s ychiatry. 2002;51:972. Heres co-Levy U, J avitt DC , E rmilov M, Mordel C , Lichenstein M: E fficacy of high-dose glycine in the treatment of enduring negative symptoms of schizophrenia. Arch G e n P s ychiatry. 1999;56:29. *K irkpatrick B , B uchanan R W , R os s DE , C arpenter A s eparate dis eas e within the s yndrome of schizophrenia. Arch G en P s ychiatry. 2001;58:165. Lahti AC , Holcomb HH, Medoff DR , W eiler MA, T amminga C A, C arpenter WT J r: Abnormal patterns regional cerebral blood flow in s chizophrenia with primary negative symptoms during an effortful recognition task. Am J P s ychiatry. 2001;158:1797.

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*Leonard S , G ault J , Hopkins J , Logel J , V ianzon R , M, Drebing C , B erger R , V enn D, S irota P , Zerbe G , A, R os s R G , Adler LE , F reedman R : As sociation of promoter variants in the α7 nicotinic acetylcholine receptor s ubunit gene with an inhibitory deficit found in s chizophrenia. Arch G e n P s ychiatry. Lewis DA, Lieberman J A: C atching up on Natural his tory and neurobiology. Neuron. Lieberman J A, F enton W S : Delayed detection of ps ychos is : C aus es , cons equences, and effect on health. Am J P s ychiatry. 2000;157:1727. Mirnics K , Middleton F A, S tanwood G D, Lewis DA, P : Dis ease-specific changes in regulator of G signaling 4 (R G S 4) express ion in s chizophrenia. Mol P s ychiatry. 2001;6:293. Mortensen P B , P edersen C B , W estergaard T , E wald H, Mors O, Anders en P K , Melbye M: E ffects family history and place and s eas on of birth on the of schizophrenia. N E ngl J Me d. 1999;340:603. S chooler NR , K eith S J , S evere J B , Matthews S M, AS , G lick ID, Hargreaves W A, K ane J M, Ninan P T , A, J acobs M, Lieberman J A, Mance R , S imps on Woerner MG : R elaps e and rehospitalization during maintenance treatment of schizophrenia. Arch G e n P s ychiatry. 1997;54:453. S hergill S S , B rammer MJ , F ukuda R , W illiams S C , 1424 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/12.1.htm

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R M, McG uire P K : E ngagement of brain areas in proces sing inner speech in people with auditory hallucinations . B r J P s ychiatry. 2003;182:525. S tefans son H, S igurds son E , S teinthors dottir V , B jornsdottir S , S igmunds son T , G hosh S , G unnarsdottir S , Ivars son O, C hou T T , Hjaltason O, B irgisdottir B , J ons son H, G udnadottir V G , G udmundsdottir E , B jornss on A, Ingvars son B , A, S igfus son S , Hardardottir H, Harvey R P , Lai D, B runner D, Mutel V , G onzalo A, Lemke G , S ainz J , J ohannes son G , Andress on T , G udbjarts son D, Manoles cu A, F rigge ML, G urney ME , K ong A, J R , P eturs son H, S tefans son K : Neuregulin 1 and susceptibility to schizophrenia. Am J Hum G ene t. 2002;71:877. S traub R E , J iang Y , MacLean C J , Ma Y , W ebb B T , Myakis hev MV , Harris -K err C , W ormley B , S adek H, K adambi B , C esare AJ , G ibberman A, W ang X, Walsh D, K endler K S : G enetic variation in the gene DT NB P 1, the human ortholog of the mous e dysbindin gene, is as sociated with s chizophrenia. Hum G e ne t. 2002;71:337.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 13 - Mood Dis orders > 13.1: Mood Disorders : His torical C onceptual Overview

13.1: Mood Dis orders : His toric al Introduc tion and C onc eptual Overview Hagop S . Akis kal M.D. P art of "13 - Mood Dis orders "

C L INIC A L A ND P UB L IC HE A L TH OF MOOD DIS OR DE R S Prevalenc e F or nearly 2,500 years , mood dis orders have been described as one of the mos t common illnes ses of humankind, but only recently have they commanded major public health interes t. T he World Health Organization (WHO) has ranked depres sion fourth in a of the mos t urgent health problems worldwide. T he Agency for Health C are P olicy and R esearch, a federal agency concerned with medical practice from a public health pers pective, devoted two volumes to depres sion out of the first ten it has publis hed on s uch topics as hypertens ion, diabetes mellitus, and coronary artery disease. Univers ity of C alifornia psychiatrist K enneth demonstrated that the dis ability induced by depres sion compares with and often exceeds those of s uch Moreover, there are now data from s everal s ources indicating that the morbidity and mortality from many of 1426 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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these dis eas es are increas ed with depress ive Depress ive disorders afflict one out of five women and out of ten men at some time during their lives. episodes alternating with mania or hypomania the domain of bipolar dis orders. Increas ingly, the conventional figure of 1 percent for bipolar disorders in the general population is challenged, and there are convincing data that this group of dis orders may for 5 percent of the population and up to 50 percent of depres sions . T he enlargement of the boundaries for bipolar disorder is largely due to better detection of the bipolar II subtype (depres sion plus hypomania rather mania). T he current evidence for and the clinical, therapeutic, and public health implications of s uch a broadened bipolar concept have been s ummarized in a World P s ychiatric Ass ociation monograph. Des pite the availability of effective treatments, many persons with mood dis orders are disabled, and rates of suicide (which occurs in approximately 15 percent of depres sive patients , es pecially in thos e with bipolar II disorder) are high in young and, particularly, elderly Although depres sive dis orders are more common in women, more men than women die of s uicide. Highprofile cases of infanticide recently publicized on have brought into the public's awarenes s the role of the reproductive cycle in severe pos tpartum psychosis more generally, the high burden of all forms of in women. T he suboptimal outcome of mood disorders in recent res earch reports cannot be as cribed to underdiagnosis and undertreatment alone for several reasons. F irs t, G erald K lerman and colleagues have 1427 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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suggested that the incidence of mood dis orders may increasing in younger age groups , es pecially in cohorts born in the 1960s, and may be as sociated with rising of alcohol and s ubs tance abus e. S econd, mood once believed to be es sentially adult dis orders, are increasingly diagnosed in children and adolescents . clinical s tudies sugges t higher rates of chronicity, recurrence, and refractoriness than previously F or ins tance, chronicity, reported by E mil K raepelin to occur in no more than 5 percent in the early 20th in G ermany, is now s een in varying degrees in one out three affectively ill patients. Nonetheless , outcome coming from university centers tend to overestimate proportion of cases with less favorable prognos is , and, undeniably, many patients seen in private practice experience a favorable outcome. Als o, not current data indicate that depres sed patients treated by ps ychiatris ts in private s ettings receive much better than those in other settings.

C onc epts of Mood Dis orders In the E uropean tradition, the broader rubric of affe ctive dis order (which subsumes mood and anxiety disorders ) been conceptualized along two influential schools. Lewis and his followers from the Mauds ley school have promoted a continuum model—from anxiety dis orders mild neurotic depres sions to s evere endogenous and ps ychotic depress ions. T he Newcas tle school, led by R oth, has s harply demarcated thos e conditions from another. Although vestiges of both approaches are s till influential in clinical and basic research, their is presently overshadowed by E uropean s tudies in G ermanophone countries that s ubdivide mood 1428 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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on the bas is of polarity: unipolar (depres sive episodes only) and bipolar (depress ive epis odes plus manic, hypomanic, or mixed epis odes ). T hat s ubdivision, in supported by studies in the United S tates , has s erved the bas is for much recent res earch into the biology, treatment, and class ification of mood dis orders, and is reflected in the fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ) tenth revision of the Inte rnational S tatis tical Dis e as es and R e late d H ealth P roble ms (IC D-10). official sanction, many authorities today continue to s ee cons iderable continuity between recurrent depres sive bipolar disorders . T his has led to wides pread and debate about the bipolar s pectrum, which incorporates class ic bipolar dis order, bipolar II, and recurrent depres sions . E merging data also tend to favor a continuum between juvenile and adult mood disorders . T his is bas ed on the pioneering contributions by E lva P oznanski at the Univers ity of Michigan, as well as the work of Leon and colleagues at the National Institute of Mental (NIMH), G abrielle C arls on in collaboration with Dennis C antwell at the Univers ity of C alifornia at Los Angeles, J oachim P uig-Antich at C olumbia University in New P.1560 C hildhood bipolarity, too, is receiving increas ing clinical attention, thanks to the s eminal work of E lizabeth and colleagues, originally conducted at Ohio S tate Univers ity. In addition, clinical observations at the Univers ity of T enness ee by the pres ent author on the juvenile offs pring of adult patients with bipolar dis order 1429 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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have led to a greater appreciation of the bipolar nature complex clinical presentations of affective illness in the juvenile offs pring and kin of adult bipolar probands. recent work by B iederman's group at Harvard s ugges ts intriguing links between pediatric bipolar dis order and attention-deficit/hyperactivity dis order (ADHD). C urrent concepts of mood disorders in the United embrace a wide s pectrum, including many conditions previous ly diagnos ed as s chizophrenia, personality disorder, or neuros is. T he diagnos tic s hift occurred in as a res ult of the U.S .–U.K . Diagnostic P roject, which demonstrated that s chizophrenia was being diagnosed the expense of mood dis orders (F ig. 13.1-1). boundaries were further broadened by the availability new and effective treatments and by the unacceptable for tardive dys kines ia and suicide in persons with misdiagnos ed mood disorders. More generally, pres ent res earch interest in mood disorders in the United emanated from a landmark 1969 NIMH conference on ps ychobiology of affective illness es : T he NIMH C ollaborative Depres sion S tudy—a long-term project deriving directly from recommendations made the conference—has legitimatized the broader perspective.

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FIGUR E 13.1-1 C omparison of B ritis h (London) and (New Y ork) concepts of schizophrenia. (Adapted C ooper J E , K endell R E , G arland B J , et al. Diagnos is in Ne w Y ork and L ondon. London: Oxford Univers ity P res s; 1972.)

Morbidity and Mortality Unfortunately, findings publis hed by Martin K eller and colleagues in the 1980s documenting gross undertreatment of mood dis orders continue to describe the current treatment lands cape worldwide. W hatever 1431 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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changes have occurred in diagnos tic practice do not appear to have significantly affected the morbidity and mortality of mood disorders. T his is all the more scandalous because the 1990s have s een new clas ses us er-friendly antidepress ant and mood-stabilizing as well as depres sion-specific ps ychotherapies . In the author's opinion, this state of affairs results , in part, the fact that clinical exposure to mood disorders in both specialized (ps ychiatric) and primary care (general medical) training is suboptimal. Mood disorders , as prevalent and lethal dis orders, mus t command a share in the clinical curriculum of both psychiatris ts and general medical practitioners. As most mood disorders chronically relaps ing conditions , long-term exposure to patients with these dis orders in mood or bipolar clinics should be obligatory training for young doctors . Unfortunately, few academic centers have such clinics, those that exist are largely devoted to research. T he primary goal of these clinics is the execution of protocols rather than gaining clinical experience in for such patients . Nearly half of all cas es of depres sion, jus t like those adult-onset diabetes, remain undetected for years or inadequately controlled—both of which s eem to lag behind hypertens ion, in which early detection and treatment have significantly reduced complications as stroke. E fforts by patient-advocacy organizations — often in concert with national ps ychiatric organizations and governmental mental health agencies—appear to increasing public and government awareness of mood disorders . Ultimately, however, the challenge is to all primary care physicians with the requis ite hands-on 1432 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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experience in this prevalent group of disorders . Userfriendly tools to detect suicidal patients in the general medical sector would further enhance preventive T hese would require significant changes in the health care, including, but not limited to, the greater participation of nurses and s ocial workers as liaisons in primary mental health and continuity of care for or s uicidal patients . B ecaus e mood dis orders underlie 50 to 70 percent of suicides, effective treatment of these dis orders on a national level s hould, in principle, drastically reduce major complication of mood disorders . T hat elderly depres sed patients, often with medical comorbidity, cons titute the highest risk group for s uicide yet es cape clinical detection and treatment is particularly for public health. A small-scale S wedish study by R ihmer and R utz, although not specifically targeted the elderly, has yielded promising results in this regard. addition, clinical findings in recurrent mood dis orders clearly s hown the value of lithium prophylaxis in the prevention of suicide and overall mortality. E merging suggest that such benefits may accrue from all treatments for mood disorders .

DE F INITIONS Mood dis orders encompass a large group of disorders in which pathological moods and related vegetative and psychomotor disturbances dominate the clinical picture. K nown in previous editions of DS M as affe ctive dis orde rs , the term mood dis orders is today becaus e it refers to s ustained emotional s tates, merely to the external (affective) expres sion of the 1433 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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emotional state. Mood disorders are bes t cons idered syndromes (rather than discrete dis eas es ) consisting of clus ter of signs and symptoms, sus tained over a period weeks to months, that represent a marked departure a pers on's habitual functioning and tend to recur, often periodic or cyclical fashion.

Major Depres s ive Dis order and Dis order Major depress ive disorder (unipolar depress ion) is reported to be the most common mood dis order. It may manifest as a s ingle epis ode or as recurrent epis odes . cours e may be s omewhat protracted—up to 2 years or longer—in those with the s ingle-episode form. the prognos is for recovery from an acute episode is for mos t patients P.1561 with major depress ive disorder, three out of four experience recurrences throughout life, with varying degrees of res idual symptoms between episodes . dis orders (previous ly called manic-de pres s ive cons ist of at leas t one hypomanic, manic, or mixed episode. Mixe d e pis ode s repres ent a simultaneous of depress ive and manic or hypomanic manifestations. Although a minority of patients experience only manic episodes , most bipolar dis order patients experience episodes of both polarity. Manias predominate in men, depres sion and mixed s tates in women. T he bipolar disorders were clas sically des cribed as ps ychotic mood disorders with both manic and major depress ive (now termed bipolar I dis order), but recent clinical 1434 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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have shown the existence of a s pectrum of ambulatory depres sive s tates that alternate with milder, short-lived periods of hypomania rather than full-blown mania (bipolar II dis order). B ipolar II dis order, which is not easily dis cernible from recurrent major depres sive disorder, illustrates the need for more res earch to the relation between bipolar disorder and major depres sive dis order.

Dys thymia and C yc lothymia C linically, major depres sive epis odes often aris e from a low-grade, intermittent, and protracted depres sive subs trate known as dys thymic dis orde r. Likewise, instances of bipolar disorders , es pecially ambulatory forms, represent epis odes of mood disorder on a cyclothymic background, which is a biphasic alternating pattern of numerous brief periods of hypomania and numerous brief periods of depres sion. Dys thymic and cyclothymic disorders represent the two prevalent s ubthres hold mood conditions roughly corres ponding to the basic temperamental described by K raepelin and E rnst K retschmer as predis pos ing to affective illness . It is not always easy to demarcate full-blown s yndromal episodes of depres sion and mania from their counterparts commonly obs erved during the periods. T he s ubthres hold conditions appear to be terrain for interpersonal conflicts and postaffective pathological character developments that may ravage lives of patients and their families. In North America— some W es tern E uropean countries—many such end up being labeled with borderline pers onality 1435 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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which, unfortunately, often tends to obscure the origin of the presenting ps ychopathology. C yclothymic and dysthymic conditions also exist in the community without progress ion to full-blown mood episodes . As such, they are bes t cons idered, as trait bipolar and trait depres sive conditions. Understanding the factors that mediate trans ition from trait to clinical state is important for preventing manic major depress ive epis odes .

Other S ubthres hold Mood S tates E pidemiological studies in both E urope and North have als o revealed other subsyndromal conditions with depres sive and hypomanic manifes tations with few symptoms (oligos ymptomatic mood states ) and of short duration (brief epis odes). V ariously referred to as s ubs yndromal, brie f, or intermitte nt, thes e descriptions not merely represent arbitrary lowering of diagnostic thresholds , but herald increasing realization of their importance in early detection of at-ris k individuals —as happened in other medical fields (e.g., diabetes and es sential hypertens ion). If dis abling mood afflict 5 to 8 percent of the general population (E pidemiologic C atchment Area [E C A] s tudy), milder still clinically significant mood disorders would raise lifetime rates to 17 percent (National C omorbidity S tudy [NC S ]); if subclinical mood states are added, that figure doubles to involve a third of the general population (as reported, for ins tance, by K enneth K endler and colleagues). New evidence from both E urope and the United S tates has s hown that bipolar spectrum (bipolar I, bipolar II, and bipolar disorder not otherwise 1436 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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specified [NOS ] in formal diagnos tic manuals such as IV -T R and IC D-10) may account for at least 50 percent mood dis orders in the community and in psychiatric practice. C omorbidity in mood dis orders involves cons iderable overlap with anxiety dis orders. As s ummarized in an monograph, anxiety dis orders can occur during an of depress ion, may be a precurs or to the depress ive episode, and, les s commonly, may occur during the cours e of a mood disorder. T hos e findings suggest that least some depress ive disorders share a common with certain anxiety disorders . More recent clinical experience s uggests intriguing comorbidity patterns between bipolar II disorder on one hand and panic, obses sive-compuls ive, and s ocial phobic states on the other. F urthermore, bipolar I and II dis orders are particularly likely to be complicated by us e of alcohol, stimulants, or both. In many cases , the alcohol or subs tance abus e represents attempts at “selfthe depres sion and as sociated anxiety or ins omnia (or both) and, in the case of mania and hypomania, to maintain or enhance the positive moods and energy. F inally, physical illnes s—both s ys temic and cerebral— occurs in as sociation with depres sive dis orders with a greater frequency than expected by chance alone. properly treated, s uch depress ion negatively impacts prognos is of the phys ical disorder. More provocatively, there is current reawakening in the contribution of cerebral and cardiovascular factors to the origin of lateonset ps ychotic depress ions (previous ly clas sified as involutional me lancholia). An integrated framework of pathogenes is is neces sary 1437 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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unders tanding ps ychopharmacological, s omatic, and ps ychotherapeutic approaches in the clinical of patients with mood dis orders . A his torical on current developments is als o a valuable les son in study of mood dis orders.

G R E C O-R OMA N DE S C R IP TIONS Much of what is known today about mood disorders described by the ancient G reeks and R omans , who the terms me lancholia and mania and noted their T he ancients als o hypothes ized a temperamental origin those disorders . Much of modern thinking about mood disorders (e.g., the work of F rench and G erman the middle and latter part of the 19th century, which influenced current B ritish and American concepts ) can traced back to these ancient concepts .

Melanc holia Hippocrates (460 to 357 B C ) des cribed melancholia bile”) as a state of “avers ion to food, des pondency, sleeples sness , irritability, and res tless nes s.” T hus, in choos ing the name of the condition, G reek phys icians (who may have borrowed the concept from ancient E gyptians ) pos tulated the earliest biochemical of any mental disorder. T hey believed that the illness arose from the substrate of the somber melancholic temperament, which, under the influence of the planet S aturn, made the spleen secrete black bile, ultimately leading to mood darkening through its influence on the brain. G reek descriptions of the clinical manifestations depres sion and of the temperament prone to are reflected in the DS M-IV -T R in the s ubdepres sive 1438 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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lethargy, self-denigration, and habitual gloom of the person with dysthymic disorder. One Hippocratic aphorism recognized the clos e link between anxiety and depres sive states : “P atients with of long-standing are s ubject to melancholia.” who des cribed the first his torical case of melancholia, have als o been the first to describe a depress ive mixed state, an activated form of depress ion: P.1562 A woman of T hasos became morose becaus e of a justifiable grief, and although she did not take to her she s uffered from ins omnia, los s of appetite… she complained of fears and talke d much; s he s howed despondency and… talke d at random and us e d foul language … many intens e and continuous pains … s he le apt up and could not be re s traine d… (emphases by author). According to G alen (131 to 201 AD), melancholia manifested in “fear and depres sion, dis content with life, and hatred of all persons.” A few hundred years later, another R oman, Aurelianus , citing the now-lost works S oranus of E phes us, amplified the role of aggres sion in melancholia (and its link to s uicide) and des cribed how illness as sumed delusional coloring: “Animos ity toward members of the household, s ometimes a desire to live at other times a longing for death, suspicion on the part the patient that a plot is being hatched against him.” In addition to natural melancholia, which, presumably, arose from an innate predispos ition to overproduce the dark humor and led to a more s evere form of the 1439 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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G reco-R oman medicine recognized such contributions to melancholia as immoderate of wine, perturbations of the s oul due to the pass ions love), and dis turbed s leep cycles . Autumn was the season mos t dis posing to melancholy.

Mania A s tate of raving madness with exalted mood was by the ancient G reeks , although it referred to a broader group of excited ps ychoses than that in nosology. Its relation to melancholia was probably as early as the first century B C , but, according to Aurelianus , S oranus discounted it. Nonetheles s, had observed the coexis tence of manic and features during the same epis ode, cons is ting of wakefulnes s and fluctuating states of anger and and, s ometimes , of s adness and futility. T hus , S oranus seemed to have des cribed what today are called mixe d epis odes in DS M-IV -T R and IC D-10. Natural generally considered a chronic disorder, but S oranus noted the tendency for attacks to alternate with periods remis sion. Although others before him hinted at it, Aretaeus of C appadocia (circa 150 AD) is generally credited with making the connection between the two major mood states : “It appears to me that melancholy is the commencement and a part of mania.” He described the cardinal manifes tations of mania as it is known today: T here are infinite forms of but the dis ease is one of them. If mania is as sociated with joy, the 1440 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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patient may laugh, play, dance night and day, and go to the market crowned as if a victor in some contes t of skill. T he ideas patients have are infinite. T hey believe they are experts in as tronomy, philosophy, or Aretaeus described the extreme ps ychotic excitement could complicate the foregoing clinical picture of mania: T he patient may become excitable, s us picious, and hearing may become sharp… they might] get nois es and buzzing in the ears; or may have visual hallucinations ; bad and his s exual des ires may get uncontrollable; arous ed to he may become wholly mad and run unres trainedly, roar aloud; his keepers, and lay violent upon hims elf. Noting the fluctuating nature of symptoms in the affectively ill, Aretaeus commented: “T hey are prone to change their mind readily; to become base, meanilliberal, and in a little time extravagant, munificent, not from any virtue of the soul, but from the of the dis eas e.” Aretaeus was thus keenly aware of the characterological distortions so commonly manifes ted during the different phases of cyclical mood dis orders. 1441 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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F inally, consolidating the knowledge of s everal Aretaeus described mania as a dis eas e of adoles cent young men given intermittently to “active habits, drunkenness , lechery” and an immoderate lifes tyle today might be called cyclothymic dis orde r). were mos t likely to occur in the spring.

Affec tive Temperaments T he concept of health and dis ease in G reco-R oman medicine was bas ed on harmony and balance of the humors , of which s anguine humor was deemed the healthies t. B ut even a des irable humor s uch as blood, which made persons habitually active, amiable, and to jes t, could, in excess , lead to the pathological s tate mania. T he melancholic temperament, dominated by bile and predisposed to pathological melancholia, was described as lethargic, s ullen, and given to brooding or contemplation; its modern counterparts are depres sive personality dis order (now in a DS M-IV -T R appendix) clinical express ion as dys thymic disorder (included in IC D-10 and DS M-IV -T R ). A long tradition dating back Aris totle (384 to 322 B C ) attributed creative qualities to otherwis e tortured melancholic temperament in s uch fields as philosophy, the arts, poetry, and politics. T he remaining two temperaments , choleric and phlegmatic, were les s desirable, as yellow bile made persons (irritable, hos tile, and given to rage) and phlegm made them phlegmatic (indolent, irres olute, and timid). T he choleric and phlegmatic temperaments would probably be recognized today as borderline personality dis order and avoidant or s chizoid pers onality disorder, Many of the original G reek texts on melancholia were 1442 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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transmitted to posterity through medieval Arabic texts such as thos e of Is haq Ibn Imran and Avicenna (and Latin rendition by C ons tantinus Africanus ). In different affective s tates , Avicenna developed the of the temperaments to its fullest. He s peculated that a special form of melancholia s upervened “if black bile mixed with phlegm” when the illnes s was “coupled with inertia, lack of movement, and quiet.” F urther, mania not neces sarily linked to the s anguine (what today is termed hype rthymic) temperament, as many forms of excited madnes s were believed to repres ent a mixture black and yellow bile. Avicenna further observed that the mixture of anger res tless nes s in melancholia indicated that the disease manic in nature and that the appearance of such s igns symptoms along with violence heralded the transition from melancholia to mania. Avicenna was prescient in res pect, because these activated, irritable depres sions racing thoughts have yet to receive the DS M-IV -T R “bless ing” for being clas sified as bipolar mixed s tates . T hose elaborations on G alen's temperamental types be considered the forerunners of current personality dimensions , deriving mood s tates from various neuroticism and introversion-extrovers ion. (What both IC D-10 and DS M-IV -T R describe as cyclothymic represents the intens e mood lability of high neuroticis m coupled with cyclic alternation between extroversion introversion.) S peculation on how diverse depress ive phenomena could be understood as a mix of humors anticipated modern multiple-transmitter hypothes es of depres sion. Ishaq Ibn Imran s ummarized the exis ting knowledge of melancholia by cons idering the 1443 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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of genetic factors (“injured prenatally as the res ult of father's sperm having been damaged”) with a s pecial temperament given to “mental overexertion”—although not necess arily phys ical overactivity—that, in turn, was as sociated with “disruption of the correct rhythms of sleeping and waking.” T hose views, too, have a very modern ring to them.

MODE R N E R A T he firs t E nglish text (F ig. 13.1-2) entirely devoted to affective illnes s was R obert B urton's Anatomy of Me lancholy, published in 1621. A scholarly review of medical and philosophical wisdom accumulated in past centuries , it als o anticipated many modern T he concept of affective dis order endors ed by B urton rather broad (as it always has been in the United K ingdom), embracing mood disorders and many that are today considered somatoform disorders , P.1563 including hypochondriasis. Although he described “caus eles s” melancholias, B urton als o categorized the various forms of love melancholy and grief. P articularly impres sive was his catalogue of caus es , culminating in grand conceptualization:

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FIGUR E 13.1-2 F rontis piece of R obert B urton's Me lancholy (1621).

S uch as have S aturn their genitures such as are born melancholy parents as offend in those six non-natural things , are a high s anguine complexion, are solitary by nature, great given to much contemplation, lead a life out of action, are mos t subject to melancholy. Of s exes both, but men more often. Of seas ons of the year, autumn is most melancholy. J obertus excepts neither young nor old. B urton's s ix nonnatural things referred to such environmental factors as diet, alcohol, biological and perturbations induced by pass ions s uch as intens e love. B urton hims elf did not definitively indicate age prevalences . Like nearly all of his predeces sors, he male (rather than the currently reported female) preponderance. F inally, B urton considered both the melancholic (contemplative) and the sanguine (hotblooded) temperaments to be substrates of B urton's work thus linked certain forms of depres sion the softer express ions of the manic disposition, or disorder, from which he himself appears to have T he 18th and 19th centuries introduced humane 1446 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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care of the mentally ill, thereby permitting s ys tematic clinical observation of the ps ychopathology and of mood disorders .

C onc ept of Affec tive Dis order Although C elsus (circa 30 AD) had des cribed “forms of madness that go no further than s adness ,” the F rench alienist J ean-P hilippe E s quirol (1840) may have been first psychiatrist in modern times to sugges t that a disturbance of mood might underlie many forms of depres sion and related paranoid ps ychoses . Until E squirol's work, melancholia had been categorized as form of insanity (i.e., ascribed to deranged reas oning or thought disturbance). E s quirol's obs ervations on melancholic patients led him to pos tulate that their insanity was partial (dominated by one delusion, a monomania) and that “the s ymptoms were the of the dis order of the affections. T he s ource of the evil the pas sions .” He coined the term lype mania (from the G reek, “sorrowful insanity”) to give nosological s tatus subgroup of melancholic disorders that were affectively based. E squirol cited B enjamin R ush (1745 to 1813), father of American ps ychiatry, who had earlier tris timania, a form of melancholia in which s adness predominated. E squirol's influence led other E uropean psychiatrists to propos e milder s tates of melancholia without delus ions, which were eventually categorized as simple and, ultimately, as primary depres sions. S uch culminated in the Anglo-S axon psychiatric term dis order, coined by Henry Maudsley (1835 to 1918), renowned B ritish psychiatrist after whom the London 1447 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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hospital is named.

Manic -Depres s ive Illnes s and the Ques tion of Ps yc hogenic Although the connection between mania and had been redis covered sporadically s ince it was firs t described 2,000 years ago, the clinical work that finally es tablis hed circular ins anity (J ean-P ierre F alret's term) folie à double forme (J ules B aillarger's term) as discrete nosologic entities with both depres sive and manic was undertaken by thes e two E squirol disciples in the 1850s . T hat accomplis hment built on P hilippe P inel's reforms , which championed humane treatment of the mentally ill in P aris around the turn of the 18th century and emphasized systematic clinical obs ervations of patients, which were detailed in cas e records. F rench alienists made longitudinal obs ervations on the s ame patient from one ps ychotic attack into another. F urthermore, E squirol had introduced chronicling in statis tical tables. T hus , the Hippocratic approach to defining a particular cas e by its ons et, circums tances, cours e, and outcome was applied by F rench alienis ts studying the affectively ill. T he humanitarian reforms introduced in the 19th century ensured that s tandards general health and nutrition would improve the outlook for the mentally ill—es pecially those with potentially revers ible disorders such as affective disorders —who could now be discharged from the asylums. T he school, by s egregating the nondeteriorating mood disorders from other types of ins anity, then paved the for the K raepelinian system. K raepelin's (1856 to 1926) unique contribution was not 1448 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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much his grouping together of all the forms of melancholia and mania, but his methodology and pains taking longitudinal obs ervations, which manic-depres sive illness as a nosological entity and hoped) a disease entity. His rationale was that (1) the various forms had a common heredity measured as a function of familial aggregation of manic and cases, (2) frequent transitions from one to the other occurred during longitudinal follow-up of patients , (3) a recurrent cours e with illnes s-free intervals most cas es , (4) the s uperimposed epis odes were commonly opposite to the patient's habitual temperament—that is , mania could be superimposed P.1564 depres sive temperament and depress ion on a temperament—and (5) both depress ive and manic features could occur during the same epis ode (mixed states ). K raepelin's synthesis was developed as early sixth (1899) edition of his L e hrbuch de r P s ychiatrie and explicitly stated in the opening pas sages of the s ection manic-depres sive psychosis in the eighth edition (published in four volumes , 1909 to 1915): Manic-depres sive ins anity on the one hand the whole domain of so-called periodic and circular ins anity, on the other simple mania, the greater part of the morbid states termed melancholia and also a not inconsiderable number of cases 1449 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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confusional ins anity. Las tly, we include here certain s light and slightes t colorings of mood, of them periodic, some of them continuously morbid, which on the one hand are to be regarded as the rudiment of more s evere disorders , on the other hand, over without boundary into the domain of pers onal F or K raepelin, the core pathology of clinical depres sion cons isted of lowered mood and slowed (retarded) and mental proces ses. In mania, by contrast, the mood elated, and both phys ical and mental activity were accelerated. His earlier observations on what he involutional me lancholia (referring to 40- to 65-year-old patients with extreme anxiety, irritability, agitation, and delus ions) had led him to s eparate that entity from the broader manic-depres sive rubric. B ut, in the eighth of L e hrbuch de r P s ychiatrie , he united melancholia with manic-depres sive group, with the jus tification that it special form of mixed state and that follow-up by his pupil Dreyfus had demonstrated unmistakable excited phas es . T he clas sification of mood disorders is still evolving. Leonhard in 1957, J ules Angs t in 1966, C arlo P erris in and G eorge W inokur, P aula C layton, and T heodore 1969, working independently in four different countries, propos ed that depress ive disorders without manic or hypomanic epis odes (unipolar depress ive disorder) appear in middle age and later are distinct from 1450 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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episodes that begin at earlier ages and alternate with manic or hypomanic episodes (bipolar disorder). T he difference between the two affective subtypes is the greater familial loading for mood disorder—es pecially bipolar disorder—among bipolar dis order probands. K raepelin had conceded the occurrence of states of depres sion occasioned by s ituational However, he believed manic-depres sive illnes s was hereditary—yet he could not document postmortem anatomopathological findings in the brains of manicdepres sive patients . T herefore, manic-depres sion had be considered a functional mental dis order in which disturbances were pres umed to lie in altered functions . S uch biological factors were deemed abs ent the ps ychogenic depres sions . T hus, K raepelin's clas sification of mood disorders is both dualistic and unitary. It is dualis tic to the extent that he designated them as either ps ychologically occas ioned or caus ed. It is unitary with res pect to disorders in the group, which have been termed endoge nous affective dis orders (i.e., due to internal biological causes ). In words , K raepelin restricted the concept of clinical depres sion to what DS M-T R -IV terms major depre s s ive dis order with me lancholic fe ature s . Moreover, he a continuum between that condition and what DS M-IV and IC D-10 now term bipolar dis orders . As summarized in T able 13.1-1, until recently, depres sions were contrasted with those of exogenous caus e (i.e., external and, presumably, psychogenic T ransitions between the two groups are s o frequent, however, that the two-type thes is of depres sion has largely abandoned in official clas sifications in North 1451 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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American psychiatry and mos t parts of the world. In study conducted by the author's mood clinic team in Memphis during the 1970s, 100 patients with neurotic depres sion (the prototype of exogenous depress ion), prospectively followed over 3 to 4 years , developed episodes with endogenous , ps ychotic, and even bipolar features (T able 13.1-2). Nonetheles s, the exogenous dichotomous grouping s till has a few adherents in E ngland and Australia who continue to res earch its potential for clinical predictions. S uch generally attempts to validate the various s ubtypes on basis of their clinical characteristics rather than caus e. T oday, most mood disorder experts would agree that depress ive illnes s has endogenous and exogenous components in mos t patients pres enting clinically. T his does not neces sarily imply that a exis ts between all forms of depress ive disorders, but suggests that neurotic and endogenous clinical are not the bes t way to capture the heterogeneity of disorders . C ons ens us would be les s likely reached on to delimit clinical depres sive dis order from comorbid disorders s uch as the various anxiety dis orders, us e disorders , and personality disorders . C larifying the boundaries between thos e disorders has emerged as a principal challenge in the class ification of mood

Table 13.1-1 Overlapping Dic hotomies of Affec tive That Are Not Nec es s arily S ynonymous 1452 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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Manic-

P sychogenic

S (s omatic) type

J (jus tified) type

Autonomous

R eactive

E ndogenous

E xogenous

P sychotic

Neurotic

Acute

C hronic

Major

Minor

Melancholic

Neurasthenic

T ypical

Atypical

P rimary

S econdary

B iological

C haracterological

Table 13.1-2 Three- to Four-Year Pros pec tive Follow-up in Depres s ions (N = 100) 1453 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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Diagnos is and Outc ome

Na

Manic epis ode

4

Hypomanic episode

14

P sychotic depres sion

21

E ndogenous depres sion

36

E pisodic course

42

Uns table characterological features

24

S ocial invalidism

35

S uicide

3

aT he

total exceeds 100 because more than one outcome was poss ible in each patient. S ummarized from Akis kal H, B itar A, P uzantian al.: T he nosological status of neurotic depres sion: prospective 3- to 4-year examination in light of primary-secondary and unipolar-bipolar

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dichotomies . Arch G e n P s ychiatry. 1978;35:756, permis sion.

C artesian thinking in 17th-century F rance conceptually separated mind from body, thereby providing autonomy over the somatic sphere, free from by the C hurch. T he dichotomous paradigm ens ured the s tudy of the two as pects of the human organism would not be confounded by the complexities of mind– body interactions . T hat is one reas on K raepelin's descriptive obs ervations have proved valuable to subs equent generations of clinicians . F urthermore, his approach exemplifies the best tradition of s cientific humanis m in medicine: Des cription and diagnostic categorization of an individual patient are necess ary for the physician to P.1565 apply the knowledge gained from pas t observation of similarly described and diagnos ed patients . One to the K raepelinian approach is that becaus e of its biological reductionis m, it is not s ufficiently articulate to account for mind–body interactions in the genes is of mental disorders . 1455 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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Depres s ions as Ps yc hobiologic al Affec tive R eac tion Types B ridging the divide between psyche and s oma was the ambition of S wis s-born Adolf Meyer (1866 to 1950), dominated ps ychiatry from his chair at J ohns Hopkins Univers ity during the firs t half of the 20th century. coined the term ps ychobiology to emphas ize that both ps ychological and biological factors could enter into the caus ation of depres sive and other mental disorders. B ecaus e of the nas cent s tate of brain s cience during Meyer's time, he was more adept at biography than biology and, therefore, paid greater attention to ps ychos ocial causation. He preferred the term (press ed down) to me lancholia because of its lack of biological connotation. He conceived of depress ive in terms of unspecified constitutional or biological interacting with a s eries of life s ituations beginning at or even at conception. F rom that viewpoint arose the unique importance accorded pers onal history in depres sive reactions to life events. Meyer's terminological revision left a somewhat legacy in that the term de pres s ion is now applied to a broad range of affective phenomena ranging from and adjus tment disorders to clinical depres sion and bipolar disorders . R epercus sions can be seen in the threshold for diagnos ing major depres sive dis order in DS M-IV -T R , which makes it difficult to differentiate depres sive dis order from transient life s tres ses that produce adjus tment dis order with depress ed mood. Nos ological nuances to which Meyerians paid little attention, such as the difference between melancholic depres sion and more mundane depres sions , are not 1456 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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matter of s emantics . T o the extent that thos e two forms depres sion are s een in different clinical s ettings , hypothes es bas ed on one population may not apply to other. F or instance, uncontrollable traumatic events have taught s tudy s ubjects to feel helpless or to view world in a negative light, but that does not equate with clinical depres sion; nor does the proces s appear to be specific to depress ion. F ailure to make s uch distinctions further clouds interpretations of the res ults trials comparing ps ychotherapy and pharmacotherapy depres sive dis orders. On the other hand, the Meyerian emphasis on factors for the patient represented a more practical approach to depth psychology. R ecent sociological interpretations of depress ion can also be traced to work. B ut, in final analysis, the Meyerian concern for uniquenes s of the individual has proved heuristically sterile. It deemphas izes what is diagnostically common different individuals , thereby obscuring the relevance of accrued clinical wisdom for the index patient. F or that reason, the Meyerian approach, after enjoying clinical popularity for several decades in North America, has way to neo-K raepelinian rigor. However, the ps ychobiological vision of bridging biology and ps ychology, one of the major preoccupations of ps ychiatric thought and res earch today, owes much to Meyer's legacy.

C ONTE MP OR A R Y MODE L S OF DE P R E S S ION F rom clas sical times through the early part of the 20th century, advances in the unders tanding of mood 1457 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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involved conceptual s hifts from s upernatural to explanations ; from reductionis tic, unitarian theories of caus ation to pluralistic theories; and from dualism to ps ychobiology. K nowledge of thos e conceptual developments provides a useful base from which to scrutinize models and concepts of mood disorder developed later in the 20th century. T he new derived from competing theoretical positions, have generated models for understanding various aspects of mood disorders , particularly depress ive disorders 13.1-3).

Table 13.1-3 Major Models of D

Proponents (Year)a

Model

Mechanis m

K arl Abraham (1911)

Aggress ion inward

T ransduction of aggres sive ins tinct into depres sive affect

S igmund F reud J ohn

Object los s

Dis ruption of an attachment bond

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(1960) E dward B ibring (1953)

S elf-es teem

Helples sness in attaining goals of ego ideal

Aaron B eck (1967)

C ognitive

Negative cognitive schemata as intermediary between remote and proximate caus es

Martin S eligman (1975)

Learned helpless nes s

B elief that one's res ponses will not bring relief from undes irable events

P eter Lewins ohn (1974)

R einforcement

Low rate of reinforcement, or reinforcement presented noncontingently; social deficits preclude

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res ponding to potentially rewarding events J oseph S childkraut (1965) William B unney and J ohn Davis (1965) Alec C oppen (1968) I. P . Lapin and F. (1969) J anows ky al. (1972) Arthur P range et (1974) S iever and K enneth Davis

B iogenic amine (neurochemical)

Impairment or dysregulation of aminergic transmis sion

B ernard C arroll et (1981)

 

Impaired glucocorticoid and mineralocorticoid receptors (neuroendocrine)

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Alec and D. M. S haw P eter Whybrow and J oseph Mendels (1968) R obert P os t (1990)

Neurophysiological E lectrophysiologica disturbances leading to hyperexcitability and/or kindling

Hagop Akiskal and William McK inney (1973) F rederick G oodwin and K ay J amison (1990)

F inal common pathway

S tres s-diathesis interaction converging on midbrain mechanisms of reward and biological rhythms

aDates

provided for the models refer to the original pape they first appeared. In some ins tances , the bibliography section provides references reflecting more updated thin 1461 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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Updated from Akiskal H, McK inney W : Overview of rece depres sion: integration of 10 conceptual models into a c frame. Arch G e n P s ychiatry. 1975;32:285.

T he formative influence of early experience as it is dynamically s haped by emerging mental structures development is the common denominator for the ps ychoanalytic concepts of ps ychopathological phenomena. B y contrast, behavioral approaches in more traditional formulations focus on the pathogenetic impact of proximate contexts. T he cognitive which are akin to the behavioral–pathogenetic tradition, nonetheless concede that negative styles of thinking might mediate between proximate stress ors and more remote experiences. In explaining the origin of mood disorders , all three s chools —ps ychoanalytic, and cognitive—emphasize psychological cons tructs. biological models , however, are concerned with the s omatic mechanis ms that underlie or predis pos e individuals to morbid affective experiences . T he s chism between psychological and biological is an ins tance of the mind–body dichotomy that has characterized the Wes tern intellectual tradition s ince Des cartes. After all, ps ychological and somatic represent merely convenient inves tigational strategies that attempt to bypas s the methodological gulf between 1462 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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mental and neural structures. T he ultimate aim is to unders tand how mood disorders develop within the ps ychoneural framework of a given person.

Aggres s ion-Turned-Inward Model S igmund F reud was initially interested in a project for all mental phenomena. Limitations of the sciences of the day led him to adopt instead a model relied on a concept of mental function borrowed from phys ics . T he notion that depres sed affect is derived retroflexion of aggres sive impuls es directed against an ambivalently loved internalized object was actually formulated by his B erlin dis ciple K arl Abraham and elaborated by F reud. Abraham and F reud that turned-in anger was intended as punis hment for love object that had thwarted the depres sed patient's need for dependency and love. B ecaus e, in an attempt prevent the traumatic los s, the object had already been internalized, the patient then became the target of his her own thanatotic impuls es. A central element in those ps ychic operations was the depress ed patient's ambivalence toward the object, which was perceived frus trating parent. Aggres sion directed at a loved object (parent) was therefore attended by considerable guilt. the extreme, s uch ambivalence, guilt, and retroflexed anger could lead to s uicidal behavior. According to this model, depress ion is an of the transduction of thanatotic energy, a reaction that takes place in the closed hydraulic s pace of the mind. F reud's earlier writings had s imilarly portrayed anxiety being derived from the transformation of dammed-up sexual libido. Although F reud envisioned that 1463 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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ps ychoanalytic cons tructs would one day be localized neuroanatomically, the hydraulic mind is a metaphor does not refer to actual physiochemical s pace in the T he conceptualization of emotional behavior as an of incompatible forces confined to a ps yche that is relatively impervious to current influences outs ide the organism is the major liability of the aggres sion-turnedinward model and, perhaps, of orthodox its elf. Although the s exual energy trans duction of anxiety has been dis carded in modern thought, in modified vers ion, the aggres sion-turnedinward model continues to be used in clinical conceptualization today. T he lingering popularity of the model may be due, in part, to its compatibility with the clinical observation that many depress ed patients P.1566 suffer from lack of as sertion and outwardly directed aggres siveness . However, a s ubs tantial number of depres sed patients are als o encountered in clinical practice (indeed “depres sion with anger attacks ” has recently des cribed), and clinical improvement in mos t patients typically leads to decreas ed, not increas ed, hostility. S uch observations s hed doubt on the turned-inward mechanism as a univers al explanation depres sive behavior. F inally, little evidence exists to support the contention that outward express ion of has therapeutic value in clinical depres sion. Outwardly directed hos tility in depress ion is not a new clinical observation; in fact, G reco-R oman phys icians noted it. Hos tility is best cons idered a manifestation than a cause of depres sive dis order, es pecially when 1464 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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disorder is attended by mixed bipolar features. T he hostility of the depress ed patient can als o be as an exaggerated reaction to frustrating love objects , secondary to self-referential attribution, or simply as nonspecific irritability of an ego in affective turmoil; this could, in part, be a function of a concurrent pers onality disorder from the erratic clus ter. S uch common-sens e explanations that do not invoke unobs ervable hydraulic transmutations have greater appeal from heuristic and clinical perspectives.

Objec t L os s and Depres s ion O bje ct los s refers to traumatic s eparation from objects of attachment. E go-ps ychological of the Abraham–F reud conceptualization of depress ion have paid greater attention to the impact of such loss es the ego, deemphas izing the id-libidinal and related hydraulic as pects . T he depress ant impact of separation events often resides in their symbolic meaning for a person rather than in any arbitrary objective weight that the event may have for clinical raters . However, love bereavement, and other exits from the social s cene, as defined by the London ps ychiatris t E ugene P aykel, are presently the concepts most commonly us ed in and res earch. Although love melancholy had been des cribed since antiquity, the two affective s tates were s ys tematically compared for the first time in F reud's 1917 paper on mourning and melancholia. According to current data, transition from grief to pathological depress ion occurs no more than 10 percent of adults and 20 percent of children. T hes e figures s ugges t that such transition 1465 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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largely in persons predisposed to mood disorders . J ohn B owlby of the T avistock C linic, London, did a comprehensive clinical investigation of the attachment that the child es tablis hes with the mother or mother subs titutes during development, a bond P.1567 cons idered the prototype for all s ubs equent bonds with other objects . Like many psychoanalytic explanations adult s ymptom-formation, the object los s model is formulated as a two-step hypothesis , cons is ting of breaks in affectional bonds , which provide the predis pos ition to depres sion, and adult loss es, which said to revive the traumatic childhood loss and so precipitate depres sive episodes. However, the role of proximate separations in provoking depres sive res ts on more s olid clinical evidence than the hypothes ized s ens itization resulting from object loss . T hat realization has led B owlby to regard childhood s ens itization resulting from early deprivation a generic characterological vulnerability to a host of ps ychopathological conditions . C ompared with aggress ion turned inward, object loss is more directly relevant to clinical depress ion, yet it is s till pertinent to question whether it is an etiological factor. S tudies at the W is consin P rimate C enter have that optimal homeos tas is with the environment is most readily achieved when the individual is s ecurely to significant others , and the diss olution of such ties appears relevant to the emergence of a broad range of ps ychopathological disturbances rather than per se. A related methodological question is whether 1466 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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object loss operates independently of other etiological factors . F or instance, a history of early breaks in attachment may reflect the fact that one or both of the patient's parents had mood dis order, with res ultant separation, divorce, suicide, and so forth. On balance, the ego-ps ychological object loss model is conceptually s uperior to its id-ps ychological In pos tulating an open s ys tem of exchange between a person and the environment, the model permits cons ideration of etiological factors other than such as heredity, character s tructure, and adequacy of social s upport—all of which might modulate the depres sant impact of adult s eparation events. C onceptualizing the origin of depres sion along those is in the mains tream of current ideas of adaptation, homeostasis , and diseas e. An important treatment implication is the value of social s upport in preventing relaps e and mitigating chronicity of depres sion. T hat is , indeed, an ingredient in the interpersonal of depres sion, which can be conceptualized as a form brief, focused, and practical ps ychodynamic therapy.

L os s of S elf-E s teem and Depres s ion R eformulation of the dynamics of depress ion in terms the ego s uffering a collaps e of self-es teem repres ents further conceptual break with the original idformulation; depres sion is said to originate from the inability to give up unattainable goals and ideals. T he model further posits that the narciss is tic injury that crushes the depress ed patient's s elf-es teem is the internalized values of the ego rather than the press ure of retroflected thanatotic energy deriving from 1467 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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the id. B ecause the cons truct of the ego is rooted in and cultural reality, los s of self-es teem may res ult from symbolic los ses involving power, s tatus, roles, identity, values, and purpose for exis tence. T hus, the exis tential sociocultural implications of depres sion conceived as a derivative ego s tate provide the clinician with a far flexible and pragmatic tool for unders tanding persons than the archaic hydraulic metaphors related libidinal viciss itudes . T hat model represents one of the attempts to formulate depress ion in terms that subs equent psychological theory and res earch could operationalize in more testable form. S elf-es teem is part of the habitual core of the individual and, hence, is integral to the pers onality s tructure. low self-es teem conceived as a trait is a major defining attribute of the depress ive (melancholic) personality. Although it is understandable that such individuals can easily s ink into melancholia in the face of advers ity, it is not obvious why pers ons with apparently high s elf-es teem (e.g., thos e with hypomanic and narcis sistic pers onalities) als o s uccumb to melancholy relative ease. T o explain s uch cases, one mus t invoke underlying instability in the system of s elf-es teem that renders it vulnerable to depres sion. T he oppos ite is known to occur; that is , manic epis odes may develop a baseline of low s elf-es teem, as in the case of bipolar disorder patients with antecedent traits of s hynes s, insecurity, and dys thymia. T he foregoing cons iderations suggest that the of s elf-es teem deemed central to the model of as loss of s elf-es teem are manifes tations of a more fundamental mood dysregulation. In class ic 1468 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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ps ychoanalys is, such dys regulation is considered to be cons titutional origin. In general, attempts by ps ychoanalytic writers to account for bipolar have not progress ed beyond metaps ychological jargon, with the notable exception of denial of painful affects as mechanism in the phenomenology of mania.

C ognitive Model T he cognitive model, developed by Aaron B eck at the Univers ity of P enns ylvania, hypothes izes that thinking along negative lines (e.g., thinking that one is helples s, unworthy, or useles s) is the hallmark of clinical In effect, depress ion is redefined in terms of a cognitive triad, according to which patients think of thems elves helpless , interpret most events unfavorably vis -à-vis self, and believe the future to be hopeless . In more formulations in academic psychology, thes e cognitions said to be characterized by a negative attributional that is global, internal, and s table and that exis ts in the form of latent mental schemata that generate bias ed interpretations of life events . B ecaus e the cognitive model is based on retrospective observations of already depres sed pers ons, it is impos sible to prove that caus al attributions s uch as negative mental schemata precede and, therefore, predis pos e to clinical depres sion; they can just as be regarded as subclinical manifes tations of T he theoretical importance of the cognitive model lies the conceptual bridge it provides between egops ychological and behavioral models of depres sion. It also led to a new and widely accepted s ys tem of ps ychotherapy that attempts to alter the negative 1469 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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attributional s tyle, to alleviate the depress ive s tate, ultimately, to fortify the patient against future lapses negative thinking, despair, and depress ion. T he cognitive model, therefore, has the cardinal virtue focus ing on key revers ible clinical dimens ions of depres sive illnes s, s uch as helpless ness , suicidal ideation, while providing a testable and ps ychotherapeutic approach. T hat approach, however, less likely to succeed in patients with the full-blown melancholic manifes tations of a depres sive dis order. It doubtful that negative cognitions alone could account the profound disturbances in sleep, appetite, and autonomic and ps ychomotor functions encountered in melancholic depres sions . F urthermore, conceptualizing multifaceted malady s uch as depres sion largely or a function of distorted cognitive proces ses is of pre-E squirolian notions that emphasized impaired reasoning in the development of depress ion. F inally, recent extensions or modifications , or both, of cognitive therapy in as sociation with behavioral therapy behavioral therapy) for all emotional dis orders (and for schizophrenia) are reminiscent of earlier global of the ps ychodynamic pers pective.

L earned Helples s nes s Model T he learned helpless nes s model is, in s ome ways, an experimental analog of the cognitive model. T he model propos es that the depress ive posture is learned from situations in which the pers on was unable to terminate undes irable contingencies . T he model is bas ed on experiments in dogs that were prevented from taking adaptive action to avoid unpleasant electrical shock 1470 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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subs equently, s howed no motivation P.1568 to escape such aversive stimuli, even when es cape avenues were readily available. Armed with evidence many such experiments , Univers ity of P enns ylvania ps ychologist Martin S eligman pos tulated a trait of helpless nes s (a belief that it is futile to initiate personal action to reverse aversive circumstances) formed from cumulation of past epis odes of uncontrollable helpless nes s. T he learned helpless nes s paradigm is a general one refers to a broader mental dis position than depres sion. T hus, it is potentially useful in unders tanding such conditions as s ocial powerles sness , defeat in s porting events, and posttraumatic s tres s dis order (P T S D). In addition, pas t events might s hape a characterological clus ter, consis ting of pas sivity, lack of hostility, and blame, relevant to certain depres sive phenomena. T he hostility observed in s ome patients during clinical depres sion could, for instance, be as cribed to the operation of s uch factors . Learned helpless nes s could thereby provide plaus ible links between as pects of personal biography and clinical phenomenology in depres sive dis orders. T herapeutic predictions for alleviating depress ion and related ps ychopathological states capitalize on new cognitive s trategies geared to modifying expectations of uncontrollability and the negative attributional s tyle. T his illustrates how ins ights gained from experimental paradigms can be combined fruitfully to address clinical disorders . Nonetheles s, the clinician should be wary of 1471 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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clinical extrapolations. F or example, s ome therapis ts argued that the depress ed patient's pass ivity is “manipulative,” serving to obtain interpersonal rewards . has also been s uggested that s uch factors have a influence on the development of the depress ive T hat interpretation appears more relevant to s elected as pects of depres sion than to the totality of the Depress ive behavior and verbalizations clearly have a powerful interpers onal impact, but cas ting depres sion merely a mas ochis tic lifes tyle developed to s ecure interpersonal advantages represents a mechanistic argument that could be viewed as dis respectful of the clinical agony of patients with mood disorders . F inally, although mos t formulations focusing on helples sness emphasized acquis ition through learning, recent experimental res earch in animals tends to implicate genetic factors in the vulnerability of learning to behave helpless ly. T he value of the helples sness paradigm res ide in its utility to predict a variety of subthres hold affective dis turbances generic to civilian reactions to advers ity and trauma.

Depres s ion and R einforc ement Other behavioral inves tigators , including, notably, ps ychologist P eter Lewins ohn, have developed clinical formulations of depres sion that hinge on certain deficits reinforcement mechanis ms . According to the reinforcement model, depress ive behavior is with lack of appropriate rewards and, more s pecifically, with receipt of noncontingent rewards . T he model identifies s everal contributory mechanis ms . S ome environments may cons is tently deprive persons of rewarding opportunities, thereby placing them in a 1472 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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chronic s tate of boredom, pleasureless nes s, and, ultimately, des pair. T hat reasoning, however, may offer more insight into social mis ery than clinical depres sion. more plaus ible postulated mechanism is the provision rewards that are not in res ponse to the recipient's in other words , the gratis provis ion of what a person cons iders undes erved rewards may lead to lowering of self-es teem. P redis pos ition to depres sion is formulated terms of inadequate s ocial skills, which are to decreas e a pers on's chances of res ponding to potentially rewarding contingencies in the environment. Indeed, recent research on the relationship between personality and depress ion sugges ts that such deficits might underlie certain depres sive states. T herefore, ps ychotherapeutic approaches designed to enlarge a patient's repertoire of social s kills may prove valuable preventing some types of depres sion. T he concepts of depress ion that have been derived behavioral methodology and developed in the pas t decades are s cientifically articulate and, therefore, approaches to clinical depres sion. However, the distinction between depres sion on s elf-report and clinical depres sion tends to be overlooked in inves tigations tes ting the reinforcement paradigm. F urthermore, the behavioral model does not addres s distinct pos sibility that reinforcement deficits may, in represent the ps ychomotor deficits of depress ive Nevertheles s, by focusing on reward mechanisms, the behavioral model provides a conceptual bridge purely ps ychological and emerging biological conceptualizations of depres sion.

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B iogenic Amine Imbalanc e F ormulation of sophis ticated biological explanations of mood disorders had to await development of neurobiological techniques that could probe the parts the brain involved in emotions . Although the complex phys iology of the limbic-diencephalic centers of behavior generally cannot be directly obs erved in much has been learned from animal work. T he limbic cortex is linked with both the neocortex, which higher s ymbolic functions, and the midbrain and lower brain centers, which are involved in autonomic control, hormonal production, and sleep and wakefulness . Norepinephrine-containing neurons are involved in functions that are profoundly disturbed in melancholia, including mood, arousal, appetite, reward, and drives. Other biogenic amine neurotrans mitters that mediate such functions are the catecholamine dopamine— es pecially important for drive, pleasure, s ex, and ps ychomotor activity—and the indoleamine serotonin, which is involved in the regulatory control of affects , aggres sion, s leep, and appetite. C holinergic neurons, secreting acetylcholine at their dendritic terminals , are generally antagonis tic in function to catecholaminergic neurons . Although the opioid system might, on experimental and theoretical grounds, als o s erve as one of the neurochemical s ubs trates for mood regulation, in the author's opinion, no cogent model of mood disorders involving that s ys tem has appeared to date. Likewis e, biochemical formulations of mood disorders have paid relatively little attention to the major excitatory brain neurotransmitter glutamate and the inhibitory 1474 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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neurotransmitter γ-aminobutyric acid (G AB A).

B iogenic A mine Hypothes es J oseph S childkraut at Harvard University and W illiam B unney and J ohn Davis at NIMH published the first hypothes is connecting depletion or imbalance of amines (s pecifically norepinephrine) and clinical depres sion. T he s erotonin counterpart of the model emphasized in the models propos ed by Alec C oppen in E ngland and I. P . Lapin and G . F . Oxenkrug in R uss ia. catecholamine and indoleamine hypothes es were es sentially based on two sets of pharmacological observations . F irst, reserpine (S erpasil), which blood pres sure by depleting biogenic amine s tores, precipitates clinical depres sion in s ome patients. antidepres sant medications , which alleviate clinical depres sion, rais e the functional capacity of the amines in the brain. T his s tyle of thinking is known as pharmacological bridge , extrapolating from evidence the mechanis m of drug action to the neurotrans mitter pathologies pres umed to underlie a given psychiatric disorder. S uch pharmacological strategies have been heuris tic value in developing research methods for inves tigation of mood dis orders and s chizophrenia. Indeed, the res earch methodology developed by the relatively few investigators working in this area during past half century is among the most elegant in the of psychiatry. P.1569 V ariations of the biogenic amine model as sign different relative weights to the biogenic amines 1475 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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norepinephrine and serotonin in the development of pathological mood s tates. Arthur P range and the Univers ity of North C arolina formulated a biogenic amine hypothesis in which s erotonin deficits permit expres sion of catecholamine-mediated or manic states. T hat hypothesis was s upported by subs equent animal res earch showing that an intact serotonin system is necess ary for optimal functioning noradrenergic neurons. Omis sion of tryptophan from diet of antidepres sant-res ponsive depress ed patients annul the efficacy of the antidepres sant; among healthy volunteers , that s pecial diet also induces sleep electroencephalographic characteristics of clinical depres sion. Although s uch findings are provocative, precurs or-loading s trategy to increase the brain s tores serotonin (e.g., with L-tryptophan) has not been unequivocally s ucces sful in revers ing clinical Dietary loading with catecholamine precursors has even worse than serotonin-precurs or loading in the treatment of depres sion. T he cholinergic-noradrenergic imbalance hypothesis propos ed by David J anowsky and colleagues yet another attempt to elucidate the roles of biogenic amines. T his hypothes is, along with the related supers ens itivity hypothesis developed by J . C hris tian has been tes ted extensively at the Univers ity of at S an Diego. S ubs equent formulations by Larry S iever K enneth Davis at the Mount S inai Hos pital in New Y ork have refocus ed on noradrenergic dys regulation. T he model as sumes os cillation from one output mode to the other at different phases of depres sive illness . In a provocative extrapolation from that model, bipolar 1476 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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depres sion would have low noradrenergic output, but many ins tances of major depres sive disorder, as with anxiety dis orders, could be biochemically as high-output conditions . Des pite more than four decades of extens ive res earch indirect evidence, however, no deficiency or excess of biogenic amines in specific brain s tructures has been shown to be neces sary or sufficient for the occurrence mood dis orders. It has not been poss ible to either the putative role of central norepinephrine in or to discard it altogether. T he role of dopamine as formulated, among others, by the Italian G ian Luigi C es sa, although s tudied les s extensively that of norepinephrine, des erves greater recognition, may have relevance to atypical and bipolar depress ion well as to mania. P reliminary data from a small brain imaging study has shown blunted s erotonin res pons ivity in prefrontal and temporoparietal areas in unmedicated patients with depres sive dis order. S uch data, cons idered in the of the overall s erotonin literature in depres sion, is provocative but not conclus ive and s erves to illus trate fact that the cas e for serotonergic disturbance in depres sion continues to be bas ed on indirect evidence. Moreover, the putative permis sive role of s erotonin is better documented for aggress ive s uicide attempts. S erotonergic dysfunction might s ubserve other characterized by lack of inhibitory control, among them, obses sive-compuls ive disorder (OC D), panic disorders, bulimia nervosa, certain forms of ins omnia, alcoholism (alcohol abus e or dependence), and a hos t of impulseridden personality dis orders. S uch considerations have 1477 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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Dutch psychiatris t Herman van P raag and colleagues postulate a dimensional neurochemical dis turbance generic to a large group of dis orders within the nosology. T his hypothes is might be variously regarded challenge to psychiatric nos ology or as a statement of need to supplement clinical class ification with parameters . B oth interpretations are in line with clinical observations during the pas t two decades tes tifying to high prevalence of comorbidity in depress ive, other emotional disorders , and certain impulse-control disorders . It is implied that the foregoing pos tulated biochemical faults are genetically determined. Although biogenic amine models of mood dis orders were developed retrospectively from the pharmacological action of antidepres sant and thymoleptic agents , they have stimulated development of new clas ses of with more s elective action on s pecific neurotrans mitter receptors. T heir introduction has virtually revolutionized the treatment of depres sion. Y et the fundamental biochemistry of mood disorders is s till far from being unders tood. C urious ly, although s elective in action, the new compounds working on the serotonin s ys tem have broad effectiveness in a variety of mood-related conditions, such as dys thymic disorder, P T S D, OC D, disorder, s ocial phobia, bulimia nervosa, and borderline personality dis order. S uch data indirectly favor the hypothes is of an underlying biological commonality to several of these dis orders. T he foregoing have, in turn, led to a provocative formulation of an increasingly prevalent “social s yndrome” in populations experiencing social disruption, immigration, and abus e 1478 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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and characterized by anxiety, depress ion, violenceproneness , impulsivity, and s uicidality—reflecting a perturbed s erotonin system, the oldest, mos t basic structure involved in human s ocialization and coping with s tres s, danger, and s urvival. New antidepres sants with dual action on both serotonergic and noradrenergic receptors and data on their poss ible greater efficacy in melancholic depres sions do s ugges t that the biochemistry of mood disorders involves more complex dys regulation than is implied in s ingle-neurotransmitter hypothes es . T he of G eorge Henninger and colleagues at Y ale Univers ity further s ugges ts that monoamines better explain how antidepres sants facilitate recovery from depres sion being the fundamental caus es of depres sion. emerging biochemical paradigms are moving away distal biochemical lesions to focus on molecular perturbations closes t to the putative genetic underpinnings of mood disorders . Originally tied to the mechanism of action of mood stabilizers in bipolar disorder, s uch work is exploring second mess enger systems , phos phorylation G proteins , s ignal deoxyribonucleic acid (DNA) transcription, and ribonucleic acid (R NA) translation. Again, s uch search molecular mechanisms repres ents “backward logic” the putative mechanis m of action of selected agents . T he s ame can be s aid about F rederick P etty's G AB Aergic and S hih-J en T s ai's brain-derived factor (B DNF ) hypothesis in the origin of bipolar

Neuroendoc rine L inks F unctionally inadequate mobilization of 1479 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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in the face of continued or repeated stress , as indirectly reflected in pathological modification of noradrenergic and s erotonergic receptor function, could repres ent neurochemical final common pathways of homeos tatic failure. S uch mechanisms could also provide links with ps ychoendocrine dysfunction; the hypothes ized neurotransmitter deficits may underlie the dis inhibition the hypothalamic-pituitary-adrenal axis , characterized steroidal overproduction, the most widely s tudied endocrine dis turbance in depres sive illnes s. W hen challenged with dexamethas one (Decadron), the axis res ists s uppress ion, thereby offering B ernard team (then at the Univers ity of Michigan) the poss ibility developing the dexamethas one suppres sion for melancholia. P resently, this procedure is of specificity for depres sive illnes s, and, thus , is serve as a diagnostic tes t. However, that line of has been useful in pathogenetic unders tanding. F or instance, it led to the demonstration by the E mory Univers ity's C harles Nemeroff of increas ed of corticotropin-releas ing factor (C R F ) in the fluid (C S F ) of patients with major depres sive dis order. also P.1570 appears relevant to the pathophys iology of anxiety disorders , such as panic dis order, and P T S D. T he of F lorian Holsboer's group at Munich's Max P lanck Ins titute has shown impaired glucocorticoid and mineralocorticoid receptor function in thes e disorders , with relevant pathophysiological and therapeutic implications. 1480 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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Another neuroendocrine index of noradrenergic dysregulation, blunted growth hormone respons e to the α2 -adrenergic receptor agonis t clonidine (C atapres ) likewise points to limbic-diencephalic disturbance. However, s tudies performed in the United S tates that it is pos itive in both endogenous depress ion and severe anxiety dis order (panic dis order). T hyroidstimulating hormone (T S H) blunting upon thyrotropin stimulation, another common neuroendocrine in depress ion, also shows limited s pecificity. What is remarkable, however, is that the DS T , and thyrotropin challenge data, in aggregate, identify most pers ons with clinical depres sion. S uch evidence midbrain dis turbance argues for considering clinical depres sion to be a legitimate disease. T he disease of depres sion is further buttres sed by computed tomography (C T ) s cans showing enlarged pituitary and adrenal glands , a state marker of depress ive illness .

S tres s and Depres s ion T he concept of a pharmacological bridge implies twotraffic. T he hypothes ized chemical aberrations may be primary or genetically based. P rovis ion should also be made, however, for the likelihood that psychological events that precipitate clinical depress ion might initiate exacerbate neurochemical imbalance in vulnerable subjects . T hat s uggestion is supported by s tudies in animals in which early separation from peers and inescapable frustration effect profound alterations in turnover of biogenic amines and in posts ynaptic sens itivity. T hus , in genetically predisposed persons, environmental s tres sors might more easily lead to 1481 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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perturbations of limbic-diencephalic neurotrans mitter balance. F inally, in vulnerable individuals , especially the formative years of childhood, psychological mechanisms might more easily perturb midbrain neurochemis try. T raumatic experiences appear potent in this regard. T he hippocampus has been the subject of intense recent res earch as the poss ible anatomical s ubs trate linking s uch loss and trauma to depres sion. Ongoing ingenious experimental primates and rodents continue to explore the role of experience and s tres s in s ubs equent depress ive-like behaviors in thes e animals . In humans , a new finding indicates that a polymorphism of the s erotonin transporter gene would identify who among children would develop adult depress ion. Likewis e, a polymorphis m of the monoamine oxidase (MAO) A plays a significant role in determining who among battered children will grow into an adult sociopath. models of mania are sparse and problematic.

Neurophys iologic al Approac hes Neuronal Hyperexc itability Lithium is known to replace intracellular s odium and hyperpolarize the neuronal membrane, thereby decreasing neuronal excitability. Abnormalities in electrolyte balance (an exces s of res idual s odium, by radioisotope techniques ) and hypothes ized neurophys iological disturbances were the focus of inves tigations by Alec C oppen and colleagues in the 1960s . T he exis ting data appear compatible with the hypothes ized movement of exces s sodium into the during an epis ode of mood disorder and redis tribution 1482 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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toward the preillnes s electrolyte balance acros s the neuronal membrane during recovery. Intraneuronal sodium leakage is pos tulated in both depress ive and manic disorders but deemed more extreme in the B ecaus e the harmonious activity of the neuronal cell by implication, that of a group of neurons depends on electrical gradient maintained across its membrane by differential distribution of s odium, abnormalities in concentrations and trans port are hypothetically to the production of an unstable state of neurophys iological hyperexcitability. In formulating their thesis of neurophys iological arousal in melancholic J oseph Mendels and P eter W hybrow (both of whom worked at the Univers ity of P enns ylvania) have on the foregoing electrolyte dis turbances. T he view that mania repres ents a more extreme electrophysiological dysfunction in the s ame direction as depres sion the common-sens e notion of s ymptomatological “oppos ition” between the two kinds of dis order, yet, it may, in part, account for the exis tence of mixed s tates which s ymptoms of depress ion and mania coexist. T he NIMH team led by F rederick G oodwin firs t s howed that subs tantial minority of depres sed patients with a subs trate respond to lithium salts , which further the concept of a neurophysiological common denominator to mania and depres sion. P erturbations of calcium metabolis m als o appear relevant to bipolar patients. T herapeutic implications of this observation the us e of calcium channel inhibitors in bipolar I have not yielded consistent res ults. F inally, rubidium, another alkali metal, has been explored in the phase of bipolar dis orders , again with inconclusive 1483 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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R hythmopathy E uropean studies have shown that depress ed patients phase advanced in many biological rhythms, including latency to the first rapid eye movement (R E M) in sleep. S hortened R E M latency, which has been extensively studied by David K upfer and colleagues at the of P itts burgh, has been propos ed as another laboratory “tes t” for depress ive disorder. S hortened R E M latency serve as a trait marker for depress ion, because it has found in dysthymia and so-called borderline well as among the clinically “well” offspring of adults major depress ion. F ormulations of circadian rhythms by T homas Wehr Norman R os enthal, working at NIMH, have focused on abnormalities on brain regulation of temperature, and s leep cycles . Others have investigated the role of pineal hormone melatonin in mood dis orders , without achieving cons is tent res ults. T he application of rhythm res earch concepts to women with mood has also led to imaginative methods , but, again, definitive characterization of the neurophysiologic At a bas ic level, instrumental R E M s leep deprivation in neonates has been recently s hown to lead to adult “depres sion-like” behaviors in rats . In human s tudies, deprivation and exposure to bright white light has been shown to correct phase dis turbances and thereby terminate depress ive episodes , es pecially in subjects periodic and seasonal depress ions. It has even been that the average citizen is light deprived, and that phototherapy can benefit even thos e without clear-cut seas onal patterns . Unfortunately, except for their us e in 1484 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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mild seasonal depress ions and s uppres sion of sleep deprivation to prevent hypomania in bipolar dis order, foregoing circadian s tudies have not had a palpable impact on practice. T heir application in the large of mood-disordered patients remains cumbersome, if elusive. T heir impact can be better ass es sed at the theory. Although the specificity and efficacy of these neurophys iological indices and manipulations for depres sion and bipolar disorder require more extensive res earch, cumulatively, they point to midbrain dysregulation as the likely common neurophys iological subs trate of affective disorders . T he foregoing cons iderations further suggest that the ancient G reeks , who P.1571 as cribed melancholia to malignant geophys ical did not indulge in mere poetic metaphor. T he ancients observed the dis turbed circadian patterns and their readjustment to res tore euthymia.

A ffec tive Dys regulation A major challenge for research in mood disorders is to characterize the basic molecular mechanisms that the neurophys iological rhythmopathies, which, in turn, might account for the recurrent nature of the affective pathology as envis ioned by K raepelin. T his means that the most typical recurrent forms of the disorders , the cons titutional foundations (manifes ted as cyclothymic dysthymic traits and/or a broad range of emotional disequilibrium covered by the rubric of “neuroticism”) so unstable that the illness may run its entire course 1485 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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or les s autonomously, with the environment largely serving to turn on and off the more florid phas es (episodes ). P arisian psychiatrist J ean Delay, a pioneer ps ychopharmacology in the 1950s , has also affective dysregulation as the fundamental pathology in the spectrum of mood dis orders. R obert P ost (at NIMH) hypothes ized that the electrophys iological substrates could be so kindled that an oligoepisodic dis order triggered by environmental s tres sors could as sume an autonomous and polyepisodic course. He hypothes izes that this phenomenon might occur because neuronal perturbations brought about by stress ors in the early cours e of mood disorders get incorporated into the T his fascinating kindling hypothesis, however, does not seem to pertain to garden-variety mood dis orders, but those with extreme cyclicity. T he monograph on manicdepres sive illnes s by F red G oodwin and K ay J amison presents in-depth arguments for this cyclical paradigm thymopathy.

THE OR E TIC A L S YNTHE S IS Pathophys iologic al Unders tanding Modern ps ychobiology attempts to link experience and behavior to the central nervous s ys tem (C NS ). B uilding conceptual bridges between the ps ychological and biological approaches to mood dis orders requires sophisticated s trategies that go beyond the C artesian notion of limited mind–body interactions through the pineal gland and the generalizations of the Meyerian school. In collaboration with W illiam McK inney in 1973, the 1486 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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developed the conceptual framework that considers the affective syndromes as the final common pathway of various psychological and biological proces ses . T he overarching hypothes is is that ps ychological and biological etiological factors converge in reversible in the diencephalic substrates of pleasure and reward. T hose areas of the brain s ubs erve the functions that disturbed in melancholia and mania. T he integrative model links the central chemistry and phys iology of reward mechanis ms with the object los s and behavioral models of depres sion, both of which give s ingular importance to the depress ant role of loss of rewarding interpersonal bonds. A key element of the model is the circadian disturbances observed since ancient times in both depres sive and manic s yndromes. B oth are conceptualized as clinical manifestations of a disordered limbic s ys tem with its subcortical and prefrontal extensions . T he brain imaging s tudies in melancholic patients by W ayne Drevets , originally at Was hington Univers ity, have visualized limbic extending into s ubcortical structures and occurring primarily in thos e with a familial diathesis for the amygdala appears to be the focal limbic s tructure in the latter s tudies . C linical experience and res earch suggest that multiple factors described below converge produce or exacerbate dys regulation in these brain regions, leading to the final common pathway of clinical depres sion. T he data on mania are more tentative and be mentioned when relevant.

Heredity C urrent evidence indicates a significant genetic role in caus ation of bipolar and recurrent major depress ive 1487 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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disorders . Although it is not known exactly what is inherited, and biological endophenotypes have not delineated, temperamental dysregulation might be hypothes ized to fulfill the role of a behavioral endophenotype. T he depres sive inheritance may into impaired coping under s tres s (neuroticism), and bipolar inheritance might translate into affective dysregulation (cyclothymia), involving over- and underreactivity to life s ituations, circadian events , and biological s tres sors. W hatever the precise nature of the inherited fault or excess , current res earch s uggests heritability involves a broad spectrum of dis orders, including milder affective states , as well as inclinations . R ecent findings, both from clinical and genetic investigations , have emphas ized the of broad affective phenotypes that incorporate panic anxiety reactivity within both traditional unipolar and bipolar disorders . F or ins tance, the affective underlying bipolar disorder can manifes t in euphoria, irritability, depress ion, panic attacks, and social S uch tendencies are observed among both patients their first-degree relatives. G enetic heterogeneity is and may involve inheritance of a single dominant gene with variable penetrance in some families or s pecific subtypes , or oligogenic inheritance in the majority of cases. Different genetic mechanisms will, in all involve more than one disorder (e.g., depress ion and generalized anxiety; bipolar I disorder, psychosis, abuse, and dipsomania; bipolar II dis order, panic and bulimia nervosa). Another dis tinct poss ibility is that some forms of s chizophrenia, bipolar I and II dis orders , recurrent depres sions lie on an oligogenic bipolar spectrum. A polymorphis m involving the s hort alleles of 1488 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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the serotonin trans porter gene appears relevant to depres sive dispositions. T he genetic mechanis m mood reactivity and panic appear to be subserved by chromosome 18q. T he partial overlap of manic and schizophrenic phenomenology might be related to a polymorphis m in the G R K 3 s ys tem.

Developmental P redis pos ition P arents with mood disorders are often in conflict, which may lead to separation, divorce, and s uicide. It can be that heredity often determines the type of environment into which the child predisposed to mood disorder is Developmental object loss , although not s pecifically involved in caus ing mood disorder, might modify the expres sion of the illness , pos sibly by leading to earlieronset, more s evere epis odes , and an increased of pers onality disorder and s uicide attempts. T he transporter polymorphis m mentioned above appears to mediate the relations hip between early trauma and depres sion. Likewis e, this polymorphism appears to neuroticism and suicide attempts .

Temperament S ince ancient times , persons prone to mania and melancholia have been des cribed as poss es sing temperamental attributes, representing variations on theme of what today is subsumed under cyclothymic, dysthymic, and anxious -inhibited temperaments, as the traits of high neuroticis m describing emotionality. Many monozygotic twins discordant for full-blown mood disorders studied by Aks el B ertelsen's Danish res earch team exhibited affective instability with temperamental 1489 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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moodines s, which s trongly sugges ts that such are genetically determined. R esearch conducted by K endler's team at the Medical C ollege of V irginia suggests that s everal of the temperamental attributes P.1572 might be trans mitted as part of the genetic liability to mood dis orders. T he author's res earch has identified temperaments in the prepubertal offspring of parents bipolar I disorders , s uggesting that they precede by to decades the overt ons et of major mood disorder episodes . T he high express ed emotion atmos phere the negative critical remarks by relatives and affectively unstable patients documented in the recent literature on mood dis orders often reflect the interpersonal clashes between patients and their temperamentally intens e relatives . T hus, appear intimately involved in generating much interpersonal friction, emotional arousal, and s leep loss (just to cite common perturbations), thereby eliciting many of the life stress ors that precipitate affective episodes . T he us e of stimulant drugs either to self-treat lethargy or enhance hypomanic traits could further contribute to epis ode precipitation. As for the disposition, the work of Maria K ovacs at the University P ittsburgh has shown that dysthymia in children into major depres sive epis odes postpubertally, of which proportion s witch to bipolar states . T hese data cohere the work of the present author conducted at the of T enness ee, Memphis, s howing s hortened R E M early-onset dys thymic s ubjects. T he familial bipolar diathesis revealed in the T enness ee work, along with 1490 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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tendency to s witch to hypomania, s uggest between depres sive and bipolar II disorders .

L ife E vents Most individuals do not develop clinical depress ion expos ed to environmental adversity. S uch advers ity to play a pathogenic role primarily in those with an affective diathesis . In fact, the work of K endler at the Medical C ollege of V irginia indicates that genetic might underlie the depres sive dis order patients' susceptibility to life events . F urthermore, current data suggest that social stress ors in the ons et of depres sion more relevant to the first few episodes of the illness . evidence linking s uch events to mania is les s At any rate, stress ful events often appear to be by the temperamental ins tability that precedes clinical episodes . Interpersonal los ses are common events in lives of individuals with intens e temperaments . T he arousal and s leep loss as sociated with s uch events precipitate both depres sive and manic states . A recent study by P eter McG uffin's team at the Ins titute P sychiatry, London, rais ed the poss ibility that one mechanism by which heredity produces depress ion is creation of environmental advers ities in the lives of individuals predis pos ed to this illnes s. T his work is now replicated by independent groups of inves tigators . Whatever the origin of environmental adversity, it is common clinical experience that loss represents an important, perhaps even central, theme in clinical depres sion. V ariables that seem to modulate the adult los ses include concurrent life events , res ultant changes in lifestyle, lack of interpersonal support, 1491 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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social s kills , and the s ymbolic meaning of the putative T he res earch program of G eorge B rown and his in London capitalizes on the foregoing considerations, particularly the importance of early and proximate in socioeconomically disadvantaged women who lack supportive relations hips. However, that downplays the degree to which the s ocial context of the depres sion reflects the dys thymic temperamental liabilities of thos e depres sed women. R ecent research indicates that even social s upport is determined to a cons iderable degree by the genetic mechanis ms that underlie mood dis orders. Indeed, the short alleles of serotonin trans porter gene are now implicated in mediating between adverse events and clinical depres sion.

B iologic al S tres s ors Many physical diseases and pharmacological agents known to precede the onset of both depress ive and episodes . Like psychos ocial s tres sors , however, they generally seem to caus e de novo epis odes but them in persons with a pers onal and family his tory of mood dis orders. T hyroid disturbances have a role in practice becaus e they are ass ociated with rapid cycling bipolar patients, especially women; lithium is often contributory to such dis turbances occurring in the depres sions in which bipolar women are not “stuck.”

S ex C linical and epidemiological studies concur in that women are at higher risk for mood disorders , with 1492 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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ris k highes t for depres sion. T his now appears to be, in a function of anxious -depres sive traits represented by neuroticism. T hese traits have strong genetic determinants. W omen have higher concentrations of monamine oxidase (the enzyme that breaks down monamine transmitters) in the brain and more thyroid s tatus. In addition, low estrogen and high proges terone concentrations have been postulated as poss ible mediating factors in pos tpartum depress ions, premenstrual accentuation of affective ins tability, and women's vulnerability to the depres sant effect of contraceptives. F inally, recent data point to the role of es tradiol in depress ions occurring during the trans ition menopaus e. P ers onality factors might also be relevant the sex differences in depress ion. In recent work with University of P is a psychiatrist G iulio P erugi, author has proposed the hypothes is that female sex favor greater express ion of dys thymic attributes , hyperthymic traits appear favored by male sex. T hos e cons iderations tend to parallel, res pectively, the and active cognitive res ponse styles reported by S us an Nolen-Hoeksema, originally at S tanford Univers ity, to distinguish the sexes . W hat s pecific s ex-related biographical factors might interact with s ex-related biological factors to produce s uch trait differences is, at present, largely unknown. An intriguing pos sibility is women, becaus e of temperamental inclination to depres sive cognitions , might react more intens ely to childhood advers ities , as well as be more specifically vulnerable to adult s tres sors related to bonding with and child rearing. R es earch by Mark G eorge and has raised the provocative pos sibility that women overres pond to sad circums tances over a lifetime, 1493 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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permanently altering anterior limbic and prefrontal brain function in a “depres sive” direction. T he high anxious-depres sive conditions in women—most pronounced at the clinical level—might be linked, hypothetically, to an evolutionary adaptive advantage conferred by traits of fear, inhibition, and avoidance to women who bear the res ponsibility of pregnancy and rearing. T he higher prevalence of minor depres sions in women, redis covered in a recent Danish study, are in with the foregoing hypothes is . T he integrative model presented here (F ig. 13.1-3) beyond the general provis ions of the unified approach developed three decades ago. It is submitted that, at in the highly recurrent forms of the malady, affective temperaments represent the intermediary s tage remote (hereditary) and proximate (s tres sful) factors that limbic-diencephalic dysfunction is best as the biological concomitant of the clinical of the affective s yndromes . Like the temperamental dysregulations, thes e biological dis turbances represent putative s tage in the pathogenetic chain. T hey emerge temperamental instabilities that react to, provoke, or life events, substance us e, and alterations in circadian rhythms—which, in turn, appear to usher in the behavioral, emotional, and cognitive manifes tations of illness . It is finally relevant to point out that biological stress ors such as hormonal disturbances and traumatic brain injury appear to compromis e limbic-diencephalic function as their depress ant mechanism.

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FIGUR E 13.1-3 An integrative pathogenetic model mood disorders .

Therapeutic Pers pec tives T he foregoing integrative model mandates the joint use somatic-pharmacological and ps ychos ocial P.1573 interventions . Although the milder forms of mood disorders can be managed with ps ychotherapy, treatments are usually required to reverse the disturbances in melancholia before the patient can res pond to interpers onal feedback. Depress ive with ps ychotic features often necess itate more somatic interventions , such as electroconvuls ive 1495 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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(E C T ). C ontinued psychopharmacological treatment is effective in decreas ing rates of relaps e and future recurrence in mos t. T oday, bipolar disorder, as well as forms of depres sion, are considered lifelong illnes ses needing indefinite maintenance pharmacotherapy. P sychos ocial therapy by s killed clinicians can provide support, combat demoralization, change maladaptive attributions, and improve conjugal and vocational functioning. R ecent fascinating data support the notion that ps ychos ocial interventions such as cognitivebehavioral therapy modulate cortical-limbic function described earlier as the final common pathway of depres sive illnes s. W hether s uch therapy can also personality traits to fortify the patient agains t new episodes is a future res earch challenge. In the author's view, it may prove more profitable to attempt to help patients explore profes sional and object choices that match their temperamental proclivities and as sets, in turn, might provide them greater harmony and adaptation in life. Although much needs to be learned about the indications for medication and ps ychotherapy different s ubtypes of mood disorders , res earch to date only does not support a negative interaction between two forms of treatment, but, on selected parameters, suggests additive and even s ynergis tic interaction. a great need for patients , their families, and clinicians unders tand how a biologically driven illness like depres sion s hould be approached from a pragmatic ps ychotherapeutic pers pective. T he challenge for psychiatric research in the decade is to elucidate the basic mechanisms whereby the predis pos ing, precipitating, and mediating variables 1496 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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reviewed here and others yet to be identified interact to produce the final common path of decompensation in melancholia. B ecaus e of the heterogeneity of conditions pres enting as a ps ychobiological final clinical s yndrome and because antidepress ant agents , irrespective of s pecificity to one or another biogenic amine, are approximately equally effective in two-thirds those with depress ive disorders, the antidepress ant may be acting not on the primary lesions of these disorders but on a neurochemical substrate distal to underlying biological faults. C hoice of antidepres sants still highly determined by the side effect profile least objectionable to a given patient's phys ical s tatus, temperament, and lifestyle. T hat s o many different of antidepress ants —with different mechanis ms of action—have been marketed s ince the 1990s indirect evidence for heterogeneity of putative biochemical lesions . T he inves tigation of central neurotransmitter receptor function continues to occupy much current effort to delineate the mechanis m of antidepres sant action and s ide effects of class ic well as the new compounds that have made the of depress ion “clinician and patient friendly.” Whether study of specific receptors will unravel the molecular mys tery of depres sion remains to be s een. S ince the studies have begun on antidepress ant and moodstabilizing effects on molecular mechanisms believed clos er to the “genetic underpinnings ” of mood Herein is the promise of the future, a new generation of ps ychiatris ts convers ant with both clinical phenomenology and molecular biology. Data suggest the biological s pecificity of genetic factors in mood disorders might be translated into distinct 1497 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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dysregulations, which, in turn, might predis pos e to different affective s ubtypes . R eturning to the therapeutic arena, mounting clinical evidence indicates that, in a special s ubgroup of patients with bipolar disorder, antidepress ants might provoke mixed epis odes, hypomanic episodes , or both, and poss ibly increase later cycling. T he kindlingsens itization model s uggests the utility of medication on epis ode escalation and might represent another example of pathophys iological intervention. Whatever the merit of this model, the 1990s have witness ed intens e clinical and res earch interest and F ood and Drug Administration (F DA) approval of introduction of divalproex (Depakote) and lamotrigine (Lamictal) for bipolar disorder, and many other anticonvuls ants are being developed for that disorder. Anticonvulsant mood stabilizers appear to pos sess a spectrum of activity on bipolar dis orders, including dysphoric and rapid-cycling forms . Lithium, by contras t, seems more specific to euphoric or “clas sic” mania. On other hand, the introduction of olanzapine (Zyprexa), ris peridone (R is perdal), and quetiapine (S eroquel), antips ychotics , for mania raises intriguing questions a common neural substrate for s chizophrenic and disorders . P sychoeducational interventions geared to dis turbed rhythms of the disorder repres ent another example of rational therapeutics . Mood clinics s hould help patients and their s ignificant others to dampen s timulation s o it is kept at an optimal level for depres sed patients with cyclothymic traits. All offending drugs (e.g., cocaine, caffeine, and sedative-hypnotic agents ) should be 1498 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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gradually eliminated and circadian disruptions and loss minimized. T he greater challenge is learning how curb the ill-advis ed actions of patients with cyclical depres sions . P sychoeducation and ps ychotherapy the tas k of ameliorating the resulting s ocial problems. C ompliance with mood-stabilizer regimens that, for would attenuate epis odes and prevent such s equelae difficult to achieve. F urther research on treatment or medication-adherence techniques is needed for promoting more efficient use of mood s tabilizers . It is tempting to sugges t that biogenic amines, the “humors ” of modern ps ychobiology, play the same heuris tic role as the ancient humors did for many centuries . T he black humor, appropriately evoked in cons truct of melancholia in DS M-IV -T R , may not have same claim for etiological relevance to depress ive disorders as norepinephrine and s erotonin, but at least a clas sic heritage. Dopamine, by contrast, may the sanguine humor that drives hypomanic and manic behavior. W hen genetic factors contributing clinical depres sion and mania are discovered, in all likelihood, they will be more linked to temperamental dispositions than to full-blown P.1574 affective dis ease phenotypes . T he clinician will s till interpret the myriad of influences that impinge on s uch inclinations to produce dis ease in an individual that is , fundamental s cientific advances in mood rather than diminishing the role of practitioners , will actually increase it. R egretfully, despite efforts and a rich armamentarium of therapeutic 1499 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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developments, the actual clinical care of affectively ill at the severe end of the s pectrum continues to be gross ly inadequate. More research will not improve this dis mal situation unles s the human and s ocial dimens ions of severe mood dis orders are addres sed with the clinical and public health policies. C aring for the ill is a dimens ion distinct from evidence-based along ps ychopharmacological and psychotherapeutic lines : It requires the allocation of human res ources and integrated mental health s tructures geared to the total patient. In any dis cipline, scientific truth is a function of its technology, but understanding the phenomena under cons ideration is a matter of philosophical temperament that s eeks integration and the hope for a unified vision. R es earch into the caus es and treatment of mood has generated abundant recent data s uitable for integration into theory and practice, and the origin and treatment of mood disorders can no be justified on the grounds of ideological preference alone.

S UG G E S TE D C R OS S S ections 13.2 13.3 13.4 13.5 13.6 13.7 13.8 13.9 cover various aspects of mood disorders in great detail.

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McMahon F J , S imps on S G , McInnis MG , B adner MacK innon DF , DeP aulo J R : Linkage of bipolar to chromosome 18q and the validity of bipolar II disorder. Arch G e n P s ychiatry. 2001;58:1025–1031. Murray C J L, Lopez AD, eds . T he G lobal B urden of G eneva: W orld Health Organization; 1996. Nazroo J Y , E dwards AC , B rown G W: G ender in the onset of depress ion following a s hared life a s tudy of couples. P s ychol Me d. 1997;27:9. Nemeroff C B , Widerlov E , B iss ette G : E levated concentrations of C S F corticotropin-releas ing factorimmunoreactivity in depres sed patients. S cience . 1984;226:1342. Nes tler E J , B arrot M, DiLeone R J , E isch AJ , G old Monteggia LM: Neurobiology of depres sion. Neuron. 2002;34:13–25. Niculescu AB , Akis kal HS : S ex hormones, depres sion. Arch G e n P s ychiatry. 2001;58:1083– Nolen-Hoeksema S , Morrow J , F redericks on B L: R es pons e s tyles and the duration of epis odes of depres sed mood. J Abnorm P s ychol. 1993;102:20. Olsen LR , Mortens en E L, B ech P : P revalence of depres sion and s tres s indicators in the Danis h population. Acta P s ychiatr S cand. 2004;109:96–103. 1510 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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P arry B L, Haynes P : Mood disorders and the reproductive cycle. J G e nd S pe cif Me d. 2000;3:53– P erugi G , Akis kal HS , P amacciotti S , Mass ini S , Milanfranchi A, Musetti L: Depress ive comorbidity of panic, s ocial phobic and obsess ive compuls ive disorders : Is there a bipolar II connection? J R es . 1999;33:53–61. P erugi G , Mus etti L, S imonini E , P iagentini F , G B , Akiskal HS : G ender mediated clinical features depres sive illnes s: the importance of temperamental differences. B r J P s ychiatry. 1990;157:835–841. P etty F : G AB A and mood disorders : a brief review hypothes is. J Affect Dis ord. 1995;34:275–281. P os t R M: T ransduction of ps ychos ocial stress into neurobiology of recurrent affective disorder. Am J P s ychiatry. 1992;149:999. P oznanski E , Zrull J P : C hildhood depres sion: clinical characteristics of overtly depress ed children. Arch P s ychiatry. 1970;23:8. P range AJ J r, Wilson IC , Lynn C W , Alltop LB , R A: L-T ryptophan in mania: contribution to a hypothes is of affective dis orders. Arch G e n 1974;30:56. P uig-Antich J . Affective disorders in children and adoles cents . In: Meltzer HY , ed. 1511 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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T he T hird G ene ration of P rogres s . New Y ork: R ihmer Z, R utz W, P ihlgren H: Depres sion and G otland: an intensive study of all s uicides before after a depres sion-training programme for general practitioners. J Affe ct Dis ord. 1995;35:147. R ihmer Z, K is s K : B ipolar dis orders and s uicidal behaviour. B ipolar Dis ord. 2002;(S uppl 1);21–25. R oth R M, B arnes T R : T he clas sification of affective disorders : a s ynthes is of old and new concepts . P s ychiatry. 1981;22:54–77. R utz W: R ethinking mental health: a E uropean W HO perspective. W orld P s ychiatry. 2003;2:125–127. S childkraut J J : T he catecholamine hypothes is of affective dis orders: a review of s upporting evidence. J P s ychiatry. 1995;22:509–522. S chulberg HC : T reating major depres sion in primary care practice. E ight-month clinical outcomes . Arch P s ychiatry. 1996;53:913. S eligman MD. Helple s s ne s s : O n De pres s ion, and Death. S an F rancisco: F reeman; 1975. S iever LJ , Davis K L: Overview: toward a hypothes is of depres sion. Am J P s ychiatry. 1985;142:1017.

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T s ai S -J : Is mania caused by overactivity of central derived neurotrophic factor? Me d Hypothe s e s . 2004;62:19–22. Unutzer J : Diagnosis and treatment of older adults depres sion in primary care. B iol P s ychiatry. 292. van P raag HM, K ahn R S , As nis G M, W etzler S , B leich A, K om ML: Denosologization of biological ps ychiatry or the specificity of 5-HT disturbances in ps ychiatric disorders. J Affect Dis ord. 1987;13:1. Wehr T A, R osenthal NE : S easonality and affective Am J P s ychiatry. 1989;146:829. Weller E B , Weller R A: B ipolar dis order in children: misdiagnos is, underdiagnosis, and future diagnosis . Am Acad C hild Adole s c P s ychiatry. 1995;34:709. Whybrow P , Mendels J : T oward a biology of some sugges tions from neurophys iology. Am J P s ychiatry. 1969;125:45. Wilhelm K , P arker G , Hadzi-P avlovic D: F ifteen evolving ideas in researching sex differences in depres sion. P s ychol Me d. 1997;27:875. Winokur G , C layton P J , R eich T . Manic-Depre s s ive S t. Louis: Mos by; 1969. Y erevanian B I, K oek R J , Mintz J : Lithium, 1513 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/13.1.htm

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and s uicidal behavior in bipolar disorder. J Affe ct 2003;73:223–228. Zis K D, Zis A: Increas ed adrenal weight in victims of violent s uicide. Am J P s ychiatry. 1987;144:1214.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 14 - Anxiety Dis orders > 14.1 Anxiety Dis orders : Introduction a n Overview

14.1 Anxiety Dis orders : Introduc tion and Overview Dennis S . C harney M.D. P art of "14 - Anxiety Dis orders " Anxiety disorders are the mos t prevalent mental in the general population. Approximately one in four adults in the U.S . population has an anxiety dis order at some point in his or her life. S imilar to adults , anxiety disorders are the mos t common mental dis order in children and adoles cents. However, the rates of childhood anxiety dis orders s uggest the importance of brain development in the phenotypic express ion of anxiety proneness . T his is reflected by the findings of prospective community-based investigations revealing differential peak periods of ons et of specific anxiety disorders : separation anxiety disorder and specific in middle childhood, overanxious disorder in late childhood, s ocial anxiety disorder in middle panic dis order in late adolescence, generalized anxiety disorder in young adulthood, and obs es sivedisorder (OC D) in early adulthood. G ender differences rates appear by 6 years of age when girls are more likely to have an anxiety disorder than boys.

S E L E C TE D P S YC HOL OG IC A L C HA R A C TE R IS TIC S R E L A TE D TO 1515 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/14.1.htm

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R IS K OF A NX IE TY DIS OR DE R S S everal ps ychological factors have been ass ociated increased risk for anxiety dis orders. Among the most intens ively res earched has been the concept of anxiety sens itivity. Anxie ty s ens itivity has been defined as the individual respons e to physiological alterations with anxiety and fear. P atients with anxiety disorders exaggerated ps ychological reactions that are reflective misinterpretation of bodily cues , s uch that the patient misperceives thes e s ens ations inappropriately as being harmful and dangerous , leading in a circular fas hion to increased anxiety and fear. Anxiety s ens itivity is with a s elective cognitive bias toward threat. Anxiety sens itivity predicts the frequency and intensity of panic attacks. T here is evidence that parental concern about anxiety increas es anxiety sensitivity in their children. Anxiety s ens itivity appears to be a trait abnormality and increases the ris k for anxiety dis orders. Increas ed sens itivity can be reduced by cognitive-behavioral (C B T ). R es earchers have investigated whether specific temperamental factors affect the development of disorders in children and adolescents . It has become that s ome children have an inherited neurobiological predis pos ition to increased phys iological reactivity and anxious symptoms in the context of unfamiliar environments and cons equently are more vulnerable to one or more of the anxiety disorders . J erome K agan es timates that roughly 20 percent of healthy children born with such a temperamental bias, which is termed be havioral inhibition. E nvironmental influences with temperament, and, by adolescence, approximately 1516 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/14.1.htm

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one-third of behavioral inhibition children ultimately exhibit indications of serious s ocial anxiety. In a recent study, behavioral inhibition was as sociated with s ocial anxiety dis order in children whos e parents had panic disorder. T hes e data s uggest that parental panic and childhood behavioral inhibition could be us ed to identify children at high ris k for s ocial anxiety disorder. K agan has als o s uggested that behavioral inhibition children may be es pecially susceptible to anxiety or posttraumatic stress disorder (P T S D) after threatening events. S tudies of children who developed anxiety after traumatic event suggest that a prior avoidant was a major ris k factor. However, it is noteworthy to out that the majority of behavioral inhibition children do not develop anxiety dis orders in later adult life, the importance of other intervening biological and factors . T he presence of behavioral inhibition and evidence of insecure attachment to caregivers are likely to to the variance in the express ion of anxious symptoms preschoolers . T his may be related to the findings that parental overprotection, excess ive criticis m, and lack of warmth are ris k factors for the appearance of anxiety disorders in childhood. E nvironmental ris k factors for development of anxiety dis orders (as well as include poverty, expos ure to violence, s ocial is olation, repeated loss es of interpersonal significance. T he neurobiological phenotype and genotype with temperamental ris k factors for anxiety dis orders as anxiety s ensitivity and behavioral inhibition remain be precis ely defined. An example of the type of inves tigations needed is increas es in amygdala 1517 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/14.1.htm

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res ponsiveness in adults categorized as behavioral inhibited as children.

G E NE TIC S T he genetics of anxiety disorders is a relatively area of res earch compared to other s erious psychiatric disorders , such as schizophrenia and bipolar disorder. Des pite increased age-adjus ted morbidity in firstrelatives of probands with most of the anxiety progres s has been slow in defining s pecific regions of human genome and, more importantly, specific genes as sociated with vulnerability to anxiety dis orders. T hus endophenotypes for the anxiety dis orders have not reliably demons trated with the pos sible exception of carbon dioxide–induced panic attacks in relatives of disorder patients . In the future, it will be extremely important to relate the ps ychological and environmental ris k factors for anxiety disorders to s pecific P.1719 genotypes . T he precise determination of gene– environment interactions relevant to anxiety dis orders greatly facilitate the discovery of novel preventative therapeutic approaches.

C L INIC A L A ND FE A TUR E S T he overreliance on s tandardized diagnostic s ys tems genetic and neurobiological inves tigations of anxiety disorders has impeded progress . Daniel S . P ine and McC lure review the history and current clas sifications 1518 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/14.1.htm

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systems for anxiety disorders . T hey emphas ize that the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ) clas sification system for anxiety dis orders is not based on etiology, pathophys iology, or treatment res ponse. T he tenth of the Inte rnational S tatis tical C las s ification of Dis e as e s R elated He alth P roblems (IC D-10) recognizes a category of ne urotic, s tre s s -re late d and s omatoform dis orders that includes each of the nine DS M-IV -T R disorders , as well as a number of disorders not anxiety dis orders in DS M-IV -T R . As currently described in DS M-IV -T R , the nine anxiety disorders described in this s ection represent a heterogeneous set of dis orders. T his probably part, for the findings of neurotransmitter and neuropeptide s tudies implicating abnormalities in noradrenergic, benzodiazepine, corticotrophinhormone, and other neurotransmitter and neuropeptide systems acros s different diagnos tic conditions, as by Alexander Neumeister, Omer B onne, and Dennis S . C harney. S imilarly, the neuroimaging s tudies of anxiety disorders have identified roles for a variety of brain structures , including the amygdala, hippocampus, cingulate, and medial and orbital prefrontal cortex, in regulation of emotion and cognition relevant to anxiety disorders . However, neural circuits have not been identified that corres pond s pecifically to s tandardized diagnostic criteria for anxiety disorders . A more fruitful approach may be to investigate the neural circuits and as sociated neurotransmitters and neuropeptides that mediate the neural mechanisms of fear conditioning, reward, and s ocial interactions that are relevant to the 1519 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/14.1.htm

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symptoms that are relevant to all of the anxiety F urthermore, identification of the genes that contribute the regulation of these circuits may lead to better diagnostic methods and novel targets for drug development.

TR E A TME NT OF A NX IE TY G iven the high prevalence and morbidity of anxiety disorders in children, adoles cents , and adults , more effective ps ychotherapeutic and treatments are needed. S hawn P . C ahil and E dna B . their comprehens ive review of C B T acknowledge that, although C B T is an effective treatment, there are many patients who res pond incompletely or not at all. T here need for new forms of ps ychotherapy that go beyond tenets of C B T , particularly therapies that are s ens itive developmental cons iderations in children and with anxiety disorders . Murray B . S tein extens ively the current status of s omatic treatments for anxiety disorders . T he mainstay of drug treatments for anxiety disorders remains the monoamine reuptake inhibitors, monoamine oxidase inhibitors (MAOIs ), and benzodiazepines. P s ychiatris ts eagerly await the ongoing or soon-to-be-commenced clinical trials with novel putative anxiolytic drugs, such as corticotrophinreleas ing hormone antagonis ts, substance P anxioselective benzodiazepines, glutamate releas e modulators , and vas opress in V 1a receptor antagonis ts. Anxiety disorder research has not yet identified reliable descriptive, genetic, or neurobiological predictors of therapeutic res ponse for any of the anxiety dis orders. However, the tremendous advances in basic relevant to the pathophys iology of anxiety disorders 1520 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/14.1.htm

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should facilitate s ubs tantial progress in these areas in not-too-distant future. T he emergence of a new neurobiology of anxiety dis orders will redefine clas sification, will more precisely delineate gene– environment interactions , will inform the choice of therapy, and will promote the discovery of more and s elective class es of drugs for anxiety disorders .

S UG G E S TE D C R OS S Neural s ciences are covered in C hapter 1, and neurops ychiatry and behavioral neurology are covered C hapter 2. T he s ections within C hapter 14 s hould a guide to developments in research and treatment in field of anxiety disorders : E pidemiology of anxiety disorders is dis cuss ed in S ection 14.2; biochemical of anxiety disorders in S ections 14.3, 14.4, and 14.5; genetics of anxiety disorders in S ection 14.6; clinical features of anxiety disorders in S ection 14.8; s omatic treatment for anxiety dis orders in S ection 14.9; and ps ychological treatments for anxiety disorders in 14.10. C hapter 46 covers anxiety disorders in children, S ection 51.3c discus ses anxiety disorders in the

R E F E R E NC E S Doyle AC , P ollack MH: E stablishment of remiss ion criteria for anxiety disorders . J C lin P s ychiatry. [S uppl 15]:40–45. Hariri AR , Mattay V S , T ess itore A, K olachana B , G oldman D, E gan MF , W einberger DR : S erotonin transporter genetic variation and the res ponse of the 1521 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/14.1.htm

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human amygdala. S cience. 2002;297:400–403. *K agan J , R eznick J S , S nidman N: B iological bas es childhood s hyness . S cience. 1998;240:167–171. K agan J , S nidman N: E arly childhood predictors of anxiety dis orders. B iol P s ychiatry. 1999;46:1536– K agan J , S nidman N, Arcus D: C hildhood high and low reactivity in infancy. C hild De v. 1998;69:1483–1493. K agan J , S nidman N, Zentner M, P eterson E : Infant temperament and anxious symptoms in s chool age children. Dev P s ychopathol. 1999;11:209–224. *K eogh E , Dilon C , G eorgiou G , Hunt C : S elective attentional biases for phys ical threat in physical sens itivity. J Anxiety Dis ord. 2001;15:299–315. McNally R J : Anxiety s ens itivity and panic disorder. P s ychiatry. 2002;52:938–946. P igott T A: Anxiety disorders in women. P s ychiatr North Am. 2003;26:621–672. P rior M, S mart D, S anson A, Oberklaid F : Does s hyinhibited temperament in childhood lead to anxiety problems in adolescence? J Am Acad C hild Adole s c P s ychiatry. 2000;39:461–468. *P ynoos R S , F rederick C , Neder K , Arroyo W , 1522 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/14.1.htm

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A, E th F : Life threat and post-traumatic stress school-age children. Arch G e n P s ychiatry. 1063. R apee R M: T he development and modification of temperamental ris k for anxiety dis orders: P revention a lifetime of anxiety? B iol P s ychiatry. 2002;52:947– *S chwartz C E , S nidman N, K agan J : Adoles cent anxiety as an outcome of inhibited temperament in childhood. J Am Acad C hld Adole s c P s ychiatry. 1999;38:1008–1015. S chwartz C E , Wright C I, S hin LM, K agan J , R auch Inhibited and uninhibited infants “grown up”: Adult amygdala res ponse to novelty. S cience. 1053. S tein MB : Attending to anxiety dis orders in primary care. J C lin P s ychiatr. 2003;64[S uppl 15]:35–39. V as ey MW , Dadds MR . T he Deve lopme ntal P s ychopathology of Anxie ty. New Y ork: Oxford P res s; 2001. V elting ON, S etzer NJ , Albano AM: Update on and advances in as ses sment and cognitive-behavioral treatment of anxiety dis orders in children and adoles cents . P rofe s s ional P s ychology—R es e arch & P ractice . 2004;35:42–54. Wittchen HU, B eesdo K , B ittner A, G oodwin R D: 1523 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/14.1.htm

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Depress ive episodes : E vidence for a causal role of primary anxiety dis orders? E ur P s ychiatry. 393.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > 15 - S omatoform Dis order

15 S omatoform Dis orders Mic hael A. Hollifield M.D. T here are s even s omatoform disorders in the revised fourth edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-IV -T R ), two of which are subs yndromal or nonspecific disorders (T able 15-1). nosology overlaps with the tenth edition of the Inte rnational S tatis tical C las s ification of Dis e as e s and Health P roble ms (IC D-10) class ification (T able 15-2), there are important differences that are apparent from criteria. T he DS M-IV -T R has convers ion disorder and dysmorphic dis order in its class ification, whereas the 10 does not, but instead s pecifies somatoform dysfunction and other s omatoform disorders . In the 10, conversion is clas sified as a dis sociative disorder, somatoform autonomic dys function is s imilar to the symptoms ass ociated with anxiety and depress ive disorders in the DS M-IV -T R . In the IC D-10, body dysmorphic dis order is subsumed under disorder. Nonetheles s, the two class ification systems more s imilar than different in how they represent the phenomenology and the history that links the disorders together. S omatization disorder is the and has the best evidence for being a discrete, and s table illness over time. T he other somatoform disorders are linked together by certain core features , 1525 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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also have features that call into question their fit in this category of illness . F or example, there is s upport for clas sifying convers ion dis order as a diss ociative and s ubs ets of hypochondriacs and body dysmorphics monos ymptomatic delusional disorders or anxiety disorders . T he his tory and phenomenology of the somatoform disorders have much in common.

Table 15-1 DS M-IV-TR Dis orders Diagnos tic C riteria 300.81 S omatization dis order    A. A history of many physical complaints before 30 years of age that occur over a period of several years and res ult in treatment being significant impairment in s ocial, occupational, or other important areas of functioning.    B . E ach of the following criteria must have been met, with individual symptoms occurring at any during the course of the disturbance: 1. F our pain s ymptoms . A history of pain related at leas t four different sites or functions (e.g., head, abdomen, back, joints , extremities , rectum, during menstruation, during sexual intercours e, or during urination). 2. T wo gas trointes tinal s ymptoms . A history of 1526 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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least two gas trointes tinal s ymptoms other pain (e.g., naus ea, bloating, vomiting other during pregnancy, diarrhea, or intolerance of several different foods). 3. O ne s exual s ymptom. A his tory of at least sexual or reproductive symptom other than (e.g., s exual indifference, erectile or dysfunction, irregular mens es, exces sive mens trual bleeding, or vomiting throughout pregnancy). 4. O ne ps e udone urological s ymptom. A history least one s ymptom or deficit suggesting a neurological condition not limited to pain (conversion s ymptoms , s uch as impaired coordination or balance, paralys is or localized weaknes s, difficulty s wallowing or lump in throat, aphonia, urinary retention, loss of touch or pain sens ation, double vision, blindnes s, deafnes s, and s eizures; symptoms, s uch as amnes ia; or loss of cons ciousnes s other than fainting).    C . E ither (1) or (2): 1. After appropriate investigation, each of the symptoms in C riterion B cannot be fully explained by a known general medical or the direct effects of a s ubstance (e.g., a of abus e, a medication). 2. When there is a related general medical condition, the phys ical complaints or resulting 1527 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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social or occupational impairment are in of what would be expected from the history, phys ical examination, or laboratory findings .    D. T he symptoms are not intentionally feigned (as in factitious disorder or malingering). 300.81 Undifferentiated s omatoform dis order    A. One or more phys ical complaints (e.g., loss of appetite, or gastrointestinal or urinary complaints ).    C . E ither (1) or (2): 1. After appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a subs tance (e.g., a drug of abuse or a 2. When there is a related general medical condition, the phys ical complaints or resulting social or occupational impairment is in excess what would be expected from the his tory, phys ical examination, or laboratory findings .    C . T he symptoms caus e clinically s ignificant distress or impairment in s ocial, occupational, or other important areas of functioning.    D. T he duration of the disturbance is at least 6 months. 1528 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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   E . T he dis turbance is not better accounted for another mental dis order (e.g., another disorder, s exual dysfunction, mood disorder, disorder, s leep disorder, or ps ychotic dis order).    F . T he symptom is not intentionally produced or feigned (as in factitious disorder or malingering). 300.11 C onvers ion dis order    A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest neurological or other general medical condition.    B . P sychological factors are judged to be with the symptom or deficit, becaus e the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stress ors .    C . T he symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering).    D. T he symptom or deficit cannot, after inves tigation, be fully explained by a general medical condition or by the direct effects of a subs tance, or as a culturally s anctioned behavior experience.    E . T he symptom or deficit caus es clinically 1529 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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significant dis tres s or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.    F . T he symptom or deficit is not limited to pain sexual dys function, does not occur exclus ively during the course of s omatization dis order, and is not better accounted for by another mental    S pe cify the type of s ymptom or deficit:    

With motor symptom or deficit With s ens ory symptom or deficit With s eizures or convulsions With mixed presentation

Pain dis order    A. P ain in one or more anatomical s ites is the predominant focus of the clinical pres entation and of sufficient severity to warrant clinical attention.    B . T he pain caus es clinically s ignificant dis tres s impairment in s ocial, occupational, or other important areas of functioning.    C . P sychological factors are judged to have an important role in the onset, s everity, maintenance of the pain.    D. T he symptom or deficit is not intentionally 1530 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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produced or feigned (as in factitious disorder or malingering).    E . T he pain is not better accounted for by a anxiety, or ps ychotic dis order and does not meet criteria for dyspareunia.    C ode as follows : 307.80 Pain dis order as s oc iated with ps ychologic al fac tors : P s ychological factors are judged to have the major role in the ons et, exacerbation, or maintenance of the pain. (If a general medical condition is pres ent, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) T his of pain disorder is not diagnosed if criteria are met for somatization disorder.    S pe cify if:  

Acute: duration of less than 6 months C hronic : duration of 6 months or longer

307.89 Pain dis order as s oc iated with both ps ychologic al fac tors and a general medic al condition: B oth ps ychological factors and a medical condition are judged to have important roles in the onset, s everity, exacerbation, or maintenance of the pain. T he ass ociated general medical condition or anatomical site of the pain 1531 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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the following discus sion) is coded on Axis III.    S pe cify if:  

Acute: duration of less than 6 months C hronic : duration of 6 months or longer

Note: T he following is not cons idered to be a disorder and is included here to facilitate diagnosis. Pain dis order as s ociated with a general condition: A general medical condition has a role in the onset, s everity, exacerbation, or maintenance of the pain. (If ps ychological factors present, they are not judged to have a major role the ons et, severity, exacerbation, or maintenance the pain.) T he diagnos tic code for the pain is selected bas ed on the as sociated general condition if one has been es tablis hed or on the anatomical location of the pain if the underlying general medical condition is not yet clearly es tablis hed—for example, low back (724.2), (724.3), pelvic (625.9), headache (784.0), facial (784.0), chest (786.50), joint (719.4), bone abdominal (789.0), breast (611.71), renal (788.0), (388.70), eye (379.91), throat (784.1), tooth and urinary (788.0). 300.7 Hypochondrias is

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   A. P reoccupation with fears of having, or the that one has, a serious diseas e based on the misinterpretation of bodily symptoms .    B . T he preoccupation pers is ts despite medical evaluation and reass urance.    C . T he belief in C riterion A is not of delusional intens ity (as in delusional disorder, somatic type) and is not res tricted to a circumscribed concern about appearance (as in body dys morphic    D. T he preoccupation causes clinically distress or impairment in s ocial, occupational, or other important areas of functioning.    E . T he duration of the disturbance is at least 6 months.    F . T he preoccupation is not better accounted generalized anxiety disorder, obsess ivedisorder, panic disorder, a major depress ive separation anxiety, or another s omatoform S pe cify if: 

With poor ins ight: if, for mos t of the time during the current episode, the pers on does recognize that the concern about having a serious illness is excess ive or unreasonable

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300.7 B ody dys morphic dis order    A. P reoccupation with an imagined defect in appearance. If a s light phys ical anomaly is the person's concern is markedly exces sive.    B . T he preoccupation causes clinically distress or impairment in s ocial, occupational, or other important areas of functioning.    C . T he preoccupation is not better accounted by another mental dis order (e.g., diss atisfaction body shape and s ize in anorexia nervosa). 300.81 S omatoform dis order, not otherwis e s pecified    T his category includes dis orders with symptoms that do not meet the criteria for any specific s omatoform disorder. E xamples include 1. P seudocyesis: a false belief of being that is as sociated with objective signs of pregnancy, which may include abdominal enlargement (although the umbilicus does not become everted), reduced menstrual flow, amenorrhea, subjective sensation of fetal movement, naus ea, breas t engorgement and secretions, and labor pains at the expected of delivery. E ndocrine changes may be but the syndrome cannot be explained by a 1534 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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general medical condition that causes changes (e.g., a hormone-secreting tumor). 2. A disorder involving nonpsychotic hypochondriacal symptoms of less than 6 months' duration. 3. A disorder involving unexplained phys ical complaints (e.g., fatigue or body weakness ) less than 6 months' duration that are not due another mental dis order.

Adapted from American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal 4th ed. T ext rev. W as hington, DC : American P sychiatric P ublishing; 2000.

Table 15-2 IC D-10 S omatoform Dis orders Diagnos tic C riteria F45.0 S omatization dis order    A. T here must be a his tory of at leas t 2 years ' complaints of multiple and variable physical symptoms that cannot be explained by any detectable phys ical disorders . (Any phys ical disorders that are known to be present do not 1535 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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explain the s everity, extent, variety, and of the physical complaints , or the ass ociated disability.) If s ome symptoms clearly due to autonomic arous al are present, they are not a feature of the disorder in that they are not particularly pers istent or dis tres sing.    B . P reoccupation with the s ymptoms caus es persis tent distress and leads the patient to s eek repeated (three or more) cons ultations or s ets of inves tigations with primary care or specialist In the abs ence of medical s ervices within the financial or physical reach of the patient, there be persistent s elf-medication or multiple cons ultations with local healers.    C . T here is pers is tent refusal to accept medical reass urance that there is no adequate physical for the physical symptoms. (S hort-term of such reass urance, i.e., for a few weeks during immediately after investigations , does not this diagnos is .)    D. T here must be a total of six or more from the following lis t, with symptoms occurring in at leas t two s eparate groups: 

G as trointes tinal s ymptoms 1. Abdominal pain 2. Naus ea 3. F eeling bloated or full of gas 1536

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





4. B ad tas te in mouth or excess ively coated tongue 5. C omplaints of vomiting or regurgitation of food 6. C omplaints of frequent and loose bowel motions or discharge of fluids from anus C ardiovas c ular s ymptoms 1. B reathless nes s without exertion 2. C hes t pains G enitourinary s ymptoms 1. Dys uria or complaints of frequency of micturition 2. Unpleas ant sensations in or around the genitals 3. C omplaints of unus ual or copious vaginal discharge S kin and pain s ymptoms 1. B lotchines s or discoloration of the skin 2. P ain in the limbs , extremities, or joints 3. Unpleas ant numbness or tingling

   E . Mos t commonly us ed e xclus ion claus e . do not occur only during any of the s chizophrenic related dis orders (F 20 through F 29), any of the (affective) disorders (F 30 through F 39), or panic disorder (F 41.0). F45.1 Undifferentiated s omatoform dis order    A. C riteria A, C , and E for s omatization disorder

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(F 45.0) are met, except that the duration of the disorder is at least 6 months.    B . One or both of C riteria B and D for disorder (F 45.0) are incompletely fulfilled. F45.2 Hypochondriac al dis order    A. E ither of the following must be present: 



A persistent belief, of at leas t 6 months ' of the presence of a maximum of two s erious phys ical diseases (of which at least one mus t specifically named by the patient). A persistent preoccupation with a presumed deformity or disfigurement (body dys morphic disorder).

   B . P reoccupation with the belief and the caus es pers istent dis tres s or interference with personal functioning in daily living and leads the patient to seek medical treatment or (or equivalent help from local healers).    C . T here is pers is tent refusal to accept medical reass urance that there is no physical cause for symptoms or phys ical abnormality. (S hort-term acceptance of s uch reass urance, i.e., for a few during or immediately after investigations does exclude this diagnosis.)

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   Mos t commonly us ed e xclus ion claus e . T he symptoms do not occur only during any of the schizophrenic and related dis orders (F 20 through F 29, particularly F 22) or any of the mood disorders (F 30 through F 39). F45.3 S omatoform autonomic dys func tion    A. T here must be s ymptoms of autonomic that are attributed by the patient to a phys ical disorder of one or more of the following s ys tems organs :  

  

Heart and cardiovas cular s ys tem Upper gas trointestinal tract (es ophagus and stomach) Lower gas trointestinal tract R es piratory system G enitourinary system

   B . T wo or more of the following autonomic symptoms mus t be pres ent:     

P alpitations S weating (hot or cold) Dry mouth F lushing or blus hing E pigas tric dis comfort, “butterflies ,” or in the s tomach

   C . One or more of the following s ymptoms mus t 1539 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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present: 

  

  

C hes t pains or dis comfort in and around the precordium Dys pnea or hyperventilation E xces sive tirednes s on mild exertion Aerophagy, hiccough, or burning s ens ations ches t or epigastrium R eported frequent bowel movements Increased frequency of micturition or dysuria F eeling of being bloated, dis tended, or heavy

   D. T here is no evidence of a disturbance of structure or function in the organs or s ys tems which the patient is concerned.    Mos t commonly used exclusion clause. T hes e symptoms do not occur only in the presence of phobic disorders (F 40.0 through F 40.3) or panic disorder (F 41.0).    A fifth character is to be us ed to clas sify the individual dis orders in this group, indicating the organ or system regarded by the patient as the origin of the s ymptoms:    F 45.30 Heart and cardiovas cular s ys tem       Includes : cardiac neurosis, neurocirculatory as thenia, and Da C os ta's s yndrome.

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   F 45.31 Upper gastrointestinal tract       Includes : ps ychogenic aerophagy, hiccough, gastric neuros is .    F 45.32 Lower gastrointestinal tract       Includes : ps ychogenic irritable bowel ps ychogenic diarrhea, and gas s yndrome.    F 45.33 R es piratory system       Includes : hyperventilation.    F 45.34 G enitourinary s ys tem       Includes : ps ychogenic increas e of frequency micturition and dys uria.    F 45.38 Other organ or system F45.4 Pers is tent s omatoform pain dis order    A. T here is persis tent s evere and distress ing (for at leas t 6 months , and continuously on most days ), in any part of the body that cannot be explained adequately by evidence of a proces s or a physical dis order and that is the main focus of the patient's attention.

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   Mos t commonly us ed e xclus ion claus e . T his does not occur in the pres ence of s chizophrenia related dis orders (F 20 through F 29), or only any of the mood (affective) disorders (F 30 F 39), s omatization disorder (F 45.0), somatoform disorder (F 45.1), or hypochondriacal disorder (F 45.2). F45.8 Other s omatoform dis orders    In these dis orders, the pres enting complaints not mediated through the autonomic nervous system and are limited to specific s ys tems or the body, such as the s kin. T his is in contrast to multiple and often changing complaints of the origin of s ymptoms and dis tres s found in somatization disorder (F 45.0) and somatoform disorder (F 45.1). T is sue damage is involved.    Any other dis orders of sens ation not due to phys ical disorders , which are clos ely as sociated time with stress ful events or problems or which res ult in significantly increased attention for the patient, personal or medical, should also be clas sified here. F45.9 S omatoform dis order, uns pec ified

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Adapted from IC D-10 C las s ification of Me ntal and B ehavioural Dis orde rs . G eneva: World Health Organization; 1993:105–109.



B R IE F HIS T OR Y



G E NE R AL P HE NOME NOLOG Y



G E NE R AL E T IOLOG IE S



T R E AT ME NT P R INC IP LE S



S OMAT IZAT ION DIS OR DE R



HY P OC HONDR IAS IS



C ONV E R S ION DIS OR DE R



B ODY DY S MOR P HIC DIS OR DE R



P AIN DIS OR DE R



UNDIF F E R E NT IAT E D S OMAT OF OR M



S OMAT OF OR M DIS OR DE R NOT OT HE R WIS E



S P E C IAL C ONS IDE R AT IONS



F UT UR E DIR E C T IONS



S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > B R IE F HIS T OR

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B R IE F HIS TOR Y P art of "15 - S omatoform Dis orders" S omatoform means taking the form of (or in) soma, implies that these illnes ses are nonsomatic. thus a misnomer and reflects the historical and current of knowledge about the physiology of these dis orders. With res pect to the epistemological problems of mind– body dualis m, the general category of s omatoform disorders is better thought of as une xplained clas s of illnes ses that have changed in their presumed etiology over time. T he earlies t notions about symptoms were focus ed on disturbances of organs and body systems . Hippocrates and the G reeks believed abdominal organs were the s ource of emotional T he word hypochondrium, being the part of the body caudal to the rib cage, arose from this era. T his body was to be distinguished from the prae cordia, which was the ches t over the heart. T he G reek view, prominent into the s econd millennium, held that the pertained to diges tive s ymptoms and emotional disturbances and that the praecordia was the s eat of melancholia, which had little connection to depres sive illness as it is now known. B efore the R enais sance, was a disorder of the uterus , which could wander the body and even caus e s uffocation by press ing on organs of respiration. T reatment included physical manipulation of the uterus and applications of to vulvar tis sues. T he 1600s brought increas ed understanding of the 1544 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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nervous s ys tem (C NS ) and ideas that unexplained symptoms were a product of the brain. T he father of neurology, T homas W illis (1621 to 1675), regarded in women and hypochondrias is in men as nervous disorders of the brain and advocated hitting affected patients with a stick to the head as one treatment. S ydenham (1624 to 1689) may have had the most on the shift to consider hysteria and hypochondrias is ps ychological diseases of the mind and not the body. However, he did recommend treatments integrating phys ical and ps ychological modalities, consisting of regular exercise, ps ychological s trengthening, and purification of the blood, as well as tending to the welfare of the patient. T he 1700s saw continued sophistication of terms to describe unexplained as nervous disorders . G eorge C heyne (1671 to 1743) coined the term E nglis h malady, and many great about this disorder were produced. Debate raged about the mechanis m of hypochondriasis in men and hys teria women, which continued to be cons idered nervous disorders of the brain or mind, or both. William C ullen (1712 to 1790) is widely quoted as coined the term ne uros is , and he wrote that all cons idered to be related to hypochondriasis and were of just one primary, idiopathic species, namely hypochondrias is me lancholia. Hysteria, he held, was a separate disorder that had been confused with hypochondriasis. Later, in the 1800s, hypochondrias is cons idered to be a form of ins anity, which could begin the abdominal organs but would progres s to caus e a general inflammation of all organs, including the brain. P os tmortem cases s uggested that hypochondriasis 1545 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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be as sociated with cortical plaques and s oftening of the brain. However, when pathological studies in the 19th century failed to demons trate anatomical abnormalities the body or brain, hypochondriasis and hys teria began be considered subtle or functional. J ean-Martin and his pupils were certain that hys teria in women and hypochondriasis in men were dis orders of the nervous system and it centers throughout the body, but they not sure of its nature or location. P hys ical therapies , as manipulation of the hypochondrium or press ure on ovaries, paralleled this line of thinking. Other writers to consider this set of dis orders as problems of in which the combined mind and body had s ome in overfeeling or oversensing. T he early 20th century brought about a paradoxical which unexplained physical s ymptoms were thought of primarily ps ychological. It was paradoxical becaus e it the students of C harcot, including S igmund F reud, who were the impetus for this s hift. T hey were certain that these were disorders of the C NS and were P.1801 P.1802 due to repress ed phys ical energy caus ed by conflict. T he paradoxical s hift occurred becaus e of the of good physical treatments and the development of ps ychological treatments , including psychoanalys is , demonstrated treatment success . Once the province of general medicine and neurology, unexplained medical symptoms now became entrenched in the burgeoning field of ps ychiatry. With ps ychiatry's movement away 1546 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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the res t of somatic medicine in the early 20th century, too moved the dis orders of unexplained symptoms. F ormal ps ychiatric class ification divided unexplained phys ical s ymptoms in the s econd edition of the DS M (DS M-II) (1968) into the categories ne uros e s , ps ychophys iologic dis orde rs (ten types ), and s pecial s ymptoms . Neuros es were further divided into ne uros e s (divided into conversion and diss ociative ne uras the nia, depe rs onalization, hypochondrias is , and ne uros e s . T here was also a hys te rical pe rs onality T he third edition of the DS M (DS M-III) (1980) made the shift to s eparating the dis orders with phys ical (s ubtyped organic me ntal dis orders and s omatoform dis orders ) from the dis s ociative dis orde rs , a new Hys terical personality dis order was replaced with pe rs onality dis orde r. C onversion disorder was with somatization, ps ychogenic pain, and under s omatoform dis orders . T here remains a fair debate about the relevance of the category of s omatoform dis orders , the way in which diagnoses are cons tructed, and the us efulness of diagnostic entities . S omatoform dis orders overlap with anxiety, affective, dis sociative, and personality S omatic s ymptoms are more common manifestations anxiety, depress ion, and trauma syndromes throughout the world than are ps ychological symptoms . Inclusion broader range of international and cultural conceptualization is needed. However, there is not debate about the importance of this s et of disorders to ps ychiatry and the res t of medicine. Unexplained symptoms ass ociated with high distress and high care use are a common problem for clinical medicine. 1547 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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More than one-half of the most common symptoms in primary care are not adequately explained by a current biomedical paradigm. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > G E NE R AL P H E NO ME NO LO

GE NE R AL P art of "15 - S omatoform Dis orders"

E mbodiment E xpres sing general distress bodily is common P sychologizing of general dis tres s s eems to be a born of W es tern intellectual commitments to mind– dualism. Many body s ys tems are us ed to determine the source of dis tres s and the requisite action to counter it. S ensory and motor systems are activated during appraisal, and res olution of threat. During normal conditions, a person accurately appraises the s ource of threat and the behavior needed to counter it, and succes sful res olution quiets s ys tems back to normal. although s ens ory systems are always active, they are cons ciously felt if there is an appraisal of no threat. V arious elements of human ps ychobiology create conditions in which a pers on perceives ongoing threats that are felt in the body. T emperament may influence degree to which a child is focus ed on s ens ory systems cue for danger. F or example, young children of parents with panic dis order are more likely than children of without panic dis order to inhibit their exploring behavior in novel situations . S econd, there is s trong evidence 1548 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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young children learn how to expres s their dis tres s. inves tigators describe case reports and cas e s tudies in which a child comes to medical care talking about pain one or another body system that is similar to how a expres ses his or her dis tres s. T hird, psychiatric are as sociated with an increase in bodily sensation, succes sful treatment of the disorder, s uch as an affective illnes s, can markedly reduce the somatic preoccupation and distress . F ourth, ongoing life coupled with poor coping s kills lead to generalization P.1803 P.1804 acros s multiple situations of the general s tres s and the flight, fight, or freeze respons e. T his phenomenon is s trongly conditioned by the intermittent and random nature of the life s tres sors and is mitigated res olution of the fear respons e by adequate coping. early-life adverse experiences may cause changes in ps ychobiology, s uch as pers is tent hyperadrenalis m hyper- or hypocortis olism, which have an impact on sens ory perception and reflex behavior. T here is good evidence in animal and human res earch indicating that advers e experiences , s uch as maternal s eparation, is olation, and deprivation, and overt forms of trauma influence the development and functioning of central peripheral nervous s ys tem components and the system and are ass ociated with worse health and wors e health by objective meas ures . T he phenomenon of reexperiencing in posttraumatic s tres s disorder (P T S D) is perhaps the best example of how 1549 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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trauma becomes embodied. It has been known since late 1980s that there is a heightened autonomic to general threat cues in people with P T S D and that res ponse is incrementally larger to greater specificity of trauma cue. R ecently, inves tigators have determined the sensory cortex as sociated with specific body areas stimulated as s een on pos itron emis sion tomography in res pons e to a cue of a pas t trauma to that body T he integration of memory of pas t events with of current events occurs in s ens ory pathways just as it in cognitive pathways. T hes e memories are designed protective but, as in all organic s ys tems, can become pathological and maladaptive. In any cas e, as pas t are learned and stored in brain, they are als o learned stored in thos e s ens ory circuits that extend from brain are called body.

P erc eption and C ognition Many studies have demons trated that certain and cognitive s tyles are ass ociated with somatoform disorders . P eople with s omatization and have a lower threshold for perceiving certain proces ses and think that minor physical complaints be catas trophic phys ical events. T hey often have high negative self-appraisal and s elf-concepts of being and unable to tolerate stress . P eople with s omatoform disorders generally are more accurate in dis tinguishing between s maller increments of sensory s timuli than people without thes e disorders , although there are a mitigating s tudies about this. P eople with these tend to overreport s ymptoms during minor illnes ses during medical tests , s uch as pulmonary function tests , and notice s ymptoms more often when they read about 1550 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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them. P eople with hypochondriasis differ from normal subjects and anxiety patients in their perception and misinterpretation of normal bodily s ens ations , and this may be due to fluctuations in emotion.

A mplific ation B odily sensations are felt, thought about, appraised for meaning, and acted on. Many investigators have noted interactive relations hip and mutual reinforcement between sensation, cognitive appraisal, and behavior people with somatoform disorders. T hese reinforcing interactions have been termed s omatos e ns ory amplification, a proces s in which a pers on learns to feel body sensations more acutely, s ometimes more and may catastrophically dis tort the meaning of thos e sens ations by equating them with illness . T his phenomenon is likely part of a cognitive style of self-observation coupled with selective perception and amplification of phys ical s ens ations , which lead to excess ive perception of body vulnerability and overes timation of the likelihood of being ill.

Interac tion with A nxiety and Depres s ion Unexplained s omatic symptoms are highly prevalent in anxiety and affective disorders and diminish with adequate treatment of the anxiety or depres sive disorder. T here are numerous hypothes es about how occurs, including selective perception, amplification, increased autonomic nervous system activity. E ightyto 95 percent of people who come to primary care around the world and who are subsequently diagnosed 1551 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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with an anxiety or depres sive disorder pres ent with somatic symptoms as their chief complaint. T his may because somatic s ymptoms are actually prominent in these dis orders becaus e of their ps ychobiology or people us e s omatic s ymptoms as the mos t acceptable currency to obtain care, or both.

P rimary and S ec ondary Dis orders It is thought that C . F . Michea (1815 to 1882) was the to postulate an idiopathic (primary or true) form and a secondary form of hypochondriasis, which he called tris te (s ad monomania). T hes e forms are important conceptually for purpos es of clas sification and for determining treatment and predicting outcomes. forms are when the s omatoform dis order is the only condition of concern or, when there is comorbidity, the somatoform disorder precedes the other disorder and res ponsible for the unexplained physical symptoms. secondary form occurs when another dis order the ons et of the s omatoform disorder, and the unexplained physical symptoms are thought to be due or s econdary to, the other illness . S omatoform P.1805 may be s econdary to other ps ychiatric or other medical illness . T here is empirical s upport for the importance of both forms .

R elations hip to F ac titious and Malingering Dis orders T here is often confus ion about the relations hip somatoform disorders and factitious and malingering 1552 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disorders . T his is partly because they are all viewed as faking of symptoms in common medical parlance. However, they are different process es , with overlap between them, with features that are critical for the general ps ychiatris t to be familiar with. A concept that helps dis tinguis h between them is how symptom is produced and whether it is really being felt and not faked. It is not a critical feature of thes e that the phys ician believe in the authenticity of the symptoms, as this is not a reliable feature for P hysicians often only cons ider symptoms authe ntic if can be meas ured in the context of the biomedical In fact, the realnes s of a given symptom has to do with whether it is produced cons cious ly or uncons ciously by patient. In somatoform disorders , symptoms are unconsciously and are thus as authentic as a symptom diabetes mellitus. T he somatoform-disordered patient not making the s ymptom up for any reas on for which she is aware, and he or s he is rightfully offended when suggested that the s ymptom is being faked. In disorders , the patient has some awarenes s that he or intentionally produces the symptom, although this awarenes s is us ually les s than complete. In disorders , the pers on is clearly and cons cious ly the symptom to obtain external incentives. T he other concept that helps dis tinguis h thes e is the reason for, or the gain produced by, the regardless of the nature of s ymptom production. In somatoform disorders , the patient has no awarenes s of why this symptom has been produced, even if ps ychological factors are res pons ible for its production. this regard, the reas on for the s ymptom is s aid to be for 1553 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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primary gain. T his implies that the patient has no incentives for the s ymptoms, which may be due to ps ychophys iological variables that are out of the awarenes s of the patient. T he gain in s omatoform disorders is generally primitive—the patient who has symptoms s imply hopes that there is s omeone who help him or her feel better. However, because the somatoform patient feels sick, he or s he often reques ts phys ical or social benefits of illness , s uch as time off duties or dis ability benefits. In factitious dis orders, the reason for the s ymptoms is als o generally unconscious is thought to be due to the need to ass ume the s ick and to obtain the benefits that go along with being ill. T hese benefits are us ually primary, or about the self, but these needs and benefits may als o extend to phys ical or social world of the patient. As long as this remains partially or fully uncons cious to the patient, a factitious, not a malingering, disorder is pres ent. In malingering, the person is fully aware of why he or s he producing the illnes s, and the gain is said to be or external, to the s elf. T he malingering pers on is cons cious of using s ymptoms to obtain money or medications or to avoid duties. One problem for the clinician is that all three conditions can result in the as king for as sistance with things external to the s elf, thus, all three often get equated with being faked for external gain. T he difference is that the s omatoform factitious patient thinks they des erve what they are reques ting to gain bas ed on an illness , whereas the malingerer has no illus ions that s ymptoms are the for the attempted gain. F igure 15-1 demonstrates the relationship of s ymptom 1554 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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production and gain between these three dis orders. C linically, there is a spectrum between these dis orders how symptoms are produced and for what gain, and it the expertise of the clinician that allows him or her to clas sify a pers on who has s ymptoms that are not by known biomedical caus e. S omatoform and factitious disorders imply the pres ence of ps ychopathology or illness , whereas malingering implies the abs ence of ps ychopathology and the presence of s ociopathy.

FIGUR E 15-1 S omatoform, factitious, and malingering disorders : a comparison of s ymptom production, gain, phys iological bas is . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins

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> T able of C ontents > V olume I > 15 - S omatoform Dis orders > G E NE R AL E T IO LOG

GE NE R AL E TIOL OG IE S P art of "15 - S omatoform Dis orders" T he etiologies of all somatoform disorders are T here are theories and some phys iological data to some of thes e theories.

G enetic T here is no direct evidence of a genetic etiology for any the s omatoform dis orders . T he few family and twin that have been conducted s upport a familial etiology for somatization disorder but not for hypochondriasis. support for a familial component for somatic anxiety a general population twin s tudy. Adoption s tudies demonstrate a weak, but present, familial relations hip the somatization phenomenon. T aken as a whole, it appears that a small amount of the variance for developing a preoccupation with body s ensation or a propens ity to amplify bodily sensations is genetically determined.

L earning and S oc ioc ultural A large body of research s upports the idea that early experiences and learning are the primary etiological factors of somatic s ensitivity and bodily preoccupation. C hildren's s ymptoms are often a copy of other family members' s ymptoms . Adult s omatoform s ymptoms are similar to those symptoms that were given attention by parents in childhood. Habitual attention to a given body 1556 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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part improves the ability of a person to detect in that body part. R es earch has demons trated that can be trained to improve perception of bodily S ociocultural construction of body and mind has an impact on how people feel emotion and how it T here is evidence for differential conditioning of phys iological arousal acros s different cultural groups. C ulture also teaches people what is acceptable to and what is not, and this influences the manifes tation emotion and body sensation. S ocioeconomic class , education level, and subculture influence the rates of expres sing emotional distress as somatic complaint. P.1806

P s yc hodynamic F ac tors It is recommended that the reader consult cross material for comprehensive reading on this complicated is sue. T he most compelling theory with some empirical evidence is that the development of narciss is m is into bodily preoccupation. W hen a young child begins make the trans ition to unders tanding that there is something other than self, and thus begins the process separation and identity formation, parental figures can continue to be present and to acknowledge the needs the child during this transition, or they can be intermittently present and absent, creating in the child a sens e of anxiety, fear of abandonment, and betrayal. the latter occurs, the child becomes afraid of the other and is not yet certain of self. Ambivalent anger at other is turned inward as guilt in a defens ive maneuver protect the s elf–other complex, for, if that complex is 1557 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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good, then neither can be the child. T he child does not learn to trus t other or self and begins a proces s of selffocus , s elf-criticis m, and increas ed mis trus t of self. T his abnormal focus on the self through self-reproach and mistrust occurs well before cognition has s ubs tantially developed and thus becomes ass ociated with body sens ations and perception, as well as with affect. T he other complex has betrayed the child, and there fear throughout life that the body as s elf may abandon betray the individual at any time. T he individual, who learned how to focus on the body s elf, begins to do s o more often as a defens e against a catas trophe of body betrayal.

S tres s ors and C oping T he late 20th century brought improved unders tanding the relations hip between life events , trauma, and subs equent s omatic s ymptoms and phys ical health. Advers e life events provide multiple s timuli to which a person res ponds , and that res ponse, often s omatic due autonomic nervous s ys tem and endocrine activation, become conditioned as memory. T his memory is to serve the person to remember the event and to learn avoid other s uch events. However, in pathological syndromes in which memory systems are altered, body memory may be reexperienced in res ponse to s timuli are reminders of earlier s tres sors and trauma. T his phenomenon is cons idered more fully later in the Day-to-day s tres sors also create s omatic experiences may be learned by continued selective perception to sens ation. C oping style then predicts individual to stress ors. If s tres sors are many, pers is tent, or of 1558 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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impact quality, somatic respons es occur and may be learned. If one's coping s tyle is inadequate to res olve phys iological consequences of the s tres sors , then persis tent s omatic res pons es may be learned. who are burdened with an unusually high number of persis tent and high-impact s tres sors and poor coping mechanisms are at the highest ris k of somatoform disorders , as well as s ome other ps ychiatric disorders. Anger, impulsivity, hos tility, is olation, and lack of in others are s ome coping s tyles that have been with an increas ed risk for somatic s ymptoms and somatoform disorders . T here are many empirical that link anger and hostility to somatization. Hos tility, in particular, is as sociated with cardiovascular reactivity greater increas e in blood pres sure in res pons e to compared to nonhostile s ubjects and, along with is the component of the type A personality that is predictive of developing cardiovascular dis eas e. T his provides indirect evidence that this coping style is to physiological reactivity, which is as sociated with somatic sensation and amplification. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > T R E AT ME NT P R INC IP

TR E ATME NT PR INC IPL E S P art of "15 - S omatoform Dis orders"

P atient–P hys ic ian R elations hip S truc ture of Treatment P erhaps there is no set of dis orders that better 1559 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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the importance of the therapeutic relationship between doctor and patient and of treatment structure than the somatoform disorders . T he doctor–patient relations hip the primary element of diligent and committed and is the foundation of all medical practice. It partly imbues the phys ician with power to hurt or to heal, dependent on how the relationship unfolds . P articularly with the somatoform-disordered patient, there are three elements of this relationship that make or break other specific treatment effects. T he firs t of these elements is attention. It has been that one difference between doctors of today and of the past is that, with the advent of and reliance on phys icians today have forgotten how to attend to and to s e e the patient. It is not the dis eas e, but the man or the woman, who needs to be s een and treated. Attending primarily to laboratory values or to the abdomen or the heart only leads to wors ening of the patient with a somatoform disorder and failure on the part of the phys ician. Attention—that s imple yet hard-to-conduct behavior of looking, watching, and listening—if pres ent, allows doctor and patient to move toward care and treatment and, if absent, promotes dislike and anger between doctor and patient and disallows any effective care. T he second important element is unconditional care. It the role of the physician to understand the illnes s and patient who has the illnes s and to provide care. It is not job of the patient to unders tand and to care for the In a patient with a s omatoform dis order, the as tute phys ician unders tands that he or she must know the patient to provide unconditional care, which is 1560 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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characterized by [black right-pointing arrowhead]Acceptance and res pect for the person, his or her symptoms , and the symptoms are adversely affecting the person, which is why he or s he comes to the doctor as a patient. [black right-pointing arrowhead]Hearing what is said by listening to words , s killfully eliciting words are not said, and intentional watching of body movement, and affect. [black right-pointing arrowhead]R eflecting back to patient what has been s aid via all forms of communication and letting him or her know that he she is attended to. [black right-pointing arrowhead]Not expecting or needing appreciation, as many patients with somatoform disorders as sumed a parental role life for parent or other authority figure. R equiring of a s omatoform patient may make his or her symptoms worse. T he third element is skillful treatment. S pecific are cons idered later in this chapter in each s ection. treatment elements in all s omatoform dis orders are es sential to encourage the patient to engage in s pecific treatments . S ome of these elements are referred to as nons pe cific variables of treatment. However, some are general modalities that are more specific to disorders than to other ps ychiatric illness . [black right-pointing arrowhead]Attend to 1561 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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transference and countertransference. T he former allows treatment to occur, and the latter can treatment. P atients with s omatoform dis orders generally do not appreciate their providers , are unsatisfied with care, are not loyal patients , and are attached to their s ymptoms and not to their doctor and his or her caring. E ffective treatment begins by doctor managing his or her countertransference, which, if not done effectively, may res ult in the phys ician avoiding or firing the patient or res cuing him. [black right-pointing arrowhead]F ormulate without labels when the diagnosis is uncertain. T he somatoform patient is s tanding ready to hear the doctor tell him or her that “it is all in your head.” Unfortunately, the s omatoform patient is easily able interpret that this is being s aid, regardless of behavior. T his cue likely acts as the s timulus that recreates scenes in which the patient was not heard, not respected, and not cared for. P.1807 [black right-pointing arrowhead]E valuate appropriately with s tandard and limited workup. the history. C onduct an examination. Order tests one might order for any patient with the s igns and symptoms of the patient being treated. C ons ider ordering a test that is requested by a patient, but it if one would otherwise. Do not pursue the symptom. Do not order repeat tes ts before they are reasonably due. 1562 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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[black right-pointing arrowhead]F rame and make boundaries . Once diagnosed, it is in the bes t the patient to know his or her diagnosis and the treatment plan of the phys ician. It is important to conduct the ps ychos ocial his tory and to dis cuss its relevance to the dis order in a s low, deliberate, and rational way. T his helps the phys ician to restrain impulse to rapidly trans late the phys ical into the ps ychological and gradually allows the patient to unders tand and to integrate information about the role of ps ychos ocial factors in his or her disorder. [black right-pointing arrowhead]C onnect for the patient the languages of ps yche and s oma. T his is perhaps the s ingle mos t important general s kill that allows the therapeutic relationship to move on to specific treatment. Mos t people do not have a with the idea that the mind and body are and, in fact, patients generally wish that doctors think this way more often. However, most people have a hard time unders tanding how the mind and body are connected and how symptoms are Draw pictures of brain centers and how they are connected to and influence peripheral organ functioning. G ive patients homework, cons is tent their educational level, to better unders tand thes e relations hips and to teach the doctor about them. the patient to keep diaries and logs about the relations hip of body symptoms to external events. G ive them s cientific information about ps ychophys iology and s omatic symptom Als o, do not be afraid to discuss what is not known about his or her disorder; just do s o in a competent 1563 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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and confident way. [black right-pointing arrowhead]R eass ure appropriately and s paringly. T his topic is dis cus sed more in this chapter's section on hypochondriasis. R eas sured too much, the s omatoform-disordered patient is certain that the phys ician is not attending the so-called real illness , and, if reass ured too little, patient is convinced that the doctor is hiding information about the ominous medical disorder is lurking. [black right-pointing arrowhead]C ommunicate V olumes have been written on this subject. S uffice say that the phys ician needs to be clear with the somatoform patient on what is said and what is heard without being pedantic or demeaning. T ake time to hear from the patient what is sues were discuss ed during each sess ion, and reframe this information for the patient if it is incorrect. F inally, the structure of treatment is an ess ential part of treatment of the somatoform patient. F ollow-up appointments should be time contingent, not s ymptom contingent. Dis cuss ing the follow-up schedule, its intervals , and its changes is neces sary. E ach might bes t begin by discus sing gains in functioning or changes in emotion or life events . T ime s hould be s et to attend to symptoms with history or physical examination, or both. E ach appointment should end by verifying the next s cheduled appointment and how to urgent care systems . Once diagnosed properly, referral other s pecialis ts s hould be prudently res trained. T here always an urge to refer, and this urge should always be 1564 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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viewed in relation to the countertransference. T hus, the best thing that the doctor can do for the s omatoform patient is to commit to the therapeutic relations hip than to zealous workup or treatment of individual symptoms.

R eas s uranc e R eas surance is discus sed in this chapter's s ection on hypochondriasis, and the reader is als o referred to the reference s ection. R eass urance is a general technique all of medicine and is als o a specific technique to be skillfully with the s omatoform-disordered patient.

C ognitive-B ehavioral and Other P s yc hotherapies T he value of the psychotherapies for somatoform disorders are jus t beginning to be understood. T he should be aware that the rubric cognitive -be havioral the rapy (C B T ) repres ents many modalities that are delivered over a relatively brief period of time, s uch as 20 sess ions . P s ychoanalys is was, as dis cus sed in the history, partly res ponsible for the categorization of the hysterias because of its s ucces s in the hands of some. T here have been more than 30 controlled trials to date designed to evaluate the efficacy of C B T in patients somatization or symptom syndromes . Most of thes e studies targeted a specific s yndrome, s uch as chronic fatigue or irritable bowel dis order, although eight on more general somatization or hypochondriasis. T he most common outcomes meas ured were physical symptoms, ps ychological distress , and functional P hysical symptoms appeared to be the most 1565 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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treatment, as the C B T -treated patients had greater improvement than control subjects in more than twothirds of the s tudies , and there were trends toward improvement in approximately 10 percent of the P sychological dis tres s was definitely improved by C B T compared to control s ubjects in approximately 40 of the studies , with trends toward improvement in approximately 10 percent of the studies . F unctional was definitely helped by C B T in approximately 50 of the studies , and trends toward improvement were shown in approximately 25 percent of the studies. care use seems to be decreased by approximately 25 percent in two s tudies . In s tudies that followed up participants, gains were generally maintained at 12 to months after treatment completion. R andomized, controlled s tudies to date als o s upport efficacy of individual C B T for the treatment of hypochondriasis, body dysmorphic dis order, and undifferentiated s omatoform disorders , which include medically unexplained s ymptoms, chronic fatigue syndrome, and noncardiac ches t pain. G roup C B T has shown effective for the treatment of body dys morphic disorder and s omatization disorder. Long-term and dynamic therapies were the first treatments available for dis orders of unexplained symptoms in the late 19th century and early 20th T here is s ome modern empirical evidence that their use in s omatoform dis orders , and s ome s uggest dynamic therapy is a contraindication (i.e., in disorder) until more basic ps ychosocial is sues have addres sed. One problem with ass es sing outcomes of group of therapies is that there is a range of modalities 1566 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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labeled as dynamic, and thes e therapies als o variably overlap with modalities called C B T . Methods sections some s tudies of s omatoform dis orders often do not describe the kind of therapy conducted or, better, what was actually done and for how long. It will be critical in coming decade to identify the specific and nonspecific ingredients of therapies that are useful for somatoform disorders .

P harmac otherapy T here is mounting evidence for the usefulness of antidepres sant medications in somatoform disorders . C onvers ely, it has been argued that, in these studies, somatoform s ymptoms are often secondary to mood or anxiety disorders , and these comorbid dis orders are effectively treated, decreasing the s omatoform One critical diagnostic feature to determine the choice pharmacotherapy is whether the somatoform disorder primary or s econdary and, if primary, whether there is a comorbid psychiatric condition present. Information is presented in individual dis order s ections of this chapter current pharmacological P.1808 approaches, which should be interpreted in light of the problems with class ification and diagnos is .

C ombination Therapies As in all of medicine, a prudent clinical approach that does no harm is always warranted. S omatoform are dis tres sing, impairing, and costly but are usually emergencies . T his gives the clinician time to diagnose, 1567 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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formulate, and to plan treatment. In most cas es , given epidemiology, comorbidity, and current treatment knowledge, combination therapies of modalities previous ly are used. F urthermore, there are emerging that combination therapies are likely to be the most efficacious for the treatment of somatoform disorders. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > S OMAT IZAT ION DIS O R D

S OMATIZATION DIS OR DE R P art of "15 - S omatoform Dis orders"

Definition S omatization dis orde r is an illnes s of multiple somatic complaints in multiple organ systems that occurs over period of several years and res ults in s ignificant impairment or treatment s eeking, or both. S omatization disorder is the prototypic s omatoform disorder and has the best evidence of any of the somatoform disorders being a s table and reliably meas ured entity over many years in individuals with the disorder.

His tory T he term s omatization was firs t used by W ilhelm S tekel 1943. B riquet's s yndrome was the DS M-III predecess or current somatization dis order, which was named in the revis ed third edition of the DS M (DS M-III-R ).

C omparative Nos ology In the IC D-10, somatization s yndromes of the DS M-IV 1568 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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are distributed among the s omatoform disorders (F 45), diss ociative dis orders (F 44), and neurasthenia (F 48).

E pidemiology S tudies report widely variable lifetime prevalence rates somatization disorder, ranging from 0.2 to 2.0 percent among women and less than 0.2 percent in men. there is evidence that less res trictive diagnos tic criteria than the current DS M-IV -T R criteria carry prevalence of as great as 5 percent with s imilar levels of this population. Approximately 5 percent of primary patients meet diagnostic criteria for the disorder, but more s omatize psychosocial distress . R ecent work demonstrated that 9 percent of hos pitalized general medical patients had s omatization disorder, and 12 percent of chronic pain patients and 17 percent of outpatients with irritable bowel s yndrome met the diagnostic criteria. Differences in prevalence rates on whether the interviewer is a phys ician, on the of ass es sment, and on the demographic variables in samples studied. In epidemiological s tudies , interviewers diagnose somatization disorder more frequently than phys icians . T he onset is before 25 age in 90 percent of people with the dis order, but initial symptoms generally develop during adolescence. R isk factors for children to develop s omatization dis order living with a family member who has the dis order and parental s ubs tance abus e and antis ocial symptoms . female to male ratio ranges from 5 to 1 to 20 to 1. S omatization dis order is relatively more common in areas and in people who are nonwhite and unmarried who have less education. T he type and frequency of 1569 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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somatic symptoms in s omatization disorder, as in and anxiety dis orders, may differ across cultures. F or example, burning hands and feet or nondelusional symptoms of insects crawling under the s kin are symptoms that may be more common in Africa and Asia than in North America. Accordingly, diagnosis take into account cultural norms. T he DS M-IV -T R lists symptoms in order of frequency as found in res earch within the United S tates . C ultural factors may also influence the gender ratio, as there is a higher reported frequency in G reek and P uerto R ican men than in American men. S omatization dis order is obs erved in 10 to 20 percent female first-degree biological relatives of women who have the dis order. T he male relatives of women with somatization disorder s how an increased ris k of personality dis order and substance-related dis orders. Having a biological or adoptive parent with any of these three disorders increases the risk of developing personality dis order, a s ubs tance-related disorder, or somatization disorder. S omatization dis order is not highly prevalent but is proportionally costly. T hese patients seek care approximately three times more often than the U.S . and they incur between 6 and 14 times the national average for health care expenditures for physician and hospital services .

E tiology T he etiology for s omatization disorder is considered in section G eneral E tiologies. 1570 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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A 34-year-old female temporary clerk pres ented with chronic and intermittent dizziness , pares thes ias , pain in multiple areas of her body, and intermittent naus ea and diarrhea. On further his tory, the patient said that the symptoms had been pres ent most of the time, although they had been undulating s ince s he was approximately years of age. In addition to the s ymptoms previous ly mentioned, s he had mild depres sion, was disinterested many things in life, including sexual activity, and had to many doctors to try to find out what was wrong with her. E ven though she had s een many doctors and had many tests , s he s tated that “no one can find out what's wrong” with her. S he wanted another opinion. S he commented that s he had been “sick a lot” since and had been on various medications on and off. examination revealed a normotens ive, s lightly female in no acute distress . S he had diffus e and mild abdominal tendernes s, without true guarding or tenderness . Her neurological examination was normal. winced when physical examination was conducted on various parts of her body, although this wincing went away when the phys ician was s peaking with her while conducting the examination.

Diagnos is and C linic al F eatures T he es sential feature of s omatization dis order is or recurring s omatic complaints in multiple organ that caus e medical treatment or significant impairment social, occupational, or other important areas of functioning. P hys ician-rated legitimacy of the not an es sential criterion of the disorder. T he begin before 30 years of age and occur over s everal 1571 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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(C riterion A), although the type and severity of may change over time. T he multiple s ymptoms are not fully explained by another medical condition or by a subs tance, or, if they do occur as part of another condition, the phys ical complaints or resulting is in excess of what would be expected from the phys ical examination, or laboratory tes ts (C riterion C ). F urther diagnos tic criteria include pain in at leas t four different anatomical sites, at leas t two gas trointes tinal symptoms other than pain, at least one sexual or reproductive s ymptom other than pain, and at leas t one symptom, other than pain, that P.1809 suggests a neurological condition (C riterion B ). T he common pain symptoms in U.S . populations are the head, the back, the abdomen, the joints or the chest, and the rectum, and pain is often present mens truation and with intercourse. T he most common symptoms are naus ea and abdominal bloating, but vomiting, diarrhea, and food intolerance are les s S exual and reproductive s ymptoms may consist of irregular mens es, menorrhagia, or vomiting throughout pregnancy in women. Men are mos t likely to have or ejaculatory dysfunction. Women and men may have sexual indifference. T he ps eudoneurological symptoms commonly include impaired coordination or balance described by the patient as dizzines s, paralysis, paresthes ias or localized weaknes s, difficulty aphonia, urinary hesitancy or retention, hallucinations , diminis hed or loss of touch or pain sensation, double vision, diminished hearing, amnesia, or los s of 1572 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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cons ciousnes s other than fainting. As mentioned previously, a les s restrictive form of somatization that requires fewer s ymptoms for more prevalent than DS M-IV -T R s omatization disorder. T his abridged form has moderate to s trong empirical support for being a sound diagnos is by demons trating similar levels of impairment and health care use as the DS M-IV -T R disorder. T his also highlights the s pectral of somatization and the resultant diagnostic difficulties . P eople with s omatization dis order consider themselves be ill and are us ually reluctant to entertain the idea that the cause of their symptoms arises from psychological social dis tres s. P artly becaus e of the undulating nature the disorder, people with somatization are us ually poor historians, and they seem to exaggerate various each at different times. T hey often defy good medical by attending various clinics and by getting multiple opinions from different doctors. F urthermore, people this dis order often do not report overall improvement, even when s pecific s ymptoms have been address ed by phys ician and have improved. In fact, the improved symptom seems to be forgotten, and the patient moves being bothered by another s ymptom. T his has led to idea that s ymptom s ubs titution occurs in these which one s ymptom develops in place of another that improved. T hese clinical features of the patient do not engender the affection of phys icians. In fact, one study indicated that patients who s omatize are among the illness types who are the least liked by doctors , the being people with s ubs tance abuse, with neurological deficits , and with pers onality disorders . One common feature of these four dis orders is that they are not as 1573 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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unders tood and treated by W estern medicine as are other disorders . T he s omatizing patient often frustrates phys icians , as if the patient is challenging the and good s kill of the doctor. T his frustration alludes to a weaknes s in the s cientific clinical medical education of U.S .-trained physicians , is the lack of education about how mind and body are integrated in their function. As discuss ed previous ly, general distress can be embodied as s omatic which is more common around the world than is ps ychological distress . T he embodiment of distress is cultural odds with much of W estern medical care, views bodily s ymptoms as evidence that there should an identifiable illness in peripheral organs. W hen the search for this propos ed illnes s ends without the symptoms and the patient are logically deemed to inauthentic. T his clinical feature, which becomes part of the countertransference of physician to patient, can an advers arial relations hip between doctor and patient. P sychiatric comorbidity is high in s omatization dis order. P rominent anxiety and mood s ymptoms are common are us ually the reasons for being s een in mental health settings . Major depress ive disorder, panic disorder, subs tance-related dis orders are commonly as sociated I disorders , and histrionic, borderline, and antis ocial personality dis orders are the most commonly Axis II disorders . T here may be impuls ive behavior, threats and attempts, and marital dis cord. T he lives of these individuals are often as chaotic and complicated their s ymptoms . F requent and intermittent us e of medications may lead to s ide effects and s ubs tancedisorders . P eople with somatization dis order are at 1574 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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relatively high risk of iatrogenic harm owing to their increased health care us e, numerous medical examinations, diagnostic procedures, surgeries, and hospitalizations.

P athology T here is no known tiss ue pathology in s omatization disorder. E xperimental studies demonstrate that somatizing patients are more s omatically s ens itive and often are more accurate in dis tinguishing between differences in s timuli compared to normal control F or example, s omatizing subjects are more likely to pain at less er amounts of barium in the colon and can detect smaller volumes of inflation of a balloon at the of an es ophageal endos cope than normal control S omatic amplification is thus the primary pathological finding in this dis order, but thes e phenomena are not easily used in clinical medicine for diagnos is . P hysical examination elicits different s igns on different examinations and is remarkable for the abs ence of objective findings to fully explain the degree of the subjective complaints of patients with this disorder. Laboratory tes t res ults are remarkable for the absence findings to s upport the s ubjective complaints.

Differential Diagnos is T able 15-3 s hows the vas t differential diagnosis for somatization phenomena. T here are three features that most sugges t a diagnos is of somatization dis order of anothe r me dical dis orde r, and thos e are the of multiple organ s ys tems, early onset and chronic without development of physical s igns or s tructural 1575 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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abnormalities , and absence of laboratory abnormalities that are characteristic of the s uggested medical In the process of diagnos is , the as tute clinician other medical disorders that are characterized by multiple, and confus ing s omatic symptoms, s uch as dis e as e , hyperparathyroidis m, inte rmittent porphyria, multiple s cle ros is (MS ), and s ys te mic lupus cours e, other medical disorders may be comorbid with somatization disorder and, in fact, are risk factors for developing s omatization. T he onset of multiple phys ical symptoms late in life must be cons idered to be another medical condition until proven otherwis e.

Table 15-3 Differential Diagnos is the S omatizing Patient P sychophys iological symptoms    P s ychological factors affecting phys ical illness    Nonpathological, transient ps ychogenic s omatic symptoms (all are acute but may become       G rief and bereavement, with physical       F ear, with phys ical s ymptoms       E xaggeration or elaboration of physical

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symptoms (e.g., pos taccident, when litigation or compens ation is involved)       S leep deprivation, with phys ical symptoms       S ensory overload or deprivation, with physical symptoms P sychiatric syndromes (other than s omatoform disorders )    Mood disorders (e.g., major depres sion and dysthymia)    Anxiety dis orders (e.g., panic disorders )    S ubs tance use, abus e, and withdrawal    P s ychotic dis orders (e.g., s chizophrenia, depres sion, and monosymptomatic hypochondriasis)    Adjus tment dis orders with anxiety or or both    P ersonality dis orders    Dementias S omatoform dis orders 1577 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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   S omatization disorder    Hypochondriasis    B ody dys morphic dis order    S omatoform pain dis order    C onversion disorder    S omatoform disorder, not otherwise s pecified V oluntary psychogenic symptoms or s yndromes    F actitious , with physical symptoms (e.g., Munchaus en syndrome)    Malingering, with physical s ymptoms

Adapted from R ubin R H, V os s C , Derks en DJ , et eds. Me dicine : A P rimary C are Approach. WB S aunders; 1996:390. G iven the nature of the multiple somatic complaints in somatization disorder, there are many other pos sible somatoform and psychiatric disorders in the differential diagnosis. W hen full criteria are not met, s omatoform dis order is diagnosed if the duration of the syndrome is 6 months or longer, and s omatoform 1578 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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not othe rwis e s pecifie d (NOS ) is diagnosed for of shorter duration. As noted in the previous discus sion the core phenomenology of s omatoform dis orders , is overlap between these dis orders and factitious and malinge ring disorders , dependent on whether the symptom production is volitional and on the nature of gain. W hen these elements are mixed, s omatization disorder and a factitious dis order or malingering can be diagnosed. Mood and anxie ty dis orders often, but not always , have prominent s omatic s ymptoms, which do exis t separately from the mood or anxiety dis order. However, s omatization disorder may be diagnos ed as comorbid condition with mood and anxiety disorders . S chizophre nia and other ps ychotic dis orde rs with somatic delusions need to be differentiated from the nondelus ional s omatic complaints of individuals with somatization disorder. Hallucinations can occur as ps eudoneurological symptoms and mus t be from the typical hallucinations s een in P.1810 schizophrenia. S omatization disorder s ymptoms are us ually eas ier to distinguis h from ps ychotic dis orders is the case for hypochondrias is , the disease fears of can reach delusional quality.

C ours e and P rognos is S omatization dis order is a chronic, undulating, and relaps ing disorder that rarely remits completely. It is unusual for the individual with s omatization disorder to free of symptoms or help seeking for greater than 1 R es earch has indicated that a pers on diagnos ed with 1579 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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somatization disorder has approximately an 80 percent chance of being diagnos ed with this dis order 5 years Although patients with this dis order cons ider to be medically ill, there is good evidence that they are more likely to develop another medical illnes s in the 20 years than people without s omatization disorder.

Treatment T he primary mainstay of treatment is managing and helping the patient unders tand that symptom does not equal dis eas e. P romoting function is a key of education and treatment. An early s tudy that s ending a cons ultation letter to primary care phys icians suggesting how to treat identified patients somatization disorder resulted in increas ed physical functioning and decreas ed health care cos ts for those patients. R ecent work s hows promis e for cognitive and behavioral therapies . One uncontrolled study us ing C B T that focus ed on patient education and s tres s reduction demonstrated moderate but significant improvement of phys ical s ymptoms , s omatic preoccupation, hypochondriasis, and health care use compared to a control group of untreated patients. Another uncontrolled trial of ten sess ions of individual demonstrated patient-reported significant improvement in symptomatology and phys ical functioning between baseline and pos ttreatment, as well as between and follow-up 8 months later. One randomized clinical trial of group therapy with 70 patients demonstrated significantly better patient-reported phys ical and mental health in a 1-year period during after therapy. T he more group sess ions attended, the greater the improvement in general and mental health. 1580 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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T here was also a 52 percent net savings in health care charges in the year after treatment compared to the before. P harmacological treatment for somatization dis order is well unders tood. In one pros pective, 8-week, openstudy, 15 patients diagnos ed with full or abridged somatization disorder were treated with nefazodone (S erzone). F ourteen of the 15 patients achieved the dosage of 300 mg per day and completed the trial, and percent of the patients were rated as globally improved and s ignificantly improved on functional abilities as meas ured by the Medical Outcomes S tudy S hort F orm(S F -36). E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > HY P OC HO NDR IAS

HYPOC HONDR IAS IS P art of "15 - S omatoform Dis orders"

Definition Hypochondrias is is characterized by 6 months or more general and nondelus ional preoccupation with fears of having, or the idea that one has, a s erious dis eas e the person's mis interpretation of bodily symptoms. T his preoccupation caus es significant distress and in one's life, it is not accounted for by another or medical disorder, and a s ubs et of individuals with hypochondriasis has poor ins ight about the presence of this dis order. 1581 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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His tory C onfusion and conceptual change epitomize the hypochondriasis. Is sy P ilowsky was the first modern inves tigator to identify the three dimens ions of bodily preoccupation, disease phobia, and disease conviction with a failure to res pond to medical evaluation and reass urance that now compris e hypochondriasis. inves tigators have replicated the validity of these dimensions .

C omparative Nos ology IC D-10 hypochondriacal dis orde r is s imilar to DS M-IV hypochondriasis, but also includes body dysmorphophobia as one potential “A” criterion, which not pos sible by DS M-IV -T R criteria. DS M-IV -T R hypochondriasis highlights the element of misinterpretation of body s ymptoms.

E pidemiology T here are no good community epidemiological data hypochondriasis. T he E pidemiological C atchment Area S tudy and the National C omorbidity S urvey failed to include hypochondrias is. T his reinforces the notion that hypochondriasis is cons idered les s important than ps ychiatric disorders or that it is cons idered invalid or unreliable, or that both are true. F or whatever reason, this has rendered knowledge of the of this disorder deficient. E arly researchers sugges ted community prevalence rates between 4 and 25 R obert K ellner pioneered the Illness Attitudes S cales determined a 2 to 13 percent prevalence of disease in many nonclinical settings, including employee 1582 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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community samples, and medical and law students. current es timates are that there is a 1.1 to 4.5 percent prevalence of hypochondriasis in the community and additional 10 percent of people who have hypochondriacal fears and beliefs . P.1811 Data from nonps ychiatric medical s ettings have relied primarily on s creening instruments for prevalence and have used both dimens ional and categorical to determine rates . Hypochondrias is is probably more common in these settings with a prevalence between and 10.3 percent. Medical s pecialty clinics, such as gastroenterology, otolaryngology, neurology, and endocrinology, have a higher rate of hypochondriacs. prevalence is approximately 12 to 22 percent in outpatients and 30 to 45 percent in ps ychiatric although people with other psychiatric disorders are uncommonly diagnosed with hypochondrias is . T he onset of the disorder is mos t commonly in the third fourth decade of life, and the s ymptoms at different do not differ s ignificantly, except for a higher depres sion in the elderly. Hypochondriasis is equally common in men and women. S tudies s uggest a s lightly higher prevalence in people with lower education and income levels and in African Americans after for socioeconomic status . P hysical dis ease does not to be as sociated with hypochondrias is . Dis eas e does predict the onset nor do people with hypochondriasis develop more physical disease over many years after diagnosis. Little is known about other factors people to hypochondriasis, although there is a 1583 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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that certain personality features and adverse life events may contribute to the genesis of this dis order.

E tiology T he etiology of hypochondriasis is cons idered in the section G eneral E tiologies.

Diagnos is and C linic al F eatures T he critical diagnos tic feature of hypochondriasis is at 6 months of impairment caus ed by preoccupation with fears of having, or the idea that one has, a s erious based on a misinterpretation of one or more bodily or s ymptoms (C riteria A, D, and E ), and the persis ts despite medical reass urance (C riterion B ). F or hypochondriasis to be diagnos ed when another condition is present, the phys ical s igns or symptoms cannot fully account for the person's preoccupation disease. T he dis eas e phobia present in not of delusional intens ity and is not res tricted to a circums cribed concern about appearance, as s een in dys morphic dis orde r (C riterion C ). T he preoccupation better accounted for by other ps ychiatric disorders cons idered in the following discus sion of differential diagnosis (C riterion F ). T he W hiteley Index and the Attitude S cales have demons trated 71/80 percent and 72/79 percent, res pectively, to diagnosis. T here are rational doubts about hypochondrias is as a distinct entity. Inves tigators have established internal validity bas ed on DS M criteria and external and validity to measures of fear, anxiety, depress ion, vulnerability to illnes s, somatic amplification, and health 1584 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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care s ervice us e. T hree s tudies have demons trated predictive validity, demonstrating that 50 to 70 percent hypochondriacs continue to have the diagnos is after 1 years and that those who no longer meet diagnos tic criteria s till have more bodily preoccupation than subjects . However, family and twin studies have failed demonstrate a genetic basis for hypochondrias is . hypochondriacal probands have a s tronger family as sociation to s omatization dis order. Dis criminant for hypochondriasis is less s ound than internal and concurrent validity. T he preoccupation in hypochondrias is may be with functions , minor physical abnormalities , or ambiguous phys ical s ens ations . T he pers on attributes these or s igns to a sus pected disease and is concerned with meaning and cause. T he concerns may involve several body systems or may be about a s pecific organ or a disease. E xaminations , diagnostic tests , and from the phys ician do not generally reass ure the hypochondriac, es pecially in chronic conditions and these examinations and tes ts are conducted in a perceived as flippant by the patient. F or example, an individual preoccupied with having MS may not be reass ured by the repeated lack of findings on phys ical examination or neuroimaging studies. In fact, showing radiological pictures to a hypochondriacal patient may elicit heightened distress when the patient sees a structure and firmly interprets it as being abnormal. T he actual preoccupation with dis ease may be so that s pecific s ymptoms are not the central concern or absent. However, hypochondriacal patients do report more s ymptoms than healthy control s ubjects. P eople 1585 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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hypochondriasis are also highly thanatophobic, and degree of death fear is greater than in people with s omatization dis order. T hanatophobia is a central clinical feature of hypochondriasis and highlights the relations hip to and embodiment of personality features . Hypochondriacs focus so much on their own body that there is a decrease of interes t in other people or other matters outside of their body. T hey obsess ionally focus on thoughts about having a dis eas e, first this one and then maybe that one to the exclusion of, or marked in, thoughts about anything other than s elf. have noted this conflictual relations hip of the hypochondriac to his or her body, having s evere fears somatic uncertainty coupled with rigid certainty about state of his or her health. T his manifests in help s eeking and attention to details of s ymptoms that irrelevant to their overall health coupled with rejecting help for real health problems and inattention to health behaviors . F or example, a hypochondriac may certain that he or s he has heart disease, even when a reasonable evaluation is negative, yet he or s he may ignore sugges tions to prevent pos sible heart disease through exercise, a low-fat diet, and cholesterolmedications . T hey are persistent s eekers of rather than of treatment, are largely uns atis fied with medical care, and often feel that physicians have not recognized their needs. In this way, hypochondriasis is embodiment of neurotic, obs ess ional, and narcis sistic personality features, which are the pers onality traits the most empirical s upport in their relations hip to hypochondriasis. C lass ical and contemporary authors 1586 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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emphasized how hypochondrias is develops from, or is of, a defective ego s tructure, pos sibly as a result of object relations and insecure attachments during development, and how narciss is tic injury res ults in a defens ive focus on the body s elf. T his defensive with perfect health res ults in amplified and s elective somatic perception, cognitive distortions about the meaning of s ymptoms, and fear of illness and death because of the belief that inner badness may cause the body to s uddenly and perhaps fatally betray the at any time.

P athology T here is no known s omatic pathology s pecific to hypochondriasis. Nineteenth-century investigators who conducted postmortem examinations on debated whether there was inflammation and in the upper G I tract. T his was refuted.

Differential Diagnos is T he most common condition in the differential of hypochondriasis is trans ie nt preoccupation with the of having a dis eas e . T his is a commonly dis cuss ed phenomenon that may occur during the course of training, known as the me dical s tude nt s yndrome . T his syndrome has been reported in two s tudies to occur 70 to 79 percent prevalence in medical students. another study compared medical students with law students, who had the s ame level of hypochondriacal and beliefs and took only s lightly less precautions their P.1812 1587 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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health and paid only slightly les s attention to s omatic symptoms. T hus , trans ie nt fe ars of having a dis eas e limited to medical students but are most likely to occur when a person has s ome experience with major disease, or death, such as when one's family member or when one's friend contracts a s erious illnes s. T he most important s et of conditions to consider in the differential diagnosis of hypochondriasis is another me dical condition. B efore the use of improved techniques and instruments , it may have been common for early, undetected medical disorders to be thought to be a form of hypochondriasis , perhaps in as many as percent of people diagnosed as hypochondriacal. approximately 2 to 5 percent of people diagnosed with hypochondriasis are symptomatic of another medical disorder that is s ubs equently diagnos ed. However, are no good pros pective s tudies on this is sue, and the purported hypochondriacal s ymptoms could be symptoms of many subsequent medical conditions, at least one of which everyone, at some time, acquires . are no typical diseases that s hould be cons idered in differential diagnosis. T he physician is implored to think clearly about other ins idious dis eas es that could be the caus e of the patients ' symptoms , s uch as those in the endocrine, neurological, autoimmune, and malignant categories . However, a phys ician s hould als o not iatrogenic harm by conducting tes ts without good rationale. T he pres ence of another medical condition not rule out coexisting hypochondrias is . In fact, people with chronic medical illnes s are more likely than those without chronic illness to have a comorbid somatoform 1588 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disorder, usually hypochondriasis or somatization E ven if the patient has a known medical illness , the diagnosis of hypochondriasis can be made if it can be definitively es tablis hed that the symptoms and preoccupation with the fear of having dis ease are out proportion to the seriousness of the organic pathology. However, given the variability in normal respons e to and disease, the diagnosis of hypochondrias is in the context of other known medical pathology s hould be res erved for individuals who are able to benefit from diagnosis by having an explanation for the degree of suffering and by being able to benefit from treatment hypochondriasis. Other somatoform dis orders are in the differential diagnosis. S omatization dis orde r occurs in 7 to 40 of individuals diagnosed with hypochondriasis . Much of the des criptive literature to date cons iders s omatization disorder and hypochondriasis together in their genes is and phenomenology. A few recent studies conclude they are s eparate entities and that people with somatization disorder are more concerned with actual symptoms, have more abnormal personality and more depres sion and anxiety, and are more likely seek treatment, whereas people with hypochondriasis more afraid of death. F igure 15-2 depicts a model of hypochondriasis P.1813 and s omatization that helps identify s hared and characteristics , as well as places to intervene with treatment. P eople with body dys morphic dis order and hypochondriasis s hare elements of obsess ive 1589 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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preoccupation with their body as sociated with specific overvalued ideas . However, the difference is that with body dys morphic disorder focus on specific, presumed defects , are not as fearful of having a of death, and are more likely to s eek s pecific medical such as cos metic surgery or dermatological advice.

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FIGUR E 15-2 S omatization and hypochondriasis. (Data from Hollifield M, T uttle L, P aine S , K ellner R : Hypochondrias is and somatization related to and attitudes toward s elf. P s ychos omatics . 1591 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Other psychiatric dis orders are also in the differential diagnosis of hypochondrias is . A ps ychotic dis orde r, a de lus ional dis orde r, a major affective dis order with ps ychotic fe atures , and s chizophre nia, mus t be ruled before establishing the diagnosis of hypochondriasis. It may be difficult to dis tinguis h between disease phobia, disease conviction, and a ps ychotic process . Many with hypochondriasis have a firm conviction that they have a disease, and there is a fair debate about delus ional thoughts are part of hypochondriasis. an individual with hypochondriacal delus ions has a unfounded belief that a dis eas e is present. those with hypochondriacal delus ions often have explanations for their belief or gross impairment of or both, such as being convinced they have been poisoned, that their organs have somehow moved, or someone or s omething outside of s elf has agency over their organs and health. Hypochondriacal beliefs accompany de pres s ion in at leas t a great minority of people with s ignificant depress ive s ymptoms . T here good s tudies that determine whether hypochondriacal beliefs are more common in major depress ion than in dysthymia or depres sion in the context of bipolar disorder. A diagnosis of a major affective disorder is likely if the hypochondriacal preoccupations begin in life. T reatment of depress ion is likely to diminis h or to ablate hypochondriacal fears that are s econdary to the depres sion, whereas comorbid primary much les s likely to abate with s uccess ful treatment of comorbid depress ion. Anxie ty dis orders are highly 1592 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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comorbid with hypochondrias is. Individuals with hypochondriasis have intrusive thoughts about the fear having a dis eas e and also may have as sociated behaviors (e.g., checking their blood press ure). T he relations hip between hypochondriasis and obsess ional personality is well known. However, although this preoccupation in hypochondrias is is distress ing, the patient believes that he or s he has a disease, and, in sens e, the disease conviction is not ego-dystonic. separate diagnos is of obs e s s ive -compuls ive dis order is warranted only when the obses sions or compulsions not res tricted to concerns about illnes s and meet other criteria for the dis order, including that the s ymptoms ego-dystonic. S pe cific phobias are generally not limited the body but s hould be cons idered in the person with hypochondriasis. P anic dis orde r and ge neralize d dis order are highly comorbid with hypochondrias is . Approximately 50 percent of patients diagnosed with panic dis orde r have significant hypochondriacal preoccupations. C onversely, one study demonstrated more than 50 percent of patients with hypochondriasis had panic disorder. G e ne ralize d anxie ty dis orde r is less common in hypochondriasis than in panic but studies about this comorbidity are scarce. T hese anxiety dis orders s hare common features with hypochondriasis, s uch as pathological fear and worry behaviors designed to diminish anxiety. However, in people with hypochondrias is , the fear and worry are limited to the idea of disease, and they do not have the autonomic s ymptoms ass ociated with panic or generalized anxiety disorder. Malinge ring and pe rs onality dis orde rs are in the 1593 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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diagnosis of hypochondriasis and are cons idered more fully in other parts of this chapter.

C ours e and P rognos is T he cours e of hypochondrias is is us ually intermittent chronic. Approximately two-thirds of people diagnos ed with hypochondrias is continue to have the dis order 1 later, and thos e who are not diagnos able have hypochondriacal symptoms. P oor prognostic factors include s everity and duration of symptoms, comorbid ps ychiatric disorders, and neuroticis m, including instability and interpers onal vulnerability. Acute onset, medical comorbidity, the abs ence of a current or past or II ps ychiatric disorder, and the abs ence of gain are favorable prognos tic indicators . R is k factors developing trans ient hypochondriasis are a past ps ychiatric history, pers onality pathology, and an underlying s ens itivity to somatic s ens ations . Well-devis ed reas surance, cons is ting of the of a s hared explanatory model between doctor and patient, education, and the rational use of examination and laboratory tes ting can improve the prognosis in than one-half of people with hypochondrias is , those with trans ient or s hort duration of s ymptoms and with other positive prognos tic factors .

Treatment R eas s uranc e A thorough description of the definition and us e of reass urance in hypochondriasis has recently been well discuss ed. Discus sion with the hypochondriacal patient 1594 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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about the fals e nature of his or her illnes s is not However, reass urance that is delivered confidently by a competent doctor us ing multiple modalities , including skillful examination, effective communication, and education, is the corners tone of treatment of the hypochondriacal patient. W ithout s ucces sful more s pecific treatments are not likely to be accepted adhered to by the patient. Important elements of reass urance are s hown in T able 15-4.

Table 15-4 E lements of E ffec tive R eas s uranc e in Hypoc hondrias is T horough examination of medical records and history Acceptance of the patient, his or her complaints , their legitimacy S cheduling regular visits with a clear goal Using clear and s imple language with terms P roviding relevant information and explanations F os tering the patient's respons ibility for his or her treatment

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S hifting attention from physical symptoms to underlying ps ychological and s ocial problems and focus ing on patient as sets Adjusting a reass uring s tyle in a way that is for a given patient P roviding repeated reas surance P erforming appropriate examinations and tests adequate explanation

Adapted from S tarcevic V . R eas surance in the treatment of hypochondriasis . In: Lipsitt D, V , eds. Hypochondrias is : Modern P ers pective s Ancie nt Malady. Oxford, UK : Oxford University 2001:299-308. It is important that all therapies work to diminis h the preoccupation with the fear of having a dis ease. T hus , reass urance is effective when preoccupation and is harmful when it gets wors e. T his can happen, for example, when examinations and tes ts iatrogenically reinforce the notion that a dis eas e is present. Another example is when the patient believes that a doctor is competent to find the dis eas e that is believed to be present or that the doctor is dis miss ing the patient's concerns by shifting attention to emotional or social is sues. However, when there is a therapeutic 1596 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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that is trusting due to the competence and s kill of the phys ician, then examinations, tes ts, and shifting to important ps ychosocial is sues in the patient's life encourage the patient to focus on relevant features of illness and not on the diseas e phobia. P.1814

C ognitive-B ehavioral Therapy (C B T) Uncontrolled case series have demons trated promis ing res ults of C B T in hypochondriasis . T wo controlled are als o s upportive for C B T being effective in hypochondriasis. P s ychoeducation and cognitive aimed at changing the thoughts that there is a disease present have been the standard of treatment for many years . P oor prognos tic factors for success ful C B T wors e hypochondriasis, more somatic s ymptoms , ps ychiatric comorbidity, more dysfunctional thoughts about body functions , and higher levels of health care and s ocial impairment.

Pharmac ologic al S elective serotonin reuptake inhibitors (S S R Is) and serotonin norepinephrine reuptake inhibitors (S NR Is ) been s hown to be us eful for hypochondriasis in a few small, open-label studies. Larger clinical trials were way at this writing. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > HY P OC HO NDR IAS

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P art of "15 - S omatoform Dis orders"

Definition Hypochondrias is is characterized by 6 months or more general and nondelus ional preoccupation with fears of having, or the idea that one has, a s erious dis eas e the person's mis interpretation of bodily symptoms. T his preoccupation caus es significant distress and in one's life, it is not accounted for by another or medical disorder, and a s ubs et of individuals with hypochondriasis has poor ins ight about the presence of this dis order.

His tory C onfusion and conceptual change epitomize the hypochondriasis. Is sy P ilowsky was the first modern inves tigator to identify the three dimens ions of bodily preoccupation, disease phobia, and disease conviction with a failure to res pond to medical evaluation and reass urance that now compris e hypochondriasis. inves tigators have replicated the validity of these dimensions .

C omparative Nos ology IC D-10 hypochondriacal dis orde r is s imilar to DS M-IV hypochondriasis, but also includes body dysmorphophobia as one potential “A” criterion, which not pos sible by DS M-IV -T R criteria. DS M-IV -T R hypochondriasis highlights the element of misinterpretation of body s ymptoms.

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E pidemiology T here are no good community epidemiological data hypochondriasis. T he E pidemiological C atchment Area S tudy and the National C omorbidity S urvey failed to include hypochondrias is. T his reinforces the notion that hypochondriasis is cons idered les s important than ps ychiatric disorders or that it is cons idered invalid or unreliable, or that both are true. F or whatever reason, this has rendered knowledge of the of this disorder deficient. E arly researchers sugges ted community prevalence rates between 4 and 25 R obert K ellner pioneered the Illness Attitudes S cales determined a 2 to 13 percent prevalence of disease in many nonclinical settings, including employee community samples, and medical and law students. current es timates are that there is a 1.1 to 4.5 percent prevalence of hypochondriasis in the community and additional 10 percent of people who have hypochondriacal fears and beliefs . P.1811 Data from nonps ychiatric medical s ettings have relied primarily on s creening instruments for prevalence and have used both dimens ional and categorical to determine rates . Hypochondrias is is probably more common in these settings with a prevalence between and 10.3 percent. Medical s pecialty clinics, such as gastroenterology, otolaryngology, neurology, and endocrinology, have a higher rate of hypochondriacs. prevalence is approximately 12 to 22 percent in outpatients and 30 to 45 percent in ps ychiatric 1599 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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although people with other psychiatric disorders are uncommonly diagnosed with hypochondrias is . T he onset of the disorder is mos t commonly in the third fourth decade of life, and the s ymptoms at different do not differ s ignificantly, except for a higher depres sion in the elderly. Hypochondriasis is equally common in men and women. S tudies s uggest a s lightly higher prevalence in people with lower education and income levels and in African Americans after for socioeconomic status . P hysical dis ease does not to be as sociated with hypochondrias is . Dis eas e does predict the onset nor do people with hypochondriasis develop more physical disease over many years after diagnosis. Little is known about other factors people to hypochondriasis, although there is a that certain personality features and adverse life events may contribute to the genesis of this dis order.

E tiology T he etiology of hypochondriasis is cons idered in the section G eneral E tiologies.

Diagnos is and C linic al F eatures T he critical diagnos tic feature of hypochondriasis is at 6 months of impairment caus ed by preoccupation with fears of having, or the idea that one has, a s erious based on a misinterpretation of one or more bodily or s ymptoms (C riteria A, D, and E ), and the persis ts despite medical reass urance (C riterion B ). F or hypochondriasis to be diagnos ed when another condition is present, the phys ical s igns or symptoms cannot fully account for the person's preoccupation 1600 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disease. T he dis eas e phobia present in not of delusional intens ity and is not res tricted to a circums cribed concern about appearance, as s een in dys morphic dis orde r (C riterion C ). T he preoccupation better accounted for by other ps ychiatric disorders cons idered in the following discus sion of differential diagnosis (C riterion F ). T he W hiteley Index and the Attitude S cales have demons trated 71/80 percent and 72/79 percent, res pectively, to diagnosis. T here are rational doubts about hypochondrias is as a distinct entity. Inves tigators have established internal validity bas ed on DS M criteria and external and validity to measures of fear, anxiety, depress ion, vulnerability to illnes s, somatic amplification, and health care s ervice us e. T hree s tudies have demons trated predictive validity, demonstrating that 50 to 70 percent hypochondriacs continue to have the diagnos is after 1 years and that those who no longer meet diagnos tic criteria s till have more bodily preoccupation than subjects . However, family and twin studies have failed demonstrate a genetic basis for hypochondrias is . hypochondriacal probands have a s tronger family as sociation to s omatization dis order. Dis criminant for hypochondriasis is less s ound than internal and concurrent validity. T he preoccupation in hypochondrias is may be with functions , minor physical abnormalities , or ambiguous phys ical s ens ations . T he pers on attributes these or s igns to a sus pected disease and is concerned with meaning and cause. T he concerns may involve several body systems or may be about a s pecific organ or a 1601 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disease. E xaminations , diagnostic tests , and from the phys ician do not generally reass ure the hypochondriac, es pecially in chronic conditions and these examinations and tes ts are conducted in a perceived as flippant by the patient. F or example, an individual preoccupied with having MS may not be reass ured by the repeated lack of findings on phys ical examination or neuroimaging studies. In fact, showing radiological pictures to a hypochondriacal patient may elicit heightened distress when the patient sees a structure and firmly interprets it as being abnormal. T he actual preoccupation with dis ease may be so that s pecific s ymptoms are not the central concern or absent. However, hypochondriacal patients do report more s ymptoms than healthy control s ubjects. P eople hypochondriasis are also highly thanatophobic, and degree of death fear is greater than in people with s omatization dis order. T hanatophobia is a central clinical feature of hypochondriasis and highlights the relations hip to and embodiment of personality features . Hypochondriacs focus so much on their own body that there is a decrease of interes t in other people or other matters outside of their body. T hey obsess ionally focus on thoughts about having a dis eas e, first this one and then maybe that one to the exclusion of, or marked in, thoughts about anything other than s elf. have noted this conflictual relations hip of the hypochondriac to his or her body, having s evere fears somatic uncertainty coupled with rigid certainty about state of his or her health. T his manifests in help s eeking and attention to details of s ymptoms that 1602 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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irrelevant to their overall health coupled with rejecting help for real health problems and inattention to health behaviors . F or example, a hypochondriac may certain that he or s he has heart disease, even when a reasonable evaluation is negative, yet he or s he may ignore sugges tions to prevent pos sible heart disease through exercise, a low-fat diet, and cholesterolmedications . T hey are persistent s eekers of rather than of treatment, are largely uns atis fied with medical care, and often feel that physicians have not recognized their needs. In this way, hypochondriasis is embodiment of neurotic, obs ess ional, and narcis sistic personality features, which are the pers onality traits the most empirical s upport in their relations hip to hypochondriasis. C lass ical and contemporary authors emphasized how hypochondrias is develops from, or is of, a defective ego s tructure, pos sibly as a result of object relations and insecure attachments during development, and how narciss is tic injury res ults in a defens ive focus on the body s elf. T his defensive with perfect health res ults in amplified and s elective somatic perception, cognitive distortions about the meaning of s ymptoms, and fear of illness and death because of the belief that inner badness may cause the body to s uddenly and perhaps fatally betray the at any time.

P athology T here is no known s omatic pathology s pecific to hypochondriasis. Nineteenth-century investigators who conducted postmortem examinations on debated whether there was inflammation and 1603 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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in the upper G I tract. T his was refuted.

Differential Diagnos is T he most common condition in the differential of hypochondriasis is trans ie nt preoccupation with the of having a dis eas e . T his is a commonly dis cuss ed phenomenon that may occur during the course of training, known as the me dical s tude nt s yndrome . T his syndrome has been reported in two s tudies to occur 70 to 79 percent prevalence in medical students. another study compared medical students with law students, who had the s ame level of hypochondriacal and beliefs and took only s lightly less precautions their P.1812 health and paid only slightly les s attention to s omatic symptoms. T hus , trans ie nt fe ars of having a dis eas e limited to medical students but are most likely to occur when a person has s ome experience with major disease, or death, such as when one's family member or when one's friend contracts a s erious illnes s. T he most important s et of conditions to consider in the differential diagnosis of hypochondriasis is another me dical condition. B efore the use of improved techniques and instruments , it may have been common for early, undetected medical disorders to be thought to be a form of hypochondriasis , perhaps in as many as percent of people diagnosed as hypochondriacal. approximately 2 to 5 percent of people diagnosed with hypochondriasis are symptomatic of another medical disorder that is s ubs equently diagnos ed. However, 1604 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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are no good pros pective s tudies on this is sue, and the purported hypochondriacal s ymptoms could be symptoms of many subsequent medical conditions, at least one of which everyone, at some time, acquires . are no typical diseases that s hould be cons idered in differential diagnosis. T he physician is implored to think clearly about other ins idious dis eas es that could be the caus e of the patients ' symptoms , s uch as those in the endocrine, neurological, autoimmune, and malignant categories . However, a phys ician s hould als o not iatrogenic harm by conducting tes ts without good rationale. T he pres ence of another medical condition not rule out coexisting hypochondrias is . In fact, people with chronic medical illnes s are more likely than those without chronic illness to have a comorbid somatoform disorder, usually hypochondriasis or somatization E ven if the patient has a known medical illness , the diagnosis of hypochondriasis can be made if it can be definitively es tablis hed that the symptoms and preoccupation with the fear of having dis ease are out proportion to the seriousness of the organic pathology. However, given the variability in normal respons e to and disease, the diagnosis of hypochondrias is in the context of other known medical pathology s hould be res erved for individuals who are able to benefit from diagnosis by having an explanation for the degree of suffering and by being able to benefit from treatment hypochondriasis. Other somatoform dis orders are in the differential diagnosis. S omatization dis orde r occurs in 7 to 40 of individuals diagnosed with hypochondriasis . Much of the des criptive literature to date cons iders s omatization 1605 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disorder and hypochondriasis together in their genes is and phenomenology. A few recent studies conclude they are s eparate entities and that people with somatization disorder are more concerned with actual symptoms, have more abnormal personality and more depres sion and anxiety, and are more likely seek treatment, whereas people with hypochondriasis more afraid of death. F igure 15-2 depicts a model of hypochondriasis P.1813 and s omatization that helps identify s hared and characteristics , as well as places to intervene with treatment. P eople with body dys morphic dis order and hypochondriasis s hare elements of obsess ive preoccupation with their body as sociated with specific overvalued ideas . However, the difference is that with body dys morphic disorder focus on specific, presumed defects , are not as fearful of having a of death, and are more likely to s eek s pecific medical such as cos metic surgery or dermatological advice.

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FIGUR E 15-2 S omatization and hypochondriasis. (Data from Hollifield M, T uttle L, P aine S , K ellner R : Hypochondrias is and somatization related to and attitudes toward s elf. P s ychos omatics . 1607 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Other psychiatric dis orders are also in the differential diagnosis of hypochondrias is . A ps ychotic dis orde r, a de lus ional dis orde r, a major affective dis order with ps ychotic fe atures , and s chizophre nia, mus t be ruled before establishing the diagnosis of hypochondriasis. It may be difficult to dis tinguis h between disease phobia, disease conviction, and a ps ychotic process . Many with hypochondriasis have a firm conviction that they have a disease, and there is a fair debate about delus ional thoughts are part of hypochondriasis. an individual with hypochondriacal delus ions has a unfounded belief that a dis eas e is present. those with hypochondriacal delus ions often have explanations for their belief or gross impairment of or both, such as being convinced they have been poisoned, that their organs have somehow moved, or someone or s omething outside of s elf has agency over their organs and health. Hypochondriacal beliefs accompany de pres s ion in at leas t a great minority of people with s ignificant depress ive s ymptoms . T here good s tudies that determine whether hypochondriacal beliefs are more common in major depress ion than in dysthymia or depres sion in the context of bipolar disorder. A diagnosis of a major affective disorder is likely if the hypochondriacal preoccupations begin in life. T reatment of depress ion is likely to diminis h or to ablate hypochondriacal fears that are s econdary to the depres sion, whereas comorbid primary much les s likely to abate with s uccess ful treatment of comorbid depress ion. Anxie ty dis orders are highly 1608 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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comorbid with hypochondrias is. Individuals with hypochondriasis have intrusive thoughts about the fear having a dis eas e and also may have as sociated behaviors (e.g., checking their blood press ure). T he relations hip between hypochondriasis and obsess ional personality is well known. However, although this preoccupation in hypochondrias is is distress ing, the patient believes that he or s he has a disease, and, in sens e, the disease conviction is not ego-dystonic. separate diagnos is of obs e s s ive -compuls ive dis order is warranted only when the obses sions or compulsions not res tricted to concerns about illnes s and meet other criteria for the dis order, including that the s ymptoms ego-dystonic. S pe cific phobias are generally not limited the body but s hould be cons idered in the person with hypochondriasis. P anic dis orde r and ge neralize d dis order are highly comorbid with hypochondrias is . Approximately 50 percent of patients diagnosed with panic dis orde r have significant hypochondriacal preoccupations. C onversely, one study demonstrated more than 50 percent of patients with hypochondriasis had panic disorder. G e ne ralize d anxie ty dis orde r is less common in hypochondriasis than in panic but studies about this comorbidity are scarce. T hese anxiety dis orders s hare common features with hypochondriasis, s uch as pathological fear and worry behaviors designed to diminish anxiety. However, in people with hypochondrias is , the fear and worry are limited to the idea of disease, and they do not have the autonomic s ymptoms ass ociated with panic or generalized anxiety disorder. Malinge ring and pe rs onality dis orde rs are in the 1609 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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diagnosis of hypochondriasis and are cons idered more fully in other parts of this chapter.

C ours e and P rognos is T he cours e of hypochondrias is is us ually intermittent chronic. Approximately two-thirds of people diagnos ed with hypochondrias is continue to have the dis order 1 later, and thos e who are not diagnos able have hypochondriacal symptoms. P oor prognostic factors include s everity and duration of symptoms, comorbid ps ychiatric disorders, and neuroticis m, including instability and interpers onal vulnerability. Acute onset, medical comorbidity, the abs ence of a current or past or II ps ychiatric disorder, and the abs ence of gain are favorable prognos tic indicators . R is k factors developing trans ient hypochondriasis are a past ps ychiatric history, pers onality pathology, and an underlying s ens itivity to somatic s ens ations . Well-devis ed reas surance, cons is ting of the of a s hared explanatory model between doctor and patient, education, and the rational use of examination and laboratory tes ting can improve the prognosis in than one-half of people with hypochondrias is , those with trans ient or s hort duration of s ymptoms and with other positive prognos tic factors .

Treatment R eas s uranc e A thorough description of the definition and us e of reass urance in hypochondriasis has recently been well discuss ed. Discus sion with the hypochondriacal patient 1610 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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about the fals e nature of his or her illnes s is not However, reass urance that is delivered confidently by a competent doctor us ing multiple modalities , including skillful examination, effective communication, and education, is the corners tone of treatment of the hypochondriacal patient. W ithout s ucces sful more s pecific treatments are not likely to be accepted adhered to by the patient. Important elements of reass urance are s hown in T able 15-4.

Table 15-4 E lements of E ffec tive R eas s uranc e in Hypoc hondrias is T horough examination of medical records and history Acceptance of the patient, his or her complaints , their legitimacy S cheduling regular visits with a clear goal Using clear and s imple language with terms P roviding relevant information and explanations F os tering the patient's respons ibility for his or her treatment

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S hifting attention from physical symptoms to underlying ps ychological and s ocial problems and focus ing on patient as sets Adjusting a reass uring s tyle in a way that is for a given patient P roviding repeated reas surance P erforming appropriate examinations and tests adequate explanation

Adapted from S tarcevic V . R eas surance in the treatment of hypochondriasis . In: Lipsitt D, V , eds. Hypochondrias is : Modern P ers pective s Ancie nt Malady. Oxford, UK : Oxford University 2001:299-308. It is important that all therapies work to diminis h the preoccupation with the fear of having a dis ease. T hus , reass urance is effective when preoccupation and is harmful when it gets wors e. T his can happen, for example, when examinations and tes ts iatrogenically reinforce the notion that a dis eas e is present. Another example is when the patient believes that a doctor is competent to find the dis eas e that is believed to be present or that the doctor is dis miss ing the patient's concerns by shifting attention to emotional or social is sues. However, when there is a therapeutic 1612 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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that is trusting due to the competence and s kill of the phys ician, then examinations, tes ts, and shifting to important ps ychosocial is sues in the patient's life encourage the patient to focus on relevant features of illness and not on the diseas e phobia. P.1814

C ognitive-B ehavioral Therapy (C B T) Uncontrolled case series have demons trated promis ing res ults of C B T in hypochondriasis . T wo controlled are als o s upportive for C B T being effective in hypochondriasis. P s ychoeducation and cognitive aimed at changing the thoughts that there is a disease present have been the standard of treatment for many years . P oor prognos tic factors for success ful C B T wors e hypochondriasis, more somatic s ymptoms , ps ychiatric comorbidity, more dysfunctional thoughts about body functions , and higher levels of health care and s ocial impairment.

Pharmac ologic al S elective serotonin reuptake inhibitors (S S R Is) and serotonin norepinephrine reuptake inhibitors (S NR Is ) been s hown to be us eful for hypochondriasis in a few small, open-label studies. Larger clinical trials were way at this writing. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > C ONV E R S ION DIS O R D

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P art of "15 - S omatoform Dis orders"

Definition C onvers ion dis orde r is an illnes s of s ymptoms or that affect voluntary motor or sensory functions , which suggest another medical condition, but that is judged to be due to psychological factors because the illnes s is preceded by conflicts or other s tres sors. T he deficits of convers ion dis order are not intentionally produced, are not due to substances, are not limited to pain or sexual s ymptoms, and the gain is primarily ps ychological and not social, monetary, or legal.

His tory C onvers ion dis order is one of many dis orders that s tem from early concepts of hysteria, which was considered previous ly in this chapter.

C omparative Nos ology DS M-IV -T R convers ion dis order is considered a disorder in IC D-10. Approximately 30 percent of diagnosed with DS M-IV -T R convers ion dis order have a comorbid dis sociative disorder, all of whom report a history of childhood neglect and s exual abuse.

E pidemiology R eported rates of conversion disorder vary from 11 out 100,000 to 300 out of 100,000 in general population samples . F ive to 16 percent of all ps ychiatry patients in a general hos pital s etting have s ymptoms are consistent with conversion dis order. C onvers ion 1614 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disorder is the focus of treatment in 1 to 3 percent of outpatient referrals to mental health clinics. S ome suggest a lifetime risk of approximately 33 percent for transient or longer-term convers ion symptoms . B y contrast, convers ion disorder repres ents less than 1 percent of all admis sions to psychiatric hospitals and is infrequently diagnos ed in emergency departments. C onvers ion dis order appears to be more frequent in women than in men, with reported ratios varying from 2 1 to 10 to 1. S ymptoms are more common on the left on the right side of the body in women. W omen who present with conversion s ymptoms are more likely to subs equently develop somatization dis order than who have not had convers ion symptoms . T here is an as sociation between convers ion disorder and antis ocial personality dis order in men. T he ons et of convers ion disorder is generally from late childhood to early adulthood and is rare before 10 years of age or after 35 years of age, but ons et as late as the ninth decade of has been reported. W hen symptoms s uggest a disorder onset in middle or old age, the probability of occult neurological or other medical condition is high. C onvers ion symptoms in children younger than 10 age are us ually limited to gait problems or seizures. C onvers ion dis order s eems to be more common in populations, developing nations and regions , people in lower socioeconomic clas s, and people with less education and medical knowledge. T he form of symptoms may reflect cultural ideas about acceptable ways to expres s dis tres s. F alling or an alteration of cons ciousnes s is a feature of some culture-specific syndromes. On the other hand, behaviors resembling 1615 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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conversion or diss ociative s ymptoms are aspects of culturally s anctioned religious and healing ceremonies. T hus, cultural norms are important to consider in the diagnosis. Limited data sugges t that convers ion symptoms are frequent in relatives of people with convers ion dis order. An increas ed risk of convers ion disorder in but not dizygotic, twin pairs has been reported.

E tiology T he term conve rs ion arose from the hypothes is that a symptom or deficit represents a symbolic playing out of unconscious psychological conflict aimed at reducing anxiety about the conflict and s erving to keep the out of awareness (primary gain). T he individual may derive secondary gain from the convers ion symptom, these external benefits are generally not the aim of the conversion s ymptom or deficit. T his hypothes is has support from s tudies that demons trate that aimed at helping the patient gain ins ight about the conflict can make the physical convers ion worse, and treatment aimed at rehabilitation, allowing the patient to further avoid the conflict, helps res olve the s ymptoms . Mr. J . is a 28-year-old s ingle man who is employed in a factory. He was brought to an emergency department his father, complaining that he had lost his vision while sitting in the back seat on the way home from a family gathering. He had been playing volleyball at the but had sustained no s ignificant injury except for the volleyball hitting him in the head a few times . As was for this man, he had been reluctant to play volleyball 1616 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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because of the lack of his athletic s kills , and was a team at the las t moment. He recalls having s ome problems with s eeing during the game, but his vision not become ablated until he was in the car on the way home. B y the time he got to the emergency his vis ion was improving, although he s till complained blurriness and mild diplopia. T he double vis ion could attenuated by having him focus on items at different distances. On examination, Mr. J . was fully cooperative, uncertain about why this would have occurred, and nonchalant. P upillary, oculomotor, and general sens orimotor examinations were normal. After being cleared medically, the patient was sent to a mental center for further evaluation. At the mental health center, the patient recounts the story as he did in the emergency department, and he still accompanied by his father. He began to recount his vis ion started to return to normal when his father pulled over on the side of the road and began to talk to him about the events of the day. He spoke with his about how he had felt embarrass ed and s omewhat conflicted about playing volleyball and how he had felt that he really should play becaus e of external F urther his tory from the patient and his father revealed that this young man had been shy as an adolescent, particularly around athletic participation. He had never had another episode of visual loss . He did recount anxious and sometimes not feeling well in his body athletic activities . P.1815 1617 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Dis cus sion with the patient at the mental health center focus ed on the potential role of psychological and factors in acute vis ion loss . T he patient was somewhat perplexed by this but was als o amenable to dis cuss ion. stated that he clearly recognized that he began seeing feeling better when his father pulled off to the s ide of road and discuss ed things with him. Doctors admitted they did not know the caus e of the vision loss and that would likely not return. T he patient and his father were satis fied with the medical and ps ychiatric evaluation agreed to return for care if there were any further symptoms. T he patient was appointed a follow-up time the outpatient ps ychiatric clinic.

Diagnos is and C linic al F eatures T he es sential feature of convers ion dis order is that ps ychological factors are judged to be proximal to and res ponsible for the presence of s ymptoms or deficits affecting voluntary motor or s ens ory function that a neurological or other general medical condition, the initiation or exacerbation of the s ymptom or deficit preceded by conflicts or other s tres sors (C riteria A and T he symptoms are not intentionally produced or (C riterion C ), and the disorder is not diagnosed if the symptoms or deficits are fully explained by a or other medical condition, by the direct effects of a subs tance, or as a culturally sanctioned behavior or experience (C riterion D). It is not diagnos ed if are limited to pain or s exual dys function, occur only the cours e of somatization dis order, or are better accounted for by another mental dis order (C riterion F ). symptoms or deficits caus e marked dis tres s, 1618 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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or the s eeking of medical care (C riterion E ). Motor s ymptoms or deficits include impaired or balance, paralys is or localized weaknes s, tremor or flaccidity, difficulty s wallowing or a sensation of a lump the throat, aphonia, and urinary retention. S ens ory symptoms or deficits include loss of touch or pain sens ation, hyperesthes ia and pares thesia, double blindnes s, deafnes s, and hallucinations . T hus, the can s pecify two types of conversion disorder: (1) with motor s ymptom or deficit and (2) with s ensory or deficit. Movements that mimic a form of seizures also occur, but there is a rich academic debate about whether thes e s ymptoms are best class ified as or as dis sociative, and this debate is highlighted by conversion proponents adding a third type: (3) with seizures or convulsions. T he clinician can als o specify fourth type: (4) with mixed presentation. It is perhaps obvious that a diagnosis of conversion disorder s hould be made only after a thorough medical inves tigation has been performed to rule out another medical condition as etiological for symptoms or However, it is only recently that research has demonstrated that mis diagnosis is uncommon, perhaps reflecting increased awarenes s of the dis order, as well improved knowledge and diagnos tic techniques . E arly studies found other medical etiologies to be for the purported illnes s in approximately one-fourth to one-half of pers ons initially diagnos ed with conversion symptoms. T hese studies were beset by different methodologies and the problem of attributing caus ality. Nonetheles s, there has been concern among years that attributing symptoms or deficits to the 1619 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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diagnosis of conversion disorder is deprecatory and medically risky for the patient and less ens the s tature the physician owing to his or her inability to find something real. T his attitude can be helpful to a patient because of the insistence to find organic pathology it is eventually found but, at other times, can relegate a patient to becoming a s ubject of the obses sive and insecure physician's s earch for the Holy G rail. T he diagnosis of conversion disorder is not jus t one of exclusion and should be made firmly and tentatively at same time, with an ever-present eye to the overall biops ychos ocial context of patient and symptoms . the diagnosis is made with too much certainty, other medical illnes s is mis sed. When too tentative, multiple irrational medical evaluations are conducted, and iatrogenic reinforcement and harm are produced. His tory and physical examination must be us ed to diagnos e convers ion dis order. As this disorder is not diagnosis of exclusion, there must be pos itive data on history and examination that the s ymptoms or deficits , both, are functional and poss ibly trans ient and not from stable organic lesion or illnes s. T aking care to history in the context of a thorough examination and versa is critical to make or to exclude the diagnosis of conversion dis order. T here are no s ine qua non events to make the diagnos is , and there are us ually conflicting signs on examination. T able 15-5 that historical data generally thought to be helpful for diagnosis have not actually been found to be s pecific markers. T hus , as a working differential diagnosis is developed, each diagnos is is propos ed and worked through s equentially with history and examination, 1620 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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sometimes in an iterative fas hion. Determining that a symptom or deficit is being experienced in the abs ence findings consistent with other organic diseas e and is being intentionally produced can be difficult. It must be inferred from a careful evaluation of the s ymptom contextualized by its development, its potential external rewards, or the as sumption of the s ick role. A his tory of other unexplained somatic or diss ociative symptoms increases the likelihood that the symptoms or deficits due to conversion disorder, especially if criteria for somatization disorder have been met in the pas t. A positive his tory for other medical dis orders does not the ris k for a convers ion disorder unles s the current symptoms are clearly of that medical disorder. In fact, a medical illnes s is a ris k factor for conversion disorder, is for other somatoform disorders .

Table 15-5 R elative Diagnos tic Validity of C riteria for S ymptoms

Diagnos tic

Validationa

R eference (s ) b

S omatization

3+

7, 8

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ps ychopathology

3+

9

Model for the symptom

2+

8,10

E motional stress before the onset of symptoms

1+

—

Dis turbed s exuality

0–1+

11

S ibling position

0–1+

12, 13

S ymptom as symbolism (primary gain)

0

14

S econdary gain

0

8

Hys terical

0

—

L a be lle indiffé re nce

0

8, 15

aE xpres sed

on a s cale of 0 to 3+, according to es tablis hed validity. b

R eference number in original article.

Adapted from Lazare A: C urrent concepts in 1622 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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ps ychiatry. C onversion symptoms . N E ngl J Me d. 1981;305:745.

A phenomenological problem with convers ion disorder that, although the diagnos is requires that ps ychological factors be judged proximal to and responsible for the symptoms or deficits , there are no good data that ps ychos ocial stress ors are s ensitive or s pecific a convers ion reaction. It may be that there are that are as sociated with convers ion disorder, but data about this are lacking. T he alternative is that there no natural P.1816 relations hip between s tres sors and convers ion An epis temological problem surrounds the concept of ps ychos ocial s tre s s . Although this concept has been discuss ed through medical history and across dis eas e states , meas uring it outside of experimental conditions remains as crude as it is difficult. T hus , in s pite of the experimental evidence, the notion that recent s tres sors caus al to conversion is a long-standing intellectual commitment for psychiatry, one that has been over centuries from a plethora of theoretical writings forceful thinkers , and one that is thus difficult to 1623 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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DS M-IV -T R s its firmly on this fragile fence by not using words “caus e” or “res ponsible for” in C riterion B . the phrase “ps ychological factors are judged to be as sociated with the s ymptom or deficit” supports and s cience by indicating that there is believed to be a relations hip between s tres sors and convers ion even though s cience has not yet proven it. T his paradox is als o present with the concept of la indiffé rence, which, since the time of P ierre J anet, has us ed to characterize the lack of concern about symptoms or deficits s een in thes e patients . T his is a striking phenomenon to obs erve and goes by the synonym de nial in the patient with myocardial infarction and ne gle ct in the neurologically impaired patient. Although la be lle indiffére nce is also hard to measure, is no good evidence that it is more common in disorder than in other medical disorders .

P athology T he lack of tiss ue pathology and s ymptoms and signs do not correlate well is the pathology s een in disorder. C onversion s ymptoms typically do not to known anatomical pathways and physiological mechanisms but instead follow the individual's conceptualization of his or her illness . T able 15-6 examples of various convers ion s ymptoms and their phys ical examination findings that demons trate that conversion patterns do not conform to anatomically known patterns and may change on multiple and with sugges tion. E xpert skill with examination procedures is indis pensable for the proper diagnos is of conversion dis order, and there are multiple text 1624 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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on how to conduct s uch examinations. However, knowledge of anatomical and physiological incomplete, and available methods of objective as sess ment have limitations. T his is highlighted in a of patients with ps ychogenic nonepileptic seizures (P NE S s), comparing them to s ubjects with other somatoform disorders and healthy controls . T he with P NE S s reported more minor head injuries in the than did the two comparison groups , and the P NE S had more nons pecific electroencephalogram (E E G ) dysrhythmias on E E G . T he mean number of comorbid ps ychiatric diagnoses was higher in the P NE S group 0.3 compared to 1.5 ± 0.5 in the somatoform group). 23 P NE S patients also had a s omatoform pain seven had an undifferentiated somatoform disorder.

Table 15-6 Dis tinc tive Phys ic al E xamination Findings in C onvers ion Dis order

C ondition

Anesthesia

Tes t

C onvers ion Findings

Map dermatomes.

S ensory loss does not conform to recognized

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pattern of distribution. C heck midline.

S trict half-body split.

Astasia-abasia

Walking, dancing.

With suggestion, those who cannot walk may s till be to dance; alteration of sens ory and motor findings with suggestion.

P aralys is , paresis

Drop paralyzed hand onto face.

Hand falls next to face, not on it.

Hoover test.

P res sure noted in examiner's hand under paralyzed leg when attempting straight leg

Hemianesthes ia

 

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raising.  

C oma

C heck motor strength.

G ive-away weaknes s.

E xaminer attempts to open eyes .

R es ists gaze is away from doctor.

Ocular cephalic maneuver.

E yes s tare straight ahead and do not move from to s ide.

R equest a cough.

E ss entially, normal coughing sound that cords are clos ing.

 

Aphonia

S hort nas al grunts with little or no sneezing on inspiratory phase; little or no

Intractable 1627

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sneezing

Observe.

aerosolization of secretions ; minimal facial expres sion; open; s tops when as leep; abates when alone.

Head-up tilt tes t.

Magnitude of changes in signs and venous pooling does not explain continuing symptoms.

T unnel vision

V is ual fields .

C hanging pattern on multiple examinations.

P rofound monocular blindnes s

S winging flash light (Marcus G unn).

Abs ence of relative papillary

S yncope

S ufficient vision in “bad 1628 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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B inocular fields .

eye” precludes plotting normal phys iological blind spot in good eye.

S evere blindnes s

“Wiggle your fingers , I'm just testing coordination.”

P atient may begin to mimic new movements before the s lip.

 

S udden flas h of bright light.

P atient

“Look at your hand.”

P atient does not look there.

“T ouch your index

E ven blind patients can do this by proprioception.

 

 

Adapted from S adock B J , S adock V A. K aplan S adock's C ompre hens ive T e xtbook of P s ychiatry. ed. P hiladelphia: Lippincott W illiams & Wilkins; 1629 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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2000:1512.

No s pecific laboratory abnormalities are as sociated conversion disorder. In fact, the abs ence of findings supports the diagnos is of convers ion disorder. laboratory findings cons is tent with another medical condition do not exclude the diagnos is of convers ion disorder, becaus e the diagnosis requires that the symptoms or deficits not be fully explained by the other medical condition. E xperimental psychophysiology has suggested two abnormalities in convers ion dis order. F irst, when given increasingly higher anxiogenic s timuli, convers ion have increas ing levels of sympathetic nervous s ys tem (S NS ) discharge, as meas ured by skin conductance, moderately high level, and then S NS discharge levels contrast, anxiety disorder s ubjects continue to have S NS discharge to higher levels of anxiogenic stimuli. S econd, convers ion subjects may have more rapid evoked potential spikes in contralateral sensory cortex than in ipsilateral cortex to P.1817 phys ical s timuli, s uggesting that the affected paralytic 1630 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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is actually more s ens itized to s timuli, even though the subject states that he or she has no s ens ation. Other psychopathology that is commonly comorbid with conversion disorder includes mood and anxiety on Axis I in approximately 25 to 50 percent of patients C lus ter B pers onality disorders on Axis II in 10 to 40 percent of patients.

Differential Diagnos is T he most important conditions in the differential are ne urological or other me dical dis orders and induce d dis orde rs . Appropriate evaluation for thes e conditions includes a careful history of the current symptoms and context, a thorough medical history, complete neurological and general phys ical that focus on detection of s igns to include or to exclude medical illnes s, and appropriate laboratory s tudies, may include urine or serum toxicology. T horough documentation of the his tory, examination, context, laboratory tes ts, and clinician impres sion of the factors ruling in or out various medical conditions is important alleviate further unneces sary medical evaluations. 15-7 lists s ome of the more frequent neurological, other medical, and substance conditions that need to be cons idered in the differential diagnosis. P artial comple x s e izure dis orde rs and autoimmune dis orders may be misdiagnos ed for years , given the variability in symptomatology and the undulating nature of the illness es. Approximately 30 percent of systemic lupus erythematosus cas es pres ent with predominantly neurops ychiatric s ymptoms or deficits , or both, us ually mania or psychosis. 1631 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Table 15-7 Medic al Dis orders in Differential Diagnos is of C onvers ion Dis order Myas thenia gravis S ys temic lupus erythematosus P eriodic paralysis B rain tumor Multiple sclerosis Optic neuritis P artial vocal cord paralysis G uillain-B arré syndrome On-off syndrome of P arkinson's disease Degenerative neurological dis eas es Acquired myopathies Idiopathic and s arcoma-induced osteomalacia

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S ubdural hematoma Acquired, hereditary, and drug-induced dys tonias C reutzfeldt-J akob (prion) dis eas e E arly manifes tations of acquired immune syndrome Other somatoform and ps ychiatric dis orders are in the differential diagnos is of convers ion. If the or deficits are limited to pain or s exual function, then a pain dis orde r or a s e xual dis orde r is diagnosed instead conversion disorder. An additional diagnosis of disorder is not made if the s ymptoms or deficits occur during the course of s omatization dis order. T he must include body dys morphic dis order, for which the emphasis is on a preoccupation with an imagined or defect in appearance, rather than a change in voluntary motor or sens ory function. Hypochondrias is must be cons idered in the differential, although it distinguis hes its elf from convers ion by dis eas e phobia, not symptoms or loss of function. F actitious and dis orders need to be considered. B oth of these share the feature of intentionally produced s ymptoms , which distinguish them from convers ion disorder. However, determining whether s ymptoms are volitional us ually not an easy task. T he pres ence of catatonia or somatic delus ions mus t bring to cons ideration s chizophre nia or other ps ychotic dis orde rs , including a mood dis orde r with ps ychotic fe ature s . It is 1633 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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whether hallucinations s hould be cons idered as the presenting symptom of convers ion dis order. When they occur in convers ion disorder, they generally present without other ps ychotic s ymptoms , often involve more than one s ens ory modality, and often have a vague or fantas tic content. High anxiety states are as sociated multiple somatic s ymptoms or deficits that are sudden in onset. F or example, difficulty swallowing as sociated with a panic attack in the cours e of panic dis order or a phobic dis order. It is becoming unders tood that early advers e life experiences can lead a chronic and undulating course of P T S D, which may as sociated with s ymptoms or loss of function in body that were involved in the traumatic experience. T hus , a careful history of trauma type and res idual pos ttrauma symptoms is ess ential when thinking about the diagnosis of conversion disorder. C onvers ion dis order s hares features with dis s ociative dis orders . B oth involve symptoms that s ugges t neurological involvement, they may have antecedent stress ors , and the history may be difficult to obtain, because of the nature of the s ymptoms. At present, if a patient meets criteria for conversion and diss ociative symptoms, both diagnos es can be made.

C ours e and P rognos is T he onset of convers ion dis order is us ually acute, but a crescendo of symptomatology may also occur. or deficits are us ually of s hort duration, and 95 percent of acute cases remit spontaneously, us ually within 2 weeks in hospitalized patients . If s ymptoms been present for 6 months or greater, the prognos is for 1634 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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symptom res olution is less than 50 percent and further the longer that conversion is pres ent. occurs in one-fifth to one-fourth of people within 1 year the firs t epis ode. T hus, one episode is a predictor for episodes . A good prognos is is heralded by acute presence of clearly identifiable s tres sors at the time of onset, a s hort interval between ons et and the institution treatment, and above average intelligence. P aralysis , aphonia, and blindness are ass ociated with a good prognos is , whereas tremor and s eizures are poor prognos tic factors.

Treatment In acute cas es without a previous history of conversion, accurate reass urance coupled with reas onable rehabilitation to fit the s ymptoms is warranted. T he the symptoms remain, the more aggress ive the rehabilitation should be. C onfrontation of the patient about the s o-called false nature of the s ymptoms is contraindicated. P sychotherapy is a relative contraindication, but attention to the patient's ps ychos ocial needs is likely to be a valuable to symptom resolution. In acute cases with a his tory of conversion, reas surance and s uggestion of recovery coupled with early rehabilitation are the treatments of choice. If s ymptoms continue, more aggres sive rehabilitation is indicated. C hronic cases are more difficult to treat. As with acute cases, comorbid ps ychiatric illnes ses need to be aggres sively. T reatment then needs to begin with thorough and rational evaluation, open explanation to patient about the findings , and education aimed at 1635 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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helping the patient unders tand that, although the symptoms are real and are caus ing impairment, there hope for a full recovery. T his education focus es on the although not well-unders tood, ps ychophys iological P.1818 mechanisms that are likely contributing to the illness how rehabilitation can change these mechanis ms back normal, because the physiological pathways in are likely intact. T hree specific treatments must then be cons idered. F irst, psychomotor and s ens ory rehabilitation is us eful when aggres sively purs ued by an experienced multidis ciplinary team cons is ting of phys iatrists, ps ychiatris ts, and physical and occupational therapists . E arly rehabilitation aimed at the dys function coupled motivational interviewing, reass urance, and sugges tion may be followed by the ethical use of placing the in a double -bind if the initial treatment is not s ucces sful. T he double-bind works on the principle that the symptoms or deficits are being maintained to avoid ps ychological or s ocial conflict, or both, and that the unconscious will do anything, even get better, to avoid discuss ing the conflict. T hus, lack of progress is to the patient as being due to one of three poss ible reasons: (1) T he patient is not trying to get better, cons titutes a reason to end treatment; (2) the are caused by excess ive overstimulation and fatigue, which would necess itate periods of deep res t without stimulation of any kind; or (3) the continued s ymptoms due to deep-seated ps ychological conflicts , which neces sitate long-term ps ychotherapy and dis cus sion of 1636 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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these conflicts . T he patient agrees that the second is the most likely caus e, because he or s he neither lose the therapeutic relationship nor wants to engage in interpersonal therapy. T reatment proceeds to have the patient work hard with intermittent periods of deep rest, which means no reading, no television watching, and social contact. T his encourages the patient to engage treatment s es sions to avoid deep rest periods and to rightful discharge. If the patient likes the deep rest then the alternative explanations for failure to improve need to be dis cuss ed again. T his technique has proven us eful to refractory cases when conducted on an rehabilitation unit. S econd, pharmacotherapy may be useful. Anxiolytic antidepres sant medications may decreas e s ome of the symptoms to allow the patient to engage in physical rehabilitation or psychotherapy. Medication-induced sedation therapy, such as an amobarbital (Amytal) interview, may be useful to gain information about early hidden conflicts and may facilitate integration of this information by the patient under s killed therapeutic supervis ion. Infusion of 50-mg doses of amobarbital is adminis tered in a dextrose 5 percent in water (D5W ) solution over 5 minutes every 30 to 40 minutes , until patient is sleepy, usually requiring between 100 and mg per interview. S tandard practice is that another in addition to the therapist is pres ent and that a cras h is available for us e by a capable clinician in the event severe res piratory depres sion. T he interview is meant relate symptoms to events , proximal or remote, and to elicit from the patient ways to ameliorate the symptoms conflicts. V ideotaping may be useful as feedback to the 1637 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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patient, when appropriate, to augment therapis t interpretation. F inally, psychotherapy may be us eful but also may be contraindicated in a patient who remains highly to it or who gets wors e when it is initiated. T herapy is directed at increasing function and having the patient demonstrate to hims elf or herself that the symptom or deficit is alterable and that it is als o related to ps ychological or s ocial phenomena, or both. T here is strong support for any given type of psychotherapy, further empirical work is needed to improve knowledge about how and when to apply ps ychological therapies. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > B ODY DY S MOR P HIC DIS OR

B ODY DYS MOR PHIC DIS OR DE R P art of "15 - S omatoform Dis orders"

Definition B ody dys morphic dis orde r is characterized by a preoccupation with an imagined defect in appearance caus es clinically s ignificant dis tres s or impairment in important areas of functioning. If a s light phys ical is actually pres ent, the person's concern with the is excess ive and bothers ome.

His tory B ody dys morphic disorder was initially clas sified in the 1638 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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United S tates as the atypical s omatoform dis order dys morphophobia in DS M-III in 1980. It has been in many parts of the world with various names over the past 150 years. Over this history, body dysmorphic has often been des cribed as a disorder with obsess ive neurotic features about one's body coupled with shame and s elf-loathing.

C omparative Nos ology B ody dys morphic disorder is included in the IC D-10 diagnosis of hypochondriacal dis orde r.

E pidemiology T he epidemiology of body dys morphic disorder is not unders tood. In a cross -sectional s ample of 318 and 658 nondepres sed women between 36 and 44 of age who were selected from seven B os ton area communities, the overall point prevalence was 0.7 percent and was significantly ass ociated with the of major depres sion and anxiety disorders . Other es timate community prevalence between 1.0 and 2.2 percent and prevalence in dermatology and cos metic surgery clinics between 6 and 15 percent.

E tiology T he neurobiology of body dysmorphic dis order is not known. G iven the high comorbidity of depress ion and obses sive features and the reputed benefits of S S R I medication in body dysmorphic dis order, it is ass umed that frontal, s erotonin pathways are involved in body dysmorphic dis order. S ociocultural bases for body dysmorphic dis order are more clear. T he epidemiology 1639 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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varies between geographical region and gender, as do concepts of body normality, perhaps making body dysmorphic dis order the somatoform disorder with the strongest sociocultural basis . T here is an extensive literature describing how culture influences individual experience of ps ychopathology, and the clinical manifestations, course, diagnosis, treatment, and treatment outcomes of ps ychiatric illnes s. P redominant social contexts become internalized as ps ychobiology, pathogenes is is influenced by an ongoing s ociocultural fabric and a biogenetic s ubstrate. T his is why bodily preoccupation varies in type, clinical and cons equent behavior across the world. Ms. J ., a 30-year-old s ingle unemployed woman, to a ps ychiatris t with this chief complaint: “My biggest wis h is to be invisible so that no one can s ee how ugly I am. My biggest fear is that people are laughing at me thinking I'm ugly.” In reality, Ms . J . is an attractive who has been preoccupied with her s upposed ugliness since 12 years of age. At that time, s he became with her nos e, which she thought was too “big and B efore the onset of this concern, Ms. J . had been a good student, and s ocially active. However, as a her fixation on her nos e, s he became s ocially and was unable to concentrate in s chool; her grades plummeted from As to Ds and F s . At age 18 years , Ms. J . dropped out of school because her concern about her nos e. S hortly after this , she took job s he disliked and, at that time, als o became focus ed on her minimal acne. S he frequently picked at few “blemishes ”—sometimes all night long—with tweezers and needles, a behavior she 1640 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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P.1819 found difficult to res ist. Over the following years, Ms. J . developed additional excess ive preoccupations with appearance of her hair, which “was n't smooth and neat enough”; her breasts , which she thought were too her suppos edly thin lips; and her s upposedly large buttocks . Ms. J . thinks about her “defects ” nearly all long and s tates that “I always have two tapes playing— one s aying not to worry and the other s aying I'm ugly.” Ms. J . frequently checks her s uppos ed defects in and other reflecting s urfaces , such as windows , car bumpers, and spoons . B efore s he can leave her as ks her family members “at least 30 times ” whether looks OK , but she cannot be reass ured by their S he als o combs her hair excess ively and attempts to camouflage her s upposed defects with clothing, and elaborate makeup that takes several hours a day apply. Des pite her efforts to hide her “ugliness ,” Ms. J . thinks that others are probably taking s pecial notice of staring at her or laughing at her behind her back. S he sometimes drives through red lights, becaus e s he is “unable to tolerate people looking at me.” On one occasion, when s he was s tuck in a traffic jam, Ms . J . became s o anxious over her belief that other drivers staring at her nose, skin, and hair that she fled her car left it in the middle of the highway. Ms. J . thinks that her view of her appearance and her that others are ridiculing her are probably accurate. However, s he is able to acknowledge that she has “a amount of doubt” about her beliefs, noting that it is poss ible—although unlikely—that s he has a distorted 1641 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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view of her defects. Nonetheless , Ms. J . occasionally feels “100 percent” convinced that s he is hideous ly and is “completely certain” that others are taking notice of her, as happened when she abandoned her At thes e times , s he firmly believes that the neighbors staring at her through binoculars, and s he hides where thinks they cannot see her. As a res ult of her preoccupation with her appearance, J . has been able to work only briefly and intermittently. S he became increasingly s ocially isolated and avoided dating and other s ocial interactions . As her concern intens ified, Ms . J . began to go out only at night when could not be s een. F inally, after more than a decade of symptoms, Ms . J . stopped working altogether and went disability. S he als o became completely housebound, hiding when relatives came to visit. As she explains , “I didn't leave my hous e because I didn't want people to how ugly I was.” Although Ms. J . relies on her family members to buy her clothes , food, and other she is unable to tell them about her concerns about her appearance, because she is too embarrass ed. S he has become increas ingly depress ed, with poor s leep, and energy, and has s uicidal ideation. As a res ult of social isolation and her feelings of hopeless ness about appearance, Ms. J . has made two suicide attempts and been hospitalized on s everal occas ions. B efore s he became housebound, Ms. J . received from s everal dermatologists , but this did not alleviate concerns about her appearance. S he was refused a rhinoplas ty by a plastic s urgeon she consulted. Ms. J . sought outpatient psychiatric treatment but was never able to discus s her preoccupations with her therapist, 1642 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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because she was too embarras sed to do so.

Diagnos is and C linic al F eatures T he critical feature to make the diagnos is of body dysmorphic disorder is preoccupation with an imagined defect in one's body or any of its parts or markedly excess ive concern about a s light phys ical defect A). T o meet diagnos tic criteria, as in other disorders , critical feature (dysmorphophobia) must cause distress or impairment in s ocial, occupational, or other important areas of functioning (C riterion B ) and must be better accounted for by another mental dis order (C riterion C ). Ass es sment instruments with acceptable ps ychometric properties have been developed to specifically ass es s body dysmorphic dis order (e.g., the B ody Dysmorphic Disorder E xamination and the Y aleB rown Obses sive-C ompulsive S cale modified for B ody Dys morphic Dis order). Determining C riterion C , that dysmorphophobia is not to another mental disorder, can be challenging. P eople with anorexia ne rvos a have the perception that they obese when they are not. It is common for people with s chizophre nia to think that a part or parts of their body distorted or defective when there is no objective of a defect. Highly anxious and depress ed people or with P T S D believe that something is wrong with their body, and this may take the form of dysmorphophobia. E ffective treatment of these other disorders does not always make the concern with body abate. F inally, dysmorphic dis order is highly comorbid with anxiety, affective, and eating disorders , although this is not well known. 1643 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Imagined or exaggerated flaws of the face and head the most common symptoms in body dys morphic disorder, s uch as wrinkles and s cars, vascular paleness or redness of the complexion, s welling, acne other lesions , facial as ymmetry or disproportion, hair thinning, or excess ive facial hair. Other imagined or exaggerated defects include the size or s hape of the eyes or their components , ears, mouth, lips , teeth, jaw, chin, cheeks, or head. Other body parts may be the dysmorphobic focus as well, and this may include specific parts, such as the s hape of a finger; larger areas, s uch as the shape of the hips ; or even the size shape of the whole body. P athological preoccupation focus on several body parts simultaneously. G etting an accurate his tory may be challenging owing to the high level of embarrass ment that s ome people have about imagined defects , the person's perception and of the defects , and the fear by the pers on that will not take them serious ly. T hus, they avoid their imagined or real, slight defects in detail and may instead refer only to the general s hame or uglines s of body. T he most common personality features as sociated with body dysmorphic dis order include obs ess ional and avoidant traits, although any clus ter of traits may be present, and no single personality trait or disorder dominates as comorbid with body dysmorphic dis order. T hese patients are shy, have a history of being highly sens itive to remarks about their body, and can often remember a single event in which negative comments about their body were as sociated with the ons et of bothers ome preoccupation with body image. If the 1644 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disorder begins in early adoles cence, it is likely a his tory of having fewer friends than others , dating than others , and being more is olated than their peers . Many individuals with this disorder describe their preoccupations as being intens ely painful. Ideas of reference related to the imagined defect are also in which people with this dis order think that others are taking s pecial notice of their reported flaw. S ome individuals are preoccupied with thoughts that their flawed body part will fail them. T hus , the are bothers ome and not des ired, but the belief about presence of the imagined defect is ego-syntonic. In body dys morphic disorder patients have difficulty controlling their bodily preoccupations, and they us ually make little or no attempt to res is t them becaus e they believe that they have P.1820 the imagined defect. As with hypochondriasis, a subs et people with body dys morphic disorder cannot easily be convinced or reass ured that the imagined defect is not present. T hus, there is a debate about whether there is subs et of body dys morphic disorder patients that more accurately be diagnos ed with a de lus ional As a res ult of this conflictual relationship between the dislike of the preoccupation and the belief that they are defective, people with body dysmorphic dis order often spend hours a day thinking about their defect, and thoughts and s ubsequent behaviors may dominate lives . C hecking the defect in any available reflecting surface may consume many hours of their day. S ome individuals us e magnifying glass es to s crutinize their 1645 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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defect and conduct excess ive grooming behavior. mental and phys ical behaviors are intended to diminis h anxiety about the defect, but, as in all pathological states , the behaviors actually reinforce and intensify only the anxiety, distress , and isolation, but also the frequency and strength of the behaviors. this dis order becomes s o dis tres sing that s ome people with body dysmorphic dis order then s pend a lot of time and energy avoiding mirrors and other checking accoutrements and further is olate to prevent anxiety. may instead try to camouflage the defect by us ing excess ive makeup or padded clothing. In severe individuals may leave their homes only at night s o that they cannot be s een, or may become housebound. may quit their jobs, drop out of school, or work below capacity in an attempt to hide. F urther maladaptive behaviors ensue. T he dis tres s and dys function with body dysmorphic dis order, although variable, can lead to repeated hospitalization, s uicide attempts, and completed s uicide. S ome people with body dys morphic disorder try to the conflict and distress by getting help in medical, not ps ychiatric, s ettings . T hey may first go for frequent reques ts for diagnosis of or reas surance about the but such reas surance leads to only temporary, if any, After engaging in a pattern of comparing their body to those of others by observing others in the natural environment or in magazines or on televis ion, they decide to obtain medical or s urgical care, or both. In in which s elf-evaluation has been highly dis torted, and expectations for medical or surgical care are inappropriately high, such treatment may caus e the 1646 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disorder to worsen, leading to intens ified or new preoccupations. T his may lead to further unsuccess ful procedures , s o that these individuals eventually have a synthetic-looking body part. As with all the very elements of the dis order that are intended to us ed as a helpful defens e become maladaptive, and, in case of body dys morphic dis order, the literally worn on the patient's s leeve, or on the nos e, or breas ts , as it were. It is one of the disorders in in which the maladaptive ps ychological defens e may become vis ible. B ody dys morphic disorder is highly comorbid with affective, anxiety, substance us e, and eating disorders . S tudies about the epidemiological and pathogenesis of these dis orders are lacking. T here is s ome evidence high anxiety states more commonly predate body dysmorphic dis order, whereas depres sion and us e disorders are more a result of chronic body dysmorphic dis order, but more investigation of these relations hips is needed.

P athology T here is no known neurobiological pathology in body dysmorphic disorder. One preliminary s tudy s howed caudate asymmetry similar to that seen in OC D. T he ps ychopathology was described previous ly and als o demonstrates a s trong relations hip to anxiety

Differential Diagnos is T he primary condition in the differential diagnosis is somewhat excess ive, but nonpathological, concerns body features and appearance. Unlike normal 1647 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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about appe arance , the preoccupation with appearance specific imagined defects in body dys morphic disorder and the changed behavior becaus e of the are exces sively time consuming and are as sociated significant dis tres s or impairment. T here is a significant and academic literature about the quest for certain types and body features in modern U.S . culture. T here also evidence that, for s ome individuals , exercise, body shaping, and cos metic surgery designed to change appearance can be helpful ps ychologically. there is also evidence that these behaviors can be maladaptive and harmful to an individual's and s ocial development. T he diagnosis of body dys morphic disorder s hould not made if the excess ive bodily preoccupation is better accounted for by another psychiatric disorder. bodily preoccupation is generally res tricted to concerns about being fat in anorexia nervos a, to discomfort with sens e of wrongness about his or her primary and secondary s ex characteristics occurring in ge nde r dis order, and to mood-congruent cognitions involving appearance that occur exclusively during a major de pres s ive e pis ode . Individuals with avoidant dis order or s ocial phobia may worry about being embarrass ed by imagined or real defects in but this concern is usually not prominent, persistent, distress ing, or impairing. T aijin kyofu-s ho, a diagnosis J apan, is similar to s ocial phobia but has s ome are more cons istent with body dysmorphic dis order, as the belief that the pers on has an offensive odor or parts that are offens ive to others. Although individuals with body dysmorphic dis order have obs ess ional 1648 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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preoccupations about their appearance and may have as sociated compulsive behaviors (e.g., mirror separate or additional diagnos is of O C D is made only the obsess ions or compulsions are not restricted to concerns about appearance and are ego-dystonic. An additional diagnosis of de lus ional dis order, s omatic be made in people with body dys morphic disorder only their preoccupation with the imagined defect in appearance is held with a delusional intensity.

C ours e and P rognos is B ody dys morphic disorder us ually begins during adoles cence, although it may begin later after a diss atis faction with body. Age of onset is not well unders tood because there is variably long delay symptom onset and treatment s eeking. T he ons et may gradual or abrupt. T he disorder usually has a long and undulating cours e with few s ymptom-free intervals . T he part of the body on which concern is focused may the same or may change over time. T he prognos is with and without treatment is not well unders tood. R eass urance is not thought to be effective, but it may be that adoles cents with a gradual ons et are reass ured in their home or social context quite often never are detected by the medical profes sion. It is also clear whether an abrupt or gradual onset of the a higher ris k for s ymptom continuation.

Treatment It appears that many individuals with body dysmorphic disorder receive nonpsychiatric medical treatment and surgery. One study that ass es sed this iss ue in 289 1649 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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individuals (250 adults and 39 children and with DS M-IV -T R body dysmorphic dis order found that percent of adults received nonps ychiatric treatment. Dermatological treatment was most often received (45 percent), followed by s urgery (23 percent). T hese treatments rarely improved body dys morphic dis order symptoms. R esults were s imilar in children and adoles cents . T hese findings s ugges t that a majority P.1821 of patients with body dys morphic disorder receive nonps ychiatric treatment and tend to have a poor outcome. R andomized, controlled s tudies support the efficacy of individual and group C B T for the treatment of body dysmorphic dis order. R es earch on the body dys morphic disorder is limited. T here is evidence from one open-label study and one placebo-controlled study that S S R Is may be effective for body dysmorphic disorder. In a published chart-review s tudy of 90 with DS M-IV -T R body dysmorphic dis order treated for long as 8 years by the authors in their clinical practice, subjects received an adequate dos e of an S S R I, and percent had improvement in body dysmorphic dis order symptoms. S imilar res ponse rates were obtained for type of S S R I. Dis continuation of an effective S S R I in relaps e in 84 percent of cases. Augmentation of the with clomipramine (Anafranil), buspirone (B uS par), (E skalith), methylphenidate (R italin), or antipsychotics improved the respons e rate between 15 and 44 E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > P AIN DIS O R DE

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PAIN DIS OR DE R P art of "15 - S omatoform Dis orders"

Definition A pain dis orde r is characterized by the presence of and focus on pain in one or more body s ites and is s evere enough to come to clinical attention. P s ychological are neces sary in the genesis, s everity, or maintenance the pain, which causes s ignificant distress or or both. T he physician does not have to judge the pain be “inappropriate” or “in exces s of what would be expected,” as these DS M-III criteria are not reliably R ather, the phenomenological and diagnos tic focus is the importance of psychological factors and the degree impairment caus ed by the pain.

C omparative Nos ology T he IC D-10 has a s imilar category called pe rs is te nt s omatoform pain dis orde r, which is not divided into subtypes by the pres umed role of ps ychological factors in the DS M-IV -T R . T he IC D-10 excludes back pain, and migraine headache, and general mus cle tension the diagnosis. T he IC D-10 retains an approach similar the DS M-III-R in which ps ychological factors are be the primary cause of the pain, whereas the DS M-IV now specifies genes is, severity, or maintenance of a combination of these, as different elements of the disorder on which the important ps ychological factors act. 1651 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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T he S ubcommittee on T axonomy of the International Ass ociation for the S tudy of P ain propos ed a five-axis system for categorizing chronic pain according to (1) anatomical region, (2) organ s ys tem, (3) temporal characteristics of pain and pattern of occurrence, (4) patient's s tatement of intens ity and time s ince the onset pain, and (5) etiology. T his five-axis s ys tem focus es primarily on the physical manifestations of pain. It for ps ychological factors on the second axis , where a mental disorder can be coded, and on the fifth axis , poss ible etiologies include ps ychophys iological and ps ychological.

E pidemiology T he prevalence of pain disorder appears to be R ecent work indicates that the 6-month and lifetime prevalence is approximately 5 percent and 12 percent, res pectively. It has been estimated that 10 to 15 adults in the United S tates have s ome form of work disability due to back pain alone in any year. Approximately 3 percent of people in a general practice have persistent pain with at least one day per month of activity res triction due to the pain. P ain disorder may begin at any age. T he gender ratio unknown. P ain disorder is ass ociated with other ps ychiatric disorders, es pecially affective and anxiety disorders . C hronic pain appears to be mos t frequently as sociated with depress ive dis orders, and acute pain appears to be more commonly as sociated with anxiety disorders . T he as sociated psychiatric disorders may precede the pain dis order, may cooccur with it, or may res ult from it. Depress ive disorders , alcohol 1652 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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and chronic pain may be more common in relatives of individuals with chronic pain dis order. Individuals pain is as sociated with severe depress ion and those pain is related to a terminal illness , s uch as cancer, are increased ris k for s uicide. T here may be differences in various ethnic and cultural groups respond to pain, but us efulnes s of cultural factors for the clinician remains obscure to the treatment of individuals with pain because of a lack of good data and because of high individual variability.

E tiology T he caus e of pain in general is complicated and is not pertinent to this chapter. W hat is important are the mechanisms thought to underlie how pain is phys iologically and perceptually enhanced by ps ychological factors , s uch as emotion and cognition. F igure 15-3 demonstrates a relations hip between nociception, cognition, and affect, in which all three interact to either enhance or diminis h pain perception. T here is phys iological evidence to support the between thes e three elements in the gating and theories of pain perception. F urthermore, treatment as mindfulness meditation and pain medication has shown to change these relations hips, as if the three are being pulled apart from each other, diminis hing the interaction that enhances pain perception.

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FIGUR E 15-3 E lements of pain perception.

Diagnos is and C linic al F eatures T he critical diagnos tic feature of pain dis order is that is the predominant focus of the clinical pres entation of sufficient severity to warrant clinical attention A) and that psychological factors are cons idered in the ons et, severity, exacerbation, or maintenance of pain (C riterion C ). As in all ps ychiatric dis orders, the caus es s ignificant dis tres s or impairment in important areas of functioning (C riterion B ) and is not due to disorders considered in the dis cuss ion of differential diagnosis (C riteria D and E ). 1654 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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T he diagnosis of pain disorder is divided into s ubtypes best characterize the factors involved in the etiology maintenance of the pain. P ain disorder ass ociated with ps ychological factors is the subtype diagnos ed when ps ychological factors are judged to have the P.1822 major role in the onset, s everity, exacerbation, or maintenance of the pain and when other medical conditions are thought to be unimportant to the onset maintenance of the pain. P ain dis order as sociated with ps ychological factors and a general medical condition the s ubtype diagnos ed when psychological factors and another medical condition are thought to be important the ons et, severity, exacerbation, or maintenance of pain. In this subtype, the other medical condition is an III diagnos is . P ain disorder ass ociated with another medical condition is the subtype that is not cons idered Axis I mental dis order, and the medical disorder res ponsible for the pain is diagnos ed on Axis III. P ain disorder as sociated with ps ychological factors and pain disorder as sociated with psychological factors and general medical condition may be acute (<6 months) or chronic (6 months or longer). T he psychological factors thought to be responsible for pain disorder may be another formally diagnos ed Axis I or Axis II dis order or be other factors that do not reach the thres hold for another diagnosis (e.g., personality traits or reactions social s tres sors). E xamples of diagnostic levels of impairment resulting from the pain include diminished capacity or attendance at school or work, high or expensive use of health care, and interpersonal and 1655 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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problems , such as marital dis ruption or discord in the social environment due to pain behavior. Illnes s behavior is the observed manifes tation of pain disorder, because pain is a reported s ubjective phenomenon. C linicians may us e any of various pain available to help determine the severity, place, and of pain. T hese scales may also help the clinician if there is a reliably reported pattern of pain, and, in this way, scales may help with the differential diagnos is. However, the interpersonal and social nature of the disability is the mos t reliably measured aspect of pain disorder, and treatment is best aimed at improving function and not necess arily ablating pain. Obs erving quality and quantity of the many s evere disruptions in various aspects of daily life—such as unemployment, family problems , and dependence and addiction on medications and other s ubs tances —and their to various ps ychological gains and loss es is an meas ure in the development of a therapeutic plan. It is important to commence treatment aimed at decreasing inactivity and social isolation as and as soon as pos sible to diminis h the ris k of further ps ychological and social problems .

P athology In pain disorder as sociated with psychological factors another general medical condition, tes ting may reveal pathology that is as sociated with the medical condition that is partly res ponsible for the pain (e.g., finding of a herniated lumbar disc on a magnetic res onance [MR I] s can in an individual with low-back pain). T here known histopathology for pain disorder ass ociated with 1656 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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ps ychological factors .

Differential Diagnos is T he most important conditions in the differential are other medical dis orde rs caus ing pain that have overlooked. It is well es tablis hed that the ability to meas ure pain from the variety of s ources and is not adequate. It is not uncommon for pain to be because of a dis order that cannot be well detected or to a mechanism for which enough is not yet known. reflected in the fact that dys pareunia, for example, is excluded from the diagnosis of pain dis order. T here is evidence that people may develop pain in early stages illness es such as rheumatoid arthritis or malignancies are clinically below detection methods. Myofas cial pain syndromes are common, are often overlooked in medical practice, and are evaluated by a s killed musculoskeletal examination. T hus , in the early s tages the diagnostic process for pain disorder, the clinician is well advis ed to carefully revis it the poss ibility of other medical dis orders while not iatrogenically reinforcing pain disorder and mis perceptions of its caus e by the patient. Other somatoform dis orders are to be considered in differential diagnosis of pain dis order. P ain symptoms be part of the s ymptomatology in s omatization However, if the pain occurs exclus ively during the of s omatization dis order, an additional diagnosis of disorder as sociated with ps ychological factors is not P ain complaints may also be prominent in individuals conve rs ion dis orde r, but, by definition, convers ion is not limited to pain s ymptoms . P ain symptoms may 1657 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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intentionally produced or feigned in factitious dis order malinge ring. P ain s ymptoms are commonly ass ociated with other ps ychiatric disorders , s uch as major depre s s ion, dis orders , and ps ychotic dis orde rs , in which pain may partly due to nociceptive phenomena or may be delus ional. An additional diagnos is of pain dis order be considered only if the pain is an independent focus clinical attention and meets other diagnos tic criteria for pain disorder. T he relationship between other disorders and pain has received much theoretical and empirical attention. P ain dis order is not a s omatic of depress ion, but depres sion interacts with pain to wors en the course and prognos is. Anxiety is not thought to cause pain but can increase catecholamines and corticotropin-releas ing factor, both of which are as sociated with enhanced pain perception. B ecause of common comorbidity and the relations hip between of the mechanis ms of pain dis order and other disorders , empirical treatment of the diagnosed disorder is important to diminis h pain and to determine which dis order is primary.

C ours e and P rognos is Acute pain dis orders have a more favorable prognosis chronic pain dis orders. T here is a wide range of in the ons et and course of chronic pain disorder. In cases, the pain has been present for many years by time the individual comes to psychiatric care, owing to reluctance of patient and phys ician to s ee pain as a ps ychiatric disorder. P eople with pain disorder who res ume participation in regularly s cheduled activities 1658 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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despite the pain have a more favorable prognosis than people who allow the pain to become the determining factor in their lifestyle.

Treatment A metaanalys is of 11 studies s howed that decreased pain intensity significantly more than patients with psychogenic pain or somatoform pain disorder. T he overall effect s izes were moderate (mean C ohen's d, 0.48; range, 0 to 0.91). P ositive effects of autogenic relaxation training in at least three studies found for s omatoform pain dis order, unspecified type, tension headache and migraine, as well as for mild to moderate ess ential hypertension, coronary heart as thma, R aynaud's disease, anxiety dis orders, mild to moderate depres sion and dys thymia, and functional disorders . T here are s ingle or uncontrolled s tudies that indicate poss ible benefit for other treatments . In one, (Luvox) was significantly more likely than placebo to reduce pain intensity and to normalize urinary flow men with prostatodynia. T his therapeutic effect could be attributed to change in mood, as the two groups did not differ with res pect to affective ratings at the end of study. T he fluvoxamine-treated group also had significantly lower final s cores on the G eneral Health Ques tionnaire, indicating an overall benefit from pain relief. In two other s tudies, inpatient rehabilitation P.1823 aimed at improving functioning was shown to decreas e pain, to increase functioning, and to decrease short1659 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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health care use. Another feature of one of these 200 people with chronic back pain was the high rate of comorbid psychiatric illnes ses and their temporal relations hip to back pain. T he results indicated that ps ychiatric s yndromes appear to precede chronic lowpain (s ubs tance abuse and anxiety disorders ), whereas others (specifically, major depres sion) develop before after the onset of chronic low-back pain. One literature review concluded that exercis e may reduce pain, but further s tudies are needed to examine this relations hip. One s tudy did not s upport the clinical practice of low-dose neuroleptics to low-dose antidepress ants in treatment of somatoform pain disorder. Mindfulnes s meditation has been shown to reduce pain significantly and to increase functioning in approximately 70 percent people with chronic pain that has been refractory to treatment. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > UNDIF F E R E NT IAT E D DIS OR DE R

UNDIFFE R E NTIATE D S OMATOFOR M DIS OR DE R P art of "15 - S omatoform Dis orders"

Definition Undiffe re ntiated s omatoform dis orde r is characterized one or more unexplained physical symptoms of at leas t months' duration, which are below the threshold for a diagnosis of somatization disorder. T hes e s ymptoms 1660 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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not due to or fully explained by another medical, ps ychiatric, or substance abuse dis order, and they clinically significant distress or impairment.

C omparative Nos ology T he category of undifferentiated s omatoform disorder also in the IC D-10, and it is virtually identical to the IV -T R category. Neurasthenia (T able 15-8) is an IC Ddiagnostic s yndrome characterized by at least 3 exhaustion, fatigue and weaknes s, and an inability to recover from the fatigue with res t and is clas sified in DS M-IV -T R as an undifferentiated somatoform disorder symptoms have persis ted for longer than 6 months. However, neurasthenia is of dis order status in many parts of the world, and there are empirical data that support the validity of the construct.

Table 15-8 IC D-10 Diagnos tic C riteria for Neuras thenia F48.0 Neuras thenia    A. E ither of the following must be present: 



P ers is tent and dis tres sing complaints of of exhaustion after minor mental effort (such performing or attempting to perform everyday tas ks that do not require unus ual mental P ers is tent and dis tres sing complaints of 1661

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of fatigue and bodily weakness after minor phys ical effort.    B . At leas t one of the following s ymptoms mus t present:      

F eelings of mus cular aches and pains Dizzines s T ension headaches S leep disturbance Inability to relax Irritability

   C . T he patient is unable to recover from the symptoms in C riterion A (1) or (2) by means of relaxation, or entertainment.    D. T he duration of the disorder is at least 3    E . Mos t commonly us ed e xclus ion claus e . T he disorder does not occur in the presence of emotionally labile dis order (F 06.6), syndrome (F 07.1), pos tconcuss ional syndrome (F 07.2), mood (affective) disorders (F 30 through panic dis order (F 41.0), or generalized anxiety disorder (F 41.1).

Adapted from IC D-10 C las s ification of Me ntal and B ehavioural Dis orde rs . G eneva: World Health 1662 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Organization; 1993:109–110.

E pidemiology As undifferentiated somatoform disorder is cons idered category that is residual to s omatization dis order, there little epidemiology about its prevalence. One s tudy of a representative community s ample in G ermany found a 19.7 percent prevalence using a G erman version of the DS M-IV –adapted C ompos ite International Diagnostic Interview. J avier E s cobar and his colleagues have demonstrated that somatization dis order may be described as a s pectrum on a s omatic symptom index, that four symptoms in men and six s ymptoms in predict s imilar levels of impairment and help s eeking as 13-item index or as full s omatization dis order. T he prevalence of this s ubs yndromal dis order is as much 100 times higher than that for somatization dis order. other investigators have argued for less res trictive for somatization disorder, which is why the DS M-IV -T R less res trictive than the DS M-III-R . F urther work on the most pars imonious class ification of s omatization is required and is being considered by many

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E tiology No s pecific etiology for undifferentiated somatoform disorder is known.

Diagnos is and C linic al F eatures T he critical feature of undifferentiated somatoform disorder is the presence of one or more unexplained phys ical s ymptoms (C riterion A) that pers is t for 6 or longer (C riterion D) but do not meet full diagnostic criteria for somatization disorder and are not due to another defined illnes s (C riteria B and E ). T his is a category for persistent s ymptoms that do not meet the criteria for somatization or another s omatoform However, that does not imply a less severe illness . As ps ychiatric disorders, symptoms must cause clinically significant dis tres s or impairment in social, or other important areas of functioning (C riterion C ). F urthermore, as in other somatoform disorders, are not intentionally produced or feigned (as in disorder or malingering) (C riterion F ). C ommon are chronic fatigue, loss of appetite, and G I or genitourinary s ymptoms, but an array of other may als o occur. One diagnos tic challenge is to between normal symptomatic dis tres s and a proces s. It is normal for people to experience some distress even while in good health, and s omatic are more common than ps ychological symptoms in random community s amples. Approximately 80 percent healthy individuals experience s omatic s ymptoms in given week. However, only a fraction of thes e go on to have pers istent symptoms that are dis tres sing and unexplained. It has been estimated that more than 4 1664 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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percent of people in U.S . communities have chronic somatic complaints. A s econd diagnos tic challenge is in dis tinguishing between an unexplained symptom and a s ymptom that may be due to another medical or ps ychiatric disorder. S ymptoms comprising an undifferentiated disorder are directly due to or cannot be fully explained by any general medical or ps ychiatric condition or the direct effects of a s ubs tance. T hus , if the s ymptoms are another dis order, but the phys ical complaints or impairment is gross ly in exces s of what would be from the history, physical examination, or laboratory findings, an undifferentiated s omatoform dis order may exis t. T his highlights the fact that s omatoform disorders are not diagnos es of exclus ion nor are they mutually exclusive of other medical illness es. In fact, medical ps ychiatric illnes ses are risk factors for also having unexplained dis tres sing P.1824 somatic symptoms. T he challenge lies in proving that is no significant underlying medical disorder that is caus ing the s ymptoms without reinforcing the idea of illness to a patient by conducting multiple diagnostic evaluation tests . E xcluding s ignificant medical illnes s not mean that there is no physical cause for the T he literature is replete with des criptions of altered he ighte ne d phys iological res ponses in people with somatoform disorders . T rying to verbally convince a patient—just like trying to convince him or her with medical technology—that there is nothing wrong with him or her may make the somatoform disorder worse. 1665 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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B oth kinds of attempted reass urance may caus e reinforcement of the illness because there is no explanation for the felt s ymptoms. A third diagnos tic challenge is that unexplained symptoms and worry about illnes s may constitute culturally s haped idioms of dis tre s s that are us ed to concerns about a broad range of pers onal and social problems , without necess arily indicating ps ychopathology. Unexplained physical complaints with high frequency in young women of low socioeconomic s tatus , although thes e s ymptoms are limited to any age, gender, or s ociocultural group.

P athology T here is no specific histopathology for undifferentiated somatoform disorder.

Differential Diagnos is B ecaus e phys ical complaints are so common in life, the differential diagnos is for undifferentiated somatoform disorder is large and broad. Other disorders are in the differential diagnos is. S omatization dis order requires more symptoms of several years ' and an ons et before 30 years of age. S omatoform NO S is diagnosed when the phys ical complaints have persis ted for les s than 6 months but are not due to medical, ps ychiatric, or s ubs tance use disorder. Hypochondrias is is often express ed with s omatic complaints , but preoccupation with the fear of having a disease or the belief that one has a disease coupled res is tance to reass urance is more prominent in hypochondriasis than in undifferentiated s omatoform 1666 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disorder. C hronic pain and s omatoform pain dis orders diagnosed when the unexplained s omatic s ymptoms exclusively pain related. However, pain may be part of undifferentiated s omatoform dis order. T he medical literature has multiple accounts and s tudies of unexplained somatic s ymptoms in affe ctive dis orders , anxie ty dis orde rs , s ome ps ychotic dis orders , s ubs tance dis orders , adjus tme nt dis orders , and pe rs onality C hronic me dical illnes s e s make it more likely that a will develop a comorbid somatoform dis order. C hronic illness is reas onably perceived as a threat, which in caus es heightened vigilance and scanning of bodily functions , leading to amplification of somatic s ens ation and perception. Diagnos ing a s omatoform dis order in context of chronic medical illness s hould be a prudent thorough proces s, balancing the need to obtain data with the need to do no harm to the patient. T rans ie nt une xplaine d s omatic s ymptoms are normal. Amplification of somatic s ens ations may occur in times personal s tres s or los s or even with positive events that caus e a pers on to become more aware of bodily sens ations, such as in the “medical student syndrome.” common theme of the pers onal context in each case is perception of some threat, res ulting in a hypervigilant survey of bodily s ys tems.

C ours e and P rognos is T he cours e of unexplained phys ical s ymptoms is unpredictable. G iven the time criteria for somatoform disorder, there is res olution or the eventual diagnosis of another medical or ps ychiatric dis order. 1667 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Treatment T here is no specific treatment for undifferentiated somatoform disorder. R eass urance by interpreting the threat and the phys iology of heightened arous al and perception is the treatment of choice in these cas es succes sful in more than 95 percent of the cas es . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > UNDIF F E R E NT IAT E D DIS OR DE R

UNDIFFE R E NTIATE D S OMATOFOR M DIS OR DE R P art of "15 - S omatoform Dis orders"

Definition Undiffe re ntiated s omatoform dis orde r is characterized one or more unexplained physical symptoms of at leas t months' duration, which are below the threshold for a diagnosis of somatization disorder. T hes e s ymptoms not due to or fully explained by another medical, ps ychiatric, or substance abuse dis order, and they clinically significant distress or impairment.

C omparative Nos ology T he category of undifferentiated s omatoform disorder also in the IC D-10, and it is virtually identical to the IV -T R category. Neurasthenia (T able 15-8) is an IC Ddiagnostic s yndrome characterized by at least 3 exhaustion, fatigue and weaknes s, and an inability to 1668 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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recover from the fatigue with res t and is clas sified in DS M-IV -T R as an undifferentiated somatoform disorder symptoms have persis ted for longer than 6 months. However, neurasthenia is of dis order status in many parts of the world, and there are empirical data that support the validity of the construct.

Table 15-8 IC D-10 Diagnos tic C riteria for Neuras thenia F48.0 Neuras thenia    A. E ither of the following must be present: 



P ers is tent and dis tres sing complaints of of exhaustion after minor mental effort (such performing or attempting to perform everyday tas ks that do not require unus ual mental P ers is tent and dis tres sing complaints of of fatigue and bodily weakness after minor phys ical effort.

   B . At leas t one of the following s ymptoms mus t present:    

F eelings of mus cular aches and pains Dizzines s T ension headaches S leep disturbance 1669

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 

Inability to relax Irritability

   C . T he patient is unable to recover from the symptoms in C riterion A (1) or (2) by means of relaxation, or entertainment.    D. T he duration of the disorder is at least 3    E . Mos t commonly us ed e xclus ion claus e . T he disorder does not occur in the presence of emotionally labile dis order (F 06.6), syndrome (F 07.1), pos tconcuss ional syndrome (F 07.2), mood (affective) disorders (F 30 through panic dis order (F 41.0), or generalized anxiety disorder (F 41.1).

Adapted from IC D-10 C las s ification of Me ntal and B ehavioural Dis orde rs . G eneva: World Health Organization; 1993:109–110.

E pidemiology As undifferentiated somatoform disorder is cons idered category that is residual to s omatization dis order, there little epidemiology about its prevalence. One s tudy of a representative community s ample in G ermany found a 19.7 percent prevalence using a G erman version of the DS M-IV –adapted C ompos ite International Diagnostic 1670 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Interview. J avier E s cobar and his colleagues have demonstrated that somatization dis order may be described as a s pectrum on a s omatic symptom index, that four symptoms in men and six s ymptoms in predict s imilar levels of impairment and help s eeking as 13-item index or as full s omatization dis order. T he prevalence of this s ubs yndromal dis order is as much 100 times higher than that for somatization dis order. other investigators have argued for less res trictive for somatization disorder, which is why the DS M-IV -T R less res trictive than the DS M-III-R . F urther work on the most pars imonious class ification of s omatization is required and is being considered by many

E tiology No s pecific etiology for undifferentiated somatoform disorder is known.

Diagnos is and C linic al F eatures T he critical feature of undifferentiated somatoform disorder is the presence of one or more unexplained phys ical s ymptoms (C riterion A) that pers is t for 6 or longer (C riterion D) but do not meet full diagnostic criteria for somatization disorder and are not due to another defined illnes s (C riteria B and E ). T his is a category for persistent s ymptoms that do not meet the criteria for somatization or another s omatoform However, that does not imply a less severe illness . As ps ychiatric disorders, symptoms must cause clinically significant dis tres s or impairment in social, or other important areas of functioning (C riterion C ). F urthermore, as in other somatoform disorders, 1671 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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are not intentionally produced or feigned (as in disorder or malingering) (C riterion F ). C ommon are chronic fatigue, loss of appetite, and G I or genitourinary s ymptoms, but an array of other may als o occur. One diagnos tic challenge is to between normal symptomatic dis tres s and a proces s. It is normal for people to experience some distress even while in good health, and s omatic are more common than ps ychological symptoms in random community s amples. Approximately 80 percent healthy individuals experience s omatic s ymptoms in given week. However, only a fraction of thes e go on to have pers istent symptoms that are dis tres sing and unexplained. It has been estimated that more than 4 percent of people in U.S . communities have chronic somatic complaints. A s econd diagnos tic challenge is in dis tinguishing between an unexplained symptom and a s ymptom that may be due to another medical or ps ychiatric disorder. S ymptoms comprising an undifferentiated disorder are directly due to or cannot be fully explained by any general medical or ps ychiatric condition or the direct effects of a s ubs tance. T hus , if the s ymptoms are another dis order, but the phys ical complaints or impairment is gross ly in exces s of what would be from the history, physical examination, or laboratory findings, an undifferentiated s omatoform dis order may exis t. T his highlights the fact that s omatoform disorders are not diagnos es of exclus ion nor are they mutually exclusive of other medical illness es. In fact, medical ps ychiatric illnes ses are risk factors for also having unexplained dis tres sing 1672 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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P.1824 somatic symptoms. T he challenge lies in proving that is no significant underlying medical disorder that is the symptoms without reinforcing the idea of illnes s to a patient by conducting multiple diagnostic evaluation E xcluding significant medical illness does not mean that there is no phys ical caus e for the symptoms. T he is replete with des criptions of altered he ighte ne d phys iological res pons es in people with s omatoform disorders . T rying to verbally convince a patient—just trying to convince him or her with medical technology— that there is nothing wrong with him or her may make somatoform disorder worse. B oth kinds of attempted reass urance may cause iatrogenic reinforcement of the illness becaus e there is no explanation for the felt symptoms. A third diagnos tic challenge is that unexplained physical symptoms and worry about illnes s may constitute shaped idioms of dis tre s s that are us ed to express about a broad range of pers onal and social problems , without necess arily indicating ps ychopathology. Unexplained phys ical complaints occur with high frequency in young women of low socioeconomic although thes e s ymptoms are not limited to any age, gender, or s ociocultural group.

P athology T here is no specific histopathology for undifferentiated somatoform disorder.

Differential Diagnos is 1673 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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B ecaus e phys ical complaints are so common in life, the differential diagnos is for undifferentiated somatoform disorder is large and broad. Other disorders are in the differential diagnos is. S omatization dis order requires more symptoms of several years ' and an ons et before 30 years of age. S omatoform NO S is diagnosed when the phys ical complaints have persis ted for les s than 6 months but are not due to medical, ps ychiatric, or s ubs tance use disorder. Hypochondrias is is often express ed with s omatic complaints , but preoccupation with the fear of having a disease or the belief that one has a disease coupled res is tance to reass urance is more prominent in hypochondriasis than in undifferentiated s omatoform disorder. C hronic pain and s omatoform pain dis orders diagnosed when the unexplained s omatic s ymptoms exclusively pain related. However, pain may be part of undifferentiated s omatoform dis order. T he medical literature has multiple accounts and s tudies of unexplained somatic s ymptoms in affe ctive dis orders , anxie ty dis orde rs , s ome ps ychotic dis orders , s ubs tance dis orders , adjus tme nt dis orders , and pe rs onality C hronic me dical illnes s e s make it more likely that a will develop a comorbid somatoform dis order. C hronic illness is reas onably perceived as a threat, which in caus es heightened vigilance and scanning of bodily functions , leading to amplification of somatic s ens ation and perception. Diagnos ing a s omatoform dis order in context of chronic medical illness s hould be a prudent thorough proces s, balancing the need to obtain data with the need to do no harm to the patient. T rans ie nt une xplaine d s omatic s ymptoms are normal. 1674 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Amplification of somatic s ens ations may occur in times personal s tres s or los s or even with positive events that caus e a pers on to become more aware of bodily sens ations, such as in the “medical student syndrome.” common theme of the pers onal context in each case is perception of some threat, res ulting in a hypervigilant survey of bodily s ys tems.

C ours e and P rognos is T he cours e of unexplained phys ical s ymptoms is unpredictable. G iven the time criteria for somatoform disorder, there is res olution or the eventual diagnosis of another medical or ps ychiatric dis order.

Treatment T here is no specific treatment for undifferentiated somatoform disorder. R eass urance by interpreting the threat and the phys iology of heightened arous al and perception is the treatment of choice in these cas es succes sful in more than 95 percent of the cas es . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > S O MAT OF O R M DIS OR DE R NOT S P E C IF IE D

S OMATOFOR M DIS OR DE R NOT OTHE R WIS E P art of "15 - S omatoform Dis orders"

Definition S omatoform dis orde r NO S is diagnosed in people with 1675 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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somatoform s ymptoms that do not meet the criteria for any of the s pecific s omatoform dis orders and that are due to another psychiatric, medical, or substance us e disorder. T he epidemiology and etiology of this are not studied.

C omparative Nos ology T he IC D-10 has a s imilar res idual category called other s omatoform dis orders , but it specifies that the are not mediated through the autonomic nervous and are not persistent as they are in s omatization

Diagnos is and C linic al F eatures T his diagnos tic category includes s omatoform that do not meet the criteria for any s pecific disorder. E xamples provided in the DS M-IV -T R include 1. P seudocyesis: a false belief of being pregnant that as sociated with objective s igns of pregnancy, such abdominal enlargement without umbilical eversion, reduced mens trual flow or amenorrhea, naus ea, engorgement and s ecretions, subjective s ens ation fetal movement, and labor pains at the expected of delivery. P s eudocyes is may be as sociated with endocrine changes that cannot be explained by another medical condition. 2. Nonpsychotic hypochondriacal symptoms of less 6 months ' duration. Hypochondriacal symptoms occur separate from other dis orders and also occur people with high s omatic sensitivity and with other specific ps ychiatric disorders . Although these hypochondriacal symptoms may be transient, even 1676 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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they are s evere, they may progres s to a primary or secondary form of hypochondriasis or may remit reass urance or treatment of comorbid conditions . 3. Unexplained phys ical s ymptoms of les s than 6 duration that are not due to another illness or subs tance use dis order.

P athology T here are no known cellular or histopathological pathology features of unexplained phys ical symptoms . T here is ample evidence for physiological activity that accentuated by s tres s and emotions, which may cause unexplained s ymptoms.

S mooth and S triated Mus c le C ontrac tion Abnormalities of s mooth mus cle contraction, such as abnormal motility of the esophagus and intestinal tract, may cause symptoms in the chest and the right upper quadrant and middle or lower quadrants of the S triated muscle contracts and also returns to baseline more s lowly during various emotional states. Different emotional states affect various muscle groups Anxiety and depres sion are ass ociated with higher electromyographic (E MG ) activity in s ome mus cle C linical research has demonstrated a relations hip specific types of pain, s uch as headache and low-back increased avers ive emotional states , and increased activity. P.1825 1677 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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B lood Flow and E ndoc rine P sychophys iology res earch has demons trated adrenergic and corticos teroid changes as sociated with various emotional s tates, particularly fear and anger. Increased sympathetic adrenergic tone in respons e to and anger may cause heightened blood pres sure, an increase in heart rate and s troke volume, increas ed res piration, and redis tribution of blood flow away from visceral organs and toward striated muscle. this increas ed tone in res ponse to fear and anger may res ponsible for vas cular s pas m, transient is chemic and instability of blood flow regulation in s ome people. T he cardiologist B ernard Lown demonstrated changes vascular tone, blood flow, and even atherogenesis and sudden death in respons e to severe emotional distress . Although death is not to be equated with unexplained phys ical s ymptoms, the point is that thes e phys iological changes in respons e to emotional distress are spectral, some people have s ymptoms due to thes e changes are not neces sarily measurable in the routine clinical setting. Other symptoms and s igns caus ed by stress emotional mechanis ms include cold s ens itivity of the R aynaud's type, acrocyanosis and erythromelalgia, perhaps , nutcracker esophagus.

Phys iologic al Arous al and T here is a demons trated ass ociation between arousal, perception of this arous al, and experiencing this various s omatic areas . Individuals have an and recurrent pattern of phys iological res ponse to which may explain the recurring unexplained s omatic symptoms in individuals during different stress 1678 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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However, healthy subjects and anxious subjects with predominantly ps ychological symptoms may have sens ations that correlate poorly with physiological On the other hand, anxious patients with predominantly somatic symptoms have physiological arous al that correlates with their physical s ens ations .

Differential Diagnos is As with undiffe rentiate d s omatoform dis order, the differential diagnosis for s omatoform disorder NOS primarily includes other s omatoform, affective , and dis orders , undiagnos ed medical illne s s , and trans ie nt normal s omatic s ymptoms . When other psychiatric, medical and s ubs tance use disorders are excluded, the primary diagnos es to be cons idered are undiffe rentiate d s omatoform dis orde r trans ie nt amplification of normal s ymptoms . T here are empirical data about how to best distinguis h between these three categories . It is likely that there is a between trans ient amplification, the NOS category, the undifferentiated category, and full-blown s omatoform disorders in terms of s ymptom number, s everity, and as sociated dis tres s. T he NOS category is the only somatoform disorder that does not have explicit in the DS M-IV -T R diagnostic criteria about caus ing significant clinical dis tres s. T his does imply that the category is mos t like transient distress ing somatic symptoms. T hus , this diagnos is can be made when the patient has one or more distress ing somatic symptoms and when the clinician is not certain if this is transient the symptoms are beginning to form part of a disorder. If the symptoms persist for longer than 6 1679 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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and are not due to another medical dis order, the of undifferentiated somatoform disorder becomes appropriate.

C ours e, P rognos is , and Treatment Approximately 95 percent of new-onset dis tres sing symptoms remit with competent reass urance. Once symptoms become chronic, the diagnos is should be changed to one of the more specific somatoform disorders . T he most appropriate first-line treatment is the presenting s omatoform s ymptoms become distress ing, then two treatments are indicated. F irst, cognitive and behavioral therapies can be us ed to help patient maintain functioning and not equate symptoms with being an illness or disease. E ducation about the nature of s ymptom amplification and its phys iological basis is important, so that the patient does not think the phys ician is lying or not competent. F amiliarizing patient with the concept of cognitive distortions is for the patient to learn that symptoms do not mean that there is an illness or disease pres ent and that can create catas trophizing cognitions that are P rudent examination and testing procedures s hould be us ed only when the physician truly believes that further clinical investigation is warranted. If the patient laboratory or radiological examinations that are unwarranted, the phys ician must review the s ymptoms, their meaning, and the need for tes ting rather than jus t send the patient for tes ting out of frustration. T he latter maneuver reinforces the patient's belief that his or her body may fail at any time and that the doctor is not 1680 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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competent. T he patient can be instructed to keep a behavioral log to enhance learning about how certain activities change symptoms . E xercise is als o a behavioral approach. S tretching and s trengthening specific muscle groups is the treatment of choice for myofascial pain s yndromes, which are a common in people with somatoform symptoms. T his may be prescribed through phys ical therapy programs or yoga or meditation clas ses, or both. F urthermore, exercise has demonstrated efficacy for depres sion and some anxiety disorders , which are highly comorbid with somatoform s ymptoms . T he second treatment is the prudent use of combined with patient education. Anxiolytics , antidepres sants, muscle relaxants, and hypnotics may warranted to ass ist with symptom relief if the patient unders tands the meaning and value of this treatment if there are no contraindications to their use. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > S P E C IAL C ONS IDE R AT IO

S PE C IAL P art of "15 - S omatoform Dis orders"

P res entations in Different T he paradox that unexplained somatic symptoms cons idered ps ychological and entrenched in ps ychiatry has one remaining paradoxical twis t. T he patients did know about this nor have they accepted it. T hey 1681 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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present to nonpsychiatric s ettings .

Primary C are S omatoform dis orders in primary care are common, ranging from 0.8 to 14.0 percent of all visits. T hes e have abnormal body sensations and authentically for help to understand and to manage them. T hey also have characteristics that are different from nonsomatoform patients. F or example, patients in primary care pres ent with more pain and levels of ps ychological distress , have les s cons is tent maintenance, and more often pres ent owing to anxiety fear than nonhypochondriacal patients. T hey worry their health and their emotional s tate, but they usually only s hare the somatic complaints with their doctor. often ass umed by doctors to be becaus e of the somatization and lack of psychological mindedness , high number of patients report that they wis h that their doctor would talk with them about emotional and is sues.

Other Tertiary S ettings S omatoform dis orders have a prevalence of 5 to 40 percent in some s ubs pecialty clinics, such as gastroenterology, neurology, cardiology, and endocrinology. Unexplained physical symptoms not meeting diagnos tic criteria are even more common in these settings. P atients with s omatoform dis orders who are P.1826 not satis fied with their primary care often seek an 1682 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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explanation from a s pecialis t physician. T hes e patients often disappointed that the specialist finds nothing with them.

Inpatient C ons ultation-L iais on Ps yc hiatry R eports about the prevalence of somatoform disorders patients referred to cons ultation psychiatry services widely. T he two largest s tudies found that 16 and 55 percent of all referred patients have a somatoform disorder, respectively. T hes e patients tend to be older have more active medical problems than patients in primary care with s omatoform dis orders . T his highlights the particular challenge in the cons ultation-liais on of making the diagnos is of a somatoform disorder in and more medically ill patients.

Ps yc hiatry Other psychiatric illnes ses are highly comorbid with somatoform disorders , which are rarely the focus of attention. R ather, unexplained phys ical s ymptoms are subs umed under diagnos es of major depres sion, panic disorder, s chizophrenia, and other illness es . Although there is little doubt that other psychiatric disorders have ris k of increased s omatic complaints, s omatoform disorders themselves are cons idered les s often than disorders , and patients are often encouraged to s ee primary care doctor for complaints about their stomach, head, heart, or back. P s ychiatris ts s ee their limits in the practice of general medicine, yet the primary care phys ician has referred the patient becaus e of the of a s omatoform process , and the ps ychiatris t's 1683 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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places the patient firmly between doctors and s ys tems. T hus, somatoform patients are at high ris k of being los t care, which may reinforce narciss is tic and obses sional that are so common in these patients.

C ros s -C ultural Dis orders T his chapter is not about the authenticity of culturedisorders or the range of cultural effects on the process somatization. R ather, this section is here to s tress the importance of cultural variables to body sensation and expres sion. A few examples are given that highlight symptoms may occur and what the impetus for the symptoms might be.

P ibloqtoq (and Other Arc tic T his dis order, one of the arctic hys te rias (others amos , akek, kajat, matamuk, kalagik, s anraq, montak, s autak, te s ogat, and nirik), originated from made during a series of expeditions by R obert P eary expedition doctors to E llesmere Island and G reenland between 1891 and 1909. T he historian Lyle noted that this syndrome was described in 40 of 150 E skimo tribe members by expedition members . T he commonality between the numerous profes sional inves tigators who have s ince described this syndrome that none of them has witnes sed an epis ode of this intermittent disorder. P ibloqtoq has been des cribed as intermittent epis odes of withdrawal, followed by s inging or s creaming; rolling on the ground; making nois es like birds, dogs, or seals , with subs equent clonic and carpopedal s pas ms while “walking on the sky,” followed by up to an hour of trembling with resultant 1684 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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weaknes s and dazedness . T he native treatment for an epis ode is generally for men not to intervene, the episode occurs in a wife, and for women to s oothe another woman who has an attack. E xpedition and doctors took a more interventional and approach, including prescriptions for sleep, brandy and whis key ingestion, emetics, and injections of mus tard water. More recent workers believe that this is multifactorial and not necess arily culture bound, with poss ible etiologies including partial complex s eizures , vitamin A exces s, infections , s omatoform phenomena, a s ocial protest res ulting from power differences in the contact between native and expedition people.

K oro K oro, a so-called culture-bound syndrome, occurs in S outheas t As ia and may be related to body disorder and hypochondriasis. However, koro has been diagnosed and s ucces sfully treated with S S R Is in the United S tates . It occurs primarily in men and is characterized by a belief that the penis or testicles will shrink and disappear into the abdomen, resulting in When koro occurs in women, the belief is usually that labia or nipples will involute and res ult in death. K oro differs from body dys morphic disorder by its usually duration, different as sociated features (primarily acute anxiety and fear of death), more of a positive res ponse reass urance, and occas ional occurrence as an

Other Medic al Dis orders L ikely to Mas querade as a S omatoform Dis order 1685 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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Any medical dis order that presents with vague or nonclass ic s ymptoms may be taken to be a disorder. One problem is that most medical illnes s presents nonclas sically a large minority of the time. debating whether symptoms are due to another illness or a somatoform disorder, the clinician should cons ider the diagnos es of thyroid dis eas es; parathyroid disease; uncommon infections, s uch as s yphilis; other infections, s uch as human immunodeficiency virus and diss eminated gonococcus; nervous s ys tem such as MS or tumor; and autoimmune disorders, such lupus erythematosus or myas thenia gravis.

C hildren and A doles c ents During childhood, people learn to integrate affect and body s ens ation with cognition to expres s thems elves . During infancy, body s ensation is the primary feeling to learn about the s elf in relation to other things. E arly childhood continues by pairing precognitive affect with somatic s ens ations . Late childhood brings thought and cognition to the pers on in his or her expres sion about self and its relation to the outs ide world. S omatic complaint or pleasure is thus the first, primary modality expres sing displeas ure or joy about the self and its to the world. Affect and then cognition are later, modalities that are learned parallel to s omatic E arly concepts of self and its relation to others are thus wrapped up in body-feeling, and the express ion of complaint in children is the expres sion of displeas ure the self or one's relations hip to other people or other things . T hat displeasure may be due to any number of noxious agents , including virus, phys ical injury, tumor, learned general sens ation that all is not right with the 1686 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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in its world. It is the task of the phys ician to determine source of dis pleasure. S omatic s ymptoms in children are common, although prevalence in the community, schools , or primary care not known. S chool is a common place for expres sion of somatic dis tres s, which can influence the child's attendance and grades . T here may be gender in childhood somatization, with some evidence that have a higher prevalence of abdominal pain and that a higher prevalence of chest and back pain. B ecaus e somatic symptoms are common in children, the should be more concerned with the social and ps ychological context that may be respons ible for the symptoms than with diagnosis. S omatization disorder hypochondriasis diagnoses s hould be held in res erve, unles s the child has a prolonged course of unexplained symptoms in multiple body s ys tems or preoccupation having a serious illness . B ody dys morphic disorder is an underrecognized and underdiagnosed problem that is relatively common among adoles cents and may P.1827 be becoming more common with the increase in media depicting unattainable ideals of beauty and perfection. B ody dys morphic disorder has a high rate of with depress ion and s uicide, which argues for prompt diagnosis and treatment in adolescents. E ffective treatment options include C B T and pharmacotherapy S S R Is.

G eriatric P opulations 1687 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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R es earch about somatoform dis orders in the elderly is limited. T he late onset of a s omatoform disorder should cons idered another medical disorder until clearly otherwis e. However, the astute clinician realizes that somatoform disorders may be comorbid with other medical dis orders and that bodily preoccupations and fears of debility may be frequent in elderly persons. multiple los ses that occur with aging may caus e heightened distress , which may interact with the pains chronic illness . T he onset of preoccupation with health concerns in old age is more likely to be realis tic or to as sociated with an affective dis order or poor s ocial support, or both, than to be a s pecific s omatoform disorder.

R elations hip of P ers onality to S omatoform Dis orders T here are s ome data, given throughout this chapter, the relations hip of s omatoform dis orders to specific personality traits and disorders . T here are also and traits , such as defense and res olution of conflict, communication style, hos tility and anger, and certain cognitive s tyles, that have been studied and written in their relations hip to s omatoform dis orders . As is from the history of somatoform disorders , the between somatoform dis orders as pers onality cons tructs —stable characteristics of the pers on—and disorders that develop later in life is a lively academic debate. T he primary problem with this debate is the inability to distinguish between inherent traits of the person (i.e., temperament) and traits that develop into disorders . F or psychiatry, s eparating Axis I from Axis II disorders is problematic. T hey are both characterized 1688 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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symptoms and enduring patterns of internal experience and behavior that develop over time, becoming chronic and pervas ive parts of the individual. T he trend of transforming chronic Axis I disorders into personality disorders becaus e of their duration is already evident other disorders , s uch that social phobia is thought of as avoidant personality dis order, and dysthymia is a depress ive personality disorder. T his is in light of the that personality dis orders have little empirical s upport discrete entities . T he state–trait problem is no more evident than in hypochondriasis. T here is s upport for cons idering this disorder a pers onality disorder. However, the s tate personality construct and the trait dis order are more than different. T hey are both defined by rigid preoccupation with amplified bodily s ymptoms, the that these symptoms equal illnes s, and behaviors to refute these frightening beliefs but that reinforce because of the rigidity of the conviction. F urthermore, both cons tructs can be viewed as the res ult of cognitive process ing that includes amplification and misinterpretation of bodily symptoms and the outcomes of help seeking coupled with resistance to reass urance. However, a view that is alternative to the state–trait dichotomy exists . T his view uses a developmental and life span approach to demonstrate that s omatoform disorders develop in the context of developmental tasks. E arly childhood experiences with temperament and culture to come together in adulthood as somatization—a process in which bodily distress is one way in which a person can express that something is not right with one's relations hip to s elf or 1689 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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things outside of the self. T his developmental view accurately describes how s omatoform disorders occur without forcing dis tinctions that have little or no support.

R elations hip of Trauma to S omatoform Dis orders T here is evidence that chronic stress and trauma are as sociated with increased physical s ymptoms. T he of the studies that examine this relations hip have been conducted in veterans of war. T he presence of unexplained phys ical s ymptoms is as sociated with ps ychological distress at the time of trauma; ongoing ps ychopathology; alcohol, tobacco, and medication and s ymptoms of P T S D. C ombat veterans with P T S D higher rates of cardiovas cular, neurological, G I, audiological, and pain symptoms compared to combat veterans without P T S D. T here is mounting evidence phys ical s ymptoms are a part of P T S D and also may nonspecific res ponse to trauma that is independent of P T S D. It has been documented that pain s ymptoms often localized to the s ite of previous trauma in people with P T S D. S omatization and hypochondrias is are ass ociated with presence of self-reported traumatic experiences. T here numerous reports about the increased history of people with somatization dis order. T here are two about this relationship in hypochondriasis. In one there was a three- to fourfold higher risk for having experienced traumatic s exual contact, phys ical major parental upheaval before 17 years of age in hypochondriacal people compared to normal control 1690 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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subjects . T he other s tudy validated an interpersonal of hypochondrias is , which posits that early adverse experiences lead to ins ecure and fearful attachment high levels of physical symptoms and illnes s phobia, interpersonal problems in daily life and in medical care. T here is also mounting evidence that people with body dysmorphic dis order, diss ociative convers ion reactions , and pain dis orders experience a higher number of early advers e experiences than normal control s ubjects. T he mechanis ms for unexplained phys ical symptoms in people who have experienced trauma are unclear. Neuroimaging s tudies in trauma s urvivors with P T S D demonstrate dys function of the anterior cingulate with a failure to inhibit amygdala activation or an intrins ically lower threshold of amygdala res ponse to fearful stimuli, both. T here is als o s ome evidence that somatosens ory cortex and B rodmann's areas 1 through 4 and 6 have increased regional blood flow during traumatic recall that this activation is as sociated with s elf-reports of phys ical s ens ations . S ome investigators are propos ing subcortical memory s ys tems help determine this neurobiological respons e to trauma recall. It is well es tablis hed that memory function is changed in P T S D that cognitive and s omatos ens ory proces sing is Multiple physiological s ys tems are activated or with stress , and chronic stres s can produce lasting in autonomic nervous, immune, and hypothalamicpituitary-adrenal (HP A) axis systems . F urthermore, produces increas es of cortisol and epinephrine levels, of which have adverse effects on brain and body when unchecked. P erhaps the most parsimonious theory is that of Hans 1691 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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S elye who observed in medical s chool that there was a nonspecific “syndrome of jus t being s ick” that was acros s various medical illness es . S elye went on to elegant laboratory work with animals to define the adaptation s yndrome (G AS ), which occurs with multiple stress ors , s uch as behavioral stress , heat, cold, trauma, hemorrhage, and other s timuli. T he G AS has stages: (1) the alarm reaction, (2) resistance and and (3) exhaus tion. If the s tres s is not resolved, then chronic changes begin to occur after days and weeks, including fatigue, s leep disorders , symptoms of and anxiety, and an increas ed risk for infection and res piratory and cardiovas cular compromis e. T he involvement of central memory and somatosensory proces sing, the HP A axis involving cortisol and epinephrine, and diminis hed immunity res ults in phys iological P.1828 changes in nearly every body system. T hus , phys ical sens ations are more prominent in those expos ed to stress ors that activate the G AS . W ithout rapid the stress res ponse, physiology can become so altered that it would be surprising if an individual did experience ongoing physical sensations. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > F UT UR E DIR E C T IO

FUTUR E DIR E C TIONS P art of "15 - S omatoform Dis orders" 1692 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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P sychiatrists need improved training about recognition and treatment of individual somatoform dis orders, as as somatoform disorders that are comorbid with other ps ychiatric and medical illnes ses. P articularly when a patient is referred to ps ychiatry for care, it is bes t for ps ychiatris t to conduct relevant examinations and laboratory studies and to obtain the relevant history to make or to exclude a somatoform disorder. T his may include knowledge and s kill of a focused, thorough neurological examination to determine if conversion disorder is present or if there is pathology to s upport another medical dis order in the differential diagnos is . is where ps ychiatry can be at its bes t and where ps ychiatris ts bes t maintain their identities as doctors capable of diagnosing and treating the whole pers on. If this training is not improved, then patients with somatoform disorders will continue to receive care and to be dis miss ed as “crocks.” P rimary care phys icians require further education the known phys iology of somatoform dis orders; the distinction between s omatoform, factitious, and malingering dis orders ; and pharmacological and ps ychotherapeutic treatment principles and modalities. E xcluding other medical disorders is only one-half of equation in the care of the somatoform-disordered patient. T he other half is to make a pos itive diagnos is to use standard, helpful, nons pecific and s pecific treatment modalities that have been shown effective for this group of dis orders . P sychiatrists and primary care physicians need to forge further multidis ciplinary relations hips and care models 1693 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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appropriate for the care of the s omatoform-disordered patient. T hese patients need a place to be s een and to taken serious ly rather than being s hunted back and between clinics. P s ychos omatic and medicalparadigms need to be introduced further into curricula and s ys tems of care, s o that the patient's illness is not being perpetuated by firs t being viewed through a biomedical paradigm and then a ps ychological one, mimicking the mind–body split in W estern culture that so elemental to their disorder. T he public will benefit from education about the high prevalence of unexplained physical s ymptoms and the that, although thes e are not necess arily life they can be dis abling. T he public should also know that there are treatments available for thes e disorders . F inally, research about s omatoform dis orders s hould be neglected. T hese disorders are impairing to patients and costly to s ociety, and medicine needs to better unders tand the pathogenes is , phenomenology, and treatment options for s omatoform dis orders. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > S UG G E S T E D C R O S S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "15 - S omatoform Dis orders" R elated dis orders are discus sed in C hapter 16 on disorders and C hapter 17 on diss ociative disorders . 1694 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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24.11 on consultation-liais on ps ychiatry, S ection 30.12 noncompliance with treatment, and S ection 26.1 on malingering als o have information relevant to disorders . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 15 - S omatoform Dis orders > R E F E R E NC

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F abrega H, P arron DL, eds . C ulture and P s ychiatric Diagnos is : A DS M-IV P e rs pe ctive . W ashington, DC : American P s ychiatric P res s; 1996. *F ord C V . T he S omatizing Dis orde rs : Illne s s as a L ife . New Y ork: E lsevier S cience; 1983. F ord C V : T he s omatizing dis orders. 1986;27:327. F oulks E . In: Maybury-Lewis D, ed. T he Arctic the North Alas kan E s kimo. Anthropological S tudie s , 10. W ashington, DC : T he American Anthropological Ass ociation; 1972. F rances A, R os s R . DS M-IV C as e S tudie s : A Diffe rential Diagnos is . W ashington, DC : American P sychiatric P ress ; 1996:208. F reud S . On narciss ism: An introduction. In: E dition of the C omple te P s ychological W orks of F re ud. London: Hogarth P res s; 1955. G rabe HJ , Meyer C , Hapke U, R umpf HJ , Dilling H, J ohn U: S pecific somatoform disorder in general population. P s ychos omatics . 2003;44:304. Hiller W , R ief W , F ichter MM: Dimensional and categorical approaches to hypochondrias is . P s ychol Me d. 2002;3:707. Hollifield M. Hypochondrias is and pers onality 1696 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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disturbance. In: S tarcevic V , Lips itt DR , eds. Hypochondrias is : Modern P ers pective s on an Malady. Oxford, UK : Oxford University P ress ; 2001. Hollifield M, T uttle L, P aine S , K ellner R : and s omatization related to pers onality and attitudes toward s elf. P s ychos omatics . 1999;40:387. K aton W , K leinman A, R osen G : Depress ion and somatization: A review. P art I. Am J Med. *K ellner R . S omatization and Hypochondrias is . New P raeger; 1986. K ellner R . Abridge d Manual of the Illnes s Attitude Albuquerque, NM: Department of P sychiatry, of New Mexico S chool of Medicine; 1987. K ellner R . P s ychos omatic S yndrome s and S omatic S ymptoms . W ashington, DC : American P sychiatric 1991. K irmayer LJ , R obbins J M: T hree forms of primary care: P revalence, co-occurrence and sociodemographic characteris tics. J Ne rv Ment Dis . 1991;179: 647. K raus R . P ibloqtoq R e vis ite d. P aper presented at: annual meeting of T he S ociety for the S tudy of P sychiatry and C ulture; October 19, 2002; C harlottesville, V A.

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Ladee G A. Hypochondriacal S yndrome s . North-Holland P ublis hing; 1966. Lipows ki ZJ : S omatization: T he concept and its application. Am J P s ychiatry. 1988;145:1358. Lipsitt DR . T he patient-phys ician relationship in the treatment of hypochondriasis . In: S tarcevic V , Lips itt eds. Hypochondrias is : Modern P e rs pe ctive s on an Malady. Oxford, UK : Oxford University P ress ; 2001. Looper K J , K irmayer LJ : B ehavioral medicine to somatoform disorders . J C ons ult C lin P s ychol. 2002;70:810. Morris on J : C hildhood sexual histories of women somatization disorder. Am J P s ychiatry. Noyes R J r, Holt C S , Happel R L, K athol R G , Y agla family s tudy of hypochondriasis. J Ne rv Ment Dis . 1997;185:223. Noyes R J r, K athol R G , F is her MM, P hillips B M, MT , Holt C S : T he validity of DS M-III-R Arch G e n P s ychiatry. 1993;51:961. Noyes R J r, S tuart S P , Langbehn DR , Happel R L, S L, Muller B A, Y agla S J : T est of an interpersonal of hypochondrias is . P s ychos om Me d. 2003;65:292. P hillips K A. S omatoform and F actitious Dis orde rs . Was hington, DC : American P sychiatric P ublis hing, 1698 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/15.htm

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depers onalization. Int J P s ychoanal. 1979;60:201. T ezcan E , Atmaca M, K uloglu M, G ecici O, A, T utkun H: Dis sociative disorders in T urkis h with conversion disorder. C omp P s ychiatry. T orgers en S : G enetics of s omatoform dis orders. G e n P s ychiatry. 1986;43:502. T yrer P . T he R ole of B odily F e elings in Anxiety. Oxford Univers ity P res s; 1976. T yrer P : S omatoform and personality dis orders: personality and the s oma. J P s ychos om R e s . Weintraub MI. Hys terical C onvers ion R e actions : A G uide to Diagnos is and T re atme nt. New Y ork: S P and S cientific B ooks ; 1983.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > 16 - F actitious Dis order

16 Fac titious Dis orders Dora Wang M.D. Deepa N. Nadiga M.D. J ames J . J ens on M.D. According to the American Heritage Dictionary, the factitious means “artificial; false,” derived from the Latin facticius , which means “made by art.” T hose with disorder s imulate, induce, or aggravate illnes s, often inflicting painful, deforming, or even life-threatening on thems elves or those under their care. Unlike malingerers who have material goals , such as gain or avoidance of duties , factitious dis order patients undertake thes e tribulations primarily to gain the emotional care and attention that comes with playing role of the patient. In doing s o, they practice artifice art, creating hospital drama that often causes and dismay. C linicians may exclaim, “He's not really He's doing it to himself!” and thus dis mis s, avoid, or to treat factitious disorder patients. S trong countertransference of clinicians can be major toward the proper care of these patients who arguably among the most psychiatrically dis turbed. S ignificant morbidity or even mortality often occurs. T herefore, even though pres enting complaints are falsified, the medical and psychiatric needs of thes e 1701 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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patients mus t be taken serious ly. F actitious ly produced wounds can result in infection and os teomyelitis and even necess itate amputation. One woman factitious ly complained of an extens ive family his tory of breas t incurring a medically unneces sary bilateral C as es resulting in death are not uncommon. A 21operating room technician, the daughter of a phys ician, repetitively injected herself with ps eudomonas, caus ing multiple bouts of s epsis and bilateral renal failure her death. F or patients with factitious disorder, unmet emotional needs are so great that even imperilment of life or limb be merited. F actitious illness behavior often represents severe underlying ps ychiatric disturbance, such as a personality dis order. Ironically, even thos e pres enting factitious ps ychological complaints , such as or psychosis, usually have another ps ychiatric for which they are not s eeking help. T reatment involves harm reduction and efforts to steer patients toward the ps ychiatric care that they need, in face-saving, nonthreatening ways. Des pite potentially high stakes , relatively little empirical knowledge is available about the etiology, cours e and prognosis , and effective treatment of disorders . Most knowledge comes from cas e reports , information that is frequently s uspect, given the fals e, unreliable nature of the information thes e patients give. Methodological problems are inherent in the study of these deceptive patients, as they are difficult to identify, and, when found out, they often flee to avoid charges fraud from the hospital and ins urance companies. S ys tematic s tudies of factitious dis order are few, and 1702 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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federally funded investigation is nonexistent, despite subs tantial human and financial cos t imposed by the disorder. However, the s ituation is not as grim as previous ly as sumed. Munchausen syndrome, the prototypical factitious disorder and the first to engender wide interes t, is now known to be a chronic, severe variant, comprising only a small portion of all factitious F actitious illness behavior represents a wide spectrum at one end, represents normal behavior, s uch as when children exaggerate dis tress from s crapes and bruises gain parental attention. It is important to remember that not all factitious illness behavior is as refractory or as chronic as that demons trated by Munchaus en patients. 

DE F INIT ION

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HIS T OR Y

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C OMP AR AT IV E NOS OLOG Y

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E P IDE MIOLOG Y

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E T IOLOG Y

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DIAG NOS IS AND C LINIC AL F E AT UR E S

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P AT HOLOG Y AND LAB OR AT OR Y R E P OR T S

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DIF F E R E NT IAL DIAG NOS IS

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C OUR S E AND P R OG NOS IS

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T R E AT ME NT AND MANAG E ME NT

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F UT UR E DIR E C T IONS

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S UG G E S T E D C R OS S -R E F E R E NC E S 1703

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > DE F INIT ION

DE FINITION P art of "16 - F actitious Dis orders " T he main clinical feature is the intentional production or feigning of physical or psychological s igns or with the motivation of ass uming the s ick role. T he definition of factitious dis order, according to the revised fourth edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-IV -T R ), is given in T able 16-1.

Table 16-1 DS M-IV-TR Diagnos tic C riteria for Fac titious Dis order A. Intentional production or feigning of physical or ps ychological signs or s ymptoms . B . T he motivation for the behavior is to as sume sick role. C . E xternal incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving phys ical well-being, as in malingering) absent.

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C ode based on type:    300.16 With predominantly ps ychologic al and s ymptoms : if ps ychological signs and symptoms predominate in the clinical    300.19 With predominantly phys ic al s igns s ymptoms : if physical s igns and s ymptoms predominate the clinical presentation.    300.19 With c ombined ps ychologic al and phys ic al s igns and s ymptoms : if ps ychological phys ical s igns and s ymptoms are pres ent, but neither predominates the clinical pres entation.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. Munchaus en s yndrome , a colorful name coined by Asher in his landmark 1951 publication, is also known chronic factitious dis orde r with predominantly phys ical and s ymptoms . T he two terms are us ed T hese cases are a s mall s ubs et of the most severe factitious disorder in which factitious illness behavior becomes a lifes tyle, usually precluding s table or employment. C ons tantly seeking medical care and hospitalization, these patients often ass ume grandiose, 1705 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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false identities , s ometimes claiming to be royalty, of celebrities , or figures in important historical events. T hey travel from hospital to hos pital s eeking medical and, when they become well-known in town, take their on the road to another locale, where they begin the behavior anew. T he nicknames hos pital hoboes , addicts , and profes s ional patients have been applied to them. T wo distinguishing features of Munchaus en syndrome are ps eudologica fantas tica, the telling of tall and fascinating but untrue tales , and pe re grination, as these patients tend to be well traveled. Munchaus en syndrome comprises only approximately percent of all cases of factitious disorder, and the two should be distinguished. Not all those with factitious disorder have the same poor prognosis as the s mall minority of Munchausen syndrome patients. In factitious dis order by proxy, a person intentionally simulates illness in another pers on who is under that individual's care. Most commonly, the perpetrator is a mother causing illness in her own child s o that that s he gains the emotional gratification of the sick role vicariously. In other cases, factitious disorder by proxy be committed by one adult against another adult, such an elder or spouse. Medical pers onnel have committed factitious disorder by proxy on patients, causing of hos pital deaths. P erpetrators usually gain the admiration of others, appearing like s elf-sacrificing caretakers . B ecause factitious dis order by proxy almos t always constitutes child abus e or a criminal act, the forens ic terms pe rpetrator P.1830 1706 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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and victim are us ed even in the medical literature. F actitious disorder by proxy currently falls under the category of factitious disorder not otherwise specified (NOS ), according to DS M-IV -T R . It is listed as a criteria deserving of further s tudy, and its research criteria are listed in T able 16-2. T he terms factitious dis order by and Munchaus en s yndrome by proxy are us ed interchangeably, and, at the current time, there is no distinction between the terms . Although, by DS M-IV -T R criteria, the term factitious dis order by proxy refers to perpetrator, not the victim, there is s ome variance of the literature.

Table 16-2 DS M-IV-TR R es earc h C riteria for Fac titious Dis order Proxy A. Intentional production or feigning of physical or ps ychological signs or s ymptoms in another who is under the individual's care. B . T he motivation for the perpetrator's behavior is as sume the s ick role by proxy. C . E xternal incentives for the behavior (such as economic gain) are absent. D. T he behavior is not better accounted for by another mental dis order. 1707 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > HIS T O R Y

HIS TOR Y P art of "16 - F actitious Dis orders " S elf-inflicted illnes s occurs throughout his torical In the s econd century AD, the G reek-born phys ician wrote of patients inducing or simulating s ymptoms such as vomiting or rectal bleeding. T he B ible relates of people self-inflicting injury. In the E uropean middle ages, hys te rics reportedly put leeches in their mouths simulate hemoptysis and abraded their s kin to skin conditions. However, judging historical accounts through contemporary mindsets is often problematical, and it is difficult to say if thes e accounts actually factitious disorder. In 1838, the S cottis h military phys ician Hector G avin published his es say, “On the F eigned and F actitious Dis eas es of S oldiers and S eamen, on the Means Us ed 1708 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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S imulate or P roduce T hem, and on the B es t Modes of Dis covering Impos tors .” Although most of G avin's were malingering, aiming to es cape duty in the high casualty Napoleonic Wars , G avin als o noted that the motive of s ome was simply “to excite compass ion or interes t” and that “some soldiers, indeed, without any ulterior object, s eem to experience an unaccountable gratification in deceiving their officers, comrades, and surgeon.” J ean-Martin C harcot, in approximately 1890, us ed the mania ope rativa activa to des cribe a young girl who continually sought surgery for pain in a knee joint, until she found a s urgeon who amputated the leg. S ubsequently, no pathology was found in the leg. In the S wis s phys ician Henri F . S ecretan described a syndrome, to which he lent his name, of nonhealing traumatically induced edema of the dorsum of the G eorge R eading, in 1980, confirmed that S ecretan's syndrome is factitiously produced. In 1934, K arl described polys urgical addiction. Interes t in factitious disorder increased markedly when term Munchaus en s yndrome was coined in a 1951 publication by B ritish physician R ichard As her. As her Here is des cribed a common syndrome which mos t doctors have seen, but about which little has been written. Like the B aron von Munchausen, the persons affected have always traveled widely; and their like thos e attributed to him, are 1709 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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both dramatic and untruthful. Accordingly, the syndrome is res pectfully dedicated to the baron, and named after him. Asher's provocative paper described three patients with false abdominal complaints , all of whom us ed multiple identities and s ought care at a number of hos pitals . paper inspired much correspondence and subs equent reports . T he B aron K arl F riedrich Hieronymus von (1720 to 1797) was an honorable nobleman who the R us sian army in war agains t the T urks (F ig. 16-1). retirement, he entertained friends with embellished of his war adventures. T he peregrinating, figure was in fact the B aron's friend, R udolph E ric who was forced to flee G ermany for E ngland after he caught embezzling from a mus eum. S eeking to pay off debts , R aspe published an account of the baron's tales 1785.

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FIGUR E 16-1 T he B aron K arl F riedrich Hieronymus von Munchhausen (1720 to 1797). Left: T he B aron wears military armor in this 1750 portrait by G . B ruckner. An honorable nobleman who served in the R uss ian army in war against the T urks, the B aron entertained friends in retirement with embellished s tories of his war His tales gained fame when published by R udolph E . R ight: T he B aron appears as a caricature in this 19th-century artis t G ustave Dore. Like the B aron, with factitious disorders are pers ons deserving of even though they often pres ent themselves as (P ortrait courtes y of B ernhard W iebel, http://www.muenchhaus en.ch/. T he actual portrait was in W orld W ar II. C aricature from T he Adve ntures of Munchaus en: O ne Hundred and S ixty Illus trations by Dore . New Y ork: P antheon B ooks, Inc.; 1944, with 1711 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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permis sion.) In 1968, Herzl R . S piro noted that, of the 38 cas es of Munchaus en s yndrome then published, none involved detailed psychiatric workup and les s than one-half evaluated by a psychiatrist. He advocated greater unders tanding of thes e patients and pres ented the first detailed psychiatric case study, confirming information with collateral sources. He called the Munchausen syndrome label “facetious ” and recommended the les s pejorative term chronic factitious s ymptomatology. F actitious disorder with ps ychological s ymptoms was described by Alan J . G elenberg in 1977, who mused although other factitious dis order patients avoided ps ychiatris ts, his patient, a war veteran, gained to more than 30 psychiatric hospitals within a few us ually feigning depres sion and s uicidal tendency various pseudonyms. T he term Munchaus en s yndrome by proxy was first 1976 by J ohn Money and J une W erlwas , who reported cases of child abuse and deprivation that resulted in ps ychos ocial dwarfism. T he motive of as suming the role was not a feature of thes e cas es. T he term Munchaus en s yndrome by proxy as it is us ed today applied in 1977 by B ritis h pediatrician R oy Meadow published the widely read article, “Munchaus en's by T he Hinterland of C hild Abuse,” which detailed the accounts of a mother P.1831

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who caused salt pois oning in her child and another fabricated urinary tract infections in her daughter. T he latter cas e was of a 6-year-old girl who had undergone hospitalizations, more than 150 urine cultures , s ix examinations under anes thesia, five cystoscopies, and seven major X-ray procedures . W hen the girl was for obs ervation, the diagnosis of Munchausen by proxy was made based on urine s amples that were bloody when they were collected by the mother but normal when they were collected by the nurse. Of note, the mother had als o s ought medical treatment for factitiously induced urinary tract infections in hers elf. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > C O MP AR AT IV E NO S O LO

C OMPAR ATIVE P art of "16 - F actitious Dis orders " T he third edition of the Diagnos tic and S tatis tical Me ntal Dis orde rs (DS M-III) in 1980 was the first edition the DS M to recognize factitious disorder. Munchaus en syndrome was called the prototype of all factitious disorders , and, accordingly, emphasis was placed on chronic factitious dis order with physical s ymptoms. F actitious disorder with ps ychological s ymptoms was recognized, as was atypical factitious disorder, which included dis orders that would now fall into the DS M-IV category of factitious disorder with predominantly phys ical s igns and s ymptoms. S ubsequent editions of the DS M increas ingly 1713 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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the rarity of Munchaus en s yndrome and accordingly placed more emphas is on a greater s pectrum of disorders . T he revised third edition of the DS M (DS Mrecognized factitious dis order with physical symptoms factitious disorder with ps ychological s ymptoms. T he emphasis on Munchaus en syndrome was less ened. F actitious disorder with combined phys ical and ps ychological symptoms made its appearance under category of factitious disorder NOS . In contras t, the fourth edition of the DS M (DS M-IV ) to es pouse a s ingle category, factitious disorder, with types : (1) with predominantly psychological s igns and symptoms, (2) with predominantly phys ical s igns and symptoms, and (3) with combined ps ychological and phys ical s igns and s ymptoms. F actitious disorder NOS exemplified by factitious disorder by proxy, a dis order named as a category des erving of more research, with res earch criteria listed. T he DS M-IV -T R criteria for disorders are unchanged in comparis on with DS M-IV criteria. When the diagnosis of factitious disorder by proxy is it s hould be coded as factitious disorder NOS . T he diagnosis applies to the perpetrator, not the victim. P hysical abuse of child for the caregiver and phys ical of child for the child should also be coded. E mphas izing the pers onality disorder aspect of disorders , the tenth revis ion of the Inte rnational C las s ification of Dis e as e s and R e late d He alth 10) lis ts factitious disorder under the category other dis orders of adult pe rs onality and be havior. T wo corres ponding with common notions of factitious are identified: (1) elaboration of phys ical s ymptoms for 1714 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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ps ychological reasons and (2) intentional production or feigning of s ymptoms or disabilities , phys ical or ps ychological (factitious disorder). Under the s econd subtype, hos pital hopper syndrome, Munchaus en syndrome, and peregrinating patient are listed. T he excludes “person feigning illnes s (with obvious motivation),” just as DS M-IV -T R excludes malingering. IC D-10 makes no mention of factitious disorder by Limitations exist in the DS M-IV -T R and IC D-10 B oth clas sification s ys tems s pecify that s ymptoms of factitious disorder are intentionally or consciously produced. However, in reality, intent can be difficult to discern, and consciousness may repres ent a s pectrum awarenes s. Likewise, the DS M-IV -T R and the IC D-10 exclude cas es in which there are obvious or external motivations . Motive, however, can als o be difficult to determine. C riteria of intent and motivation are completely subject to the clinician's opinion. E ven the DS M-IV -T R and the IC D-10 exclude malingering, reality is that factitious disorder and malingering can coexist, as when patients who habitually gratify thems elves in the sick role dis cover that they can als o receive dis ability payments or pleasurable pain medications at the s ame time. Neither the current DS M-IV -T R nor the IC D-10 accommodates the growing literature about disorder by proxy diagnoses in which parents impose ps ychiatric disorders or emotional needs on their F or example, hypochondrias is by proxy can result in repetitive pediatric vis its and unnecess ary tes ts and procedures for a child, but without fabrication of of illnes s. Anore xia ne rvos a by proxy and malinge ring 1715 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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proxy are other examples. Interes tingly, although the psychiatric nosology equivocal about the existence of factitious dis order by proxy as a disease entity, the legal system has 50 states require reporting of Munchausen syndrome proxy to child protective s ervices as a form of child Munchaus en s yndrome by proxy is well established in legal literature, with an abundance of representation in case law. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > E P IDE MIOLO G

E PIDE MIOL OGY P art of "16 - F actitious Dis orders " No comprehens ive epidemiological data on factitious disorder exis t, as traditional epidemiological methods would be problematical with this deceptive population. B ecaus e factitious dis order may be difficult to detect, prevalence may be underestimated. On the other hand, prevalence might be overestimated, as many of thes e patients s eek care at multiple venues . F urthermore, with factitious disorders may not present to a health setting but may play the s ick role with family, friends, or coworkers. F or example, a fan of the B roadway R ent feigned terminal illnes s and s uicidal tendency, the sympathies of fellow fans and even the cas t, who dedicated songs to her during performances. Internet bulletin boards P.1832 1716 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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and chat groups provide new opportunities to fabricate illness and to play the sick role in cybers pace. Limited s tudies indicate that factitious dis order patients may compris e approximately 0.8 to 1.0 percent of ps ychiatry consultation patients . Of 1,288 medical inpatients referred for psychiatric cons ultation at a T oronto teaching hospital, 0.8 percent were diagnos ed with factitious disorder. At a New Y ork C ity hospital, 1 percent of psychiatry cons ultation patients were diagnosed with factitious disorders . F ever is one of the most commonly detected factitious symptoms, and s tudies indicate that 2.2 to 9.3 percent fevers of unknown origins may be factitious. A S tanford Univers ity study showed that, of 506 cas es, 2.2 percent were factitious . On the other hand, more than four that percentage, a remarkable 9.3 percent of 343 the National Ins titute for Allergy and Infectious were found factitious. Other es timates include 3.5 in a s tudy of 199 cases in the 1980s and 6.5 percent of cases at the National Institutes of Health. In a s tudy of urinary calculi, 3.5 percent of s tones brought in by were factitious , cons isting of materials s uch as quartz felds par. F actitious dis orders may play a larger role expected in health care us e and may be an underrecognized confounding factor in medical V arious authors agree that approximately two-thirds of patients with Munchaus en syndrome are male. T hey to be middle-aged, unemployed, unmarried, and significant social or family attachments. F or thos e with non–Munchaus en syndrome factitious dis orders with predominantly phys ical s igns and s ymptoms, women 1717 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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outnumber men, with a ratio of 3 to 1. T hey are us ually to 40 years of age with a history of employment or education in nurs ing or a health care occupation. In a year retros pective s tudy, 28 of 41, or 68 percent, of hospitalized patients with factitious dis orders had in medically related fields, 15 as nurs es. F actitious disorders usually begin for patients in their 20s or 30s , although the literature contains cas es ranging from 4 to years of age. R eported cases are almost exclus ively whites, although two African-American men with Munchaus en syndrome have been reported. reports have come from E urope and Africa. F ar les s information is available about the factitious disorders with predominantly ps ychological signs and s ymptoms. Dines h B hugra estimated Munchaus en syndrome at 0.5 percent of adult admis sions who were younger than 65 years of age, on four diagnoses of Munchaus en syndrome out of 775 admis sions . In a s tudy of 4,500 visits to a ps ychiatric emergency room (E R ), seven vis its , or 0.15 percent, represented factitious disorder. S imilarly, a 1994 s tudy es timated the prevalence at 0.14 percent in a sample. F actitious disorder by proxy is most commonly perpetrated by mothers against infants or young R are or underrecognized, it accounts for les s than 0.04 percent, or 1,000 of three million cas es of child abus e reported in the United S tates each year. G ood epidemiological data are lacking. Of infants brought to Aus tralian clinic for apparently life-threatening an es timated 1.5 percent represented factitious by proxy. A clinical practice at G reat Ormond S treet in 1718 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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E ngland reported that, in 20 years, 43 children from 37 families were diagnos ed as having induced illness es. Donna A. R osenberg's review of 117 cases revealed valuable information. Male and female children were equally victimized. T he mean age of a child at was 3.3 years of age, with the onset of s ymptoms mean of 1.24 years earlier. All perpetrators were with 98 percent being biological mothers and 2 percent being adoptive mothers. P aternal collus ion was in only 1.5 percent of the cases . In one-half of the illness was actively produced and inflicted on the child, whereas , in 25 percent, illness was simulated without direct infliction on the child. In 25 percent, illness was simulated and produced. Interes tingly, in 25 percent of cases, morbidity on the child was iatrogenic only, procedures and investigations . S urprisingly, 70 percent produced illnes s occurred in the hospital, making inves tigation during hos pitalization a valuable option. In R osenberg's review, 10 percent of perpetrators were thought to have Munchaus en s yndrome themselves , whereas another 14 percent s howed features of the syndrome. On the other hand, data collected from the G reat Ormond S treet clinic over a 20-year period that approximately one-third of perpetrating mothers a his tory of factitious dis order themselves. Nearly oneof them described s erious marital problems. Approximately one-half of the perpetrating caregivers a his tory of psychiatric s ymptoms ; approximately onegave his tories of emotional neglect or physical abuse. F athers were generally absent or peripheral. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di

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C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > E T IOL OG

E TIOL OGY P art of "16 - F actitious Dis orders " T he etiology of factitious dis order is not known, and a variety of caus es likely explain the wide s pectrum of factitious illness behavior. Although factitious illness behavior is, by definition, consciously produced, the underlying motivations for the behaviors are largely cons idered to be unconscious. T wo factors underlie cases of factitious disorder: (1) an affinity to the system and (2) poor, maladaptive coping s kills . A majority of factitious dis order patients have training in medicine, and many work as nurs es . In a review of s ix series compris ing a total of 165 patients , P eter R eich Lili A. G ottfried found that 60 percent worked in the medical profess ion. Motives behind medical career appeared to be lifelong preoccupations with health than access to information to deceive. Indeed, many factitious disorder s ee health care providers as allies, advers aries. In this case s eries, many patients had ties with their phys icians, having worked in their offices having baby-sat for them. C oping deficits are widely noted. P atients often have immature coping s kills , not falling into any current category of personality dis order. T his is consistent with observations that many factitious disorder patients from large families or have been neglected as children, therefore lacking the nurturing conducive to the 1720 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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development of mature coping. T his is als o consis tent the fact that children often demonstrate factitious behavior that is not cons idered pathological, for feigning a stomachache to gain parental attention. On other end of the spectrum, poor coping may be part of personality dis order, such as borderline personality or antis ocial pers onality disorder. Dependent and personality traits may als o be evident. An underlying psychiatric diagnos is may predis pos e to factitious illness behavior. Many cas e reports indicate less ening or alleviation of factitious illness behavior major depress ion is treated. Other cas e reports point to hypochondriasis as an underlying factor. F or example, 27-year-old phys ician simulated ins ulinoma by ins ulin injections. W hen insulin and a syringe were found in toilet tank, he confess ed a preoccupation that he had pancreatic cancer and that he was trying to provoke further investigation. A 15-year-old boy, convinced that had a les ion in his urogenital system, s imulated to encourage investigation. S ubs tance abus e, disorders , and mental retardation have also been implicated. No genetic or familial inheritance pattern has been No s ubs tantial evidence of a biological etiology has found, des pite scattered P.1833 reports of abnormal brain s cans and deficits in neurops ychological testing in a few patients. Indeed, a great percentage of factitious dis order patients achieve advanced degrees , maintain high-functioning jobs as medical profess ionals , and demonstrate great cognitive 1721 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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as tutenes s in their manipulations of medical s igns and symptoms. P sychodynamic theories have focus ed on the concepts mastery, masochism, and mothering. Achieving may be especially true for factitious disorder patients predominantly ps ychological signs and s ymptoms. F or example, as those who present with factitious often progres s to develop a genuine psychotic the feigning of ps ychos is may actually be a way of in control of initial psychotic s ymptoms . As for phys ical factitious disorder, many of these patients experienced traumatic illness es as children, and their adult factitious illness behavior may allow them to mas ter s ituations to feel control that they never did as children. T hey demand or refus e procedures and leave the hospital agains t medical advice when they feel that they are control. Mas ochism may be involved when patients repetitively endure painful or deforming surgeries and procedures , s uch as amputations of limbs and fingers, exploratory abdominal s urgeries that res ult in scars even the gridiron s tomach that As her des cribed as a symptom of Munchaus en s yndrome. T he theory here is that the patient relives childhood phys ical or emotional abuse in a repetition compulsion. T he physician and medical system at large become symbolic parents whom the patient reenacts dependency, idealization, anger. T he s ys tem res ponds with caring but also with phys ical and emotional abus e and, too often, ultimately with deris ion and abandonment. Indeed, for those with chronic factitious dis order, the medical system the main object relation in the patient's life, a s ubs titute mother. T he medical system may be a place to 1722 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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caring, while avoiding emotional intimacy. F actitious illness behavior often occurs in the setting of loss , s uch as the death of a relative or an occupational S ecuring the attention of medical clinicians, family, and friends may be a way of obtaining emotional s olace without directly confronting the loss . Dependency and narcis sistic needs are fulfilled. F actitious illness behavior may organize s ome patients, giving them a role and identity. T hey acquire the role of patient and masterful orches trator of medical drama. T hrough ps eudologica fantas tica, they might even cons truct desirable and interes ting identities. B ehavioral theories postulate that, early in life, these patients received pos itive reinforcement while in the role. Many experienced childhood illness es and gained nurturing from the medical community that they did not receive at home. P erhaps, they learned to see the system as a s ource of caring and emotional support. Alternatively, many of these patients came from large families and became the center of focus when were ill. In factitious dis order by proxy, ps ychodynamic explanations predominate. A common view is that caretakers often have a profound s ense of loss , a his tory of early abandonment particularly by the or loss of contact with another child. C ontrovers y exists regarding the likelihood of a history of abuse for the mothers, as many have reported his tories of abuse that were later dis qualified by collateral sources. T he objectification of the child to serve the parent's ps ychological needs characterizes all variations of the 1723 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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disorder. A dis order of empathy among perpetrating mothers was recognized by R os enberg, along with pervas ive themes of lonelines s and isolation, often circums tances of uninvolved or abs ent hus bands. the ill child, the mother seeks a relationship with the phys ician, the idealized parent, who substitutes for the uninvolved hus band. T he relations hip with the a highly ambivalent one in which the caregiver seeks clos enes s, although often belittling the physician in contexts . T he more s evere the child's illness , the more mother is needed, and the more s he fulfills her own for caretaking, vicarious ly through the child and more directly in her relations hip with the physician. F athers to be uninvolved or dis tant. D. Mary E minson and P os tlethwaite argue that two axes play a role in disorder by proxy: the desire to consult and the inability the parent to distinguish parental needs from the child's needs . Herbert A. S chreier and J udith A. Libow call Munchaus en syndrome by proxy a pe rve rs ion of in which the child is dehumanized and instead is seen the mother as a fetishis tic object through which her dependency needs are met. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > DIAG NO S IS AND C LINIC AL

DIAGNOS IS AND C L INIC AL FE ATUR E S P art of "16 - F actitious Dis orders "

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Fac titious Dis order with P redominantly P hys ic al S igns and S ymptoms E arly diagnos is and intervention can minimize physical harm to the patient and iatrogenic complications . T herefore, the diagnosis of factitious disorder s hould actively pursued. Dis eas es of every organ s ys tem have been simulated, including rare illness es , such as G oodpasture's and panhypopituitaris m. Dis eas e s imulation is limited by the patient's creativity and knowledge and the technological means available. As they tend to have medical training, the factitious patient's knowledge of disease may exceed that of his or her phys icians . T his es pecially true, as they often pres ent to hospital E R s or clinics during evenings or weekends when less experienced staff or resident phys icians are on duty. F actitious s ymptoms can be (1) fabricate d, for giving a fals e his tory of cancer, acquired immune deficiency syndrome (AIDS ), or another illness ; (2) for example, by faking s ymptoms such as pain or (3) induce d, by actively producing s ymptoms through infliction of injury or through injection or ingestion; or aggravate d, s uch as manipulating a wound so that it not heal. T able 16-3 lists various reported presentations of disorders along with the means us ed to produce the symptoms and pos sible means of detection. V iewing list, one can appreciate the creativity and of thes e patients , as well as their willingness to pain, injury, and inconvenience for the sake of 1725 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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emotional needs .

Table 16-3 Pres entations of Fac t Dis order with Predominantly Phys ic and S ymptoms with Means of S im and Pos s ible Methods of Detec S ymptom

Means of S imulation That Have B een R eported

Pos s ible Me Detec tion

Autoimmune

 

 

G oodpas ture's syndrome

F alse his tory, adding blood to urine

B ronchoalveo lavage negat hemos iderincells

S ys temic lupus erythematosus

Malar rash simulated cosmetics , feigning joint pain

Negative anti antibody tes t, removability o

Dermatologic al

 

 

B urns

C hemical agents,

Unnatural sha

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such as oven cleaner

lesions , strea chemicals , m injury to finge

E xcoriations

S elf-infliction

F ound on acc parts of the b for example, preponderanc sided les ions right-handed

Lesions

Injection of exogenous material, such as talc, milk, or gasoline

P uncture ma needles, dis c syringes

E ndoc rine

 

 

C us hing's

S teroid ingestion

E vidence of exogenous s t

Hyperthyroidis m

T hyroxine or Liodothyronine inges tion

24-hr iodineuptake is sup in factitious d and increase G raves' disea

Hypoglycemia or insulinoma

Ins ulin injection

Ins ulin to C -p ratio is greate

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one, detectio serum ins ulin antibodies Inges tion of oral hypoglycemics

S erum levels of hypoglycemic medication

P heochromocytoma E pinephrine or metaraminol injection

Analys is of u catecholamin reveal epinep only or other suspicious fin

Gas trointes tinal

 

 

Diarrhea

P henolphthalein or cas tor oil inges tion

T es ting of sto laxatives, inc stool weight

Hemoptysis

C ontamination of sputum s ample, self-induced trauma, s uch as cuts to tongue

C ollect speci under observ examine mou

Ulcerative colitis

Laceration of colon with knitting needle

—

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Hematologic al

 

 

Aplastic anemia

S elfadminis tration of chemotherapeutic agents to suppress bone marrow

Hematologycons ultation

Anemia

S elf-induced phlebotomy

B lood s tudies

C oagulopathy

Inges tion of warfarin or other anticoagulants

—

Infec tious

 

 

Abdominal

Injection of feces into abdominal wall

Unus ual path microbiology

Acquired immune deficiency syndrome

F alse his tory

C ollateral info

Neoplas tic

 

 

C ancer

F alse medical family history,

C ollateral examination

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shaving head to simulate chemotherapy Neurologic al

 

 

P araplegia or quadriplegia

F eigning, history

Imaging s tud electromyogr

S eizures

F eigning, history

V ideo electroencep

 

 

Antepartum hemorrhage

V aginal puncture wounds, us e of fake blood

E xamination, blood

E ctopic pregnancy

F eigning abdominal pain while s elfinjecting hC G

Ultrasound

Menorrhagia

Using s tolen blood

T ype blood

P lacenta previa

Intravaginal use hat pin

E xamination

Obs tetric and gynecologic al

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P remature labor

F eigned uterine contractions , manipulation of tocodynamometer

E xamination

P remature rupture of membranes

V oiding urine into vagina

E xamine fluid

T rophoblas tic disease

Addition of hC G urine

—

V aginal bleeding

S elf-mutilation with fingernails , nail files, bleach, knives, tweezers , nut picks, glas s, and pencils

E xamination

V aginal discharge

Applying as h to underwear

E xamination

S ys temic

 

 

F ever

Warming thermometer agains t a light bulb or other source, drinking hot fluids , friction from mouth or

S imultaneous of temperatur two different (orally and re recording temperature o voided urine,

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anal s phincter, false recordings , injection of pyrogens such feces , vaccines, thyroid hormone, or tetanus toxoid

despite high thermometer readings, nor white blood c count, unusu or incons is ten temperatures

Urinary

 

 

B acteriuria

C ontamination of urethra or specimen

Unus ual path

Hematuria

C ontamination of specimen with blood or meat, warfarin foreign bodies in bladder (pins)

C ollect speci under observ

P roteinuria

Ins erting egg protein into urethra

—

S tones

F eigning of renal colic pain, bringing in made of exogenous

P athology rep

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materials or inserting them into urethra

hC G , human chorionic gonadotropin.

T able 16-4 lists clues that s hould trigger s uspicion of factitious disorder. F actitious dis order should be whenever medical signs or s ymptoms defy medical understanding or when they do not res pond to us ual medical treatment, for example, when a wound refuses to heal or when test res ults s how a pattern that inconsistent with us ual disease pres entation. F actitious disorder patients may also demons trate an exceptional eagerness to undergo invasive or extensive testing. may deny access to collateral sources of information, refusing to sign releases of information and refus ing to give contact information for family or friends. An medical his tory, evidence of multiple s urgeries , and reports of multiple drug allergies may also provide for the astute clinician. T hese patients often have jobs medical profess ion, have few visitors , and often have known to forecast the progres sion of their s ymptoms .

Table 16-4 C lues That S hould Trigger S us pic ion of Fac titious Dis order 1733 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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Unus ual, dramatic pres entation of symptoms that defy conventional medical or psychiatric unders tanding S ymptoms do not respond appropriately to us ual treatment or medications E mergence of new, unusual s ymptoms when symptoms resolve E agernes s to undergo procedures or tes ting or to recount s ymptoms R eluctance to give access to collateral sources of information, that is, refus ing to s ign releas es of information or to give contact information for and friends E xtens ive medical his tory or evidence of multiple surgeries Multiple drug allergies Medical profess ion F ew vis itors Ability to forecas t unusual progress ion of or unus ual res ponse to treatment 1734 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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S imply raising the s us picion of factitious dis order is the first important step toward diagnosis. After this , information s upporting the diagnosis s hould be A review of past medical records may reveal inconsistencies. G athering collateral information from family, friends, or other health care providers may show inconsistencies. Ward clerks may be the first to notice waxing and waning levels of distress , depending when the patient thinks clinicians P.1834 P.1835 are obs erving. C ollection of laboratory s pecimens clos e observation can minimize contamination or manipulation of s amples . S ometimes, laboratory values can provide important diagnostic clues, s uch as in the of high insulin and low C -peptide levels in patients simulating ins ulinoma through self-adminis tration of insulin or when microbiology reports reveal unusual pathogens . C onclusive confirmation of factitious dis order can be difficult. S urveillance techniques, s uch as covert observation, covert video, or s earching the patient's belongings for syringes or illness -inducing substances, have been us ed. When these techniques are is es sential to involve legal counsel as the patient's privacy, as well as constitutional protections against searches and seizures , is at stake. In s ome cases, orders should be obtained. C onsultation from a team can help weigh the benefits and risks of these violations of privacy versus morbidity from factitious 1735 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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disorder. T his phase of acquiring information to confirm diagnosis is often a time of conflict for staff who may split opinions about the patient and about the means being used to confirm diagnosis. R egular meetings are helpful.

C hronic Fac titious Dis order with P redominantly P hys ic al S igns and S ymptoms (Munc haus en B ecaus e of more dramatic, exaggerated presentations , chronic factitious disorders with predominantly physical signs and s ymptoms are often more eas ily diagnosed those with les s chronic factitious dis order, even if treatment and management can be far more As thes e patients are prone to peregrination, they often arrive new in town. T hey demonstrate ps eudologia fantas tica, with grandiose and far-fetched tales . T hey appear eerily comfortable in hospital settings, talking to nurses , phys icians , and medical s taff as Many show up for hospital admis sion wearing surgical scrubs. One patient, who claims to be the s on of a golfer, arrives at the University of New Mexico Hospital each spring s eeking medical or psychiatric admiss ion, having made his rounds at other hos pitals acros s states , using various pseudonyms. T he cos t of this can be tremendous , as illus trated by the B ritish report “million-dollar man” who, over a 13-year period, s pent 1,300 days in ps ychiatric units, 556 days in prison, and days in medical care for 261 hospital admis sions . All diagnostic cons iderations that apply to factitious disorder also apply here. As the risk of morbidity and mortality may be higher in thes e patients, it may be 1736 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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prudent to involve bioethics cons ultations and hos pital legal couns el early. Mr. S . was a 25-year-old, right-handed, married white who was admitted for s quare-shaped burns on his left forearm. B ecaus e of the odd shape of the burns, disorder was suspected, and psychiatry cons ultation promptly obtained. T wo weeks earlier, the patient was admitted for necrotizing fasciitis of the left forearm. that hospitalization, his wife gave birth to an infant s on. F actitious disorder was not s uspected at that time. Mr. reported a past medical his tory of juvenile-onset from 1 year of age, as thma, and accidental hot water to his left forearm and left lateral thigh at 10 years of He reported allergies to 13 medications. Mr. S . presented in a dramatic manner to the cons ultants s aying, “I'm safe nowhere! T hey happen while I'm here in the hos pital!” He pulled open his gown to reveal a square-shaped burn on his upper He reported being the 15th of 16 children born to a Mormon family. He des cribed his childhood as “good,” he denied a history of phys ical or sexual abuse. He that his father died of a fall P.1836 when he was 10 years of age. Mr. S . proudly s tated even though he was diabetic, he was admitted to the F orce at 16 years of age in which he worked as a and an emergency medical technician. S ubs equently, worked at commercial airlines, which took him to live in four different s tates over 4 years. He s tated that his marriage was his s econd and that he had los t a s on, a 1737 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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daughter, and his firs t wife all on the same day. As his year-old daughter was dying in the hos pital of a brain tumor, his 7-year-old s on was killed in a motor vehicle accident while cros sing the s treet to vis it her. Under the stress of los ing both children, his wife left him that day. His s econd wife had s chizoaffective disorder and heroin dependence in remiss ion. S he was known to the ps ychiatry cons ult team who evaluated her after the of her s on. T he diagnosis of factitious disorder was made, and the patient was informed in a nonconfrontational manner emphasized that he mus t have been under great emotional distress to have inflicted such physical pain hims elf. T he birth of his s on, childhood neglect, and traumatic experiences that he may not have dis closed were cited as poss ible s ources of s tres s. He was ps ychiatric services . T he week after discharge, the patient returned to seek the cons ulting psychiatrist who had confronted him. He voiced concern that his wife was having auditory hallucinations telling her that she was the next bride of C hris t. His eagernes s to seek treatment for his wife noted in the context of his reports of the deaths of his two children. T he vague pos sibility of Munchausen syndrome by proxy was first entertained at this time. Mr. S . s ought ps ychiatric s ervices , as directed by the ps ychiatry cons ultation team. At the ps ychiatric clinic, was pres cribed nefazodone (S erzone) and later was switched to sertraline (Zoloft) to target depres sive NOS , with the primary symptom being irritability toward his wife, with occasional urges to s trike her. presented to the ps ychiatric emergency s ervices 1738 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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complaining of urges to be violent with his wife. He s pent most of the next 4 months admitted to various hospitals in town. Of note, the records of one of the hospitals s tated that Mr. S . told them that he had been F -15 fighter pilot. T wo days after dis charge from that hospital, he was readmitted to the univers ity hospital necros is of a skin graft that he had received. T he burn surgery team initially refus ed to treat him, stating that was doing it to himself and that they suspected that he was s eeking narcotics . T hey agreed to accept care after conversation with the ps ychiatry consultation During this admis sion, his arm was placed in a cast, began to heal. T he next month, he was readmitted with wors ening of necrotizing fasciitis with poss ible osteomyelitis . He for amputation of the arm, citing his long treatment and s tating that he wanted to be rid of the pain. therapists noted that his arm healed whenever placed cast that precluded tampering of the wounds but that it wors ened when placed in loos er casts that allowed to the wounds. At this time, becaus e of the of los ing his arm, he was admitted to the ps ychiatric hospital involuntarily for clos e observation. He was informed of a new treatment plan that, whenever he admitted for a factitious illnes s, involuntary admiss ion the ps ychiatric hos pital would follow. On the psychiatric ward, the patient accepted ps ychotherapy and with sertraline. He continued to deny that his wounds were self-inflicted but inquired about treatment for Munchaus en s yndrome. At one point, when the ps ychiatris t as ked him, “Why do you do this? ” he don't know why I do it either.” Of note, during the 1739 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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ps ychiatric hos pitalizations, he required no slidinginsulin, and he rarely required it while in the medical hospital. One other admis sion to the univers ity hospital occurred wors ening of his wounds . He was transferred to the ps ychiatric hos pital according to plan. After this, he seeking admis sion to the univers ity hospital. Within 1 month, outpatient physical therapy notes indicated that the wound was 90-percent healed, and, within another month, it was near closure. Approximately 6 months later, he pres ented to the ps ychiatric emergency s ervices complaining of difficulty containing his anger toward his wife. S hortly after that, wife relaps ed on heroin and left Mr. S . alone to care for their 1-year-old s on. S ince his birth, pediatricians had recognized the precarious s ituation of this child and been s eeing him for s cheduled biweekly visits. C hild P rotective S ervices were already involved. During a with family in another state, the patient brought his s on an E R seeking admiss ion. His son was not admitted died the next day. Munchausen syndrome by proxy suspected. An autops y was performed, but no charges were ever filed against the patient. One year later, near the annivers ary of the s on's death, S .'s then ex-wife pres ented to the ps ychiatric services for relapse on heroin and wors ening auditory hallucinations telling her that she would be the next of C hris t. S he stated that she too found it s uspicious three of Mr. S .'s children had died. S he had recently him at a bus stop. His arm was healed, and he healthy. He ins is ted to her that the university had confirmed that his wounds had indeed been 1740 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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by spider bites.

DIS C US S ION Mr. S . s howed the class ic features of Munchaus en syndrome: peregrination, pseudologica fantas tica, and presentation of unusual s ymptoms that were selfHis case als o illus trates the overlap of different types of factitious disorder, as he s ought psychological and demonstrated activity consistent with factitious disorder by proxy. Lastly, his case demonstrates that Munchaus en syndrome, which generally has a grim prognos is , is not completely refractory to intervention. S elf-infliction was suspected, becaus e the squareburns defied us ual medical understanding, and they did not heal with usual treatment. T hat the nonhealing wounds healed when in a cast and was virtually diagnostic of s elf-infliction. Mr. S . sought from various hospitals locally, demonstrating peregrination. He had als o recently lived in s everal states in which he may have s ought medical care. he s ought hospitalization in the same month that he moved to town. P seudologica fantas tica was demonstrated in his bragging about admiss ion to the F orce, even though he was diabetic (the Air F orce accept diabetics). His tale of los ing two children and his first wife on the same day seemed exaggerated and had the hint of ps eudologica fantas tica. Although the patient sought narcotic pain medication, he had acces s narcotics without needing to endanger his arm or to pain, as his wife was a heroin user. His primary motive appeared to be to gain care and attention by ass uming patient role. Like many others with factitious disorder, Mr. S . 1741 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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being from a large family in which he was poss ibly neglected. Other characteris tics present that are in factitious disorder patients included an affinity to a medical profess ion (he claimed he was an emergency medical technician), a history of childhood illness 10 years of age that injured his left arm), and multiple medication allergies. Like others with factitious he sought medical care at a time of interpersonal los s. the birth of his s on, he faced loss of his wife's attention, addition to facing other s tres ses of fatherhood. C omorbidity with other ps ychiatric disorders is more rule than the exception. Mr. S . was treated for disorder NOS . Opiate abus e was also diagnosed. Malingering for opiates may also have been part of his motivation. His eagerness to procure psychiatric treatment for his may have demons trated genuine concern, but, in the context of the death of his s on and the poss ible deaths two other children, it is quite likely that Mr. S . also had factitious disorder by proxy. T he comorbidity of disorder and factitious dis order by proxy is estimated to from 10 to 30 percent, and there is an extremely high likelihood of s iblings being victimized, us ually s erially. P.1837 Mr. S . s ought ps ychiatric treatment after referral from ps ychiatry consultation team. Often, he went to the ps ychiatric emergency s ervices complaining of anger potential violence toward his wife. Although there is no clear evidence that he feigned or fabricated ps ychiatric symptoms, he clearly enjoyed the attention of receiving ps ychiatry services. 1742 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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Intervention from the psychiatry consultation team cons isted of gentle, nonaccusatory confrontation and ps ychiatric referral, which the patient accepted. Later, when he was in danger of los ing his arm, the intervention of involuntary psychiatric hospitalization deterred the course of s elf-injury, and the wounds to heal cons istently. Although morbid cons equences ensued with the death of the patient's son, at least intervention was able to prevent amputation of his arm.

Fac titious Dis order with P redominantly P s yc hologic al and S ymptoms F actitious psychological s ymptoms are more to diagnos e because of the lack of clear objective for psychiatric dis orders. Methods of confirmation applicable with factitious phys ical dis orders, s uch as contradictory laboratory tests or findings on room searches , do not apply here. Nevertheles s, certain of the patient's pres entation can alert the ps ychiatris t the patient may be s imulating illnes s. As with phys ical factitious disorders , the patient may pres ent with symptoms that fail to corres pond to any recognizable diagnosis. F or example, one patient reported no other ps ychotic symptoms except s eeing the entire cast of a television s how emerge from her clos et. Other features include worsening of s ymptoms when the patient is of being observed, inconsistencies in the patient's s tory over time, and the patient's overeagerness to recount symptoms of the illness . T he patient is often and readily admits to additional s ymptoms on questioning. T he patient may refuse to cooperate with 1743 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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obtaining collateral information, and untraceable prior health care providers are not unus ual. On admiss ion to ward, patients may reveal familiarity with hos pital although denying previous hos pitalizations . T hey may exhibit dramatic and unus ual reactions to medications . T hey may demonstrate attention-getting tactics by breaking ward rules . V is itors are us ually few or abs ent. In contras t to patients with physical factitious disorders who tend to avoid psychiatric care, these patients seek contact with the ps ychiatric s ys tem and readily acknowledge the presence of a ps ychiatric disorder, it may not be the one that the patient actually has . F eigned bereavement and then ps ychos is appear to be most common presenting s ymptoms. Ironically, one patient sought ps ychiatric admis sion for his syndrome, claiming that he feigned phys ical illness in fact, there was no evidence of this. In a s eries of 20 patients who pres ented with factitious bereavement, 15 also exhibited a history of factitious phys ical s ymptoms. A majority of them met criteria for other psychiatric disorders . T hey typically reported dramatic, violent, and, often, multiple deaths of loved ones, whereas collateral information s howed that, in no deaths had occurred. Another series of 12 cases of factitious bereavement yielded s imilar findings of complaints of violent, dramatic deaths and referral from medical wards for s upposed phys ical illness . Although complaints of bereavement were factitious, thes e exhibited prominent symptoms of depress ion. A theory about factitious bereavement is that patients are expres sing the underlying truth of their emotional s tate, not the factual truth. In contras t to the s tigma 1744 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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with ps ychiatric illnes s, sympathy and care are us ually offered to thos e in mourning. T his may be why bereavement is the mos t commonly seen factitious ps ychological disorder. One patient stated that she had fabricated the complaint of bereavement to rationalize depres sion. In a s eries of 219 consecutive cases of ps ychos is, nine percent) met criteria for factitious disorder. All nine patients demons trated s evere personality dis order. patients were doing poorly when followed up 4 to 7 later, with multiple hospitalizations and poor quality of T heir outcome was no better than for s chizophrenics were concurrently followed. In another study of s ix patients who presented with feigned psychosis to the Univers ity Hos pital of S outh Manches ter, five of the s ix developed s chizophrenia when followed up 3 months 10 years later. C ons is tent with ps ychodynamic theories about factitious dis orders being an attempt to feel mastery, feigning ps ychos is may have been a way for patients to feel in control over early ps ychotic T hese studies s how that factitious ps ychosis may bode poor a prognosis as genuine psychos is. P os ttraumatic stress dis order (P T S D) can be fabricated through the reporting of subjective symptoms , without requiring the patient to feign or to act. F actitious P T S D be elucidated through collateral sources of information about alleged trauma, for example, by checking military records for actual tours of duty. Ms. M. A. was 24 years of age when s he firs t 1973 after an overdose. S he gave a his tory of recurrent overdoses and wris t-slas hing attempts since 1969, 1745 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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admis sion, she stated that she was controlled by her sister who kept telling her to take her own life. Her history was negative. S he was found to be carrying a list of s chneiderian rank s ymptoms in her handbag; she behaved bizarrely, picking imaginary objects out of the was tepaper bas ket and opening imaginary doors in the waiting room. S he admitted to visual hallucinations and offered four of the first-rank s ymptoms on her list, but her mental s tate reverted to normal after 2 days . When s he was at a case conference, the cons ens us view was that she been s imulating schizophrenia but had a gros s disorder; however, the cons ultant in charge diss ented that general view, feeling that she was genuinely ps ychotic. On follow-up, this turned out to be the case. S he was readmitted in 1975 and was mute, catatonic, gross ly thought disordered, and the diagnosis was changed to that of a s chizophrenic illnes s. S he has been followed regularly s ince and now pres ents the picture of a mild schizophrenic defect s tate; s he takes regular depot medication but s till complains of auditory hearing her dead s ister's voice. S he is a day patient.

DIS C US S ION Ms. M. A.'s diagnos is was factitious disorder with predominantly ps ychological s igns and s ymptoms, with a personality dis order. Although her initial symptoms were elaborate and feigned, 2 years after initial presentation, she developed ps ychotic symptoms believed to be genuine by clinicians , even after observation as a day patient. T his cas e illustrates that, even if ps ychotic symptoms 1746 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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factitious, they are often a s ign of serious ps ychopathology, s uch as a severe personality a prodrome to a genuine ps ychotic dis order.

Fac titious Dis order with P s yc hologic al and P hys ic al F actitious disorder with combined ps ychological and phys ical s ymptoms is the appropriate diagnos is P.1838 for patients who pres ent with ps ychological and signs and s ymptoms of factitious disorder, with neither dominating the clinical picture. Mr. M. T . was a man who appeared to be middle-aged who arrived at a children's ps ychiatric hos pital claiming be 17 years of age and s uicidal. As he held a gun to head, s taff called s ecurity officers who promptly recognized him as the Munchausen s yndrome patient arrived in early May each year. He was denied Late that evening, he pres ented to the E R of the main hospital claiming that he was diabetic, dizzy, and weak. Intern phys icians found his blood glucose to be low and immediately admitted him. Hos pital s taff on the wards recognized him as “that Munchausen syndrome and a psychiatric cons ultation was reques ted. T he continued to ins ist that he was 17 years of age and that was the son of famous golfer Lee T revino. Hospital couns el revealed that he us ed at least two other ps eudonyms and social s ecurity numbers and was for health ins urance fraud in at least two other s tates. When the ps ychiatry consultants greeted him with 1747 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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familiarity, the patient immediately claimed suicidal tendency, but, when denied ps ychiatric admiss ion, he the hos pital agains t medical advice. An inquis itive student called local pharmacies , which informed him if a customer claimed to be diabetic, traveling, and insulin, they would give the customer insulin even a pres cription to avoid liability. In this manner, Mr. M. T . could have procured ins ulin to induce hypoglycemia. At a care conference, a psychiatry cons ultant that, in the past, common practice was to call E R s in to alert them to Munchaus en s yndrome patients, giving poss ibly helpful descriptions and information. However, because of heightened attention to confidentiality she now instead advocated calling E R s and simply them about the pos sible appearance of a patient with factitious hypoglycemia. An E R phys ician, however, that he would go ahead and give a detailed des cription the patient to friends in each E R in town. T he May of following year, the patient failed to appear for the first time in s everal years.

DIS C US S ION T his cas e demonstrates an almos t exaggerated peregrination and pseudological fantas tica, typical Munchaus en syndrome patients. T he debilitating cons equences of the disorder are also demons trated, his life, by all indications, consisting of s hort hos pital acros s many states , precluding s table relations hips or employment. T he case als o illus trates the complexity of legal and ethical is sues involved in the management of factitious disorder in regard to privacy. As he s ought hospitalization for ps ychological and phys ical disorders equally in this ins tance, Mr. M. T .'s 1748 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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diagnosis was factitious disorder with combined ps ychological and phys ical s igns and s ymptoms .

Fac titious Dis order by P roxy Als o called Munchaus en s yndrome by proxy, the feature of factitious dis order by proxy is the intentional feigning or production of physical or ps ychological symptoms in another person who is under an care. T he perpetrator's motive is to ass ume the s ick proxy. Mothers of young, preverbal children are the common perpetrators , however, fathers , grandmothers, fos ter mothers , stepmothers, and even baby-sitters also been implicated. V ictims can also be spouses, parents , or anyone under the care of the perpetrator. In unusual cas e of adult factitious dis order by proxy, a 34year-old man drugged his wife with s leeping pills in her coffee, then injected gas oline into her skin to caus e from which she eventually died. S ubs equently, he repeated his actions with a female baby-sitter whom he hired to care for his children. In each case, he role of the concerned caretaker in the center of hospital drama. F actitious dis order by proxy has als o been cited the etiology for death epidemics at hospitals and homes . P erpetrators have largely been nurs es and aides who produced illnes s through various means , as injection of ins ulin, lidocaine, digoxin, or other subs tances . B y and large, however, reported cases have involved mothers and their children. Difficulties in recognizing deception and diagnosing this condition are illus trated two unfortunate examples. F irs t Lady Nancy R eagan presented an award to an apparently valorous foster 1749 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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mother of extremely ill children. T he woman was later suspected of having killed her children through disorder by proxy. S udden infant death syndrome was initially thought to have a strong genetic as it often occurred in s iblings . T oday, when siblings S IDS , infanticide is suspected. A s tudy of 81 children died at the hands of parents but who were initially to have died of S IDS or natural causes s howed that half of the perpetrating parents had factitious dis order another somatizing dis order. In both of these in other cases, perpetrators were initially regarded with sympathy and respect. T he variety of medical pres entations of factitious by proxy is impres sive. In the first comprehens ive the disorder published in 1987, R osenberg des cribed different induced or fabricated signs or s ymptoms. T he most common presentations were bleeding (44 seizures (42 percent), central nervous system (C NS ) depres sion (19 percent), apnea (15 percent), diarrhea percent), vomiting (10 percent), fever (10 percent), and ras h (9 percent). Many children had more than one presentation. T wenty-five percent of cases involved simulation of illness , 50 percent involved illnes s production, and, in the remaining 25 percent, and production of illness were concurrent. P erpetrating caregivers us ually appear concerned and interes ted in every as pect of their children's care. T hey exemplary in their interactions with medical staff, support and s ympathies , often cros sing profes sional boundaries by helping nurses with duties or eating with s taff. T hey may demons trate unusual willingness even excitement at the prospect of invasive procedures 1750 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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their children. F actitious disorder by proxy s hould not be cons idered a diagnosis of exclusion. C onfirmatory evidence s hould actively pursued, s o as to less en risk to the child. the child should be ens ured at the s ame time. T he gold standard for confirming factitious disorder by proxy is covert video s urveillance that may record evidence of a parent causing harm to a child. C overt video has als o shown cas es in which mothers , who appear concerned the presence of s taff, behave indifferently toward their children when they are not aware of being watched. C overt video s hould only be undertaken after with legal counsel. A court order may need to be and a bioethics cons ultation may be helpful to weigh potential benefits to the child versus compromis es of privacy for the parent. Other means of confirming factitious dis order by proxy include s earching the mother's belongings for illness inducing agents , reviewing collateral information and medical records for incons istencies , gathering on siblings , recording temporal as sociations between parental visits and the child's s igns and s ymptoms , observing the child's well-being when removed from parent's care for extended periods, and analyzing specimens taken in the pres ence of the parent to thos e taken in the parent's absence. T he international literature on Munchaus en s yndrome proxy indicates that the s igns and s ymptoms appear cons istent across the world. P erpetrators are usually mothers, and s erial abus e of children P.1839 1751 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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is common. T his does not appear to be a phenomenon that is exclusive to medicalized societies . B . C . was a 1-month-old girl admitted for evaluation of temperature elevation. P s ychiatric consultation was reques ted owing to incons istencies in the mother's reporting of medical information, des pite her initial presentation as a knowledgeable and caring mother worked as an emergency medical technician. B . C .'s said that she was diagnos ed with ovarian cancer at 3 months' ges tation with B . C ., that s he had had a hysterectomy during the cesarean section, and that had been getting radiation therapy at a local hospital B . C .'s birth. T he pediatrician called the local hos pital the mother's permis sion and found that she had a luteum cys t removed at 3 months' gestation and mild hydronephrosis, but no cancer and no hysterectomy. B . mother, when confronted with this , stated only that s he might need a kidney transplant for the hydronephros is . On further exploration, it was dis covered that the had pursued care for her children in multiple E R s and reported inaccurate histories that res ulted in excess ive tes ting. F or example, she told clinicians that her 2son had lupus and hypergammaglobulinemia and, at another time, that he had asthma and seizures . S he pursued a minor cosmetic s urgical procedure for her agains t the recommendation of his pediatrician. No clinicians suspected that B . C .'s mother had produced symptoms in any of her children, but rather that s he intentionally fabricated symptoms by raising the temperature on B . C .'s thermometer. S he had been in keeping medical appointments . Her children 1752 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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healthy and well cared for, des pite her descriptions of illness . T he mother denied a ps ychiatric his tory but permis sion for clinicians to call the local ps ychiatric hospital to inquire. Her record there showed a history depres sion, anorexia, and panic disorder and included ps ychiatric hos pitalization after a s uicide attempt. S ubsequently, s he received ps ychotherapy and ps ychopharmacotherapy, which s he stopped a few months before this presentation. During B . C .'s for temperature elevation, her mother agreed to treatment with her previous psychiatric clinicians . A services referral was als o made, and the children's pediatrician agreed to coordinate regularly s cheduled follow-up visits and monitoring of the children.

DIS C US S ION B . C .'s cas e illustrates several common features of disorder by proxy. T his mother, who had medical simulated fever in her child in the hos pital as a means maintaining contact with the hos pital s ys tem and obtaining the sympathy of clinicians. S he had a history that, in this cas e, included depres sion, and panic disorder. S hortly before this pres entation, had lost the s upport of her ps ychiatric clinicians, which may have exacerbated her need for contact with the medical system. S everal of her children had been the victims of her s imulations of illness , as is common in factitious disorder by proxy. A less common aspect of this case was the mother's willingnes s to engage in treatment. T he medical team's supportive, nonaccusatory approach most likely helped enable her to cooperate as much as she did. toward clinicians , including overt praise and 1753 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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alternating with covert rage and belittling, is more common. Acceptance of psychiatric treatment recommendations is not often s o s mooth. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > P AT HO LOG Y AND LAB OR AT O R Y

PATHOL OGY AND LAB OR ATOR Y R E POR TS P art of "16 - F actitious Dis orders " No laboratory or pathology tests are diagnostic of factitious disorders , although they may be us eful in demonstrating deception and helping to confirm diagnosis. In the firs t Munchaus en syndrome by proxy article published in 1977, Meadow reported the case of a 6old girl with unexplained hematuria. T able 16-5 urine s amples collected during one evening that helped es tablis h the diagnosis.

Table 16-5 Urine S amples C onfirming Munc haus en by Proxy from a 6-Year-Old G irl with Unexplained Hematuria

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Time

Appearanc e

C ollec tion

5:00 P M

Normal

B y nurs e

6:45 P M

B loody

B y mother

7:15 P M

Normal

B y nurs e

8:15 P M

B loody

B y mother

8:30 P M

Normal

B y nurs e

Adapted from Meadow R : Munchaus en s yndrome proxy: T he hinterland of child abus e. L ance t. 1977;2:343. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > DIF F E R E NT IAL DIAG NO

DIFFE R E NTIAL DIAGNOS IS P art of "16 - F actitious Dis orders " A true phys ical or ps ychiatric dis order is the main cons ideration in the differential diagnosis of a factitious disorder. T his is particularly true of factitious disorders , as they are most often a 1755 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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of, or a prodrome to, an actual psychiatric illness . C omorbid phys ical or ps ychiatric dis orders are more rule than the exception in factitious disorder. F or most patients who feign ps eudos eizures have true underlying s eizure dis orders. T hos e who manipulate sugars to produce symptoms are us ually diabetics . Munchaus en syndrome patients who compuls ively the sick role for emotional reas ons may als o become addicted to narcotics or learn to seek dis ability thereby also demonstrating s ubs tance abus e and malingering. A woman who consciously produced by smearing feces on a leg wound was sometimes also seen in a diss ociative state, uncons ciously picking at wounds. Often, factitious disorder patients aggravate actual phys ical illness . F urthermore, even factitiously produced phys ical symptoms , s uch as infections or poisonings, must be treated s eriously, as, once the symptoms are induced, they are all too real. In all factitious disorder, underlying psychopathology should suspected. Other special cons iderations in the differential are detailed in the following sections.

Fac titious Dis order with P redominantly P hys ic al S igns and S ymptoms F igure 16-2 provides an algorithm for the differential between factitious dis order, malingering, and disorders .

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FIGUR E 16-2 Differential diagnosis of factitious with predominantly physical s igns and s ymptoms. NOS , otherwis e s pecified. If the primary goal is not to play the patient role but is material, such as procuring dis ability payments, or an excuse from work, the diagnosis is malingering. If symptoms are manifes t unconscious ly, then the somatoform disorders should be considered. In dis order, neurological s ymptoms, such as paralysis or ps eudoseizures , are uncons cious ly manifested, usually res ponse to stress es . In s omatization dis order, the has a pattern of multiple unexplained medical in four categories : at leas t four pain s ymptoms, four gastrointestinal (G I) symptoms, one s exual s ymptom, one neurological symptom. F or thos e with unexplained phys ical complaints that last 6 months or longer but do not meet the threshold for the diagnosis of somatization disorder, undiffe rentiate d s omatoform 1757 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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dis order s hould be P.1840 diagnosed. In pain dis order, psychological factors contribute to the exacerbation or ons et of pain. T hos e hypochondrias is are preoccupied with the fear of and are vigilant about bodily s ymptoms, falsely that they are ill. T hos e with body dys morphic dis order preoccupied with an imagined or exaggerated defect in bodily appearance. S omatoform dis orde r NO S s hould diagnosed for patients who uncons cious ly manifest phys ical s ymptoms but who do not meet criteria for the previous ly mentioned dis orders . In actuality, whether a symptom has conscious or unconscious origins can be difficult to dis cern. F urthermore, whether the patient's primary motive is to as sume the s ick role or to avoid a court date of which clinician is unaware can also be difficult to dis cern. judgments are completely dependent on the s ubjective opinion of the clinician. F or these reasons, Marc D. F eldman, J ames C . Hamilton, and Holly N. Deemer that these dis orders fall along a continuum: “T here is to be gained, and much to be los t, by the us e of the current practice of viewing the somatoform disorders , factitious disorder, and malingering as discreet and distinct clinical entities .”

Fac titious Dis order with P redominantly P s yc hologic al and S ymptoms With ps ychological factitious s ymptoms , it can be es pecially difficult to separate conscious from 1758 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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production of symptoms . F or this reas on, R ichard questions the legitimacy of this diagnostic category. F urthermore, many authors propose that and unconsciousness cons titute a continuum and are distinct entities. G ans er s yndrome, first des cribed in 1897, consists of twilight s tates, memory dis turbances, and vorbe irede n, G erman term loos ely translated as “talking at cross purpos es.” An example would be answering “65” to the question of “How much is eight times eight? ” G ans er syndrome is thought to be diss ociative in nature or due organic caus es . Again, comorbidity s hould be s trongly considered, as these patients often have coexisting pers onality F actitious psychological s ymptoms can often be a prodrome to true ps ychiatric illnes s, as in the case of factitious psychosis evolving into s chizophrenia.

Fac titious Dis order by P roxy F actitious disorder and malingering at the initiation of child s hould also be considered, es pecially in older children and teenagers . Other by-proxy disorders be considered. C hildren can be made to manifest the ps ychopathologies of their parents . F or example, in hypochondriasis by proxy, a hypochondriac mother is preoccupied with the health of her child and repetitively seeks pediatric care, putting her child at risk for unnecess ary procedures and iatrogenic illnes s. In nervos a by proxy, an anorexic mother restricts her food owing to unfounded fears of excess ive weight in child. One mother with malingering by proxy put her through multiple evaluations to maintain dis ability 1759 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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payments . A paranoid father with a his tory of psychos is feared that his son was being pois oned by breas t milk insis ted that the E R check his s on's hair for mercury. by-proxy syndromes described in the literature include mas querade s yndrome (in which illness fabrication in the child's increasing dependency on the mother), mothe ring to de ath (confining a child to a sick role as if child were ill, while avoiding phys icians and agencies ), extreme illne s s e xaggeration (when a parent the child's symptoms in an effort to increase a pediatrician's attention to the child), and achie ve me nt proxy (as in youth sports). C linicians s hould also keep in mind the wide range of normal behavior in parents who seek medical care for children. According to Meadow, “exaggeration and mild deception are part of everyday behavior.” T o aid in differential diagnos is , it is helpful to keep in that, in factitious disorder by proxy, illness es tend to exotic, dramatic presentations , and parents often remarkable lack of relief as the child's condition E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > C O UR S E AND P R OG NO

C OUR S E AND PR OGNOS IS P art of "16 - F actitious Dis orders "

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T he wide spectrum of factitious dis order with predominantly phys ical s igns and s ymptoms should be remembered when considering course and prognosis . the more benign end of the spectrum, factitious illnes s behavior can be cons idered normal, as when a child exaggerates distress from a knee s crape to gain or when a mother magnifies her child's symptoms to reass urance. F urther along the spectrum, factitious behavior can be a maladaptive way of coping with and does not necess arily imply an ongoing factitious disorder. An underlying mood, anxiety, or s ubs tance abuse that is treatable bodes for a better prognos is , whereas underlying personality disorder, especially antis ocial personality dis order, bodes for a poorer prognosis . patients with factitious dis order experience remis sion at approximately 40 years of age, corresponding to the remis sion for many with borderline pers onality disorder. Munchaus en syndrome or chronic factitious dis order predominantly phys ical s igns and s ymptoms , on the hand, has an unremitting, refractory cours e. and treatment are directed toward harm reduction, than remis sion or cure.

Fac titious Dis order with P redominantly P s yc hologic al and S ymptoms P sychological factitious dis order is also thought to forebode a poor prognosis. A 1982 study of patients factitious ps ychosis s howed that at follow-up 4 to 7 later, the functioning of thes e patients was comparable the functioning of schizophrenic patients in the same 1761 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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study. Other s tudies found that feigned psychosis is commonly a precurs or to actual ps ychosis , leading one inves tigator, Hays , to comment: “Acting crazy may more ill than being crazy.” In general, factitious with predominantly ps ychological s igns and s ymptoms thought to have a poor prognos is comparable to that of Munchaus en syndrome.

Fac titious Dis order by P roxy F or victims of factitious dis order by proxy, the mortality rate is from 6 to 22 percent, P.1841 us ually through s uffocation or pois oning. In 1987 review, 10 of the 117 children in the review died, mortality rate of 9 percent, and the youngest were the most vulnerable to death. A s obering statis tic is that, in percent of the deaths, caretakers were confronted with diagnosis of Munchaus en syndrome by proxy, but the children were sent back to them, s ubs equently to die. the survivors , 8 percent had long-term morbidity, including impairment of G I functioning, des tructive joint changes, limp, cerebral palsy, cortical blindness , and serious psychiatric problems . In 75 percent of the morbidity was caused by the medical staff and the perpetrator. In 25 percent of the cas es, however, was solely iatrogenic, caus ed by procedures and inves tigations . S iblings of victims of factitious disorder by proxy are at great risk. S tudies indicate that 9 to 29 percent of die, unders coring the vital importance of inves tigating siblings of sus pected factitious disorder by proxy 1762 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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T he involvement of different children tends to occur serially rather than simultaneous ly, so one must always on the alert for additional victims. In 1990, Meadow studied 27 young children s uffocated by their mothers . Over 13 years , nine died, and one had s evere brain damage. T hes e 27 children had 18 siblings who had “suddenly and unexpectedly in early life.” In another of 32 children pres enting with factitious epilepsy, 21 percent of siblings (7 of 33) had died of S IDS . S imilarly, separate s tudy of suffocation cas es, 21 percent of (3 of 14) had died unexpectedly. In another study of 56 victims of Munchaus en s yndrome by proxy, 39 percent siblings were subjected to illnes s fabrication. Among R os enberg's review of 117 cas es , ten siblings had died under “unusual circumstances.” E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > T R E AT ME NT AND MANAG E M

TR E ATME NT AND MANAGE ME NT P art of "16 - F actitious Dis orders " G uidelines for the treatment and management of factitious disorder are given in T able 16-6. T here are major goals in the treatment and management of factitious disorders : (1) to reduce the ris k of morbidity mortality, (2) to addres s the underlying emotional ps ychiatric diagnosis underlying factitious illnes s and (3) to be mindful of legal and ethical iss ues . 1763 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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Table 16-6 G uidelines for Management and Treatment of Fac titious Dis order Active pursuit of a prompt diagnosis can minimize the risk of morbidity and mortality. Minimize harm. Avoid unneces sary tests and procedures , es pecially if invas ive. T reat clinical judgment, keeping in mind that subjective complaints may be deceptive. R egular interdis ciplinary meetings to reduce and s plitting among staff. Manage s taff countertransference. C ons ider facilitating healing by us ing the doublebind technique or face-saving behavioral such as s elf-hypnosis or biofeedback. S teer the patient toward ps ychiatric treatment in empathic, nonconfrontational, face-saving Avoid aggress ive direct confrontation. T reat underlying ps ychiatric disturbances , s uch Axis I dis orders and Axis II dis orders. In ps ychotherapy, address coping s trategies and emotional conflicts. 1764 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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Appoint a primary care provider as a gatekeeper all medical and ps ychiatric treatment. C ons ider involving risk management and bioethicists from an early point. C ons ider appointing a guardian for medical and ps ychiatric decis ions. C ons ider prosecution for fraud, as a behavioral disincentive.

Management of countertransference is also a major as strong negative feelings on the part of clinicians can interfere with appropriate patient care. Allowing the patient to save face is es sential to establishing a therapeutic alliance and preventing the patient from simply taking the factitious illness behavior els ewhere. is es pecially true, as factitious disorder patients us ually have immature personalities or pers onality disorders make them es pecially s ens itive to narcis sistic injury. disincentives might be purs ued. In Arizona, a woman factitious disorder was prosecuted for fraudulent procurement of medical, psychiatric, and dental and s he pled guilty.

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T he hippocratic doctrine of “first do no harm” should be kept firmly in mind. P rompt recognition of factitious disorder can reduce the risk of morbidity or mortality. T herefore, active purs uit of the diagnosis and timely management are es sential. F or example, in the cas e of woman who sought prophylactic mastectomy for an extensive family his tory of breas t cancer, early of the factitious dis order may have prevented the mastectomies that were performed. R ecognition of factitious as thma or arthritis prevents the pres cribing of potentially harmful steroid medications. Likewis e, and potentially harmful tests, procedures, and can be minimized. Once symptoms are confirmed or agreed on as factitious, clinicians s hould adminis ter medical treatment according to their own clinical judgment, weighing objective evidence and keeping in mind that subjective complaints and reques ts from the patient can be deceptive. Of cours e, in many patient has induced illnes s, so that invas ive treatments must be adminis tered. In a medical setting, ps ychiatric cons ultation should be promptly obtained. Involvement of ris k management bioethicists is us ually prudent. As these patients are to cause confus ion and splitting of caretakers, good communication between all involved is ess ential. interdisciplinary meetings are helpful. S everal strategies have been success fully used to the healing of factitiously produced symptoms in facesaving ways. S tuart J . E is endrath has advocated a bind technique, whereby patients are told that, if the phys ical or psychological symptoms are genuine, then they s hould improve with the treatment being 1766 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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adminis tered. If the s ymptoms do not improve, then are factitious . T his technique can be used with wounds, factitious paralysis, or ps ychological factitious symptoms that should improve with medications . F or example, factitious patients who chronically induce or wors en wounds can be informed, “this treatment heal your wound. If it doesn't, we have no choice but to conclude that this is due to a factitious dis order.” S elf-hypnosis and biofeedback can also allow the to relinquis h factitious behavior while s aving face. F or example, a patient can be told that, under selfblood flow to a wound can be increas ed and therefore promote healing. In this manner, the patient can take control of healing the wound, rather than s eek control wors ening s ymptoms . P os itive feedback should be to patients when their efforts res ult in healing. B iofeedback can be used in a s imilar way. On an outpatient bas is, all medical care should be through a single primary care phys ician through whom care is coordinated. T his can minimize unneces sary repetition of tests and treatments . However, it s hould remembered that the patient may s eek care from in another system, in another city, or even in another or country. Appointments with the gatekeeping primary care phys ician should be regular and frequent and not dependent on medical crises. P.1842 T his fosters object constancy while minimizing the patient's need to induce illness to seek medical Once the factitious disorder is confirmed, or sus picions 1767 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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deemed s ufficient, the patient s hould be gently and artfully s teered toward ongoing ps ychiatric treatment in face-saving, sympathetic manner that the patient can accept. T he patient can be told that the factitious behavior is an express ion of great emotional need or distress . T he clinician can make empathic s tatements about the neglect, abuse, or trauma that the patient undergone. T his allows the patient to save face, while promoting ins ight about probable origins of the patient's factitious behavior. T he patient should then be steered toward s eeking care in a ps ychiatric s etting in which underlying ps ychiatric is sues can be address ed and in which the risk of morbidity and mortality is s ubs tantially less . P ers onality-disordered patients usually crave to unders tood and to have their emotional needs T his type of unders tanding confrontation that focuses the patient's genuine, rather than factitious, needs can well accepted by patients . Direct or aggress ive confrontation is generally not effective. T he patient us ually res ponds with anger and denial and may leave against medical advice only to perpetuate the factitious illnes s behavior els ewhere, need for mastery through deception now amplified. C linicians s hould remember that confess ion is not a neces sary aspect of management or treatment. P sychiatric treatment should first focus on the underlying Axis I disorders. Although rare, the a comorbid Axis I disorder, such as a mood disorder, anxiety dis order, or s ubs tance abuse disorder, bodes a better prognosis. P harmacological and treatments should be us ed according to the diagnosis . Other than targeting comorbid ps ychiatric dis orders, 1768 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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is no standard pharmacological treatment for factitious disorder. C omorbid Axis II disorders are more common than Axis I disorders . B orderline personality dis order is most common comorbid diagnosis. Antis ocial traits are als o common, es pecially in thos e exhibiting ps eudologica fantas tica and Munchausen s yndrome. P sychiatric treatment should be directed at thes e underlying disorders . P sychiatrists s hould be aware of their own countertransference and then s hould help medical clinicians cope with their countertrans ference, so that do not let negative feelings interfere with treating thes e patients who may falsify symptoms but who als o have genuine needs . Negative countertransference can lead therapeutic nihilis m, nonemergent breaches of confidentiality, or denial of care. C ountertrans ference feelings of frustration and anger s hould be us ed cons tructively, as a way of understanding the patient's long-standing feelings . Once in psychiatric treatment, relaps es should be expected in a s imilar manner as for s ubs tance abus ers . C linicians s hould not be disappointed at relaps es but should s ee them as opportunities for further unders tanding about the patient. F or example, if a has a pattern of relaps ing under conditions of new romantic involvements or arguments with authority figures , then this provides valuable insight into the patient's vulnerabilities , and these is sues can be in ps ychotherapy. Legal and ethical is sues play prominently in the management of factitious disorder patients , and, for reason, ris k management profes sionals and 1769 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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should be involved from an early point. C onfidentiality, right to privacy, and the constitutional protection unwarranted s earches and s eizures are major iss ues . once-common practice of alerting all E R s about disorder patients is now not routinely practiced heightened sens itivity about confidentiality rights . Nevertheles s, this kind of wides pread alerting can be with the consent of the patient. F or example, once a patient acknowledges having factitious disorder, the patient can be as ked, “I'd like to minimize harm to you. I have your permis sion to alert E R s and some doctors community? ” Likewise, the patient's right to should be res pected when gathering collateral information in nonemergent s ituations. V erbal or, preferably, signed releas es of information should be obtained before contacting collateral s ources , except in emergency s ituations. C linicians should be careful revealing information to the patient's employers , or family. T he diagnosis of factitious disorder mus t be revealed, even to spouses or s ignificant others, the explicit permis sion of the patient. S earching a hospital room or pers onal belongings for illnes smeans may facilitate the diagnosis of factitious disorder and may les sen morbidity, but this should only be done after cons ulting with risk management or other legal couns el, as it may violate a patient's constitutional protections. Likewis e, covert s urveillance, s uch as video, s hould only be undertaken after careful legal cons ultation. It should als o be remembered that, s imply because an action is legal, it is not necess arily ethical. T herefore, the involvement of bioethicists can be

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P redominantly P s yc hologic al and S ymptoms T he most widely used strategy is empathic that the feigned illness represents intraps ychic distress that can be alleviated through proper psychiatric treatment. B rief but regular contacts on a timerather than a distres s-contingent, basis are the therapy. C onsis tent long-term ps ychotherapy is aimed enabling patients to expres s their feelings , to gain and coping s kills , and to provide a reliable and outlet for communication. T he double-bind approach can be applied. P atients are told that their conditions should improve with certain medications and ps ychotherapy and that, if they do not improve, factitious dis order will be suspected. A critical as pect of treatment in an inpatient s etting is management of s taff reaction, which can include and negative countertransference. It is es sential to preserve good staff communication and to formulate a clear management plan involving the whole team, to minimize s plitting. T he ps ychiatris t or psychotherapist also be prone to negative countertransference, aris ing from feelings of being duped or manipulated. T he must take care to manage poss ible feelings of nihilism and other feelings that may interfere with the ability to form a therapeutic alliance. C omorbid mental illness es mus t be recognized and treated appropriately. F or example, mos t cases of bereavement are comorbid with major depress ion. One patient claimed to have feigned bereavement to justify depres sion. Another claimed to have recently been 1771 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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and s ought help for P T S D. Although she was not raped, she had experienced long-standing childhood sexual abus e. F eigned mental illnes ses may express emotional truth for the patient, if not a factual truth.

Fac titious Dis order by P roxy P rotection of the child is the firs t priority in factitious disorder by proxy. Active pursuit of the diagnos is and prompt intervention are es sential toward minimizing the ris k of morbidity and mortality to the vulnerable child. In the proces s of gathering clinical information and clinicians should keep in mind that, if the mother feels suspicions are raised or that she is los ing control of the situation, she is likely to take the child out of the setting and to seek care els ewhere. W hen the factitious disorder by proxy is confirmed, or as sufficient s o that clinicians are convinced, parents be confronted together. In this way, the father's involvement in the perpetration, as well as his pos sible as an ally, can be ass es sed. In advance of P.1843 C hild P rotective S ervices should be involved, and a hold s hould be instituted to prevent parents from with the child. In all 50 s tates, reporting of factitious disorder by proxy to child abuse protection authorities mandatory. In R osenberg's review of cases, 20 percent of children died of factitious disorder by proxy were sent home their parents, after parents were confronted with the diagnosis. G iven the high rate of mortality and in these cas es , the child should be removed from the 1772 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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parents until treatment and further as ses sment indicate that it is safe for the family to be reunited. C hild S ervices usually take respons ibility for this action. this is done, there is a high likelihood that the mother need intervention for s uicidal ideation. Inves tigation poss ible abuse of s iblings s hould also be initiated. After separation, the child mus t be treated for ongoing medical problems , as well as for psychological F or many children, long-standing refractory medical illness es resolve, once they are separated from perpetrators . P sychologically, many children P T S D and s hould be treated. As is typical of those with P T S D, many victims avoid medical care as adults. On other hand, others develop factitious disorder B y adolescence, many victims of factitious disorder by proxy collude with parents in perpetrating deception. T he perpetrator, usually the mother, should also treatment. Underlying ps ychiatric dis orders s hould be addres sed. T he mother should be evaluated to whether it is likely that she will ever achieve good parental s tatus and whether reunification with the child a realistic goal. T hos e who actively induce illness in children are less likely to ever be adequate parents. If reunification is unrealistic, then psychotherapy s hould focus on the mother's underlying psychopathology, as as her los s of the child. If reunification is the goal, then treatment s hould address emotional maturation of the mother, the ability to put the child's needs before her relinquis hing the defens e of denial, and learning to help and to expres s herself in appropriate ways . T he mother should also work on boundary iss ues and learn to distinguish her own needs from the needs of 1773 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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child. If reunification occurs, careful monitoring should follow. C hild P rotective S ervices s hould be involved. A primary pediatrician should act as a gatekeeper who monitors approves all medical care. Although the literature on factitious disorder by proxy is cast in the s hadow of the mos t severe cases, mild occur. Meadow advocates that, in these mild cas es, mothers s hould be s upported and prevented from their children through needles s investigations and treatments . P sychotherapy s hould be undertaken. T he prognos is in thes e cas es may not be so grim. T here is little literature on the treatment of factitious disorder by proxy between adults. In thes e cases, of the victim through legal means is usually not an as the victim is an adult. T he victim mus t us ually be res ponsible for initiating s eparation. In cases in which health care providers are sus pected of perpetrating among their patients, removal of the health care is es sential, and legal prosecution s hould be E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > F UT UR E DIR E C T IO

FUTUR E DIR E C TIONS P art of "16 - F actitious Dis orders " C learly, the entire area of factitious disorder would from more research, as little empirical evidence is available, and virtually no controlled s tudies have been done. T he deceptive nature of the illnes s makes 1774 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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study difficult. At the current time, factitious dis order by proxy is not official DS M diagnosis but is cons idered a diagnosis deserving of further study. Acceptance as an official and IC D-10 diagnosis s hould increase its recognition in clinical s etting and s hould lead to decreas ed morbidity and mortality. W ithin the realm of factitious disorder by proxy, perifactitious disorders , s uch as hypochondrias is proxy and other by-proxy dis orders that res ult in medical care for children, s hould als o be further cons idered. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > S UG G E S T E D C R OS S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "16 - F actitious Dis orders " S omatoform dis orders are discus sed in C hapter 15. Malingering is the s ubject of S ection 26.1. P ers onality disorders are address ed in C hapter 23. P s ychotherapy discuss ed in C hapter 30. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 16 - F actitious Dis orders > R E F E R E NC

R E FE R E NC E S Ads head G , B rooke B , eds. Munchaus en's P roxy: C urrent Is s ue s in As s es s ment, T re atme nt R es e arch. London: Imperial C ollege P ress ; 2001. 1775 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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Aduan R P , F auci AS , Dale DD: F actitious fever and induced infection: A report of 32 cases and review of the literature. Ann Inte rn Me d. 1979;90:230. Allison DB , R oberts MS . Dis orde r Mothe r of Diagnos is ? Munchaus e n by P roxy S yndrome . T he Analytic P ress ; 1998. *Asher R : Munchausen's s yndrome. L ance t. Ayoub C C , Alexander R : Definitional iss ues in Munchaus en by proxy. AP S AC Advis or. 1998;11:7. B hugra D: P s ychiatric Munchausen's syndrome: Literature review with case reports. Acta P s ychiatr S cand. 1988;77:497. E di-Osagie E C , Hopkins R E , E di-Osagie NE : Munchaus en's syndrome in obstetrics and A review. O bs te t G yne col S urv. 1998;53:45. E is endrath S J : F actitious physical dis orders: without confrontation. P s ychos omatics . E is endrath S J , McNeil DE : F actitious dis orders in litigation: T wenty cas es illus trating the s pectrum of abnormal illnes s -affirming behavior. J Am Acad P s ychiatry L aw. 2002;30:391. E mins on DM, P os tlethwaite R J : F actitious illness : R ecognition and management. Arch Dis C hild. 1776 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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1992;67:1510. F eldman MD, E is endrath S J , eds . T he S pe ctrum of F actitious Dis orde rs . W ashington, DC : American P sychiatric P ress ; 1997. *F eldman MD, Hamilton J C , Deemer HN. F actitious disorder. In: P hillips K A, ed. S omatoform and Dis orde rs . W ashington, DC : American P sychiatric P ublis hing; 2001. F olks DG : Munchaus en's syndrome and other disorders . Neurol C lin. 1995;13:2. F ord C F . T he S omatizing Dis orde rs : Illne s s as a New Y ork: E lsevier S cience; 1983. G avin H. O n the F e igne d and F actitious Dis e as e s of S oldie rs and S e ame n, on the Me ans Us e d to P roduce T he m, and on the B e s t Mode s of Impos tors . E dinburgh: University P ress ; 1838. G elenberg AJ : Munchaus en's syndrome with a ps ychiatric pres entation. Dis Ne rv S ys t. Hay G G : F eigned psychosis: A review of the of mental illness . B r J P s ychiatry. 1983;143:8. K rahn LE , Li H, O'C onnor MK : P atients who strive to ill: F actitious disorder with phys ical s ymptoms . Am J P s ychiatry. 2003;160:1163.

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*Meadow R : Munchaus en s yndrome by proxy: T he hinterland of child abus e. L ance t. 1977;2:343. Meadow R : Management of Munchaus en syndrome proxy. Arch Dis C hild. 1985;60:385. Meadow R : Unnatural sudden infant death Arch Dis C hild. 1999;80:7. P hillips MR , W ard NG , R ies R K : F actitious P ainless patienthood. Am J P s ychiatry. P ope HG , J onas J M, J ones B : F actitious ps ychos is: P henomenology, family his tory, and long-term outcome of nine patients . Am J P s ychiatry. 1982;139:1480. *R eich P , G ottfried LA: F actitious dis orders in a hospital. Ann Inte rn Me d. 1983;99:240. R ogers R , B agby R M, R ector N: Diagnos tic factitious disorder with ps ychological s ymptoms. Am P s ychiatry. 1989;146:1312. *R osenberg DA: W eb of deceit: A literature review of Munchaus en s yndrome by proxy. C hild Abus e 1987;11:547. S chrier H: Munchaus en by proxy defined. P ediatrics . 2003;110:958. S chreier HA, Libow J A. Hurting for L ove : 1778 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/16.htm

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P roxy S yndrome . New Y ork: G uilford P res s; 1993. S nowdon J , S olomons R , Druce H: F eigned bereavement: T welve cases. B r J P s ychiatry. S piro HR : C hronic factitious illness : Munchaus en's syndrome. Arch G e n P s ychiatry. 1968;18:569. S utherland AJ , R odin G M: F actitious disorders in a general hospital s etting: C linical features and a of the literature. P s ychos omatics . 1990;31:392. Wallach J : Laboratory diagnosis of factitious Arch Inte rn Med. 1994;154:1690. Wise MG , F ord C V : F actitious disorders . P rimary 1999;26:2.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > 17 - Dis s ociative Dis orde

17 Dis s oc iative Dis orders R ichard J . L oewens tein M.D. Frank W. Putnam M.D. 

DIS S OC IAT ION AND DIS S OC IAT IV E

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DIS S OC IAT IV E AMNE S IA

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DE P E R S ONALIZAT ION DIS OR DE R

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DIS S OC IAT IV E F UG UE

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DIS S OC IAT IV E IDE NT IT Y DIS OR DE R

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DIS S OC IAT IV E DIS OR DE R NOT OT HE R W IS E

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F OR E NS IC IS S UE S AND DIS S OC IAT IV E

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S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IO N AND P HE NO ME NA

DIS S OC IATION AND DIS S OC IATIVE P art of "17 - Dis sociative Dis orders "

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Introduc tion According to the text revision of the fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs IV -T R ), “the es sential feature of the diss ociative a disruption in the us ually integrated functions of cons ciousnes s, memory, identity, or perception of the environment. T he dis turbance may be s udden or transient or chronic.” T he DS M-IV diss ociative diss ociative identity disorder, depersonalization diss ociative amnesia, diss ociative fugue, and disorder not otherwis e s pecified (NOS ). In the following section, many iss ues that are common to all the diss ociative dis orders are discuss ed together, with separate s ections on the different disorders to follow.

Diagnos tic C riteria: DS M and IC D T he study of the diss ociative dis orders began at the the 18th century. However, the modern notion that conditions are a dis tinct group of disorders , with systematic res earch about them, did not really begin the advent of the third edition of the DS M (DS M-III) in 1980. Although the first edition of the DS M (DS M-I) distinguished dis s ociative re actions from other the second edition of the DS M (DS M-II) subsumed diss ociative conditions under the s uperordinate of hys terical neuros is . T he latter was conceptualized as conversion or diss ociative s ubtype. In DS M-III, conditions that developed from the 19th century cons truct of hys te ria were dis tributed among different diagnostic categories : diss ociative dis orders , somatoform disorders (es pecially convers ion dis order 1781 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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somatization disorder), pos ttraumatic s tres s dis order (P T S D) (in the anxiety dis order section), and his trionic borderline personality dis orders. T he DS M-III took the stance that the label hys te ria had become so imprecise variously defined that it had become meaningles s. T he DS M-III took the approach that thes e conditions would defined and organized separately, s o that s ys tematic, empirical res earch could better clarify their reliability validity. T he tenth edition of the Inte rnational S tatis tical C las s ification of Dis e as e s and R e late d He alth 10) class ifies the dis sociative disorders among the s tre s s -re late d, and s omatoform dis orders . T he IC D-10 explicitly states that the term hys te ria s hould be because of its lack of precis ion. T he IC D-10 [convers ion] dis orders include diss ociative amnesia, diss ociative fugue, diss ociative stupor, trance and poss ess ion disorder, and diss ociative dis orders of movement and s ens ation (roughly equivalent to the IV -T R convers ion dis order diagnosis ). T he latter diss ociative motor disorders , diss ociative convulsions , diss ociative anes thesia and sensory loss . G ans er and multiple pers onality disorder are clas sified under diss ociative dis orders. Depers onalization disorder is clas sified separately. T he IC D-10 diagnostic criteria for these disorders are found in T able 17-1.

Table 17-1 IC D-10 Diagnos tic C riteria for Dis s oc iative (C onvers ion) Dis orders 1782 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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   G 1. T here must be no evidence of a phys ical disorder that can explain the characteristic symptoms of this dis order (although phys ical disorders may be present that give rise to other symptoms).    G 2. T here are convincing as sociations in time between the ons et of symptoms of the dis order stress ful events , problems , or needs. Dis s ociative amnes ia    A. T he general criteria for diss ociative dis order must be met.    B . T here must be amnesia, partial or complete, recent events or problems that were or s till are traumatic or s tres sful.    C . T he amnesia is too extensive and persistent be explained by ordinary forgetfulness (although depth and extent may vary from one ass es sment the next) or by intentional s imulation. Dis s ociative fugue    A. T he general criteria for diss ociative dis order must be met.

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   B . T he individual undertakes an unexpected yet organized journey away from home or from the ordinary places of work and social activities , which s elf-care is largely maintained.    C . T here is amnes ia, partial or complete, for the journey, which als o meets C riterion C for amnes ia. Dis s ociative s tupor    A. T he general criteria for diss ociative dis order must be met.    B . T here is profound diminution or absence of voluntary movements and s peech and of normal res ponsiveness to light, nois e, and touch.    C . Normal muscle tone, s tatic posture, and breathing (and often limited coordinated eye movements) are maintained. Tranc e and pos s es s ion dis orders    A. T he general criteria for diss ociative dis order must be met.    B . E ither of the following must be present:    (1) T rance . T here is temporary alteration of the 1784 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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state of cons cious nes s, shown by any two of the following:    (a) Loss of the usual s ens e of personal identity    (b) Narrowing of awarenes s of immediate surroundings or unusually narrow and s elective focus ing on environmental s timuli    (c) Limitation of movements, postures , and to repetition of a s mall repertoire    (2) P os s e s s ion dis orde r. T he individual is that he or s he has been taken over by a s pirit, deity, or other pers on.    C . (1) and (2) of C riterion B must be unwanted troublesome, occurring outs ide, or being a prolongation of, s imilar states in religious or other culturally accepted situations.    D. Mos t commonly us ed e xclus ion claus e . T he disorder does not occur at the same time as schizophrenia or related dis orders, or mood (affective) disorders with hallucinations or Dis s ociative motor dis orders    A. T he general criteria for diss ociative dis order must be met. 1785 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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   B . E ither of the following must be present:    (1) C omplete or partial los s of the ability to movements that are normally under voluntary control (including s peech)    (2) V arious or variable degrees of ataxia, or inability to s tand unaided Dis s ociative c onvuls ions    A. T he general criteria for diss ociative dis order must be met.    B . T he individual exhibits s udden and spas modic movements, clos ely resembling any of the varieties of epileptic seizure but not followed loss of cons cious nes s.    C . T he symptoms in C riterion B are not accompanied by tongue biting, serious bruis ing or laceration due to falling, or urinary incontinence. Dis s ociative anes thes ia and s ens ory los s    A. T he general criteria for diss ociative dis order must be met.    B . E ither of the following must be present:

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   (1) P artial or complete loss of any or all of the normal cutaneous sens ations over part or all of body (specify: touch, pin prick, vibration, heat,    (2) P artial or complete loss of vision, hearing, or smell (s pecify) Mixed dis s ociative (c onvers ion) dis orders Other dis s oc iative (convers ion) dis orders T his residual code may be us ed to indicate other diss ociative and convers ion states that meet G 1 and G 2 for diss ociative (conversion) disorders do not meet the criteria for the diss ociative listed previous ly. G ans er s yndrome (approximate ans wers) Multiple pers onality disorder    A. T wo or more distinct personalities exis t the individual, only one being evident at a time.    B . E ach personality has its own memories , preferences , and behavior patterns and, at some time (and recurrently), takes full control of the individual's behavior.    C . T here is inability to recall important pers onal 1787 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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information, which is too extens ive to be by ordinary forgetfulness .    D. T he symptoms are not due to organic mental disorders (e.g., in epileptic dis orders) or subs tance-related dis orders (e.g., intoxication or withdrawal). T ransient dis sociative (conversion) dis orders occurring in childhood and adoles cence Other specified dis sociative (convers ion) S pecific research criteria are not given for all disorders mentioned previously, because these other diss ociative s tates are rare and not well described. R es earch workers studying these conditions in detail s hould s pecify their own according to the purpose of their s tudies . Dis s ociative (c onvers ion) dis order,

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permiss ion.

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Dis orders T he DS M-IV -T R and the IC D-10 take divergent to the relations hip of convers ion dis orders to disorders . T he former treats them as s eparate and the latter treats them as conditions with similar underlying mechanisms. T his difference symbolizes one of the many pass ionate disagreements that the disorders that have evolved from clas sic hys teria. Indeed, it is unlikely that any other group of disorders in ps ychiatry can evoke so much heated controversy, and fervent debate than the conditions derived from the hysteria concept, particularly the diss ociative dis orders. T his is especially ironic, becaus e, s ince the 1980s , finally an increasingly rigorous body of research data many of the DS M-IV -T R diss ociative dis orders, as well the phenomenon of dis sociation, itself. Why s hould there be s uch a pas sionate debate? Why should appeals to the res ults of scientific research not res olve it? More so than other ps ychiatric conditions, disorders touch on many complex and contentious as pects of personal, political, philosophical, and even religious beliefs. T hes e include the nature of memory, volition, and consciousness and the res ponsibility of individuals for their own behavior. Indeed, the debate touches on fundamental ques tions about the nature of mind, the self, and the mos t intimate human behaviors . When viewed within a larger s ociopolitical perspective, diss ociation theory inters ects with many of the mos t controvers ial social iss ues of modern times. R ecent systematic res earch cons is tently has found a robust relations hip between diss ociation and traumatic experiences . T he role of trauma in Wes tern culture, 1789 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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particularly intergenerational violence and sexual cross es into historically taboo subjects, such as rape, inces t, child abus e, and domestic violence, and their prevalence in W estern society. In addition, the s tudy of trauma leads into larger legal, s ocial, and cultural questions related to peace and war, the meaning of violence in W es tern society, and even varying religious views about the relations hip between men, women, children and the nature of the family. In psychiatry and ps ychology, thes e disorders are the of controversies that include the long-standing debates between mentalists and behaviorists , between ps ychodynamically orie nte d and biologically oriente d clinicians , between various res earchers in cognitive ps ychology, between cognitive res earchers and clinical res earchers and practitioners , and between different theoretical s chools at odds over the nature of hypnos is. S ome fundamentalist C hris tian clinicians even have viewed demonic poss es sion as part of the differential diagnosis of diss ociative disorders . P.1845 P.1846 Is sues here include the significance of early trauma for human ps ychopathology; the existence of uncons cious mental life and intraps ychic de fens es , s uch as nature of memory; and the nature of hypnos is and whether it involves altered s tates of consciousness . F urthermore, the exis tence of diss ociative amnesias delayed recall of traumatic events raise difficult-to1790 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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questions about the reliability of traumatic memory. latter iss ue has been a significant controversy in the ps ychiatric community that has s pilled over into the and the popular media, arenas in which dispass ionate scientific inquiry is unlikely to be the central concern of participants. A particularly contentious debate has evolved over the relations hip of dis sociative disorders to psychological trauma. T his idea has been the s ubject of s ys tematic res earch, generally s howing a repeated, robust relations hip between trauma and diss ociative and disorders . In fact, this research led the American P sychiatric Ass ociation (AP A) DS M-IV Advis ory on P T S D to include diss ociative amnesia, diss ociative fugue, and diss ociative identity disorder/multiple personality dis order among the dis orders most strongly related to an antecedent history of traumatic or experiences , or both. Alternatively, another group of psychiatric clinicians res earchers has decried the emphas is on trauma in the conceptualization of diss ociative dis orders. T hes e doubt the relations hip between traumatic and the development of diss ociative dis orders, in regard to diss ociative amnes ia and diss ociative disorder. T hey dis pute the notion that there is a strong as sociation between the development of diss ociative identity dis order and early childhood maltreatment. S imilarly, they insist that amnesia for trauma does not occur, particularly for childhood s exual abus e. S ome of these critics have argued that diss ociative disorder and diss ociative amnes ia are not valid all and s hould be dropped from the DS M-IV -T R . Others 1791 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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have proposed a resurrection of the term hys te ria to account for these conditions. Others have them as factitious conditions , related to patient suggestibility and clinician naïveté. S ome relate the development of thes e disorders to underlying disorders , particularly borderline personality dis order. this view, the pers onality disorder is s een as the disorder, with the diss ociative dis order developing secondary to s ociocognitive factors. T he clas h of views about thes e iss ues has been notable in the debate over re pre s s ed or re cove red that has divided the mental health community since the 1990s . High-profile legal cas es have been the center of debate. In one incarnation, so-called victims alleging delayed recall for childhood maltreatment have been given standing to s ue or to bring criminal actions bas ed the de laye d dis covery rule, overcoming the statute of limitations . In the alternative form, accused parents or recanting former victims, or both, have sued mental health alleging malpractice or alienation of affections , or both, based on the notion that there is no s uch thing as diss ociation, amnesia, repres sion of memory, and diss ociative disorders . T hese cases have been the of considerable media attention.

Dis s oc iation and the Media F rom the middle of the 19th century to the pres ent, the popular media has nurtured public fascination with various forms of dis sociation, es pecially multiple personality. Accounts of 19th century cas es were popular magazines s uch as Harpe rs , and famous 1792 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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such as Morton P rince's Mis s B eauchamps (1905), the subjects of books and plays. R obert Lewis T he S trange C as e of Dr. J e kyll and Mr. Hyde (1886) is most well-known of these works . Other popular 19th century novels and plays focused on fugue, amnesia, crimes committed under the influence of hypnosis or in somnambulistic s tates. F rom at leas t the 1930s sens ational reports of patients with generalized diss ociative amnesia or fugue, or both, were featured the daily news papers. S imilar cases are s till featured in the news when amnestic patients are found who cannot be identified. In the late 20th century, popular accounts of multiple personality, s uch as T he T hre e F ace s of E ve , S ybil, recent s pate of s imilar first-person accounts , continued this vein. T he widespread us e of multiple pers onality as fictional plot device—generally to give a bizarre twis t to the story—has contributed to the public and confusion that s urrounds this disorder. S imilarly, for life circums tances and for trauma is als o a recurrent story mechanis m in contemporary novels, films , and television—almos t never portrayed accurately. Media stereotyping occurs for many forms of mental illnes s, the distortions typical in mos t fictional depictions of diss ociative dis orders are particularly mis leading. Highly publicized criminal and civil cas es, such as the Hillside S trangler, the F ranklin murder case, the case, and many others, have brought additional media attention to claims of multiple personality, amnes ia, recovered memory. T hese contentious cas es, with their warring academic experts and s ens ationalized media depictions, have also fueled popular s tereotyping of 1793 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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diss ociative dis orders. Media s pin about thes e cases often been inaccurate and mis leading. B ecaus e of all this, one commentator ruefully obs erved that most clinicians get the bulk of their training about diss ociation and diss ociative disorders from television. the foreseeable future, becaus e of the complexity of social, cultural, philosophical, and political is sues that these conditions evoke, it is unlikely that debates about them will remain purely in the academic arena.

His tory T he study of hys teria and diss ociation begins at the the 18th century with s hift of interest in thes e from the religious to the medical realm. P aracels us , in 1646, is credited with the first medical report of an individual with alternating s elves . In 1791, E berhardt G melin described a G erman woman who alternately exchanged her peasant personality for that of an aristocratic F rench lady, each amnesic for the other's exis tence. B y the early 19th century, such cas es , with diagnos es dual, double, or duplex consciousness , were being regularly reported on both s ides of the Atlantic. In B enjamin R ush, considered the father of American ps ychiatry, included a clas sic example in his medical school lectures . R us h propos ed that dual personality reflected a functional disconnection between the two cerebral hemispheres . In the same year, the case of R eynolds, who became the American archetype of diss ociative identity disorder for the remainder of the century, was first publis hed. 1794 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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In E urope, disciples of F ranz Anton Mesmer developed first s ys tematic descriptions of what is now called T hese thinkers developed an interes t in magne tic (from Mesmer's theories of animal magnetis m): fugue, somnambulis tic states , and alternating or personality that could be treated with artificial s omnambulis m, that is, hypnos is . T hese magne tize rs mostly outs ide the mains tream of E uropean academic medicine, and their works are not widely known. them, Antoine Des pine, a F rench family doctor, wrote systematic case studies and reports about s everal multiple pers onality patients , including child and adoles cent cases. Mos t of these 19th century patients had extensive convers ion and s omatoform s ymptoms part of the clinical pres entation. P sychiatric his torians have charted the s hift in interest from s omnambulism to multiple personality to hys teria and back over the cours e of the 19th century, with finally s een as a unifying concept for all these Many contemporary debates about diss ociation were prefigured by those in the 19th century. F or example, B riquet, who wrote a famous study of hysteria in the 19th century, dis puted the prevailing notion that P.1847 the disorder was caused by s exual frustration. He that traumatic, overwhelming, and grief-engendering experiences led to the development of hys teria. T he famous 19th century F rench psychiatrist, J eanC harcot, s ynthes ized the teachings of the magnetizers with those of the more accepted medical and es tablis hment, including B riquet's etiological theories. 1795 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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C harcot influenced major figures in psychiatry and neurology, such as S igmund F reud, P ierre J anet, G illes de la T ourette, and J oseph B abinski. As is well known, he gave public demonstrations of hysterical patients and hypnos is at his hos pital, La S alpetriere. Unknown to the careless C harcot, however, many were readily prompted in various ways to perform spectacularly for him. S ome were magnetized (i.e., hypnotized) on the wards or encouraged by followers of C harcot to act as dramatically as poss ible the great man. In addition, C harcot's methods of demonstrating his patients abundantly cued them to expected res pons es . After his death, two of C harcot's mos t important succes sors , B abins ki and J anet, took divergent views hysteria. B abinski took the radically nihilis tic view that hysteria was caus ed by s ugge s tion and could be by persuasion or counters uggestion. He coined the pithiatis m as a s ubs titute for hysteria. In addition, the Nancy school of hypnos is , led by Hippolyte B ernheim, believed that hypnos is was not neces sarily a s ign of pathology, as C harcot believed, but an effect of suggestion. B abinski and B ernheim believed that the symptoms of C harcot's patients were artifacts of suggestion and contagion, not of bone fide dis orders. view continues today, most prominently in the thinking P aul McHugh, a vehement critic of the current traumabased theories of dis sociation. At the end of the 19th century, P ierre J anet in F rance, P rince and W illiam J ames in the United S tates, and acros s E urope were engaged in a lively trans atlantic discuss ion about pos sible psychological and 1796 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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mechanisms underlying cas es of multiple pers onality, amnes ia, and fugue. Medical models of the time phenomena such as sleep and dreams, hypnos is and somnambulism, epilepsy, and disconnections between cerebral hemispheres to explain multiplicity. P ierre res earch and clinical theory, in particular, his emphasis the role of traumatic antecedents of dis sociation, are widely regarded as the foundation for modern views of diss ociation. As the 20th century began, however, interest in diss ociation waned, and alternative theories, like ps ychoanalys is, began their ascendance. However, interes t in diss ociative phenomena has reoccurred in war s ince the turn of the century with the observation of amnes ia, fugues , and conversion s ymptoms in soldiers . S ubs equently, thes e observations tended to forgotten by the ps ychiatric community, as the wars thems elves fade from memory. F or example, B abinks i's ideas had cons iderable on E uropean ps ychiatris ts until the onset of W orld W ar that time, with the development of the concept of s hell s hock, ps ychiatris ts systematically reported that of the symptoms of diss ociation, amnesia, automatism, and hysteria could be found among battle traumatized soldiers , plainly contradicting B abinski's ideas and supporting those of J anet.

J anet and Freud J anet is generally regarded as the founder of modern approaches to diss ociation and dis sociative disorders . was als o the first psychiatrist to provide s ys tematic, modern des criptions of obs ess ive-compuls ive disorder 1797 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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(OC D), phobias, and anorexia nervosa. He was deeply knowledgeable of the works of the magnetizers and early papers on diss ociation, hys teria, and multiple personality. He developed theories of hysteria and diss ociation, s ugges ting that many cases of hysteria based on covert, dis sociated aspects of the personality that were engendered by traumatic experiences in susceptible individuals . He believed that the lesion in hysteria was the narrowing of cons cious ne s s which the hys terical pers on is unable to perceive of subjective or objective phenomena. T hese then diss ociated, independent-agent aspects of the mind. also pos ited a kind of s tre s s -diathe s is model in which cons titutional and environmental factors coincided to produce the ps ychopathological diss ociative outcome. J anet developed a s ort of cognitive behavioral ps ychotherapy for his patients , involving hypnos is and search for a hierarchy of hidden traumatic memories related fixed ide as going back in the patient's history. also used hypnotic suggestion, imagery, and creative engagement with his patients to modify their bizarre hallucinations , disturbed perceptions, and hys terical alterations of consciousness . J anet worked intensely the hysterical cris es of the patients and, des pite symptomatic s torms and s uicidal cris es , found that the patients improved after this work. In addition, tas ks and work were pres cribed for the patient. J anet described many is sues in the proces s of therapy that been redis covered by contemporary students of the diss ociative dis orders. T hes e include a kind of altered states of consciousness and intens e with the therapis t, leading to therapeutic s talemate. 1798 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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J anet was attacked by followers of B abinksi and a credulous disciple of the dis credited ideas of C harcot. critics notwithstanding, J anet hims elf was dis tress ed by the contamination of patients under C harcot's hospital adminis tration; C harcot's failure to fully understand the work of prior scholars, such as the magnetizers ; and factitious nature of many of the patients' s ymptoms . F or the most part, he refus ed to work with former patients C harcot and took careful histories of patients ' prior treatments to uncover potential therapeutic s haping of symptoms. F reud and J os eph B reuer's revered S tudie s in H ys te ria (1893) referenced J anet's work, and us ed s imilar fixed ideas and traumatic etiology, and introduced the cathartic method of cure for hysteria. Anna O., the archetypal F reudian hys teric, is clearly des cribed as a dual pers onality and a plethora of dis sociative symptoms, such as complex amnes ias for current and historical experience; spontaneous age regres sions trances; depersonalization; fluctuations in handwriting, handednes s, and language; and alternating s tates of cons ciousnes s. However, as time went on, many psychoanalys ts excoriated J anet, as serting that he dis hones tly claimed priority for these ideas related to hysteria, even though J anet's work clearly antedated F reud's . J anet, for his was uncharacteris tically publicly angry at this failure to acknowledge his work. T hroughout his career, he remained critical of F reud and ps ychoanalytic ideas . Des pite the janetian ideas found in early freudian hysteria, freudian theories of hysterical and diss ociative phenomena differ in important ways from those of 1799 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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F reud posited the ideas of the dynamic unconscious, intraps ychic conflict, and intraps ychic defense related unacceptable thoughts, wishes, ideas, and memories. Later, he developed theories of transference and countertransference. After F reud repudiated the theory and developed a new and different theory of mental life, he and his followers increas ingly focused the somatoform as pects of hys terical phenomena, to neglect of the dis sociative ones . David R appaport, G ill, Margaret B renman, C harles F is cher, and E lisabeth G eleerd, among others , wrote important psychoanalytic papers on fugue, amnesia, and diss ociation in the and 1950s . However, psychoanalytic thinkers have ignored this work. It is unfortunate that disputes over primacy of ideas led a s chism between J anet and the freudians . Modern conceptualization of diss ociative disorders often synthes is of janetian ideas and freudian ones . F or current theories of treatment include the janetian of s ys tematic work with traumatic memories using adjunctive hypnotic and imagery techniques, work with posttraumatic cognitive distortions, using cognitive P.1848 and behavioral ps ychotherapy, ps ychoeducation, and building of life skills. T he psychoanalytic concepts of transference, countertrans ference, object relations, intraps ychic defens e, and conflict, among others, are es sential to understanding modern therapy of patients. J anet continued to be active in ps ychology and until his death in 1947, writing on many different 1800 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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theoretical, and philosophical subjects . J anet never developed a formal s chool of psychology nor a group disciples committed to his theories . He was deeply concerned with the protection of patient confidentiality, perhaps in part as a reaction to the excess es of the era. Accordingly, he had his library of detailed cas e histories , including those of the mos t famous clas sic hysterics, des troyed at his death. B ecaus e of this, and because of the primacy of the psychoanalytic theories the latter part of the 20th century, his work was largely neglected until the recent resurgence of interes t in diss ociation. J anet's contributions to modern diss ociation theory include (1) recognition of the caus al role of trauma in diss ociation in a stres s-diathesis model; (2) the taxonometric approach—J anet believed that was not on a continuum from normal ps ychological experience; (3) recognition that the underlying mental mechanisms of somatoform and diss ociative dis orders were s imilar; (4) the role of fixed ide as in diss ociative disorders and attempts to find the most fundamental that influence the patient's behavior; (5) treatment multimodal approach with hypnotic and trauma-focus ed methods combined with cognitive therapy, behavioral therapy, and life-skills building.

World Wars I and II and after C linicians treating battlefield cas ualties in W orld W ars I II readily noted dis sociative s ymptoms , such as fugue, automatisms , and s omatoform s ymptoms , in traumatized s oldiers as part of traumatic war ne uros is , came to be known in W orld W ar II. T he extent of 1801 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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described in ps ychiatric battlefield casualties in W orld II ranged from relatively brief periods of time to amnes ia for life history (generalized amnes ia), as well fugue epis odes. T reatment of these W orld War II amnesia cases hypnosis , narcosynthesis with sodium amobarbital (Amytal), or individual and group ps ychotherapy, or a combination of thes e. Attempts were made to treat soldiers on the front lines and to return them rapidly to combat. Detailed cas e descriptions of dis sociative and fugue can be found in clinical studies from that S oldiers from the K orean conflict also were noted to amnes ia as part of the posttraumatic s yndromes combat experiences and were treated with s imilar modalities. T he observations of thes e military ps ychiatris ts were mostly los t until the resurgence of interest in trauma diss ociation in the 1970s and 1980s . Authorities cite several s ocial and cultural factors leading to this T hese include the return of the V ietnam veterans and systematic academic s tudy of their ps ychiatric the recognition of the prevalence of childhood physical and s exual abus e with its as sociated mandated development of clinical attention to, mandated of, and res earch on child abuse and family violence; ris e of feminism with its critique of ps ychological that as cribed sexual abuse reports to fantas y; academic rigor in theories about hypnosis , s uch as Hilgard's ne odis s ociation theory, and greater academic hypnosis research; popular interes t in personality owing to works, such as S ybil; and the with its promulgation of diagnostic criteria for the 1802 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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diss ociative dis orders and P T S D.

L ater His tory S ince the publication of the DS M-III in 1980, a large of s ys tematic res earch has developed about disorders , particularly diss ociative identity disorder, diss ociative amnesia, and depersonalization disorder. Many academic studies have also investigated as a quantifiable trait in clinical and nonclinical S tudies have als o looked at the prevalence and phenomenology of amnes ia, particularly as it relates to question of delayed recall for traumatic experiences . As noted previous ly, the study of the diss ociative appears to be ins eparable from the social and cultural ambiance in which it occurs. Academic interest in and its clinical outcomes has been paralleled by s ocial religious movements focusing on self-identification as a victim of childhood abus e, and the s eeking of recovery through a variety of therapeutic and s elf-help F urthermore, some feminis t theorists opined that from childhood s exual abus e mandated confrontation with alleged perpetrators in personal meetings or in the courts , or both. Legal theoris ts, concerned that victims of childhood maltreatment did not have standing to sue for damages to bring criminal actions under us ual s tatutes of limitations , lobbied s tate legislatures to expand the of time that victims could s eek legal redres s. T his was based on the idea that many survivors had amnes ia for abuse or did not recognize the harm that had been to them until many years after the abus e had occurred, 1803 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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both. Many states did alter the s tatute of limitations for childhood s exual abus e, allowing the statute to begin to toll after the person recovered memory of the abuse or, alternatively, after recognizing the harm that had been done whether amnes ia was present or not. A number succes sful legal actions were brought under these theories, with courts accepting expert tes timony concerning the validity of “repress ed memory” for childhood maltreatment. In the 1980s, clinicians working with diss ociative began to report patient accounts of multiperpetrator, multivictim abus e in the context of suppos ed underground cult groups . T hes e frightening and chilling accounts were amplified by highly publicized day care abuse cases that alleged multiple perpetrators , in some cases with elements of occultism and ritualized abuse. S everal state governments developed commis sions to inves tigate allegations of ritual abuse and claimed to found evidence of these activities. Needless to s ay, the media also developed an intense interest in thes e with publication of popular autobiographical accounts patients with reported histories of “ritual abus e,” as well frequent news s tories and televis ion s pecials on this related topics . Unfortunately, s ome clinicians working with thes e diss ociative patients chose to respond to their patients ' reports in a highly publicized and s ens ationalized rather than s ubjecting them to dispass ionate and scrutiny. S ome of these clinicians painted themselves crusaders against a vast criminal cons piracy that threatened the nation, pres enting thems elves and their 1804 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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patients on televis ion and in the newspapers. P atients some specialized diss ociative disorders units shared detailed recollections of trauma in group therapy and in the hos pital milieu, with relatively little concern for poss ible cross -contamination or confus ion about the origin of accounts of trauma. C autionary or critical among dis sociative disorders res earchers and were ignored or rebuked. F orens ic and clinical was dis regarded that cast doubts on the veracity of patients' accounts and s uggested alternative for many of these ritual abus e narratives . Ultimately, an extens ive backlas h occurred that broadly on a large number of claims related to maltreatment. T his included a wholes ale debunking of day care criminal cas es, even those that had res ulted convictions and for which there was s olid proof. T here increased s kepticis m about the reliability of children's reports of childhood maltreatment, particularly for childhood s exual abus e. P opular works that readers to work on recovery from abuse were suggesting abus e to millions when none had occurred. Allegations of delayed recall for childhood trauma in clinical and forens ic cas es were dis paraged as P.1849 based on erroneous views of human memory and cognition. T he diss ociative dis orders cons truct was dismiss ed completely as engendered by suggestion sociocognitive factors . T herapy based on working with traumatic memories was dis counted as ris ky. T he of an extensive prevalence of childhood abuse in the general population and its actual impact on 1805 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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ps ychopathology were questioned. S ome critics raised doubts about the validity of the diagnos tic cons truct of P T S D. As always, the print and television media, looking for a new angle on an old story with which to increase or viewer and reader interest, devoted extensive space these critiques. W here they once had devoted hours to crying child abuse victims , they now showed hours of crying wrongfully accus ed parents, day care providers, recanting former victims . A s ignificant impact on this debate was produced by F alse Memory S yndrome F oundation, founded in 1992 parents whos e psychologist daughter had privately accused her father of sexual abuse, reportedly recalled only in adulthood. T hese parents sought out other with similar histories , s ome of whom had had criminal or civil judgments brought against them of their children's allegations of abuse. T he sought to publicize the claims of its founders and members that their adult children's accounts of trauma were confabulations caus ed by psychotherapy. T his organization, accompanied by several attorneys , developed a legal theory that was a direct counterpoint that developed by the feminist clinicians and attorneys who had sought legal confrontation with alleged In this theory, there was no such thing as delayed trauma. Ins tead, clinicians who were ignorant of the complexities of human memory engaged in risky strategies , s uch as hypnosis or guide d image ry. T hey convinced credulous patients that their difficulties were based on a history of repress ed childhood abus e and engaged in therapeutic techniques that led patients to 1806 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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believe that thes e confabulations were accurate. T he patients then made these abuse accounts the center of their lives , as cribing all problems to their early maltreatment. T he patients were urged to or to s top all contact with family members accused of sexual abus e, ritual abuse, and other forms of maltreatment. A group of attorneys and a coterie of academic expert witness es s ought out patients and ex-patients to bring cases throughout the country in which therapis ts were sued for malpractice or were subject to licensing board complaints , or both, bas ed on diagnos es of diss ociative identity dis order and diss ociative amnes ia and engagement in therapy involving work with apparent traumatic memories . Many of these cases were settled without ever ending up in court. S everal resulted in jury findings for the plaintiffs with s ignificant damage Others concluded with juries finding for the defendant doctors. A federal mail fraud case agains t several ended in a mistrial before the prosecution's cas e had concluded, with the prosecution declining to retry the case. Only one published s tudy has looked s ys tematically at retractors of abus e allegations, amnes ia, and identity dis order. It found that virtually all of these individuals had long psychiatric histories , with P T S D diss ociative s ymptoms predating contact with clinicians . V irtually all of these patient-plaintiffs had significant pers onality disorders in which they readily the victim role and looked to forces outside themselves explanation of their problems . F actitious elements were prominent in many patients' presentations. W ith 1807 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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treatment, mos t had actually improved with res pect to their diss ociative ps ychopathology, but the other Axis I and Axis II difficulties remained s ubs tantial. Later, after termination of treatment by their clinicians, the patients s hifted their perception of victimization from parents to their prior therapists , now putting their attorneys in the role of res cuer, usually with the large s ums of money if they prevailed in their laws uits. Des pite its popularity in the media, fals e me mory as a clinical construct has never been operationalized studied using methods to validate it as a cons truct. V irtually no res earch has been done on this entity as a clinical disorder. However, a number of experiments on memory have been performed by cognitive psychology res earchers, s ubs equent to the naming of the false memory s yndrome, that s upport or cast doubts on whether memory is permanently altered by various of mis information and sugges tion. S tudies are regarding whether memory is easy to modify for a of types of experiences . S tudies vary with the studied, the type of information (or misinformation) provided, and the res earch paradigm to test memory fallibility. Often pres ented as a s imple problem in that has been definitively solved, the oppos ite is more accurate: T his is a complex area of res earch on a set highly complex phenomena in which a number of competing paradigms exis t. Nonetheles s, the experience of many experts however, that s ome therapies that resulted in false memory lawsuits could have been s ubject to litigation without this factor. Although many such treatments were exemplary, others resulted in a 1808 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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outcome, des pite clinicians ' difficulties in managing transference and countertransference, therapeutic and boundaries , and overinvolvement with the patient. case example s uggests the complexity of many of cases. Ms. C ., a s ingle woman in her mid-20s, brought a malpractice suit against her former primary therapist, several clinicians who had seen her as a hospital and a hos pital s ys tem that has a specialty trauma and women's program. Ms . C .'s psychiatric history adoles cence. S he ran away from home repeatedly, res ulting in a social s ervice inves tigation. S he was from her parental home bas ed on her reports of sexual, and emotional abuse primarily perpetrated by father. S he s ubs equently recanted these accus ations , her father was not pros ecuted. Attempts to return her home were unsuccess ful, however, and she lived in a succes sion of fos ter placements . S poradic contact with family continued, usually as sociated with clinical deterioration. S he was treated with multiple trials of outpatient, inpatient, and day hospital care throughout her adoles cence and early adulthood. S he received different diagnoses and was treated uns uccess fully several different psychopharmacological regimens. reported amnes ia, fugue, automatic writing, and a shifting internal states to s everal treating clinicians who documented a dis sociative disorder diagnos is in the T he patient was terrified of this diagnosis and was reluctant to cooperate with as sess ing it. E ventually, s he was hospitalized in the women's unit and became the patient of Dr. Z., a clinical ps ychologist. Ms . C . developed an intense therapeutic 1809 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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relations hip with Dr. Z., who made the diagnos is of diss ociative identity disorder based on switching to defined alter identities and the presence of diss ociative amnes ia. Dr. Z. rapidly became overinvolved with Ms . telling her that s he loved her and cons idered her to be one of her daughters. In addition to treatment ses sions , which Ms. C . was not billed for ins urance copayments, Z. saw Ms. C . outside of sess ions in s everal social T hey als o engaged in a voluminous e-mail on a daily basis. Ms. C . began to report a bizarre multiperpetrator occultist abus e, based in her family rural hometown. S ome of thes e accounts appeared to fanciful and unlikely to be poss ible in physical reality. Des pite this, Dr. Z. repeatedly reass ured Ms. C . that believed her accounts. Dr. Z. would s creen Ms. C .'s mail mes sages , lest evil “cult programming” calls her. Dr. Z. als o helped Ms. C . financially. P.1850 T he treatment lasted s everal years. Despite the problems , Dr. Z. ins is ted that the patient work on maintaining hers elf free from self-harm and out of the hospital. Ms . C . was gradually more able to do this. Her social function improved, with a more cons istent performance at school and work. S he did require hospitalization, but these became less frequent. Her identities worked on becoming less s eparate and many them fused, with decreased diss ociative symptoms and better functioning. As the therapy wore on, however, found hers elf increas ingly enervated by the extensive demands that Ms. C . continued to place on her for outsess ion contacts , e-mail, cris is management, and 1810 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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support. Dr. Z. consulted with more s enior clinicians suggested more rigorous boundaries and attention to transference and countertransference iss ues . W hen attempted to change the therapy framework according these sugges tions, Ms . C . reacted catastrophically to a profound rejection. F inally, Ms . C . physically attacked Z. in her office, resulting in summary termination of the therapy. Ms. C . eventually began treatment with a clinician who debunked the diss ociative identity disorder and memory ideas and encouraged Ms. C . to sue Dr. Z. other clinicians to right the so-called wrongs that had done to her. E ventually, the case was settled out of for a relatively s mall s um from Dr. Z. As the previous discus sion indicates, thes e academic social debates of the me mory wars parallel many of that polarized the field in the days of B abinski and Like J anet, modern authorities on the diss ociative disorders generally accept the trauma-based etiology diss ociative conditions and the validity of the traumadiss ociation cons truct. T his model mos t completely and rigorously accounts for the current data about these patients. Like J anet, s ophisticated modern s tudents of diss ociative dis orders have a healthy respect for the of phenomenological and ps ychotherapeutic that many dis sociative patients embody and the multilayering of pathologies that may appear in their treatment. F or example, there is a broad spectrum of dis sociative individuals . At one extreme are high-functioning with significant adaptive res ources and relatively circums cribed and treatment-res ponsive pers onality 1811 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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disorder s ymptoms. At the other extreme are patients major multiaxial difficulties , factitious and antis ocial clinical features, s ignificant s ubs tance abus e, in criminal subgroups, and major life problems in most spheres of function. T he current polarization of the ps ychiatric community about diss ociative dis orders it more difficult to develop res earch that evaluates these subgroups . A comprehensive model evaluating this complexity could include genetic factors relative vulnerability or res ilience, or both, ps ychobiological developmental factors, the differential effects of trauma and neglect, res titutive environmental factors , and the impact of differing forms of family and dysfunction on the individual.

S c ientific Inves tigation of Dis s oc iation T he scientific investigation of diss ociation dates to the experiments of P rince in 1908 us ing a crude polygraph meas ure galvanic s kin res is tance (G S R ) acros s the personality s tates of a dis sociative identity disorder patient—a physiological meas ure that remains of today. P rince reported seeing differential G S R words that were emotionally laden for one alter personality s tate but not for another. Over the next century, s everal dozen psychophysiological and performance s tudies were added to the literature. Many these reported findings s uggesting differential acros s diss ociative identity disorder alter pers onality states . T he s mall s ample sizes —often only a s ingle and the frequent lack of controls limit their credibility, however. T he few s tudies with larger samples and controls generally s upport the earlier findings of 1812 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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differences acros s alter personality states . T he experimental methodologies and the often idios yncratic differential res ponses elicited in dis sociative identity disorder s ubjects have limited opportunities for replication. Nonetheless , inves tigation of differential ps ychophys iological res ponses and cognitive acros s alter pers onality states of dis sociative identity disorder patients continues to be an important s ource information about the nature of dis sociation. T he advent of reliable and valid measures of opened up a new avenue of experimental inves tigation. T he correlation of scale scores with a variety of phys iological, neuroendocrine, cognitive, and brain imaging data facilitates examination of the biological underpinnings of dis sociation and the impact of diss ociation on phys ical and mental functioning. B y dividing subjects into high and low dis sociative subgroups , inves tigators have identified s ignificant differences in the way in which highly diss ociative individuals perform on physiological and cognitive meas ures . Meas ures such as the C linicianDis sociative S tates S cale (C ADS S ) document pharmacologically induced diss ociative-like normal controls and in clinical populations, such as patients. T hes e s tudies primarily focus on traumatized individuals , most of whom do not have a diagnosable diss ociative disorder but often have P T S D or traumaas sociated psychopathology. Much of what has been learned since the 1990s is a result of the large studies including meas ures of dis sociation in their as sess ment.

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Dis s oc iation S c ales and Diagnos tic Interviews F ollowing the example set by affective and anxiety disorder res earchers, dis sociation screening measures DS M–based structured diagnos tic interviews were developed in parallel. After approximately a decade of clinical and research application, the best of these instruments equal the levels of reliability and validity es tablis hed for meas ures of depres sion, anxiety, and R eliable and valid meas urement of diss ociation has particularly important in neurobiological s tudies, as well for understanding the clinical contribution of to trauma-as sociated dis orders. Many of these are now available on the Internet or are reproduced in articles and books. A number have been modified by others and then circulated under names s imilar to the original, so provenance should be established to that a properly validated vers ion is being used.

S Y MP TOM S C R E E NING ME A S UR E S S everal general dis sociation s creening s cales exist. best known of these is the Diss ociative E xperiences (DE S ), developed by E ve B ernstein C arlson and F rank P utnam in the mid-1980s and now included in studies. T here are 28 items, which primarily tap identity alteration, depers onalization, derealization, and absorption. T he overall DE S s core can range from 0 to S everal studies using receiver operating characteristic (R OC ) methodology converge on DE S scores of 30 or greater as the cut-point for identifying pathological of dis sociation. S tudies comparing high- and lowsubjects typically use an overall DE S score of 30 or a 1814 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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of 30 on the eight-item, DE S taxon (DE S -T ) s ubs cale dividing line. T he DE S has high coefficients of internal tes t-retest reliability acros s multiple s tudies , and DE S scores are highly correlated with other diss ociation meas ures and diss ociative dis order structured scores. F actor analyses with clinical s amples generally produce trifactorial s olutions with s ubs cales for depers onalization, and abs orption. G ender, status , and, within reas on, intelligence quotient (IQ), do not appear to have significant confounding effects on scores. T he DE S has been translated into more than languages , and s tudies across cultures reveal s trong similarities P.1851 for W es tern and non-Wes tern samples , attes ting to the universality of the dis sociation. T he P eritraumatic Dis sociative E xperiences (P DE Q) developed by C harles R . Marmar and as sess es dis sociative experiences at the time of the traumatic event. S everal vers ions exis t, with the P DE Q item s elf-report vers ion (P DE Q-10-S R V ) now widely for research and clinical s creening. A metaanalytical es tablis hed that peritraumatic diss ociation is the s ingle best predictive factor for the subsequent development P T S D. T he 20-item S omatoform Dis sociation (S DQ-20) developed by E llert R . S . Nijenhuis taps the somatosens ory and convers ion s ymptoms common diss ociative patients . T hese include motor inhibitions, of function, anesthesias and analgesias, pain, and problems with vis ion, hearing, and s mell. T he S DQ-20 good reliability and validity for discriminating 1815 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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disorder patients . T he five-item S DQ (S DQ-5) provides quick s creening meas ure. T he C ADS S by J . Douglas B remner is administered by a clinician, usually in the context of an experimental s tudy, to as sess symptoms amnes ia, depers onalization, and derealization. T he has proven particularly useful in pharmacological and in military s tres s studies . It has good convergent validity with other meas ures of dis sociation and high interrater and test-retest reliability. T wo other self-report inventories , the Multis cale Dis sociation Inventory (MDI) and the Multiaxial of Diss ociation (MID), have been developed to as ses s pathological dis sociative s ymptoms and to ass is t in differential diagnosis of diss ociative dis orders. T hree primary dis sociation measures exist for children adoles cents . T he C hild Dis sociative C hecklis t (C DC ) is parent-caretaker-teacher 20-item report measure that a three-point scale. T he C DC is a reliable and valid for dis sociation in children who are 5 to 12 years of S cores can range from 0 to 40, with s cores of 12 or indicative of pathological levels of diss ociation. A diss ociative s ubscale has also been extracted by inves tigators from the popular C hild B ehavior C hecklis t (C B C L) and has proven useful in res earch s tudies , its clinical usefulness has not, as yet, been tes ted with diss ociative patients . T he Adoles cent Dis sociative E xperiences S cale (A-DE S ) is an adoles cent-oriented version of the DE S with differences in item content but similar constructs of amnesia, identity alteration, depers onalization, and derealization. T his 30-item instrument us es a 0-to-10 ans wer format and has good reliability and validity as a research tool and a clinical 1816 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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screening instrument.

DIA G NOS TIC INTE R VIE WS T wo DS M-based structured interviews have been developed for the formal diagnosis of dis sociative disorders , the S tructured C linical Interview for DS M-IV Dis sociative Dis orders, R evis ed (S C ID-D-R ) and the Dis sociative Dis orders Interview S chedule (DDIS ). T he S C ID-D-R by Marlene S teinberg is widely regarded as gold s tandard for research studies requiring a is a semi-structured clinician-adminis tered interview as sess es the pres ence and s everity of amnesias , confusion and alteration, depers onalization, and derealization and renders a DS M-IV diagnos is for all diss ociative disorders and for acute s tres s disorder. It includes 276 questions and rates the s everity of each symptom on a four-point scale. F or dis sociative patients, administration time typically ranges from 1 to hours but is much briefer for nondiss ociative patients. T he S C ID-D-R has good to excellent tes t-retest reliability and well-es tablis hed validity in numerous studies. It has been trans lated into at least a dozen languages with s imilar results in different T he DDIS by C olin R os s is primarily a clinical instrument and is s ometimes used as a screen for pathological dis sociation. It inquires about a wide range phenomena in addition to dis sociative s ymptoms , including child abuse his tory, major depres sion, complaints , substance abus e, and paranormal It requires approximately 30 to 60 minutes to diss ociative identity disorder patients . E xcept for depers onalization disorder, interrater reliability is 1817 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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acceptable, and convergent validity includes s trong correlations with the DE S and clinical diagnos es of diss ociative dis orders.

Memory and C ognitive Dys func tions Dys functions of memory are a central feature of the diss ociative disorders . Dis sociative identity dis order, its apparent web of directional amnesias among alter personality s tates, was the focus of early attempts at experimental inves tigation. Many of the cas e s tudies followed also sought to document thes e amnesias. A National Ins titute of Mental Health (NIMH) s tudy us ed diss ociative identity disorder patients and ten matched controls, who were tes ted as themselves and in a simulated alter pers onality s tate. T hey tested the separateness of memory between pairs of reportedly mutually amnes ic alter personality states by measuring intrus ions from categorically s imilar word lis ts learned the other alter personality states . T he diss ociative disorder patients were more likely to compartmentalize the stimuli learned, whereas thos e mimicking showed far less evidence of information partitioning. S ubsequent studies s ugges ted that diss ociation had differential impacts on the domains of implicit and memory. C onvers ely, in some recent s tudies of memory and amnes ia in diss ociative identity disorder, cognitive res earchers have not been able to document claimed amnes ia between s ubjectively mutually amnes tic alters us ing a variety of implicit and explicit memory In one study, feigning control s ubjects familiar with diss ociative identity disorder s howed lack of priming in 1818 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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implicit memory task because they “knew” they were supposed to be amnestic, although actual dis sociative identity dis order subjects did s how normal priming. On other hand, in another s tudy, researchers could not document suppos ed trans fer of information between alters claiming to be “co-cons cious” us ing implicit and explicit memory tasks. Accordingly, some researchers have questioned the actuality of diss ociative identity disorder amnesias. However, the failure of transfer of information in supposedly co-cons cious alters s ugges ts other implications of these studies. T hes e include that diss ociative identity disorder patients may not always reliable reporters of either amnesia or coawareness between alter self-states . F or example, in a single case study, a dis sociative identity dis order subject was randomly signaled by a beeper and filled out mood and activity rating scales , as well as information pertaining the personality s tate who was “out.” R ating s cales filled in real time were discrepant with the alters ' selfmood and activity reports during clinical interviews . F inally, it may be more us eful to devise studies using autobiographical memory paradigms and to more and naturalis tically s tudy diss ociative identity disorder patients' memory problems and s witching behaviors without necess arily devoting s pecific attention to which alter does or does not have recall at a given time. However, the exis tence of differential and directional amnes ias acros s dis sociative identity dis order alter personality s tates has been found in most studies to T he more rigorous s tudies , however, also document cons iderable leakage or transfer of information across 1819 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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personality s tates, which report being completely for one another. T he mos t parsimonious neurops ychological explanation put forward, that these amnes ias are examples of s tate-dependent learning retrieval, was first articulated by T heodule R ibot at the of the 19th century. T he degree of amnesia in diss ociative identity disorder patients , however, that typically s een in experimental studies of s tate dependent memory. S tudies s how that memory tasks can be constructed that highly diss ociative individuals perform better or than control s ubjects. Memory tasks that involve of attention or compartmentalization of highly P.1852 similar information seem to favor highly diss ociative individuals . Memory tasks that demand focused place them at a s ignificant disadvantage. T hese and memory differences, perhaps together with other unrecognized cognitive differences, operating during critical periods of development and over the life span of the individual, could lead to cons iderable deviation normal developmental trajectories, as described in the section on the developmental model.

Ps yc hophys iology of Dis s oc iation C linical obs ervations of differences in handednes s; acuity; s ens itivity to various vis ual, tactile, olfactory, auditory s timuli; and energy level date to some of the earliest cas e descriptions and became a staple of 19th century cas e reports . In a study measuring a battery of autonomic nervous system indices , including G S R , 1820 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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nine diss ociative identity disorder patients consistently manifested phys iologically dis tinct pers onality s tates a s everal week period. T hree of the five simulating could, by us ing hypnosis or deep relaxation, also distinct pe rs onality s tate s , although thes e differed phys iologically from thos e produced by the patients . C as e reports continue to report electroencephalogram (E E G ) differences across dis sociative identity dis order personality s tates, but, increasingly, investigators are turning to the newer brain imaging technologies in their efforts to document these. A functional magnetic res onance imaging (fMR I) s tudy of 12 s witches among three alter pers onality states found changes in brain activity bilaterally in the hippocampus and in the right parahippocampal and medial temporal regions. In a comparing 15 diss ociative identity disorder patients to eight controls , the patients showed s ignificant hypoactivity bilaterally in the orbitofrontal region and increased left lateral temporal activity. No differences found between alter personality states , however. An study of alpha wave coherence us ing five s imulator controls and five diss ociative identity disorder s ubjects found s ignificant differences between pers onality s tates for alpha wave coherence in s ix brain regions, whereas there were no differences for the controls . Another compared event-related potentials elicited by words learned in the same or a different alter personality state four diss ociative identity disorder patients. Here, little support was found for the existence of amnes ia personality s tates, when compared to controls from another study who had deliberately concealed of previously learned words. 1821 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Using s cript-driven traumatic imagery to evoke diss ociative s tates in P T S D patients, one fMR I study significantly increas ed activation in the s uperior and middle temporal gyri (B rodmann's area [B A] 38), the inferior frontal gyrus (B A47), the occipital lobe (B A19), parietal lobe (B A7), medial frontal gyrus (B A10), the cortex (B A9), and the anterior cingulate (B A24 and A recent study us ed positron emiss ion tomography to investigate the functional anatomical repres entation autobiographical s elf-awarenes s in 11 diss ociative disorder patients . S ubjects were tested with pers onally relevant s cript-driven imagery of traumatic vers us narratives . Dis sociative identity dis order subjects were tes ted in s elf-states that reported subjective owners hip a traumatic event with accompanying emotional (T raumatic P ers onality S tate [T P S ]) and, in alternation, self-states that denied emotional reactivity to the event and denied that the event had happened to them P ers onality S tate [NP S ]). C omparison of s ubjects in various conditions , s uch as neutral s cript, NP S -neutral script, T P S -traumatic script, NP S -traumatic script, in various trials s howed that T P S subjects res ponded to trauma s cripts with changes in perfus ion of right hemisphere frontal, visual and parietal integration areas similar to thos e of normal subjects res ponding to autobiographical episodic retrieval. T P S subjects showed activation of areas to regulation of emotion and pain. NP S subjects did not show changes in perfusion between neutral and scripts, consistent with their failure to recognize the trauma scripts as autobiographical. T he authors that the res ults are cons istent with a single human 1822 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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brain/mind generating at leas t two dis tinct s tates of awarenes s with differing acces s to autobiographical memory primarily related to differential activation of medial prefrontal cortex (MP F C ) areas and pos terior as sociation areas. S imilarly, another group us ed fMR I to s tudy s criptimagery in traumatized s ubjects with and without F unctional connectivity analys is s howed significantly different patterns of activation between the P T S D and non-P T S D groups with script-driven imagery. P T S D subjects experienced the trauma s cripts as producing flashbacks with strong emotional, s omatic, and s ens ory res ponses . Non-P T S D s ubjects experienced recall as personal narratives without intense emotion. Nonsubjects s howed a more left-hemis phere activation pattern including verbal ass ociation areas. P T S D showed a right-hemis phere dominance pattern with increased blood flow to right brain frontal, posterior as sociation, s ubcortical, and paralimbic areas similar to findings in the P E T study of diss ociative identity subjects and prior P E T and fMR I s tudies of P T S D fMR I has also recently been used to study a laboratory paradigm of memory s uppres sion/repres sion using subjects instructed to either think or not think of the second member of a pair of words previous ly seen. S ubsequent cued recall of suppres sion items was to recall of baseline items and actually generalized to novel tes t cues . Neural networks implicated in this suppress ion res pons e involved bilateral prefrontal paralimbic, s ubcortical, and parietal integration areas . addition, suppres sion reduced activation bilaterally in hippocampal areas. Hippocampal activation patterns 1823 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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differed from trials involving ordinary forgetting with those involving s uppress ion-induced forgetting. Hippocampal activation was increas ed in s uppress ioninduced forgetting compared to that found in items that were recalled. T he authors concluded that activation of a broad neural network was involved in memory s uppress ion, including interrelation of the dorsolateral prefrontal cortex, hippocampus, anterior cingulate cortex, medial-temporal lobe, dorsal premotor cortex, presupplementary motor area, and intraparietal areas. In addition, the authors stated that thes e strongly sugges t a neurobiological model for memory control in res ponse to trauma, including the poss ibility that these networks are involved in producing lasting amnes ia in res ponse to traumatic events. A few individual case studies of patients with global diss ociative amnesia and with dis sociative fugue with of pers onal identity have s hown unus ual metabolic and activation patterns using P E T scanning and single emis sion computed tomography (S P E C T ). T hes e revers al of the us ual patterns of right and left activation during autobiographical and s emantic recall, res pectively, with s imilarities to some individuals with traumatic brain damage and related memory deficits. A recent review of these s tudies sugges ted that or functional dis connections between major neural networks may be etiological in dis sociative amnesia syndromes. T he strategy of dividing traumatized s ubjects into high and low diss ociative subgroups has als o yielded interes ting res ults for ps ychophysiological meas ures . S everal studies of rape victims , s ubjects with P T S D 1824 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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script driven imagery, and s exually abused girls to controls on a meas ure of mos t traumatic life have found a unique pattern of psychophysiological res ponding in high diss ociatives. Using indicators of subjective dis tres s, P.1853 heart rate, and G S R , high dis sociatives s howed heart rate and G S R with highes t reported subjective distress . T his combination of increas ed dis tres s and decreased heart rate predicted more P T S D s ymptoms, blunted emotion, and poorer outcome. T wo s tudies have found an invers e relations hip diss ociation s cores and urinary catecholamines. Delahanty and colleagues collected 15-hour urine from motor vehicle accident victims on hos pital admiss ion. men, peritraumatic diss ociation was correlated with epinephrine but not norepinephrine, whereas women showed a revers ed pattern of significance. Us ing DS Mdepers onalization disorder s ubjects, Daphne S imeon colleagues found s trong negative correlations between urinary norepinephrine and depers onalization s cores . T hese res ults are congruent with the phys iological suggesting that high levels of dis sociation act to arousal in the face of s tres sors but do little or nothing dampen s ubjective dis tres s.

Neurobiology of Dis s oc iation Understanding of the neurobiology of diss ociation is based on two primary s ources of information. T he firs t body of case reports des cribing diss ociative reactions the context of illicit drug use or as a side effect of 1825 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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medications . Drugs that can precipitate dis sociativereactions include alcohol, barbiturates and related hypnotics, benzodiazepines , scopolamine (T ransdermS cop), β-adrenergic blockers , marijuana, other ps ychedelics , and anes thetics , s uch as ketamine and its relatives . T he array of implicated drugs and range of activities would sugges t that many neurotransmitter s ys tems might be involved in diss ociative reactions. T he second s ource is data from placebo-controlled, challenge s tudies using a range of diss ociative drugs . C hallenge s tudies that have elicited depers onalization other diss ociative phenomena include marijuana, of lactate, yohimbine (Actibine), metachlorophenylpiperazine (mC P P ), and ketamine. studies appear to narrow down the number of neurotransmitter s ys tems that are likely to make significant contributions to diss ociative s tates. evidence suggests that the N-methyl-D-as partate glutamate receptor plays a central role in diss ociative symptoms. A s eries of studies, using ketamine, an NMDA that increases glutamate releas e, found that the drug produced dose-dependent increases in diss ociation High dos es of ketamine produced slowed perception of time, tunnel vis ion, derealization, and similar to that des cribed by trauma victims. with a benzodiazepine or lamotrigine (Lamictal), an anticonvuls ant that decreas es glutamate release, but did not entirely eliminate the diss ociative effects of ketamine. T hese studies s ugges t that diss ociation, heretofore widely regarded as virtually impervious to 1826 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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medication, may be res ponsive to certain clas ses of Neurobiological theories of diss ociation draw on preclinical data indicating that stres s increas es the of glutamate and the s imilarity of the effects of NMDA antagonis ts with stres s- and traumainduced dis sociative symptoms. In s ummary, it that NMDA blockade decreases inhibitory tone, leading increased glutamate release and s ubs equent symptoms. T his theory als o accounts for the structural brain changes in the hippocampus found in magnetic res onance imaging (MR I) s tudies of P T S D s ubjects controls. In two studies, dis sociation measures s trongly correlated with volume los s in key brain regions in P T S D. G lutamate has a well-documented role in and increased glutamate releas e can lead to cellular events . It s hould be noted, however, that studies with marijuana and mC P P implicate s erotonin, studies with yohimbine sugges t that noradrenergic systems may play roles in diss ociation and P T S D symptoms. Also, in two s tudies of military s ubjects undergoing high s tres s training, a s trong negative relations hip was found between neuropeptide Y (NP Y ) levels and dis sociative symptoms.

C omparative Nos ology T his s ection discuss es nos ological is sues for all of the diss ociative dis orders, although is sues related to the specific disorders are described briefly in the individual sections . T he disorders are dis cus sed together, most of the major nos ological is sues bear on the group disorders and their relations hip to other DS M-IV -T R 1827 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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disorders . T he early DS M definitions and IC D-10 have been reviewed in the introduction. S cales and meas ures for the ass ess ment of diss ociation and diss ociative dis orders are also dis cuss ed.

His tory T he DS M-III criteria for dis sociative disorders were es tablis hed by expert consens us. B y the time the was publis hed, there was a body of s ys tematic the diss ociative dis orders . Little changed in the criteria for depersonalization disorder, psychogenic amnes ia, and ps ychogenic fugue. However, the criteria multiple pers onality disorder changed considerably to make them more flexible, less reified, and more compatible with research findings about the phenomenology of alter identities. In the DS M-IV revis ion, the names of most of the were changed; for example, ps ychoge nic amne s ia and ps ychoge nic fugue became, respectively, dis s ociative amne s ia and dis s ociative fugue , and multiple dis order became dis s ociative ide ntity dis order. T he for diss ociative amnes ia now specified that the us ually occurred for traumatic or s tres sful Dis sociative fugue now could be diagnos ed even if were no ass umption of another identity. Amnes ia was added back as a criterion s ymptom for dis sociative disorder. T he disorders were s tructured to reflect pathologies of memory, identity, and perception, res pectively.

Dis s oc iation and Trauma T he current diagnos tic categories for diss ociative 1828 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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developed from nosological s ys tems based on the concept, not on modern res earch showing a robust relations hip between diss ociation and trauma. F urthermore, the complexity and overlapping nature of the phenomenology of diss ociative amnes ia, fugue, and dis sociative identity dis order were not appreciated. In particular, the complexity of the phenomenology of diss ociative identity disorder was unders tood with its multifaceted amnesias, fugues, and depers onalization and derealization s ymptoms. In addition, the DS M-IV work group for P T S D unsuccess fully proposed adding to DS M-IV the of dis orders of extreme s tres s NOS . T his cons truct was developed to des cribe a group of multiply traumatized individuals with problems of affect regulation, somatization, and relations hip, identity, and safety problems . Despite its lack of inclus ion in the DS M-IV , res earchers have begun to systematically s tudy this complex form of P T S D to help differentiate patients single acute traumas from thos e with multiple types of trauma and life advers ity. F or example, recent s tudies shown that the complex P T S D paradigm more conceptualizes traumatized borderline patients than the borderline pers onality disorder cons truct. Mos t patients with dis sociative identity dis order, diss ociative disorder NOS , and dis sociative amnesia fit readily into the of extreme s tres s NOS or complex P T S D paradigms, both. Many trauma res earchers cons ider these to be s lightly diss imilar ways of conceptualizing the spectrum of patients . R ecent neurobiological s tudies of diss ociative identity disorder patients show similarities neurobiological variables to P T S D patients without 1829 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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diss ociation. Accordingly, some members of the DS M-IV work for P T S D and the diss ociative dis orders propos ed that DS M-IV create a s ection of posttraumatic P.1854 or s tres s-related dis orders (trauma s pectrum disorders) that would include P T S D, acute stress disorder, the diss ociative dis orders, and, pos sibly, other disorders , as conversion disorder, somatization dis order, and borderline pers onality disorder. A trauma spectrum dis orders category would help logically integrate multiple lines of res earch s howing different ps ychopathological outcomes to trauma and would help better organize future res earch efforts . F urthermore, such a category would help with confusion; for example, amnesia is a criterion symptom the avoidance clus ter of DS M-IV P T S D and for disorder, not just for diss ociative amnes ia and identity dis order. F inally, s uch a class ification would be more helpful for the clinician confronted with typical patients with mixtures of pos ttraumatic, diss ociative, somatoform s ymptoms who now frequently wind up in NOS categories. It would be more logical to combine the DS M-IV -T R diss ociative disorders and P T S D work groups as of a s ingle trauma and s tres s disorders work group for fifth edition of the DS M (DS M-V ). T his group could nosological categories that better define the broad spectrum of posttraumatic conditions, from acute to chronic, from simple to complex, and from thos e with 1830 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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marked diss ociation to those with minimal diss ociation. Many of thes e s uggested changes would involve res tructuring of several DS M diagnos tic categories. might involve negotiations among s everal different groups of clinicians and researchers who otherwis e relatively s eparately from one another. However, the strongly sugges t that, at the least, a unifying trauma spectrum dis orders s ection, including P T S D and the diss ociative dis orders, would be the mos t logical clas sification of apparently disparate dis orders related trauma.

R evis ions to Dis s oc iative Dis order C ategories E ven if this radical pers pective is not adopted, major critiques have been launched at the current disorders class ification. In general, thes e involve the relatively greater complexity and pleomorphism of diss ociative, P T S D, and somatoform s ymptoms in diss ociative patients . F or example, patients with diss ociative amnesia, diss ociative fugue, and identity dis order may exhibit or describe a number of significant s ymptoms that are not included in the diagnostic criteria. Dis sociative identity dis order patients commonly of s pontaneous autohypnotic phenomena, depers onalization, derealization, P T S D s ymptoms, somatoform s ymptoms , and ps eudops ychotic in addition to complex amnes ias and s witching to alter self-states . In clinical evaluation of diss ociative identity disorder, thes e as sociated symptoms are frequently 1831 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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es sential in arriving at a correct diagnosis. Many patients with diss ociative amnesia or dis sociative fugue describe depers onalization, derealization, alterations of consciousness , s omatoform and symptoms, and autohypnotic s ymptoms along with the DS M-IV -T R criterion symptoms . Accordingly, many of patients may be placed in the dis sociative disorder category, becaus e they have a number of diss ociative symptoms that go beyond the current diagnostic for diss ociative amnes ia and diss ociative fugue, some of thes e are described in the text as as sociated features. T his creates the awkward s ituation in which clinician mus t wres tle with the problem that a large number of typical patients potentially will be class ified NOS . Many patients with acute dis sociative amnesia and diss ociative fugue may actually be in an epis ode of diss ociative identity disorder amnesia. Modern clinical as sess ment of such patients frequently finds a much chronic history of multiple types of diss ociative including partial or full alter identities or personality Accordingly, several critics have s uggested developing new diagnostic criteria bas ed on the data s ets already acquired using the S C ID-D-R , the DDIS , the MID, the and s imilar ins truments , along with data sets from case series . S ome have proposed radical restructuring the diss ociative dis orders category to reflect the phenomenological data. Others have proposed more a cons ervative position maintaining the current structure but moving to a polythetic clas sification with additional s ymptom categories as part of the 1832 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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diagnostic criteria for mos t dis orders.

E pidemiology T here is only one systematic general population study the prevalence of diss ociative dis orders. R oss and colleagues studied a random s ample of 1,055 adults in Winnipeg, C anada. T hey were given the DE S , and a representative subsample of 502 res pondents was subs equently reevaluated with the DDIS . T able 17-2 the findings for the various diss ociative dis orders.

Table 17-2 Prevalenc e of Dis s oc iative Dis orders in the General Population of Winnipeg, C anada (N = 502) Diagnos is

S ubjects (%)

Dis sociative amnes ia

6.0

Dis sociative fugue

0

Dis sociative identity dis order

1.3

Depersonalization dis order

2.8

Dis sociative disorder not otherwis e

0.2

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specified All dis sociative disorders

12.2

F rom R os s C A. Dis s ociative Ide ntity Dis orde r: Diagnos is , C linical T re atme nt of Multiple P e rs onality. Y ork: J ohn W iley & S ons ; 1997:109, permis sion. T his s tudy has significant limitations and needs to be replicated. T hese include the lack of validating clinical interviews , the unknown validity of the DDIS in samples , the relatively s mall s ample size from only one city, and the lack of other diagnos tic ins truments given the participants . T he DE S findings, however, have been replicated in studies. T hese include the finding that dis sociation is found in a left-skewed distribution, indicating that most individuals in the general population experience few diss ociative s ymptoms . A s mall s ubs et of the to 5 percent, endorses many forms of pathological diss ociative experience. A taxonometric reanalysis of data of R oss and colleagues found that 3.3 percent of population s howed pathological dis s ociation and could completely dis criminated from nondiss ociative controls and normal s ubjects.

E tiologic al Theories 1834 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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T his s ection discuss es etiological theories about diss ociation and diss ociative dis orders. A etiological model involves integration of data from of thes e models and theories .

Taxon Model of Pathologic al Dis s oc iation R ecent interest in the taxon model res urrects a debate about whether dis sociation occurs along a continuum proceeding from normal to pathological or whether pathological diss ociation, such as diss ociative identity dis order, represents a different type (a taxon) ps ychological organization. J anet favored the latter, believing that cons titutional factors , sugges tibility, and powerful emotional events contributed to creation of a group of individuals who were fundamentally different from normal individuals . J ames and P rince argued for a continuum model, ranging from s o-called normal diss ociative P.1855 phenomena, s uch as abs orption, to pathology, s uch as amnes ias, fugues, and multiple personalities. T he continuum theory carried the day, although s ome hypnosis res earchers continued to caution about discontinuities between normal consciousness and deep trance phenomena. As data with dis sociation measures accrued acros s and normal populations, it became apparent that there exis ted a distinct group of high-scoring individuals. Different diagnos tic groups contained different percentages of these high s corers, yielding different 1835 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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diagnostic group mean s cores. T he greater the of high scorers, the greater the elevation of the group's mean score relative to the group's modal score. On the DE S , for example, high s corers cluster around a mean of 45, with the rest of the s ample clustering around 8. T hese obs ervations led to a statis tical study directly inves tigating the poss ibility that there exists a type of individual who differs s ignificantly on meas ures from other individuals , irrespective of their ps ychiatric status . Using newly developed taxonometric approaches, researchers examined item-res ponse data manifestations of a latent clas s variable. T hey identified eight DE S items, compos ing the DE S -T s ubs cale, that robustly differentiate dis sociative disorder patients from other psychiatric patients and normal controls , who never endorsed these items. T hese items are listed in 17-3.

Table 17-3 Dis s oc iative S c ale Items That Make Up the Dis s oc iative E xperienc es S c ale Taxon S c ore S ubjects are asked to rate the percentage of from 0 to 100 percent, that they have the experience. 3. S ome people have the experience of finding 1836 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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thems elves in a place and having no idea how got there. 5. S ome people have the experience of finding things among their belongings that they do not remember buying. 7. S ome people sometimes have the experience feeling as though they are s tanding next to thems elves or watching thems elves do and they actually s ee themselves as if they were looking at another pers on. 8. S ome people are told that they s ometimes do recognize friends or family members. 12. S ome people have the experience of feeling other people, objects , and the world around them are not real. 13. S ome people have the experience of feeling their body does not s eem to belong to them. 22. S ome people s ometimes find that, in one situation, they may act so differently compared to another situation that they feel almos t as if they were two different people. 27. S ome people s ometimes find that they hear voices inside their head that tell them to do things 1837 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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comment on things that they are doing.

F rom W aller NG , P utnam F W , C arlson E B : T ypes diss ociation and diss ociative types : A analysis of diss ociative experiences. P s ychol 1996;1:300–321, with permis sion. S tudies have subsequently affirmed that a taxonic approach is a clinically us eful way to cull out a dis tinct subgroup of diss ociative patients within any given diagnosis who differ on s ymptoms and features from res t of the group. In ps ychophysiological investigations diss ociation, s imply dividing samples into high and low scorers has proven fruitful in identifying distinctly phys iological and cognitive res ponses to stimuli that as traumatic reminders. T he taxon model implies a significantly different developmental s cenario than the continuum model, as well as a different approach to treatment. T he differences between high diss ociators and virtually everyone else would have to lie in a s trong genetic predis pos ition or a fundamentally different early developmental trajectory, or both, that es sentially wires their brains differently. A convincing genetic difference remains to be demons trated, but res earch linking diss ociation with type D attachment dis turbances offers potential mechanis m for the latter. In a continuum model of dis sociation, a pos itive 1838 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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res ponse would be conceptualized as moving a diss ociative individual more toward the normal diss ociation s egment of the continuum. B y contrast, a positive treatment outcome in a taxon model implies changing an individual's type from the diss ociative to nondis sociative category. T he clinical lore on fus ion or integration of dis sociative identity dis order alter personalities into a unified personality hints at this poss ibility. However, beyond thes e clinical accounts, empirical data exis t to confirm that integration produces taxonic clinical change. T he few studies of diss ociative identity dis order that include pretreatment and posttreatment dis sociation measures show moderate significant) decreas es in scale scores rather than a significant taxonic s hift from the diss ociative to nondis sociative categories. T he taxonic model has valuable in spurring res earchers to compare high and diss ociators on a variety of measures, but its clinical us efulnes s as a index of treatment s ucces s remains to demonstrated.

Dis s oc iation As a R es pons e to S ince the 1980s, research has elucidated multiple lines evidence linking dis sociative disorders with antecedent trauma. In aggregate, these s eparate lines of evidence cons titute a strong cas e for significant trauma as a neces sary antecedent to the development of diss ociation. T he most bas ic set of thes e lines of evidence involves quantification of J anet's early clinical observations. F or each of the DS M-IV -T R diss ociative dis orders, there exis t multiple independent case series , including non1839 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Wes tern samples , documenting unusually high rates of trauma in diss ociative dis order patients (although this linkage is notably weaker for depers onalization Although critics often point out that thes e s tudies are retrospective, and, thus, the accuracy of the reports of trauma cannot be es tablis hed, s everal cas e s eries which the majority of subjects had one or more verified. S everal hundred peer-reviewed s tudies have found significantly higher levels of dis sociation, as meas ured well-validated instruments, such as the DE S , in groups compared to nontraumatized clinical and population s amples . T he frequency of this finding for many different forms of traumatic experience (e.g., combat, rape, natural dis asters, child abus e, and C ambodian holocaust, among others) and across cultures indicates the universality of the ass ociation between trauma and diss ociation. Measures of trauma severity, for example, combat intensity or rape s everity scales, are approximately equally correlated with P T S D diss ociation meas ures (r ≈ .025 to .40), indicating a to moderate dose effect–like relationship. T he lack of a stronger correlational relationship between trauma and P T S D and diss ociation may reflect the difficulties in quantifying the s ubjective elements of traumatic experience. Although thes e findings significantly link diss ociation with antecedent trauma, they are not sufficient to demons trate that the trauma actually the diss ociation. More s ophisticated statis tical approaches are new lines of evidence indicating that increased diss ociation is instrumental in shaping outcomes 1840 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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traumatic experience and ps ychophys iological to future stress and trauma. P eritraumatic diss ociation, meas ured proximal to the trauma in some s tudies and retrospectively in others , has been found to predict the subs equent development of P T S D. T his predictive important for identifying individuals at risk for P T S D after an P.1856 acute trauma. A smaller number of studies has demonstrated that dis sociation qualifies as a mediator the relationship between antecedent trauma and subs equent psychopathology, including P T S D. T his that, if the level of diss ociation is statis tically controlled, the s trength of the relationship between trauma and ps ychopathology is s ignificantly decreased or High levels of diss ociation also alter the ps ychophys iological res ponses of traumatized to traumatic reminders . Not every s tudy meas uring peritraumatic dis sociation that it predicts subsequent P T S D, nor have there, as been a sufficient number of replications for the phys iological and statis tical mediation s tudies to be unques tionably accepted. T hes e findings do sugges t, however, that trauma-as sociated dis sociation may an important mechanism mediating the transformation traumatic experiences into subsequent T he remarkable studies of C harles A. Morgan and colleagues conducted on military special operations under extremely s tres sful conditions are as clos e as can ethically come to an experimental model of induced dis sociation. Working with units undergoing 1841 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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forms of s imulated combat, such as s urvival s chool, Morgan examined the neurobiological and effects of intens e s tres s uniformly applied to drug-free, healthy, nonclinical s ubjects . S tress ors included semistarvation, exhaustion, sleep deprivation, lack of over hygiene and bodily functions , and control over movement, s ocial contact, and communication. T he neuroendocrine stress effects meas ured in thes e was equal to or exceeded thos e reported for individuals subjected to life-threatening experiences. T here were significant differences between pretes t and posttest on the C ADS S overall and for virtually all s cale items, the greates t effects for depers onalization items , s uch looking at the world through a fog, feeling time slow down, and s pacing out. Life threat from a prior trauma significantly correlated with prestress and posts tres s diss ociative s ymptoms . Dis sociation scores also for 41 percent of the variance in health complaints after the stress experience. Morgan's s ys tematic studies are congruent with observational reports of the high frequency of es pecially depers onalization s ymptoms, in normal individuals expos ed to life-threatening stress . T he of increas ed acute levels of diss ociation during stress indicates that other factors, perhaps the of prior life-threatening trauma, are operative in the peritraumatic dis sociation–P T S D linkage dis cuss ed previous ly. T he highest dis sociation scores were with intens e s ubjective appraisal of life threat from past trauma. One highly traumatized subgroup, S pecial soldiers , had low life-threat appraisals of their pas t and, cons equently, the lowes t prestress and pos ts tress 1842 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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change in diss ociation s cores. T his s tres s -hardy group unders cores the importance of ps ychological to prior trauma on responses to current stress ors. T he significant relations hip (r = .67) between the pres tres s posts tres s change in diss ociation s core and somatic symptoms is congruent with many clinical studies reporting linkages between somatization and In summary, a number of independent lines of point to a caus al relationship between trauma and diss ociation. T his relationship is apparent for many of trauma and has been found across all cultures in it has been investigated. S ignificant levels of in the immediate aftermath of a trauma appear to predis pos e an individual to developing P T S D and ps ychopathology, although additional factors related to ps ychological apprais al of prior trauma also appear to involved. Dis sociation appears to serve as a major mediating proces s between traumatic experiences and subs equent psychopathology and thus is an important target for prevention and early intervention efforts . res is tant individuals can be characterized, in part, by lack of dis sociative res ponses to significant s tres sors.

Dis c rete B ehavioral S tates Model T he discrete behavioral states (DB S ) model pos tulates diss ociative dis orders belong to a group of ps ychiatric conditions characterized by rapid—often triggered—discrete shifts in s tate of cons cious nes s. E xamples include rapid-cycling bipolar disorder, panic disorder, periodic catatonia, and P T S D. Although these disorders differ in many respects, a central feature of pathology is abrupt s witches between two or more 1843 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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states of consciousness , at least one of which is pathological in some fashion. P anic attacks and the abreactions and flas hbacks of P T S D are examples of dysfunctional behavioral s tates, often triggered by stimuli or interactions , that rapidly reorganize an individual's emotions, thinking, and behavior. B ipolar patients often cycle through a s pectrum of dis tinct affective s tates extending from deep depress ion to ps ychotic mania. T he concept of a s tate of consciousness —as a dis tinct of behavioral organization—has been part of the ps ychological vocabulary for s everal centuries. R ibot's speculations that s tate-dependent learning and explained the phenomena seen in diss ociative identity disorder arose in the context of widespread interes t clinical experimentation with hypnos is, s omnambulism, and trance-like states . In his 1896 Lowel lectures on exceptional mental s tates, J ames often referred to states of consciousness as underlying multiple fugues , convers ion symptoms , and other hysterical symptoms. Modern s tate theory owes much to ps ychologist C harles T art, who advocated for a science discrete states of cons cious nes s. Hilgard's theory, which he traces in part to J anet, conceptualizes hypnosis as a set of altered s tates of consciousness characterized by increased s uggestibility, enhanced imagery, decreas ed planning capacity, and a reduction reality testing. R esearch with drug-induced altered and meditation has also contributed to current theory unders tanding. It remained, however, for a group of child ps ychologists and ps ychiatris ts to formally operationalize the s tudy of 1844 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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DB S of consciousness . Heinz P rechtl, R obert E mde, Harmon, and P eter W olff empirically validated a multidimens ional class ification system us ed in the normal infants . B y us ing as few as four or five variables , s uch as heart rate, res piratory rate, extremity muscle tone, skin perfusion, vocalization, or facial expres sion, researchers were able to delineate a bas ic of DB S shared by mos t full-term, newborn infants . As child matures , additional behavioral s tates are added, the pathways of connections among the dis tinct s tates grow more complex—corres ponding to an increased behavioral repertoire on the part of the child. T he ability self-modulate the express ion of thes e DB S and to the many additional states created with growth and development is regarded as fundamental to healthy emotional regulation. T he DB S model conceptualizes dis sociative the manifes tations of alternations among dis tinct s tates cons ciousnes s that differ in terms of the individual's of identity, access to explicit, implicit, and autobiographical memory, and psychophysiological reactivity. Identity dis turbances are the nucleus around which other features of the diss ociative state organize much the same fashion as dis tinct affects serve to the DB S of a bipolar patient. Dis sociative disturbances memory are viewed as extreme examples of statedependent learning, s torage, and retrieval. Alterations ps ychophys iological s ens itivity in diss ociative disorders reflect state-dependent changes in autonomic nervous system and neuroendocrine function. C hanges of equal magnitude have been measured in laboratory studies panic attacks and P T S D flas hbacks. 1845 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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P.1857 T he DB S model of dis sociation pos tulates that early childhood trauma or dis turbances in attachment, or disrupt the proces ses ess ential to self-modulation and developmental integration of new behavioral states. T he DB S model pos tulates three levels of psychopathology inherent in such s tate disorders . T he firs t is intrinsic to nature of the pathological s tates per se, for example, anxiety, depress ion, mania, catatonia, or T he second level res ults from the individual's inability to self-modulate the express ion of thes e dys functional or to better integrate them into their lives. T he third level res ults from the cons equences of maladaptive attempts block the often painful experiences of these pathological states , for example, attempts to self-medicate social withdrawal to avoid triggering flashbacks . T he increased ps ychiatric comorbidity commonly noted in these patients is a consequence of the s econd and third levels of ps ychopathology. T he DB S model predicts that effective treatment s hould facilitate better selfof intense or dys phoric states and should addres s the dependency of dysfunctional perceptions , cognitions, as sumptions .

Developmental Model of Dis s oc iation Modern interes t in a developmental model of disorders , es pecially diss ociative identity disorder, can traced to pioneers with child cases, such as C ornelia and R ichard K luft. S ubsequently, long-forgotten case reports were discovered in which 19th century clinicians us ed Latin phrases to hint at inces t and uns peakable 1846 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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familial trauma. S mall cas e s eries and reviews of diss ociative dis orders appeared in the mid- to late with more s ys tematic s tudies coming in the last with the adult cas e s eries, his tories of severe trauma commonly noted. T he core phenomenology of child cases is, for the most part, s imilar to adult cases with the corresponding diss ociative dis order diagnos is . As is the cas e for most childhood manifestations of lifelong ps ychiatric the day-to-day manifes tation of core s ymptoms varies the child's age. In general, older children and are more overtly s ymptomatic than younger children. In part, this may reflect the ability of older children to report s ubjective distres s, as well as their greater opportunity to manifes t ps ychopathology in a variety of settings . In a pooled s ample of 177 child and adoles cent diss ociative disorder cas es, amnes ias , identity disturbances , and auditory hallucinations increased age, whereas trance-like and spacey behavior was ubiquitous acros s all age groups. R elated ps ychopathology, s uch as s uicidal ideation, s elfand s omatization, increas ed with age in parallel with diss ociative s ymptoms . B oys and girls did not differ on diss ociative s ymptoms , but girls were s ignificantly more symptomatic for anxiety and phobic symptoms , P T S D, sleep dis turbances , sexual acting out, and T hese findings clos ely parallel the gender differences adult clinical profiles . C hildren and adolescents with dis sociative identity dis order were the mos t symptomatic acros s all age groups, which is cons onant with the clinical belief that diss ociative identity disorder 1847 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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the most severe of the diss ociative disorders . V alidated child and adolescent dis sociation meas ures been adminis tered to a variety of clinical and samples . S cores were s ignificantly higher for (typically child abus e) vers us nontraumatized s ubjects acros s all age groups. Higher levels of dis sociation also significantly as sociated with more general ps ychopathology. Among maltreated preschoolers , were robus t correlations with externalizing and internalizing behavior problems for boys and girls . A comparis on of these maltreated preschoolers with demographically and family cons tellation-matched, nontraumatized preschoolers found that the group had s ignificantly increased levels of diss ociation year later, with the phys ically abus ed children for the greatest increas e in s cores. T he controls subs tantial decreas es in their dis sociation s cores over same period, in line with the often reported decrease in diss ociation s cores with age in normal children. S tudies have explored the pos sible mediating role of diss ociation in the development of ps ychopathology in sexually abus ed children and adolescents . Meas uring ps ychopathology with a variety of s tandard measures, main effect of sexual abus e on behavioral problems disappeared when levels of diss ociation were for, as measured by a self-report meas ure (A-DE S ) or observer report (C DC ). T he poss ibility that dis sociation critical mediating variable for s ubs equent ps ychopathology has s ignificant implications for early intervention with maltreated and traumatized children. Ass es sment of diss ociation s hould be a standard part the evaluation of traumatized children and adolescents , 1848 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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and s ignificant elevations s hould be addres sed as part the treatment plan.

S E A R C H F OR DE VE L OP ME NTA L P R E C UR S OR S A ND S UB S TR A TE S DIS S OC IA TION Imaginary C ompanions hip T he focus on child dis sociative identity dis order led inves tigators to initially focus on childhood fantasy phenomena, s uch as imaginary companions hip, as poss ible developmental precursors for dis sociative disorders . Imaginary companions are reported in 20 to percent of normal children, depending on the age of child and the definition us ed. Normal imaginary companions hip is widely regarded as benign and is commonly cons idered to be a sign of creativity in children, but it becomes increasingly s uspect in older children and adoles cents and is thought to be always pathological in adults . In dis sociative children, the rates imaginary companions hip range from 42 to 84 percent, with the highes t rates reported for children diagnos ed with dis sociative identity dis order. S tudies comparing normal children's imaginary companions with thos e of maltreated boys s how differences. T he maltreated boys averaged 6.4 entities compared to 2.5 entities for the normal boys . T he latter first appeared between 2 and 4 years of age and had disappeared by 8 years of age. T he imaginary reported by the boys in residential treatment, however, served other functions, including (1) helpers and comforters , (2) powerful protectors , and (3) family 1849 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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members. In s ome cases, the boys reported feeling as they had los t control, and their imaginary companions took over their behavior. T he maltreated boys reported that their imaginary companions were s till present at a mean age of 10.6 years , well after they had the normal boys. T he imaginary companions of the maltreated boys often had names s uch as G od, the and guardian ange l. A number of authorities theorize some of the imaginary companions found in maltreated children eventually evolve into the alter personality that personify diss ociative identity disorder. As yet, no has documented this transformation, but diss ociative identity disorder patients sometimes report that this happened with them.

Type D Attac hment T ype D attachment is characterized by the child disorganized and conflicting movement patterns when primary caregiver returns to the room after a period of enforced s eparation during the s trange s ituation, a standardized procedure for as ses sing attachment in preverbal children. T he child may exhibit contradictions intention, lack of orientation to the environment, and sudden immobility as sociated with a dazed expres sion trance-like state, termed s tilling in the attachment literature. T ype D attachment disturbances are maltreated infants and toddlers and are thought to when the child periodically experiences the primary caretaker as frightening. S tudies s how that the best predictor of type D attachment is a high DE S s core in P.1858

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mother. It is hypothes ized that an infant with multiple incompatible models of s elf and other res ulting from intermittent frightening experiences with the caretaker would rapidly s witch back and forth between models when confronted with a s tres sful interaction involving the primary caretaker, such as the s trange situation. In a prospective longitudinal s tudy, 168 high-ris k were followed over a 19-year period, examining trauma, sense of self, quality of early mother–child relations hip, temperament, intelligence, and meas ured at four time points were related to diss ociative s ymptomatology with a clinical measure (C DC ). Age of onset, chronicity, and s everity of trauma were highly correlated and were predictive of T wo forms of attachment dis orders, avoidant and type attachment, were strong predictors of subsequent diss ociation. A subsequent structural equation model analysis found that type D attachment acted as a mediating variable, accounting for 15 percent of the variance in dis sociation scores (DE S ) at 19 years of

Developmental Mediation of Ps yc hopathology by Dis s oc iation T he negative effects of high levels of dis sociation on development are pos tulated to operate through impacts on the development of s ens e of self, emotional impulse control, and impairments in information proces sing and coping with s tres sors. C hildren and s eek to integrate a complex, multidimens ional of self over the cours e of development. Dis sociative components, such as autobiographical amnesias, 1851 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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depers onalization, and pas sive influence experiences , interfere with the integration of self and the of a unified s ens e of self-agency. Dis sociative amnes ias also dis rupt the child's unders tanding of caus e-and-effect sequences , s o that negative or ris ky behaviors may not appear to be connected to their subs equent cons equences , which be experienced as coming from out of the blue. C onvers ely, cons equences may not be well related to behaviors that caus ed them, so that diss ociative have a great deal of difficulty learning from experience. T he impact of dis sociation on the metacognitive of self-monitoring one's behavior is thought to disrupt integration of experience across contexts , further complicating the child's ability to learn and to practice control, particularly in the context of s tres sors . diss ociation is well correlated with increas ed impulsivity, and poorer social s kills in a number of child and adolescent s tudies . P ros pectively comparing s exually abus ed girls with carefully matched controls, s tudies have found that diss ociation is negatively as sociated with competent learning and overall class room performance and is strongly predictive of school avoidance. T he of cognitive dysfunctions and negative school puts the diss ociative child at an academic which has profound implications for adult attainment. C hronic depersonalization, clos ely as sociated with emotional numbing in P T S D patients , is thought to promote a s ense of detachment from self that fosters and s elf-destructive behavior, s uch as self-mutilation. mutilation has been strongly ass ociated with increas ed 1852 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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diss ociation in numerous studies. Diss ociative patients often describe s elf-inflicting pain in attempts to break through profound states of depersonalization. At other times , they report feeling nothing as they cut or burn thems elves . Alienation from self is also thought to play role in the high rate of suicide attempts in diss ociative patients. In addition, dis sociation has been implicated predis pos ing an individual to revictimization. In these experiences expose dis sociative individuals to further traumatization, which takes a cumulative toll the individual's life. Identification of environmental protective factors may help s timulate intervention models that prevent the development of s ignificant diss ociation in acutely traumatized children.

Hypnotic Model In its bas ic form, the hypnotic model hypotheses that a traumatized individual uses his or her innate hypnotic capacity to induce autohypnos is as a defens e against overwhelming or repetitive traumatic experiences. W ith continued us e, the autohypnotic s tate is transformed an independent alter personality s tate. S everal lines of evidence are said to support the autohypnotic T he firs t is that diss ociative, es pecially dis sociative disorder, patients are highly hypnotizable. S econd, of the clinical phenomena as sociated with pathological diss ociation, s uch as trance states , age regres sion, hallucinations , and amnes ias , can be produced in individuals us ing hypnos is . F inally, a pair of studies suggested that childhood trauma might increas e hypnotizability. 1853 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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More s ys tematic research has dis pelled the notion that childhood trauma generally increas es hypnotizability. least six s tudies found no differences between and nontraumatized adult or child s amples , nor are discernible dos e effects between meas ures of trauma severity and hypnotizability in clinical and general population s amples . However, a small group of termed double dis s ociators , s core high on meas ures of diss ociation and hypnotizability. T hes e individuals generally have histories of earlier and more severe T his obs ervation is most compatible with the taxonic model of pathological diss ociation and may explain the greater hypnotizability of diss ociative identity disorder patients. Hypnotizability studies have shown that there may be different types of hypnotizability, with high diss ociators making up a dis tinct type. T hey are in to other subgroups of highly hypnotizable people, like fantas y-prone pe rs onality, a specific construct in people elucidated in hypnotizability res earch s tudies . Autohypnos is is not the only pathway to dis sociative symptoms, but it remains a pos sible contributing mechanism in s ome individuals.

Neurologic al Models T wo bas ic neurological explanations of diss ociation been repeatedly propos ed over the las t century and a the epileptic model and the hemispheric laterality V ariants of thes e two models continue to be offered as explanations for dis sociation, although recent empirical tes ts have not provided substantial s upport for either. T he epileptic model originates from the clinical observation that diss ociative symptoms s uch as 1854 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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depers onalization; amnesias for complex behavior, fugue epis odes; and phenomena such as autos copy sometimes ass ociated with ictal and preictal s tates in seizure patients . S everal cases s eries of s eizure with dis sociative identity dis order–like or diss ociative disorder NOS –like clinical profiles have been and abnormal E E G s , particularly temporal s low waves , be more common in dis sociative disorder patients than ps ychiatric patients in general. Y et, the vast majority of seizure patients score in the normal range on scales. T he strongest finding to emerge from thes e thus far is that high levels of child abus e and as meas ured by high DE S s cores, are common in diagnosed with ps eudoseizures. More than 12 s tudies documented this relationship in well-diagnosed patient samples in which genuine seizure patients had low scores and low clinical levels of diss ociative symptoms . However, recent s tudies have identified abnormal E E G activity, particularly left-hemis phere s lowing, as significantly more common in abus ed children than in nonabused ps ychiatric inpatients or normal controls . there may be an effect of child abus e on the brain that accounts for the high rates of E E G seen in diss ociative identity disorder patients . T he hemis pheric laterality model was s timulated by clinical observations of differences in the dominant handednes s of alter personality P.1859 states . S uch handedness changes are s till frequently reported today. S everal modern s ingle-case studies 1855 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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document apparent s hifts in laterality us ing indirect meas ures , s uch as the G S R . One study of two identity dis order patients with seizures involved anesthetizing each cerebral hemis phere individually an intracarotid injection of amobarbital (the W ada tes t). T hey reported emergence of different alter personality states s eemingly related to inactivation of one or the cerebral hemispheres . E E G monitoring during thes e procedures revealed no epileptiform activity ass ociated with the alter personality s tates. T he largest s ample only controlled study to examine the laterality however, did not find evidence of shifts in laterality alter personality. S tudies of split-brain patients who had commis surotomies for intractable epilepsy do not find evidence of alter pers onality–like phenomena. In s hort, intriguing as the s hifts in dominant handednes s are, in laterality or differences in hemispheric laterality do readily account for many of the clinical features of diss ociative identity disorder patients .

Iatrogenic and S oc ioc ognitive of Dis s oc iative Dis orders S ome authorities believe that diss ociative identity and diss ociative amnes ia are not authentic ps ychiatric disorders but rather the product of sugges tion on susceptible individuals that leads them to believe that have a diss ociative dis order and to enact the role of a person with multiple selves or amnes ia for childhood maltreatment. T his has been called the iatroge nic or s ociocognitive mode l (S C M). C aution should be used concerning the term iatroge nic, however. T his term is rarely defined rigorous ly and frequently is us ed pejoratively. T he term is almos t never operationalized, 1856 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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its boundaries are unclear with res pect to other as pects of clinical encounters, s uch as s ide effects , complications , misdiagnos is, or acceptance by factitious or malingered pres entations, or a these. T he S C M pos its several interrelated factors that the phenomenon. T he firs t, a s us ceptible patient, is commonly described as being highly s ugges tible, hypnotizable, or having a fantas y-prone personality, or combination of thes e. In the clinical literature, thes e patients usually are described as having personality disorders characterized by dependent, borderline, or histrionic traits , or a combination of thes e, and who are conceptualized as des perate to find acceptance or a of identity, or both. T he second factor is a therapist who unwittingly, or through an ideological belief in the existence of diss ociative identity disorder or amnes ia for traumatic experiences , engages in a therapy that implicitly or explicitly encourages the patient to undertake the role the diss ociative identity disorder patient or the patient with so-called recovered memories for abus e. the condition is worsened by paying attention to the apparent diss ociative dis order and engaging therapeutically with the alter identities. T he patient develops a real, albeit iatrogenic dis order, now truly believing in the roles that he or she enacts. A third factor has to do with broader cultural and s ocial influence, often promulgated by the mas s media, selfbooks , or victim s upport groups in which people, in North America, come to accept the poss ibility of multiple identity enactments or a his tory of forgotten 1857 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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childhood victimization, or both, as part of an social role. In this view, therapy may not be a factor in the development of a diss ociative disorder; a susceptible person could do s o s imply through social influence. R ecent comprehens ive reviews of the S C M for disorders have made s everal points. V irtually no scientific studies have been performed in clinical populations to attempt to examine the S C M or related ideas . T he original database supporting this cons truct comes from a small, heterogeneous group of studies in the 1940s and 1950s, mos tly uncontrolled, quas iexperimental, anecdotal case reports. T hes e that s ome degree of role enactment of an alternative identity occurred with hypnos is , automatic writing, and strong repeated sugges tions . S ome of the subjects the students of the researchers and were of the goals of the studies. T he role enactments were limited to the experimental situation. In fact, one of the res earchers, s tudying a traumatized soldier, concluded that hypnosis allowed access to authentic, previous ly diss ociated self-as pects , not to artifacts of the S tudies of thousands of s ubjects undergoing hypnosis res earch over s everal decades have shown that a of highly hypnotizable individuals can exhibit limited, temporary alter self-states with hypnotic sugges tions. T hese were diss imilar phenomenologically to clinical of dis sociative identity dis order and were limited to the experimental situation. T he res earchers noted that they could not determine whether these procedures previous ly existing dis sociated aspects of the mind or created them de novo. 1858 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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A s mall s eries of s tudies on college student volunteers variety of hypnotized and nonhypnotized conditions found that highly hypnotizable, fantasy-prone s tudents would enact the role of a diss ociative identity dis order murderer with amnes ia when given a series of robus tly explicit s uggestions to do s o. Hypnosis was not a or s ufficient condition for this finding. T hese latter have been critiqued on a variety of grounds , including lack of controls (e.g., enacting another psychiatric such as a murderer with schizophrenia); lack of equivalence of the research design with the clinical situation; conflation of dis sociative identity dis order with role enactments, rather than the complex polys ymptomatic picture des cribed in the clinical and res earch literature; failure to produce alter behavior reactivity typical of dis sociative identity dis order; lack of control for strong expectancies and demand characteristics of the research des ign; role enactments limited to the experimental situation; and failure to for preexis ting diss ociated s elf-states and traumatic experiences . F inally, it is generally agreed among dis sociative authorities , beginning with J anet, that the shaping of fide diss ociative identity dis order us ually does occur in clinical s ituation, although this phenomenon itself has never been subject to s ys tematic res earch. In this the core s ymptoms of diss ociative identity disorder are created in the therapeutic encounter. A variety of developmental, s ocial, cultural, intrapsychic, and cognitive factors, which can include are hypothesized to account for the secondary structuralization of the dis sociative process into the 1859 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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individualized dis sociative identity disorder alter characteristic of a given person. Little res earch has been conducted on clinical disorders patients to as ses s factors such as fantasypersonality and other forms of s ugges tibility. A recent report s tudied 17 diss ociative identity disorder patients with the G udjonss on S uggestibility S cale (G S S ), an inventory developed to as ses s sus ceptibility to making false confes sions to crimes . It tests memory for an and liability to interpers onal press ure to change one's story about the event. In this study, diss ociative identity disorder patients scored lowe r in overall s uggestibility control groups with P T S D, borderline pers onality and trauma victims without P T S D. Dis sociative identity disorder s ubjects were more res is tant than the other clinical groups to interpersonal pers uas ion. In another study of patients with so-called recovered memories of childhood s exual abus e, thes e patients als o had lower scores when compared to nonabus ed control patients. F urthermore, ps ychological ass es sment of large of diss ociative identity disorder patients us ing the R ors chach tes t and other as sess ment instruments did show a pers onality profile typical of borderline or personality types. R ather, dis sociative identity dis order individuals show P.1860 a unique personality structure characterized by obses sional features, traumatic reactivity, complexity of res ponse, introversion, unus ual thinking at times , and 1860 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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insightfulness . It remains a researchable question whether fully autonomous clinical diss ociative identity disorder can produced in s usceptible individuals by s ociocognitive factors alone. T hese studies would be difficult to design from an ethical s tandpoint. However, to be definitive, would have to rigorously demonstrate a lack of diss ociative psychopathology or history of trauma, or similarity of the experimental to the clinical s ituation res pect to the interactions of res earchers and s ubjects; production of the extensive clinical phenomenology of diss ociative identity disorder reported in the literature, just role enactments ; automatization of the s ymptoms outside the experimental situation; us e of control populations enacting other ps ychiatric dis orders; for researcher bias ; and extensive longitudinal followE ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IV E AMNE

DIS S OC IATIVE AMNE S IA P art of "17 - Dis sociative Dis orders " According to DS M-IV -T R (T able 17-4), the es sential of dis sociative amnes ia is an inability to recall personal information, us ually of a traumatic or stress ful nature, that is too extensive to be explained by normal forgetfulness .

Table 17-4 DS M-IV-TR Diagnos tic 1861 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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C riteria for Dis s oc iative Amnes ia A. T he predominant dis turbance is one or more episodes of inability to recall important pers onal information, us ually of a traumatic or s tres sful nature, that is too extens ive to be explained by ordinary forgetfulness . B . T he disturbance does not occur exclusively the cours e of dis sociative identity dis order, diss ociative fugue, posttraumatic s tres s disorder, acute stress dis order, or s omatization disorder not due to the direct phys iological effects of a subs tance (e.g., a drug of abuse, a medication) neurological or other general medical condition (e.g., amnestic disorder due to head trauma). C . T he s ymptoms cause clinically s ignificant or impairment in s ocial, occupational, or other important areas of functioning.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T he disturbance does not occur exclus ively during the cours e of diss ociative identity disorder, dis sociative 1862 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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P T S D, acute stress disorder, or somatization dis order not due to the direct phys iological effects of a or a neurological or other general medical condition. Dis s ociative amne s ia can be more broadly defined as a revers ible memory impairment in which groups of memories for pers onal experience that would ordinarily available for recall to the cons cious mind cannot be retrieved or retained in a verbal form (or, if temporarily retrieved, cannot be wholly retained in consciousness ). T his dis turbance may be based on neurobiological changes in the brain caused by traumatic stress . the disorder manifes ts its elf as a potentially reversible of psychological inhibition. T he diagnosis of dis sociative amnesia generally four factors. F irst, relatively large groups of memories as sociated affects have become unavailable, not just memories , feelings , or thoughts . S econd, the memories us ually relate to day-to-day information that would ordinarily be a more or less routine part of cons cious awareness : who a person is , what he or s he where he or s he went, what happened, with whom he she s poke, what was said, what he or she thought and at the time, and s o forth. T hird, the ability to remember new factual information, general cognitive functioning, and language capacity are usually intact, although, in extreme cases, the dis sociative proces s can interfere retrieval of procedural memory information and registration of new memories. F inally, the diss ociated memories often indirectly reveal their pres ence in more less dis guised form, s uch as intrusive visual images, flashbacks , somatoform s ymptoms, nightmares , conversion s ymptoms , and behavioral reenactments . 1863 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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is , in most cas es , diss ociative amnes ia mus t be as a part of the spectrum of memory dysfunction traumatic stress , often alternating with forms of hyperamnesia or a derealized awarenes s in which the person experiences detachment or es trangement from elements of autobiographical memory, or both. T here are two bas ic pres entations of diss ociative T he first is a dramatic, sudden dis turbance in which extensive aspects of memory for personal information not available to conscious verbal recall. T hes e patients often s een in emergency departments or general or neurological services , because the sudden of memory loss requires medical as ses sment. In during an acute amnes tic epis ode, some of these individuals may demons trate dis orientation, perplexity, alterations in cons cious nes s, somatoform symptoms, purpos eless wandering, or a combination of these. A 45-year-old, divorced, left-handed, male bus was seen in ps ychiatric consultation on a medical unit. had been admitted with an epis ode of ches t discomfort, light headedness , and left-arm weaknes s. He had a of hypertension and had a medical admiss ion in the year for is chemic chest pain, although he had not a myocardial infarction. P s ychiatric consultation was called, as the patient complained of memory los s for previous 12 years, behaving and res ponding to the environment as if it were 12 years previous ly (e.g., he didn't recognize his 8-year-old s on, ins isted that he was unmarried, and denied recollection of current events , as the current president). P hys ical and laboratory were unchanged from the patient's usual baseline. 1864 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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computed tomography (C T ) s can was normal. On mental s tatus examination, the patient displayed intellectual function but insisted that the date was 12 earlier, denying recall of his entire subsequent personal history and of current events for the last 12 years . He denied awarenes s of his current addres s, life circums tances , job, recent political events, and so was perplexed by the contradiction between his and current circumstances. T he patient described a history of brutal beatings and phys ical discipline. He decorated combat veteran, although he described amnes tic episodes for some of his combat the military, he had been a champion golden glove noted for his powerful left hand. He was educated about his dis order and given the suggestion that his memory could return as he could tolerate it, perhaps overnight during s leep or perhaps a longer time. If this strategy was uns uccess ful, an amobarbital interview was proposed. On the s ubs equent examination, the patient reported his memory had returned. B efore the amnestic described an escalating s eries of conflicts at work, in marriage, and with his s on. His wife was discus sing a separation and had as ked him to discuss this with his He felt completely res ponsible for his coworkers and the care of his relatives . He had felt panicked, overwhelmed, and enraged. He had felt violently angry his wife but had vowed in the past that he would “beat death anybody who tried to hurt her.” He s tated that he would have attempted s uicide, but he “couldn't,” he had too many people relying on him. T he amnes ia developed after he felt a kind of “paralysis ” in his left 1865 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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His wife had rushed him to the hospital and had been extremely concerned about his well-being. P.1861 He was aware that none of these problems exis ted 12 years before and that he had unconsciously returned to less stress ful time by losing his memory. T he patient treated with s upportive psychotherapy in the hos pital, coordination of care was arranged with his cardiologis t. T he patient was referred for marital and individual ps ychotherapy and for ps ychopharmacological intervention. Des pite its relative rarity, this type of dis sociative is featured in the media and in mos t textbooks as representative of the condition. However, a far more prevalent form of dis sociative amnes ia is a deletion cons cious memory of significant aspects of the history. Ordinarily, patients do not complain of this, and is us ually only discovered in taking a careful life his tory. Dis sociative amnes ia typically has a clear-cut onset offset, so that the pers on is subjectively aware of a gap continuous memory. F or example, a patient may report that s he does not remember being in third grade, although having clear memory for other s chool years. Usually s uch s ymptoms are ass ociated with traumatic circums tances , for example, the patient reports that has been told that, during third grade, s he was by her es tranged father in a custody dis pute, held by for a number of months , and was sexually abus ed by during that time. In extreme cas es, the patient may recall for his or her entire childhood or other major life 1866 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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epochs. Dr. G . is a 33-year-old clinical ps ychologist who was admitted to the hospital becaus e of repeated acts of severe s elf-mutilation. S he reported chronic depress ed mood, anxiety, and interpers onal problems with to form intimate relations. S he had periods of bulimia anorexia requiring hospital treatment during her early and ongoing s truggles with eating. S he described a of OC D s ymptoms, including recurrent checking “to sure” that the doors were locked to her home, things to “prevent harm from befalling me,” and rituals of counting and s inging in her mind. Medications and intens ive outpatient ps ychotherapy had helped moderate s ome of her symptoms, but s he had become increasingly demoralized by her overall failure to in treatment. Mental s tatus revealed an oddly cheerful, cerebral woman who could not explain the profound impulses that s he felt to harm hers elf or to commit S he was articulate and s poke in intellectualized ps ychodynamic formulations . When asked about her childhood his tory, s he virtually no recall for her life between 5 and 13 years of age. Her siblings would joke with her about inability to recall family holidays , s chool events, and vacation trips. S he described her relationship with her family as “great,” reporting a warm, supportive with her parents. On further ques tioning, however, she revealed that her father had been an alcoholic her childhood, only achieving sobriety in her early adoles cence. S he had reported s everal epis odes of sexual” touching by him to her s eventh grade teacher, res ulting in a social s ervice inves tigation. Her father 1867 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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acknowledged thes e epis odes at the time and received treatment for alcoholism and “sex addiction.” He denied any other epis odes of s exual abus e toward his T he children were not removed from the home. Dr. G . denied any feelings about thes e episodes , s tating that took care of the problem. Now, he's a great support. I no reas on to be mad at him.” S he explained her by saying that “maybe nothing important happened and that's why I don't remember.” T reatment focused on establishing safety from selfC ognitive therapy focused on the patient's self-blame, of affect, minimization of s elf-harm, and a profoundly negative view of herself. T he patient was provided with education about her disorders and was taught management s kills . T he patient increasingly became of affects of s hame, anger, hurt, and betrayal related to having been abus ed. T hese s eemed to precede of self-harm. T he latter als o occurred after phone conversations with her parents . As therapy progress ed, patient began to s pontaneous ly remember other of abus e that her father had not acknowledged, s uch episodes of oral and vaginal s ex. As this occurred, she more intrus ive P T S D s ymptoms , including nightmares, flashbacks , and intrus ive images and bodily S he remembered that, as a child, s he would arrange obses sively in the belief that, by doing so, she could prevent her father's nocturnal visits. During the abus e, recalled that she sang and counted in her head to herself from the experience. S he also began to recall more s erious conflict and chaos in the family related to father's alcoholis m during the years for which she had been amnestic. Dr. G . reported intense dis tres s at the 1868 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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conflict between the attachment to her parents and and the implications of these emerging memories. S he became increas ingly aware of the extent to which she avoided thinking about the abus e, her response to it, its impact on her life. F ollowing J anet, s everal different patterns of amnes ia have been identified. T hese are lis ted in T able 5.

Table 17-5 Types of Dis s oc iative Amnes ia Localized amnesia    Inability to recall events related to a period of time S elective amnes ia    Ability to remember some, but not all, of the occurring during a circums cribed period of time G eneralized amnes ia    F ailure to recall one's entire life C ontinuous amnes ia

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   F ailure to recall succes sive events as they S ys tematized amnes ia    Amnesia for certain categories of memory, such all memories relating to one's family or to a particular pers on

E pidemiology As noted in the overview, dis s ociative amne s ia, as by DS M-IV -T R , has been reported in approximately 6 percent of a general population s ample in W innipeg C anada, studied with the DE S and the DDIS . T here is known difference in incidence between men and C as es generally begin to be reported in late and adulthood. Dis sociative amnesia may be es pecially difficult to ass ess in preadolescent children becaus e of their more limited ability to describe subjective experience. It may be confused with daydreaming, inattention, anxiety, oppos itional behavior, learning disorders , and ps ychotic dis turbances. Adoles cents are better able to verbalize the experience of amnesia. F or example, one teenager s aid, “I s kip time” to des cribe amnes ia experience. P atients may des cribe more than amnes ia episode. A variety of s tudies have looked at the prevalence of amnes ia for s pecific types of traumatic experiences: combat, s exual abuse, physical abuse, and emotional 1870 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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abuse. Other studies have reported amnesia along with other s ymptoms of P T S D in various traumatized P.1862 Across several s tudies , the prevalence of amnes ia combat reported among several thous and active duty soldiers in W orld War II ranged from 5 to 14.4 percent. a s mall percentage of these soldiers were reported to suffered s ignificant head injuries . In one study of 1,000 soldiers , 35 percent of the group expos ed to the most intens e combat had amnesia. P ast or family his tory of diss ociation or hysterical s ymptoms was ass ociated amnes ia in s oldiers with minimal battlefield expos ure. S tructured interview data using the S C ID-D-R have significantly higher amnesia scores in V ietnam era with P T S D compared to combat veteran controls P T S D. S tudies of Nazi Holocaust survivors , K orean veterans, and V ietnam era combat veterans with P T S D adult s urvivors of childhood sexual abus e have documented deficits in explicit memory on memory tests as compared to matched controls. F orty percent of a s ample of 50 randomly selected survivors of the C ambodian Holocaust endorsed on P T S D diagnostic inventories . T he average DE S this group of s everely traumatized individuals was 37.1. Amnes ia was reported in 3 to 10 percent of Holocaust survivors as sess ed with a P T S D inventory. T he highest prevalence was found in tattooed s urvivors of S tudies of natural dis asters, such as the S an F rancisco earthquake in 1989, have found that 3 to 5 percent of survivors report amnesia for at leas t s ome as pects of 1871 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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events. With res pect to delayed recall of sexual or physical or both, more than 70 studies have confirmed this in clinical, community, and forens ic populations, retrospective, prospective, and longitudinal s tudy In various s tudies of clinical populations and individuals who identified thems elves as survivors of abuse, 16 to almos t 100 percent reported amnesia for the abus e at some time in their lives, averaging approximately 30 percent acros s s tudies . Lower prevalence was found in outpatients. In studies of college undergraduates and women in the community, prevalence of amnes ia for abuse ranged from 13 to more than 50 percent. A random s ample of 505 men and women in the population found that approximately 21 percent a his tory of childhood s exual abus e. Of these, 20 described full amnesia, and 22 percent reported partial amnes ia for the abus e at some time in their lives . S omewhat lower rates of amnes ia for phys ical and emotional abuse have been reported in clinical and nonclinical samples : Approximately 20 percent of endors e this finding across studies. Longitudinal and pros pective s tudies , primarily up large s amples of individuals with documented prior childhood s exual trauma from court or medical reports , have found that almost 40 percent of res pondents recall a forens ically or medically documented episode childhood s exual abus e when interviewed 20 years or more later, even though, in some cases , other trauma or maltreatment were recalled. S ome denied any history of maltreatment at all. 1872 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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In a recent 10-year follow-up study of children of ages involved in criminal pros ecution against their abuse perpetrators, 19 percent of this highly s elected sample appeared unable or unwilling to describe the abuse at a later time. F actors thought to predispose to amnes ia for trauma are listed in T able 17-6. However, of thes e factors has been shown to exclusively those with amnesia for trauma from those without amnes ia.

Table 17-6 Fac tors L eading to Dis s oc iative Amnes ia after Traumatic E xperienc es T rauma caused by human as sault rather than disas ter R epeated traumatization as oppos ed to single traumatic events Longer duration of trauma F ear of death or significant harm during trauma T rauma caused by multiple perpetrators C los e relations hip between perpetrator and victim

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B etrayal by a caretaker as part of abus e T hreats of death or s ignificant harm by the victim dis closes his or her identity or regarding the traumatic experience V iolence of trauma (i.e., phys ical injury caus ed by trauma) E arlier age at onset of trauma

Note: No factor has exclusively been as sociated diss ociative amnesia. Adapted from Loewens tein R J . Diss ociative and diss ociative fugue. In: G abbard G O, ed. T re atme nt of P s ychiatric Dis orde rs , 3rd ed. V ol 2. Was hington, DC : American P s ychiatric P res s; 2001:1625.

E tiology S everal different theories have been developed to diss ociative amnesia. A unified theory combines these.

B ehavioral S tate and Information Proc es s ing Model In the behavioral state and information process ing diss ociation is conceptualized as a bas ic part of the 1874 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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ps ychobiology of the human res ponse to lifedanger: a protective activation of altered s tates of cons ciousnes s that change perception, pain sensation, time s ense, and sense of self. Memories and affects to the trauma are encoded during these altered s tates . When the person returns to the baseline s tate, there is relatively less access to the diss ociated information, leading, in many cases, to dis sociative amnesia for at some part of the traumatic events . However, the diss ociated memories and affects can manifes t in nonverbal forms: posttraumatic nightmares, reenactments , intrus ive imagery, and s omatoform symptoms. Not only is there amnes ia for the trauma, the person als o frequently has diss ociated that certain basic as sumptions about the self, relations hips, other people, and the nature of the world have been altered the trauma. T his model does not pos it that trauma is forgotten. F urthermore, the model does not necess itate that pain is the controlling variable in the onset of amnesia, although the latter may be a factor in inhibiting retrieval diss ociated information. R ather, it s uggests that trauma encoded and remembered but remains relatively inacces sible owing to difficulty in retrieving information acros s different DB S . S ome authorities have made the analogy between posttraumatic diss ociative amnesia experimentally produced hypnotic amnes ia. In both implicit memory for the material can usually be demonstrated. F ollowing J anet, some have that amnes ia occurs when there is a relative decrease executive control or synthesis among groups of ps ychic memory elements and the inhibition of control elements 1875 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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that can give access to information that is stored in memory. T he res ults of recent neuroimaging s tudies of s mall of trauma survivors s upport this model by indicating poss ible neurobiological s ubs trates of diss ociative amnes ia. F or example, P E T and fMR I studies of P T S D subjects have shown that stimulation of trauma recall script driven imagery is as sociated with activation of nondominant hemisphere areas, limbic areas, and the occipital lobe with relative suppres sion of left-brain language areas , s uch as B roca's area, and inhibition of prefrontal cortex. S ome researchers have focus ed on the finding of significant reduction of hippocampal volume in various traumatized populations as a marker for pathological proces ses involving memory in pos ttraumatic Als o, s tudies using ketamine, a noncompetitive of the NMDA receptor, res ult in increases in symptoms as measured by the C ADS S , including

Amnes ia and E xtreme Intraps yc hic C onflic t Acute, florid amnestic epis odes and the chronic covert amnes ias generally occur after severe, overwhelming, threatening traumas , s uch as combat, childhood sexual as sault, adult rape, threats of death or physical and P.1863 other s imilarly overwhelming events. However, in many cases of acute dis sociative amnes ia, the ps ychos ocial environment out of which the amnesia develops is not 1876 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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traumatic per se, but, rather, mas sively conflictual, with patient experiencing intolerable emotions of shame, despair, rage, and des peration. T hese are usually to result from conflicts over unacceptable urges or impulses, s uch as intense s exual, s uicidal, or violent compuls ions. T hus , these patients are conceptualized experiencing mass ive ps ychological conflict from which fight or flight s eems impos sible or ps ychologically unacceptable. However, mos t of the latter cas es have histories of severe trauma predating the episode of amnes ia. T he los s of memory in s ome of thes e has been conceptualized as an alternative to suicide. Indeed, premature therapeutic efforts to overcome amnes ia have been reported to res ult in success ful in some cas es .

B etrayal Trauma A related explanatory model is derived from social ps ychological principles and from developmental attachment theory. B etrayal trauma attempts to explain amnes ia by the intensity of trauma and by the extent a negative event represents a betrayal by a trus ted, needed other. T his betrayal is thought to influence the in which the event is proces sed and remembered. F or example, in this model, a child is more likely to develop amnes ia when subjected to abus e by a family member another pers on whom the child trusts or on whom the child is dependent. T he amnes ia is protective of the developmentally mediated need for attachment, for pres ervation of overall emotional and cognitive growth, despite the abus e. In this model, information about the abus e is not linked to mental mechanis ms 1877 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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control attachment and attachment behavior. Lack of s hareability of trauma experiences is also to contribute to amnesia for trauma. T hat is , in addition the neurobiological factors that inhibit verbal access to such events , they are less likely to be s hared with because of threats , s hame, lack of developmental have words for the experience, and intense confus ion emotional arousal engendered by the abuse. T hus, it is theorized that traumas involving betrayal are differently cognitively from other autobiographical experiences , leading to s ubjective memory deficits . B etrayal trauma theory als o helps to explain the lower prevalence of amnes ia for wartime trauma, natural disas ters , and the Nazi Holocaus t, among others, as compared to that for childhood s exual or physical V arious studies have supported the betrayal trauma model. In one s tudy of college undergraduates , abuse caretaker was a better predictor of memory impairment related to the abus e than age at the time of the abuse duration of the abuse. S troop tes t data have als o that high DE S s ubjects who report more trauma and betrayal trauma, compared to low DE S s ubjects , may actively inhibit threatening information, but not neutral information, from being acces sed cons cious ly. A unified information process ing and betrayal model predicts the relative likelihood of amnes ia under circums tances , s uch as high threat and low betrayal, threat and high betrayal, and s o forth.

Validity of Dis s oc iative Amnes ia S tudies that addres s the validity of dis sociative 1878 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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have primarily centered on the exis tence of the phenomenon, not on the study of the clinical disorder. noted previous ly, all of the studies that have attempted inves tigate the pres ence of amnes ia for trauma have reported that it occurs . Alternative hypotheses about trauma and memory that trauma virtually always caus es an indelible of memory in the brain and that diss ociative amnes ia is myth. T he debate about the exis tence of dis sociative amnes ia has also focused in part on hypothesized ps ychological mechanis ms for the reported amnes ia, as repress ion or dis sociation. C ritics have s uggested more mundane proces ses , s uch as failure to report, cognitive avoidance, or ordinary forgetting, might for the apparent delayed recall, although it is difficult to unders tand how thes e alternative mechanisms could account for the findings of amnesia during acute such as combat. Data from a variety of research studies s how that individuals who report problems with recall of trauma describe several s ubjective proces ses . S ome inability to recall some or all of traumatic life events or epochs in which the trauma occurred. Others report deliberate attempts to avoid thinking about the traumas because of the s ubjective dis tres s or s hame that they experience when they try to do so. Another group describes lack of ability to appreciate the abusive trauma until they were older or more emancipated from abusive social milieus , or both. In clinical practice, all of these mechanis ms may help account for as pects or apparent diss ociative amnesia in an individual patient. Many studies have found corroboration for the abuse 1879 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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trauma recalled by individuals with diss ociative T ypes of corroboration have included medical records , social s ervice records , church dioces an records, verbal written admiss ion by perpetrators, criminal convictions civil judgments against perpetrators, reports of family members, and information from witnes ses or other of the same perpetrator. Als o, s tudies have s hown no significant differences in the accuracy of delayed recall trauma compared to accounts of individuals who report continuous memory for trauma. Like continuous memories , delayed memories may be shown by corroboration to be generally accurate, accurate, or completely confabulated. R eliable corroboration, which may be very difficult to obtain, particularly in cas es of reported childhood or intimate-partner violence, is the only way to resolve extent to which a memory is generally accurate.

Diagnos is and C linic al F eatures As des cribed in prior sections, there are two major presentations of dis sociative amnes ia.

C las s ic Pres entation C las sically presenting patients are the textbook cas es form the image of dis sociative disorders for mos t health profess ionals . T he clas sic disorder is an overt, dramatic clinical dis turbance that frequently res ults in patient being brought quickly to medical attention specifically for s ymptoms related to the diss ociative disorder. T he paradigmatic case is that of the individual who is found without memory for identity or life history, sometimes leading to media reporting of the case. Less 1880 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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extreme forms of amnesia, s uch as acute amnesia for recent traumatic circumstances, s uch as combat or also fall into this category. T his pres entation of amnesia is frequently found in who have experienced extreme acute trauma. also commonly develops in the context of profound intraps ychic conflict or emotional s tres s. F or example, terrified s oldier in combat experiences excruciating conflict over his or her urge to flee and his or her belief that “all cowards s hould be shot.” T here are little systematic modern data about patients with this form of diss ociative amnesia. P atients may present with intercurrent somatoform or conversion symptoms, or both, alterations in cons cious nes s, depers onalization, derealization, trance s tates, spontaneous age regress ion, and even ongoing anterograde dis sociative amnesia. Depress ion and ideation are reported in many, but not all, cas es . No personality profile or antecedent history is consis tently reported in thes e patients , although a prior personal or family history of s omatoform or diss ociative s ymptoms been s hown to predis pos e individuals to develop acute amnes ia during traumatic circums tances . C as e reports suggest that many of these patients have his tories of adult or childhood abuse or trauma. However, in the wartime cas es , as in other forms of combat-related P.1864 posttraumatic disorders , the most important variable in the development of diss ociative symptoms appears to the intensity of combat. 1881 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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F actors relating to avoidance of res pons ibility may be prominent in s ome of thes e cas es, with s exual indis cretions, legal difficulties , financial problems , or of anticipated combat being part of the clinical matrix surrounds the amnesia. T here is a poss ible as sociation some cases with an antecedent history of head trauma with or without los s of cons cious nes s, although this finding has never been s tudied rigorous ly using controls. T here are no data on the prevalence of P T S D symptoms in these patients. If carefully ques tioned, some of these patients give a history of recurrent epis odes of amnes ia or fugue. actually meet criteria for diss ociative identity disorder diss ociative dis order NOS . In the diss ociative identity disorder cases, the amnesia occurs when the person creates a new alter s elf state that experiences its elf as unaware of s ome or all of the past history of the pers on cope with overwhelming or traumatic circums tances . In mos t of the acute dis sociative amnes ia cas es , the amnes ia res olves within hours to months , or through psychotherapy, hypnotherapy, pharmacologically facilitated interviews , or of thes e modalities . However, in rare cases , a chronic cours e develops , with the patient s eemingly unable to tolerate recall of the events that surrounded the onset the amnes ia. Ms. M. is a 55-year-old woman who was seen in cons ultation because of the s udden, complete loss of memory for her entire life history. F or the s everal years preceding this event, the patient had been s eeking “meaning” in her life subsequent to the las t of her 1882 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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leaving home. S he had been involved in a number of community activities in her home city but began to s eek inner understanding through ps ychotherapy. S he a reported history of neglect, emotional abus e, and phys ical abus e in her family of origin and a history of childhood s exual abus e involving several women her family. S he became friends with a female ps ychotherapis t who encouraged the patient to seek training as a counselor, hers elf. T he friend declared a sexual attraction to the patient, although the patient apparently did not reciprocate this attraction. T he two became involved in therapy training and activities, culminating in their attendance at a new age– oriented therapy workshop in a distant city. T hey room, and the friend began to press ure the patient sexually. T he patient remains uncertain whether she rebuffed these advances . On one hand, she was that her friend would be “mad” about her refus al. On other hand, she was panicked les t her family find out about the s exual press ures from her friend. T he cons isted of a number of group s ess ions involving movement, imagery, “inner child work,” artwork, and similar experiences . During an intens e s es sion picturing oneself going back in time and being reborn, patient appeared to enter a deep trance s tate. At the conclus ion of the s es sion, s he remained in a fetal When ques tioned, s he could not identify who s he was, where she was , or anything else about herself or her situation. Ins tead of seeking psychiatric help, the works hop organizers took the patient back to her hotel room, lit candles, and provided aromatherapy. At the end of 1883 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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days , there was no change in the patient's condition, the members of the workshop and the patient's companion left. T he patient's family found her in a confused, and disoriented s tate, unable to recognize or to provide any his tory of recent events. S he had difficulty learning new information, s eemingly forgetting as it was provided. S he was panicked and complained not “feeling in my body.” In addition to los s of autobiographical memory, she appeared to have dress ing hers elf until s hown how, did not know how to in her contact lenses, and was confused about a activities of daily living. B rought to neuropsychiatric attention, the patient was given an extensive neurological and workup, all of which showed that the cognitive deficits were consistent with a psychologically based amnes ia, a neurological process . On mental s tatus examination, patient presented as a s cared, confused, neatly woman who frequently entered trance s tates, s taring and losing track of the convers ation. S he had relearned variety of information, including the identities of her children and spouse but had no s ens e that s he had any of this before being recently taught it. S he “knew” about a variety of family events but had no sens e of hand memory for them. S he complained of ongoing amnes ia, spontaneous trances , and periods of intens e depers onalization and derealization. S he was unable to perform daily functions, s uch as driving and cooking, having no recall of thes e s kills . Mood was depres sed, periods of intens e s uicidal preoccupation. In reviewing history with family members , the patient's former ps ychotherapis ts, and the patient herself, s ignificant 1884 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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marital conflicts and family conflicts between the her siblings , and her elderly mother were described. As treatment progres sed, the patient began to describe the s ubjective experience of different self-states , it was quite difficult to determine if they met DS M-IV criteria for a diss ociative identity disorder alter identity. S he des cribed the belief that “the old M.” had been to cope with the family, marital, and personal conflicts preceding the amnes ia “and just crumbled into pieces .” T he workshop exercis es that preceded the memory uncannily recreated features of s ome of the patient's reported childhood trauma, about which s he had extensively before the ons et of the amnes ia. At times , experienced hers elf as “the little girl” who recalled horrifying epis odes of sadis tic childhood maltreatment and was terrified lest they recur. At other times, she experienced hers elf as the “new M.” who had to relearn entire life his tory. S he was rediagnosed as diss ociative disorder NOS . After several years , despite individual ps ychotherapy supportive, psychodynamic and cognitive-behavioral modalities, hypnotherapy, couples therapy, family and antidepres sant medication, the patient continues to experience amnesia, although s he has “relearned” to manage her day-to-day life. Mood has improved, the patient has made some adjustment to her difficult family s ituation. S ettlement of a laws uit agains t the workshop organizers did not res ult in any clinical S he has repeatedly refused an amobarbital interview.

Nonc las s ic Pres entation T he nonclass ic diss ociative amnesia patients can be 1885 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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have a cove rt diss ociative syndrome, becaus e their complaints infrequently relate directly to amnes ia. recurrent, or persistent diss ociative amnes ia, or a combination of thes e, is the most common s ymptom in these cas es , although s ome may als o describe a fugue-like s tates. C ommonly, patients with the presentations of amnesia do not reveal the presence of diss ociative s ymptoms unles s directly as ked about T hese patients are often uncomfortable when amnes ia inquired about and may minimize the presence or rationalize the importance of the symptom. In thes e patients , the amnes ia manifes ts its elf as a circums cribed memory gap or series of memory gaps the life history, primarily for times when traumatic occurred, such as childhood or wartime. T hese patients frequently come to treatment for a of s ymptoms, such as depress ion or mood swings , subs tance abus e, s leep disturbances , s omatoform symptoms, anxiety and panic, s uicidal or s elf-mutilating impulses and acts , violent outbursts , eating problems , interpersonal problems. S elf-mutilation and violent behavior in these patients may als o be accompanied amnes ia. Amnesia may als o occur for flas hbacks or behavioral reexperiencing epis odes related to trauma. P.1865 Only one systematic study exists that has examined characteristics of thes e patients. In a small, highly sample referred for consultation at a specialty clinic for diss ociative dis orders, mos t diss ociative amnes ia were women. Almos t all had a prior his tory of childhood 1886 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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adult physical, sexual, or emotional abuse and neglect, combination of thes e. T he trauma history was less than has been reported in patients with diss ociative identity dis order. Duration of reported amnes ia ranged from minutes to years . S lightly les s than one-half of the sample had recurrent epis odes . T raumatic precipitants the amnes ia were most common, although, in 30 of cas es , amnes ia was pres ent for problematic such as sexual indis cretions and s elf-mutilation. T he common comorbid conditions were mood dis orders, P T S D, and a mixed pers onality disorder. P atients from diss ociative identity disorder patients in that they had lower rates of s ubs tance abus e, s elf-mutilation, hallucinations , fugues , sexual dysfunction, and somatoform s ymptoms . DE S scores averaged lower those of diss ociative identity disorder patients . F amily history was characterized by alcoholism and mood disorders .

P athology and L aboratory E xamination Dis sociative amnes ia can be diagnos ed with the DDIS the S C ID-D-R , or both. Dis sociative amnes ia patients been reported to have high hypnotizability, as with standardized hypnos is scales.

Differential Diagnos is Ordinary Forgetfulnes s and Nonpathologic al Amnes ia T he DS M-IV -T R diagnostic criteria for dis sociative specify that the disturbance mus t be “too extens ive to explained by normal forgetfulness .” F urthermore, 1887 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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nonpathological forms of amnes ia have been such as infantile and childhood amnesia, amnesia for and dreaming, and hypnotic amnes ia. Most forms of diss ociative amnesia are thought to primarily involve difficulties with episodic and autobiographical memory, not implicit or semantic memory. S everal s tudies have confirmed the clinical observation that s ubjects with pathological dis sociative amnes ia for their life his tory can demons trate implicit autobiographical memory while amnesic. W hen asked free as sociate, to imagine, or to make up a story or expos ed to projective tests, patients with diss ociative amnes ia include in their productions elements that contain autobiographical information without being consciously aware of this. Amnes ic patients may als o have intens e reactions to stimuli that are emotionally significant, without knowing cons ciously the reason for the reaction or the of the stimulus, such as when a patient with P T S D has flashback without consciously knowing what triggered it and often without clear recall later of the memory being evoked. S tudies of autobiographical memory in s everal populations support the notion that infantile and childhood amnes ia can be experimentally documented. However, there is now a substantial body of data being accumulated on preverbal learning and memory in children. Amnesia may result in later years owing to the difficulty in translating this preverbal memory into form. However, experiments designed to overcome this factor in young children have shown that children can report preverbal memories accurately in verbal form 1888 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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suitable experimental conditions . S tudies demonstrate that normal adult autobiographical memory has a retention gradient for memory for the recent 20 to 30 years of the s ubject's life, often with a subjective sense of wearing away of memories for the in contras t to the subjective gaps in memory typical of diss ociative amnesia. E lderly patients in memory s tudies have been shown to have a relative decrease in recent autobiographical memories and a re minis cence compone nt for the subject's youth. S ubtle cumulative memory difficulties may be a feature of aging, often with decreased ability to retain new information, increas ed time to recall already learned information, or both, res ulting in age -re late d cognitive de cline , also known as be nign forge tfulne s s of the Memories for repeated routine events , such as going to work or s chool every day, may not be encoded as memories for each day, but rather as broad memory categories for the events that repeatedly reoccur. T his also thought to occur with some traumatic experiences , such as repeated epis odes of childhood sexual abus e happen recurrently over many years. C linically, patients with dis sociative amnesia may exaggerated or extended forms of childhood amnesia. finding has been documented in an experimental study a cognitively normal diss ociative identity dis order who, unlike normal controls, showed a virtual abs ence memories for the firs t 10 years of her life. In another a patient with a global dis sociative amnes ia after a was evaluated with cognitive tes ting while amnesic and after memory recovery. As compared to an organically impaired control, the diss ociative amnes ia patient was 1889 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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able to recall memories from various parts of the life history without the temporal gradient that characterized the retrograde amnes ia of the organic patient. R ecall of autobiographical information during dis sociative seemed related to life events with positive affects that were unconnected with the traumatic events the amnes ia. Implicit autobiographical memory phenomena were documented as well in this patient. S imilar phenomena have been des cribed in amnes ia, with implicit demons tration that the memories for which amnesia has been s ugges ted have been encoded and s tored, but without their being access ible directly for retrieval.

Dementia, Delirium, and Organic Amnes tic Dis orders T here is no single test or examination that can absolutely whether a memory dis order is dis sociative, organic, malingered, or of mixed etiology. T he clinician evaluating the amnesic patient must have a reasonable index of s us picion about any of thes e. In ambiguous there s hould be careful reass ess ment of the clinical situation on an ongoing bas is. However, mos t cases of diss ociative amnesia present differently from other disorders with memory impairment (T able 17-7).

Table 17-7 Differential Diagnos is Dis s oc iative Amnes ia

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Ordinary forgetfulnes s    Age-related cognitive decline Nonpathological forms of amnesia    Infantile and childhood amnesia    Amnesia for s leep and dreaming    Hypnotic amnes ia Dementia Delirium Amnes tic dis orders Neurological disorders with dis crete memory los s episodes    P osttraumatic amnesia    T rans ient global amnes ia    Amnesia related to s eizure disorders S ubstance-related amnes ia    Alcohol 1891 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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   S edative-hypnotics    Anticholinergic agents    S teroids    Marijuana    Narcotic analges ics    P s ychedelics    P hencyclidine    Methyldopa (Aldomet)    P entazocine (T alwin)    Hypoglycemic agents    β-B lockers    Lithium carbonate    Many others Other dis sociative disorders    Diss ociative fugue

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   Diss ociative identity disorder    Diss ociative dis order not otherwise s pecified Acute s tres s dis order P os ttraumatic stress dis order S omatization dis order P sychotic epis ode    Lack of memory for ps ychotic epis ode when returns to nonpsychotic state Mood dis order episode    Lack of memory for as pects of epis ode of when depres sed and vice vers a or when F actitious disorder Malingering

T he evaluation of acute dis sociative amnes ias is in T able 17-8.

Table 17-8 E valuation of Ac ute 1893 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Amnes ia C omplete history (to the extent that this can be gathered)    Medical history    P s ychiatric history    T rauma history (combat, violence, childhood maltreatment, etc.)    Developmental history    C ollateral informants (if available)    F amily and concerned others    Medical, military, police, and s ocial service    S equential clinical observation P hysical and neurological examination    B aseline phys ical and laboratory examination    F ull mental status examination    Mini-Mental S tate E xamination 1894 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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   Dementia workup    E lectrocardiogram    E lectroencephalogram    T elemetry in unusual cas es    B rain imaging    Neuropsychological as sess ment

In patients with dementia, organic amnes tic disorders, delirium, the memory loss for personal information is embedded in a far more extensive s et of cognitive, language, attentional, behavioral, and memory Loss of memory for personal identity is usually not without evidence of a marked disturbance in many domains of cognitive function. C onfabulation may be present to various degrees and is us ually implausible bizarre. C aus es of organic amnes tic dis orders include K ors akoff's psychosis, cerebral vas cular accident postoperative amnes ia, pos tinfectious amnesia, anoxic amnes ia, and transient global amnesia. therapy (E C T ) may als o caus e a marked temporary amnes ia, as well as pers is tent memory problems in cases. Here, however, memory loss for experience is unrelated to traumatic or overwhelming experiences and seems to involve many different types 1895 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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personal experience, most commonly that occurring before or during the E C T treatments.

Pos ttraumatic Amnes ia In pos ttraumatic amnesia due to brain injury, there is us ually a history of a clear-cut phys ical trauma, a unconsciousness or amnesia, or both, and P.1866 objective clinical evidence of brain injury. In general, length of the posttraumatic amnesia is a reas onable predictor of cognitive outcome. R etrograde amnes ia also occur. An extens ive retrograde amnesia out of proportion to the extent of the head injury sugges ts that an inves tigation for dis sociative factors may be

S eizure Dis orders In mos t s eizure cas es , the clinical presentation is quite different from that of diss ociative amnesia, with clearictal events and s equelae. P atients with seizures may also have dis sociative symptoms, such amnes ia and an antecedent his tory of psychological trauma. R arely, patients with recurrent complex partial seizures may present with ongoing bizarre behavior, memory problems , irritability, or violence, leading to a differential diagnostic puzzle. In some of these cases , diagnosis can only be clarified by telemetry or E E G monitoring.

S ubs tanc e-R elated Amnes ia A variety of s ubs tances and intoxicants have been implicated in the production of amnes ia. C ommon 1896 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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offending agents are listed in T able 17-7. In mos t cas es, a careful history from the patient and ancillary s ources , sequential clinical observation, and objective testing clarify the s ubs tance-related nature of the amnes ia. In s ome instances of pathological intoxication, in which a small amount of alcohol or subs tance produces a major behavioral disinhibition, alcohol may be producing its effect by facilitating the onset of a dis sociative epis ode in a susceptible T his may be analogous to the disinhibition that occurs clinical amobarbital interview. S ubjects may report amnes ia for violent or other out-of-character behavior during such an epis ode. T he most difficult differential diagnos tic problem us ually involves patients with a history of substance-induced diss ociative memory problems. S ome of these patients may minimize dis sociative amnesia and vice versa. C linically, the relative contribution of the substance and the diss ociation may only be fully clarified by sequential clinical observation once the patient has achieved sobriety.

Trans ient G lobal Amnes ia T ransient global amnesia may be mis taken for a diss ociative amnesia, es pecially becaus e s tres sful life events may precede either disorder. However, in global amnes ia, there is the sudden onset of complete anterograde amnes ia and learning abilities ; retrograde amnesia; preservation of memory for identity; anxious awareness of memory los s with often perseverative, ques tioning; overall normal lack of gros s neurological abnormalities in most cases ; 1897 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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rapid return of baseline cognitive function, with a persis tent s hort retrograde amnesia. T he patient older than 50 years of age and shows risk factors for cerebrovas cular disease, although epileps y and have been etiologically implicated in s ome cases. P.1867

Dis s oc iative Dis orders As noted previous ly, dis sociative identity dis order can present with acute forms of amnes ia and fugue episodes . However, dis sociative identity dis order are characterized by a plethora of symptoms, only which are us ually found in patients with dis sociative amnes ia. With res pect to amnes ia, most dis sociative identity dis order patients and patients with diss ociative disorder NOS with dis sociative identity dis order report multiple forms of complex amnesia, including recurrent blackouts, fugues, unexplained pos sess ions, fluctuations in skills, habits, and knowledge.

Ac ute S tres s Dis order, S tres s Dis order, and S omatoform Dis orders As dis cuss ed in the introductory nosology s ection, forms of diss ociative amnes ia are best conceptualized part of a group of trauma s pectrum disorders that acute stress dis order, P T S D, and somatization Many dis sociative amnesia patients meet full or partial diagnostic criteria for acute stress dis order, P T S D, or somatization disorder, or a combination of thes e. is a criterion symptom of each of the latter disorders . 1898 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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IV -T R s tipulates that, to be diagnosed, the diss ociative amnes ia must be dis tinct from the cours e of acute disorder, P T S D, or s omatization disorder. In practice, clinical judgment us ually determines whether the extent of the amnesia warrants a s eparate dis sociative

Malingering and Fac titious Amnes ia F eigned amnesia is more common in patients with the acute, clas sic forms of dis sociative amnes ia. However, in one recent forensic case, an adult attempting to sue an admitted abuser us ing the discovery rule was s hown to have falsified delayed for trauma in an attempt to overcome the statute of limitations . Inves tigations s howed that the patient had discuss ed the abus e with others on many occasions the purported delayed recall. On the other hand, some patients may have s econdary amnesia for having remembered and discuss ed traumatic experiences in past. T here is no absolute way to differentiate diss ociative amnes ia from factitious or malingered amnes ia. Malingerers have been noted to continue their even during hypnotically or barbiturate-facilitated interviews . As noted previously, many of the class ical were des cribed as occurring in a clinical context of financial, s exual, and legal problems or in s oldiers who wis hed to escape from combat. On the other hand, in the clinical cas e reports , many malingerers quickly confess ed their deceptions spontaneously or when confronted by the examiner. In these nonforensic reports , the malingered amnes iacs frequently pathetic individuals whos e deception was 1899 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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transparent. It was often unclear where the cons cious deception began and the uncons cious defenses ended. In the current clinical environment, a patient who to ps ychiatric attention asking to recover repres sed memories as a chief complaint is most likely to have a factitious disorder or to have been s ubject to influences. Mos t of these individuals actually do not describe bona fide amnesia when carefully questioned are often insistent that they mus t have been abused in childhood to explain their unhappines s or life

C linic al C ours e and P rognos is Little is known about the clinical course of diss ociative amnes ia. Acute dis sociative amnes ia frequently spontaneously resolves once the pers on is removed to safety from traumatic or overwhelming circums tances . the other extreme, there are patients who develop forms of generalized, continuous, or s evere localized amnes ia who are profoundly disabled and require high levels of s ocial s upport, such as nursing home or intensive family caretaking. T hose with nonclas sic dis sociative amnes ia may have persis tent form of the dis order that does not cause overt dis tres s, and, thus , they do not s eek clinical S ome of these individuals may be understood as being an episode of P T S D characterized primarily by symptoms. In s ome cases, a later traumatic event or even a relatively minor one, precipitates a florid P T S D with alternations of reexperiencing and avoidant amnes ia symptoms . S tudies have shown that recall of previously 1900 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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memory frequently occurs outside of therapeutic triggered by a variety of s timuli, including one's own children reaching an age at which one was abus ed, child being abus ed, media accounts of trauma or death of an abusive parent, a variety of s ens ory cues, feeling s afe in one's life situation, among others .

Treatment T he treatment of diss ociative amnesia became controvers ial in the 1990s . C ontroversy exis ts not only the exis tence of dis sociative amnesia, but also for how treat it. C ritics of the diss ociative amnes ia construct invented the term re cove red me mory the rapy (R MT ) to characterize treatment in which clinicians are thought make aggress ive efforts to have patients recall s oforgotten traumas as the central focus of treatment. does not repres ent a known school of therapy or of scholarly res earch. It may more accurately describe individual fringe practitioners or media or laypers on of trauma treatment. In fact, reviews of the literature on trauma treatment report that the predominant model for work on traumatic memories involves a focus on integration of pos ttraumatic memories, beliefs , affects, s omatic repres entations, and object relations, on memory recall per s e.

Phas e-Oriented Treatment P hase-oriented treatment is the current s tandard of for the treatment of trauma dis orders, including diss ociative amnesia. T reatment of the acute class ical diss ociative amnesia patient follows a similar phasic model. However, here, memory recall is a central 1901 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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because los s of memory for personal identity and large gaps in current autobiographical memory are acutely disabling s ymptoms that require relatively rapid intervention. In general, three basic phases are recognized. T his structure is heuris tic to some extent, becaus e as pects each phas e may be worked on during another. F irst, is a s tabilization phase, with a focus on safety, control, containment of affects and impuls es , and education about trauma treatment. Once adequate personal s afety and clinical stability are established, if indicated, the individual may engage in a s econd the focus of which is the integration of traumatic in greater depth. T his process ing may involve attempts overcome pers is tent amnes ia symptoms and to resolve material that is not diss ociated or les s completely diss ociated. F inally, there is a third phas e of re s olution re inte gration, in which the traumatized pers on is reconnected to ordinary life. In this phase, the focus is on the trauma per s e and more on the development of renewed, reinvigorated life apart from the lack of impos ed by symptoms of the trauma disorder and the domination of the person's ps ychology by is sues traumatization.

S afety in Ac ute Dis s oc iative In the cas e of the patient with an acute stress disorder primarily characterized or accompanied by dis sociative amnes ia, the es tablishment of the person's phys ical is the firs t concern. T his involves removing the P.1868 1902 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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from the traumatizing environment (e.g., acute evaluating and treating medical problems , and shelter, food, and sleep. S edative medications , such as benzodiazepines, may be indicated to as sis t the patient with sleep. P atients with acute amnesia for personal identity or life circums tances , or both, frequently have a relatively rapid spontaneous remis sion of s ymptoms brought to the s afety of the hospital or other protected environment. If immediate spontaneous remis sion does not occur in patients with acute amnes ia after removal from environments , s ymptoms may abate later s imply in the cours e of the clinician's taking a psychiatric his tory or merely with suggestions and reas surance.

S afety in Nonc las s ic Dis s oc iative Amnes ia P atients with nonclass ic, covert amnes ia pres entations generally s hould be managed within the framework of a longer-term ps ychotherapy directed at res olution of the complex ps ychological sequelae of the events the amnesia, us ually severe traumatization due to childhood abuse, combat, rape, domestic violence, or other forms of adult victimization, or a combination of these. Here, too, the firs t tasks of treatment are res toration of patient's phys ical well-being and safety and of a working alliance. T he clinician mus t be prepared to intervene actively if the patient is acutely dangerous to or others or is abusing s ubs tances in an uncontrollable way, or both. T ypically, thes e patients' difficulties suicide attempts, s elf-mutilation, eating disorders , 1903 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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or s ubstance abuse, involvement in abusive or relations hips , epis odes of rage or violence, abus e of individual's own children or family members , and lack adequate food, clothing, or shelter. Hos pitalization may neces sary to s tabilize s uch patients, as may referral to specialty resources, s uch as treatment for s ubs tance or eating disorders . In individuals with s evere intrusive P T S D s ymptoms alternating with amnesia, containment and of intrusive recollections rather than detailed the traumatic material are us ually the goal in the stabilization phas e of treatment. T his may be accomplis hed with s upportive ps ychotherapy, pharmacotherapy, imagery or hypnotic techniques for containment and s ymptom control, or cognitive therapy techniques, or a combination of these. T here is no pharmacological agent that specifically targets amnes ia. However, s pecific psychopharmacological treatment of the patient's P T S D, affective, dys control, ps ychotic, obs es sive-compuls ive, or anxiety s ymptoms with medications may help stabilize severe symptoms prevent the patient's meaningful participation in ps ychotherapy. Long-term treatment for these patients is focused on manifold dimensions of dys function that chronic trauma engenders . T hese include problems with mood, and impulse regulation, dis ordered attachment engendering troubled relations hips and problems with interpersonal boundaries, s pontaneous altered states diss ociation, memory problems, cognitive distortions disordered meaning s ys tems, perceptual abnormalities, problems with the sense of s elf and body image, 1904 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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somatoform s ymptoms , and s elf-destructiveness .

Treatment of Amnes ia T reatment of patients with nonclas sic forms of amnes ia necess itates that the clinician familiarize or hers elf with the current controversies about trauma memory to provide adequate informed consent to the patient. In general, studies of treatment outcome in survivors of rape and childhood s exual abus e have shown better outcome when patients directly dis cus s trauma the context of a carefully designed, phasically individual or group psychotherapy. Nonetheless , it is a matter of clinical judgment and the patient's individual decis ion whether the patient has achieved s ufficient stability and has s ufficient ego strength to move from stabilization phas e of treatment to the phas e of integration. F actors that usually contraindicate memory integration work are lis ted in T able 17-9.

Table 17-9 C ontraindic ations to Integration Phas e of Amnes ia Treatment Has not achieved safety from high-ris k behaviors C urrent s ubs tance abus e or dependence

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Has not achieved symptom stabilization    S evere, uncontrolled, intrusive posttraumatic disorder s ymptoms    S evere, uncontrolled dis sociative epis odes    Dysregulated mood s ymptoms    Dysregulated anxiety s ymptoms Inadequate therapeutic alliance C urrent or ongoing abusive relations hip Acute life crisis or times of life trans ition (divorce, change, etc.) S evere physical illnes s or infirmity S evere pers onality disorder s ymptoms, ps ychos is C urrent involvement in litigation Impending abs ence of therapist

Adapted from Loewens tein R J . Diss ociative

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and diss ociative fugue. In: G abbard G O, ed. T re atme nt of P s ychiatric Dis orde rs , 3rd ed. V ol 2. Was hington, DC : American P sychiatric P res s; 2001:1633.

Free R ec all P atients with the acute and chronic forms of amnes ia may respond well to free recall s trategies in they allow memory material to enter into T he clinician is s upportive and nondirective but focus es reluctance or resistance to allowing free recall to take place. C lass ic free-as sociation suggestions are often most helpful in understanding factors that interfere with recall and for allowing recall to occur at a pace that the patient can tolerate. In general, it is believed that accuracy is improved if the clinician as ks nonleading questions of the patient, whether in a free-recall or with methods that facilitate memory recall.

Trans ferenc e Interpretations S tudies of trans ference in patients with combat-related P T S D and s evere diss ociative dis orders indicate that a traumatic transference is us ually the predominant initial transference theme in these individuals. T his is a set of unconscious perceptions of the clinician, bas ed on relations hips formed in traumatic circums tances : T he 1907 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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therapist becomes the buddy who was killed next to the patient in battle, the pers ecutory abusive parent, the incompetent officer who sent the patient into battlefield disas ter, the neglectful relative unconcerned about the patient's abus e, or the patient himself or hers elf who is subject to the s adis tic, abus ive behaviors of an other. Identification of the overt patterns of traumatic transference observed by the therapist may be another route to undoing amnes ia. A recent study of trauma memory found that trans ference-based recall more accurate than other forms of facilitated recall.

C ognitive Therapy C ognitive therapy may have s pecific benefits for individuals with trauma disorders. Identifying the cognitive distortions that are based in the trauma may provide an entrée into autobiographical memory for the patient P.1869 experiences amnes ia. As the patient is more able to cognitive distortions, particularly about the meaning of prior trauma, more detailed recall of traumatic events occur.

Fac ilitated R ec all of Trauma Material A hierarchy of techniques for facilitation of recall has described for dis sociative amnes ia. R es earch s uggests each of these may s ucces sively introduce the potential greater error rates for what is recalled. T hese include context-reinstatement, that is , attempts to focus the patient on time periods for which there is amnes ia; (2) 1908 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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state-dependent recall, that is, intensification and focus affects or somatic s ensations that appear to be related trauma, such as terror, horror, confusion, rage, or suddenly nauseated or dizzy; and (3) s pecialized adjunctive techniques , s uch as hypnosis , relaxation, imagery, or pharmacologically as sisted interviews . these may facilitate recall of dis sociated memory information in clas sic and nonclas sic forms of amnes ia. In each of thes e, the clinician s hould use nonleading, nons uggestive questions to minimize about inaccurate or confabulated recall.

Hypnos is for Amnes ia Hypnos is has frequently played an important adjunctive role in the treatment of individuals with dis sociative amnes ia and dis sociative fugue. Hypnos is is not a treatment in itself; rather, it is a set of adjunctive techniques that facilitate certain psychotherapeutic T he cons truct of hypnosis encompass es a wide and complex domain of phenomena and res pons es that been applied to a divers e array of therapies offered to variety of individuals . C oncern about inaccuracies in hypnotically facilitated recall cite res earch studies of memory for nontraumatic information recalled with hypnosis that have shown that hypnosis increas es the subject's confidence in what is recalled, even if it is erroneous. However, critical reviews have noted the complexity of this res earch problem, the incons is tency findings among s tudies , and the many variables related hypnosis and nonhypnotic factors that appear to this and related phenomena. T he critical reviews have emphasized that memory confabulation is related to techniques of s ocial influence on sugges tible subjects, 1909 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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to hypnos is per se. T he us e of hypnos is for memory recall in no way the veracity, or lack of veracity, of the information produced. T he clinician should be well aware of the recons tructive nature of memory and should avoid suggestions to the contrary. T hus, in addition to the patient's informed consent for the use of hypnos is, currently considered prudent to also obtain informed cons ent concerning the reliability or pos sible lack for autobiographical information revealed during hypnosis . S tudies also suggest that educating patients about the controversies regarding hypnos is and and informing them of the need to critically evaluate memory material that they recall during hypnosis or at other time in treatment reduce the likelihood of acceptance of potentially inaccurate information. Als o, clinicians s hould be aware that, in s ome states , individuals who have been exposed to therapeutic hypnosis may be enjoined from giving testimony as a witness in court. T his may be s o even if the hypnosis little relations hip to the events at legal is sue. T he should attempt to discus s fully these is sues with the patient and his or her legal counsel. F inally, the use of hypnos is as part of a fore ns ic examination should proceed only after obtaining from the patient after he or s he has consulted with relevant legal authorities and attorneys involved in criminal or civil litigation. T raining in forens ic hypnos is mandatory in this context. S hould hypnosis be us ed in way, electronic recording of all hypnos is ses sions , preferably on videotape, s hould be us ed. 1910 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Hypnos is can be used in a number of different ways in treatment of dis sociative amnesia. In particular, interventions can be us ed to contain, modulate, and the intens ity of symptoms ; to facilitate controlled recall diss ociated memories ; to provide support and ego strengthening for the patient; and, finally, to promote working through and integration of dis sociated material. In addition, the patient can be taught self-hypnosis to apply containment and calming techniques in his or her everyday life. S uccess ful us e of containment whether hypnotically facilitated or not, als o increases patient's s ens e that he or s he can more effectively be control of alternations between intrusive symptoms and amnes ia. In the acutely amnes tic patient, a few s ess ions to help patient experience trance s ucces sfully and to explore containment and dis tancing techniques may be to allow focus ed hypnotic work on the material for the patient is amnes tic. However, in nonclas sic cas es severe, long-standing, pos ttraumatic dis orders, the amnes ia its elf should be address ed only gradually, in context of a longer-term ps ychotherapy in which life stability and function are the basic foci. C linicians s ince W orld W ar I have recognized the importance of the patient's repeatedly process ing diss ociated material in a number of different s ess ions, often at different levels of affective intens ity, to the process of integrating the material. In cas es of acute amnesia, the firs t s es sion for memory proces sing may neces sarily be explorative. Here, initial goal is to gain an overview of the information for 1911 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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which the patient is amnestic. As in cases of chronic amnes ia, subsequent s ess ions then focus on material in greater detail. It is useful to try to account s ys tematically for different dimensions of the traumatic experience: s ensory, cognitive, and behavioral, s o as to ensure that all key components have been identified and reconstructed. It likewise useful to attempt to account s ys tematically for variety of dysphoric affects that are commonly experienced during traumatic experiences : despair, sorrow, grief, horror, shame, helples sness , rage, guilt, confusion, anguish, and the like. Not all of these may present in a given patient; however, it is us eful for the clinician to keep track of which affects s eem most described by the patient and which s eem less Inquiry about thes e other affects may be quite helpful res olving the amnes ia. In particular, shame, horror, helpless nes s, and overwhelming confusion are that patients may have the mos t trouble identifying without ass is tance from the therapist. T he treatment process is similar when the acute res ults not from traumatic experiences , but rather from as pects of their current behavior that are in conflict with deeply held moral values or behavioral s tandards . T reatment in s uch instances s eeks to help the patient tolerate these affects and conflicts without res orting to diss ociative defenses. F requently, thes e patients developmental history characterized by a rigid family moral code enforced with harsh physical discipline. experiences often appear to be the traumatic underpinning of the diss ociative diathes is. and hypnotherapy in thes e patients are directed in part 1912 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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reducing the patient's brutally unreasonable, and often conflicting, expectations of himself or hers elf and the and s hame that s o often accompany acute F urthermore, these patients may have tremendous difficulty tolerating anger or violent impulses, becaus e such affects tend to trigger recall of earlier experiences with physical abuse or s imilar traumas , often as a experience. T hus , ps ychotherapy may s erve not only to focus on the conflicts that led to the acute amnesia, but also to explicate and to work through the patient's thoughts, feelings , and s elf-perceptions related to the antecedent traumatic events . P.1870

S omatic Therapies T here is no known pharmacotherapy for dis sociative amnes ia other than pharmacologically facilitated interviews . A variety of agents have been us ed for this purpos e, including s odium amobarbital, thiopental (P entothal), oral benzodiazepines, and amphetamines . present, no adequately controlled s tudies have been conducted that as sess the efficacy of any of these comparis on with one another or with other treatment methods. A single placebo-controlled study of the barbiturate-facilitated interview did not find s uperiority sodium amobarbital over placebo in producing more clinically us eful information. In more s ys tematic W orld II s tudies of barbiturate-facilitated interviews for and conversion reactions, this treatment was described leading to more rapid recovery, especially for amnesia, although little overall difference was found in recovery 1913 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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comparis on to subjects treated with psychotherapy or with hypnotherapy. Amobarbital narcos ynthe s is is a term devised to the need for material uncovered in a pharmacologically facilitated interview to be proces sed by the patient in or her usual cons cious state. P harmacologically interviews are used primarily in working with acute amnes ias and convers ion reactions, among other indications , in general hos pital medical and psychiatric services . T his procedure is also occasionally us eful in refractory cas es of chronic dis sociative amnesia when patients are unres pons ive to other interventions . T he current standard of care is that this procedure performed in s ettings in which res us citation equipment available in case of res piratory arrest, a poss ible, albeit complication. T he interview usually is audiotaped or videotaped to replay for the patient, becaus e amnes ia generally is present for material produced. Although in some cases repeated procedures may be helpful, in cases, repeated procedures may lead to the patient's developing a dependence on pharmacologically interviews . T he current controvers ies over delayed recall for experiences have also focus ed on the us e of pharmacologically facilitated interviews for patients with reported amnes ia for childhood maltreatment. No systematic data exis t on memory fallibility or accuracy those undergoing pharmacologically facilitated As dis cuss ed previous ly, pharmacologically facilitated interviews were used extens ively in World W ar II for treatment of combat-related dis sociation. Although wartime memories recovered with pharmacologically 1914 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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facilitated interviews were generally cons idered to be accurate, some s ubjects were reported to dis semble completely or withhold crucial information, or both, despite barbiturate treatment. G iven the current controvers ies , the clinician s hould similar informed consent regarding the nature of to the patient contemplating a pharmacologically facilitated interview for amnesia symptoms as that to the patient considering hypnosis. T he clinician emphasize that these drugs are not a truth serum; whatever apparently new information emerges under drug condition should be regarded no differently with res pect to accuracy than any other material that in the course of treatment.

Group Ps yc hotherapy for Amnes ia During W orld W ar II, group psychotherapy and group hypnotherapy were among the treatments given to promote recovery in traumatic war-related amnesia. supportive, s tructured, reass uring, and reeducative approaches were often us ed by therapis ts in s uch an attempt to accomplis h return of the patient to functional s tatus and to prevent chronic disability. T ime-limited and longer-term group psychotherapies been reported to be helpful for combat veterans with P T S D and for survivors of childhood abus e. During sess ions, some authors report that patients may memories for which they have had amnes ia. interventions by the group members or the group therapist, or both, may facilitate integration and the diss ociated material. 1915 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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On the other hand, concern has been rais ed about memory contamination in s uch group therapy s ettings , it has for patients ' involvement in 12-step or self-help groups for trauma s urvivors.

E MDR E ye movement desensitization and reprocess ing a s et of s tructured procedures for working on specific traumatic memories in P T S D. Originally, therapistfacilitated eye movements were thought to be an part of the technique for E MDR . However, subsequent res earch has shown this to be a nons pecific factor compared to the s tructured approach for work on reported traumas . S tudies have shown greater efficacy of E MDR compared to waiting lis t and other control conditions, especially for individuals reporting single traumas. However, comparis on of E MDR to forms of s tructured, multistaged trauma treatment has been performed, es pecially for individuals with multiple traumas and complex comorbidities. Longitudinal of such cas es have not s hown a pers is tent with E MDR . B ecaus e E MDR is defined as a procedure for helping res olution of consciously recalled traumatic memories, data have been presented on its efficacy for reducing diss ociative amnesia. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DE P E R S ONALIZAT ION

DE PE R S ONAL IZATION 1916 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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DIS OR DE R P art of "17 - Dis sociative Dis orders " F or many years, the ubiquity of depersonalization as a ps ychiatric s ymptom obscured its broader recognition disorder. R ecent res earch has identified clinical cours e and prognosis , and neurobiological correlates distinguish it from other ps ychiatric dis orders with symptoms of depers onalization. V alid and reliable instruments exist for s creening and diagnosis. with these measures is advancing understanding of often unrecognized condition.

Definition T he DS M-IV -T R identifies the ess ential feature of depers onalization as the persis tent or recurrent feeling detachment or es trangement from one's s elf. T he individual may report feeling like an automaton or as if dream or watching hims elf or herself in a movie. to DS M-IV -T R , “there may be a s ens ation of being an outside observer of one's mental process es , one's parts of one's body.” T here is often a s ens e of an of control over one's actions .

His tory F irst described by Maurice K ris hnaber in 1872, depers onalization was formally named in 1898 by Dugas, who s ought to convey “the feeling of los s of F reud, J anet, E ugen B leuler, and other 19th century authorities reported patients with s ymptoms of 1917 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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depers onalization and derealization. A monograph by S childer in 1914 is regarded as a turning point in ps ychiatric interest. C las sic s tudies followed by Mayer-G ross in 1939, Harold S horvonn in 1946, and J erome S aperstein in 1949 furthered the delineation of syndrome of chronic depers onalization. B rian Ackner enumerated the es sential features of current diagnos tic definitions in 1954. T hes e include “(1) the feeling of unreality or s trangeness apropos the self; (2) the of insight and lack of delus ional elaboration; (3) the affective res ponse (‘numbness ') except for the regarding depers onalization; and (4) the unpleasant property that may vary in intens ity invers ely with the subject's familiarity with the phenomenon.” In the las t decade, research by E ric Hollander, S imeon, and colleagues has significantly P.1871 increased unders tanding of depers onalization dis order with systematic case s eries, medication trials , brain imaging, and improved measurement.

C omparative Nos ology T he DS M has class ified depersonalization as a diss ociative disorder s ince its firs t inclusion in 1980. current DS M-IV -T R definition of depers onalization is found in T able 17-10.

Table 17-10 DS M-IV-TR C riteria for Depers onalization Dis order 1918 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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A. P ersis tent or recurrent experiences of feeling detached from, and as if one is an outs ide of, one's mental process es or body (e.g., feeling one is in a dream). B . During the depersonalization experience, tes ting remains intact. C . T he depers onalization caus es clinically distress or impairment in s ocial, occupational, or other important areas of functioning. D. T he depers onalization experience does not exclusively during the cours e of another mental disorder, s uch as s chizophrenia, panic dis order, acute stress dis order, or another diss ociative disorder, and is not due to the direct physiological effects of a s ubs tance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T he IC D-10 (T able 17-11), however, lists 1919 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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derealization syndrome under other neurotic dis orders. T he IC D-10 requires concurrent experiences of derealization in addition to symptoms of depers onalization. T he IC D-10 and the DS M require the affected individual mus t have intact reality tes ting must retain good ins ight into the ps ychological nature his or her symptoms .

Table 17-11 IC D-10 Diagnos tic C riteria for Depers onalizationDerealization S yndrome F or a definite diagnos is , there must be either or (a) and (b), plus (c) and (d):    (a) Depersonalization symptoms, that is, the individual feels that his or her own feelings or experiences , or both, are detached, distant, not her own, or lost    (b) Derealization s ymptoms , that is , objects , people, or surroundings , or a combination of seem unreal, dis tant, artificial, colorles s, or    (c) An acceptance that this is a s ubjective and spontaneous change, not impos ed by outs ide or other people (i.e., ins ight)

1920 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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   (d) A clear sensorium and absence of toxic confusional state or epilepsy

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural C linical Des criptions and Diagnos tic G uide line s . G eneva: W orld Health Organization; 1992:172, permis sion. S ome authorities disagree with the class ification of depers onalization as a dis sociative disorder. T hey that the absence of amnesia and its occurrence acros s many different ps ychiatric and organic conditions make likely that depersonalization is a final common pathway proces s rather than a s pecific dis order. T he DS M focus instead on the diss ociative alteration in s ens e of that is inherent in the pers is tent or recurrent of feeling detached from one's own body or mind. It is profound, but not ps ychotic, divis ion in sense of s elf qualifies it as a dis sociative disorder. Depers onalization disorder does differ in some important ways from the other diss ociative dis orders, but it may prove an informative exception. Its ubiquity as a symptom and ability to experimentally induce it in laboratory s ettings provide unique opportunities for res earch that may light on diss ociation in general.

E pidemiology T ransient experiences of depers onalization and 1921 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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derealization are extremely common in normal and populations. T hey are the third most commonly ps ychiatric symptoms, after depress ion and anxiety. A survey of a random s ample of 1,000 adults in the rural S outh found a 1-year prevalence of 19 percent for depers onalization and 14 percent for derealization. Not uncommon in seizure patients and migraine s ufferers , can also occur with us e of ps ychedelic drugs , marijuana, lysergic acid diethylamide (LS D), and and less frequently as a s ide effect of some such as anticholinergic agents. T hey have been after certain types of meditation, deep hypnos is , mirror or crystal gazing, and sensory deprivation experiences . T hey are common after mild to moderate head injury, where there is little or no loss of cons ciousnes s, but are s ignificantly les s likely if unconsciousness las ts for more than 30 minutes. One study es timated that at least 20 percent of minor head injury patients experience significant depers onalization and derealization. T hey are also common after lifethreatening experiences , with or without serious bodily injury. P sychiatric cas e s eries typically have two to four times more women than men. However, a recent, rigorous ly diagnosed s eries of 117 patients s howed a 1 to 1 ratio. Head injury and s eizure dis order samples are generally equally divided. S everal s tudies have age as a s ignificant factor for transient experiences of depers onalization and derealization, with adolescents young adults reporting the highes t rates in normal population s amples . Approximately one-half of college students (46 percent) in one s tudy reported at leas t 1922 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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significant episode of depersonalization within the prior year.

E tiology Ps yc hodynamic T raditional ps ychodynamic formulations have the disintegration of the ego or have viewed depers onalization as an affective res ponse in defense the ego. T hese explanations stress the role of overwhelming painful experiences or conflictual as triggering events. T he high rates in normal and in patients conceptualized as having borderline or narcis sistic pers onality organizations are cited as that ego immaturity or ego deficits are predisposing factors . More recently, attention has been drawn to the similarities between depersonalization and obsess ivecompuls ive s ymptoms. Depers onalization dis order patients often dis play obsess ive-like behaviors with res pect to their s ymptoms. T he split between an and a participating s elf is likened to the divis ion of and emotional experience in obsess ive patients. B oth groups res pond to serotonin reuptake inhibitors, the therapeutic res ponse for depers onalization disorder patients is usually less robust.

Traumatic S tres s A s ubs tantial proportion, typically one-third to one-half, patients in clinical depersonalization cas e s eries report histories of s ignificant trauma. S everal studies of victims find as much as 60 percent of those with a lifethreatening experience report at least trans ient depers onalization during the event or immediately 1923 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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thereafter. Military training s tudies find that symptoms depers onalization and derealization are commonly by stress and fatigue and are invers ely related to performance. One of P.1872 the few controlled, clinical studies found s ignificantly childhood trauma, es pecially emotional abuse, in welldiagnosed depers onalization disorder patients with normal s ubjects. In approximately 20 percent of a sample of chronic depers onalization patients , there was a first-degree relative with a severe ps ychotic illnes s, either schizophrenia or bipolar dis order. It was hypothesized the chronic fear engendered by the ps ychotic relative etiological in the s ubs equent development of the depers onalization disorder. F or example, one patient reported that, throughout her childhood, she was left alone by her father and older brother to handle her schizophrenic mother whenever the mother had episodes . T he patient recalled waiting in a s tate of and dread until the emergency workers came and hospitalized her mother. In general, the trauma reported by the patients was less severe than that typically reported by other diss ociative dis order patients. A large general population s tudy found that individuals with chronic were three times more likely to have episodes of depers onalization, but there was only a weakly as sociation with dangerous or ups etting experiences . A subs tantial number of individuals with disorder do not identify a traumatic antecedent and 1924 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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that the onset of their disorder occurred without a clear precipitant. On the other hand, nontraumatic s tres sors , such as interpers onal, financial, or occupational loss es, have been as sociated with the ons et or exacerbation of depers onalization disorder. In addition, chemical such as marijuana, hallucinogens, and s timulants , have been known to precipitate chronic depersonalization in some people. T hese individuals can be conceptualized having a neurobiological or genetic vulnerability to chronic depersonalization after drug us e.

Temporal L obe and L imbic Theories In the epileps y literature, there is a long-standing as sociation between symptoms of depersonalization derealization and temporal lobe and limbic s ys tem dysfunction. Wilder P enfield reported depersonalization symptoms elicited during neuros urgery by s timulation the superior and middle temporal gyri. B rain imaging studies have likewise found differential activation of areas. T he only s tudy to date res tricted to depers onalization patients found decreas ed activity in right s uperior and middle temporal gyri and increased brain glucos e metabolism bilaterally in the parietal Dis sociation and depers onalization s cale s cores were strongly correlated with increased parietal metabolic activity. Imaging s tudies of dis sociative s tates in P T S D patients find activation in all of thes e areas , as well as medial frontal gyrus and anterior cingulate gyrus. S ierra and G erman B errios propos e that involves a corticolimbic disconnection, such that left medial prefrontal activation reciprocally inhibits the left amygdala, producing detachment and decreased whereas right dorsolateral prefrontal activation with 1925 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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concomitant right amygdala inhibition leads to problems and feelings of emptines s.

Neurobiologic al Theories T he as sociation of depersonalization with migraines marijuana, its generally favorable res pons e to s elective serotonin reuptake inhibitor (S S R I) drugs , and the in depersonalization s ymptoms s een with the depletion L-tryptophan, a s erotonin precurs or, point to serotoninergic involvement. Depers onalization is the primary diss ociative symptom elicited by the drugchallenge s tudies des cribed in the s ection on neurobiological theories of dis sociation. T hese studies strongly implicate the NMDA s ubtype of the glutamate receptor as central to the genesis depers onalization symptoms. It s eems likely that serotoninergic and glutamate systems are involved in clinical depers onalization. T wo recent twin s tudies are for a genetic contribution to the development of depers onalization disorder.

Diagnos is and C linic al F eatures P atients experiencing depers onalization often have difficulty express ing what they are feeling. T rying to expres s their subjective s uffering with banal phras es , as “I feel dead,” “nothing s eems real,” or “I'm s tanding outside of myself,” depers onalized patients may not adequately convey to the examiner the distress they experience. W hile complaining bitterly about how this is ruining their life, they may nonetheles s appear undis tres sed. Accordingly, clinicians may not take the severity of this dis order as s eriously as they should. 1926 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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this outward appearance of lack of distress , depers onalization disorder patients are enduring an intens ely unpleasant, and often disabling, s ubjective experience. Many s ay that they would gladly exchange depers onalization for physical pain, which would at reconnect them with their body. T here are a number of distinct components to the experience of depers onalization. T hes e include a bodily changes , a s ens e of duality of self as observer actor, a s ens e of being cut off from others , and a sense being cut off from one's own emotions. On the other de re alization, coined by W illiam Mapother, is the s ens e that the world appears s trange, foreign, or dream-like. conceptualized as a diss ociative alteration in the perception of the environment. Objects may appear as viewed from a great dis tance and as if they are two dimensional, without depth or s ubs tance. S ounds come from a dis tance, muffled and dis torted. Objects feel strange to the touch. C olors dim and lose their vitality. faces of others change, becoming unfamiliar and frightening. T he world and all action and behavior los e meaning and purpose. Ms. R . was a 27-year-old, unmarried, graduate student a Masters in B iology. S he complained about episodes of “standing back,” us ually ass ociated with anxiety-provoking social s ituations . When as ked about recent episode, s he des cribed pres enting in a seminar cours e. “All of a s udden, I was talking, but it didn't feel it was me talking. It was very disconcerting. I had this feeling, ‘who's doing the talking? ' I felt like I was just watching. W atching someone els e talk. Lis tening to 1927 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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come out of my mouth, but I was n't s aying them. It me. It went on for a while. I was calm, even sort of It was as if I was very far away. In the back of the room somewhere—just watching myself. B ut the pers on didn't even seem like me really. It was like I was someone els e.” T he feeling lasted the res t of that day persis ted into the next, during which time it gradually diss ipated. S he thought that s he remembered having similar experiences during high school but was certain they occurred at leas t once a year during college and graduate s chool. Although she said that she us ually felt detached and s ometimes peaceful during the she was upset at the thought that s he would likely have more epis odes. S he complained that the sudden ons et, eeriness of s eemingly watching an almos t version of herself from a dis tance, and the sense of not “being in the world” were almos t unbearable in As a child, Ms. R . reported frequent intense anxiety overhearing or witnes sing the frequent violent and periodic physical fights between her parents. S he remembered lying awake in bed, listening to her imagining the terrible things that were occurring, or to occur, between them. In addition, the family was to many unpredictable dislocations and moves owing to the patient's father's intermittent difficulties with and employment. T he patient's anxieties did not abate when the parents divorced when she was a late adoles cent. Her father moved away and had little contact with her. Her relations hip with her mother increasingly angry, critical, and contentious. S he was unsure if she experienced depers onalization during childhood while listening to her parents ' fights. 1928 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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P.1873

Differential Diagnos is T he variety of conditions ass ociated with complicate the differential diagnos is of disorder. Depersonalization may result from a medical condition or neurological condition, intoxication or withdrawal from illicit drugs , or as a s ide effect of medications or may be ass ociated with panic attacks, phobias, P T S D, or acute s tres s disorder, schizophrenia, another dis sociative disorder. A thorough medical and neurological evaluation is es sential, including s tandard laboratory s tudies , an E E G , and any indicated drug Drug-related depers onalization is typically trans ient, but persis tent depers onalization may follow an episode of intoxication with a variety of s ubs tances , including marijuana, cocaine, and other psychostimulants. A neurological conditions , including s eizure disorders , tumors , postconcus sive syndrome, metabolic abnormalities , migraine, vertigo, and Ménière's dis eas e, have been reported as causes . Depersonalization organic conditions tends to be primarily s ensory without the elaborated des criptions and pers onalized meanings common to ps ychiatric etiologies.

C ours e and P rognos is Depersonalization after traumatic experiences or intoxications commonly remits spontaneously after removal from the traumatic circums tances or ending of episode of intoxication. Depersonalization mood, ps ychotic, or other anxiety disorders commonly 1929 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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remits with definitive treatment of these conditions . Depersonalization dis order its elf may have an episodic, relaps ing and remitting, or chronic course. T he latter is most common. Many patients with chronic depers onalization may have a course characterized by severe impairment in occupational, s ocial, and functioning. Mean age of ons et is thought to be in late adoles cence or early adulthood in mos t cases. Mos t depers onalization disorder patients are initially treated secondary anxiety and mood dis order symptoms. T he primary nature of the depers onalization dis order is only recognized later on. T raumatic or s tres sful events exacerbate depers onalization disorder symptoms . S ymptom exacerbations are commonly related to affects; high levels of sensory input; and threatening, stress ful, or unfamiliar situations .

Treatment C linicians working with depersonalization patients often find them to be a singularly clinically refractory group. T here is s ome s ys tematic evidence that S S R I antidepres sants, such as fluoxetine (P rozac), may be helpful to depersonalization patients. However, two recent, double-blind, placebo-controlled studies found efficacy for fluvoxetine (Luvox) and lamotrigine, res pectively, for depers onalization disorder. C linical experience s uggests that many depers onalization res pond at bes t s poradically and partially to the usual groups of psychiatric medications, s ingly or in combination: antidepres sants, mood s tabilizers , typical and atypical neuroleptics , anticonvuls ants, and s o Many different types of psychotherapy have been used 1930 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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with depers onalization patients : ps ychodynamic, cognitive, cognitive-behavioral, hypnotherapeutic, and supportive. No systematic data exist that compare modalities. C linical experience s ugges ts that many depers onalization patients do not have a robust to thes e s pecific types of standard ps ychotherapy. A large cas e s eries of severely ill depers onalization found that s tres s management strategies , dis traction techniques, reduction of sensory s timulation, relaxation training, and phys ical exercise may be somewhat some patients. Nonetheles s, many s everely impaired patients may require long-term s upportive treatment, the clinician being acutely aware of the patient's interpersonal sensitivity, distress , and s ens e hopeless nes s about the condition. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IV E F UG

DIS S OC IATIVE FUGUE P art of "17 - Dis sociative Dis orders " Dis sociative fugue is the leas t s tudied and mos t poorly unders tood of the dis sociative disorders . T he the disorder are similar to those of dis sociative and diss ociative identity disorder.

Definition T he es sential feature of diss ociative fugue (T able 17described as sudden, unexpected, travel away from 1931 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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or one's customary place of daily activities, with recall some or all of one's past (C riterion A). T his is accompanied by confusion about pers onal identity or even the ass umption of a new identity (C riterion B ). disturbance does not occur exclus ively during the of dis sociative identity dis order and is not due to the phys iological effects of a s ubs tance or a general condition (C riterion C ). T he symptoms mus t cause significant distress or impairment in s ocial, or other important areas of functioning (C riterion D).

Table 17-12 DS M-IV-TR C riteria for Dis s oc iative Fugue A. T he predominant dis turbance is sudden, unexpected travel away from home or one's customary place of work, with inability to recall past. B . C onfus ion about personal identity or of a new identity (partial or complete). C . T he disturbance does not occur exclusively the cours e of dis sociative identity dis order and is due to the direct phys iological effects of a (e.g., a drug of abus e, a medication) or a general medical condition (e.g., temporal lobe epilepsy). D. T he s ymptoms cause clinically s ignificant 1932 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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or impairment in s ocial, occupational, or other important areas of functioning.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

His tory In the 19th century, the magnetic dis orders included nocturnal s omnambulism and its waking counterpart, ambulatory automatis m or fugue. In these conditions, person performed activities that were complex and coordinated but apparently “cut off from the continuity cons ciousnes s ” with res ultant amnes ia. C harcot and contemporaries reported a number of these cases and studied them intens ively. C harcot divided the cases those with epileptic, traumatic, or hys terical etiology, although a modern reading of the cases s ugges ts that some of thos e diagnosed with epileptic or traumatic fugues would be more readily class ified as having a diss ociative dis order today. Outs ide E urope, during this time, there was interes t in similar phenomena as well. In the United S tates, described one of the paradigmatic cases of fugue with change of pers onal identity, that of Ansel B ourne. an itinerant preacher, dis appeared from his home in P rovidence, R hode Is land, in J anuary 1887, after 1933 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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withdrawing $500 from his bank account to pay some T wo months later, he “awoke,” finding hims elf in Norristown, P ennsylvania, where had been living under the name of A. J . B rown and working as a shopkeeper. S ubsequently, he had no memory for the between his disappearance and his return to the identity. Under hypnos is , he could communicate as and described his activities during the fugue but could unify his memory with that of B ourne. During the fugue, B ourne apparently behaved normally and did not unusual attention. J anet als o s tudied fugue s tates in his clas sic s tudies of diss ociation and hys teria. J anet hypothesized that was bas ed on diss ociation of more complex groups of mental functions than occurred in amnesia and was us ually organized around a powerful emotion or feeling state that linked many trains of ass ociations by a wish to run away. P.1874 Dis sociative fugue was also des cribed by World W ars I II military ps ychiatris ts. Important papers des cribing studies of diss ociative fugue in civilian and military populations were written in the 1940s by the ps ychoanalytic authors David R appaport, C harles E lisabeth G eleerd, Merton G ill, and Margaret B renman, among others. However, many of thes e cases would clas sified as dis sociative amnesia, diss ociative NOS , or, poss ibly, dis sociative identity dis order by contemporary diagnos tic criteria.

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T here are insufficient data to validate diss ociative a disorder distinct from diss ociative amnes ia, identity dis order, or other trauma s pectrum conditions. F urther research is needed to clarify whether fugue s hould be cons idered a s eparate disorder rather than a s ymptom of other disorders. Individuals with various culturally defined running syndromes may have s ymptoms that meet diagnos tic criteria for dis sociative fugue. T hese conditions are characterized by a s udden onset of a high level of trance-like states , potentially dangerous behavior in the form of running or fleeing, and ens uing exhaustion, and amnesia for the epis ode. T hey include pibloktoq among native peoples of the Arctic, gris i s iknis among Miskito of Honduras and Nicaragua, latah and amok in Wes tern P acific cultures , and Navajo frenzy witchcraft.

E tiology T raumatic circumstances, leading to an altered s tate of cons ciousnes s dominated by a wish to flee, are be the underlying caus e of most fugue episodes . have included combat, rape, recurrent childhood abuse, mass ive s ocial dis locations , and natural most other cases , there has been a s imilar antecedent history, although a ps ychological trauma was not at the ons et of the fugue epis ode. In thes e cases, of, or in addition to, external dangers or traumas, the patients were us ually s truggling with extreme emotions impulses, s uch as overwhelming fear, guilt, shame, or intens e incestuous , s exual, suicidal, or violent urges, or combination of thes e, that were in conflict with the patient's cons cience or ego ideals . T hus, the patients 1935 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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also des cribed as experiencing mas sive ps ychological conflict from which fight or flight was experienced as impos sible or psychologically unacceptable, resulting in diss ociation in which the patient could flee without cons ciously acknowledging doing s o. S hortly after the end of the G ulf War, a s oldier was to a military ps ychiatric facility after emerging from a movie in a disoriented and disorganized s tate. the police were called and determined that he had no apparent awarenes s of his identity or life his tory and he was disoriented to current circumstances. At the hospital, a complete medical, toxicological, and neurological workup was within normal limits, and a ps ychiatric consultation was reques ted. T he patient presented as a perplexed, disoriented, healthy young who des cribed complete amnesia for pers onal identity life history, depers onalization, derealization, confus ion, and anxiety and fear at his predicament. Military were located that showed the patient to have been in combat in the G ulf W ar. He had been s ubject to a fire incident in which several of his buddies were killed he himself barely escaped severe injury or death. He treated at a military hospital and was airlifted back to United S tates , where he was treated at another military facility, was adjudged healthy, and, at his reques t, was discharged back to active duty. He was noted to have gone absent without leave at this point and only res urfaced in the movie theater, 3 months later, 2,000 miles from where he was suppos ed have reported back for duty. W hen family and friends visited, he experienced them as “familiar” but did not 1936 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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who they were. T he patient's father was a decorated veteran of World II who had phys ical dis abilities and P T S D subsequent service. He enforced brutal phys ical discipline on his children but was a charis matic, complex man deeply loved by his children, who protected and him. He had died suddenly, shortly before the patient entered military s ervice. T he s on had vowed to follow his father's footsteps. T he patient did not res pond to attempts to help him regain his memory by free recall s trategies, and a hypnosis was begun. Over a s eries of hypnosis the patient was given age-regress ion suggestions , him back to the beginning of the fugue, the time during the fugue, the point of loss of awarenes s of pers onal identity, and the events during the war. T he events were recons tructed as follows: T he patient not shown it at the time but had been profoundly traumatized by the friendly fire incident. He felt guilt at surviving his friends, horror at the carnage that had place around him, terrified at what had happened, and furious at his own military and government for its in the occurrence of the friendly fire event. He was at his superiors, his branch of service, and his country, whom he felt had failed him and his friends by attacking them. At the s ame time, he was deeply loved his country, and identified with his father's wish him to be a “good s oldier.” After dis charge from the state-side hos pital, he that he needed to get back to his unit and put the past behind him. Unconsciously, however, he felt vengeful toward the military and had violent fantas ies of 1937 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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agains t his superiors. During his travels acros s the he had the overriding conviction that he had to get to join his unit, although traveling thousands of miles in the oppos ite direction. He ass umed another name and apparently attracted no attention during his In the city in which he was found, he met several who sugges ted that he attend a movie with them. T he movie plot centered around a friendly fire episode the V ietnam W ar. T he patient became emotionally overwhelmed, entered an altered s tate, and eventually brought to clinical attention. Over the course of s everal months of hypnotherapy ps ychotherapy, the patient was able to regain his and to better integrate his respons e to the wartime traumas and began to work out and tolerate his mixed feelings about his father. At times, recall of the wartime and childhood traumas was as sociated with intense of sadnes s, anger, horror, and confusion. He well to addition of an S S R I antidepress ant to help modulate symptoms of P T S D, dysphoria, depres sion, anxiety. As therapy progress ed, the patient was more to tolerate thes e emotions and was less overwhelmed them. He also began to report a much more chronic history of diss ociative s ymptoms, with pers is tent imaginary companions until late adoles cence, fugue and amnesia episodes in childhood and adoles cence, and a sens e of inner division into multiple s elf-states . He received a medical dis charge from the military with diagnoses of P T S D, diss ociative dis order NOS , and disorder NOS .

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E pidemiology As noted previous ly, no cas e of diss ociative fugue was diagnosed in a random general population s ample in Winnipeg, C anada. T he disorder is thought to be more common during natural disasters , wartime, or times of major social dislocation and violence, although no systematic data exis t on this point. Most of the pre– cases are difficult to ass ess , because the diagnostic conventions are so different. Most cas es in the describe men with diss ociative fugue, primarily in samples . However, no adequate data exis t to a gender bias to this dis order. Dis sociative fugue is described in adults . P.1875

Diagnos is and C linic al F eatures Dis sociative fugues have been des cribed to las t from minutes to months. S ome patients report multiple However, in most cases in which this was described, a more chronic dis sociative disorder, such as identity dis order, was not ruled out. In some extremely s evere cas es of P T S D, nightmares be terminated by a waking fugue in which the patient to another part of the hous e or runs outs ide, for C hildren or adolescents may be more limited than in their ability to travel. T hus, fugues in this population may be brief and involve only short distances. S ome of children or adoles cents who precipitously run away actually may be cases of diss ociative fugue, with the es caping from an abusive or violent home situation. No 1939 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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systematic res earch exis ts on this point. A teenage girl was continually sexually abused by her alcoholic father and another family friend. S he was threatened with perpetration of sexual abus e on her younger s iblings if she told anyone about the abuse. girl became suicidal but felt that she had to stay alive to protect her siblings . S he precipitously ran away from after being raped by her father and s everal of his a “birthday present” for one of them. S he traveled to a of the city where she had lived previously with the idea that s he would find her grandmother with whom she lived before the abus e began. S he traveled by public transportation and walked the s treets, apparently attracting attention. After approximately 8 hours , she stopped by the police in a curfew check. When she could not recall recent events or give her current addres s, ins isting that she lived with her grandmother. initial ps ychiatric examination, she was aware of her identity, but she believed that it was 2 years earlier, her age as 2 years younger and insisting that none of events of recent years had occurred. C las sically, three types of fugue have been described: fugue with awarenes s of loss of pers onal identity; (2) with change of pers onal identity; and (3) fugue with retrograde amnesia. In stage I, there is thought to be generation of an altered state of cons cious nes s during which complex activities may be engaged in, over long periods of time. A s ingle idea that s ymbolizes condenses, or both, a number of important ideas and emotions frequently dominates the patient's thinking in this s tage. In stage II, the patient becomes aware of 1940 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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amnes ia or loss of pers onal identity, at which point he she frequently is brought for treatment. In this s tage, amnes ia is us ually pres ent for the first stage. In s tage patient returns to his or her baseline state, usually with amnes ia for the first stage and s ometimes for the as well. An alternative view des cribes stage II as a the baseline state with amnesia for stage one or to a in which there is (1) awarenes s of loss of pers onal (2) change in personal identity, or (3) return to a chronologically earlier period of life, similar to a spontaneous hypnotic age regress ion. During a fugue, patients often appear without ps ychopathology and do not attract attention. On the other hand, some individuals may display overtly disorganized, or dangerous behavior, such as a soldier the mids t of battle who began a fugue epis ode by standing up and walking away from the front lines , expos ing hims elf to intense enemy fire. After the termination of a fugue, the patient may experience perplexity, confus ion, trance-like behaviors, depers onalization, derealization, and convers ion symptoms, in addition to amnesia. S ome patients may terminate a fugue with an epis ode of generalized diss ociative amnesia. T hey may be brought to media attention in an attempt to dis cover who they are and where they have come. As the dis sociative fugue patient begins to become diss ociated, he or s he may display mood disorder symptoms, intense suicidal ideation, and P T S D or anxiety dis order symptoms. In the class ic cases, an identity is created under whos e auspices the patient for a period of time. Many of these latter cas es are 1941 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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clas sified as dis sociative identity disorder or disorder NOS with features of dis sociative identity disorder.

P athology and L aboratory E xamination P atients with diss ociative fugue tend to have high on s tandardized measures of hypnotizability and diss ociation. Diss ociative fugue can be diagnosed with DDIS or the S C ID-D-R . B ecause dis sociative fugue res ponse to s exual trauma, clinicians s hould have an of sus picion for s exually trans mitted dis eas es and or rectal trauma. P hysical and laboratory examinations should be directed at ruling out medical caus es of diss ociative fugue.

Differential Diagnos is Individuals with dis sociative amnes ia may engage in confused wandering during an amnes ia epis ode. in dis sociative fugue, there is purpos e ful travel away the individual's home or customary place of daily us ually with the individual preoccupied by a single idea that is accompanied by a wish to run away. P atients with diss ociative identity disorder may have symptoms of diss ociative fugue, usually recurrently throughout their lives . Dis sociative identity dis order patients have multiple forms of complex amnes ias and, us ually, multiple alter identities that develop starting in childhood. In complex partial s eizures, patients have been noted exhibit wandering or semi-purpos eful behavior, or both, during seizures or in pos tictal s tates, for which there is 1942 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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subs equent amnesia. However, seizure patients in an epileptic fugue often exhibit abnormal behavior, confusion, perseveration, and abnormal or repetitive movements. Other features of s eizures are typically reported in the clinical his tory, s uch as an aura, motor abnormalities , s tereotyped behavior, perceptual alterations , incontinence, and a postictal s tate. events may be ass ociated with an increas e in s eizure frequency in some s us ceptible patients . T hus, this alone is not s ufficient as a differential diagnostic S erial or telemetric E E G s, or both, usually s how abnormalities as sociated with behavioral pathology. Wandering behavior during a variety of general medical conditions, toxic and s ubs tance-related dis orders, dementia, and organic amnes tic s yndromes could theoretically be confus ed with diss ociative fugue. However, in most cases , the s omatic, toxic, subs tance-related dis order can be ruled in by the phys ical examination, laboratory tes ts, or toxicological drug s creening. Us e of alcohol or substances may be involved in precipitating an epis ode of dis sociative Wandering and purposeful travel may occur during the manic phase of bipolar disorder or schizoaffective Manic patients may not recall behavior that occurred in the euthymic or depress ed s tate and vice versa. In purpos eful travel due to mania, however, the patient is us ually preoccupied with grandiose ideas and often attention to hims elf or herself owing to inappropriate behavior. Ass umption of an alternate identity does not occur. S imilarly, peripatetic behavior may occur in some with s chizophrenia. Memory for events during 1943 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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episodes in such patients may be difficult to ascertain owing to the patient's thought P.1876 disorder. However, dis sociative fugue patients do not demonstrate a ps ychotic thought disorder or other symptoms of ps ychosis . Malingering of diss ociative fugue may occur in who are attempting to flee a s ituation involving legal, financial, or pers onal difficulties , as well as in soldiers are attempting to avoid combat or unpleasant military duties . T hese precipitating factors may be present as in bona fide diss ociative fugue, however. T here is no battery of tests, or s et of procedures that invariably distinguish true dis sociative s ymptoms from those that malingered. Malingering of diss ociative symptoms, reports of amnes ia for purpos eful travel during an of antisocial behavior, can be maintained even during hypnotic or pharmacologically facilitated interviews. malingerers confess s pontaneous ly or when the forensic context, the examiner s hould always give careful cons ideration to the diagnos is of malingering fugue is claimed.

C ours e and P rognos is Most fugues are relatively brief, lasting from hours to Most individuals appear to recover, although refractory diss ociative amnesia may persist in rare cases. S ome studies have described recurrent fugues in the majority individuals presenting with an epis ode of dis sociative fugue. However, no s ys tematic modern data exis t that attempt to differentiate diss ociative fugue from 1944 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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diss ociative identity disorder with recurrent fugues .

Treatment Dis sociative fugue is usually treated with an eclectic, ps ychodynamically informed ps ychotherapy that on helping the patient recover memory for identity and recent experience. Hypnotherapy and facilitated interviews are frequently necess ary techniques to as sist with memory recovery. T herapy should be carefully paced, following the phas ic discuss ed in prior sections. T he initial phase is es tablis hing clinical s tabilization, safety, and a alliance us ing supportive and educative interventions . P atients may need medical treatment for injuries during the fugue, food, and sleep. Once stabilization is achieved, s ubs equent therapy is focus ed on helping the patient regain memory for life circums tances , and personal history. During this proces s, extreme emotions related to trauma or s evere ps ychological conflict, or both, may emerge that require working through. In general, the therapist should a s upportive and nonjudgmental stance, es pecially if fugue has been precipitated by intense guilt or shame an indis cretion. At the s ame time, it is important for the therapist to balance this with being a spokes pers on for patient, taking realis tic res ponsibility for misbehavior. C linicians s hould be prepared for the emergence of suicidal ideation or s elf-destructive ideas and impuls es the traumatic or s tres sful prefugue circums tances are revealed. P sychiatric hospitalization may be indicated if the patient is an outpatient. 1945 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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In this phase of treatment, hypnotherapy may be containing intense affects and impulses , titrating the of returning memory, and process ing and integrating memory material. P atients may need specific ps ychopharmacological interventions for mood, and dyscontrol s ymptoms as the acute dis sociative symptoms are reduced and the patient becomes cons ciously aware of his or her actual life situation. S ome diss ociative fugue patients may res is t their actual identity even with hypnosis or pharmacologically as sis ted interviews. Appeals through the local (or even regional) media may not alert the patient's concerned others if the patient has wandered subs tantial dis tance from home. In one case, the was as ked to randomly s elect numbers on a phone key pad. T his res ulted in the patient's tapping out a phone number—apparently outside of cons cious awarenes s — that allowed the treating clinician to find the patient's family hundreds of miles away. F amily, s exual, occupational, or legal problems , or a combination of these, that were part of the original that generated the fugue episode may be s ubs tantially exacerbated by the time the patient's original identity life s ituation are detected. T hus , family treatment and social s ervice interventions may be necess ary to help res olve s uch complex difficulties . R arely, in the mos t extreme cases, the fugue patient es tablis hed a new identity, occupation, and s ocial relations hips in a different location. When the original identity is dis covered, often by accident, a variety of predicaments may ensue regarding the real-world complications of the s ituation. In res pons e to these, the 1946 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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patient may become acutely s uicidal, overwhelmed, or confused, or a combination of these. Als o, the patient display other extreme or bizarre dis sociative such as the G anser s ymptom of approximate answers the question “What color is snow? ” is answered with “green”) or attempt to engage in another fugue to the s ituation. When diss ociative fugue involves ass umption of a new identity, it is us eful to conceptualize this entity as ps ychologically vital to protecting the person. experiences , memories , cognitions, identifications, emotions , s trivings , or self-perceptions, or a of thes e, have become s o conflicting and, yet, s o peremptory that the pers on can res olve them only by embodying them in an alter identity. T he therapeutic in such cas es is neither s uppress ion of the new identity fas cinated explication of all its attributes . As in identity dis order, the clinician s hould appreciate the importance of the psychodynamic information within the alter pers onality state and the intensity of the ps ychological forces that necess itated its creation. In cases, the mos t desirable therapeutic outcome is the identities , with the person working through and integrating the memories of the experiences that precipitated the fugue. Once the fugue had resolved, the problem of for illegal acts may become an is sue (e.g., having without divorcing a prior s pouse, financial T he treating ps ychiatris t may become involved with and legal agencies , military authorities, and others who may be brought into these complex cases . It is prudent for the treating clinician to try to balance in 1947 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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commons ens e way the patient's real respons ibility for or her behavior, as well as the ps ychopathological that may be mitigating factors. Attempts to find a mediated agreement among the contending parties than punis hment alone may be best in s ituations in sexual, marital, or financial mis deeds, or a combination these, complicate the clinical situation. However, it is important that, whatever resolution is found, it should focus on real res ponsibility for mis conduct being by the patient. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IV E IDE NT IT Y

DIS S OC IATIVE IDE NTITY DIS OR DE R P art of "17 - Dis sociative Dis orders " Dis sociative identity dis order, previously called multiple pe rs onality dis orde r, has been res earched most of all the dis sociative disorders . It is the paradigmatic diss ociative psychopathology in that the symptoms of the other diss ociative disorders are commonly found in patients with diss ociative identity disorder: amnesias, fugues , depers onalization, derealization, and similar symptoms. According to DS M-IV -T R , diss ociative identity disorder characterized by the pres ence of two or more distinct identities or P.1877 1948 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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personality s tates that recurrently take control of the individual's behavior accompanied by an inability to important pers onal information that is too extensive to explained by ordinary forgetfulness .” T he identities or personality s tates, sometimes called alters , s e lf-s tate s , ide ntitie s , or parts , among other terms , differ from one another in that each pres ents as having “its own enduring pattern of perceiving, relating to, and thinking about the environment and self” (T able 17-13).

Table 17-13 DS M-IV-TR C riteria for Dis s oc iative Identity Dis order A. T he presence of two or more dis tinct identities personality s tates (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and s elf). B . At least two of thes e identities or pers onality states recurrently take control of the person's behavior. C . Inability to recall important personal that is too extens ive to be explained by ordinary forgetfulness . D. T he disturbance is not due to the direct 1949 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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phys iological effects of a s ubs tance (e.g., or chaotic behavior during alcohol intoxication) or general medical condition (e.g., complex partial seizures ). Note: In children, the s ymptoms are attributable to imaginary playmates or other play.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

His tory After the extraordinary interest in multiple pers onality throughout the 19th century, the study of diss ociative identity dis order mostly waned after the beginning of 20th century. Authorities s ugges t that this was related variety of factors , including the rising dominance of freudian paradigms of hysteria; the dis repute into which hypnosis fell at this time; the ris e of the bleulerian cons truct of s chizophrenia, which may have s ubsumed diss ociative patients; and the los s of interest in the of J anet, P rince, and others who had been so crucial in development of models of diss ociation. A number of studies, such as the famous T hre e F ace s of E ve , to be published in the profes sional and popular In addition, periodic s ys tematic reviews of the literature continued to support the validity of the diagnos tic 1950 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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cons truct. T he modern era in the s tudy of multiple pers onality disorder began with the work of Arnold Ludwig and colleagues at the Univers ity of K entucky during the T his included their extens ive work on the single cases of diss ociative identity disorder and personality disorder, studying the differential findings among the alter identities . C ornelia W ilbur, widely identified with the cas e of S ybil, was influential in describing the clinical features of the modern construct diss ociative identity disorder and identifying the role of childhood trauma as a major factor in the etiology of disorder. W ilbur, R ichard K luft, and others began the articulation of a systematic modern treatment B eginning in the 1980s , P utnam, E ve C arls on, J udith Armstrong, R os s, P hillip C oons , S teinberg, Onno van Hart, S uzette B oon, Nel Draijer, V edet S ar, and other res earchers in the United S tates , C anada, E urope, America, T urkey, and J apan began systematic studies on the phenomenology, epidemiology, ps ychobiology, and treatment of diss ociative identity disorder in children, adoles cents, and adults . Des pite controvers y continues over the validity of the disorder, with a vocal minority of clinicians subscribing to the of dis sociative identity dis order.

Validity of the Dis s oc iative Dis order C ons truc t Debate about the existence of dis sociative identity disorder has waxed and waned for more than a However, s ufficient data on pathological diss ociation, in general, and on diss ociative identity disorder, in 1951 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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have accrued to judge this condition by the s ame standards that are applied to the validity of other ps ychiatric diagnoses . T he most widely accepted s tandards are bas ed on a criteria first articulated by E li R obins and S amuel G uze subs equently refined by others . In ess ence, a diagnosis is cons idered valid if it satis fies three basic requirements: content validity, criterion-related validity, and cons truct validity. C ontent validity requires a clinical description of the disorder that is repeatedly independently replicated. More than a dozen clinical phenomenological s tudies of dis sociative identity including those from North America, S outh America, E urope, T urkey, and Asia, document the presence of a diss ociative psychopathology in dis sociative identity disorder patients that fulfills this requirement. C riterionrelated validity requires that laboratory tests or reliable ps ychological tes ts are consis tent with the defined picture. T his stipulation is met by the reliable and valid diagnostic interviews and s cales that have increas ingly been used in diss ociation research, as well as tes ting protocols that discriminate diss ociative identity disorder patients from normals, s chizophrenics, and depres sed patients, among others . C ons truct or dis criminant validity requires that the disorder be differentiable from other disorders . T his been empirically demonstrated for diss ociative identity disorder with res pect to dis orders such as borderline and other pers onality disorders , and disorders . Als o, diss ociative identity disorder patients be dis criminated from normal individuals and other ps ychiatric patient groups , including those with 1952 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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personality dis orders, P T S D, and dis sociative disorder by structured interviews such as the S C ID-D-R . P sychological tes t batteries and experimental cognitive and ps ychophys iological s tudies have discriminated diss ociative identity dis order patients from other including s imulators. In addition, recent reviews of the diss ociative identity disorder cons truct, using a number different ps ychiatric validity paradigms , found that diss ociative identity dis order met all current criteria for valid diagnosis in ps ychiatry. R ecent psychobiological s tudies have s hown that a of variables, s uch as s alivary cortis ol, urinary catecholamines , low-dose dexamethas onetes t (DS T ), and MR I meas urements of hippocampal amygdala volume, dis criminate dis sociative identity disorder from patients with borderline pers onality and trauma controls (T C s ). However, there were only subtle biological differences between dis sociative disorder and P T S D s ubjects, although the two groups differed s ignificantly in s everal meas ures of such as the C ADS S and the DE S . On the G S S , a meas ure of susceptibility to external press ure to confabulated narrative accounts , the diss ociative disorder s ubjects s cored as le s s s uggestible than with P T S D, borderline personality dis order, and traumatized controls . T hese findings s upport the notion that diss ociative identity disorder is best a posttraumatic ps ychopathology, not an iatrogenic condition or an epiphenomenon of borderline disorder or other disorders. Accordingly, dis sociative identity dis order satis fies accepted standards for ps ychiatric validity and s hould 1953 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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regarded as a legitimate disorder requiring an informed diagnostic and treatment approach. P.1878

E pidemiology F ew s ys tematic epidemiological data exist for identity disorder. One study yielded a prevalence rate 3.1 percent for a stratified s ample (N = 1,055) of the general population of W innipeg, C anada, although a cons ervative analysis of these data sugges ts a of approximately 1.3 percent for dis sociative identity disorder. Independent analys is of the DE S data on the same s ample found a prevalence rate of 3.3 for pathological dis s ociation, a construct including DE S items for amnes ia, depersonalization, derealization, identity confus ion and alteration, and inner voices (ps eudohallucinations), a s ymptom profile typical of clinical diss ociative identity disorder patients . S everal studies have examined the prevalence rate of identity dis order in general ps ychiatric patient s amples . R es ults from the United S tates , C anada, T urkey, and Wes tern E uropean countries using structured interview data s uggest that between 1 and 20 percent of and adult psychiatric inpatients meet diagnostic criteria diss ociative identity disorder, with an average es timate 3 to 5 percent across studies. Higher rates were found subs tance abus e treatment populations and inpatient adoles cents . Available epidemiological data are insufficient, and a large-scale, population-based study neces sary to res olve controversies about the diss ociative identity disorder. 1954 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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C linicians have long noted gender differences in the frequency of diss ociative identity disorder. C linical report female to male ratios between 5 to 1 and 9 to 1 diagnosed cases. R esearch with meas ures s uch as the however, finds no evidence of gender differences in the propens ity or capacity to dis sociate. Developmental studies indicate that the ratio of female to male diss ociative identity disorder cas es s teadily increas es 1 to 1 in early childhood to approximately 8 to 1 by late adoles cence. R easons proposed for the increas ed of female dis sociative identity dis order patients relative male patients include gender-related differences in the types , age of ons et, and duration of maltreatment experienced by men and women; differences in clinical presentations , s uch that male cas es are more likely to miss ed; and the poss ibility that more male diss ociative identity dis order cases end up in the criminal jus tice or alcohol and drug treatment systems , or both, rather the mental health system.

E tiology T heories of the etiology of diss ociative dis orders have been extensively discus sed in the introductory section diss ociative phenomena. T his section briefly the theories that are most relevant to diss ociative disorder and that are best s upported by empirical data. Dis sociative identity dis order is strongly linked to experiences of early childhood trauma, us ually maltreatment, in all studies —in W estern and noncultures—that have systematically examined this T he rates of reported severe childhood trauma for child and adult diss ociative identity disorder patients range 1955 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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from 85 to 97 percent of cases acros s a wide variety of studies. P hys ical and sexual abuse, us ually in are the mos t frequently reported sources of childhood trauma in clinical research studies , although other trauma have been reported, s uch as multiple painful medical and surgical procedures during childhood and wartime trauma. C ritics have raised questions about validity of dis sociative identity dis order patients' s elfreports of childhood trauma. R ecent studies, including large s amples of maltreated children with diss ociative disorders and intensively validated case studies, have provided rigorous independent corroboration of the patients' reports of maltreatment. T hese studies to strongly s upport a developmental linkage between childhood trauma and diss ociative identity disorder. E arly life experiences resulting in dis turbances in attachment relations hip with the primary caregiver and other abnormal family proces ses have been implicated the genes is of pathological levels of diss ociation and development of diss ociative identity disorder. R ecent res earch indicates that a high level of diss ociation in mothers is ass ociated with dis turbed, often like, attachment behavior in their children. In another study, early pres ence of these attachment dis turbances prospectively predicted higher levels of diss ociation in adoles cence. T he contribution of genetic factors is only now being s ys tematically ass es sed, but preliminary have not found evidence of a significant genetic contribution. One small s tudy did find an elevated prevalence of dis sociative identity disorder and other diss ociative disorders in the firs t-degree relatives of diss ociative identity disorder patients. 1956 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Autohypnotic Model T he autohypnotic model is widely s ubs cribed to by clinicians working with dis sociative identity dis order patients. It postulates that pathological diss ociation is extreme form of s elf-hypnosis or autohypnos is . Autohypnos is is pos tulated to be adaptive in the immediate context of trauma or abus e but becomes maladaptively elaborated into dis sociative personality s tates. P roponents point to s imilarities between the phenomenology of deep trance states and some of the clinical phenomenology seen in identity dis order. Als o, adjunctive hypnotherapeutic interventions can be quite helpful in the treatment of many dis sociative identity dis order patients. In addition, studies of hypnotizability us ing s tandardized scales shown that dis sociative identity dis order patients have highes t hypnotizability compared to patients with other diagnoses, s uch as affective disorders , panic disorder, personality dis orders, and s chizophrenia, among well as normal controls. On the other hand, more than a dozen s tudies find only low correlations between meas ures of hypnotizability diss ociation in clinical and nonclinical s ubjects. A trauma is not ne ce s s arily as sociated with increas ed hypnotizability, although a s ubgroup of traumatized individuals shows high levels of hypnotizability clinically and on standardized measures. T hes e findings indicate that hypnotizability and clinical diss ociation, as defined standard meas ures , are different proces ses. Although hypnotizability may be a correlate of traumatization in some patients, the autohypnotic model of the etiology diss ociative identity disorder does not by its elf appear 1957 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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account for the disorder. However, autohypnotic and phenomena may be involved in s haping the clinical presentation of diss ociative identity disorder.

Dis c rete B ehavioral S tate Model T he DB S model conceptualizes dis sociative identity disorder as a developmental failure by a traumatized to consolidate a core s ens e of identity. Drawing on res earch demons trating the key role of DB S in the patterning and organization of normal early childhood behavior and affect regulation, the behavioral s tate postulates that trauma disrupts unification of identity in least two key ways . T he first is through the creation of as sociated with the mitigation of and res titution from repetitive traumatic experiences, s uch as incest. T hes e diss ociative behavioral s tates psychologically intolerable memories and affects through cognitive mechanisms, s uch as s tate-dependent learning and memory retrieval, described previous ly. S econd, traumatic experiences, together with disturbed child attachment and parenting, dis rupt the of normal metacognitive process es involved in the elaboration and cons olidation of a unified sense of s elf. T hese metacognitive process es, which flower between 6 years of age, enable the child to integrate the experiences of s elf that normally occur acros s different contexts , for example, with parents, peers , and others. corollary of this notion is the idea that the failure of integration of self may pres erve as pects of parent–child attachment neces sary for development, becaus e the may continue to perceive the caretaker as good, mistreatment 1958 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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P.1879 or neglect (as in betrayal trauma therapy). traumatic experiences may also permit more normal maturation in other developmental dimensions , s uch as educational and intellectual tas ks , interpersonal and artistic endeavors. Overall, however, the long-term outcome of thes e developmental deficits and deformations operating over childhood and adolescence is an individual with relatively concretized, quasi-independent s ens es of s elf, which are often in psychological conflict with each other. T he secondary s tructuring of these s elf-states , due to a variety of developmental press ures and intrapsychic res ults in the concrete elaboration of the alter identities with names , personal des criptors , and variable ways of presenting thems elves to others. T hes e s econdary elaborations are not the core aspect of the disorder. However, they may be highly invested in by some diss ociative identity disorder individuals and thus may quite resistant to change. At the other extreme, some diss ociative identity dis order patients may show liability to influence and s uggestion in outward presentational features of the alters. V irtually no empirical data in any clinical or res earch population exis t to support the sociocognitive or iatrogenes is theory of the etiology of diss ociative disorder.

Diagnos is and C linic al F eatures T able 17-13 lists the DS M-IV -T R criteria for diss ociative identity dis order. T he comparable IC D-10 dis order, 1959 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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personality dis order, falls under the other diss ociative (conversion) dis order category. T he DS M-IV -T R and criteria are virtually identical. B oth require that organic disorders (e.g., general medical conditions , s ubs tance abuse) be ruled out. DS M-IV -T R adds that, in children, symptoms cannot be attributable to imaginary or other fantasy play.

Dimens ions of Trauma T raditional characterizations of dis sociative s ymptoms largely derive from 19th century formulations and do incorporate recent unders tanding of the psychiatric of trauma. C omparative study of ps ychiatric s ymptoms as sociated with different types of trauma sugges ts that number of common dimensions underlie traumatic sequelae. Affect modulation is frequently disturbed, ris e to mood s wings, depress ion, suicidal tendency, generalized irritability. Impuls e control is often leading to ris k taking, s ubs tance abus e, and or s elf-destructive behaviors. High levels of anxiety and panic are common. A variety of dis turbances in s ens e self, from the identity diffus ion s een in borderline to the alter identities of diss ociative identity disorder, reflects dis ruptions in the ps ychological integration of traumatic and nontraumatic aspects of self. E ating disorders are common in a s ubgroup of trauma and may als o relate to disorders of body image and identity. F requent somatization, conversion, and ps ychophys iological disorders may repres ent in the integration of ps ychic and s omatic of overwhelming recollections, intolerable affects, posttraumatic cognitive s chema, and intraps ychic conflicts. In addition, studies s uggest that childhood 1960 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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abuse survivors with ps ychophysiological disorders , compared to controls , are more likely to have a lower threshold for experiencing phys iological phenomena as noxious or painful. C ons equently, initial clinical presentations in trauma victims of all kinds may encompas s or mimic a variety ps ychiatric conditions, including affective and anxiety disorders , somatoform disorders , personality dis orders , and ps ychos is . S ome of these dis orders may als o be comorbidly ass ociated with diss ociative identity es pecially P T S D, affective disorders , somatoform subs tance use dis orders, and a mixed personality most commonly with s ome combination of avoidant, obses sive-compuls ive, dependent, and borderline All systematic studies of the clinical phenomenology of diss ociative identity disorder emphasize the polys ymptomatic pres entations of these patients. T herefore, the detection and diagnosis of dis sociative identity disorder involve looking behind a confus ing plethora of symptoms for core diss ociative symptoms functional amnes ias, depersonalization and pass ive influence experiences, and identity alterations. T ables 17-14, 17-15, and 17-16 describe the symptom clus ters that are mos t commonly found in diss ociative identity dis order patients and s ome of the mental status questions that may elicit these s ymptoms in sus pected diss ociative identity disorder patients .

Table 17-14 Amnes ia and S ymptoms 1961 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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B lackouts or time loss Dis remembered behavior F ugues Unexplained poss es sions Inexplicable changes in relations hips F luctuations in skills, habits, and knowledge F ragmentary recall of entire life his tory C hronic mistaken identity experiences Microdis sociations Mental s tatus examination ques tions for dis s oc iative amnes ia    If answers are pos itive, ask the patient to the event.    Make s ure to s pecify that the s ymptom does occur during an epis ode of intoxication.    (1) Do you ever have blackouts? B lank spells ?

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Memory laps es ?    (2) Do you los e time? Have gaps in your of time?    (3) Have you ever traveled a cons iderable without recollection of how you did this or where you went exactly?    (4) Do people tell you of things you have said done that you do not recall?    (5) Do you find objects in your poss es sion clothes, pers onal items , groceries in your grocery cart, books, tools, equipment, jewelry, vehicles, weapons , etc.) that you do not remember Out-of-character items? Items that a child might have? T oys? S tuffed animals ?    (6) Have you ever been told or found evidence you have talents and abilities that you did not that you had? F or example, musical, artis tic, mechanical, literary, athletic, or other talents ? Do your tastes s eem to fluctuate a lot? F or example, food preference, personal habits, taste in mus ic clothes, etc.    (7) Do you have gaps in your memory of your Are you miss ing parts of your memory for your history? Are you mis sing memories of some 1963 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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important events in your life? F or example, weddings, birthdays, graduations, pregnancies, of children, etc.?    (8) Do you los e track of or tune out or therapy s es sions as they are occurring? Do find that, while you are lis tening to s omeone talk, you did not hear all or part of what was jus t s aid?    (9) What is the longes t period of time that you lost? Minutes? Hours ? Days? Weeks? Months ? Des cribe.

Adapted from Loewens tein R J : An office mental status examination for chronic complex symptoms and multiple personality dis order. P s ychiatr C lin North Am. 1991;14:567–604.

Table 17-15 Dis s oc iative Identity Dis order Proc es s S ymptoms P res ence of diss ociative identity disorder alter identities

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S witching behaviors (identity alteration) Identity confusion P as sive influence s ymptoms /interference phenomena between alters    Made feelings from alter identity    Made impulses from alter identity    Made actions by alter identity    T hought ins ertion from alter identity    T hought withdrawal by alter identity    Alters ' voices commenting on behavior    Alters ' voices arguing Multimodal hallucinations or pseudohallucinations (may occur in a flas hback)    V isual    Auditory    T actile

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   Olfactory    G us tatory    S omatoform Dis sociative or pos ttraumatic thought dis order P os ttraumatic stress dis order–based cognitive distortions T rance logic Other thought process abnormalities    Disorganization due to s witching, pass ive    P osttraumatic s uspicious ness    Literal and concrete alternating with abstract Linguistic usage: refers to self as we, they, us , her, etc. Depersonalization and derealization symptoms    Depers onalization    Out-of-body experiences

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   Derealization    Déjà vu    J amais vu    Déjà-vécu    Dream-like states Mental s tatus examination ques tions for dis s oc iative identity dis order proc es s    If answers are pos itive, ask the patient to the event.    Make s ure to s pecify that the s ymptom does occur during an epis ode of intoxication.    (1) Do you act so differently in one s ituation compared to another s ituation that you feel like you were two different people?    (2) Do you ever feel that there is more than one you? More than one part of you? S ide of you? Do they s eem to be in conflict or in a struggle?    (3) Does that part (those parts) of you have its (their) own independent way(s) of thinking, perceiving, and relating to the world and the self? 1967 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Have its (their) own memories , thoughts , and feelings?    (4) Does more than one of these entities take control of your behavior?    (5) Do you ever have thoughts or feelings , or that come from inside you (outs ide you) that you cannot explain? T hat do not feel like thoughts or feelings that you would have? T hat s eem like thoughts or feelings that are not under your (pass ive influence)?    (6) Have you ever felt that your body was in behavior that did not s eem to be under your control? F or example, saying things, going buying things, writing things, drawing or creating things , hurting yours elf or others , etc.? T hat your body does not seem to belong to you?    (7) Do you ever feel you have to s truggle another part of you that seems to want to do or to say s omething that you do not wish to do or to (8) Do you ever feel that there is a force part) inside you that tries to stop you from doing saying s omething?    (9) Do you ever hear voices, s ounds, or conversations in your mind? T hat s eem to be 1968 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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discuss ing you? C ommenting on what you do? T elling you to do or not do certain things? T o hurt yours elf or others ? T hat s eem to be warning you trying to protect you? T hat try to comfort, support, or s oothe you? T hat provide important about things to you? T hat argue or say things that have nothing to do with you? T hat have names ? Men? W omen? C hildren?    (10) I would like to talk with that part (s ide, facet) of you (of the mind) that is called the “angry one” (the Little G irl, J anie, that went to Atlantic last weekend and s pent lots of money, etc.). C an part come forward now, pleas e?    (11) Do you frequently have the experience of feeling like you are outside yours elf, ins ide B es ide yourself, watching yourself as if you were another person?    (12) Do you ever feel disconnected from your body as if you (your body) were not real?    (13) Do you frequently experience the world around you as unreal? As if you are in a fog or a daze? As if it were painted? T wo-dimensional?    (14) Do you ever look in the mirror and not recognize yours elf? S ee someone else there?

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Adapted from Loewens tein R J : An office mental status examination for chronic complex symptoms and multiple personality dis order. P s ychiatr C lin North Am. 1991;14:567–604.

Table 17-16 Autohypnotic S ymptoms S pontaneous trance Deep enthrallment S pontaneous age regres sion Negative hallucinations Hidden obs erver phenomenon T rance logic (tolerance of logical incons is tency during a trance state) V oluntary analges ia/anes thes ia

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E ye roll, eye blinking, etc., with switching Mental s tatus examination ques tions for s pontaneous autohypnotic s ymptoms    (1) Do you frequently s pace out, trance out, out, withdraw from the world around you? by putting yours elf in a pleasant s cene or place in your mind? B y focus ing your attention on inside or outs ide of you? (s pontaneous trance)    (2) Do you get s o wrapped up in a book or a that you can completely block out everything else around you? As if the world could end, and you would s till be completely engros sed in that (enthrallment)    (3) Do you feel that you are different ages at different times ? Do you ever feel like you get Like you become a child or an adoles cent again? When this happens, does it feel like your body changes in s ize? Do you experience it in your only, or does your whole perception of yours elf the world change also? (spontaneous age regress ion)    (4) Do you ever not s ee or hear what is going around you? Do you or can you block out people and things altogether? (negative hallucinations)

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   (5) Are you able to block out (ignore) physical if you want to? W holly? P artly? Always? (voluntary analgesia)

Adapted from Loewens tein R J : An office mental status examination for chronic complex symptoms and multiple personality dis order. P s ychiatr C lin North Am. 1991;14:567–604.

Memory and Amnes ia S ymptoms Dis sociative disturbances of memory are manifest in several basic ways and are frequently observable in settings (T able 17-14). As part of the general mental examination, clinicians s hould routinely inquire about experiences of losing time, black-out spells, and major gaps in the continuity of recall for pers onal information. P atients rarely s pontaneous ly report these experiences and require active P.1880 inquiry by the interviewer to uncover amnesia. P os itive res ponses s hould be documented with s pecific provided by the patient. In some ins tances , patients coming to or waking up in the mids t of some activity little or no recall of how they came to be involved in activity. In other instances, patients find evidence of having done or acquired things for which they have no recall. F riends and family members may tell them 1972 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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significant things that they have said or done that they cannot remember. P atients may find that they have unknowingly traveled some dis tance (a fugue episode) that days or even weeks have pas sed for which the patients cannot account. Diss ociative time loss experiences are too extensive to be explained by forgetting and typically have s harply demarcated and offsets. It is important to es tablis h that s uch time experiences occur in the absence of intoxication or subs tance abus e, although high rates of drug and abuse in dis sociative patients may complicate this determination. P atients with severe diss ociative memory dis turbances also report perplexing fluctuations in skills, habits , or learned abilities , s uch as fluency in a foreign language athletic abilities. P atients report drawing a complete for skills or knowledge at times , whereas , at other they easily and reliably access the information in T his perplexing forgetfulness is believed to be related the diss ociative s tate-dependent disturbances of memory functions that have been documented in laboratory settings. Dis sociative patients often report s ignificant gaps in autobiographical memory, especially for childhood Dis sociative gaps in autobiographical recall are usually sharply demarcated and do not fit the normal decline in autobiographical recall for younger ages . F or example, patient may complain that he or s he cannot recall anything between 8 and 12 years of age, while readily available memories before and afterward. patient may report having no memories available for first 10 years of 1973 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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P.1881 life. Available autobiographical memories may have a depers onalized quality, such that recalled events s eem be memories of a dream or as if the patient had seen happen to someone else. Ms. A. is a 33-year-old married woman, employed as a librarian in a s chool for disturbed children. S he ps ychiatric attention after discovering her 5-year-old daughter “playing doctor” with several neighborhood children. Although this event was of little cons equence, patient began to become fearful that her daughter would be moles ted. Ms . A. became panicked and increasingly obses sed with this idea, much to the bafflement of her husband. T he patient was seen by her internist and was treated with antianxiety agents and antidepres sants , but with little improvement. Ms. A. became increas ingly anxious, phobic, depres sed, and preoccupied. S he ps ychiatric consultation from s everal clinicians, but repeated, good trials of antidepres sants, antianxiety and s upportive ps ychotherapy resulted in limited improvement. After the death of her father from complications of alcoholis m, the patient became more symptomatic. He had been es tranged from the family the patient was approximately 12 years of age, owing to drinking and ass ociated antis ocial behavior. Ms. A. developed a variety of somatic complaints, headaches, abdominal pain, mens trual and (G I) problems , back pain, and sleep difficulties. medical workup was unrevealing, leading to diagnoses such as fibromyalgia, irritable bowel s yndrome, and 1974 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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premenstrual tension. F amily and marital difficulties increased as the patient withdrew from her husband was increasingly dysfunctional in taking care of her children. W ork function als o deteriorated. P s ychiatric hospitalization was precipitated by the patient's arrest disorderly conduct in a nearby city. S he was found in a hotel, in revealing clothing, engaged in an altercation a man. S he denied knowledge of how she had come to hotel, although the man insisted that s he had come under a different name for a voluntary s exual On ps ychiatric examination, the patient des cribed amnes ia for the first 12 years of her life, with the feeling that her “life s tarted at 12 years old.” S he reported that, as long as s he could remember, she had an imaginary companion, an elderly black woman, who advis ed her kept her company. S he reported hearing other voices her head: s everal women and children, as well as her father's voice repeatedly speaking to her in a way. S he reported that much of her life since 12 years age was also punctuated by episodes of amnesia: for for her marriage, for the birth of her children, and for sex life with her husband. S he reported perplexing changes in s kills ; for example, she was often told that played the piano well but had no cons cious awarenes s that s he could do so. Her husband reported that s he always been “forgetful” of conversations and family activities. He also noted that, at times , s he would a child; at times , s he would adopt a southern accent; at other times , she would be angry and provocative. frequently had little recall of these episodes . Ques tioned more closely about her early life, the appeared to enter a trance and s tated, “I just don't want 1975 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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be locked in the closet” in a child-like voice. Inquiry this produced rapid s hifts in s tate between alter who differed in manifes ted age, facial expres sion, voice tone, and knowledge of the patient's his tory. One identified its elf by a diminutive of the patient's name appeared child-like. Another s poke in an angry, filled manner and appeared irritable and preoccupied sexuality. S he discuss ed the epis ode with the man in hotel and stated that it was she who had arranged it. A third alter identified itself as a protective entity, experiencing its elf as an elderly African-American who commented sadly and philosophically about “this whole s ituation.” G radually, the alters described a of family chaos , brutality, and neglect during the firs t 12 years of the patient's life, until her mother, also achieved sobriety and fled her husband, taking her children with her. T he patient, in the alter identities, described episodes of physical abuse, sexual abuse, emotional torment by the father, her s iblings, and her mother. F amily s es sions with the mother and s iblings confirmed many of these reports, with the family recalling maltreatment that the patient did not recollect. T he patient's mother had bid the family never to s peak of earlier difficulties, hoping that everyone would “just the whole thing.” After additional as ses sment of family members, the patient's mother also met diagnos tic for dis sociative identity dis order, as did her older s is ter, who als o had been molested. A brother met diagnos tic criteria for P T S D, major depress ion, and alcohol dependence. T he patient improved significantly with ps ychotherapy 1976 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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directed at s tabilization of her dis sociative identity disorder and P T S D. S he responded well to (Anafranil) with a marked reduction in obses sivecompuls ive and depres sive symptoms . F amily therapy helpful in stabilizing the patient's marriage and helping her hus band with the aftermath of the hos pitalization its precipitants . T he hus band also reported a family of abus e, although primarily directed at his mother and siblings . He had always s een hims elf as the family protector. T he patient's mother and s iblings were in treatment but were helped by the opening up of the family history and clarification of their diagnos es. At 3follow-up, the patient reported fus ion of mos t alters and marked diminution in diss ociative, somatoform, and symptoms, although s he s till required clomipramine for stabilization of mood and OC D symptoms. P.1882

Proc es s S ymptoms Dis sociative proces s symptoms include and derealization, diss ociative hallucinations, pas sive influence and interference experiences , and cognition (T able 17-15). S ome authorities include diss ociative alterations in identity under this category. S ymptoms of depersonalization and derealization are commonly reported by diss ociative identity disorder patients and may include profound out-of-body experiences . P atients frequently report feeling s paced or dis connected from thems elves and others . T he perceived as distant or unreal, with a hazy or foggy P atients may report feeling, at times , as if they exis t in 1977 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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waking dream s tate. Out-of-body experiences take the form of watching ones elf from a distance as well as outer), as if obs erving another person, with or no ability to affect their actions . Dis sociative auditory hallucinations commonly take the form of voices heard as originating from within the (ps eudohallucinations), as oppos ed to coming from outside. Individual hallucinated voices typically have distinctive age and gender attributes. T hey may negatively about the patient, argue with each other, command the patient to perform certain acts , discus s neutral topics , or sometimes provide useful information comfort, or a combination of thes e. P atients generally recognize that the voices are hallucinations and may reluctant to reveal their exis tence for fear of being cons idered psychotic. Many patients report s ome ignore or disregard hallucinations , unles s they are Hallucinated voices often come to be identified with specific alter personality states . V is ual hallucinations typically take the form of detailed images with traumatic or frightening content. Other visual hallucinations may unders tood as depicting the alter identities or may even have a complex artistic quality. T actile, gustatory, and olfactory hallucinations may also occur, leading to misdiagnos es of s eizure disorder or other organic disorders . Intrusive pos ttraumatic flas hbacks and may als o be experienced as complex multimodal hallucinations . Negative hallucinations , in which external percepts and stimuli are not cons cious ly regis tered, are not P atients also report the volitional ability to block out various perceptions or s ens ations , including pain. Most 1978 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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hallucinations , ps eudohallucinations, and negative hallucinations in diss ociative identity disorder patients likely homologous to phenomena that can be in deep trance states among highly hypnotizable individuals and are not a manifes tation of a process ps ychos is . P as sive influence and interference symptoms include many firs t-rank s chneiderian s ymptoms, such as thoughts, voices arguing with each other, influences playing on the body, thought withdrawal and ins ertion, and made feelings , impulses, and actions . T hese were once cons idered to be pathognomonic of schizophrenia, but they can also be found in patients affective, organic, and dis sociative disorders. P as sive influence symptoms now have been demonstrated to more common in dis sociative identity dis order patients than in ps ychotic mental dis orders. However, in diss ociative identity disorder, the agents of the pass ive influence symptoms are us ually experienced as not external, as in ps ychotic dis orders. In addition, may report s trong affects or impulses that they without a sens e of personal owners hip, but with a peremptory sense of intrusion and control. Dis sociative identity dis order patients generally do not have explanations for thes e experiences . T hey may feel confused, puzzled, or ashamed of them. commonly part of the explanation, such as “I feel like someone els e wants to cry with my eyes .” T he recognition that diss ociative patients frequently manifest s ubtle, but often clinically significant, cognitive impairments emerges from clinical research with ps ychological and cognitive test batteries . R es earch 1979 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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projective testing finds distinctive cognitive process markers, including evidence of confus ing and contradictory res pons es to the s ame s timulus. res ponses to standardized projective tes ting can often helpful in distinguishing dis sociative patients from other diagnostic groups, s uch as patients with affective disorders , nondis sociative forms of P T S D, pers onality disorders , ps ychotic dis orders , and factitious dis orders.

Dis s oc iative Alterations in Identity C linically, dis sociative alterations in identity may firs t be manifested by odd first-person plural or third-person singular or plural s elf-references . In addition, patients refer to themselves using their own first names or depers onalized s elf-references , such as “the body,” describing themselves and others ; for example, “T he hurt the body s o s he was ups et. W e tried to protect but it didn't work.” P atients often des cribe a profound sens e of concretized internal division or personified internal conflicts between parts of thems elves . In some instances, thes e parts may have proper names or may designated by their predominate affect or function, for example, “the angry one” or “the wife.” P atients may suddenly change the way in which they refer to others, example, “the son” instead of “my s on.” A s et of behaviors , collectively referred to as s witching be haviors , may be manifes t during evaluation or sess ions. S witching behaviors include intrainterview amnes ias, in which the patient does not s eem to recall confused about the process and content of that T hese microdis sociative episodes may be manifested abrupt s hifts in train of thought or s udden inexplicable 1980 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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changes in affect or in rapport. A variety of physical including pronounced upward eye rolls or bursts of blinking and eyelid fluttering, may occur in conjunction with microdis sociative epis odes. T he patient's tone of voice and manner of speaking, posture, and demeanor may s how marked alteration. W hen clinicians evidence of pos sible microdiss ociative episodes, they should s eek to clarify what the patient is experiencing can recall with nondirective, open-ended ques tions T hese cognitive, behavioral, and phys ical shifts are manifestations of alter personality switching or overlap and interference between alter s tates , or both. T he personalities of dis sociative identity dis order patients best conceptualized as DB S , each organized around a prevailing affect, s ens e of s elf (often including a dis tinct body image), a s et of state-dependent autobiographical memories , and a limited behavioral repertoire. have long cautioned that alter pers onalities should not regarded as separate people. R ather, the alter are conceptualized as relatively stable and enduring patterns of behavior that are largely unintegrated with each other and are often in direct conflict. T he set of alter personality s tates, usually referred to pe rs onality s ys te m, cons titutes the pers onality of the individual. Mos t psychotherapeutic work is directed toward this larger personality system and thus toward individual as a whole. Much has been made of the ps ychological and phys iological differences among the alter personality s tates of individuals with dis sociative identity dis order, and popular accounts emphasize the presentational differences among alters . Laboratory studies s upport clinical accounts of significant 1981 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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however, much general information and many and abilities are shared in common acros s alter states and indicate the fundamental unity of the mental proces ses of the diss ociative individual. T his provides foundation for therapeutic efforts directed at the development of a more cons cious ly integrated s ens e of self in the diss ociative identity disorder patient. Apparent differences in the organization and dynamics alter personality systems have been used to class ify diss ociative identity P.1883 disorder patients into various categories for more than century. T he validity of these class ifications remains to proven, but, as a group, diss ociative identity disorder patients s how cons iderable variability in the complexity and therapeutic tractability of their alter pers onality systems . S everal alter pers onality types are commonly reported, including child alter personalities; internalized persecutory alters , who inflict pain and may attempt to the individual; and depleted and depres sed host personality s tates, who function as the primary identity with res pect to the world at large. Alter personality often reflect painful ps ychological is sues for the and frequently take the form of polarized pairs representing antithetical pos itions , although alters representing more neutral and conflict-free proces ses commonly occur. In s ome diss ociative identity disorder individuals , virtually every as pect of mental life is structuralized and personified in this form.

S ymptoms R elated to S pontaneous 1982 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Autohypnotic Phenomena Dis sociative identity dis order patients commonly exhibit describe symptoms of involuntary autohypnotic phenomena, cons is tent with their high scores on standardized hypnotizability scales (T able 17-16). include s pontaneous trance states that can be clinically disabling, s pontaneous or voluntary anes thes ia and analgesia, negative hallucinations , s pontaneous age regress ions, and the trance logic or literal-mindedness the hypnotized s ubject. Other similar s ymptoms with dis sociative process symptoms (hallucinations , thought disorder, child alter identities ) and P T S D symptoms (behavioral reexperiencing epis odes with multimodal hallucinations and age regres sion to the of the trauma).

Other As s oc iated S ymptoms B ecaus e diss ociative identity disorder is a trauma spectrum dis order, it is not surpris ing that the majority of these patients als o meet diagnos tic criteria P T S D by clinical criteria or by us ing s tandardized and diagnostic inventories (T able 17-17). Depending the study, 70 to 100 percent of diss ociative identity disorder patients have been shown to meet diagnostic criteria for P T S D by DS M-III-R , DS M-IV , and DS M-IV criteria.

Table 17-17 Dis s oc iative Identity Dis order-As s oc iated S ymptoms C ommonly Found in Dis s oc iative Identity Dis order 1983 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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P os ttraumatic stress dis order s ymptoms    Intrus ive s ymptoms    Hyperarous al    Avoidance and numbing s ymptoms S omatoform symptoms    C onversion and pseudoneurological s ymptoms    S eizure-like episodes    S omatization disorder or B riquet's s yndrome    S omatoform pain symptoms    Headache, abdominal, musculoskeletal, pelvic    Undifferentiated s omatoform disorder    P s ychophysiological s ymptoms or disorders    As thma and breathing problems    P erimens trual disorders

1984 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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   Irritable bowel syndrome    G as troesophageal reflux disease    S omatic memory Affective symptoms    Depres sed mood, dys phoria, or anhedonia    B rief mood swings or mood lability    S uicidal thoughts and attempts or s elf   G uilt and s urvivor guilt    Helpless and hopeless feelings Obsess ive-compuls ive s ymptoms    R uminations about trauma    Obs es sive counting, s inging    Arranging    W ashing    C hecking

1985 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Dis sociative identity dis order patients commonly exhibit multiple types of psychophys iological, somatoform, and conversion s ymptoms . F or example, acros s s tudies , 40 60 percent of diss ociative identity dis order patients also meet diagnos tic criteria for somatization dis order, and many others meet diagnostic criteria for somatoform disorder, somatoform pain disorder, or conversion dis order, or a combination of these. F inally, numerous recent studies have s hown a robust relations hip between certain forms of affective and an antecedent his tory of trauma, particularly childhood s exual abus e. Depres sion is increasingly unders tood as one of the outcomes following traumatic experiences . Accordingly, most dis sociative identity disorder patients meet criteria for a mood disorder, one of the depress ion spectrum dis orders. F requent, mood swings are common, but thes e are us ually due to posttraumatic and diss ociative phenomena, not a true cyclic mood dis order. T here may be cons iderable between P T S D symptoms of anxiety, dis turbed s leep, dysphoria and mood disorder s ymptoms . Obsess ive-compuls ive s ymptoms are also commonly 1986 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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found in individuals with P T S D. Obs ess ive-compuls ive personality traits are common in diss ociative identity disorder, and intercurrent OC D symptoms are regularly found in diss ociative identity disorder patients , with a subgroup manifes ting s evere OC D symptoms. OC D symptoms commonly have a pos ttraumatic quality: checking repeatedly to be s ure that no one can enter house or the bedroom, compuls ive was hing to relieve a feeling of being dirty because of abuse, and repetitive counting or s inging in the mind to dis tract from anxiety over being abus ed, for example.

C hild and Adoles c ent Pres entations A growing clinical res earch literature documents the diagnosis and treatment of child and adolescent diss ociative dis orders, including dis sociative identity disorder. In many res pects, children and adolescents manifest the same core dis sociative symptoms and secondary clinical phenomena as adults. Age-related differences in autonomy and lifes tyle, however, may significantly influence the clinical expres sion of diss ociative s ymptoms in youth. F or example, amnes ias and perplexing forgetfulness are more in s chool situations rather than work or family life. children, in particular, have a less linear and les s continuous s ens e of time and are often not able to s elfidentify dis sociative discontinuities in their behavior. F ortunately, there are often additional informants, such teachers and relatives , available to help document diss ociative behaviors. A number of normal childhood phenomena, such as imaginary companions hip and elaborated daydreams , 1987 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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must be carefully differentiated from pathological diss ociation in younger children. F or example, preadoles cent children with dis sociative identity may manifes t less in the way of gross switching than adolescents or adults. T he clinical pres entation be that of an elaborated or autonomous imaginary companions hip, with the imaginary companions taking control of the child's behavior, often experienced P.1884 through pas sive influence experiences or auditory ps eudohallucinations, or both, that command the child behave in certain ways.

P athology and L aboratory E xamination A clinical mental s tatus examination based on the symptom clus ters described in T ables 17-14 17-15 1717-17 can be helpful in the diagnosis of diss ociative identity dis order. Ques tioning about amnes ic, autohypnotic, P T S D, affective, and s omatoform us ually precedes detailed inquiry about more overt symptoms related to the alter identities. C areful inquestioning about these phenomena may readily bring forth information about dis sociative identity dis order proces s symptoms . F or example, discuss ion of amnes ia experiences may readily lead to questions how purposive behaviors can occur without apparent memory. Discuss ion of P T S D s ymptoms may lead to manifestations of alter identities related to traumatic experiences . T he development and increas ing us e of screening 1988 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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instruments and s tandardized diagnostic interviews contributed to the increas e in numbers of identified diss ociative identity disorder cas es s een over the last decade. Dis sociative identity dis order patients score over 30 on the DE S and the DE S -T . However, screening instrument and cannot be us ed to make a clinical diagnosis. T he S C ID-D-R is currently gold s tandard for diagnosis of diss ociative dis orders. major drawback of the S C ID-D-R is that it can take hours to adminis ter, especially if the patient has many positive res ponses . Accordingly, some clinicians rely shorter DDIS for its ease and speed of adminis tration. MID is a s elf-report inventory that may ass is t in of dis sociative identity dis order and other diss ociative disorders . T he C DC and A-DE S are two commonly used meas ures for as sess ment of dis sociation in children adoles cents , res pectively. T hey are reliable and valid meas ures in clinical and res earch populations. B efore the development of thes e clinical and as sess ment tools , hypnotic or amobarbital interviews often used to attempt diagnosis of diss ociative identity disorder. Due to the current academic and forens ic controvers ies s urrounding diss ociative dis orders and trauma memory, it is prudent to reserve thes e interventions for emergency situations when other methods of as sess ment have failed, for example, in a female patient who is emergently hospitalized after engaging in repeated, dangerous nocturnal fugues and who cannot account for thes e behaviors, des pite interviewing. T hese interventions should optimally be conducted by a clinician experienced in their use and in 1989 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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the differential diagnosis of diss ociative dis orders . informed cons ent should be obtained for us e of thes e interventions for diagnos is of dis sociative identity and recall of traumatic experiences .

Differential Diagnos is On average, more than 6 years pass between first ps ychiatric contact and the diagnos is of diss ociative identity dis order. Although often portrayed as hysterics, only a s mall minority of dis sociative identity disorder patients pres ent in this way. Dis sociative disorder patients are typically reticent about revealing their diss ociative symptoms, es pecially hallucinations , amnes ia, and identity divisions . T hey mos t commonly present as relatively inhibited and obses sional, with affective and somatic complaints , and typically acquire three or more ps ychiatric diagnoses before their diss ociative identity disorder is recognized. A subgroup diss ociative identity dis order patients s how dynamics that are reminis cent of borderline pers onality disorder, for which s ome diss ociative identity disorder patients qualify as a s econdary diagnos is once P T S D diss ociative s ymptoms are stabilized. T he pres ence of auditory hallucinations , disturbed thinking and confusion due to amnes ic gaps, and s chneiderian firstsymptoms contributes to the misdiagnos is of schizophrenia in approximately one-half of diss ociative identity dis order patients at some point in their histories . R apid changes in affect ass ociated with alter personality s witching may sugges t a rapid-cycling disorder or schizoaffective disorder. T able 17-18 lists most common disorders that must be differentiated diss ociative identity disorder. However, becaus e many 1990 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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these dis orders may coexist with dis sociative identity disorder, as well as being mimicked by diss ociative disorder, differential diagnos is may be a complex

Table 17-18 Differential of Dis s oc iative Identity Dis order C omorbidity versus differential diagnos is Affective dis orders P sychotic disorders Anxiety disorders P os ttraumatic stress dis order P ers onality disorders C ognitive dis orders Neurological and s eizure dis orders S omatoform dis orders F actitious disorders Malingering 1991 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Other dis sociative disorders Deep-trance phenomena, such as the hidden observer or ego s tates

Fac titious , Imitative, and Malingered Dis s oc iative Identity Dis order C oncerns about factitious and malingered diss ociative identity disorder are common. R ecently, there are increasing reports of individuals claiming to have diss ociative identity disorder who do not meet criteria for dis sociative identity dis order when carefully as sess ed clinically or with s tructured interviews , s uch the S C ID-D-R . T here may be a mixture of factors this pres entation, including misdiagnos is , and as sumption of a social role of an abus e victim or a diss ociative identity disorder patient. Dutch res earchers have named this imitative dis s ociative ide ntity dis order when there does not appear to be conscious P atients may build their lives around their diagnos is are commonly supported by concerned others and by their therapists in s o doing. Indicators of fals ified or imitative diss ociative identity disorder are reported to include those typical of other factitious or malingering presentations . T hese include symptom exaggeration, lies, use of s ymptoms to 1992 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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antis ocial behavior (e.g., amnesia only for bad amplification of symptoms when under obs ervation, refusal to allow collateral contacts , legal problems , and ps eudologia fantastica. G enuine dis sociative identity disorder patients are usually confused, conflicted, as hamed, and dis tres sed by their s ymptoms and history. T he nongenuine patients frequently show little dysphoria about their dis order. T hese imitative and factitious patients actually fit the of diss ociative identity disorder, with one exception: R igorous diagnostic efforts s how that they do not meet actual diagnostic criteria for diss ociative identity T he S C ID-D-R has been used to help distinguish from bogus diss ociative identity disorder in clinical and forens ic contexts. In addition, ps ychological a psychologis t experienced in evaluation of trauma, and diss ociation may als o be quite helpful P.1885 in differential diagnosis. On the S C ID-D-R , fabricated diss ociative identity disorder patients tend not to the typical comorbid conditions and symptoms with diss ociative identity disorder, such as amnesia, identity confus ion, and identity alteration, although they may report high levels of depers onalization and derealization. T hey often des cribe symptoms in a filled way (“I'm diss ociating” or “I'm switching”) and readily explain their subjective experience on follow-up questions on the S C ID-D-R or in clinical interviews . T here are no abs olute clinical indicators to differentiate imitative, factitious, or malingered diss ociative identity 1993 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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disorder from the actual disorder. S ome bona fide diss ociative identity disorder patients become invested a dis sociative identity dis order identity or that of being trauma s urvivor as their main social role. T here is a subgroup of diss ociative identity disorder patients who present in a dramatic, histrionic fashion, unlike the majority of diss ociative identity disorder patients who reticent and s ecretive about their illness . T here are genuine diss ociative identity disorder patients who factitious histories , produce factitious cris es , and create factitious alter identities. S ome diss ociative identity disorder patients report that their only happy childhood experiences were while medically hospitalized. Like typical factitious dis order patients, they s eek out and maintain themselves as hos pital patients in psychiatric medical s ettings . Munchaus en syndrome and syndrome by proxy als o have been reported in identity dis order patients and in their first-degree Ms. F ., a 48-year-old divorced mother of three, was to a trauma disorder inpatient unit by her managed company for a cons ultation about diagnos is and treatment. Ms . F . had been diagnosed with dis sociative identity dis order after doing “inner child work” with her outpatient therapis t, Dr. Q., to whom Ms. F . reported an extensive history of childhood neglect, as well as and s exual abus e. Ms. F . had numerous suicidal ideation, as well as for epis odes of superficial mutilation. Ms. F . was on disability. S he did not care for children adequately and had been investigated s everal times by her state division of child welfare, who had recently placed her children in fos ter care. On arrival in the trauma unit, Ms . F . proclaimed to 1994 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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and s taff that, “I have dis sociative identity dis order. I sexually abus ed.” S he did not s eem distress ed by these ideas. S he repeatedly s tated, “I'm s witching, I'm switching,” although s taff members, experienced with diss ociative identity dis order patients, did not obs erve of the typical s igns of diss ociative identity disorder switches. S taff noted that they had never observed a diss ociative identity disorder patient announce this way. Ms. F . became irritable when s taff attempted diss uade her from speaking in s uch a dramatic and way in the milieu. Ms. F . was evaluated clinically, obs erved by nursing the ward milieu, and given a battery of ps ychological including the DE S , the S C ID-D, as sess ments of P T S D, personality ass es sments . On the clinical evaluation, did not endors e complex chronic amnesia s ymptoms, amnes ia for her life history, spontaneous s elf-hypnosis , pass ive influence symptoms, or inner voices . S he episodes of depersonalization and derealization. S he reported only “child and baby alters ” but could des cribe little about them when ques tioned. S he would s ay like, “S ee, now I'm like a child. C an't you tell? T hat's my littles.” S he did not endorse any s ens e of fear, conflict, or inner struggle around switching nor were of the typical phenomena of switching noted at thes e times (e.g., eye roll; eye blinking; s ubtle s hifts in voice, posture, and facial express ion; momentary confus ion; intrainterview amnesia, and s o forth). S upposed alter identities did not s eem to have relatively independent ways of thinking, relating, perceiving, or remembering. Ms. F . des cribed a history of childhood chaos and in detail but became more stereotypically, 1995 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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vague when dis cuss ing other types of childhood “T he man hurt me. I'm here to recover from it. It's jus t what happened to K . (a friend of the patient's from the inces t s urvivors' group). Dr. Q. says I have a long way in my healing. T hat's all. Isn't that enough? ” S he did seem dis tres sed, hesitant, or ashamed when alleged history of childhood s exual abus e. S he became angry when confronted with contradictions in her accounts , the dramatic nature of her presentation, and discrepancies between her history and her emotional reactions . Ms. F . appeared uninteres ted in individual or group ps ychotherapy that s ought to teach her more effective ways to manage s ymptoms and to increase effective coping. S he was angry when nursing s taff attempted to get her to take res ponsibility for managing her of anxiety and regres sion in a more proactive and adult fas hion. S he was infuriated when the unit social worker not see her role as attempting to find Ms . F . alternative housing or intervening with the state child welfare on her behalf. S taff contacted Dr. Q., who became angry and when ques tions were raised about the patient's clinical presentation and authenticity of her sexual abuse On ps ychological and diagnostic testing, Ms . F . did not endors e most items consistent with clinical other than depersonalization and derealization. S he did not display typical P T S D or dis sociative reactivity to inquiries about the abus e history, nor did s he meet diagnostic criteria for P T S D. S he did not s how typical of diss ociative identity disorder patients on stress ful tes t batteries or during a s erendipitous event 1996 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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while being tested, when another patient suddenly required aggres sion management on the ward near the tes ting room. Other patients reacted with P T S D and diss ociative s ymptoms: panic, marked startle, trance, hiding, loss of reality orientation, ass umption of fetal position, rocking with hands over the face, into flas hback, and so forth. Ms . F . blithely continued tes ting with minimal reaction. At the conclus ion of the ass es sment, Ms . F . was with factitious disorder with psychological s ymptoms , mood dis order NOS , and personality dis order NOS histrionic, borderline, and dependent features . T he s taff struggled with the factitious diagnos is , because Ms . F . not appear to be consciously feigning dis sociative disorder in the strict sense and actually s eemed to in her self-reports of s witching and alter identities. Ms . and Dr. Q. were both res is tant to the new diagnostic formulation. Dr. Q. s tated that s he would ins is t that the managed care company s eek another expert opinion to correctly diagnose her patient.

C ours e and P rognos is Little is known about the natural history of untreated diss ociative identity dis order. A few cas e s tudies of partially treated patients followed up many years later suggest that the dis order becomes les s overt over with a decrease in florid diss ociative symptoms and intraps ychic conflict among the alter personality states . T hese cases , however, are too few and too s elected to generalize. S mall studies of diss ociative identity patients diagnosed in middle age and in geriatric populations have s hown that s evere diss ociative 1997 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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disorder s ymptoms can pers is t or can appear in olderpatients. A relaps ing and remitting cours e is common. Als o, patients can more or less succes sfully mask or suppress symptoms for periods of time. B oth of these latter phenomena may be mis taken for complete spontaneous remiss ion of the disorder. S ome untreated dis sociative identity dis order are thought to continue involvement in abusive relations hips or violent P.1886 subcultures, or both, that may res ult in the of their children, with the potential for additional family transmis sion of the dis order. Many authorities believe some percentage of undiagnosed or untreated diss ociative identity disorder patients die by suicide or res ult of their ris k-taking behaviors . E xperience with a number of diss ociative identity disorder cas es sugges ts that there are s everal s ubgroups of dis sociative identity disorder individuals . T hes e range from thos e who at quite high levels for long periods of time to others have s everely impaired and dys functional life often beginning early in development. P atient pres entations and prognos is vary s omewhat the life s pan. C hildren with dis sociative identity dis order show many dis sociative s ymptoms and behaviors but typically have fewer and les s crystallized alter states that are less inves ted in their individuality. If diagnosed early, children often have an excellent prognos is , and many seem to have relatively res olutions when removed from abusive and neglectful environments . In adoles cence, alter personality states 1998 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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become more dis tinct and more invested in their autonomy. Additional alter personalities as sociated life s tres ses, s uch as academic, athletic, s ocial, or challenges, may appear, and the pers onality s ys tem dynamics become more complicated and polarized. In general, adolescents have a poorer prognosis than children or adults, in part because they are often not inves ted in their treatment. B etter outcome with diss ociative identity disorder adolescents has been reported when the patients' families were success fully engaged in treatment. Y oung adults typically pres ent in crisis and have a layering of affective, somatic, posttraumatic, and personality dis order symptoms in addition to their core diss ociative pathology. F irst diss ociative identity dis order pres entations in diss ociative identity disorder patients frequently involve life event, s uch as the loss of a job, death of a parent, revictimization, s uch as a rape, that reactivates earlier conflicts and destabilizes the alter pers onality s ys tem. Achieving sobriety in a substance-abusing dis sociative identity dis order patient may precipitate overt identity dis order and P T S D pres entations . In adult there appear to be treatment-res ponsive and refractory s ubgroups of dis sociative identity dis order patients. T ime cours e of improvement also may vary, some patients improving relatively quickly and others requiring intensive treatment efforts over long periods time. P rognos is is poorer in patients with comorbid organic mental disorders , ps ychotic dis orders (not diss ociative identity dis order ps eudopsychos is), and severe illness es. R efractory s ubs tance abus e and eating 1999 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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also sugges t a poorer prognos is . Other factors that indicate a poorer outcome include s ignificant antis ocial personality features, current criminal activity, ongoing perpetration of abus e, and current victimization, with refusal to leave abus ive relations hips. R epeated adult traumas with recurrent episodes of acute s tres s may s everely complicate clinical cours e. B oundary violations and abus e by a therapis t or ps ychiatris t may severely prolong the treatment cours e, because the of treatment now feels uns afe and precipitates intense posttraumatic reactivity. S evere pers onality disorders overinvestment in multiplicity as a way of life, in ps ychotherapy primarily to seek gratification, and a refusal to take res ponsibility for behavior change and symptom management are also generally as sociated a poorer prognos is . Number of alter personality s tates, however, has only a moderate effect on treatment

Treatment S tages and Goals C urrent treatment approaches to diss ociative identity disorder have evolved considerably with the conceptualization of diss ociative identity disorder as a complex developmental trauma disorder and as the spectrum of diss ociative identity disorder patients has been better appreciated. Appropriate treatment of the diss ociative identity disorder patient follows a phas ic model that is the current standard of care for posttraumatic disorders . T he phases include (1) a symptom stabilization, (2) an optional phase of depth attention to traumatic material, and (3) a phase integration or reintegration in which the dis sociative 2000 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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identity dis order patient moves more completely away from a life adaptation bas ed on chronic traumatization victimization. Obvious ly, these phas es are relatively heuris tic, and as pects of each may be part of the S tabilization of the diss ociative identity disorder patient vital to permit more s uccess ful negotiation of all treatment. S tabilization focus es on s afety, stability, and management of core diss ociative identity dis order and comorbid symptoms . T he vas t majority of diss ociative identity dis order patients engage in some form of s elfdestructive behavior, including s uicide attempts, selfmutilation, eating disorders , s ubs tance abus e, ris k-taking activities, and involvement in abus ive, based relations hips. Many male, and some female, diss ociative identity disorder patients have difficulty aggres sion, violence, and homicidal tendency, perpetration of child abus e. It is incumbent on the to make these is sues the basic focus of treatment. In general, cognitive and behavioral approaches are framing these behaviors as part of a set of quas itrauma-related, homeostatic mechanis ms . E xperienced clinicians find that many diss ociative identity disorder patients can bring s elf-destructive and high-ris k under control. C ognitive and behavioral methods are to develop therapeutic agreements (also called s afety contracts ), s o that patients have a repertoire of to manage their difficulties ins tead of by selfE ating disorders , s evere s ubs tance abus e, abusive relationships , and perpetration of violence may more refractory to thes e methods and may require concurrent specialty treatment interventions and involvement of police, social s ervice, and community 2001 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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agencies . S tabilization of s evere s ymptoms generally involves with posttraumatic s tres s and diss ociative symptoms. Dis sociative identity dis order patients frequently with highly disturbing P T S D s ymptoms, such as thoughts, imagery, s omatic sens ations, hyperarousal, flashbacks . T he latter may present as acute behavioral reexperiencing epis odes with loss of reality orientation more s ubtle and pervasive reliving experiences , or P atients may be overwhelmed by dis sociative hallucinations , amnes ia and fugue epis odes , pass ive influence experiences , or profound identity confus ion disorganization. S orting out genuinely comorbid from the plethora of posttraumatic, anxiety, affective, somatic symptoms commonly manifested by patients in cris is is important, as s ome disorders , for example, affective disorders , require additional interventions . As ses sment of available family and community supports is also important.

Ps yc hotherapy A s urvey of more than 300 clinicians treating identity disorder patients found that the vas t majority cons idered psychotherapy to be their primary and mos t efficacious treatment modality. S uccess ful for the dis sociative identity dis order patient requires the clinician to be comfortable with a range of ps ychotherapeutic interventions and a willingnes s to actively work to structure the treatment. T hes e include ps ychoanalytic psychotherapy, cognitive behavioral therapy, hypnotherapy, and a familiarity with the ps ychotherapy and psychopharmacological 2002 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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management of the traumatized patient. C omfort with family treatment and systems theory is helpful in with a patient who subjectively experiences hims elf or herself as a complex s ys tem of selves with alliances, like relations hips, P.1887 and intragroup conflict. A grounding in work with with somatoform disorders may also be helpful in through the plethora of s omatic s ymptoms with which these patients commonly present.

Therapeutic E ngagement with Alter Identities E ffective stabilization in mos t diss ociative identity patients requires psychotherapeutic work with alter personality s tates. Many diss ociative identity patients are not able to s tabilize s ymptoms in the long term if the alter identities who control these s ymptoms not therapeutically engaged. C linicians new to identity dis order are frequently uncomfortable or perplexed by the need to work with individual alters how to do this without producing a chaotic regress ion. C ertain basic principles are important to understand. alter is any more or less real than any other alter or good or bad than another. All are aspects of a s ingle human being and have adaptive, ps ychological importance that needs to be heard and respected. All alters are held accountable and respons ible for the behavior of any part, even if experienced with amnes ia lack of s ubjective ownership. In the context of ps ychotherapy, alters can be unders tood as 2003 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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developmentally concretized, trauma-based metaphors forms of organizing and mobilizing mental contents . unusual metaphors have many problematic cognitions and affects, as well as adaptive attributes, s uch as the personality s tate-dependent memory data des cribed previous ly. As s uch, the fullest participation of all symbols and s ources of knowledge, s kills , and is likely to produce the best outcome in ps ychotherapy. C oncerns about iatrogenesis are often rais ed in this context. Understanding the alters as forms of symbolization reduces this concern to a more routine ps ychotherapeutic task of understanding the meaning mental contents , rather than a suppres sion of s ome states as less authentic than others . At the s ame time, clinician mus t also be able to appreciate the patient's subjective reality in which the alter s elf-states are experienced as dis tinct s elves or even as separate T he therapist mus t be able to tolerate engaging with alters as if they are s eparated entities, while maintaining the understanding that the alters represent the structuring of psychological process es in form within a s ingle human mind. T he continuity, s tability, and respectful impartiality of therapist toward the different alter pers onalities provide an important therapeutic experience that helps the experience, examine, and integrate these dis sociated as pects of s elf. T he proces sing of negative life events , from the multiple pers pectives of different alter personality s tates, is an important part of the narrative reorganization of the patient's fragmented identity into more coherent whole. T he therapist usually is actively involved in negotiating between and among the various 2004 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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alter identities to achieve therapeutic goals . T hes e can include negotiation of agreements to s top s elfbehaviors , to allow more adaptive interidentity function and communication, and to permit certain alters to participate more fully in therapy.

Initial Phas e of Dis s oc iative Identity Dis order Treatment T he initial phas e of treatment of the dis sociative disorder patient involves a number of s imultaneous and sequential tasks.

E DUC A TION A ND INF OR ME D It is important to educate the dis sociative identity patient about the disorder, its comorbidities, and the cours e of treatment. E ducative interventions help anxiety about s ymptoms that are often frightening and overwhelming, build a therapeutic alliance, and provide information that is the basis for a meaningful consent treatment. F urthermore, it is necess ary to educate the patient about the contentious and divisive debates that surround the diagnosis and treatment of diss ociative identity dis order in contemporary ps ychiatry and ps ychology. Other major iss ues in informed cons ent include the patient of potential risks and benefits of the alternative approaches, and their potential ris ks and benefits. T he patient should als o be informed about the current controvers ies about traumatic memory and its retrieval and explication in therapy. Additional informed cons ent s hould be obtained if formal hypnosis is used for administration of medications. T he patient should 2005 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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couns eled that s ymptomatic worsening may occur treatment, particularly during phases in which memory material is worked with in depth (second phas e of treatment). S imultaneously, however, s ubjective amelioration of other s ymptoms may occur, with the patient achieving a better s ens e of control, mastery, self-coherence as the patient success fully works painful material. T his s ort of dialectical proces s is common in identity disorder treatment. It is often helpful to point out as part of the informed consent proces s. F or at times, the patient may feel a sense of s ubjective and the idea of having diss ociative identity disorder unreal and impos sible. At other times, the patient's of himself or hers elf as divided and enacting alter roles seems so compelling and overwhelming that no other diagnosis s eems pos sible. S imilarly, like many obsess ional individuals, identity disorder patients often respond positively to learning that the diss ociative and P T S D s ymptoms that they experience have a name and an organizing framework for diagnosis and treatment. T here is often relief at a diagnos is that fits the patient's s ubjective and experience, especially if there has been a long prior of uns ucces sful psychiatric treatment for other At the s ame time, patients may respond with dis tres s at the diss ociative identity disorder diagnos is, partly of media and popular s tereotypes , partly because it into s harper relief the meaning of painful symptoms, partly becaus e it brings more focus to the dis tres sing history of early trauma and problematic relationships family members . 2006 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Dis sociative identity dis order patients may need to be informed that treatment does not attempt to suppres s to des troy alter identities, but rather to allow engagement with them as vital as pects of the mind. P atients us ually want to get rid of alter identities and also terrified that the therapist will attempt to do so. experienced clinicians educate patients that treatment geared toward optimal function and adaptation and that there are us ually too many variables at the beginning treatment to predict whether it will necess arily res ult in unification of all s elf-divis ions. At the same most experienced clinicians s ee unification of all alter states as us ually providing the bes t long-term outcome diss ociative identity disorder. T he education and informed cons ent proces s is an ongoing one throughout treatment. Many of thes e need to be revisited as treatment proceeds and as the patient changes over treatment time.

B oundaries and Treatment Frame Most dis sociative identity dis order patients report that their traumatic life experiences us ually occur over long periods of time in the context of clos e personal relations hips with those who have hurt them. F urthermore, dis sociative identity dis order patients report many boundary violations in s ubsequent relations hips with teachers, therapis ts, medical profes sionals, and s ocial service workers , among F or thes e P.1888 patients, the role des cription of s ignificant others does 2007 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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neces sarily predict their behavior, and relations hips are often s een as up for grabs . T he patient expects and that the clinician will violate boundaries . T here may be subtle (or not s o s ubtle) pull in the trans ference for the therapist to change the frame of treatment. P atients experience this as trying to make the inevitable that they do not have to endure the agony of waiting for things to go wrong. Accordingly, clinicians working with these patients must pay careful attention to is sues of treatment frame and appropriate and consistent boundaries . T hese include firm limits on the length of therapy s ess ions, acceptable behavior during sess ions, extent of extra sess ion contacts, and payment of fees, among many others. Interpretation of the patient's fears over the perceived inevitability of boundary violations is preferable to enacting them. C linicians working with diss ociative identity disorder patients should avoid boundary changes that make the patient “special,” the patient insis ts that only these interventions will T hese include holding or hugging the patient, holding patient's hand, accepting more than a token gift s uch card or a s mall piece of artwork, giving the patient gifts , phoning the patient while on vacation, and going for walks or other out-of-office contacts with the patient, among many others. T he dis sociative identity dis order patient may implore the therapist to make these sorts interventions . C linicians who feel overwhelmed by the treatment of these patients are more likely to accede to these importunings . It is important to recognize that the patient's reported history of abuse often involved being special to the abus er in some way. T hus , these transgress ions recreate this double-edged situation for patient. Once again, education of the patient about 2008 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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appropriate boundaries is the mos t helpful clinical strategy. Many of the clinical and conceptual is sues that help treatment workable with these patients are not taught standard training programs for mental health profes sionals. C onsultation should be considered by clinicians who are new to working with this patient population, or if s talemates or unsolvable predicaments develop in treatment.

Development of S kills to Manage S ymptoms E xperienced therapists commonly rapidly introduce a variety of s ymptom management strategies into the treatment. T his neces sitates active s tructuring of to work on containment of s evere s ymptoms and skill building T his may involve imagery techniques to the intens ity of P T S D, s omatoform, and dis sociative symptoms, success ful stabilization of alter identities embody or are experienced as creating s ymptoms , and encouragement of collaboration, communication, and empathy among alter identities . In particular, clinicians work to attenuate the impact of P T S D rather than opening up this material prematurely. T he clinician s hould be clear that the ultimate res ponsibility for s ymptom and behavioral management outside of sess ions lies with the patient, who is viewed an active partner in the treatment. In this regard, diss ociative identity dis order patients often res pond to therapeutic contracting, taking more active res ponsibility for s afety or behavioral control between sess ions. T he therapist may prescribe homework for 2009 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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patient to work on s ymptom management and internal communication between s es sions . T hese strategies often ess ential in countering the patient's tendency toward regress ion and demoralization. P atients often journal writing as a helpful adjunctive treatment that allows more controlled expres sion and communication among alter identities, fulfillment of homework as signments, and a more attenuated and distanced way of handling overwhelming subjective experiences .

C ognitive Therapy Dis sociative identity dis order patients may experience multitude of cognitive errors and distortions bas ed on traumatic life experiences and the ability of diss ociation interfere with reality tes ting. T ypical cognitive include (but are hardly limited to) the insistence that inhabit s eparate bodies and are unaffected by the of one another (delus ional separatenes s), that the is helpless to control himself or herself and requires the clinician to manage all difficulties , that the clinician is completely untrustworthy and mus t be not be allowed access to the patient's mind, that the patient is bad and deserved or caus ed childhood s exual abus e to occur, anger and violence are the s ame, that love and sex are same, that self-injury is safety, and that, becaus e and abuse are inevitable, it is best to invite them or them ones elf, so that at leas t their timing and intensity be better controlled. B ehind thes e cognitive dis tortions frequently lie exceptionally painful realizations and recollections. F or example, if the patient gives up the idea of 2010 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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blameworthines s for childhood incestuous experiences, the reality must be faced that a beloved relative has the patient grievous harm and has treated the patient an object, not a person. Accordingly, many cognitive distortions are only slowly respons ive to cognitive techniques, and s ucces sful cognitive interventions may lead to additional dysphoria. A s ubgroup of diss ociative identity disorder patients not progres s beyond a long-term s upportive treatment entirely directed toward s tabilization of their multiple multiaxial difficulties. T o the extent that they can be engaged in treatment at all, these patients require a term treatment focus on symptom containment and management of their overall life dysfunction, as would the case with any other severely and pers is tently ill ps ychiatric patient population.

Trans ferenc e and Dis sociative identity dis order patients often manifes t a complex multilayered transference as a whole, as a of pers onality s tates , and as individual alter pers onality states . C ommonly, transference is dominated by trauma and abuse, with the therapis t most commonly experienced as potentially exploitative and abus ive or uninvolved or uncaring about the patient's difficulties or a helples s victim, like the patient faced with an other. Diss ociative identity disorder alters may literally envis ion the clinician as the embodiment of an abusive figure from the pas t, requiring active interventions to the patient separate the past from the pres ent. C ountertransference respons es may vary as well, with overinvolvement, detached hos tile s kepticis m, or a 2011 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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of being exas perated, overwhelmed, and des killed quite common. C linicians may experience countertransferential autohypnotic and diss ociative phenomena during diss ociative identity disorder treatment that need to be recognized and managed. B urnout and secondary P T S D have been reported for therapists and treatment teams working with identity dis order patients, unless adequate attention is paid to limit setting, boundaries, and ass is tance to clinicians advers ely experiencing reports of extreme abusive trauma or overwhelmed by work with identity dis order patients.

S ec ond Phas e: Work on Traumatic Memories F or patients who can stabilize and form a reas onable working alliance in treatment, longer-term treatment involve the detailed, affectively intens e, proces sing of life experiences , es pecially traumatic experiences , and the transformation of the meaning of these experiences for the individual. Authorities emphasize that, in mos t cases, intensive, detailed ps ychotherapeutic work P.1889 with traumatic memories s hould only be initiated after patient has demonstrated the ability to use symptom management s kills independently, after the alter system can work together in a reasonably cooperative way, and after a solid therapeutic relations hip has been es tablis hed. T he patient should be able to give cons ent and should have a realistic understanding of 2012 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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potential risks and benefits of intensive focus on material. P otential ris ks may include acute wors ening P T S D, affective, s omatoform, and self-destructive symptoms and s hort-term interference with daily Long-term benefits may include significant amelioration diss ociative and P T S D symptoms , decreases in self-divis ion, fusion of alter identities, and freeing of ps ychological energy for daily life. T he patient mus t be able to unders tand that the goal is integration of diss ociated thoughts, feelings, recollections, and perceptions, not the exhumation of memories per s e. F urthermore, the patient should not be in the mids t of acute life cris is or major life change, comorbid medical ps ychiatric disorders s hould be s tabilized, the patient have the ego s trength and psychos ocial res ources to withstand the rigors of the process , and there mus t be adequate res ources , s uch as support by significant to support the patient for additional s es sions (T able 17E xperienced clinicians attempt to structure carefully affectively intense s es sions focus ed on traumatic with attention being given to affect modulation, res tabilization of the patient before concluding the sess ion, and reasonable availability to as sist the supportively between ses sions . In addition, many may be needed to explicate fully the cognitive and emotional meaning of traumatic events , s o that they become part of the patient's repertoire of ordinary memories for life experience.

Traumatic Memories Media attention and legal cases have led to concerns the authenticity of traumatic recollections of 2013 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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identity dis order patients. R ecent rigorous cas e s eries supported the experience of clinicians , who have found corollary information to corroborate recollections of diss ociative identity disorder patients or who have even unearthed data about traumas that the patient does not recall. B as ed on corollary information, however, s ome diss ociative identity disorder patients can be shown to misinterpret and mis represent contemporary or confabulate as pects of their pas t his tory. In addition, diss ociative patients are hardly immune to ordinary human emotions , such as greed, envy, wis hes for wis hes to evade cons equences for misbehavior, and desires to placate s ignificant others . All of thes e may complicate the patient's veracity, especially in potential financial gain, media attention, evasion of cons equences, and poss ible loss of family contacts , others . C onvers ely, collateral informants, s uch as members, may be subject to the s ame sources of unreliability as the index patient, and their input should weighed accordingly. Dis sociative identity dis order patients typically oscillate from regarding their recollections as all true to all false. S pecific alter identities may take oppos ing positions . clinician is best served by maintaining a s tance of neutrality toward the patient's recollections of his or her life. In this regard, it is generally mos t helpful for the clinician to identify for the diss ociative identity disorder patient his or her internal conflicts over the veracity of recollections and to invite an open airing of all points of view. R epeated discus sion of the complex factors that impact autobiographical recall may need to be part of ongoing informed consent process as treatment 2014 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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progres ses . T he therapist s hould respond res pectfully and to all clinical material brought by the diss ociative disorder patient. P atients can be helped not to come to premature clos ure about their views of events. S ome diss ociative identity disorder patients come to life events quite differently as they become les s diss ociative over the course of treatment. clinicians must avoid validating memories for the or dis mis sing them out of hand, in the abs ence of collateral information. T herapy is mos t s ucces sful for diss ociative identity disorder patient if the clinician maintains the role of therapis t, not personal advocate, detective, or derisive s keptic.

Third Phas e: Fus ion, Integration, R es olution, and R ec overy Over the course of treatment, significant unification of diss ociated mental proces ses may be obs erved. Alters distinctnes s P.1890 and decrease compartmentalization of thoughts, memories , and affects. T he patient develops a more unified s ens e of s elf. T ransference is modified with these changes . Amnes ia and s witching become apparent. F usion of alters results in ps ychological of two or more entities at a point in time, with a experience of los s of all s eparatenes s. T he term is s ometimes us ed s ynonymously with fus ion but is generally defined as the proces s of undoing all forms of diss ociative division during treatment. S ome patients 2015 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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proceed to what appears to be a complete fusion of all alters , with a s hift in self-representation from that of a diss ociative identity dis order individual to one with a cons istent and continuous sense of s elf across all behavioral s tates . Many patients never attain a fus ion of their alter personalities but leave treatment they have achieved a therapeutic re s olution: relative stability, adequate function, and some measure of harmony among s elf-states . As this integrative process occurs , P T S D s ymptoms improve s ignificantly. P atients often experience a of energy toward everyday life and away from traumafocus ed ways of living. C ognitive distortions frequently subs tantially s ubside. At the s ame time, and integrative coping s trategies mus t be identified and subs tituted for diss ociative respons es to life stress ors. Loss es mus t be mourned, and the patient must be to connect and cope with the larger world in a more functional manner.

Hypnos is Des pite the controvers y about its us e, hypnosis was endors ed by approximately two-thirds of respondents ps ychotherapeutic adjunct in diss ociative identity treatment. Hypnotherapeutic interventions can often alleviate self-destructive impuls es or reduce s ymptoms, such as flashbacks , diss ociative hallucinations, and influence experiences . T eaching the patient selfmay help with cris es outside of sess ions. Hypnos is us eful for acces sing s pecific alter pers onality s tates their s equestered affects and memories . Hypnos is is us ed to create relaxed mental s tates in which negative 2016 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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events can be examined without overwhelming anxiety. C linicians using hypnosis s hould be trained in its us e in general and in trauma populations. C linicians should aware of current controversies over the impact of on accurate reporting of recollections and s hould use appropriate informed cons ent for its use.

Ps yc hopharmac ologic al P harmacotherapy was the third most commonly treatment modality. Although double-blind, controlled clinical trials have not been conducted, a variety of medications are considered clinically effective with diss ociative identity disorder patients . G uidelines for us e of medications with diss ociative patients the need to identify s pecific treatment-res ponsive symptoms rather than attempting to treat the per se. Medications may be helpful in attenuating symptoms to as sist the patient in stabilizing during treatment. P atients should be advised that medication res ponse is likely to be partial, devising the best shock absorber s ys tem for the patient at a given time. In succes s is more likely if medication target symptoms present acros s a range of alter personality s tates rather than confined to one or a few pers onality s tates. Among the target symptoms cons idered mos t to medication are affective symptoms. In many these are s econdary symptoms and s how a more heterogeneous and les s robus t response than primary affective dis orders. Nonetheles s, antidepress ant medications are often important in the reduction of depres sion and s tabilization of mood. A variety of symptoms, especially intrus ive and hyperarous al 2017 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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symptoms, are partially medication respons ive. G uided clinical experience and research with P T S D patients , clinicians report s ome s ucces s with S S R I, tricyclic, and monamine oxidase (MAO) antidepres sants , β-blockers , clonidine (C atapres ), anticonvuls ants, and benzodiazepines in reducing intrusive symptoms , hyperarous al, and anxiety in diss ociative identity patients. S leep disturbances and traumatic nightmares may als o be improved by medications , although should be cautioned that dis sociative identity dis order P T S D s leep disturbances may be particularly refractory medications and res pond best to cognitive and interventions directed at patients' severe P T S D nighttime or even to s leeping. R ecent res earch that the α1 -adrenergic antagonis t, prazos in (Minipres s), may be helpful for P T S D nightmares. C ase reports that aggres sion may res pond to carbamazepine in individuals if E E G abnormalities are present. Many diss ociative identity disorder patients show significant obses sive-compuls ive s ymptoms. T hes e patients may preferentially res pond to antidepres sants with antiobses sive efficacy. Open-label studies s uggest that naltrexone (R eV ia) may be helpful for amelioration of recurrent s elf-injurious behaviors in a s ubs et of traumatized patients . Ques tions are often rais ed about the efficacy of neuroleptic medications , particularly for s ymptoms hallucinations . Although neuroleptics are only minimally effective for quas i-ps ychotic symptoms , s uch as hallucinations , in many dis sociative identity dis order patients, low doses may be us eful in some cas es for anxiety and for the s ubtle cognitive s lippage found in 2018 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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some dis sociative identity dis order patients. T he newer atypical neuroleptics , s uch as ris peridone (R is perdal), quetiapine (S eroquel), ziprasidone (G eodon), and olanzapine (Zyprexa), may be more effective and tolerated than typical neuroleptics for overwhelming anxiety and intrusive P T S D s ymptoms in dis sociative identity dis order patients. Occas ionally, an extremely disorganized, overwhelmed, chronically ill diss ociative identity dis order patient, who has not res ponded to of other neuroleptics, res ponds favorably to a trial of clozapine (C lozaril). In general, to date, dis sociative memory and process symptoms, as ps ychopharmacological targets in and of thems elves , have proven refractory to medications . Dis sociative-like symptoms and behaviors , however, be induced in some P T S D patients and normal with drugs (e.g., phencyclidine [P C P ], cannabinoids ), suggesting the presence of pharmacologically s ens itive neurobiological mechanis ms that may lead to future medications that may target diss ociative symptoms per

E lec troc onvuls ive Therapy During their long ps ychiatric careers of mis diagnosis treatment failure, many diss ociative identity disorder patients receive uns uccess ful trials of E C T . T his led to view that E C T was not an effective treatment in the population. One small clinical study of s everely diss ociative dis order patients, primarily with disorder NOS , s uggested that, for s ome patients, E C T helpful in ameliorating refractory mood dis orders and not wors en diss ociative memory problems as the DE S . C linical experience in tertiary care settings for 2019 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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severely ill diss ociative identity disorder patients that a clinical picture of major depress ion with refractory melancholic features across all alter s tates predict a pos itive respons e to E C T . However, this is us ually only partial, as is typical for mos t s ucces sful somatic treatments in the diss ociative identity disorder population. T arget s ymptoms and somatic treatments for identity disorder are listed in T able 17-19.

Table 17-19 Medic ations for As s oc iated S ymptoms in Dis s oc iative Identity Dis order Medications and somatic treatments for P T S D, affective dis orders, anxiety disorders , and OC D    S elective s erotonin reuptake inhibitors (no preferred agent, except for OC D symptoms)    F luvoxamine (Luvox) (for OC D presentations )    C lomipramine (Anafranil) (for OC D    T ricyclic antidepres sants    Monoamine oxidas e inhibitors (if patient can reliably maintain diet s afely) 2020 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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   E lectroconvuls ive therapy (for refractory depres sion with persis tent melancholic features acros s all diss ociative identity disorder alters)    Mood s tabilizers (more us eful for P T S D and than mood swings)    Divalproex (Depakote)    Lamotrigine (Lamictal)    G abapentin (Neurontin)    T opiramate (T opamax)    C arbamazepine (T egretol)    B enzodiazepines    C lonazepam (K lonopin) and lorazepam (Ativan) have bes t track records    Atypical neuroleptics    T ypical neuroleptics (if patient fails trials of atypicals)    β-B lockers (for P T S D hyperarousal s ymptoms)    C lonidine (C atapres ) (for P T S D hyperarous al 2021 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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symptoms)    P razosin (Minipress ) (for P T S D nightmares) Medications for thought dis order    Atypical neuroleptics preferred Medications for acute dys control    Oral or intramus cular neuroleptics    Oral or intramus cular benzodiazepines Medications for sleep problems    Low-dose trazodone (Des yrel)    Low-dose mirtazapine (R emeron)    Low-dose tricyclic antidepres sants    Low-dose neuroleptics    B enzodiazepines (often les s helpful for sleep problems in this population)    Zolpidem (Ambien)    Anticholinergic agents (diphenhydramine 2022 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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[B enadryl], hydroxyzine [V is taril])    C hloral hydrate (Aquachloral S upprettes) for inpatient use) Medications for self-injury, addictions    Naltrexone (R eV ia)

OC D, obs es sive-compuls ive disorder; P T S D, posttraumatic stress disorder. P.1891

Inpatient Treatment As with patients with other ps ychiatric diagnoses , inpatient hospitalization is most commonly us ed for treatment of diss ociative identity disorder patients who are acutely unsafe or completely des tabilized, or both. commonly, in the age of managed care, hos pitalization be us ed to provide a safe environment in which to do intens ive work with painful affects and memories . F or a number of reas ons , overt dis sociative identity dis order patients can have disruptive effects on the milieu of general ps ychiatric units and often stimulate divis ion conflict among staff about the best way in which to to the patient and the alter pers onalities . T ypically, the split is between the believers and the skeptics , often 2023 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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paralleling the larger societal debates as well as the subjective conflict within the patient about belief in the diss ociative identity disorder diagnos is and the authenticity of traumatic memories . Inpatient programs specializing in the treatment of diss ociative and P T S D patients may be more succes sful, because they unified treatment approach in which rigorous and firm limit s etting are combined with s pecific supportive treatment interventions to as sist with diss ociative and P T S D s ymptoms. Inpatient treatment general hospital units is mos t succes sful if there is an attempt to bridge different opinions about dis sociative identity disorder to focus on a unified approach for ameliorating specific target s ymptoms to allow the to resume outpatient treatment in safety. In specialty and general hospital units, the patient be expected to respond to his or her legal name, or at one s pecific name, in the hospital milieu and in all therapeutic interactions , except individual or individual interactions with designated hos pital s taff. T he patient s hould be expected to be able to present in reasonably functional adult mode in the hospital, with regress ed, dysfunctional, or child alters res tricted to designated one-on-one encounters or private time in patient's room or quiet room. T he patient's activities in hospital (e.g., group therapy) s hould be limited to those which the patient can participate while following thes e guidelines. S ome dis sociative identity dis order patients may be s o overwhelmed or overstimulated in the that they need time in the quiet room. However, this become a permanent berth for the patient, who may to be weaned back into more routine hos pital activities 2024 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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prevent a major regres sion. Dis sociative identity dis order patients may experience hospital cris is management strategies , s uch as quiet all-staff call, or res traints, as abusive. B ecaus e of this, patient should be urged to work proactively with staff to find reasonable clinical alternatives to help with dyscontrol. However, hos pital staff may need to use res traints or s imilar meas ures if the dis sociative identity disorder patient is acutely dangerous to s elf or others if les s restrictive alternatives have failed to dees calate situation. In specialty units , res traints are often us ed frequently with these patients than on general hospital units . S pecialty unit staff are us ually trained in helping diss ociative identity disorder patients use symptom management and containment s trategies to handle potential cris es to minimize us e of physical to control behavior. S ingle doses of intramuscular (IM) neuroleptics , such as 2 to 5 mg of haloperidol (Haldol) fluphenazine (P rolixin), with or without 1 to 2 mg of IM lorazepam (Ativan), may be helpful for management of acute dys control in dis sociative identity dis order by inducing sleep to allow a change in s tate once the patient reawakens. S ublingual olanzapine or zipras idone is a more cos tly alternative for this as suming monitoring for cardiac s ide effects of zipras idone. Anecdotal clinical reports sugges t that the latter drugs have lower rates of overs edation and extrapyramidal (E P S ) s ymptoms compared with older typical neuroleptics when us ed in this way. As with other types of patients, dis charge from hospital us ually occurs when the acute crisis has been the patient has made adequate gains in symptom 2025 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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management s kills and internal communication to problems more adaptively, medications have been adjus ted to provide better treatment of comorbid disorders , the outpatient psychosocial environment has res tabilized s ufficiently, or a treatment agreement for outpatient safety has been reached that is cons is tent discharge to the next level of care, or a combination of these. T o s ome extent, tertiary care s pecialty trauma disorders programs may be given more leeway by party providers to help patients develop a broader symptom management s kills and to have time to work more intensively to s tabilize s ymptomatic alter P atients referred to thes e centers have commonly improve, des pite multiple previous general hospital B ecaus e of this, third-party payers may be slightly open to a longer s pecialty inpatient s tay to reduce the potential for additional hospitalization.

Partial Hos pitalization P artial hos pital treatment can be an effective modality the diss ociative patient if clinical interventions target trauma-based is sues and adaptations. S pecialized partial hos pital programs with groups emphasizing symptom containment, cognitive and behavioral interventions , development of life skills, and ps ychoeducation can be effective in helping s tabilize more s everely and persistently ill diss ociative patients, well as providing an intens ive stabilization experience higher-functioning diss ociative identity disorder

Adjunc tive Treatments G R OUP THE R A P Y 2026 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Authorities agree that, in therapy groups including ps ychiatric patients, the emergence of alter can be disruptive to the group process by eliciting fas cination or by frightening other patients. T herapy groups composed only of diss ociative identity disorder patients are reported to be more success ful, although groups must be carefully s tructured, must provide firm limits, and should generally focus only on here-andis sues of coping and adaptation.

F A MIL Y THE R A P Y F amily or couples therapy is often important for longstabilization and to addres s pathological family and marital process es that are common in dis sociative disorder patients and their family members . E ducation family and concerned others about dis sociative identity disorder and diss ociative identity disorder treatment help family members cope more effectively with diss ociative identity disorder and P T S D s ymptoms in loved ones . G roup interventions for education and of family members have also been found helpful. In particular, family members should be dis couraged from interacting with individual alters , calling them out, and relating to them as s eparate individuals. F amily should be helped to s upport the goal of the diss ociative identity dis order patient becoming a functional adult in adult relations hips and a functional parent to children. therapy may be an important part of couple's treatment, the diss ociative identity disorder patient may become intens ely phobic of intimate contact for periods of time, and s pouses may have little idea how to deal with this helpful way. 2027 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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F amily therapy with the family of origin of the identity dis order patient is often extremely distress ing the diss ociative identity dis order patient. C are mus t be exercised in setting up such meetings, because some interactions with family members may lead to an acute decompensation in the dis sociative identity dis order patient. Accordingly, such contacts s hould be carefully structured for defined therapeutic purposes , and the patient should be well prepared for potential advers e reactions . However, s uch meetings may P.1892 be helpful in clarifying or resolving the conflictual emotions that diss ociative identity disorder patients frequently experience toward family members. C onfrontation of family members about pas t traumas in accusatory manner almost invariably has a dis as trous outcome for the diss ociative identity disorder patient family members . Accordingly, there is usually little for such interventions in diss ociative identity disorder treatment.

E Y E MOVE ME NT DE S E NS ITIZA TION R E P R OC E S S ING (E MDR ) E MDR is a treatment that has recently been advocated adjunctive treatment of P T S D. T here are the literature about the us efulness and efficacy of this modality of treatment, and published efficacy s tudies discrepant. No systematic studies have been done in diss ociative identity dis order patients using E MDR . reports sugges t that s ome diss ociative identity disorder patients may be des tabilized by E MDR procedures , 2028 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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acutely increas ed P T S D and dis sociative s ymptoms. authorities believe that E MDR can be used as an adjunct for later phas es of treatment in well-stabilized diss ociative identity disorder outpatients.

S E L F -HE L P G R OUP S Dis sociative identity dis order patients usually have a negative outcome to s elf-help groups or 12-step groups for inces t survivors . Accordingly, most experienced clinicians strongly dis courage dis sociative identity patients' participation in thes e modalities . A variety of problematic iss ues occur in thes e s ettings , including intens ification of P T S D s ymptoms due to discus sion of trauma material without clinical safeguards , exploitation the diss ociative identity disorder patient by predatory group members , contamination of the dis sociative disorder patient's recall by group dis cuss ions of and a feeling of alienation even from these other sufferers of trauma and diss ociation.

E X P R E S S IVE A ND OC C UP A TIONA L THE R A P IE S E xpres sive and occupational therapies , s uch as art and movement therapy, have proven particularly helpful in treatment of diss ociative identity disorder patients . Art therapy may be used for help with containment and structuring of severe dis sociative identity dis order and P T S D s ymptoms, as well as to permit dis sociative disorder patients safer expres sion of thoughts, feelings, mental images, and conflicts that they have difficulty verbalizing. Movement therapy may facilitate normalization of body s ens e and body image for these 2029 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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severely traumatized patients . Occupational therapy help the patient with focus ed, structured activities that be completed s ucces sfully and may help with and s ymptom management.

Outc ome S tudies S ingle-case des criptions of s ucces sful treatments for diss ociative identity dis order date back more than a century. S ystematic outcome s tudies , however, have appeared within the pas t few years . T he first such followed up 20 dis sociative identity dis order patients at average of 3 years after intake. T he majority were in treatment with therapists who were unfamiliar with diss ociative identity disorder. Nonetheles s, two-thirds the clinicians reported moderate to great improvement their patients . A history of severe retraumatization the cours e of treatment was ass ociated with poorer outcomes . In the Netherlands, a chart review study of diss ociative dis order patients in outpatient treatment for an average of 6 years found that clinical improvement related to the intensity of the treatment, with more comprehensive therapies having better outcomes . A us ing the DE S to track treatment progress of 21 diss ociative identity disorder inpatients found a drop in overall s cores over a 4-week hospitalization. T he larges t and most systematic treatment outcome reevaluated 54 diss ociative identity disorder inpatients years after dis charge to outpatient treatment. As a there were significant overall decreas es in ps ychopathology, including number of Axis I and Axis II disorders , decreased DE S s cores, decreas ed the B eck Depres sion Index and the Hamilton 2030 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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S cale, and decreas ed dis sociative s ymptoms on all of DDIS s ubs cales . P atients who were reported according to rigorous criteria were the mos t improved. T wo s tudies inves tigating cos t efficacy of diss ociative identity dis order treatment have concordant findings suggesting that outcome depends on clinical s ubgroup. T he more treatment-res ponsive group of diss ociative identity dis order patients s howed significant remiss ion symptoms within 3 to 5 years of beginning appropriate treatment. A second group with more alters and more personality dis order features showed good outcome required hospitalizations in addition to outpatient treatment. A third group, characterized by the longes t period of treatment before diss ociative identity disorder diagnosis, largest number of alters , and most disorder problems , had a much longer, more cos tly, more difficult cours e. Overall, however, treatment approaches s pecifically targeting diss ociative identity disorder s howed reductions in overall ps ychiatric treatment cos t after the firs t year, compared to prior treatment for these patients . S ome health maintenance organization (HMO) groups report that more intensive treatment benefits for diss ociative identity disorder patients have not only reduced overall ps ychiatric but also reduced cos ts for medical us e for somatoform symptoms. T hese preliminary s tudies have notable limitations , including the diverse and nons tandardized nature of therapy and lack of comparison groups . Nonetheles s, aggregate, they indicate that many dis sociative identity disorder patients improve with treatments focused on their diss ociative symptoms and that overall treatment 2031 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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costs may be s aved in the long term by using the trauma treatment model for thes e patients . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > DIS S OC IAT IV E DIS OR DE R NO T S P E C IF IE D

DIS S OC IATIVE DIS OR DE R OTHE R WIS E S PE C IFIE D P art of "17 - Dis sociative Dis orders " T he category of diss ociative dis order NOS covers all of conditions characterized by a primary diss ociative res ponse that do not meet diagnostic criteria for one of the other DS M-IV -T R diss ociative dis orders. disorder NOS cases must als o fail to exclus ively meet diagnostic criteria for acute stress dis order, P T S D, or somatization disorder, which all include dis sociative symptoms among their criteria. T hus, dis sociative NOS is regarded clinically as a heterogeneous diss ociative reactions , s ome of which are common expres sions of dis tres s in other cultures but are rare in W es tern societies . T here are few s ys tematic s tudies of dis sociative NOS patients. Most authorities believe that there are major dis sociative disorder NOS s ubgroups . F irst is a of patients s imilar in clinical presentation, life history, clinical cours e, and treatment respons e to those with diss ociative identity disorder but whose s ense of subjective self-divis ion does not meet the firs t DS M-IV criterion for a dis sociative identity dis order alter identity 2032 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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personality s tate. R arely, a patient may pres ent with first two DS M-IV -T R criteria for diss ociative identity disorder, but without apparent amnesia. Most of thes e diss ociative identity disorder–like patients ultimately full criteria for diss ociative identity disorder, but s ome never exhibit clear alter identities or demonstrate diss ociative amnesia and continue to be diagnos ed diss ociative dis order NOS . T he other diss ociative dis order NOS s ubgroup is a heterogeneous collection of patients with a variety of diss ociative s ymptoms and P.1893 multiple comorbidities , usually accompanied by a pas t history of severe trauma at s ome time in life. One s tudy found that the dis sociative disorder NOS patients had scores that were intermediate between those of with dis sociative amnesia and those diagnosed with diss ociative identity disorder. Mr. P . is a 22-year-old unmarried man admitted to a ps ychiatric hospital for ass es sment and treatment after serious s uicide attempt following an altercation with his girlfriend. On admiss ion his tory and mental status examination, P . reported extensive involvement in an inner fantasy world to which he retreated when life became overwhelming. He had done poorly in school, des pite documented high intelligence, because of “spacing losing track of class work owing to intense S ometimes , his inner world was filled with frightening confusing images, but, mostly, it was a place of retreat. 2033 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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reported rapid changes in his sense of age, acting like, adoles cent, and adult in alternation. He reported amnes ia for many years of his childhood, although he could recall some of it. He described ongoing amnesia experiences with disremembered behavior, changes in abilities, repeatedly spacing out while and loss of time. He denied the exis tence of fully developed alter identities but felt subdivided into that represented different emotions and age s tates . He not experience loss of sense of s elf across these state changes but experienced hims elf and was obs erved to behave differently when he reported changes in these states . He reported chronic dysphoric mood, anxiety, of falling as leep, nightmares, and panic when touched in certain ways, although he could not explain why this was . He had s ignificant OC D symptoms , compuls ively arranging things in particular ways and panicking if they were changed. He grew up in a family of “workaholic alcoholics .” All members of his own and extended family drank although Mr. P . experienced them as “more pleas ant” when drinking than when preoccupied with work. members frequently teas ed him brutally because of his emotional s ens itivity and anxiety. He denied sexual abus e or frequent phys ical discipline, although reported occas ionally being beaten or s truck by his parents . F or the most part, he was left to himself. F rom years of age to approximately 12 years of age, he was to religious s chools, day care, and camps. He reported inexplicable obsess ive preoccupations with those experiences , although he could not recall much about them, including whether anything distress ing, 2034 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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overwhelming, or traumatic had occurred in these settings . During the years in which he attended these schools and camps , he developed repeated rectal bleeding from anal fis sures and hepatitis B . No medical explanation was reportedly found for these illness es. An intensive psychological ass es sment battery, the Minnesota Multiphasic P ersonality Inventory personality inventories , projective tests , intelligence and the S C ID-D-R , s upported a diagnosis of disorder NOS , intens e preoccupation with traumatic imagery s imilar to P T S D patients, but without a clear history of trauma, and a s ubtle atypical thought Hypnotizability tes ting showed that Mr. P . scored high standardized hypnos is scaling. T reatment included a variety of cognitive behavioral strategies to provide alternatives to fantasy withdrawal when experiencing dysphoria or s trong affects. He was taught self-hypnosis to increas e control over spontaneously occurring hypnotic experiences. He res ponded well to trials of 150 mg of fluvoxamine daily and 20 mg of ziprasidone twice a day for mood, OC D, and thought confusion s ymptoms . He began to more recall of as pects of his early life for which he had been amnestic, including frightening images with content related to the religious s chool. F amily meetings were held with his parents to review the developmental history, for Mr. P . to addres s his concerns about his treatment during childhood, and to help improve his relations hip with his parents . He was discharged with diagnoses of dis sociative disorder NOS , anxiety NOS , and mood dis order NOS . P ersonality 2035 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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was thought to include avoidant, dependent, and schizotypal features. A J apanes e s tudy of 19 diss ociative patients, normal and ps ychiatric controls, diagnosed with versions of the DE S and S C ID-D-R , found a s imilar of DE S scores as in non-J apanese samples . However, diss ociative dis order NOS s ubjects and fewer identity disorder s ubjects than expected were on the S C ID-D-R , although the highest DE S s cores found in the diss ociative dis order NOS patients . T he authors s peculated that different cultural attributions meanings of the s ubjective self and normal J apanes e encouragement of highly developed social and private selves might account for more dis sociative disorders being diagnos ed on the S C ID-D-R in J apanese

C ultural Variants of Dis s oc iative Dis orders Included within diss ociative dis order NOS are the many cultural variants of diss ociative trance. Anthropologists have identified forms of diss ociation within every that they have examined. In some ins tances , this takes form of specific trance state disorders ; in others, it is manifest in religious rites and rituals ; and, in s till others, is manifest in the form of traditional healing practices . of thes e forms of dis sociation are common in many Wes tern societies. Increas ingly, measures s uch as the and S C ID-D-R are being adapted for these cultures us ed to investigate thes e conditions. T he DS M-IV -T R also includes under diss ociative NOS (T able 17-20) those diss ociative reactions elicited coercive persuasive practices , such as torture, 2036 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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brainwas hing, thought reform, mind control, and indoctrination intended to induce an individual to relinquis h basic political, s ocial, or religious beliefs in exchange for antithetical ideas and beliefs. F inally, syndrome, a rare and poorly unders tood condition, characterized by the giving of approximate answers , is included in this category.

Table 17-20 DS M-IV-TR C riteria for Dis s oc iative Dis order Not Otherwis e S pec ified T his category is included for dis orders in which predominant feature is a diss ociative symptom disruption in the us ually integrated functions of cons ciousnes s, memory, identity, or perception of the environment) that does not meet the criteria any s pecific diss ociative dis order. E xamples the following:    (1) C linical pres entations s imilar to dis sociative identity dis order that fail to meet full criteria for disorder. E xamples include pres entations in (a) there are not two or more distinct pers onality states or (b) amnes ia for important pers onal information does not occur.    (2) Derealization unaccompanied by depers onalization in adults . 2037 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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   (3) S tates of diss ociation that occur in who have been s ubjected to periods of prolonged and intens e coercive persuasion (e.g., thought reform, or indoctrination while captive).    (4) Dis sociative trance dis order: s ingle or disturbances in the state of consciousness , or memory that are indigenous to particular locations and cultures . Dis sociative trance narrowing of awareness of immediate or s tereotyped behaviors or movements that are experienced as being beyond one's control. P os sess ion trance involves replacement of the customary s ens e of pers onal identity by a new identity, attributed to the influence of a spirit, deity, or other pers on and ass ociated with stereotyped involuntary movements or amnesia, is perhaps the most common diss ociative Asia. E xamples include amok (Indonesia), (Indonesia), latah (Malays ia), pibloktoq (Arctic), ataque de nervios (Latin America), and (India). T he dis sociative or trance disorder is not normal part of a broadly accepted collective or religious practice.    (5) Loss of cons cious nes s, stupor, or coma not attributable to a general medical condition.    (6) G ans er s yndrome: the giving of approximate answers to ques tions (e.g., 2 + 2 = 5) when not

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as sociated with dis sociative amnes ia or fugue.

   F rom American P s ychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P s ychiatric Ass ociation; 2000, with permiss ion. T he IC D-10 (T able 17-1) clas sifies all diss ociative (conversion) dis orders in one s ection, which includes conditions (trance and poss es sion disorders , convuls ions, and G ans er s yndrome) that are carried diss ociative dis order NOS in the DS M-IV -T R .

Dis s oc iative Tranc e Dis order Definition Dis sociative trance dis order is manifest by a marked alteration in the s tate of consciousness or by of the cus tomary sense of personal identity without the replacement by an alternate s ense of identity (T able 21). T here is often a narrowing of awarenes s of the immediate s urroundings or a selective focus on stimuli within the environment and the manifes tation of stereotypical behaviors or movements that the experiences as beyond his or her control. A variant of poss ess ion trance, involves s ingle or episodic in the state of cons cious nes s, characterized by the exchange of the pers on's cus tomary identity by a new 2039 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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identity usually attributed to a spirit, divine power, deity, or another person. In this poss ess ed state, the exhibits stereotypical and culturally determined or experiences being controlled by the poss es sing T here mus t be partial or full amnesia for the event. T he trance or poss es sion s tate must not be a normally accepted part of a cultural or religious practice and caus e s ignificant dis tres s or functional impairment in or more of the usual domains . F inally, the dis sociative trance state mus t not occur exclusively during the of a ps ychotic dis order and is not the res ult of any subs tance or general medical condition.

Table 17-21 DS M-IV-TR R es earc h C riteria for Dis s oc iative Tranc e Dis order A. E ither (1) or (2):    (1) T rance, that is , temporary marked alteration the state of cons cious nes s or los s of customary of pers onal identity without replacement by an alternate identity, as sociated with at least one of following:    (a) Narrowing of awarenes s of immediate surroundings or unusually narrow and s elective focus ing on environmental s timuli

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   (b) S tereotyped behaviors or movements that experienced as being beyond one's control    (2) P os sess ion trance, a single or epis odic in the state of consciousness characterized by replacement of customary s ens e of personal by a new identity. T his is attributed to the of a s pirit, power, deity, or other pers on, as evidenced by one or more of the following:    (a) S tereotyped and culturally determined behaviors or movements that are experienced as being controlled by the poss ess ing agent    (b) F ull or partial amnes ia for the event B . T he trance or poss es sion trance s tate is not accepted as a normal part of a collective cultural religious practice. C . T he trance or poss es sion trance state causes clinically significant dis tres s or impairment in occupational, or other important areas of functioning. D. T he trance or poss es sion trance state does occur exclusively during the course of a ps ychotic disorder (including mood dis order with ps ychotic features and brief psychotic disorder) or identity dis order and is not due to the direct 2041 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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phys iological effects of a s ubs tance or a general medical condition.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. P.1894

A taque de Nervios Diagnos is and C linic al Features Ataque de ne rvios is the best s tudied example of the diss ociative trance s tate dis order form of dis sociative disorder NOS . It is characterized by s omatic such as fainting, numbnes s and tingling, fading of seizure-like convulsive movements , palpitations , and sens ations of heat rising through the body. Individuals may moan, cry out, curs e uncontrollably, attempt to thems elves or others , or fall down and lie with deathstillnes s. During the episode, there is a narrowing of cons ciousnes s and a lack of awarenes s of the larger environment. After the epis ode, the individual usually reports partial or full amnesia for the events and their actions. Attacks may occur only once, may be episodic, occasionally may become chronically recurring with significant functional impairment. F requency of ataque s 2042 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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was correlated with DE S s cores in one s tudy.

E tiology T riggers s eem most often to involve family, marital, or other interpersonal conflicts or los ses . Alcohol, physical sexual violence, financial loss , or stress and fear may precipitate an attack. His tories of phys ical and s exual abuse are common but are not well correlated with frequency or severity of episodes . T he triggering event may initially evoke a s ens e of being overwhelmed, hopeless , and helpless . T his is followed by an abrupt in state of cons ciousnes s, with a narrowing of cons ciousnes s and the development of more florid symptoms. Attacks can last from minutes to days but us ually a few hours in duration.

E pidemiology C ontributing demographic factors include being female; being 45 years of age or older; being divorced, or widowed; having less than a high school education; living in poverty. In P uerto R ico, there is an es timated lifetime prevalence rate of approximately 14 percent for ataque de nervios .

Differential Diagnos is T here is often significant comorbidity with depress ion, anxiety disorders , agoraphobia, and P T S D. Ataque de ne rvios is differentiated from these dis orders by its diss ociative alterations in cons cious nes s and somatos ens ory motor disturbances . T his condition may a manifes tation of dis sociative identity disorder.

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Treatment E pisodes usually end with the intervention of others , may res train the victim if he or she is in danger or as saultive or may otherwise calm him or her. P raying, rituals , use of herb or alcohol rubs, or other folk interventions are common. In addition, the individual's distress and s ymptoms usually elicit increas ed s ocial support or prompt interventions to reduce the stress ors that precipitated the attack. In mos t ins tances, help is not s ought. In cases in which the triggering stress ors are deemed minor by the victim's s ignificant others or there are concerns about chronicity, the may be brought for psychiatric treatment. No clinical have been conducted as yet, but s ome success is with antidepres sant and antianxiety medications .

P os s es s ion Tranc e Diagnos is and C linic al Features Although the G reeks believed in divine poss es sion, it not part of their explanation for mental illness , P.1895 which was largely s ubsumed under the label of melancholia, thought to be a dis order of the black bile. Demonic poss es sion, as an explanation for distress and mental illnes s, appears to date to the firs t century AD in P alestine and was common in New T es tament writings . During the Middle Ages , demonic poss ess ion was widely regarded as the caus e of epilepsy. C anon law forbade the ordination of any individual who had been publicly pos ses sed for this 2044 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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reason. E ven as the medical nature of mental illness epilepsy became increas ingly documented, rejection of the diabolical notion of pos ses sion proceeded slowly and unevenly. T oday, there are numerous subcultures within the United S tates that believe in poss ess ion, demonic and divine, and practice exorcism spirit pos sess ion rituals. P oss ess ion trance is common many third-world cultures. Anthropological s tudies suggest that pos ses sion and exorcis m occur mos t commonly in oppres sive s ocieties in which there is alienation from the es tablis hment, and protes t or direct action is dangerous or unacceptable. T he initial onset of pos ses sion trance is often s imilar to of diss ociative trance s tate, with an acute triggering stress or followed s hortly thereafter by convuls ive or uncontrolled movements , trembling, flailing, or fainting. T hen, the individual may laps e into a stupor or may to be s truggling in the grip of an unseen force, when, suddenly, a dis tinctly different personality emerges . A dramatic physical and ps ychological transformation occur in the individual's face, voice, demeanor, and behavior. T he personality may identify itself as external to and distinct from the personality of the poss es sed S ometimes , it has to be tricked or coaxed into its elf. It may claim to be a deity, demon, s pirit, ghos t, deceased relative, or historic individual. T his imbued with these attributes, now focus es attention on the conflicts or s tres sors that triggered the poss es sion. may make demands or may sugges t s tructural within the s ocial group to eas e the precipitating conditions. If these demands are met, then the 2045 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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entity agrees to relinquis h control of the victim. During period of poss es sion, the individual may exhibit strength, agility, or other abilities or may behave in a dangerous or threatening fashion. P oss es sion us ually las t hours to days . In some ins tances , it can chronically dis abling. S pirit poss es sion, although not a disorder where it is religious ly s anctioned, shares many similarities with poss ess ion trance. K nown to occur in many regions of world, es pecially wes tern Africa, the C aribbean, and America, s pirit poss ess ion is us ually induced through rituals characterized by rapid, loud drumming, feverish dancing, and, sometimes, native intoxicants. As the begins to catch, there is often a dramatic T he individual may s tagger, s way, or fall into the arms bystanders. T he body may tremble or convulse. T he may change, the voice may deepen, and another personality becomes apparent. B ys tanders may further transformation by dress ing the individual in clothing appropriate for the identified s pirit or otherwis e addres sing it in a worthy fashion. While pos ses sed, the individual may dance with even greater agitation and force or may circulate among the crowd, addres sing people, questioning their health, or making pointed suggestions . S ometimes, the individual becomes may s tutter or speak with a lisp, may soil him- or may use vulgar language. C eremonially induced spirit pos sess ion typically lasts minutes to hours , with an average duration of approximately 1 hour in one review. As with trance state disorder, the individual is largely amnesic his or her behavior and the events of the poss ess ion 2046 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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episode. In s ome instances, the individual acts as a mess enger of the powers . W ith one foot in the world of deities and the other among men and women, the mess enger exis ts in a halfway s tate between full poss ess ion and normal behavior and usually retains memory for the events of the pos sess ion.

E tiology Anthropological s tudies strongly implicate pers onal as a common precipitant. In such cas es, special paid to the mess ages and advice given by the power reported and interpreted by the audience. Dreams or visions may als o precipitate poss ess ion, although generally more fleeting events . S piritual leaders may spirit pos sess ion as a s ource of guidance for their communities or to locate lost individuals or s acred S ometimes , s pirit poss ess ion is experienced as a punis hment for profaning a s acred s ite or angering a In mos t instances, pos sess ion trance appears to be in service of reducing overwhelming s tres sors or acute cris is in the individual's life. It als o provides an opportunity to expres s forbidden impuls es , to behave in socially unacceptable ways, to ass ume cross -gender and to influence people important to the pos ses sed.

E pidemiology P os sess ion trance disorders have been des cribed in third-world countries . T he Indian ps ychiatric literature contains the most s ys tematic descriptions and larges t number of cas es . In India, poss es sion s yndrome or hysterical poss es sion is the mos t common form of diss ociative dis order, whereas diss ociative identity 2047 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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disorder is thought to be exceedingly rare. P revalence poss ess ion trance in India has been estimated to range from 1 to 4 percent of the general population, but the on which this estimate is based may not truly be representative. E pidemics of pos sess ion syndrome been reported in the context of larger s ocial crises.

Differential Diagnos is P os sess ion trance differs from dis sociative identity disorder in that (1) it is generally a sharply time-limited condition (us ually hours), (2) it is us ually related to immediate s tres sors , (3) the pos sess ing pers onality to differentiate its elf as external to the victim, and (4) poss ess ing personality is usually recognizable to its audience by its stereotypical speech and behavior. P os sess ion trance may be mis taken for a psychotic when clinicians are not familiar with the cultural of an individual's ethnic group. In the United S tates, some religious groups view the identities in diss ociative identity disorder as of demonic poss es sion. Dis sociative identity dis order patients from thes e s ubcultures may feel torn between religious pres sure from their family and friends and the views of their treating clinicians. C ommonly, thes e diss ociative identity disorder individuals have alter identities who subscribe to the religious view of their social group and other alters who do not. An additional complexity is that diss ociative identity disorder patients from these sociocultural milieus , and from other backgrounds as well, not uncommonly have s elf-states that identify themselves as demonic, angelic, or of spiritual types. In one s tudy of dis sociative identity 2048 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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disorder patients who had been subjected to exorcis m, outcome was uniformly negative, with marked clinical wors ening, increased mistrust of religious and clinical caregivers, and a more difficult overall treatment

Treatment Individuals with pos ses sion trance or spirit pos ses sion seldom s eek treatment outs ide of the individual's family ethnic group. Intervention is most likely to come from family or traditional healers , who may perform an if the individual appears to be in great dis tres s or danger. W hen psychiatric help is sought, the pres ence diss ociative identity disorder, a psychotic disorder, or an affective disorder s hould be as sess ed.

B rainwas hing Definition T he concept of brainwas hing or thought reform from W estern reactions to the S oviet C ommunis t s how trials of the late 1940s and alarm over C ommunis t methods of coercive political reeducation that were central to the ideology of Mao T s e-T ung. T hes e fears intens ified during the K orean conflict after many prisoners of war made anti-American s tatements . In a journalist, E dward Hunter (later identified as a Intelligence Agency [C IA] agent) proposed that the C hines e C ommunis ts had dis covered techniques to mental attitudes and beliefs, a process that he called brainwas hing. P.1896

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After the Armistice, a team of ps ychiatris ts and ps ychologists , including R obert J . Lifton and E dgar interviewed the returning prisoners . S imilar s tudies for the C IA als o obtained information from C ommunis t interrogators and former S oviet and C hines e pris oners . T hese studies concluded that the apparent of thes e prisoners , as well as of the victims of the show trials , was the res ult of extreme police techniques involving severe physical and ps ychological deprivation, followed by rewarding the s everely prisoners with the poss ibility of the end of their ordeal, well as food and warm clothing. T he reports concluded that the basic attitudes of the American pris oners in had not, in fact, been altered. However, the s ubs equent release of another group of prisoners (mis sionaries, bus iness men, doctors, and students) caught in C hina at the beginning of the war seem to s ugges t that some form of thought reform had occurred with these individuals , several of whom continued to fals ely insist that they were s pies. In a round of studies, Lifton, S chein, and others concluded changes in an individual's bas ic beliefs could occur in context of extreme phys ical, psychological, and social coercion. T he us e of extreme group pers uas ion by the C hinese C ommunists on political prisoners may have been influential in this outcome. C linical presentations of individuals s ubjected to extreme forms coercive pers uasion may resemble thos e of survivors other s orts of torture. One legacy of the fear of C ommunist brainwas hing was the unfortunate misuse of ps ychiatry and psychology the C IA and other U.S . government agencies from the 2050 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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1940s and onward to develop methods of behavioral control, which was revealed in release of government documents and C ongres sional hearings in the 1970s . effort to combat or to preempt potential C ommunist use of mind control, the C IA s tudied or s upported studies of ps ychedelic drugs and other toxins and intoxicants , radiation, hypnos is , sens ory deprivation, repeated E C T treatments , and bizarre conditioning experiments, others , often on unwitting civilian or military s ubjects. At least one s ubject killed hims elf during an LS D and other psychiatric casualties have brought s uits the U.S . and C anadian governments because of caus ed them during C IA-funded experiments. According to reviews of C IA documents, s ome C IA apparently believed in the poss ibility of us ing hypnosis create as sas sins or s pies with hypnotically induced identities or amnes ia, or both, who could thus resist interrogation and torture. However, it has been that other C IA officials in charge of mind control experiments doubted that this could be done B ecaus e C IA officials des troyed many documents to these activities, it is not known to what extent thes e experiments were ever attempted. P opularized continue to s uggest that the U.S . government to create multiple-personality s pies. However, a careful reading of cases purported to demonstrate this show based on available information, most bear little to clinical dis sociative identity dis order. Allegations of brainwas hing or mind control resurfaced the late 1960s and 1970s in the context of religious movements. T his theory was als o advanced group of defens e psychiatric experts that included 2051 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Wes t, Lifton, Martin Orne, and Margaret T . S inger in famous cas e of P atty Hearst, the heiress who was kidnapped, tortured, s exually abus ed, and held in prolonged solitary confinement by a radical cult-like group. After many months of this treatment, Hears t was said to have trans formed her identity into that of the revolutionary T ania, who aided her captors in criminal including bank robbery and murder. T he P atty Hearst was not convinced, however, and convicted Hearst the arguments of the defense psychiatric experts. S inger s ubs equently widely publicized her ideas about conditioning techniques that she believed were used by religious cults to render their members incapable of complex rational thought and unable to make a s eries of laws uits by ex-members agains t various religious cults , she testified that these techniques were capable of overpowering a pers on's free will and that group's control over a member could be total. T hes e sens ational trials instilled in the public the notion of brainwas hing as a common practice in religious cults . In respons e, a group of academics, primarily and s ociologis ts, challenged S inger, pointing out that members often came from dysfunctional families and joined cults to avoid the anxieties and res ponsibilities independence. P s ychiatrist Marc G alanter reframed the religious cult mind-control debate by advocating the neutral term charis matic religious s e cts and pointing that an individual's behavior within such a social group may reflect psychological adaptation rather than ps ychopathology. S urveys and studies of ex-cult indicated that the manner of leaving the group, or by being involuntarily deprogrammed, was a 2052 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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determinant of their subs equent as sess ment of they had been brainwas hed, with the latter the most to expres s this belief. In the context of a particularly s ensational case, the American P s ychological Ass ociation and American S ociological Ass ociation submitted amicus briefs the concept of brainwas hing as lacking scientific which has had the larger effect of ess entially nullifying legal status . Although the academic community has largely avoided the topic in the las t decade, the notion brainwas hing, in which individuals are rendered hypers ugges tible through hypnosis , drugs , or phys ical stress ors , and their belief s ys tems are transformed by special conditioning techniques , continues to fas cinate public and to be invoked by a few ps ychotherapis ts and others as evidence of occult or government At the s ame time, some researchers on destructive have continued to sugges t that cult membership an ego state or dis sociated s elf-as pect that allows the person to function ego-syntonically within the cult T his entity is not conceptualized as meeting diagnos tic criteria for a diss ociative identity disorder alter identity suggests a diagnos is of diss ociative dis order NOS . R es earch s tudies to attempt to fully explicate such are likely to be exceptionally difficult to perform. T he military stress studies of Morgan and colleagues however, that combinations of pain, hunger, cold, fear, s ens ory deprivation, and control over bodily and s ocial communication can profoundly alter an individual's state of consciousness , producing diss ociative s ymptoms . T he accompanying degree of identity alteration induced by s uch techniques remains 2053 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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be empirically established, but it s eems poss ible that diss ociative reactions could account for many of the ps ychological changes reported in captive individuals subjected to coercive interrogation and persuasion.

Diagnos is and C linic al Features Individuals who have been s ubjected to extreme techniques are at risk for pers is tent depersonalization poss ibly, other dis sociative s ymptoms, including trance-like behaviors, and emotional numbing. T hey exhibit reduced cognitive flexibility, behavioral and profound changes in values , attitudes , beliefs, and sens e of self. In some ins tances , an alter s elf state emerge that identifies with former tormentors and behaves in a fashion contrary to the individual's prior behavior. T his alter s elf us ually dis appears or weakens significantly when the individual is returned to s afety security but may be transiently reactivated by circums tances reminiscent of the traumatic events.

Treatment T here are no empirical studies of the treatment of individuals s ubjected to extreme coercion applied in the service of indoctrination of a belief s ys tem or an identity alteration. T he basic principles of phas ed treatment would seem to provide an organizing framework for treatment of these individuals , as it has victims of other forms of torture. T his begins with the creation of safety and s ymptom stabilization, along with educational information to help normalize the res ponse. T his is followed, when and if appropriate, by supportive but nonsuggestive exploration of the events 2054 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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and experiences to desens itize their memory and to integrate them better into the individuals' trans formed sens e of self. Any preexisting ps ychopathology likely is exacerbated by s uch experiences and P.1897 should be addres sed as the dis sociative s ymptoms F amily interventions may be necess ary as a result of duress and disruption accompanying the precipitating events and the s ocial effects of the profound changes the individuals ' attitudes, behaviors, and beliefs .

G ans er S yndrome Definition G ans er s yndrome is a poorly understood condition, reclas sified from a factitious dis order to a diss ociative disorder in the DS M-III, characterized by the giving of approximate ans wers (paralogia) together with a of cons cious nes s, and frequently accompanied by hallucinosis and other diss ociative, somatoform, or conversion s ymptoms . F irst des cribed by Dr. S . J . M. in an 1897 lecture entitled “A P eculiar Hysterical S tate,” who observed that the “most obvious s ign consists of inability to ans wer correctly the simples t questions are as ked to them even though by many of their they indicate that they have grasped a large part of the sens e of the question.” G ans er offered the example of patient who, when asked how many noses he had, “I don't know if I have a nose.”

Diagnos is and C linic al Features T he symptom of pas s ing ove r (vorbe ige he n) the 2055 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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answer for a related, but incorrect one, is the hallmark G ans er s yndrome. T he approximate ans wers often jus t miss the mark but bear an obvious relation to the indicating that it has been understood. W hen as ked old s he was , a 25-year-old woman ans wered, “I'm not Another patient, when asked how many legs a hors e replied “three.” If asked to do simple calculations (e.g., 2 = 5), for general information (the capital of the United S tates is New Y ork), to identify simple objects (a pencil key), or to name colors (green is grey), the G ans er gives erroneous but comprehens ible answers . T here is also a clouding of consciousness , us ually by disorientation, amnesias, los s of personal and s ome impairment of reality testing. V isual and auditory hallucinations occur in roughly one-half of the cases. Many of the cas e reports include his tories of injuries, dementia, or organic brain insults. examination may reveal what G ans er called hys te rical s tigmata, for example, a nonneurological analgesia or shifting hyperalges ia. Many authorities make a between G anser symptoms of approximate answers, which may occur in a number of psychiatric and neurological conditions , and G anser syndrome, which must be accompanied by other dis sociative s ymptoms, such as amnes ias , conversion s ymptoms, or trancebehaviors .

E pidemiology C as es have been reported in a variety of cultures , but overall frequency of such reports has declined with T his may reflect trends in diagnosis, cas e reporting, or genuine decline in cas es . In the clinical literature, men 2056 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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outnumber women by approximately 2 to 1. T hree of G ans er's first four cases were convicts, leading some authors to consider it to be a dis order of penal and, thus, an indicator of potential malingering. G ans er believed that he had adequately ruled out this and most authorities are convinced that thes e patients have a genuine disorder. S ubs equent cas e s eries that it occurs in other settings and is not unique to prisoners .

E tiology S ome cas e reports identify precipitating s tress ors , s uch personal conflicts and financial reverses, whereas note organic brain s yndromes, head injuries, seizures, medical or ps ychiatric illness . P s ychodynamic are common in the older literature, but organic are stress ed in more recent cas e s tudies. It is that the organic insults may act as acute s tres sors , precipitating the syndrome in vulnerable individuals. S ome patients have reported s ignificant his tories of childhood maltreatment and adversity.

Differential Diagnos is G iven the reported frequent history of organic brain syndromes, s eizures , head trauma, and psychosis in syndrome, a thorough neurological and medical evaluation is warranted. Differential diagnoses include organic dementia, depres sive pseudodementia, the confabulation of K orsakoff's s yndrome, organic and reactive psychoses. Diss ociative identity disorder patients occas ionally may als o exhibit G anser-like symptoms. 2057 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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Treatment T here have been no systematic treatment s tudies, the rarity of this condition. In most cas e reports , the patient has been hos pitalized and has been provided a protective and s upportive environment. In some instances, low doses of antips ychotic medications have been reported to be beneficial. C onfrontation or interpretations of the patient's approximate answers not productive, but exploration of poss ible stress ors be helpful. Hypnosis and amobarbital narcosynthesis also been us ed s ucces sfully to help patients reveal the underlying s tres sors that preceded the development of the syndrome, with concomitant ces sation of the symptoms. Usually, there is a relatively rapid return to normal function within days, although some cas es may take a month or more to res olve. T he individual is amnes ic for the period of the syndrome. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > F OR E NS IC IS S UE S AND DIS OR DE R S

FOR E NS IC IS S UE S AND DIS S OC IATIVE DIS OR DE R S P art of "17 - Dis sociative Dis orders " Individuals with dis sociative disorders pres ent a variety problems in criminal and civil law. In criminal law, defendants claiming to have diss ociative identity have been as sociated with highly publicized cases, primarily seeking exculpation through the insanity 2058 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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defens e. However, diss ociative identity disorder individuals have als o appeared as alleged victims or witness es in criminal actions . Many of thes e cas es been s ubject to intense media coverage. Malingered diss ociative identity disorder and amnesia are major concerns when claims of not guilty by reason of (NG R I) or diminis hed capacity for criminal acts are broached. However, less publicized diss ociative disorder defendants have been accused of driving intoxicated (DW I), s hoplifting, theft, check kiting, embezzlement, credit card fraud, child abus e and stalking, and many other crimes. T hey also may be plaintiffs , particularly in cas es involving interpersonal aggres sion: domestic violence, s talking, and rape. Dis sociative individuals also commonly appear in civil cases. T hey may be plaintiffs in a variety of tort suits , commonly malpractice litigation, s exual harass ment, therapist mis conduct complaints . T hey als o may workers' compens ation matters, dis ability litigation, and family law related to divorce and child cus tody evaluations , among many others. S ome diss ociative disorder patients have s ued alleged abusers, usually parents , claiming damages for previously forgotten childhood abuse us ing the delayed discovery rule. C onvers ely, individuals diagnosed with diss ociative disorders —us ually dis sociative identity dis order—have sued for malpractice, alleging that the diagnosis was erroneous or iatrogenically created and that the plaintiff was harmed by therapy focused on therapeutically induced fals e memories of childhood maltreatment on a belief in repress ed memory. S ome of the latter plaintiffs had previous ly sued or pros ecuted their 2059 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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for abus e before recanting and s uing their therapists! S tate juris dictions may differ among thems elves and the federal courts on a variety of legal is sues, s uch as diminis hed capacity, criminal intent, competence, of limitations, capacity to give testimony, and allowance tes timony about amnes ia for trauma. Different jurisdictions have been divergent in their approach to diss ociative individuals as well. At leas t one district rejected diss ociative identity disorder as a valid to be cons idered for an insanity defens e plea, but this ruling was revers ed on appeal. Other courts have in findings of criminal res ponsibility for dis sociative identity dis order individuals , bas ed on differing ways of viewing which alter was respons ible for the criminal P.1898 In the criminal arena, me ns rea, the s tate of mind culpability for criminal acts , may seem hard to in an individual who claims dens e amnes ia for crimes who experiences hims elf or herself as self-states that variously profes s or deny res ponsibility for criminal behavior. S ome legal scholars have suggested that diss ociative dis orders in the criminal courts rais e related to an actus reus defens e, bas ed on the inability control involuntary actions , as in crimes committed in epileptic or s omnambulis tic s tates. In this regard, in recent high-profile criminal cas e, depers onalization us ed success fully as a bas is for a finding of lack of res ponsibility due to involuntary action, claimed by a defendant who s hot and wounded an alleged past

Dis s oc iative Identity Dis order and 2060 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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L aw T he inters ection between the diagnosis of diss ociative identity disorder and the legal system has proven to be exceedingly controvers ial. T he contentious dis pute exis tence, the often sensationalized media attention, the need to rule out simulation or malingering have the forens ic evaluation of dis sociative identity dis order difficult to perform and to defend. In criminal matters, most common claims are that (1) diss ociative identity disorder defendants do not have control over or are not cons cious of their alter pers onalities and therefore be held res ponsible for their actions ; (2) diss ociative identity dis order defendants are not competent, they cannot recall the actions of their alter self-states therefore cannot participate in their own defens e; and diagnosis of diss ociative identity dis order makes it impos sible for a defendant to conform to the law or to know right from wrong. E videntiary questions , including the admis sibility of material gathered with hypnotic or amobarbital interviews and the reliability or relative independence of testimony by different alter identities, have rais ed difficult legal ques tions . In general, trial and appeals courts in s tate and federal jurisdictions have ruled that diss ociative identity meets F rye or Daubert criteria, or both, so that it may us ed legitimately as a criminal defens e, and so that diss ociative identity disorder individuals can testify in court in alter identities and in dis sociative states . In many cas es, courts have s truggled with the the alter identities, confus ing their cognitions and behaviors with thos e of s eparate pers ons and failing to view the alters as me ntal cons tructs with relatively 2061 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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independent cognitions , affects , and memory s ys tems with a capacity for behavioral and role enactment. In fact, one extreme legal theory has posited that diss ociative identity dis order self-states s hould be like s eparate individuals, so that thos e uninvolved in criminal behavior would, by definition, be absolved of res ponsibility, and a finding of not guilty by reason of insanity would be mandated. C onversely, clinicians experienced in the treatment of diss ociative identity disorder have found that holding the whole human res ponsible for the behavior of any part is far more lead to clinical progres s and increased function. An attempt to abs olve or to excuse the patient of res ponsibility for maladaptive or antisocial behaviors is to lead to s piraling regress ion and es calating Accordingly, thes e authorities have recommended that clinical s tandard of holding the whole human being res ponsible for the behavior of any part be the for any legal cons ideration of diminished respons ibility criminal conduct in the diss ociative identity disorder individual. An affirmative case should be made that the diss ociative identity dis order defendant meets the standard for legal ins anity or diminis hed capacity, just would be the case for any psychiatric defense. S imilarly, forens ic commentators have argued that it is vital not to confus e the behavior of an individual experiencing hims elf or herself as an alter identity with mental s tates and behaviors of separate persons. authorities s uggest careful attention to avoid reification the diss ociative identity dis order alters and a focus on symptoms and mental state of the whole individual at 2062 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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time of the criminal act. T here is no pathognomonic presentation of diss ociative identity disorder in the criminal setting. However, authorities s uggest that genuine diss ociative identity disorder defendants are more likely to s how a complex alter s ys tem, not just a good–bad alter dichotomy. fide diss ociative identity dis order individuals may have bizarre explanations for why and how they (in alter identities ) committed crimes , not jus t “the bad one did Authorities als o describe a number of diss ociative disorder defendants as minimizing their psychiatric symptoms and attempting to avoid being labeled ps ychiatrically ill, although a few exaggerate bona fide diss ociative identity disorder s ymptoms . G enuine diss ociative identity disorder defendants may behave in self-defeating and problematic ways that may the success of their defens es . Mr. A. was arrested and charged with the murder of his long-time gay lover. T he circums tances of the cas e complex and bizarre. Mr. A. called the police on the of the murder claiming that his lover was holding him hostage and was going to kill him. He stated that his was heavily armed and was prepared to kill police if they s tormed the hous e. A S pecial W eapons and (S WAT ) team was dis patched, contacted Mr. A. by and s pent the next s everal hours attempting to talk him out of the hous e. He spoke with them in a child-like identified hims elf by a diminutive of his actual name, described hiding in a clos et with his pet. He appeared completely terrified, repeatedly stating that he was to be killed, that “the man” was dangerous and armed, 2063 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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that he would be shot if he attempted to flee. the police s tormed the hous e, located Mr. A. hiding a couch, and found his lover in the bedroom, dead of multiple gunshot wounds. B allis tics tes ts and other forens ic evidence indicated that Mr. A. had shot his who had been killed before the phone call to the police was initiated. At the time of his arres t, Mr. A. claimed memory of the shooting, although he did describe a frightening altercation earlier in the evening in which he stated that his lover had threatened to kill him for an alleged infidelity (which Mr. A. denied). Mr. A.'s attorney sought a finding of incompetence, because Mr. A. could not as sist in his defense owing to of recall of the s hooting. A court-appointed forensics had Mr. A. transferred to a state forens ics facility for as sess ment. T here, Mr. A. engaged in a variety of confusing, and s elf-defeating behaviors. He was overly compliant, defiant and oppos itional, child-like confused, and provocative and angry. On occasion, he identified hims elf by different names . Diagnos ed with a personality disorder and P T S D related to the shooting, was declared competent, even though he continued to claim amnesia for the crime. T he defense attempted to portray the shooting as s elf-defens e but could offer no direct information about it becaus e of the reported amnes ia. T he court limited psychiatric testimony concerning Mr. A.'s amnes ia. Mr. A. was convicted of murder, although, as the trial progres sed, his behavior became increasingly bizarre the courtroom. He threw water at the district attorney, stood up and s houted at the judge, and became combative with the court guards, resulting in additional 2064 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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charges of as sault. In the cours e of the s entencing proceeding, he became even more confused, child-like, and inappropriate. During a jailhouse conference with attorney, Mr. A. apparently began to s witch s tates , identified hims elf by different names , and referred to hims elf in the third pers on s ingular and the firs t person plural. He began to recount a bizarre his tory of the shooting in which several alter identities claimed res ponsibility for “protecting the little guy” (an alleged child alter) from the murderous as sault of the dead Mr. A. recounted a long his tory of infidelity and sexual, and emotional torment by the lover. He hinted history of childhood maltreatment by his father. P.1899 T he alters switched rapidly back and forth, with the Mr. A., apparently unable to recall what was said by the other alters . He appeared terrified, ins isting that this not happening to him and demanding that his attorney not bring this material into court. Mr. A. began to claim that his attorney was untrus tworthy and not helping him adequately in his legal defens e. W hen in the alter Mr. A. described fears of other pris oners in the jail. He elaborated a variety of paranoid ideas about plots him and vowed to defend hims elf agains t the other prisoners . Defense inves tigators found only limited evidence supporting the claims of maltreatment or infidelity by murdered lover. T he defendant's family s ide-stepped questions about childhood abuse, although they confirmed that the father was a violent, rageful, who experienced war-related P T S D and had been 2065 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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several times for violent behavior. Additional defens e forens ic ass es sment, including extensive ps ychiatric evaluation, psychological as sess ment, and formal as sess ment of malingering, res ulted in an opinion s upporting a diagnos is of diss ociative identity disorder. T he alter identities were particularly bizarre and paranoid in their thinking. on all the evidence, it was unclear if the lover was shot owing to Mr. A.'s paranoia or under conditions of actual threat, or both. Under state law, the defens e forens ic evaluation s upported a finding of incompetence owing Mr. A.'s inability to control dysfunctional s witching, and paranoia, leading to inability to as sist his attorney in the sentencing procedure. T he court rejected the claim of incompetence. Mr. A. was s entenced to 50 years in Appeals are proceeding claiming that, under state law, insanity defens e s hould have been allowed at trial. Mr. B . was arrested and charged with rape and murder approximately 48 hours after he released his to her home. He had kidnapped the victim after her uncons cious and driving her to his hous e. T here, tortured her bizarrely over 10 hours , culminating in a of sexual acts, the las t of which was a vaginal rape. this, his mood s eemed to change, and the victim found him less malevolent than he had been. Up until then, had been certain that s he would be killed. S he persuaded him to releas e her with a promise that she would not call the police. S he did not keep this and Mr. B . was quickly found and arres ted. All police contacts during the arres t and initial interrogation were audiotaped or videotaped. Mr. B . admitted the ass ault to the police and become 2066 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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increasingly despondent and distress ed. E ventually, he was transferred to a state hospital forensics unit fear that he would commit s uicide. S ubsequently, Mr. was implicated in two other attempted rapes in the previous year, which he als o admitted. In the course of as sess ment by state and defense ps ychiatris ts and ps ychologists , Mr. B . began to des cribe a “bad person” lived inside him and who had “taken over” and “made commit the crimes of which he was accused. He a complex s eries of hallucinations , preoccupation with rape fantas ies done by the “bad person,” and loss of interes t in life over the year preceding the rape. He claimed that he was s o preoccupied by these fantasies he ignored many bas ic aspects of daily life. Defens e health experts made a diagnosis of diss ociative identity disorder, s exual s adism, and major depress ion. T hey opined that the defendant was not guilty by reason of insanity, based on the “bad person” doing the crimes the defendant's los s of contact with reality in the year before arres t. R eview of Mr. B .'s past revealed a documented history severe phys ical abus e, emotional abus e, and neglect perpetrated by his mentally ill mother and alcoholic Mr. B .'s history was noteworthy for a virtually lifelong ps ychiatric disturbance characterized by a with rape, s exual sadism, and murder. He hinted that might have attempted rapes at other times in his life. Additional experts hired by the s tate evaluated Mr. B . several days . T hey performed the S C ID-D-R and other ps ychometric diagnos tic as ses sments. In neither the clinical nor the ps ychometric as sess ment did Mr. B . describe typical dis sociative identity dis order 2067 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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such as amnes ia, depers onalization, spontaneous autohypnotic phenomena, s witching, internal voices , internal pass ive influence, or somatization nor did he report P T S D s ymptoms. T he pers onified entities in his mind did not have relatively independent ways of thinking, behaving, or remembering nor did they clearly take control of Mr. B .'s behavior. T hey were more like fantas y characters, rather than alter self-states . Mr. B . described ideas of influence and reference at times emanating from others in his environment, periodic paranoid thinking, and s ocial isolation. Unus ual and idios yncratic thinking was observed at times during the interviews . He proclaimed remorse for his crimes but, clos er ques tioning, actually seemed rather pleas ed hims elf for completing the rape. T he history of recent, extreme s ocial withdrawal was belied by the acknowledgment that he had traveled out of s tate, several women, and actually prepared his house for the year preceding his arrest. He acknowledged the difference between right and wrong and taking evas ive actions to avoid arres t, in all alleged states of P ros ecution experts made DS M-IV Axis I diagnoses of schizotypal personality disorder with antis ocial traits; dis sociative disorder NOS , due to the bizarre preoccupations; sexual s adis m; and major depress ive disorder, in partial remis sion. T hey concluded that Mr. did not meet criteria for a diagnos is of diss ociative disorder nor did he meet s tate criteria for NG R I. Mr. B . guilty and is now serving 25 to 50 years in state prison. T herapists may find thems elves treating dis sociative identity disorder patients who face criminal charges for minor crimes , s uch as s hoplifting, check forgery, credit 2068 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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card fraud, and DW I. It may be impos sible for the hire an independent forens ic expert. In these cases , clinician may be unable to avoid providing a written or appearing in court to testify at the reques t of the or the patient's attorney. T he clinician should educate hims elf or herself about the role of the treating profes sional tes tifying on behalf of a patient. T he should be clear with the attorney and the patient on the differing roles of the forensic expert and the treating clinician and the potential ris ks that may ens ue if the primary therapist is made to tes tify. It may be difficult the therapist to s eparate the roles of the advocate for a disturbed patient from that of a forensic examiner. However, the clinician should take s eriously the importance of protecting the public from the patient. C linically, the forens ic situation may be us eful to unders core for the patient the respons ibility of the person for behavior committed in diss ociated s tates of cons ciousnes s and to gain better adherence to behavior from antisocial alter identities.

A mnes ia for C riminal B ehavior F rom a legal s tandpoint, amnesia alone is generally not cons idered a sufficient factor to generate a finding of incompetence to stand trial or a verdict of not guilty by reason of ins anity. Accordingly, it is dis advantageous malingerer to make amnesia claims in the hopes of achieving a success ful ps ychiatric defens e. C ase have found that perpetrators claimed diss ociative in 30 to 40 percent of homicide cas es and in a less er percentage of other violent crimes. Although is often s us pected in s uch cases , many of thes e did little to avoid being charged with a crime, and s ome 2069 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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even called the authorities thems elves. In general, the cases with apparent true diss ociative amnesia were characterized by an unpremeditated P.1900 as sault in a state of high emotional arous al on a victim clos ely related to the perpetrator. T here is no absolute way to differentiate true amnes ia from malingering. Malingerers have been to continue their deception even during hypnotically or barbiturate-facilitated interviews . Malingered amnesia more common in individuals pres enting with dramatic forms of generalized or circums cribed dis sociative or fugue, or both. Many of the amnesia cases in the clas sical literature were des cribed as occurring in a context of financial, s exual, and legal problems or in soldiers who wis hed to escape from combat. On the hand, in the clinical cas e reports , many malingerers confess ed their deceptions spontaneously or when confronted by the examiner. A variety of procedures have been sugges ted to differentiate objectively between actual and malingered amnes ia. At this point, none has achieved a definitive status in differentiating among thes e conditions . T he forens ic approach outlined in the following dis cus sion should be us ed to as sess individuals claiming amnes ia in the criminal court context, buttres sed, when indicated, by s pecific diagnostic ass es sment including ps ychometric s cales to detect malingering. Individuals with dis sociative fugue may also be legal is sues . T he fugue may occur in the context of 2070 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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ps ychos ocial stress ors , s uch as combat, financial or indis cretions, fears of violent behavior toward others , so on. When the individual is dis covered, he or s he face a variety of legal problems on return home.

Forens ic A s s es s ment of Dis orders In the ass es sment of poss ible diss ociative dis order in criminal defendants, as well as plaintiffs or defendants the civil arena, a number of guidelines may be helpful: F ollow bas ic principles of rigorous independent as sess ment. (2) Undertake a comprehens ive all available documentary materials concerning the defendant and the cas e. (3) R eview all available past ps ychiatric, s ocial s ervice, and related materials . (4) It often best to perform a standard diagnostic the defendant before introducing s pecialized testing. In some cases , it may be desirable to videotape or the interview following forensic guidelines; the latter be mandatory in some states if hypnosis is involved in as sess ment. (5) Avoid s uggestive or leading ques tions during forensic ass ess ment of pos sible diss ociative disorders . (6) A longitudinal life-history interview may us eful in cases in which malingered amnesia or diss ociative identity disorder is s uspected: Ask the defendant to relate his or her entire life history, with the firs t memory and proceeding forward up to the present time, following up information as neces sary in neutral manner. (7) After completion of the basic as sess ment, formal ps ychological tes ting, including interviews as sess ing malingering, s pecialized disorders interviews (e.g., the S C ID-D-R ), or neurops ychiatric testing, or a combination of thes e, 2071 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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be done. (8) Interviews with corollary sources (e.g., family) may be necess ary to corroborate the history in addition to written records. (9) Use forensic guidelines hypnotically facilitated or drug-facilitated interviews . G uidelines for hypnotically facilitated forens ic have been publis hed by the American S ociety for Hypnos is . T hese should only be performed by forens ic examiners trained in their us e.

Dis s oc iative-Dis ordered P laintiff In the few cases in which the iss ue has been litigated, several s tate trial and appeals courts have allowed tes timony of dis sociative identity disorder plaintiffs, despite their tes tifying in dis sociative or self-hypnotic states . Nonetheles s, involvement of adult dis sociative patients as plaintiffs in legal cases frequently res ults in advers e impact on the patient's clinical cours e. T his due to the negative effect of the adversarial system on patient, who may have a highly idealized view of what occur; an increas ed s ens e of los s of control due to the continual delays inherent in the legal process ; the up of the patient's psychiatric history and clinical status the courts ; and, s ometimes , the inherent difficulties in proving allegations of crimes or civil wrongs with a severely ps ychiatrically ill, periodically amnestic, complaining witness who may become overwhelmed, confused, or unconvincing during depos ition or in court. Highly symptomatic patients in the s tabilization phas e therapy may have a particularly difficult time in the system. C linicians s hould carefully review with the patient the potential clinical risks and benefits of proceeding with 2072 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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legal cas es . In addition to the concerns enumerated previous ly, therapy for the iss ues that brought the to treatment mostly gets put on hold, except insofar as illuminates the patient's s truggles in the legal system. primary focus becomes a s upportive treatment bas ed helping the patient maintain relative s tability during the case. T he patient may need ongoing education about nature of the advers arial process , the purpose of legal procedures, such as depositions, and the role of various participants . T he clinician may also need to act an intermediary with attorneys and the police, to help them understand the patient's psychopathology and relative s trengths and liabilities during various parts of proceedings. It is inadvis able for the clinician to act as expert witness in such a context, although the clinician may be examined as a fact witnes s. S ome patients elect not to go forward with criminal or proceedings, such as prosecuting a rape, becaus e of realis tic dread of the difficulty that they will face in S ome prosecutors and police als o s hy away from going forward in such matters becaus e of the inherent in these cases , even without a dis sociative plaintiff. drop charges, or, when poss ible, s eek a plea bargain avoid a court proceeding. In the civil arena, diss ociative patients have brought a variety of tort actions, mos t commonly malpractice agains t prior psychiatric and medical treaters . S ome patients have reluctantly decided not to go forward because of the previous ly mentioned iss ues . W hen the statute of limitations permits, some patients have postponed litigation until they were clinically better stabilized. 2073 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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In the current legal climate, tort suits against family members for abus e, based on delayed recall, are likely be bitterly contested, even when there is independent, reliable confirmatory evidence of the abus e. F rom a perspective, there is no requirement that adults who childhood abus e confront their alleged abusers or prosecute them to heal. Unles s carefully thought out clinically, these sorts of confrontations often result in a poor outcome for accusers and accused. T he longclinical focus is us ually more appropriately placed on patient's res olving his or her conflicted, ambivalent attachment to the accus ed abus ive relative. W hen this better res olved, the press ure for confrontation diminis hes substantially, or, if dis closure to family members occurs , it is handled in a way that is more to lead to resolution, not exacerbation of difficulties .

Fals e Memory L itigation T he premis es of fals e memory litigation are s everalfold: It is always below the s tandard of care to diagnose and treat diss ociative identity disorder or dis sociative or both, becaus e thes e disorders do not exist, and (2) clinicians should have known this and s hould have informed patients of this before undertaking their treatment. (3) T he underlying premis e of treatment of diss ociation and amnesia is to recover memories of P.1901 abuse by whatever means neces sary. (4) Adjunctive therapeutic techniques, such as imagery, hypnosis , journaling, and amobarbital interviews, are inherently high-ris k procedures that are liable to contaminate the 2074 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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memories of patients and to produce iatrogenically diss ociative identity dis order or diss ociative amnes ia, both. (5) Inpatient s pecialty treatment for these leads to contamination of patient autobiographical accounts and a contagion of iatrogenically created diss ociative identity disorder. T o be s ure, some treatments of apparent diss ociative disorders , both inpatient and outpatient, have been characterized by misdiagnos is; failure of informed focus on recall of trauma memories to the exclus ion of symptom stabilization and proper treatment staging; misuse of hypnosis, medications , imagery, or pharmacologically facilitated interviews ; failure to appreciate the complexities of human memory; infliction of the therapist's ideology on the patient (e.g., fundamentalist C hristianity, belief in certain cons piracy theories); failure to manage inpatient milieus to intens ive discus sion of trauma material among and lack of appropriate therapeutic boundaries. Nonetheles s, the extreme fals e-memory hypothes es ignore the abundant recent research on diss ociation trauma and dis regard the complexity of the is sues to trauma, memory, and diss ociation reviewed in prior sections . Most of these cases are handled by a small group of attorneys and plaintiffs' experts who join with local couns el to develop the cas e. It is important to alert attorneys and ins urance companies that these are not regular malpractice cas es, but a s pecialized type of litigation that us ually requires a specialized defens e, experts familiar with thes e cases. Many attorneys and insurance companies are unaware of the forens ic track 2075 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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record of the attorneys and experts that typically are involved in these cas es . On the other hand, ins urance companies often choos e to settle thes e cas es, even if is a reas onable defense, rather than risk the uncertain financial expos ure of litigation. Unfortunately, this tactic may actually encourage s imilar suits, because plaintiffs ' attorneys often prefer the certainty of s ettlement to the vagaries of trial. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > S UG G E S T E D C R OS S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "17 - Dis sociative Dis orders " Alcohol-related dis orders are described in S ection Amnes tic dis orders, other cognitive disorders , and disorders due to a general medical condition are in C hapter 10. Neurops ychiatric as pects of head presented in S ection 2.5. Dis sociative mechanisms are discuss ed in C hapter 6 on ps ychoanalytic theory. Dis sociative disorders in children and adoles cents are discuss ed in S ection 49.7. T he diagnostic dis tinction between dis sociative disorders and other mental is clarified in C hapter 12 on schizophrenia and in 14 on anxiety dis orders . C hapter 15 on the somatoform disorders provides a detailed description of the s omatic symptoms that, in this chapter, are viewed as manifestations of diss ociation. E xpanded descriptions the various psychotherapeutic approaches appear in 2076 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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C hapter 30, and biological therapies are described in C hapter 31. C ulture-bound syndromes are discus sed in C hapter 27. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 17 - Dis s ociative Dis orders > R E F E R E NC

R E FE R E NC E S *Anderson MC , Ochs ner K N, K uhl B , C ooper J , E , G abrieli S W , G lover G H, G abrieli J DE : Neural underlying the suppress ion of unwanted memories . S cience. 2004;303:232–235. B ehnke S H: C onfusion in the courtroom: How have ass es sed the criminal res ponsibility of with multiple pers onality disorder. Int J L aw 1997;20:293–310. B remner J D, Marmar C R . T rauma, Me mory, and Dis s ociation. V ol 54. W ashington, DC : American P sychiatric P ress ; 1998. B rown D, S cheflin AW , Hammond DC . Me mory, T re atme nt, and the L aw. New Y ork: Norton; 1998. B rown DW , F ris chholz E J , S cheflin AW : Iatrogenic diss ociative identity disorder: An evaluation of the scientific evidence. J P s ychiatry L aw. 1999;27:549– B rown DW , S cheflin AW , Whitfield C L: R ecovered memories : T he current weight of the evidence in science and in the courts. J P s ychiatry L aw. 156. 2077 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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C hambers R A, B remner J D, Moghaddam B , S M, C harney DS , K rystal J H: G lutamate and posttraumatic stress disorder: T oward a ps ychobiology diss ociation. S emin C lin Ne urops ychiatry. 281. C oons P M: Dis sociative disorders not otherwis e specified: A clinical investigation of 50 cases with suggestions for typology and treatment. 1992;5:187–195. Dorahy M: Dis sociative identity dis order and dysfunction: T he current state of experimental and its future directions . C lin P s ychol R e v. 795. E llenberger HF . T he Dis covery of the Uncons cious . Y ork: B as ic B ooks ; 1970. F isher C : Amnes ic states in war neurosis: T he ps ychogenesis of fugue. P s ychoanal Q . 468. F reyd J J . B etrayal T rauma: T he L ogic of F orge tting C hildhood Abus e . C ambridge, MA: Harvard P res s; 1996. G leaves DH, May MC , C ardena E : An examination diagnostic validity of dis sociative identity dis order. P s ychol R ev. 2001;21:577–608. K is iel C , Lyons J : Dis sociation as a mediator of 2078 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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ps ychopathology among s exually abus ed children adoles cents . Am J P s ychiatry. 2001;158:1034– K luft R P . Dis sociative identity dis order. In: G abbard ed. T re atme nt of P s ychiatric Dis orde rs . 3rd ed. V ol Was hington, DC : American P s ychiatric P res s; 2001:1653–1693. *Lanius R A, W illiams on P C , B oksman K , Dens more G upta M, Neufeld R WJ : B rain activation during driven imagery induced dis sociative res ponses in A functional magnetic res onance imaging B iol P s ychiatry. 2002;52:305–311. Lanius R A, W illiamson P C , Dens more M, B oksman Neufeld R W J , G ati J S , Menon R : T he nature of memories : A 4-T fMR I functional connectivity Am J P s ychiatry. 2004;161:36–44. Lewis DO, Y aeger C A, S wica Y , P incus J H, Lewis Objective documentation of child abuse and diss ociation in 12 murderers with diss ociative disorder. Am J P s ychiatry. 1997;154:1703–1710. Markowitsch HJ : P s ychogenic amnes ia. 2003;20:S 132–S 138. *Morgan C A, Hazlett G , W ang S , R ichardson E G , P P , S outhwick S S : S ymptoms of diss ociation in experiencing acute, uncontrollable s tres s: A inves tigation. Am J P s ychiatry. 2001;158:1239–

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Nijenhuis E R S . S omatoform Dis s ociation: Me as urement, and T he ore tical Is s ues . As sen, van G orcum; 1999. P utnam F W. Diagnos is and T re atme nt of Multiple P ers onality Dis orde r. New Y ork: G uilford; 1989. P utnam F W. Dis s ociation in C hildren and Deve lopme ntal P e rs pe ctive . New Y ork: G uilford; R einders AA, Nijenhuis E R S , P aans AMJ , K orf J , Willems en AT M, den B oer J A: One brain, two Neuroimage . 2003;20:2119–2125. S ilberg J L: F ifteen years of diss ociation in children: W here do we go from here? C hild Maltre at. 2000;5:119–136. *S imeon D, K nutels ka M, Nelson D, G uralnik O: unreal: A depers onalization dis order update of 117 cases. J C lin P s ychiatry. 2003;64:990–997. S piegel DE . T he diss ociative dis orders. In: T asman G oldfinger S , eds . Ame rican P s ychiatric P res s R eview of P s ychiatry. V ol 10. W ashington, DC : P sychiatric P ress ; 1991. S teinberg M. Handbook for the As s es s me nt of Dis s ociation: A C linical G uide. W ashington, DC : P sychiatric P ress ; 1995. van Ijzendoorn MH, S chuengel C : T he 2080 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/17.htm

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diss ociation in normal and clinical populations : analytic validation of the Diss ociative E xperiences (DE S ). C lin P s ychol R e v. 1996;16:365–382. *V ermetten E , Loewenstein R J , Zdunek C , W ils on K , B remner J D: C ortisol, memory and the hippocampus P T S D and DID. B iol P s ychiatry. 2002;51 145S .

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 18 - Norma l H uma n S exua lity and S exual and G ender Identity > 18.1a Normal Human S exuality and S exual Dys functions

18.1a Normal Human S exuality and S exual Dys func tions Virginia A. S adock M.D. P art of "18 - Normal Human S exuality and S exual and G ender Identity Disorders" S exual behavior is diverse and determined by a interaction of factors . It is affected by one's relationship with others, by life circums tances , and by the culture in which one lives. An individual's sexuality is enmeshed other personality traits, with his or her biological and with a general s ens e of self. It includes the of being a man or a woman and reflects developmental experiences with sex throughout the life cycle. encompas ses all thos e thoughts , feelings, and connected with s exual gratification and reproduction, including the attraction of one person to another. A rigid definition of normal s exuality is difficult to draw and is clinically impractical. It is eas ier to define s e xuality—sexual behavior that is des tructive to others , that is markedly cons tricted, that cannot be directed toward a partner, that excludes s timulation of primary s ex organs, and that is inappropriately with guilt or anxiety. 2082 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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T here have been myriad advances in the field of in the areas of pharmacology and psychology and in study of the interaction of s ex and the s ocial milieu. S ignificant new developments are the availability of medications that enable men to gain and maintain erections later in their lives and hormonal therapies allow women to have pleasurable coitus postmenopaus ally. T hese medications have helped the taboo against sex in elderly adults. T heories on the ps ychology of sex have examined compulsive s exual behavior—not an official diagnosis in the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ). T he last major s tudy of sex in United S tates was conducted in 1994, consisting of a survey of sexual practices that placed the s exual of Americans in a social context.

HIS TOR Y C ultural mores regarding sexual behavior have varied throughout the history of W estern civilization. Attitudes have oscillated between the liberal and the puritanical, between the acceptance and the repress ion of human sexuality. S ince the 1960s , the prevalent attitudes sex in the United S tates have been markedly liberal. However, recent s tudies indicate a trend toward more cons ervative values . T hat s hift is attributed the fear of acquired immune deficiency syndrome One poll reported that 40 percent of Americans are concerned about contracting AIDS and are altering sexual behavior becaus e of that fear. T he greates t was expres sed by young adults , who are now more to use condoms as a precaution and to choose their partners with greater care. In 1997, the rate of teenage 2083 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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pregnancy declined for the first time in 40 years, and, 1998, the number of teenagers who had s exual fell below 50 percent for the firs t time in a decade. Nonetheles s, currently, one in five teenagers has s ex before the age of 15 years. C onservative segments of society emphas ize abstinence before marriage as the answer to the fear of AIDS . T he recurrence of attitudes in respons e to the threat of illnes s has history. T he s exual liberality of the R enais sance ended when syphilis s wept the E uropean continent and a major argument for chas tity among proponents of the R eformation. Other factors that predispose to more res trictive mores are periods of economic reces sion tend to bring people to more puritanical positions. F ew these is sues have been res olved definitively in the form new social mores , however, and the permis sive the sexual revolution of the 1960s and 1970s exert a effect on current s exual behavior. T he advent of effective birth control methods and legalized abortion clearly differentiated the pleas ure of sexual activity from its procreative function. T he movement attacked the double standard for acceptable sexual behavior for men and women, encouraged to accept sexual res ponsibility for the gratification of needs , and challenged s ociety to reevaluate male and female roles. T he women's movement also focus ed attention on rape and incest. G erontologis ts elderly people alike have drawn attention to the s exual needs of the aged. Middle-clas s adolescents became sexually active, and gay rights groups urged their s exual orientation and s ucceeded in 1980 when homos exuality was dropped as a diagnostic category in 2084 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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the third edition of the DS M (DS M-III). C oncurrent with the cultural changes of the s exual revolution was the growth in scientific research into phys iology and sexual dysfunctions. William Masters V irginia J ohns on publis hed their pioneering work on phys iology of s exual res pons e in 1966 and reported on their program for treating sexual complaints in 1970. medical centers now have programs s pecifically the treatment of sexual dys functions. His torically, problems of s exual conflict and s exual dysfunction have been the province of ps ychiatry. S uch pioneers as Havelock E llis (F ig. 18.1a-1), R ichard E bing (F ig. 18.1a-2), and S igmund F reud focus ed on human sexuality. Later, others focus ed more on sexual phys iology and dysfunctions. T he work of C harles K ins ey (F ig. 18.1a-3), who publis hed S exual B ehavior in the Human Male in 1948 and its volume, S exual B ehavior in the P.1903 Human F e male , 5 years later, was the most extens ive performed in human sexuality in America up to that T he current approach to sexual dysfunctions reflects cultural and s cientific developments of recent years, development of s pecific techniques for the treatment of these problems, the his torical interes t of ps ychiatry in area, and the recognition of its importance in practice.

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FIGUR E 18.1a-1 Havelock E llis, 1859-1939. In his S tudie s in the P s ychology of S e x (1896), E llis recorded examples of normal and abnormal s exuality. It remains clas sic in the field of s exology. (C ourtes y of New Y ork Academy of Medicine.)

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FIGUR E 18.1a-2 R ichard von K rafft-E bing (1840-1903), ps ychiatris t who publis hed a clas sic text, P s ychopathia S exualis (1898), in which he documented every sexuality, including zoophilia, necrophilia, urolagnia, lust murder, among others . C as e reports were s o lurid detailed that early editions were published in Latin. (C ourtesy of New Y ork Academy of Medicine.)

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FIGUR E 18.1a-3 Alfred K ins ey. (C ourtes y of Ins titute R es earch, B loomington, IN.)

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Anatomic al and Phys iologic al B as es K nowledge about the organs of sexuality and the phys iological sequence of male and female res ponse is neces sary for an informed unders tanding of the s exual dysfunctions. In fact, s ince the 1990s, greater been placed on the genetic, neuroanatomical, and neurochemical model of human sexuality than on ps ychological and social factors. R esearch in s exual differentiation, including the genetics of gonadal development and hormonal influences on sexuality is great interest, and new findings in thes e areas of development are occurring rapidly.

Male A natomy T he external genitalia of the normal adult man include penis , s crotum, tes tes , epididymis , and parts of the vas deferens. Internal components include the vas ejaculatory ducts, and pros tate gland. F reud referred to the penis as the executive organ of sexuality. S ince antiquity, culture has represented the penis in a variety of art forms. In ancient G reece, the of Dionysus, P riapus, and the s atyrs used the phallus recurrent s ymbol of fertility and rejuvenation. T he word pe nis has been traced from the Latin, meaning “tail” or “to hang” and refers to the pendant position of organ in its res ting or flaccid s tate. T he size of the varies within a fairly constant range, but sex over the years have dis agreed on the dimensions of range. All agree, however, that concern over the s ize of penis is practically universal among men. Masters and J ohns on report a range of 7 to 11 cm in the flaccid 2089 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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P.1904 and 14 to 18 cm in the erect s tate. Of particular interes t their observation that the flaccid dimension bears little relation to the erect dimension, as the s maller penis proportionally more than the larger one (F ig. 18.1a-4).

FIGUR E 18.1a-4 T he penis in the flaccid and erect with average size as surveyed and drawn by Dickinson. (F rom Dickins on R L. Atlas of H uman S e x Anatomy. 2nd B altimore: W illiams & W ilkins; 1949, with permiss ion.) C ircumcis ion, a procedure in which the prepuce is removed, has been practiced for centuries as a religious by J ews and Moslems and is a common medical in the United S tates today. T he circumcis ed penis, with expos ed glans, was once believed to be less s ens itive because of cornification of the epithelium. In laboratory 2090 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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studies, however, res earchers have found no tactile thres hold between the circumcis ed penis and uncircumcised penis . Intravaginally, the prepuce of the uncircumcised penis remains retracted behind the during penile thrusting, dis pelling the myth that premature ejaculation may be more common in uncircumcised men because of increas ed s timulation caus ed by preputial movements . In 1999, the American Academy of P ediatrics recommended that male circumcis ion not be performed as a routine procedure except for religious reasons. S ome studies of s exual dysfunctions, however, found a higher incidence of problems in uncircumcis ed men, but no caus al relations hip was determined. E jaculation is the forceful propulsion of s emen and fluid from the epididymis, vas deferens, seminal and prostate into the urethra. T he dilation of the urethra and the pas sage of fluid into the penile urethra provide the man with a sensation of impending climax, emis sion phas e of the ejaculatory proces s. Indeed, the prostate contracts , ejaculation is inevitable. T he ejaculate is then propelled through the penile urethra contractions of the s triated pelvic and perineal T his phas e of ejaculation is ess entially under somatic efferent control. T he ejaculate cons is ts of teaspoon (2.5 mL) of fluid and contains approximately million sperm cells. It is believed that the larger the ejaculate, the more pleas urable the orgas m, but this is highly s ubjective. T he sense of pleasure that accompanies orgas m is thought to be a cortical experience.

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F emale A natomy T he external genitalia of the normal woman, also called the vulva, include the mons pubis, major and minor clitoris, glans , vestibule of the vagina, and vaginal T he internal s ys tem includes the ovaries , fallopian uterus , and vagina. T he word vagina comes from the Latin word meaning “sheath.” T he vagina is us ually collapsed, a potential than an actual s pace. Approximately 8 cm long, the extends from the cervix of the uterus above to the vestibule of the vagina or vaginal opening below. In virgins, a membranous fold, the hymen, s eparates the vestibule and opening from the res t of the vaginal T he mucous membrane lining the vaginal walls res ts in numerous trans verse folds. T o accommodate the penis during sexual intercours e, the vagina expands in both length and width. After menopaus e, because es trogen concentrations decreas e, the vagina los es of its elas ticity. Hippocrates firs t described the clitoris in the medical literature, referring to it as the s ite of s exual excitation. Masters and J ohnson described the clitoris as the female s exual organ, because orgas m depends phys iologically on adequate clitoral s timulation. Anatomically, the clitoris has a nerve net that is proportionally three times as large as that of the penis . Alfred K insey found that when women masturbate, prefer clitoral stimulation. T hat finding was refined by Masters and J ohnson, who reported that women the shaft of the clitoris to the glans , because the glans 2092 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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hypers ens itive if s timulated exces sively. T he clitoral prepuce is contiguous with the labia and, during coitus , the penis does not s timulate the directly. R ather, penile thrusting exerts traction on the minor lips, which, in turn, stimulate the clitoris for orgasm. During heightened excitement, jus t before orgasm, the clitoris retracts under the clitoral hood because of contraction of the is chiocavernos us R etracting, the clitoris moves away from the vaginal which makes clitoral–penile contact imposs ible. T he the clitoris varies considerably and is unrelated to the sexual respons ivenes s of a particular woman. In 1950, E rns t G raefenberg described an area the female urethra in the anterior wall of the vagina that has come to be called the G s pot. Approximately 0.5 to cm in size, it becomes engorged during s exual Many women report that s timulation of the area is pleas urable and, in s ome, can induce orgasm. believed that the tiss ue here was analogous to the prostate and might account for the s purt of fluid during orgasm reported by some women, s imilar to male ejaculation.

Innervation of S ex Organs Innervation of the sexual organs is mediated primarily through the autonomic nervous system (ANS ). P enile tumes cence occurs through the synergistic activity of neurophys iological pathways. A paras ympathetic (cholinergic) component mediates reflexogenic via impuls es that pas s through the pelvic splanchnic nerves (S 2, S 3, and S 4). A thoracolumbar, mainly sympathetic pathway transmits ps ychologically induced 2093 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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impulses. B oth paras ympathetic and s ympathetic mechanisms are thought to play a part in relaxing the smooth mus cles of the penile corpora cavernosa, allows the penile arteries to dilate and caus es the blood that res ults in penile erection. R elaxation of cavernos al s mooth mus cles is aided by the release of oxide, an endothelium-derived relaxing factor. C litoral engorgement and vaginal lubrication als o res ult from parasympathetic stimulation that increas es blood flow genital tiss ue. E vidence indicates that the sympathetic (adrenergic) system is res ponsible for ejaculation. T hrough the hypogastric plexus , adrenergic impulses innervate the urethral crest, the mus cles of the epididymis , and the muscles of the vas deferens , seminal ves icles , and S timulation of the plexus caus es emiss ion. In women, sympathetic s ys tem facilitates the s mooth mus cle contraction of the vagina, urethra, and uterus that during orgasm. T he ANS functions outside of voluntary control and is influenced by external events (e.g., stress , drugs ) and internal events (hypothalamic, P.1905 limbic, and cortical s timuli). C onsidering these it is not surpris ing that erection and orgasm are so vulnerable to dys function (T able 18.1a-1).

Table 18.1a-1 R es pons es of S ex Organs to Autonomic Nerve 2094 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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Adrenergic Impuls es

C holinergic Impuls es

E ffec tor Organs

R ec eptor R es pons es Type

R es pons es

Urinary bladder

 

 

 

   Detrus or

β2

R elaxation (us ually)

C ontraction

   T rigone and sphincter

α1

C ontraction

R elaxation

Ureter

 

 

 

   Motility and tone

α1

Increase

Increase

Uterus

α1 , β2

P regnant: contraction ( α1 ), relaxation ( β2 ); nonpregnant:

V ariable

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relaxation ( β2 ) S ex male

α1

E jaculation

E rection

S kin

 

 

 

C ontraction

 

Localized secretion

G eneralized secretion

   P ilomotor α1 muscles    S weat glands

α1

Adapted from G oodman G ilman A, R all T W , Nies T aylor P , eds. G oodman and G ilman's T he P harmacological B as is of T he rapeutics . 8th ed. New P ergamon; 1990.

E ndoc rinology F rom the time of conception, hormones play a major in human s exual development. Unlike the fetal gonads, which are under chromos omal influence, the fetal genitalia are very s usceptible to hormones. mediates the development of the undifferentiated mesodermal wolffian ducts into the male vas deferens, epididymis , and s eminal vesicles. Dihydrotes tos terone, produced from tes tosterone, induces the penis and 2096 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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scrotum. T he raphe in men corresponds to the location of the vaginal orifice in women (F ig. 18.1a-5).

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FIGUR E 18.1a-5 Differentiation of male and female external genitalia from indifferent primordia. Male differentiation occurs only in the pres ence of androgenic stimulation during the firs t 12 weeks of fetal life. (F rom Wyk and G rumbach, 1968. R eprinted from B robeck J R , B es t and T aylor's P hys iological B as is of Me dical ed. Williams & W ilkins , B altimore; 1973, with E xogenous hormonal adminis tration can cause genital development inconsis tent with the fetal s ex development. F or ins tance, if the pregnant mother receives sufficient exogenous androgen, a female fetus poss ess ing an ovary can develop external genitalia res embling thos e of a male fetus . F etal, maternal, or exogenous hormones administered to a pregnant may all affect development of the external genitalia of fetus. Deprived of male and female gonads and the res pective hormones , testosterone and estrogen, the human adult does not develop normal s econdary characteristics , is incapable of reproduction, and, in the case of the woman, does not develop a mens trual T es tos terone is the hormone believed to be connected with libido in both men and women. In men, s tres s is invers ely correlated with tes tos terone blood concentration. Other factors , such as sleep, mood, and lifes tyle, influence circulating levels of the hormone. releas e of tes tos terone in men is under the control of hypothalamic-gonadal-pituitary axis. T he hormone is secreted in a pulsatile manner and in a diurnal rhythm, with the highes t levels occurring in the morning and the lowest levels in the evening. Normal concentrations 2098 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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from 270 to 1,100 ng/dL. Decreas ed testosterone concentrations are apparent by age 50 years and at the rate of approximately 100 ng/dL per decade. However, many healthy, aging men never become hypogonadal. It has als o been s ugges ted that the sens itivity of androgen receptor s ites decreases in men. Androgen administered to men complaining of loss of potency and loss of libido is usually unsuccess ful tes tos terone concentrations are below normal, and adminis tration to women may precipitate disturbing virilization. Many clinicians correct the hormone of the postmenopausal period with estrogen therapy. T estosterone has been us ed in combination es trogen in women who do not res pond to estrogen alone. T he combination is es pecially useful in treating headache, depres sion, and reduced libido. Oxytocin, secreted by the hypothalamus, stimulates lactation and uterine contractions and may enhance sexual activity. P lasma oxytocin concentrations increas e in men and women during orgasm. Diethylstilbestrol (DE S ), an androgenic s teroid, was prescribed in the 1950s and 1960s for pregnant women with threatened abortion. However, the drug had untoward effects on the children (es pecially female children) born to these mothers . R eports of cervical uterine abnormalities were reported in women and reproductive tract abnormalities were reported in men. T he children (called DE S P.1906 daughte rs and s ons ) organized a National DE S 2099 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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P rogram sponsored by the National C ancer Institute to provide information on the potential medical problems confronting those born to DE S mothers (F ig. 18.1a-6).

FIGUR E 18.1a-6 T wins born to a mother who received ethis terone during pregnancy. Note the enlarged clitoris each child. (C ourtesy of R obert B . G reenblatt, M.D., V irginia McNamarra, M.D.)

G enetic s G enes are involved in gonadal differentiation, res ulting the formation of the bipotential gonad into either a or ovary. T he best-defined gene in this proces s is S R Y determining region of the Y chromosome), located on 2100 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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short arm of the Y chromos ome. Other genes als o play smaller role, such as W T 1 (W ilms' tumor 1), S F -1 (s teroidgenic factor 1), S O X 9, DAX 1, and MIS -12 inhibiting s ubs tance 12). Defects or mutations in these genes cause failures in gonadal differentiation that produce clinical s yndromes known as inters e x F igure 18.1a-7 describes s ome genetic factors involved the determination of male s ex.

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FIGUR E 18.1a-7 A complex s eries of s teps must occur gonadal differentiation. A number of genes are critical to appropriate male genital development. S R Y (s exdetermining region of the Y chromosome), a gene on short arm of the Y chromosome, is a testis-determining factor. T he S O X 9 gene is als o important in male sexual differentiation. DAX 1, an orphan member of a nuclear hormone receptor family located on the X chromosome, interacts with steroidogenic factor 1 (S F -1). Other involved in male gonadal differentiation include the suppress or gene W T 1 (W ilms' tumor 1), and the inhibiting s ubs tance gene (MIS ) and its receptor, MIS (F rom F ederman DD: P erspective: T hree facets of differentiation. N E ngl J Me d. 2004;350:323-324, with permis sion.)

C entral Nervous S ys tem and S exual B ehavior C ortex T he cortex is involved both in controlling s exual and in process ing sexual stimuli that may lead to activity. One study using positron emiss ion tomography (P E T ) s cans to monitor the brain activity of men in their while they were s hown various films , including a documentary, a comedy, and a s exually explicit film, that s ome areas of the brain were more active during sex film than they were during the other films . T hese included the orbitofrontal cortex, which is involved in emotions , the left anterior cingulate cortex, which is involved in hormone control and s exual arous al, and 2103 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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right caudate nucleus, whose activity is a factor in sexual activity follows arous al.

L imbic S ys tem E xperimentation with animals has demonstrated that limbic s ys tem is directly involved with elements of functioning. In all mammals, the limbic system is in behavior required for self-preservation and the preservation of the species . C hemical or electrical s timulation of various sites of the limbic s ys tem, the lower part of the s eptum and the contiguous medial preoptic area, the fimbria of the hippocampus , the mammillary bodies , and the anterior thalamic nuclei have all elicited penile erection. T he hippocampus is believed to influence genital tumes cence and affect the regulation of the releas e of gonadotropins . S timulation of the amygdala in primates initiates oral (chewing, lip s macking) and then genital (penile erection) behavior. R es earchers have stated the clos enes s of these functions may derive from the evolutionary fact that the olfactory sense was s trongly involved in both feeding and mating. T hey speculate the evolution of the third subdivis ion of the limbic may reflect a shift in importance from olfactory contact visual communication in sociosexual behavior.

B rains tem B rainstem sites exert inhibitory and excitatory control spinal s exual reflexes . One site, the nucleus paragigantocellularis, has been identified as important inhibitory control of climax-like respons es in men and is suspected to be involved in female physiology as well. 2104 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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nucleus projects directly to pelvic efferent neurons in lumbosacral spinal cord, apparently caus ing them to secrete s erotonin, which is known to inhibit orgas ms. lumbosacral cord also receives strong projections from other s erotonergic nuclei in the brains tem, the raphe nuclei, pallidus, magnus , and parapyramidal region.

B rain Neurotrans mitters A vast array of neurotransmitters is produced by the including dopamine, epinephrine, norepinephrine, and serotonin, among others. All affect sexual function. F or example, an increas e in dopamine is pres umed to libido. S erotonin produced in the upper pons and midbrain is pres umed to have an inhibitory effect on sexual function. Oxytocin, the neurohormone involved the milk ejection reflex, is also releas ed with orgas m believed to reinforce pleasurable activities . B as ic and clinical res earch on brain neurotransmitters and effects on behavior (including s ex) are rapidly fields . P.1907

S pinal C ord As des cribed in the innervation of s ex organs, sexual arousal and climax are ultimately organized at the level. S ensory s timuli related to s exual function are conveyed via afferents from the pudendal, pelvic, and hypogastric nerves . T hese afferents terminate in the medial portions of the dorsal horn and in the medial central gray matter of the s pinal cord. S everal s eparate experiments sugges t that s exual reflexes are mediated 2105 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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spinal neurons in the central gray region of the lumbosacral segments .

P S YC HOS E XUA L ITY S exuality and total personality are so entwined that it is virtually impos sible to s peak of s exuality as a separate entity. T he term ps ychos exual is therefore us ed to personality development and functioning, as thes e are affected by s exuality. P s ychos e xual applies to more sexual feelings and behavior, and it is not s ynonymous with libido in the broad F reudian s ens e. F reud's generalization that all pleasurable impulses activities are originally s exual has given lay people a somewhat distorted view of sexual concepts and has ps ychiatris ts a confused picture of motivation. F or example, some oral activities are directed toward obtaining food, and others are directed toward sexual gratification. B oth activities are pleas ureand us e the s ame organs , but they are not, as F reud contended, both necess arily s exual. Labeling all seeking behaviors s e xual obviates specifying precis e motivation. P eople may also us e sexual activities to nonsexual needs , s uch as dependency, aggres sion, and s tatus . Although s exual and nonsexual impulses jointly motivate behavior, the analys is of behavior depends on unders tanding the underlying individual motivation and their interactions. S exuality is more than physical sex, coital or noncoital, and less than all behaviors directed toward gaining

Ps yc hos exual Fac tors S exuality depends on four interrelated ps ychos exual 2106 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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factors : s exual identity, gender identity, s exual and s exual behavior. T hese factors affect personality, development, and functioning. S exual ide ntity is the pattern of a person's biological characteristics : chromosomes, external and internal genitalia, hormonal compos ition, gonads , and sex characteris tics. In normal development, these characteristics form a cohesive pattern that leaves individuals in no doubt about their sex. G e nde r ide ntity is an individual's sense of maleness or femalenes s. B y the age of 2 or 3 years , almost a firm conviction that “I am a boy” or “I am a girl.” identity results from an almos t infinite series of clues derived from experiences with family members , peers , teachers, and from cultural phenomena. F or instance, infants tend to be handled more vigorous ly and female infants tend to be cuddled more. F athers s pend more with their infant sons than with their daughters, and also tend to be more aware of their s ons ' adoles cent concerns than of their daughters ' anxieties. B oys are likely to be physically dis ciplined than girls are. A sex affects parental tolerance for aggres sion and reinforcement or extinction of activity and of aesthetic, and athletic interes ts. P hys ical derived from a pers on's biological s ex (e.g., physique, shape, and phys ical dimensions ) interrelate with an intricate system of stimuli, including rewards , and parental gender labels, to es tablis h gender goals . R ecent studies of children with inters ex conditions drawn attention to a phys iological basis for gender identity. In particular, they have focus ed on the masculinization or feminization of the fetal brain. 2107 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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S exual orie ntation describes the object of a person's impulses: heterosexual (oppos ite sex), homosexual sex), or bisexual (both s exes). T he overwhelming of people have a heterosexual orientation. In the S tates, 2.8 percent of men and 1.4 percent of women identify themselves as homosexual. T hes e numbers compatible with figures from W estern E uropean as well. However, a higher percentage of pers ons have at least one s ame-sex experience in their lives . Additionally, homos exuals congregate in urban areas, the incidence of homosexuality in some large cities is high as 8 or 9 percent. S exual behavior includes desire, fantasies, purs uit of partners , autoeroticis m, and all the activities engaged expres s and gratify sexual needs . It is an amalgam of ps ychological and phys iological respons es to internal external s timuli. P.1908

Mas turbation Masturbation usually is a normal precurs or of objectrelated sexual behavior and a form of sexual pleas ure generally las ts throughout a person's lifetime. No other form of sexual activity has been as univers ally spite of being s everely condemned by many cultures long periods of time. In the class ical period, G reco-R oman writers and authorities , s uch as G alen, recommended a healthful practice for both men and women. T he categorization of masturbation as s inful in W estern derives from J udeo-C hris tian attitudes . Masturbation is 2108 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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sometimes called onanis m after Onan in the Old T es tament, who was s lain for spilling his seed upon the ground. Many biblical s cholars today posit that this punis hment was not a result of his mas turbation, but because he did not obey J ehovah's commandment to his brother's wife as his own. T he prohibition against masturbation was reinforced by C hris tian C hurch particularly by S t. Augustine, who preached celibacy held that s ex was appropriate only for purpos es of procreation. Ambivalence about mas turbation also in E as tern cultures . S ome Hindus and the ancient believed that loss of semen resulted in reduction of a male ess ence. However, the prohibitive emphas is was ejaculation and not on manipulation of the genitalia. F emale masturbation was better tolerated or ignored. F or many years, s cience held attitudes toward masturbation that were as negative as many religious views. W hat had been viewed as sinful came to be pathological (F ig. 18.1a-8). F or example, in the 1800s , K rafft-E bing believed that masturbation could lead to insanity. C urrently, and in the second half of the 20th century, a liberal attitude toward s exual behavior, including masturbation, has prevailed. R es earch by in the 1940s into the prevalence of masturbation that nearly all men and three-fourths of all women masturbate sometime during their lives . Mas ters and J ohns on dis cuss ed techniques of mas turbation in the 1960s and identified the s haft of the clitoris as the preferred site of masturbation for women. In the 1990s , study of sexual practices in America found that masturbation was the first pos tpubertal sexual practice most men and of approximately 50 percent of women. 2109 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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S tudies in E urope noted an increas ed incidence in masturbatory activity in both young men and women in the 1980s and, es pecially, in the 1990s, as compared 1960s . In thes e s tudies , most of the women had experienced masturbation before their firs t coital experience, following a pattern of s exual development that has long been typical for men. Additionally, both and women practiced masturbation regardles s of they were in a s teady relations hip. T hus, masturbation come to be s een as a s eparate s ource of s exual that is not in conflict with partnered s ex.

FIGUR E 18.1a-8 A four-pointed urethral ring, which us ed to prevent masturbation during the 19th century. engraving shows how the ring was tied to the penis. 2110 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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S adock B J , K aplan HI, F reedman AM. T he S exual B altimore: W illiams & W ilkins; 1976, with permiss ion.) Masturbation is a ps ychopathological s ymptom only it becomes a compuls ion beyond an individual's willful control. T hen, it is a symptom of disturbance not is sexual, but becaus e it is compulsive. It is also symptomatic of sexual problems when it is the only activity of a person who has an available intimate However, mas turbation is a univers al and healthy component of psychos exual development.

S E X UA L L E A R NING A ND S E X UA L B E HA VIOR T he sex drive is innate and varies in intens ity in people, but much sexual behavior is learned. E arly experiences , particularly thos e during puberty and adoles cence, can have an imprinting effect. If they are strongly ass ociated with pleas ure and release of they are likely to be repeated and the person is conditioned to a particular form of sexual express ion. In the normal pers on, sexual learning and continue throughout the life cycle, the repertoire of behavior expands , and the behaviors are compatible cultural norms.

C hildhood S exual learning begins in childhood. In a broad sense, learning occurs through parent–child interaction, including the meeting of the infant's needs , cuddling, the reinforcement or discouragement of gender2111 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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as sociated activities. C uddling and appropriate touching engender emotional s ecurity and positive feelings in infants toward their bodies. T hat physicality the groundwork for a healthy body image that is a component of sexual s elf-es teem. A good body image derives from mas tery of early physical activity and a positive parental approach to tas ks s uch as toilet G enital self-stimulation is a normal activity of babies . It particularly pronounced between the ages of 15 and 19 months, and it is part of the general interes t of children their bodies. T he activity is reinforced by the sens ations it produces . As youngs ters acquire curios ity about their own and others' genitalia motivates episodes of exhibitionism or genital exploration. Unless the child is unduly shamed, s uch experiences continued pleas ure from sexual stimulation. C hildren als o learn by watching the interaction of their parents . T hey obs erve demonstrations of phys ical (although usually not the sex act itself), and they are sens itive to the sexual undertone of flirtation, bantering, seductive interchange. S exual learning in childhood is advers ely affected by exploitative, abus ive adults . Inces tuous activity, with or without penetration, or s exual abus e by other adults (babys itter, other older relatives , teachers, coaches, damaging to the child. It may precipitate s exual dysfunction in adult life, as well as promiscuity and problems with intimacy. It may produce delinquent activities and behavioral problems in adolescence, as as learning problems in school. S ome children are inappropriately stimulated s hort of 2112 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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outright incest or genital fondling. T hey are the objects extremely s eductive parents. T ermed eroticize d they frequently become s exually precocious . C hildren who view the primal s cene —the term F reud to des cribe a child seeing sex between their parents — be traumatized. T his is particularly the cas e if they coital s ounds and movements as a phys ical aggres sion between the parents. P.1909

Adoles c enc e With the approach of puberty, the upsurge of sex hormones, and the development of s econdary sex characteristics , s exual curiosity is intensified. are physically capable of coitus and orgas m but are inhibited by social res traints . T he dual, often conflicting press ures of es tablis hing their s exual identities and controlling their sexual impulses produce a strong phys iological sexual tension in teenagers that demands releas e, and mas turbation is a normal way to reduce tension. In general, boys learn to masturbate to orgas m earlier than girls and mas turbate more frequently. C ons equently, many boys integrate their sexuality as autonomous characteristic earlier than s ome girls . An important emotional difference between the adoles cent and the younger child is the pres ence of coital during mas turbation in the adoles cent. T hes e fantas ies an important adjunct to the development of sexual identity; in the comparative s afety of the imagination, adoles cent learns to perform the adult s ex role. that accompany masturbation vary and reflect 2113 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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ps ychodynamics ; however, in general, fantas ies differ the sexes . B oys res pond to vis ual stimuli of nude or dress ed women and images of explicit physical acts. report res ponding to romantic s tories in which a man demonstrates intens e pass ion for and commitment to a woman. T heir fantas ies focus more on touching, and the partner's res pons e than on vis ualizing an sexual act. In addition to mas turbation, adolescents learn sexually through cares sing and kis sing with partners . In early adoles cence, s ex play may involve a partner of the sex for a short period of time for heterosexuals and for homos exuals. Adolescence is also when one's body becomes more definitive and a sense of s exual and s exual desirability begins to develop. P eer by the same sex and by the oppos ite sex is of importance. E ngaging in s exual talk and jokes , kis sing, touching genitalia, experimenting with degrees of and experimenting with different partners or with one partner are part of the proces s of learning about T hese experiences reinforce the adolescent's s ens e of being a s exual boy or girl.

Firs t C oitus T he firs t coitus is a rite of pas sage for both sexes. T he modal age for firs t coitus in the United S tates is 16 for boys and 17 years for girls . C urrently, both peer press ure and individual sex drive impel or young adults to participate in their first coital experience. In the past, virginity conferred status on young pers on. T oday, many young people feel embarrass ed or inadequate if they are virgins. A s mall 2114 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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backlas h is present in some groups in which sign premarital chas tity pledges in a public forum. Also, survey by the C enters for Dis ease C ontrol reported that percent of male teenagers had intercours e in 1998, from 57 percent in 1991. T he corresponding number girls was 48 percent, down from 51 percent. Many adoles cents are choos ing to have oral sex instead of in their intimate relations. F or boys, anxiety about firs t coitus relates to Will he be able to get an erection, to penetrate the to las t for some period of time before he ejaculates ? vulnerable in his masculine pride and may fear being judged inadequate by his female partner and his male peers. F irst coitus for a girl has been s urrounded by cultural ambivalence and concern about the meaning of her virginity and her as sumption of the risk of pregnancy res ponsibility for the next generation. T hat risk has eased by the availability of contraceptive methods . Development of the birth control pill in the 1960s societal attitudes about premarital sex for women and created a more permis sive climate. T he cohort of who came of age s exually after the late 1960s report a much higher frequency of premarital intercours e than women before that time. However, only 30 percent of young women us e contraception with their first sexual mate and many use it inconsistently. In effect, many women deny that they are planning to have sex by not being prepared in terms of contraception, reflecting cultural ambivalence about their s exual activity. S tudies have shown that firs t coitus is mos t likely to be positive experience for girls with s trong feelings for 2115 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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partners . In general, women report a greater need to experience s ex in the context of an affectionate relations hip than do boys.

Adulthood B y their late 20s, 70 percent of men and 85 percent of women have formed a union, either exclusive or marriage. T he sexual impulse is catalytic in forming maintaining adult love relationships . Ideally, a mature sexual relations hip encompas ses the capacity for and love for one's partner. As sexual access ceases to be problematic, more is focus ed on the activity itself. Interference with s exual activity arises from the time and energy required for the pursuit of careers , child rearing, and other family and community obligations . Nonetheles s, studies reveal a much higher frequency of s exual interaction among married persons than among s ingle persons. T he frequency for married persons is three times a month, many couples relating sexually twice a week. T he frequency of s exual interaction, four or more times a exis ts among cohabiting couples. K is sing, intercourse, and masturbation are frequent activities. E ven after a permanent s exual relations hip been established, masturbation remains a healthy during the illnes s or abs ence of a partner or when intercours e is unsatis factory. Masturbation s hould only cons idered maladaptive when it is a compuls ive activity when it is preferred to partner interaction. Many adults have some experience with oral s ex. S tudies s how although it is not a regular activity for most couples , people are likely to engage in it occasionally 2116 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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their lifetimes. T he incidence of the practice of and fellatio are the s ame; the lifetime prevalence is 75 percent of sexually active people. Anal s ex is not part the repertoire of regular sexual activities for mos t men women in the United S tates . Although a s izable (25 percent of men and 20 percent of women) report experience of anal s ex, very few repeat the practice. In general, a graph of s exual practices does not form a curve. Most curves of s exual behavior are s trongly with many pers ons indulging in a particular behavior or, conversely, very few people doing s o.

Middle A ge During middle age, the frequency of marital intercours e may decline. T he rates of interaction depend more on interes t, and the middle-aged man may devote much of his energy to his career at this point. T he decline in interaction often reflects deeroticization of the woman because of her wife–mother role. F amiliarity als o contributes to a decreas ed pass ion, and s ome men difficulty connecting marital sexual activity with the scripts they elaborated during their adoles cence. C onvers ely, a couple's experience of each other makes them comfortable and augments their s kill at mutual arousal. F or women, interest in sexual competence typically increases at this time. A woman's erotic and s exual commitment are s trongly connected to of attachment toward her partner and the s ecurity of being in a loving relations hip. With late middle age, the biological drive decreas es in intens ity. It takes the man longer to reach orgas m, he longer refractory period, and he requires more 2117 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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to achieve an erection. T he P.1910 woman mus t adjus t to the hormonal fluctuations of her perimenopaus al years, and s he, too, requires more stimulation to become aroused. Although medications available to address these specific phys iological they do not eliminate all need to adjus t to the aging proces s. In terms of family dynamics, children often the hous e for work or further education at this time. fact plus freedom from concern regarding unwanted pregnancy may enhance sexual activity for pers ons have more time to direct attention toward each other renew their life as a couple. However, middle age is the period of ris ing extramarital activity, although the frequencies of s uch occurrences low—75 percent of men and 85 percent of women faithful throughout the lifetime of their marriages . Offer has explained that the patterning of extramarital sexual activity for both sexes continues to expres s patterns of ps ychos exual development: F or men, it predominantly has the capacity for that in adolescence was directly related to the pursuit sexual fantasies and the homosocial validation of masculinity. F or women, on the other hand, it quest for circumstances that justify and confirm a self-image rather than a quest for orgas ms . In the context of a loving, communicative, and relations hip, a decreased frequency of sexual does not herald the onset of extramarital affairs or threaten the stability of the marriage. 2118 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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Old A ge An estimated 70 percent of men and 20 percent of over age 60 years are sexually active; s exual activity is us ually limited by the absence of an available partner. Longitudinal studies have found that the s ex drive does not decrease as men and women age; in fact, some an increas ed sex drive. Masters and J ohns on reported sexual functioning among thos e in their 80s. E xpected phys iological changes in men include a longer time for erection to occur, decreased penile turgidity, and ejaculatory s eepage; in women, decreas ed vaginal lubrication and vaginal atrophy are ass ociated with es trogen levels. Medications can also adversely affect sexual behavior. A s ignificant finding was that the more active a pers on's sex life was in early adulthood, the likely it is to be active in old age.

C UR R E NT TR E NDS A s tudy conducted by the Univers ity of C hicago in T he National Health and S ocial Life S urvey, was the and the most authoritative sex s urvey. B ased on a representative U.S . population between the ages of 18 59 years, it found the following: 1. E ighty-five percent of married women and 75 of married men are faithful to their s pouses . 2. F orty-one percent of married couples have sex week or more, compared with 23 percent of s ingle persons. 3. C ohabiting single pers ons have the mos t s ex of all, twice a week or more. 2119 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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4. T he median number of sexual partners over a for men is s ix; for women, two. 5. A homosexual orientation was reported by 2.8 of men and 1.4 percent of women, with 9 percent of men and 5 percent of women reporting that they at least one homosexual experience after puberty. 6. V aginal intercours e was considered the most appealing type of s exual experience by 83 percent men and 78 percent of women. 7. Among married partners, 93 percent are of the race, 82 percent are of similar educational level, 78 percent are within 5 years of each other's age, and percent are of the s ame religion. 8. B oth men and women who, as children, had been sexually abus ed by an adult were more likely, as to have had more than 10 s ex partners , to engage group s ex, to report a homosexual or bis exual identification, and to be unhappy. 9. Less than 8 percent of the participants reported sex more than four times a week, approximately thirds said they had sex a few times a month or and approximately three in ten have sex a few year or less . 10. Approximately one in four men and one in ten masturbate at leas t once a week, and masturbation less common among those 18 to 24 years of age among those 24 to 34 years of age. 11. T hree-quarters of the married women said they or always had an orgasm during sexual compared with 62 percent of the s ingle women. 2120 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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Among men, married or s ingle, 95 percent s aid us ually or always had an orgasm. 12. More than half of the men s aid that they thought about s ex every day or several times a day, with only 19 percent of the women. 13. More than four in five Americans had only one partner or no partner in the past year. G enerally, African Americans reported the mos t s exual and As ian Americans the fewest. Another report, bas ed on the s ame data and published 2001 discus sed sexual dysfunction and sexual and public health policies . F indings include the 1. T hirty-nine percent of men and 41 percent of have a sexual dysfunction and have experienced decreased well-being and quality of life as a res ult. 2. F ifteen percent of male res pondents, single before marriage or after a divorce, who experimented sexually, had multiple partners , and s ought multiple areas of s timulation (e.g., erotic videos, nude paid s ex) composed the core group implicated in maintenance of s exually transmitted diseas e in the population at large. 3. T he likelihood of a pregnant girl younger than 18 of age opting to have an abortion increased dramatically with the educational level of her

P HYS IOL OG IC A L R E S P ONS E S Normal men and women experience a sequence of 2121 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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phys iological res ponses to sexual s timulation. In the detailed des cription of thes e res ponses, Mas ters and J ohns on obs erved that the phys iological proces s increasing vas ocongestion and myotonia tumes cence subs equent release of the vascular activity and muscle tone as a result of orgasm detumescence. T ables and 18.1a-3 describe the female and male sexual cycles , res pectively. DS M-IV -T R defines a four-phase res ponse cycle: phase I, desire; phas e II, excitement; III, orgas m; phas e IV , resolution.

Table 18.1a-2 Female S exual R es p C yc lea Organ

E xc itement Phas e

Orgas mic Phas e

R es olutio Phas e

Mental

Lasts several minutes to several hours ; heightened excitement before 30 secs to 3 mins

3–15 secs

10–15 min no orgasm to 1 day

S kin

J ust before

Well-developed

F lush

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flush

disappears revers e or of appearanc inconsiste appearing of on soles o feet and palms of hands

B reasts Nipple erection in two-thirds of women, venous congestion and areolar enlargement; size to one-fourth more than normal

B reasts may become tremulous

R eturn to normal in approxima 0.5 hour

C litoris

No change

S haft retur to normal

orgasm: flush inconsistently appears ; maculopapular ras h on abdomen and s preads anterior chest wall, face, neck; can include shoulders and forearms

E nlargement in diameter of

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position in 10 secs ; detumesce in 5–30 mi if no orgas detumesce takes seve hours

glans and shaft; jus t before shaft retracts into prepuce

Labia majora

Nullipara: elevate and flatten agains t perineum

No change

Nullipara: increase to normal siz 1–2 mins

 

Multipara: congestion and edema

 

Multipara: decrease t normal siz 10–15 min

Labia minora

S ize increase two to three times more than normal; change to pink, red, red before orgasm

C ontractions of proximal labia minora

R eturn to normal wit 5 mins

V agina

C olor change to dark

3–15 C ontractions of

E jaculate forms

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transudate appears 10– secs after arousal; elongation and ballooning; lower third cons tricts before

lower third at intervals of 0.8 sec

pool in upp two thirds; congestion disappears seconds o no orgasm 20–30 min

Uterus

Ascends into false pelvis ; labor-like contractions begin in heightened excitement just before orgasm

C ontractions throughout orgasm

C ontractio ceas e, and uterus descends normal position

Other

Myotonia

Loss of voluntary muscular control

R eturn to baseline status in seconds to minutes

 

A few drops mucoid secretion

R ectum: rhythmic contractions of

C ervix colo and s ize return to

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B artholin's glands during heightened excitement

sphincter

normal, an cervix descends seminal po

C ervix swells slightly and is pass ively elevated with uterus

Hyperventilation and

 

aA

desire phas e cons isting of s ex fantasies and des ire to sex precedes the excitement phas e.

Table 18.1a-3 Male S exual R es pons Organ

E xc itement Phas e

Orgas mic Phas e

R es olut Phas e

Mental

Lasts several minutes to several hours ; heightened

3–15 secs

10–15 m no orgas to 1 day

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excitement before 30 secs to 3 mins S kin

J ust before orgasm: flush inconsistently appears ; maculopapular ras h originates on abdomen and s preads anterior chest wall, face, and neck, and can include shoulders and forearms

Wellflush

F lush disappe revers e appeara inconsis appearin of pers p on soles and palm hands

P enis

E rection in 30 secs by vasoconges tion of erectile bodies of corpus cavernos a of shaft; los s of

E jaculation: emis sion marked by to four contractions of 0.8 sec of vas, seminal prostate; ejaculation

E rection involutio 10 secs variable refractor period; f detumes in 5–30

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S crotum and tes tes

erection may occur with introduction of as exual stimulus — loud nois e; with heightened excitement, size of glans and diameter of penile shaft increase

proper marked by contractions of 0.8 sec of urethra and ejaculatory spurt of 12–20 in. at age 18, decreasing age to at 70

T ightening lifting of sac and elevation of tes tes ; with heightened excitement, 50% increase size of testes over unstimulated state and flattening agains t perineum, signaling

No change

Decreas baseline because of vasocon tes ticula scrotal d within 5– mins aft orgasm; involutio take s ev hours if orgasmi releas e place

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impending ejaculation C owper's glands

2–3 Drops of mucoid fluid that contain viable s perm are secreted during heightened excitement

No change

No chan

Other

B reasts : inconsistent nipple erection with heightened excitement before orgas m

Loss of voluntary muscular control

R eturn t baseline 5–10 mi

 

 

R ectum: rhythmic contractions of sphincter

 

 

Myotonia: semispastic contractions of facial, abdominal,

Heart rate: up 180 beats /min

 

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intercostal muscles  

 

B lood up to 40–100 mm s ys tolic; 20–50 mm diastolic

 

 

T achycardia: to 175 beats /min

 

 

 

B lood ris es to 20–80 mm s ys tolic; 10–40 mm diastolic

R es piration: up to 40 res pirations/min

 

 

R es piration: increased

 

 

aA

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Phas e I: Des ire P hase I is a psychological phas e distinct from any identified s olely through phys iology and reflects the 2130 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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ps ychiatris t's fundamental concern with motivations , drives , and personality. It is characterized by s exual fantas ies and the conscious des ire to have sexual P.1911

Phas e II: E xc itement P hase II is brought on by psychological s timulation (fantas y or the presence of a love object), physiological stimulation (stroking or kiss ing), or a combination of the two. It cons is ts of a s ubjective s ens e of pleasure and objective s igns of sexual excitement. T he excitement phase is characterized by penile tumes cence leading erection in men and vaginal lubrication in women. T he nipples of both s exes become erect, although nipple erection is more common in women than in men. T he woman's clitoris becomes hard and turgid, and her minora become thicker as a res ult of venous Initial excitement may last several minutes to s everal hours. W ith continued s timulation, the man's testes increase in s ize 50 percent and elevate. T he woman's vaginal barrel shows a characteristic cons triction along outer third, known as the orgas mic platform. T he elevates and retracts behind the symphys is pubis ; is not eas ily access ible. However, stimulation of the caus es traction on the labia minora and the prepuce, there is intrapreputial movement of the clitoral shaft. B reast s ize in the woman increases 25 percent. engorgement of the penis and vagina produces specific color changes, particularly in the labia minora, which become bright or deep red. V oluntary contractions of muscle groups occur, rate of heartbeat and res piration 2131 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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increases, and blood press ure rises . Heightened excitement las ts 30 s econds to several minutes.

Phas e III: Orgas m P hase III cons is ts of peaking s exual pleas ure, with of s exual tens ion and rhythmic contraction of the muscles and pelvic reproductive organs. A subjective sens e of ejaculatory inevitability triggers the man's orgasm, and forceful emiss ion of s emen follows. T he orgasm is also as sociated with four to five rhythmic of the pros tate, seminal vesicles, vas, and urethra. In women, orgas m is characterized by 3 to 15 involuntary contractions of the lower third of the vagina and by sustained contractions of the uterus , flowing from the fundus downward to the cervix. B oth men and women have involuntary contractions of the internal and anal s phincter. T hes e and the other contractions during orgasm occur at 0.8-second intervals. Other include voluntary and involuntary movements of the muscle groups, including facial grimacing and spas m. B lood pres sure ris es 20 to 40 mm (both diastolic), and the heart rate increas es up to 160 beats minute. Orgas m las ts from 3 to 25 s econds and is as sociated with a slight clouding of cons cious nes s.

Phas e IV: R es olution R es olution consists of the dis gorgement of blood from genitalia (detumes cence), which brings the body back its res ting s tate. If orgas m occurs, resolution is rapid; if does not occur, resolution may take 2 to 6 hours and as sociated with irritability and dis comfort. R es olution through orgas m is characterized by a subjective s ens e 2132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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well-being, general relaxation, and mus cular relaxation. After orgasm, men have a refractory period that may from s everal minutes to many hours ; in this period, cannot be s timulated to further orgas m. T he refractory period does not exis t in women, who are capable of multiple and success ive orgas ms . P.1912 S exual res ponse is a true ps ychophys iological Arousal is triggered by both psychological and phys ical stimuli, levels of tension are experienced both phys iologically and emotionally, and, with orgas m, normally a s ubjective perception of a peak of phys ical reaction and release. P s ychos exual development, ps ychological attitude toward s exuality, and attitudes toward one's s exual partner are directly involved with affect the physiology of human sexual res ponse.

A B NOR MA L S E X UA L ITY A ND DYS F UNC TIONS S even major categories of sexual dys function are lis ted DS M-IV -T R : (1) sexual desire disorders , (2) s exual disorders , (3) orgas m disorders , (4) sexual pain (5) s exual dysfunction due to a general medical (6) s ubstance-induced s exual dysfunction, and (7) dysfunction not otherwise specified.

Definition In DS M-IV -T R , s exual dysfunctions are categorized as disorders . T he syndromes listed are correlated with the sexual phys iological res ponse, which is divided into the four phases discus sed above. T he es sential feature of 2133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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sexual dys functions is inhibited in one or more of the phases, including disturbance in the s ubjective s ens e pleas ure or desire or disturbance in objective or experience (T ables 18.1a-4 and 18.1a-5). E ither disturbance can occur alone or in combination. S exual dysfunctions are diagnosed only when they are the part of the clinical picture. T hey can be lifelong or acquired, generalized or s ituational, and due to ps ychological factors , phys iological factors , or factors . If they are attributable entirely to a general medical condition, substance us e, or advers e effects of medication, then s exual dysfunction due to a general medical condition or s ubs tance-induced s exual dysfunction is diagnosed.

Table 18.1a-4 DS M-IV-TR Phas es the S exual R es pons e C yc le and As s oc iated S exual Phas es

C harac teris tic s

Dys function

1. Desire

Dis tinct from any identified solely through phys iology and reflects the patient's

Hypoactive sexual desire disorder; avers ion disorder; hypoactive

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motivations , drives , and personality; characterized by sexual fantasies and the desire to have sex.

sexual desire disorder due to a general medical condition (man or woman); subs tanceinduced s exual dysfunction impaired des ire

2. S ubjective s ens e E xcitement of sexual and accompanying phys iological changes; all phys iological res ponses noted in Masters and J ohns on's excitement and plateau phases combined in this phase.

F emale s exual arousal male erectile disorder (may also occur in stages 3 and male erectile disorder due to a general medical condition; dyspareunia to a general medical condition (man or woman); subs tanceinduced s exual dysfunction

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impaired 3. Orgasm

P eaking of pleas ure, with releas e of sexual tension and rhythmic contraction of the perineal mus cles and pelvic reproductive organs .

F emale orgasmic disorder; male orgasmic disorder; premature ejaculation; other s exual dysfunction due to a general medical condition (man or woman); subs tanceinduced s exual dysfunction impaired orgasm

4. R es olution

A s ens e of relaxation, wellbeing, and relaxation; men are refractory to orgasm for a period of time that increases with age,

P os tcoital dysphoria; postcoital headache

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women can have multiple orgasms without a refractory period.

aDS M-IV -T R

cons olidates the Mas ters and excitement and plateau phases into a single excitement phas e, which is preceded by the (appetitive) phas e. T he orgasm and res olution phases remain the s ame as originally described Masters and J ohnson.

Table 18.1a-5 S exual Not C orrelated with Phas es of S exual R es pons e C yc le C ategory

Dys functions

S exual pain disorders

V aginismus (woman)

 

Dys pareunia (woman and man)

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Other

S exual dysfunctions not otherwis e specified. E xamples :

 

1. No erotic sensation des pite phys iological res ponse to s exual stimulation (e.g., orgasmic anhedonia)

 

2. F emale analog of premature ejaculation

 

3. G enital pain occurring during masturbation

According to the tenth revision of Inte rnational C las s ification of Dis e as e s and R e late d He alth 10), s e xual dys function refers to a pers on's inability to “participate in a s exual relationship as he or s he would wis h.” T he dysfunction is expres sed as a lack of des ire pleas ure or as a phys iological inability to begin, or complete s exual interaction. B ecause s exual ps ychos omatic, it may be difficult to determine “the relative importance of ps ychological and/or organic factors .” S exual dysfunction such as lack of des ire can occur in men and women, but women more often complain of “subjective quality” of the experience than of the a s pecific respons e.” IC D-10 advis es looking “beyond presenting complaint to find the most appropriate 2138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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diagnostic category.” T able 18.1a-6 presents the IC Ddiagnostic criteria.

Table 18.1a-6 IC D-10 Diagnos tic C riteria for S exual Dys func tion, C aus ed by Organic Dis order or Dis eas e G 1. T he s ubject is unable to participate in a relations hip as he or she would wis h. G 2. T he dysfunction occurs frequently, but may absent on some occas ions . G 3. T he dysfunction has been pres ent for at least months. G 4. T he dysfunction is not entirely attributable to any of the other mental and behavioral disorders IC D-10, physical disorders (such as endocrine disorder), or drug treatment. C omments Meas urement of each form of dys function can be based on rating s cales that as sess severity as frequency of the problem. More than one type of dysfunction can coexist.

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Lac k or los s of s exual des ire A. T he general criteria for sexual dys function met. B . T here is a lack or loss of sexual desire, diminution of seeking out s exual cues, of thinking about s ex with as sociated feelings of desire or appetite, or of sexual fantas ies . C . T here is a lack of interest in initiating s exual activity either with a partner or as solitary masturbation, res ulting in a frequency of activity clearly lower than expected, taking into account and context, or in a frequency very clearly from previous much higher levels . S exual avers ion and lac k of s exual enjoyment S exual aversion A. T he general criteria for sexual dys function met. B . T he prospect of s exual interaction with a produces sufficient aversion, fear, or anxiety that sexual activity is avoided, or, if it occurs , is with strong negative feelings and an inability to experience any pleasure.

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C . T he avers ion is not the result of performance anxiety (reaction to previous failure of sexual res ponse). Lack of s exual enjoyment A. T he general criteria for sexual dys function met. B . G enital res ponse (orgas m and/or ejaculation) occurs during sexual s timulation but is not accompanied by pleas urable sensations or of pleasant excitement. C . T here is no manifes t and pers is tent fear or during sexual activity (s ee s exual aversion). Failure of genital res pons e A. T he general criteria for sexual dys function met. In addition, for men: B . E rection s ufficient for intercours e fails to occur when intercours e is attempted. T he dysfunction takes one of the following forms :    (1) full erection occurs during the early stages lovemaking but dis appears or declines when 2141 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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intercours e is attempted (before ejaculation if it occurs);    (2) erection does occur, but only at times when intercours e is not being considered;    (3) partial erection, ins ufficient for intercours e, occurs, but not full erection;    (4) no penile tumescence occurs at all. In addition, for women: B . T here is failure of genital response, failure of vaginal lubrication, together with inadequate tumes cence of the labia. T he takes one of the following forms :    (1) general: lubrication fails in all relevant circums tances ;    (2) lubrication may occur initially but fails to for long enough to allow comfortable penile entry;    (3) situational: lubrication occurs only in some situations (e.g., with one partner but not another, during mas turbation, or when vaginal intercours e not being contemplated). Orgas mic dys func tion 2142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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A. T he general criteria for sexual dys function met. B . T here is orgas mic dys function (either abs ence marked delay of orgas m), which takes one of the following forms :    (1) orgasm has never been experienced in any situation;    (2) orgasmic dysfunction has developed after a period of relatively normal respons e:       (a) general: orgas mic dysfunction occurs in all situations and with any partner;       (b) s ituational:          for wome n: orgas m does occur in certain situations (e.g., when masturbating or with certain partners ); for me n, one of the following can be applied:          i) orgas m occurs only during sleep, never the waking s tate;          ii) orgas m never occurs in the pres ence of partner;          iii) orgas m occurs in the presence of the 2143 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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but not during intercours e. Premature ejaculation A. T he general criteria for sexual dys function met. B . T here is an inability to delay ejaculation sufficiently to enjoy lovemaking, manifes t as of the following:    (1) occurrence of ejaculation before or very after the beginning of intercourse (if a time limit is required: before or within 15 s econds of the beginning of intercours e);    (2) ejaculation occurs in the absence of erection to make intercourse pos sible. C . T he problem is not the res ult of prolonged abstinence from sexual activity. Nonorganic vaginis mus A. T he general criteria for sexual dys function met. B . T here is spasm of the perivaginal muscles , sufficient to prevent penile entry or make it uncomfortable. T he dysfunction takes one of the 2144 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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following forms :    (1) normal res ponse has never been    (2) vaginis mus has developed after a period of relatively normal res ponse:       (a) when vaginal entry is not attempted, a sexual respons e may occur;       (b) any attempt at sexual contact leads to generalized fear and efforts to avoid vaginal entry (e.g., s pas m of the adductor mus cles of the Nonorganic dys pareunia A. T he general criteria for sexual dys function met. In addition, for women: B . P ain is experienced at the entry of the vagina, either throughout s exual intercourse or only when deep thrus ting of the penis occurs. C . T he disorder is not attributable to vaginismus failure of lubrication; dyspareunia of organic should be clas sified according to the underlying disorder.

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In addition for men: B . P ain or dis comfort is experienced during res ponse. (T he timing of the pain and the exact localization s hould be carefully recorded.) C . T he discomfort is not the res ult of local factors . If physical factors are found, the should be clas sified els ewhere. E xc es s ive s exual drive No research criteria are attempted for this R es earchers studying this category are recommended to design their own criteria. Other s exual dys function, not c aus ed by dis order or dis eas e Uns pecified s exual dys function, not c aus ed organic dis order or dis eas e

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion. With the poss ible exception of premature ejaculation, sexual dysfunctions are rarely found s eparate from 2146 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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ps ychiatric syndromes. S exual disorders may lead to or res ult from relational problems, and patients invariably develop an increasing fear of P.1913 failure and self-cons ciousnes s about their s exual performance. S exual dysfunctions are frequently as sociated with other mental disorders , s uch as disorders , anxiety dis orders , personality disorders , and schizophrenia. In many instances, a sexual dys function may be diagnosed in conjunction with another disorder; in other cas es, however, it is only one of signs or symptoms of the psychiatric disorder. A s exual dis order can be symptomatic of biological problems , intrapsychic conflicts, interpers onal or a combination of thes e factors. S exual function can affected by s tres s of any kind, by emotional disorders , by a lack of sexual knowledge.

Taking a S exual His tory As with all psychiatric interviews, taking a sexual not only is a time to gather information, but it als o the development of a positive doctor–patient T he development of rapport requires an accepting atmos phere and a nonjudgmental attitude on the part the therapist toward the patients' s exual values , ideas , practices . T he sexual history is more structured than the rest of ps ychiatric interview, although patients are encouraged take their own lead in areas of great personal In general, the therapis t s tructures the interview s o that both recent and early sexual histories are covered. T he 2147 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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therapist mus t as certain the specific current sexual complaint, the patient's s exual practices and pattern of interaction with partners , the patient's s exual goal and fantas ies , the patient's mas turbatory his tory, the or extent of extramarital relations hips, and the degree commitment to the marriage or the partner. P atients describe their view of the problem and when it began. If married, the courts hip, honeymoon, and reproductive history are examined in detail. P remarital expectations, mutual phys ical attraction, periods of s eparation, the of contraception used, and the effect of children on the couple's s exual life are covered. T he s atis fying as pects the marriage must also be dis cus sed. T he patient is particularly asked to evaluate the partner's contribution the present distress . E arly s exual development and education are also thoroughly discus sed. T he interviewer asks for the patient's view of the parents ' marriage as s een in retrospect and as perceived in childhood. R elations hips peers, s iblings, and important familial figures other than parents are als o explored. P articular attention is paid to ways in which affection was expres sed in the family the degree of phys ical contact between family T he sexual climate in which the patient grew up is s een through reported parental attitudes , memories of games played as a child, the way in which the patient learned sexual facts , the s pecifics of religious training, reactions to masturbation and nocturnal emiss ions or menarche, dating patterns , an adolescent rebellious and any s ignificant premarital involvements . E thnic background and the s ocioeconomic level of the primary family are also taken into account. As the 2148 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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interview progres ses, the patient's self-image emerges. T he interviewer mus t be sensitive to any event that exceptional in the patient's s exual life in either a destructive or a highly pleasant manner and s hould particular note of the people who contributed to the patient's s exual education, identity, and mores . T he interviewer mus t also ask s pecific ques tions to information that may be outs ide the patient's view of socially acceptable, s uch as premarital and affairs , group s ex, homos exual involvements, and abortions. T he sexual orientation of the pers on being interviewed should be as certained, and questions to same-sex interactions explored. All interviews review high-ris k sexual behavior regardles s of sexual orientation, as transmis sion of the human immunodeficiency virus (HIV ) occurs in all groups . Additionally, the iss ue of s exual abuse mus t be particularly becaus e a his tory of abus e predisposes to development of s exual dysfunction. S imilar disorders exist among both homos exual and heteros exual partners, with variations imposed by anatomical differences . F or example, P.1914 P.1915 although penile–vaginal dys function cannot be among homos exuals , penile–anal dys function may R egardless of s exual orientation, each phas e of the cycle applies equally to same-sex and heterosexual partners , and the methods and principles for treatment 2149 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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es sentially similar. T aking a s ex his tory is summarized T able 18.1a-7.

Table 18.1a-7 Taking a S ex I. Identifying data    A. Age    B . S ex    C . Occupation    D. R elations hip s tatus —single, married, times previously married, separated, divorced, cohabiting, s erious involvement, casual dating (difficulty forming or keeping relations hips s hould be as ses sed throughout the interview)    E . S exual orientation—heteros exual, or bis exual (this may als o be as certained later in interview) II. C urrent functioning    A. Unsatis factory to highly s atis factory    B . If unsatis factory, why? 2150 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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   C . F eelings about partner s atis faction    D. Dysfunctions? —e.g., lack of desire, erectile disorder, inhibited female arous al, anorgas mia, premature ejaculation, retarded ejaculation, pain as sociated with intercours e (dys function below)       1. Onset—lifelong or acquired          a. If acquired, when?          b. Did ons et coincide with drug use (medications or illegal recreational drugs ), life stress es (e.g., loss of job, birth of child), difficulties ?       2. G eneralized—occurs in most situations or most partners       3. S ituational          a. Only with current partner          b. In any committed relations hip          c. Only with masturbation          d. In socially proscribed circums tance (e.g., affair) 2151 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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         e. In definable circumstance (e.g., very late night, in parental home, when partner initiated play)    E . F requency—partnered s ex (coital and sex play)    F . Des ire/libido—how often are s exual feelings, thoughts, fantasies, dreams , experienced (per week, etc.)?    G . Description of typical sexual interaction       1. Manner of initiation or invitation (e.g., phys ical? Does same person always initiate? )       2. P resence, type, and extent of foreplay kiss ing, cares sing, manual or oral genital       3. C oitus? P os itions us ed?       4. V erbalization during sex? If s o, what kind?       5. Afterplay? (whether sex act is completed or disrupted by dys function); typical activities (e.g., holding, talking, return to daily activities, s leeping)       6. F eeling after s ex: relaxed, tense, angry,    H. S exual compulsivity? (intrusion of sexual 2152 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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thoughts or participation in s exual activities to a degree that interferes with relationships or work, requires deception, and may endanger the III. P as t sexual history    A. C hildhood s exuality       1. P arental attitudes about s ex—degree of openness or reserve (ass es s unus ual prudery or seductiveness )       2. P arents' attitudes about nudity and       3. Learning about s ex          a. F rom parents (Initiated by child's parent volunteering information? W hich parent? What was child's age? )? S ubjects covered (e.g., pregnancy, birth, intercourse, menstruation, nocturnal emis sion, mas turbation)?          b. F rom books, magazines , or friends at or through religious group?          c. S ignificant mis information          d. F eeling about information       4. V iewing or hearing primal s cene— 2153 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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      5. V iewing s ex play or intercours e of person than parent       6. V iewing s ex between pets or other animals    B . C hildhood s ex activities       1. G enital s elf-stimulation before Age? R eaction if apprehended?       2. Awareness of s elf as boy or girl—B athroom sens ual activities (regarding urine, feces , odor, enemas)?       3. S exual play or exploration with another (playing doctor)—T ype of activity (e.g., looking, manual touching, genital touching)? R eactions or cons equences if apprehended (by whom? )? IV . Adolescence    A. Age of onset of puberty—development of secondary s ex characteris tics, age of menarche girl, wet dreams or first ejaculation for boy (preparation for and reaction to)    B . S ens e of self as feminine or masculine— image, acceptance by peers (oppos ite sex and sex), sense of s exual des irability, ons et of coital fantas ies 2154 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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   C . S ex activities       1. Masturbation—Age begun? E ver punished prohibited? Method us ed, accompanying frequency (questions about mas turbation and fantas ies are among the mos t s ens itive for to answer)?       2. Homosexual activities —Ongoing or rare experimental episodes ? Approached by others ? If homos exual, has there been any heteros exual experimentation?       3. Dating—casual or steady; description of crush, infatuation, or firs t love       4. E xperiences of kiss ing, necking, petting (“making out” or “fooling around”), age begun, frequency, number of partners, circumstances, (s ) of activity       5. Orgasm—When first experienced (may not experienced during adolescence)? W ith masturbation, during s leep, or with partner? W ith intercours e or other s ex play? F requency?       6. F irs t coitus—age, circums tances , partner, reactions (may not be experienced during adoles cence), contraception and/or safe sex precautions used 2155 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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V . Adult sexual activities (may be experienced by some adoles cents)    A. P remarital s ex       1. T ypes of s ex play experiences —frequency sexual interactions , types and number of partners       2. C ontraception and/or safe s ex precautions us ed       3. F irs t coitus (if not experienced in adoles cence)—age, circums tances , partner       4. C ohabitation—age begun, duration, description of partner, sexual fidelity, types of activity, frequency, s atis faction, number of cohabiting relations hips, reas ons for breakup(s )       5. E ngagement—age; activity during engagement period with fiancé(e), with others ; length of engagement    B . Marriage (if multiple marriages have explore s exual activity, reas ons for marriage, and reasons for divorce in each marriage)       1. T ypes and frequency of sexual describe typical s exual interaction (s ee above). S atisfaction with s ex life? V iew of partner's 2156 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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      2. F irs t sexual experience with s pouse— What were the circumstances? W as it s atis fying? Dis appointing?       3. Honeymoon—S etting, duration, pleas ant or unpleasant, s exually active? F requency? C ompatibility?       4. E ffect of pregnancies and children on sex       5. E xtramarital s ex—Number of incidents, emotional attachment to extramarital partners? F eelings about extramarital sex       6. P ostmarital masturbation—F requency? on marital sex?       7. E xtramarital s ex by partner—effect on interviewee       8. Ménage à trois or multiple s ex (swinging)       9. Areas of conflict in marriage (e.g., finances , divis ion of res ponsibilities, priorities) V I. S ex after widowhood, separation, divorce— celibacy, orgas ms in sleep, masturbation, sex play, intercours e (number of and relationship partners ), other 2157 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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V II. S pecial is sues    A. History of rape, incest, sexual or physical    B . S pousal abuse (current)    C . C hronic illness (phys ical or ps ychiatric)    D. History or presence of s exually transmitted diseases    E . F ertility problems    F . Abortions, mis carriages, or unwanted or illegitimate pregnancies    G . G ender identity conflict—(e.g., wearing clothes of opposite s ex)    H. P araphilias —(e.g., fetis hes , voyeuris m, sadomas ochis m)

R ating S c ales In addition to the interview, several ques tionnaires are available to as ses s sexual function. T hey were primarily to evaluate illness or medication-related on sexual functioning. T he mos t commonly used s cales the Arizona S exual E xperience S cale, the B rief S exual 2158 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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F unction Ques tionnaire, the C hanges in S exual F unctioning Questionnaire, the Derogatis S exual Inventory, and the R ush S exual Inventory. T he s cales in length, reliability, validity, and method of adminis tration. S ome are rated by the patients others by the therapis t. T he formats include structured semistructured approaches. T he scales differ in symptoms ass es sed, the dysfunctions they target, and time frame they cover.

S exual Des ire Dis orders DS M-IV -T R divides sexual desire disorders into two hypoactive sexual desire dis order, characterized by a deficiency or lack of s exual fantasies and des ire for activity, and s exual aversion disorder, characterized by avers ion to and avoidance of genital contact with a partner. T he former condition is more common than the latter.

Hypoac tive S exual Des ire Dis order Hypoactive s exual des ire dis order (T able 18.1a-8) is experienced by both men and women; however, they not be hampered by any dysfunction once they are involved in the sex act. C onversely, hypoactive des ire be us ed to mask another sexual dysfunction. Lack of may be express ed by decreased frequency of coitus , perception of the partner as unattractive, or overt complaints of lack of des ire. Upon ques tioning, the is found to have few or no s exual thoughts or fantasies, lack of awarenes s of s exual cues, and little interest in initiating sexual experiences .

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Table 18.1a-8 DS M-IV-TR Diagnos tic C riteria for S exual Des ire Dis order A. P ersis tently or recurrently deficient (or abs ent) sexual fantasies and desire for sexual activity. judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning, such as age and the context the person's life. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he s exual dys function is not better accounted by another Axis I dis order (except another sexual dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:

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   Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. S ometimes , biochemical correlates are as sociated with hypoactive desire. A recent s tudy found markedly low serum tes tos terone concentrations in men complaining this dys function when they were compared with normal controls in a s leep laboratory situation. Als o, a central dopamine blockage is known to decrease des ire. T he for sexual contact and s atisfaction varies among persons, as well as in the s ame pers on over time. In a group of 100 couples with stable marriages, 8 percent reported having intercours e less than once a month. In another group of couples, one-third reported lack of sexual relations for periods averaging 8 weeks. In a of a general medical practice in E ngland, 25 percent of sample reported no sexual activity mos t of the time. It 2161 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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been estimated that 20 percent of the total population have hypoactive sexual desire disorder. T he complaint more common among women. P atients with desire problems often have good ego strengths and use inhibition of des ire defens ively to protect agains t unconscious fears about s ex. Lack of can also res ult from chronic s tres s, anxiety, or Abs tinence from s ex for a prolonged period s ometimes suppress es the sexual impulse. Des ire problems may be an express ion of hos tility toward the partner or deteriorating relations hip. T he presence of desire depends on s everal factors : biological drive, adequate s elf-es teem, previous good experiences with sex, the availability of an appropriate partner, and a good relationship in nonsexual areas one's partner. Damage to any of those factors may diminis hed des ire. Hypoactive s exual des ire dis orders often become during puberty and may remain a lifelong condition. A general medical workup s hould be conducted to rule medical cause, which, if present, would be, according DS M-IV -T R , diagnos ed as male or female s exual disorder due to a general medical condition. Mr. and Mrs . K . pres ented for therapy becaus e of the complaints regarding lack of s exuality in their marriage. Mr. K . s tated that he rarely felt sexual desire at all and this problem was not restricted to the marriage or lack desire for his wife. In the cours e of the workup, the proved to have multiple sexual dysfunctions, including dyspareunia on the part of the wife and erectile on the part of the husband, as well as lack of desire. 2162 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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and Mrs. K . were in their early 50s, had been married years , and had no children. Mrs . K . had had s ome ps ychotherapy and was currently on medication for recurrent depres sion. T he couple had similar backgrounds —both were immigrants from an E as tern E uropean country. Hus band and wife had both attained P h.D.s , valued education highly, and were s ucces sful their res pective fields. Mrs. K . had emigrated with her family. S he was the of five children and had been res ponsible for taking her younger siblings . S he received little nurturing and had been the recipient of considerable emotional abuse from her mother. Of particular importance, she been s exually abus ed by an elderly neighbor. S he discuss ed this in therapy for the first time s ince the incident occurred. Mr. K . had come to the United alone in his late adolescence. He had been s eparated his parents in early childhood and was raised by dis tant relatives . In spite of their lack of intimacy, the couple strong sense of loyalty to each other and s hared a culture and values. T hey practiced the behavioral exercis es as directed, Mrs. K . was very pleased by the touching and attention received. S he practiced using s ize-graduated dilators her dyspareunia and eventually allowed digital penetration of her vagina by her husband. Mr. K . freer in his discuss ions of sex, including voicing his that it was dirty. He used 50 mg of s ildenafil (V iagra) to facilitate his erections and felt much better about when he was able to maintain them. T he couple approached therapy as they had approached s chool, diligently and cons cientious ly. Although their s exual 2163 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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interaction remained rather rigid— planned for the time each week—they were pleas ed with their progress individually and as a couple. T hey were able to sexual pleasure manually and have had s ome intercours e.

S exual A vers ion Dis order S exual ave rs ion dis orde r (T able 18.1a-9) is defined in IV -T R as a “persis tent or recurrent and extreme and avoidance of, all or almos t all, genital s exual with a s exual partner.” S ome researchers cons ider the between hypoactive desire disorder and s exual disorder blurred, and, in s ome cases, both diagnos es appropriate. Low frequency of sexual interaction is a symptom common to both disorders . T he clinician think of the words “repugnance” and “phobia” in to the patient with s exual aversion disorder. F reud conceptualized sexual avers ion as the res ult of during the phallic ps ychos exual phase and unresolved oedipal conflicts. S ome men, fixated at the phallic development, fear the vagina and believe that they will castrated if they approach it (a concept F reud called vagina de ntata), becaus e they believe unconscious ly the vagina has teeth. Hence, they avoid contact with female genitalia entirely.

Table 18.1a-9 DS M-IV-TR Diagnos tic C riteria for S exual Avers ion Dis order 2164 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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A. P ersis tent or recurrent extreme aversion to avoidance of all (or almost all) genital s exual with a s exual partner. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he s exual dys function is not better accounted by another Axis I dis order (except another sexual dysfunction). S pe cify type:    Lifelong type    Acquired type S pe cify type:    S ituational type    Generalized type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

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F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

T he disorder may result from a traumatic sexual such as rape or childhood abuse, from repeated painful experiences with coitus , P.1916 P.1917 or from early developmental conflicts that have left the patient with uncons cious connections between the impulse and overwhelming feelings of shame and guilt. T he disorder may als o be a reaction to a perceived ps ychological as sault by the partner and to relations hip difficulties . Mr. and Mrs . J . were 38 and 36 years old, respectively, when they presented for treatment, stating they had not had coitus for 3 years . T hree years previously, Mrs . J . revealed that she had been having an extramarital for 2 months, which she then ended. At that time, s he her hus band that s he had been unhappy with their lovemaking. Upon hearing of her affair, the hus band was angry and 2166 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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refused to approach his wife sexually. W hen he finally so, s he would allow caress ing of her body but not her genitalia, although s he was willing to stimulate him sexually. At this point, the hus band also had an affair, stopped when he realized it would not s olve his with his wife, and s he then agreed to enter s ex therapy. When they pres ented for sex therapy, their sexual interaction cons is ted of mutual kiss ing and her manual stimulation of his penis until he reached orgas m. In the individual interviews that were part of the evaluation of the case, Mrs. J . reiterated that she found husband's lovemaking unsatis factory but did not have a problem allowing other men to caress her genitalia and could have coitus with other men. Mr. J . had been traumatized by his wife's rejection and s exual betrayal, he, in turn, was averse to touching her genitalia or attempting intromiss ion. T his was a case in which both partners suffered from sexual avers ion dis order. T he husband feared touching wife in an explicitly s exual way, the wife was averse to touching her genitalia, and both spouses avoided F or both partners , the dysfunction was acquired and situational.

S exual Arous al Dis orders DS M-IV -T R divides the sexual arous al disorders into female s exual arous al dis order, characterized by the persis tent or recurrent partial or complete failure to or maintain the lubrication–swelling respons e of s exual excitement until the completion of the sexual act, and male erectile disorder, characterized by the recurrent persis tent partial or complete failure to attain or 2167 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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an erection until the completion of the sex act. T he diagnosis takes into account the focus , the intens ity, the duration of the s exual activity in which the patient engages. If s exual s timulation is inadequate in focus , intens ity, or duration, the diagnosis s hould not be

F emale S exual A rous al Dis order Women who have excitement phas e dysfunction often have orgas mic problems as well. In one series of happily married couples , 33 percent of the women described difficulty in maintaining sexual excitement. Other data indicate that 14 to 19 percent of women chronic lubrication difficulties , whereas 23 percent have intermittent problems with lubrication. In s tudies of postmenopaus al women, complaints of pers is tent or intermittent lubrication difficulties increas e to 44 Numerous ps ychological factors are as sociated with female s exual inhibition. T hes e conflicts may be through inhibition of excitement or orgas m and are discuss ed under orgasmic phas e dysfunctions. In women, arous al dis orders are as sociated with or lack of des ire. Less res earch has been done on physiological of dysfunction in women than of dysfunction in men, there have been conflicting res ults. Mas ters and found normally responsive women to des ire sex premenstrually. Dysfunctional women, however, be more res ponsive immediately after their periods . Another group of dys functional women felt the greatest sexual excitement at the time of ovulation. S ome indicates that dys functional women are les s aware of phys iological res pons es in their bodies, s uch as 2168 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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vasoconges tion, during arousal. T here are s ome medical causes for female sexual disorder. Alterations in tes tos terone, estrogen, and thyroxine concentrations have been implicated. Medications with antihis taminic or anticholinergic properties les sen vaginal lubrication and interfere with arousal. Also, postmenopausal women require longer P.1918 stimulation for lubrication to occur, and there is less vaginal trans udate after menopaus e. An artificial lubricant is frequently useful in this situation. T able 18.1a-10 presents the diagnos tic criteria for sexual arous al dis order.

Table 18.1a-10 DS M-IV-TR Diagnos tic C riteria for Female S exual Arous al Dis order A. P ersis tent or recurrent inability to attain, or to maintain until completion of the s exual activity, an adequate lubrication–swelling respons e of sexual excitement. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he s exual dys function is not better accounted 2169 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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by another Axis I dis order (except another sexual dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

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Male E rec tile Dis order Male erectile disorder (T able 18.1a-11) is also called dys function and impote nce . A man with lifelong male erectile dis order has never obtained an erection for vaginal insertion. In acquired male erectile dis order, however, the man s ucces sfully achieved vaginal penetration at s ome time in his s exual life but, later, cannot do so. In s ituational male erectile dis order, the can have coitus in certain circums tances but not in others —for example, a man may function effectively a pros titute but not with his wife. K insey estimated that few men (2 to 4 percent) are dysfunctional at age 35 but 77 percent are dys functional at age 80 years . T en percent of the men in the University of C hicago s tudy reported an experience with erectile dys function in the past year, and between 15 and 20 percent experienced anxiety about performing. More recently, it was that the incidence of erectile dys function in young men approximately 8 percent. However, this s exual may first appear later in life. Masters and J ohnson a fear of impotence in all men over 40 years of age, the res earchers believed reflects the mas culine fear of of virility with advancing age. (As it happens, however, erectile dys function is not a regularly occurring phenomenon in aged men; good health and an sexual partner are more clos ely related to continuing potency than is age per s e.) T he chief complaint of between 35 and 50 percent of all men treated for disorders is erectile dys function.

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Diagnos tic C riteria for Male Dis order A. P ersis tent or recurrent inability to attain, or to maintain until completion of the s exual activity, an adequate erection. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he erectile dys function is not better for by another Axis I disorder (other than a s exual dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify: 2172 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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   Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. In general, the psychological conflicts that cause dysfunction are related to an inability to express the impulse becaus e of fear, anxiety, anger, or moral prohibition. Lifelong dys function is a more s erious but common condition than acquired erectile dis order and less amenable to treatment. Many developmental factors have been cited as contributing to erectile dis order. Any experience that hinders the ability to be intimate, that leads to a feeling inadequacy or distrust, or that develops a sense of unloving or unlovable may res ult in this problem. dysfunction in an ongoing relations hip may reflect difficulties between the partners, particularly if one cannot communicate his or her needs or angry feelings a direct and cons tructive manner. S uccess ive episodes impotence are reinforcing, with the man becoming increasingly anxious about his next sexual encounter. R egardless of the original cause of the dys function, his anticipatory anxiety about achieving and maintaining erection interferes with his pleas ure in s exual contact 2173 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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his ability to respond to s timulation, thus perpetuating problem. Mr. Y . came for therapy after his wife complained about their lack of sexual interaction. T he patient avoided sex because of his frequent erectile dysfunction and painful feelings of inadequacy he suffered after his “failures.” presented as an articulate, gentle, and s elf-blaming P.1919 He was faithful to his wife but masturbated frequently. fantas ies involved explicit sadis tic components, hanging and biting women. T he contras t between his angry, aggress ive fantas ies and his loving, cons iderate behavior toward his wife symbolized his conflicts about sexuality, his masculinity, and his mixed feelings about women. He was diagnos ed with erectile dys function, situational type.

Orgas mic Dis orders F e male orgas mic dis order (also known as inhibite d orgas m, or anorgas mia) is defined as the recurrent and persis tent inhibition of the female orgasm, manifested the abs ence or delay of orgas m after a normal sexual excitement phas e that the clinician judges to be in focus , intens ity, and duration. W omen who can orgasm with noncoital clitoral stimulation but cannot experience it during coitus in the abs ence of manual clitoral s timulation are not neces sarily categorized as anorgas mic. P hysiological research on the female s exual res ponse demonstrated that orgasms caus ed by clitoral 2174 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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are physiologically identical to those caused by vaginal stimulation. F reud's theory that women mus t give up clitoral s ensitivity for vaginal sensitivity to achieve maturity is now considered misleading, although s ome women s ay that they gain a s pecial s ens e of from an orgasm precipitated by coitus. S ome attribute to the psychological feeling of clos eness engendered the act of coitus , but others maintain that the coital orgasm is a physiologically different experience. Many women achieve orgasm during coitus by a combination manual clitoral stimulation and penile vaginal Lifelong female orgas mic dis order exists when a has never experienced orgasm by any kind of Acquired orgas mic dysfunction exis ts if a woman has previous ly experienced at least one orgas m regardles s the circums tances or means of stimulation, whether by masturbation or during s leep while dreaming. K insey found that the proportion of married women over 35 of age who had never achieved orgasm by any means only 5 percent. T he incidence of orgasm increases with age. According to K ins ey, the firs t orgasm occurs in adoles cence in approximately 50 percent of women. res t us ually experience orgas m by s ome means as older. Lifelong female orgas mic disorder is more among unmarried women than among married women; 39 percent of the unmarried women over age 35 years K insey's s tudy had never experienced orgasm. orgasmic potential in women older than 35 has been explained on the bas is of les s ps ychological inhibition, greater sexual experience, or both. Also, orgasmic cons istency has been correlated with marital although caus e and effect have not been determined. 2175 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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the Univers ity of C hicago study, three-fourths of the married female res pondents usually or always orgasm during sex, compared with two-thirds of the women. One woman in ten complained of difficulty in achieving orgas m. Mr. and Mrs . Z. were a childles s couple, both in their 20s. S he was a college ins tructor, and he was a writer. T he couple had been married for 4 years and to therapy with a mutual complaint of steadily less ening sexual frequency. During the year before they were seen, they had had intercours e s ix times . In the initial interview, Mrs . Z. that s he had never been able to have an orgas m with husband and had never experienced an orgas m during intercours e. Her frus tration made her increas ingly reluctant to have coitus and caus ed her to reject her husband s exually. Mrs . Z. could mas turbate to orgasm while indulging in masochistic fantasies, but s he did so very infrequently. S he was the oldest of four children, rais ed by rigid, intellectual, and undemons trative parents . S he stated she had been a very docile child and adolescent but openly rebelled in marrying her hus band. Her parents disapproved of him becaus e he came from a different religious background. Mrs. Z.'s father particularly and relations between Mr. Z. and his father-in-law were strained. Mrs . Z. s tated that s he often felt caught them. Mr. Z. was the middle child and the only boy in a family three s iblings. T here was a 20-year age difference his parents, and the father was not actively involved 2176 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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the children. He felt that he had always been his favorite. Mr. and Mrs . Z. met in college, and, although neither sexually experienced, they were strongly attracted to another and indulged in enjoyable s exual play s hort of intercours e. Mrs. Z. perceived her husband as a very as sertive man and was impress ed by the way he stood to her family. When he completed s chool a year ahead Mrs. Z., he broke off the relations hip with her. During year, Mrs. Z. became involved with another man and enjoyed s exual play with him. S he did not have with him but s ometimes came to orgasm through manipulation. At the time of her graduation, she ended this relations hip and managed to regain Mr. Z.'s T he couple married 6 months after her graduation. Intercours e was a disappointment to Mrs. Z. from the beginning. S he felt unfulfilled, and her husband felt rejected and inadequate. In therapy, the couple's premarital expectations were discuss ed. In effect, each had expected more from the other, and, in reality, each had some problem with pas sivity. S everal s es sions were also spent with relations with the in-laws . Mrs. Z. was encouraged give priority to her relations hip with her husband, and Z. was encouraged to face and restrain his with her father. T hey responded to the behavioral exercises that were pres cribed. At the time of their discharge from therapy, the couple was having one to two times a week. Mrs . Z. could not reach during intercourse but could frequently achieve climax after coitus through manual s timulation. Acquired female orgas mic disorder is a common 2177 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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in the clinical population. One clinical treatment facility described nonorgasmic women as approximately four times more common in its practice than patients with all other s exual dis orders. In another study, 46 percent of women complained of difficulty in reaching orgasm, 15 percent des cribed an inability to have orgas m. T he overall prevalence of inhibited orgasm in women is es timated to be 30 percent. Numerous ps ychological factors are as sociated with female s exual inhibition—fears of impregnation, by the sexual partner, or damage to the vagina; toward men; and feelings of guilt regarding sexual impulses. S ome women equate orgasm with los s of or with aggres sive, destructive, or violent behavior. those impuls es may be express ed through inhibition of excitement or orgasm. T he express ion of orgas mic inhibition varies. S ome women feel unentitled to gratify thems elves and cannot masturbate to climax. Others self-stimulation but cannot reach orgas m with a partner present. C ultural expectations and societal res trictions women are also relevant. Nonorgasmic women may be otherwis e s ymptom-free or may experience frustration variety of ways, including s uch pelvic complaints as abdominal pain, itching, and vaginal dis charge, as well increased tension, irritability, and fatigue. T he criteria for female orgasmic dis order are presented in 18.1a-12.

Table 18.1a-12 DS M-IV-TR Diagnos tic C riteria for Female Orgas mic Dis order 2178 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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A. P ersis tent or recurrent delay in, or abs ence of, orgasm after a normal sexual excitement phas e. Women exhibit wide variability in the type or intens ity of stimulation that triggers orgas m. T he diagnosis of female orgasmic dis order s hould be based on the clinician's judgment that the orgasmic capacity is less than would be for her age, sexual experience, and the adequacy sexual s timulation s he receives. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he orgasmic dysfunction is not better for by another Axis I disorder (except another dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type

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   S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. P.1920

Male Orgas mic Dis order In male orgas mic disorder (previous ly called inhibite d orgas m; also called re tarde d ejaculation), a man climax during coitus with great difficulty, if at all. A man cons idered to have lifelong orgasmic disorder if he has never ejaculated during coitus . T he dis order is as acquired if it develops after previous normal (T able 18.1a-13).

Table 18.1a-13 DS M-IV-TR Diagnos tic C riteria for Male Orgas mic Dis order 2180 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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A. P ersis tent or recurrent delay in, or abs ence of, orgasm after a normal sexual excitement phas e during sexual activity that the clinician, taking into account the person's age, judges to be adequate focus , intens ity, and duration. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he orgasmic dysfunction is not better for by another Axis I disorder (except another dysfunction) and is not due exclus ively to the phys iological effects of a s ubs tance (e.g., a drug abuse, a medication) or a general medical S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:

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   Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. S ome s uggest that orgasm and ejaculation s hould be differentiated. C ertainly, inhibited orgas m mus t be differentiated from retrograde ejaculation, in which ejaculation occurs but the seminal fluid pass es into the bladder. T his condition always has an organic caus e. R etrograde ejaculation can develop after genitourinary surgery and is als o ass ociated with medications that have anticholinergic adverse effects , as the phenothiazines, particularly thioridazine T he incidence of male orgas mic disorder is much lower than the incidences of premature ejaculation and dysfunction. Masters and J ohnson reported only 3.8 percent in one group of 447 sexual dysfunction cases. problem is more common among men with obses sivecompuls ive disorders (OC Ds ) than among others . Male orgasmic disorder may have phys iological causes and occur after surgery of the genitourinary tract, s uch as prostatectomy. Male orgas mic dysfunction may also be as sociated with P arkinson's disease and other disorders involving the lumbar or s acral s ections of the 2182 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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spinal cord. T he antihypertensive drugs guanethidine monos ulfate (Ismelin) and methyldopa (Aldomet) have been implicated in retarded ejaculation. P henothiazines have als o been ass ociated with the dis order, as have almos t all the antidepres sants . T ransient retarded ejaculation may occur with exces sive alcohol intake or with hyperglycemia. S trictly organic cases and that are symptomatic of other Axis I ps ychiatric are not to be included in the diagnosis. P rimary male orgas mic disorder indicates a more ps ychopathology. T he man often comes from a rigid, puritanical background; he perceives s ex as sinful and genitals as dirty and may have cons cious or inces t wis hes and guilt. Usually, difficulties with exis t that extend beyond the area of sexual relations . S ome cas es involve men with adult attention-deficit disorder. It is as though these men are so eas ily that they cannot focus on the pleas urable sensations of arousal cons is tently enough to attain a degree of excitement necess ary for orgas m. Another theory holds that men with retarded ejaculation are preoccupied with sex, unus ually voyeuris tic, and easily arous ed. their elaborate fantasies of exceptionally beautiful or driven women and atypical s exual activities require to work unus ually hard to achieve orgasm in more sexual encounters. In an ongoing relationship, s econdary ejaculatory inhibition frequently reflects interpers onal difficulties . disorder may be the man's way of coping with real or fantas ized changes in the relationship. T hos e changes include plans for a pregnancy about which the man is ambivalent, the los s of s exual attraction to the partner, 2183 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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demands by the partner for greater commitment as expres sed by s exual performance. In s ome men, the inability to ejaculate reflects unexpres sed hostility women. In a version of the dysfunction, some men experience partial inhibition of ejaculation. T hes e men experience slow dribbling of ejaculation (not related to age) rather than an ejaculatory s purt. T hey usually do not the pleas urable s ens ations of orgas m. A couple presented with the man as the identified suffering from an inability to ejaculate with intercourse. T he problem was of recent onset and had s tarted after the couple decided to have a baby. T he man was years of age and the woman was 39 years of age. they had been married for 2 years and had agreed to children when they married, the hus band had put off trying to have a child. He had started a new bus iness time the couple married and felt a great deal of press ure. T he wife had been s ympathetic to his but, as her 40th birthday loomed, she insis ted that they to conceive. T he hus band express ed his understanding and agreed but promptly developed the symptoms of retarded ejaculation. He was diagnos ed with male orgasmic disorder, acquired type. P.1921

P remature E jac ulation In pre mature e jaculation, the man recurrently achieves orgasm and ejaculates before he wishes to do s o. no definite time frame within which to define the 2184 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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dysfunction. T he diagnosis is made when the man regularly ejaculates before or immediately after the vagina or after minimal sexual s timulation. T he clinician s hould consider factors that affect duration of excitement phas e, s uch as age, novelty of the s exual partner, and the frequency and duration of coitus. and J ohnson conceptualized the dis order in terms of couple and cons idered a man a premature ejaculator if could not control ejaculation long enough during intravaginal containment to satis fy his partner in at half of their epis odes of coitus . T his definition ass umes the female partner is capable of an orgas mic respons e. with other dysfunctions, the disturbance is diagnosed if it is not caus ed exclus ively by medical factors or is symptomatic of any other Axis I s yndrome. P remature ejaculation is more common today among college-educated men than among men with les s education and is thought to be related to their concern partner satisfaction. It is es timated that 30 percent of male population have the dys function, and 40 percent of men treated for s exual dis orders have premature ejaculation as the chief complaint. Difficulty in ejaculatory control may be ass ociated with anxiety regarding the s ex act. B oth anxiety and are mediated by the s ympathetic nervous system. ps ychological factors that have been noted include guilt, a history of parent–child conflict, interpersonal hypers ens itivity, and perfectionism or unrealis tic expectations about sexual performance. C urrent res earch als o s uggests that a subgroup of premature ejaculators (particularly those with a lifelong history of premature ejaculation) may be biologically 2185 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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predis pos ed to this dys function. S ome res earchers that certain men are cons titutionally more vulnerable to sympathetic s timulation, hence, they ejaculate rapidly. Others have found a s horter bulbocavernosus reflex latency time in men with lifelong premature ejaculation than in men who had acquired the dys function. P remature ejaculation als o may result from negative cultural conditioning. T he man who has mos t of his sexual contacts with prostitutes, who demand that the act proceed quickly, or in situations in which dis covery would be embarrass ing, such as in an apartment with roommates or in the parental home, may become conditioned to achieving orgas m rapidly. In ongoing relations hips , the partner has some influence on the premature ejaculator. A stress ful marriage exacerbates disorder. T able 18.1a-14 gives the diagnostic criteria premature ejaculation.

Table 18.1a-14 DS M-IV-TR Diagnos tic C riteria for Premature E jac ulation A. P ersis tent or recurrent ejaculation with minimal sexual s timulation before, on, or s hortly after penetration and before the pers on wishes it. T he clinician mus t take into account factors that affect duration of the excitement phas e, s uch as age, novelty of the s exual partner or s ituation, and 2186 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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frequency of s exual activity. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he premature ejaculation is not due to the direct effects of a substance (e.g., from opioids). S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation.

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and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

S exual Pain Dis orders Dys pareunia Dys pare unia refers to recurrent and persistent pain intercours e in either a man or a woman. In women, the dysfunction is related to and often coincides with vaginis mus . R epeated episodes of vaginismus may dyspareunia and vice vers a, but, in either cas e, caus es mus t be ruled out. Dyspareunia s hould not be diagnosed as such when a medical basis for the pain is found or when (in a woman) it is as sociated with vaginis mus or with lack of lubrication. T he true incidence of dyspareunia is unknown, but it been es timated that 30 percent of surgical procedures the female genital area res ult in temporary Additionally, among women seen in s ex therapy clinics , the complaint is more common in women with a history rape or childhood s exual abus e. Dynamic factors are usually cons idered caus ative, although s ituational factors probably account for more secondary dysfunction. P ainful coitus may res ult from 2188 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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tense vaginal muscles. T he pain is real and makes intercours e unbearable or unpleas ant. Anticipation of further pain may caus e the woman to avoid coitus altogether. If the partner proceeds with intercours e regardless of the woman's s tate of readines s, the is aggravated. Dys pareunia can also occur in men, but it is and us ually as sociated with a medical condition such P eyronie's diseas e, prostatitis, or gonorrheal or infections. V asoconges tion during sexual activity orgasmic releas e also may lead to discomfort. R arely, men experience pain on ejaculation (pos tejaculatory disorder). T his pain is caus ed by an involuntary spasm the perineal mus cles that may be due to psychological conflicts about the sex act or may be an advers e effect some antidepres sant medications . T able 18.1a-15 lists diagnostic criteria for dyspareunia. In DS M-IV -T R , dys pareunia due to a gene ral me dical condition is us ed when the medical condition is the s ole or major caus al factor.

Table 18.1a-15 DS M-IV-TR Diagnos tic C riteria for A. R ecurrent or pers is tent genital pain as sociated with sexual intercours e in either a man or a B . T he disturbance causes marked distress or 2189 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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interpersonal difficulty. C . T he disturbance is not caus ed exclusively by vaginis mus or lack of lubrication, is not better accounted for by another Axis I dis order (except another sexual dysfunction), and is not due exclusively to the direct physiological effects of a subs tance (e.g., a drug of abuse, a medication) general medical condition. S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors

F rom American P sychiatric As sociation. 2190 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Vaginis mus V aginis mus is an involuntary and persistent the outer one-third of the vagina that prevents penile insertion and intercourse. T he res ponse may be demonstrated during a gynecological examination involuntary vaginal cons triction prevents introduction of the speculum into the vagina, although some women have vaginis mus during coitus . T he diagnosis is not if the dys function is caus ed exclus ively by medical or surgical factors or if it is symptomatic of another Axis I ps ychiatric syndrome (T able 18.1a-16). V aginismus is prevalent than anorgas mia. It most often afflicts highly educated women and those in the higher groups . A milder form of the dysfunction, in which vaginal tightnes s makes penile entry difficult, is experienced by more women on an intermittent or basis .

Table 18.1a-16 DS M-IV-TR Diagnos tic C riteria for 2191 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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A. R ecurrent or pers is tent involuntary s pas m of musculature of the outer third of the vagina that interferes with s exual intercourse. B . T he disturbance causes marked distress or interpersonal difficulty. C . T he disturbance is not better accounted for by another Axis I dis order (e.g., s omatization and is not due exclus ively to the direct effects of a general medical condition. S pe cify type:    Lifelong type    Acquired type S pe cify type:    Generalized type    S ituational type S pe cify:    Due to ps yc hological fac tors    Due to combined fac tors 2192 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

A woman suffering from vaginis mus may consciously to have coitus but unconsciously prevents penile into her body. A sexual trauma, s uch as rape, may vaginis mus . W omen who have experienced pain with nonsexual bodily traumas , through accidents or of illnes s or s urgery, may become s ens itized to the penetration. W omen with ps ychosexual conflicts P.1922 may perceive the penis as a dangerous weapon. P ain the anticipation of pain at the first coital experience vaginis mus in some women. A s trict religious that as sociates sex with s in is frequently noted in such cases. Others have problems in the dyadic woman who feels emotionally abus ed by her partner protes t in this nonverbal fashion. Miss B . was a 27-year-old, s ingle woman who therapy because of an inability to have intercourse. described episodes with a recent boyfriend in which he had tried vaginal penetration but had been unable to enter. T he boyfriend did not have erectile dysfunction. 2193 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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Miss B . experienced desire and was able to achieve through manual or oral stimulation. F or almost a year, and her boyfriend had s ex play without intercours e. However, he complained increas ingly about his at the lack of coitus , which he had enjoyed in previous relations hips . Mis s B . had a cons cious fear of and dreaded going to the gynecologist, although she able to us e tampons when she menstruated. S he was diagnosed with vaginismus , lifelong type.

S exual Dys func tion Due to a G eneral Medic al C ondition T he category s exual dysfunction due to a general condition covers s exual dysfunction that results in distress and interpers onal difficulty when there is from the history, physical examination, or laboratory findings of a general medical condition judged to be caus ally related to the sexual dysfunction (T able 18.1a-

Table 18.1a-17 DS M-IV-TR Diagnos tic C riteria for S exual Dys func tion Due to a General Medic al C ondition A. C linically significant s exual dys function that res ults in marked distress or interpers onal predominates in the clinical picture.

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B . T here is evidence from the his tory, phys ical examination, or laboratory findings that the dysfunction is fully explained by the direct phys iological effects of a general medical C . T he disturbance is not better accounted for by another mental dis order (e.g., major depres sive disorder). S ele ct code and term bas ed on the predominant sexual dys function:    Female hypoactive s exual des ire dis order to… [indic ate the general medical c ondition]: deficient or absent s exual des ire is the feature    Male hypoac tive s exual des ire dis order due [indic ate the general medical c ondition]: if deficient or absent s exual des ire is the feature    Male erectile dis order due to… [indic ate the general medic al c ondition]: if male erectile dysfunction is the predominant feature    Female dys pareunia due to… [indic ate the general medic al c ondition]: if pain as sociated intercours e is the predominant feature

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   Male dys pareunia due to… [indic ate the medical condition]: if pain as sociated with intercours e is the predominant feature    Other female s exual dys func tion due to… [indic ate the general medical c ondition]: if other feature is predominant (e.g., orgas mic disorder) or no feature predominates    Other male s exual dys func tion due to… [indic ate the general medical c ondition]: if other feature is predominant (e.g., orgas mic disorder) or no feature predominates C oding note: Include the name of the general medical condition on Axis I (e.g., male erectile disorder due to diabetes mellitus ); also code the general medical condition on Axis III.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Male E rec tile Dis order Due to a Medic al C ondition Many studies have focus ed on the relative incidences ps ychological and organic male erectile disorder. 2196 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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indicate that 50 to 80 percent of men with erectile have an organic bas is for the disorder. P hysiologically, erectile dys function may be due to a variety of medical caus es (T able 18.1a-18). In the United S tates , it is that two million men cannot gain erections becaus e suffer from diabetes mellitus ; an additional 300,000 are dysfunctional becaus e of other endocrine diseases; 1.5 million are dys functional as a res ult of vas cular 180,000 because of multiple s cleros is; 400,000 traumas and fractures leading to pelvic fractures or cord injuries ; and another 650,000 as a result of radical surgery, including prostatectomies , P.1923 colos tomies, and cys tectomies . In addition, the clinician should be aware of the poss ible pharmacological medication on s exual functioning. T he increased of organic causes for erectile dys function in the past 15 years may partly reflect the increased us e of and antihypertens ive medications . Advers e effects of medication may impair male s exual functioning in a of ways . C as tration (removal of the testes ) does not lead to sexual dys function, depending on the pers on. E rection may still occur after castration via a reflex arc pass es through the s acral cord erectile center. It is triggered when the inner thigh is s timulated.

Table 18.1a-18 Dis eas es and Medic al C onditions Implic ated in E rec tile Dys func tion 2197 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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Infectious and parasitic diseases

Neurological disorders

   E lephantias is

   Multiple s cleros is

   Mumps

   T rans verse myelitis

C ardiovascular disease

   P arkinson's diseas e

   Atherosclerotic disease

   T emporal lobe epileps y

   Aortic aneurysm

   T raumatic and spinal cord dis eas es

   Leriche's

   C entral nervous s ys tem tumor

   C ardiac failure

   Amyotrophic lateral sclerosis

R enal and disorders

   P eripheral neuropathy

   P eyronie's

   G eneral paresis

   C hronic renal failure

   T abes dorsalis

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   Hydrocele and varicocele

P harmacological contributants

Hepatic dis orders

   Alcohol and other dependence-inducing subs tances (heroin, methadone, morphine, cocaine, amphetamines , and barbiturates )

   C irrhos is (us ually as sociated with alcohol P ulmonary

   P rescribed drugs (ps ychotropic drugs , antihypertens ive drugs, es trogens , and antiandrogens )

   R espiratory failure

 

G enetic dis orders

P oisoning

   K linefelter's syndrome

   Lead (plumbism)

   C ongenital penile vascular and structural

   Herbicides

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abnormalities Nutritional dis orders

S urgical procedures

   Malnutrition

   P erineal pros tatectomy

   V itamin

   Abdominal–perineal res ection

E ndocrine dis orders

   S ympathectomy (frequently interferes with ejaculation)

   Diabetes mellitus

   Aortoiliac s urgery

   Dysfunction of the pituitary-adrenaltes tis axis

   R adical cystectomy

   Acromegaly

   R etroperitoneal lymphadenectomy

   Addis on's dis ease

Miscellaneous

   C hromophobe adenoma

   R adiation therapy

   Adrenal neoplasia

   P elvic fracture

   Myxedema

   Any s evere s ys temic 2200

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disease or debilitating condition    Hyperthyroidism

 

P HY S IOL OG IC A L TE S TS A number of procedures, benign and invas ive, are help differentiate psychogenic erectile dysfunction. T he procedures include monitoring nocturnal penile tumes cence (erection that occurs during s leep) as sociated with rapid eye movement; monitoring tumes cence with a s train gauge; meas uring blood press ure in the penis with a penile plethys mograph or ultras ound (Doppler) flow meter, both of which as sess blood flow in the internal pudendal artery; and pudendal nerve latency time. Neurological impairment penile function may be indicated by decreas ed perception in the penis . Other diagnos tic tes ts that delineate organic bas es for erectile disorder include glucose tolerance test, plasma hormone ass ays , liver thyroid function tests, prolactin and follicle-stimulating hormone (F S H) determinations, and cystometric examinations. Invasive diagnos tic studies include arteriography, infus ion cavernos onography, and radioactive xenon penography. Invasive procedures require expert interpretation and are used only for 2201 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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who are candidates for vas cular reconstructive

ME DIC A L VE R S US P S Y C HOG E NIC C A US E S A good his tory is crucial to determining the caus e of male erectile dis order. If a man reports having spontaneous erections at times when he does not plan have intercourse, having morning erections or only sporadic erectile dys function, or having good erections with masturbation or with partners other than his us ual one, then organic causes for his disorder can be cons idered negligible, and cos tly diagnostic procedures can be avoided. W hen a medical bas is for erectile dysfunction is found, psychological factors often contribute to the dys function, and psychiatric treatment may be helpful. S ome diabetics, for instance, may experience psychogenic erectile dysfunction.

Dys pareunia Due to a G eneral C ondition An estimated 30 percent of all surgical procedures on female genital area result in temporary dys pareunia. In addition, 30 to 40 percent of women with the complaint who are s een in sex therapy clinics have pelvic Organic abnormalities leading to dys pareunia and vaginis mus include infected hymenal remnants or congenitally imperforate or unus ually thick hymens; episiotomy scars; B artholin's glands infections; various forms of vaginitis and cervicitis ; tes tos terone vulvodynia; vaginal treatment, such as radiation or that has caus ed scarring; dermatological dis order, such lichens sclerosis or lichens planus; and endometrios is . 2202 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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P os tcoital pain reported by women with myomata and endometriosis P.1924 is attributed to the uterine contractions during orgasm. P os tmenopaus al women may have dyspareunia of thinning of the vaginal mucos a and reduced Dys pareunia can also occur in men, but it is and is us ually as sociated with an organic condition P eyronie's diseas e, which cons is ts of s clerotic plaques the penis that cause penile curvature.

Hypoac tive S exual Des ire Dis order to a G eneral Medic al C ondition Des ire commonly decreases after major illnes s or particularly when body image is affected after s uch procedures as mastectomy, ileos tomy, hysterectomy, prostatectomy. Illness es that deplete a person's chronic conditions that require physical and adaptation, and s erious illnes ses that may cause the person to become depress ed can all res ult in a marked less ening of sexual desire in both men and women. In some cases, biochemical correlates are ass ociated hypoactive sexual desire disorder (T able 18.1a-19). A recent study found markedly lower s erum tes tos terone concentrations in men complaining of low des ire than normal controls in a sleep laboratory s ituation. Drugs depres s the central nervous system (C NS ) or decreas e tes tos terone production can decreas e desire.

Table 18.1a-19 Neurotrans mitter E ffe 2203 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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Dopamine

S erotonin

Adrenergic

Ch

E rection

++

+/-

α, β

+/-

 

 

 

-+

 

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E jaculation +/and orgasm

+

+

+/-

 

 

α1

 

 

+/- minimal or no effect; + facilitates effect; - inhibiting ef oxidase inhibitor.

Other Male S exual Dys func tion Due G eneral Medic al C ondition T he category other male s e xual dys function due to a me dical condition is us ed when some dys functional other than thos e discus sed above predominates (e.g., orgasmic disorder) or no feature predominates. Male orgasmic dysfunction may have physiological causes can occur after s urgery on the genitourinary tract, such prostatectomy. It may also be ass ociated with 2205 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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disease and other neurological disorders involving the lumbar or s acral s ections of the s pinal cord. T he antihypertens ive drug guanethidine monos ulfate, methyldopa, the phenothiazines , the tricyclic drugs , serotonin reuptake inhibitors , among others, have been implicated in retarded ejaculation. Male orgas mic must als o be differentiated from retrograde ejaculation, which ejaculation occurs but the s eminal fluid pas ses backward into the bladder. R etrograde ejaculation has an organic caus e. As mentioned above, it can after genitourinary s urgery and is also as sociated with medications with anticholinergic adverse effects, such the phenothiazines.

Other F emale S exual Dys func tion a G eneral Medic al C ondition T he category other fe male s exual dys function due to a ge neral me dical dis orde r is us ed when some feature than those discus sed above (e.g., orgasmic dis order) predominates or no feature predominates . S ome conditions—specifically, such endocrine diseases as hypothyroidism, diabetes mellitus, and primary hyperprolactinemia—can affect a woman's ability to orgasms.

S ubs tanc e-Induc ed S exual T he diagnosis s ubs tance-induce d s exual dys function is when evidence from the his tory, phys ical examination, laboratory findings indicates s ubstance intoxication or withdrawal when dysfunction follows the us e of prescribed medication. Distress ing sexual dysfunction occurs within a month of s ignificant s ubs tance 2206 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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or withdrawal (T able 18.1a-20). S pecified subs tances include alcohol; amphetamines or related s ubs tances ; cocaine; opioids; s edatives , hypnotics, or anxiolytics; other or unknown substances.

Table 18.1a-20 DS M-IV-TR Diagnos tic C riteria for Induc ed S exual Dys func tion A. C linically significant s exual dys function that res ults in marked distress or interpers onal predominates in the clinical picture. B . T here is evidence from the his tory, phys ical examination, or laboratory findings that the dysfunction is fully explained by subs tance use manifested by either (1) or (2):    (1) the symptoms in C riterion A developed or within a month of, substance intoxication    (2) medication use is etiologically related to the disturbance C . T he disturbance is not better accounted for by sexual dys function that is not s ubs tance-induced. E vidence that the s ymptoms are better accounted for by a s exual dys function that is not s ubs tance-

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induced might include the following: the precede the onset of the s ubs tance use or dependence (or medication us e); the s ymptoms persis t for a s ubs tantial period of time (e.g., approximately a month) after the ces sation of intoxication, or are s ubs tantially in excess of what would be expected given the type or amount of subs tance used or the duration of us e; or there is other evidence that s uggests the exis tence of an independent non–subs tance-induced s exual dysfunction (e.g., history of recurrent non– subs tance-related episodes ). Note: T his diagnos is should be made instead of diagnosis of substance intoxication only when the sexual dysfunction is in exces s of that us ually as sociated with the intoxication s yndrome and the dysfunction is sufficiently s evere to warrant independent clinical attention. C ode [S pecific substance]-induced s exual dysfunction:    Alcohol; amphetamine [or amphetamine-like subs tance]; cocaine; opioid; sedative, hypnotic, anxiolytic; other [or unknown] substance S pe cify if:    With impaired des ire 2208 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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   With impaired arous al    With impaired orgas m    With s exual pain S pe cify if:    With ons et during intoxic ation: if the criteria met for intoxication with the s ubs tance and the symptoms develop during the intoxication syndrome

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. Abused recreational s ubs tances affect sexual function various ways. In s mall doses, many s ubs tances sexual performance by decreas ing inhibition or anxiety by temporarily elevating mood. However, continuous impairs erectile, orgasmic, and ejaculatory capacities. abuse of s edatives , anxiolytics, and, particularly, nearly always depress es desire. Alcohol may fos ter the initiation of sexual activity by removing inhibitions, but it impairs performance. C ocaine and amphetamines similar effects . Although no direct evidence indicates sexual drive is enhanced by stimulants , the us er 2209 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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has a feeling of increas ed energy and may become sexually active. Ultimately, dys function occurs. Men go through two stages: prolonged erection without ejaculation and then a gradual loss of erectile capacity. R ecovering substance-dependent patients may need therapy to regain s exual function. In part, this is one of psychological readjus tment to a nondependent state. Many substance abusers have always had difficulty intimate interactions. Others have miss ed the that would have enabled them to learn social and skills becaus e they spent their crucial developmental under the influence of some substance.

Pharmac ologic al Agents Implic ated S ex Dys func tion Many pharmacological agents , particularly thos e us ed ps ychiatry, have been as sociated with an effect on sexuality. In men, thes e effects include decreased s ex drive, erectile failure (impotence), decreas ed volume of ejaculate, and delayed or retrograde ejaculation. In women, decreas ed s ex drive, decreased vaginal lubrication, inhibited or delayed orgas m, and absent vaginal contractions may occur. Drugs may also enhance the s exual res ponse and increase the s ex but this effect is less common than are inhibiting

A ntips yc hotic Drugs Antips ychotic drugs that block adrenergic and receptors are accompanied by advers e s ex effects . C hlorpromazine (T horazine), thioridazine, (S telazine), and haloperidol (Haldol) are potent anticholinergic agents that impair erection and 2210 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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in men and inhibit vaginal lubrication and orgasm in women. C hlorpromazine and thioridazine also block adrenergic receptors. T hioridazine has a particular P.1925 effect of caus ing retrograde ejaculation, in which the seminal fluid backs up into the bladder rather than propelled through the penile urethra. P atients still have pleas urable s ens ation of orgas m, but it is dry. W hen urinating after orgas m, the urine may be milky white because it contains the ejaculate. T he condition is but harmless and may occur in up to 50 percent of taking the drug. P aradoxically, rare cases of priapism been reported with antips ychotics . S econd-generation antips ychotic drugs , s uch as quetiapine (S eroquel), lower incidence of s exual side effects.

S elec tive S erotonin R euptake T he most commonly prescribed group of are the s elective serotonin reuptake inhibitors (S S R Is ). Advers e s exual effects may occur with this group of because of increased s erotonin concentration. A of the sex drive and difficulty reaching orgas m occur in both s exes. Of the S S R Is , the most frequent s exual effects are seen with paroxetine (P axil), next with fluoxetine (P rozac), and the least with sertraline S imilar symptoms have been ass ociated with (Luvox), citalopram (C elexa), and es citalopram R eversal of negative s exual side effects has been with cyproheptadine (P eriactin), an antihis tamine with antis erotonergic effects ; amantadine (S ymmetrel), a dopamine agonis t; yohimbine (Y ocon), a central α2 2211 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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adrenergic receptor antagonis t us ed in treating male erectile dis order; and methylphenidate (R italin) and dextroamphetamine (Dexedrine), which are and have adrenergic effects. T here are reports of (V iagra), a nitric oxide enhancer us ed to treat erectile dysfunction, overcoming orgas mic problems with the S S R Is. B uspirone (B uS par) helps s ome overcome advers e s exual effects of S S R Is , poss ibly it is 5-hydroxytryptamine type A (5-HT A ) agonist or because it suppress es S S R I-induced elevation of

Heteroc yc lic A ntidepres s ants T he tricyclic and tetracyclic antidepres sants have anticholinergic effects that interfere with erection and delay ejaculation. B ecause the anticholinergic effects among the cyclic antidepress ants, thos e with the side effects (e.g., desipramine [Norpramin]) produce fewest s exual s ide effects . T he effects of the drugs in women have not been s tudied s ufficiently; however, few women seem to complain of any effects . S elegiline (E ldepryl) is a selective monoamine oxidase B (MAO B ) inhibitor reported to increase sex drive, by dopaminergic activity and increased production of norepinephrine. S ome men report a pleas urable increas ed sensitivity of glans with this class of drugs that does not interfere erection, although it delays ejaculation. In some cas es , however, the tricyclic drug caus es a painful ejaculation, perhaps as the res ult of interference with s eminal propulsion caus ed by interference with urethral, vas, and epididymal s mooth muscle contractions. C lomipramine (Anafranil) has been reported to 2212 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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sex drive in some individuals.

Monoamine Oxidas e Inhibitors T he MAOIs affect biogenic amines broadly. they produce impaired erection, delayed or retrograde ejaculation, vaginal dryness , and inhibited orgasm. T ranylcypromine (P arnate) has a paradoxical sexually stimulating effect in s ome individuals , poss ibly as a of its amphetamine-like properties.

G eneral E ffec ts of A ntidepres s ants B ecaus e depres sion is ass ociated with a decreas ed varying levels of s exual dys function and anhedonia are part of the dis eas e proces s. T his phenomenon makes as sess ment of dys function as a res ult of s exual side difficult in patients taking the drugs. S ome patients improved sexual function as their depres sion improves with antidepres sant medication. S ometimes, s exual effects disappear with time, perhaps becaus e a amine homeostatic mechanis m comes into play. In cases, antidepress ants without as sociated side effects sexual dys function are substituted, s uch as bupropion (W ellbutrin), nefazodone (S erzone), or mirtazapine (R emeron). T here have been rare, individual reports of orgasmic dysfunction with the latter two drugs . Mrs. J . presented with the complaint of inability to orgasm. Her problem dated from the time, 18 months previous ly, when she had been placed on fluoxetine. B efore that time, she had been able to achieve orgas m through masturbation and in the majority of her s exual interactions with her husband. 2213 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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Mrs. J . tried s everal other S S R Is , as well as (E ffexor), but the side effect of anorgasmia pers is ted. Unfortunately, none of the us ual antidotes to S S R Ianorgas mia proved effective, and the patient did not res pond well to antidepress ants of other categories. was able P.1926 to achieve orgas m with the aid of a vibrator, even while she was on an S S R I. S ex therapy, in this case, encouraging her husband to accept inclus ion of the vibrator in their s ex play and reass uring him that its us e was not a reflection of his lovemaking skills. Mrs. J . diagnosed as having s ubs tance-induced s exual dysfunction.

L ithium Lithium regulates mood and, in the manic state, may reduce hypersexuality, poss ibly via dopamine S ome patients have reported impaired erection.

P s yc hos timulants P sychos timulants are s ometimes us ed in the treatment depres sion and include such drugs as amphetamine methylphenidate, which rais e plasma concentrations of norepinephrine and dopamine. Libido is increas ed; however, with prolonged use, men may experience a of des ire and erections. One study found that sulfate facilitated arous al in functional women.

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Adrenergic receptor antagonists are us ed to treat hypertens ion, angina, and certain cardiac arrhythmias . T hey diminish tonic s ympathetic nerve outflow from vasomotor centers in the brain. As a result, they can impotence, decrease the volume of ejaculate, and retrograde ejaculation. C hanges in libido have been reported in both sexes . S ugges tions have been made us e the s ide effects of drugs therapeutically. T hus, a that delays or interferes with ejaculation (s uch as fluoxetine) might be used to treat premature

A ntic holinergic s T he anticholinergics block cholinergic receptors and include s uch drugs as amantadine and benztropine (C ogentin). T hey can produce drynes s of the mucous membranes (including thos e of the vagina) and erectile dysfunction.

A ntihis tamines Drugs s uch as diphenhydramine (B enadryl) have anticholinergic activity and are mildly hypnotic. As a they may inhibit s exual function. C yproheptadine, although an antihistamine, als o has potent activity as a serotonin antagonist. It is used to block the advers e s exual effects produced by S S R Is, such as orgasm and erectile dysfunction.

A ntianxiety A gents T he major class of antianxiety drugs is the benzodiazepines (e.g., diazepam [V alium]). T hey act γ-aminobutyric (G AB A) receptors, which are believed involved in cognition, memory, and motor control. 2215 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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B ecaus e they decrease plasma epinephrine they diminish anxiety, thus improving s exual function in individuals inhibited by anxiety.

A lc ohol Alcohol s uppress es C NS activity generally and, hence, produce erectile dis orders in men. Alcohol has a direct gonadal effect that decreases testosterone in men; paradoxically, it can produce a s light increase tes tos terone concentrations in women. T his may for increas ed libido in women after drinking small of alcohol. Long-term us e of alcohol reduces the ability the liver to metabolize estrogenic compounds; in men, produces signs of feminization (e.g., gynecomastia as res ult of testicular atrophy).

Opioids Opioids such as heroin have such adverse sexual erectile failure and decreased libido. Altered may enhance the sexual experience in occasional

Halluc inogens T he hallucinogens include lysergic acid diethylamide (LS D), phencyclidine (P C P ), ps ilocybin (from s ome mushrooms), and mes caline (from peyote cactus). In addition to inducing hallucinations, thes e drugs caus e of contact with reality and an expanding and of consciousness . S ome us ers report that the s exual experience is s imilarly enhanced; others experience anxiety, delirium, or ps ychos is , which clearly interferes with sex function.

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C annabis T he altered state of cons ciousnes s produced by may enhance s exual pleasure for some individuals. Its prolonged use depress es tes tos terone concentrations.

B arbiturates and S imilarly A c ting B arbiturates are sedative-hypnotics that may enhance sexual res ponsivenes s in persons who are sexually unrespons ive because of anxiety. T hey have no direct effect on the s ex organs, but they do alter which s ome individuals find pleas urable. T hey are to abus e and may be fatal when combined with alcohol other C NS depres sants. Methaqualone (Quaalude) acquired a reputation as a sexual enhancer that had no biological bas is in fact. It is no longer marketed in the United S tates .

S exual Dys func tion and S exual Dis order Not Otherwis e S pec ified DS M-IV -T R us es two categories —sexual dys function otherwis e s pecified and s exual dis order not otherwis e specified. T he diagnos tic criteria are listed in T ables 21 and 18.1a-22, respectively. T he dis tinction between two categories is unclear, however, and there is between them. Many sexual disorders are not as sexual dys functions or as paraphilias. T hes e disorders are rare, poorly documented, not eas ily clas sified, or not s pecifically des cribed in DS M-IV -T R . 10 has a s imilar res idual category for problems related sexual development or preference (T able 18.1a-23).

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Table 18.1a-21 DS M-IV-TR Diagnos tic C riteria for S exual Dys func tion Not Otherwis e S pec ified T his category includes sexual dys functions that not meet criteria for any s pecific s exual E xamples include    1. No (or substantially diminis hed) s ubjective feelings des pite otherwis e normal arousal and orgasm    2. S ituations in which the clinician has that a sexual dysfunction is pres ent but is unable determine whether it is primary, due to a general medical condition, or substance induced

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

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Dis order Not Otherwis e T his category is included for coding a s exual disturbance that does not meet the criteria for any specific s exual disorder and is neither a sexual dysfunction nor a paraphilia. E xamples include    1. Marked feelings of inadequacy concerning sexual performance or other traits related to s elfimpos ed standards of masculinity or femininity    2. Dis tres s about a pattern of repeated s exual relations hips involving a success ion of lovers who are experienced by the individual only as things be us ed    3. P ers is tent and marked distres s about sexual orientation

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 18.1a-23 DS M-IV-TR Diagnos tic C riteria for 2219 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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Ps yc hologic al and B ehavioral Dis orders As s oc iated with Development and Orientation T his s ection is intended to cover those types of problems that derive from variations of sexual development or orientation, when the s exual preference per s e is not necess arily problematic abnormal. S exual maturation dis order T he patient suffers from uncertainty about his or gender identity or sexual orientation, which anxiety or depres sion. E go-dys tonic s exual orientation T he gender identity or sexual preference is not in doubt, but the individual wis hes it were different. S exual relations hip dis order T he abnormality of gender identity or sexual preference is respons ible for difficulties in forming maintaining a relationship with a s exual partner. Other ps ychos exual development dis orders

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Ps yc hos exual development dis order,

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. E xamples of s uch unclass ified dis orders include who experience the phys iological components of excitement and orgas m but report no erotic sensation even anes thesia and the male experience of orgas m flaccid penis. T he orgas mic woman who desires but not experienced multiple orgasms can be class ified this heading as well. Als o, disorders of exces sive than inhibited function, such as compulsive might be diagnos ed under atypical dysfunction. Other sexual practices exist that are not listed in DS M-IV example, behaviors that attempt to enhance s exual arousal by oxygen deprivation (hypoxyphilia) or other deviant methods . Atypical dysfunction als o might be to cover complaints engendered by couple, rather than P.1927 individual, dys function—for example, a couple in which one partner prefers morning s ex and the other more readily at night or a couple with unequal of des ire.

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T he concept of compuls ive s exual behavior (T able 24), or sex addiction, was developed in the 1980s to describe persons who compuls ively seek out sexual experiences and whos e behavior becomes impaired if cannot gratify their s exual impuls es . T he concept of addiction is derived from the model of addiction to such as heroin or addiction to behavioral patterns such gambling. Addiction implies ps ychological dependence, phys ical dependence, and a withdrawal symptom if the subs tance (e.g., the drug) is unavailable or the (e.g., gambling) is frustrated.

Table 18.1a-24 S igns of S exual Addic tion or C ompuls ive S exual B ehavior 1. Out-of-control behavior 2. S evere adverse consequences (medical, legal, interpersonal) due to s exual behavior 3. P ersistent pursuit of self-destructive or highsexual behavior 4. R epeated attempts to limit or stop s exual 5. S exual obs ess ion and fantas y as a primary mechanism

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6. Need for increasing amounts of sexual activity 7. S evere mood changes related to sexual (e.g., depres sion, euphoria) 8. Inordinate amount of time s pent in obtaining being sexual, or recovering from sexual 9. Interference of s exual behavior in social, occupational, or recreational activities

Data from C arnes P . Don't C all It L ove . New B antam B ooks, 1991. DS M-IV -T R does not use the terms s e x addiction or compuls ive s e xual be havior, nor is this dis order recognized or accepted. Nevertheless , the person entire life revolves around s ex-seeking behavior and activities, who s pends an excess ive amount of time in behavior, and who often tries to stop s uch behavior but cannot do so is well known to clinicians. S uch pers ons show repeated and increasingly frequent attempts to a s exual experience, and deprivation evokes distress . In the author's view, s ex addiction is a useful concept heuristically becaus e it can alert the clinician seek an underlying caus e for the manifest behavior.

P os tc oital Dys phoria P os tcoital dysphoria is not listed in DS M-IV -T R . It 2223 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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during the res olution phase of s exual activity, when individuals normally experience a s ens e of general being and mus cular and psychological relaxation. individuals , however, experience postcoital after an otherwis e s atis factory s exual experience, they become depress ed, tens e, anxious , and irritable and ps ychomotor agitation. T hey often want to get away the partner and may become verbally or even abusive. T he incidence of the disorder is unknown, but more common in men than in women. Its s everal relate to the person's attitude toward s ex in general the partner in particular. It may occur in adulterous s ex with pros titutes , when there is a profound fear of or when individuals cannot experience sex without cons equent s trong feelings of guilt. T he fear of sexually transmitted disease caus es some pers ons to postcoital dys phoria. T reatment requires insightps ychotherapy to help patients unders tand the unconscious antecedents to their behavior and

Unc ons ummated Marriage A couple involved in an uncons ummated marriage never had coitus and are typically uninformed and inhibited about s exuality. T heir feelings of guilt, s hame, inadequacy are increas ed by their problems, and they experience conflict between their need to seek help their need to conceal their difficulty. C ouples pres ent the problem after having been married s everal months several years . Mas ters and J ohns on reported an unconsummated marriage of 17 years ' duration. F requently, the couple does not s eek help directly, but woman may reveal the problem to her gynecologis t on 2224 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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visit os tensibly concerned with vague vaginal or other somatic complaints. On examining her, the may find an intact hymen. In s ome cases, however, the wife may have undergone a hymenectomy to res olve problem. Inquiry by a physician who is comfortable in dealing with s exual problems may be the first opening frank dis cus sion of the couple's dis tres s. Often, the of the medical vis it is a dis cuss ion of contraceptive methods or even a reques t for an infertility workup. presented, the complaint often can be s ucces sfully T he duration of the problem does not significantly the prognos is or the outcome of the case. P.1928 T he caus es of unconsummated marriage are varied: sex education, s exual prohibitions overly s tres sed by parents or s ociety, problems of an oedipal nature, immaturity in both partners, overdependence on families , and problems in sexual identification. orthodoxy, with s evere control of sexual and s ocial development or the equation of s exuality with sin or uncleanliness , has also been cited as a dominant Many women involved in an uncons ummated marriage have dis torted concepts about their vaginas . T hey may fear that the vagina is too small or too s oft, or they may confuse the vagina with the rectum, leading to feelings being unclean. T he man may share in those distortions about the vagina and, in addition, perceive it as to himself. S imilarly, both partners may have dis tortions about the man's penis, perceiving it as a weapon, as large, or as too small. Many patients can be helped by simple education about genital anatomy and 2225 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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by suggestions for s elf-exploration, and by correct information from a phys ician. T he problem of the unconsummated marriage is bes t treated by seeing members of the couple. Dual-sex therapy has been markedly effective. However, other forms of conjoint therapy, marital counseling, traditional ps ychotherapy a one-to-one basis , and counseling from a s ensitive phys ician, gynecologis t, or urologis t are all helpful.

B ody Image P roblems S ome individuals are as hamed of their bodies and experience feelings of inadequacy related to s elfstandards of mas culinity or femininity. T hey may ins is t sex only during total darkness , not allow certain body to be s een or touched, or s eek unnecess ary operative procedures to deal with their imagined inadequacies. dysmorphic dis order should be ruled out.

Don J uanis m S ome men who appear to be hypers exual, as shown their need to have many s exual encounters or us e their sexual activities to mask deep feelings of inferiority. S ome have uncons cious homos exual which they deny by compuls ive s exual contacts with women. After having s ex, most Don J uans are no interes ted in the woman. T he condition is also referred as s atyrias is or as a form of sex addiction.

Nymphomania Nymphomania signifies exces sive or pathological for coitus in a woman. T here have been few s cientific studies of the condition. T hose patients who have been 2226 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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studied usually have had one or more s exual dis orders, us ually including female orgasmic dis order. T he often has an intense fear of los s of love. S he attempts satis fy her dependency needs rather than to gratify her sexual impuls es through her actions . It is s ometimes clas sified as a form of sex addiction.

F antas ies Other atypical dis orders are found in individuals who one or more s exual fantas ies about which they obses s, guilty, or are otherwise dysphoric. As indicated in T able 18.1a-25, however, the range of common sexual is broad.

Table 18.1a-25 C ommon S exual Fantas ies a Men

Women

Heteros exual

 

R eplacement of es tablis hed partner

R eplacement of es tablis hed partner

 

F orced sexual encounters with men

F orced sexual

Observing s exual

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encounters with  

Idyllic encounters with unknown men

Observing s exual activity

 

S exual encounters men

S exual encounters with women

G roup sex

 

Homos exual

 

Images of male

F orced sexual encounters with

F orced sexual encounters with men

 

 

Idyllic encounters with es tablis hed partner

S exual encounters women

 

Idyllic encounters with unknown men

S exual encounters with men

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Memories of pas t experiences

G roup sex

S adistic imagery

aListed

in order of occurrence. A 1994 s tudy that one in five persons experienced a s ame-sex sexual fantasy at s ome time in their lives. Adapted from Masters W, S chwartz M: T he and J ohns on treatment program for dis satisfied homos exual men. Am J P s ychiatry.

P ers is tent and Marked Dis tres s S exual Orientation Dis tres s about sexual orientation is us ually by diss atisfaction with homos exual arousal patterns , a desire to increas e heterosexual arousal, and s trong negative feelings about being homosexual. Occas ional statements to the effect that life would be eas ier if the person were not homos exual do not constitute and marked distress about s exual orientation. T reatment of sexual orientation distress is One s tudy reported that with a minimum of 350 hours ps ychoanalytic therapy, approximately one-third of approximately 100 bisexual and homosexual men achieved a heterosexual reorientation at 5-year followbut that study was challenged and never replicated. 2229 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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B ehavior therapy and avoidance conditioning have als o been used, but a bas ic problem with technique is that the behavior may be changed in the laboratory setting but not outs ide the laboratory. P rognos tic factors weighing in favor of heteros exual reorientation for men include being younger than 35 years , having s ome experience of heterosexual and having a high motivation for reorientation. Another s tyle of intervention is directed at enabling the person with persis tent and marked distress about orientation to live comfortably as a homosexual without shame, guilt, anxiety, or depres sion. G ay counseling centers are engaged with patients in s uch treatment programs. At pres ent, outcome studies of such centers have not been reported in detail. F ew data are available about the treatment of women persis tent and marked distress about sexual and those are primarily s ingle-case studies with outcomes .

P os tc oital Headac he P os tcoital headache is a headache immediately after and may last for s everal hours. It is us ually des cribed throbbing and is localized in the occipital or frontal T he caus e is unknown but may be vascular, due to contraction (tens ion), or psychogenic. C oitus may precipitate migraine or clus ter headaches in persons.

Orgas mic A nhedonia Orgas mic anhedonia is a condition in which the pers on had no phys ical s ens ation of orgasm, even though the 2230 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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phys iological component (e.g., ejaculation) remains Medical causes, s uch as s acral and cephalic lesions interfere with afferent pathways from the genitalia to cortex, must be ruled out. P sychic caus es us ually extreme guilt about experiencing s exual pleasure— feelings produce a type of diss ociative res pons e that is olates the affective component of the orgas mic experience from cons cious nes s. P.1929

F emale P remature Orgas m Data on female premature orgasm are lacking; no category for premature orgas m in women is included in DS M-IV -T R . However, in the Univers ity of C hicago percent of women felt they reached orgasm too quickly.

Mas turbatory P ain S ome individuals may experience pain during masturbation. Organic caus es should always be ruled A s mall vaginal tear or early P eyronie's disease may produce a painful sensation. T he condition should be differentiated from compulsive mas turbation. P eople masturbate to the extent that they do phys ical damage their genitals and eventually experience pain during subs equent mas turbatory acts. C ertain mas turbatory practices have resulted in what been called autoe rotic as phyxiation, which is us ually clas sified as a paraphilia (hypoxyphilia). T he practices involve masturbating while hanging by the neck to heighten erotic s ens ations and the intensity of the through the mechanis m of mild hypoxia. Although they 2231 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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intend to release themselves from the noos e after an es timated 500 to 1,000 pers ons a year accidentally thems elves by hanging. Most who indulge in the are men; transves tis m is often as sociated with the and most deaths occur among adolescents. S uch masochistic practices are us ually as sociated with mental disorders , such as schizophrenia and major disorders .

TR E A TME NT T he treatment of sexual disorders has evolved since the 1970s , when Masters and J ohnson focus ed attention of the ps ychiatric community on s exual disorders . Innovations in treatment reflect the results of res earch and changes in the patient population. F or example, in the late 1960s, most cases of erectile dysfunction were cons idered psychological in origin, approximately 20 percent of erectile problems having organic caus e. C urrently, the numbers are revers ed, the majority of cases cons idered to res ult from a phys iological problem. Actually, many cas es are of origin. S imilarly, early patients in s ex therapy were as sumed to s uffer, in part, from lack of sexual and culturally reinforced negative attitudes toward s ex. S ince the 1970s, the public has received a great deal accurate information about sex through the media, and cultural attitudes regarding s exual behavior have markedly more liberal. P atients now have more and greater sexual s ophistication. T heir dys functions a complex etiology frequently involving psychodynamic and relational is sues. P roblems of des ire are s een with increasing frequency and are among the mos t cases for therapists. C ouple is sues involve problems of 2232 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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trus t, intimacy, lack of s exual attraction, and s truggles dominance. F inally, along with the rest of ps ychiatry, therapy has experienced medicalization. B iological treatment approaches have developed rapidly. An approach that allows the us e of s everal techniques sequentially or in combination may be necess ary. B efore entering therapy, the patient s hould have a thorough medical evaluation, including a medical phys ical examination, and appropriate laboratory when neces sary. If a medical caus e for the dis order is found, treatment should be directed toward that caus e. B efore 1970, the mos t common treatment of sexual dysfunction was individual psychotherapy. C lass ic ps ychodynamic theory cons iders s exual inadequacy to have its roots in early developmental conflicts , and the sexual disorder is treated as part of a more pervasive emotional disturbance. T reatment focus es on the exploration of unconscious conflicts, motivation, and various interpers onal difficulties . T herapy as sumes that removal of the conflicts will allow the sexual to become structurally acceptable to the patient's ego thereby find appropriate means of satisfaction in the environment. Unfortunately, the symptom of s exual dysfunction frequently becomes s econdarily and persis ts after res olution of the other problems evolving from the patient's pathology. T he addition of behavioral techniques is often necess ary to cure the problem.

Dual-S ex Therapy T he theoretical basis of the dual-sex therapy approach 2233 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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the concept of the marital unit or dyad as the object of therapy. T he method of dual-sex therapy was and developed by Masters and J ohnson. Dual-sex does not accept the idea of a sick half of a patient B oth individuals are involved in a relations hip in which there is s exual dis tres s, and, thus , both must the therapy program. T he sexual problem often reflects other areas of disharmony or mis understanding in the marriage. T he marital relations hip as a whole is treated, with sexual functioning as a part of that relationship. communication in sexual and nonsexual areas is a goal of treatment. P sychological and phys iological of sexual functioning are discus sed with an educational attitude. S ugges tions are followed in the privacy of the couple's home. Initial histories are taken to determine suitability for this type of treatment. E vidence of major underlying ps ychopathology s uggests further ps ychiatric and participation in the program may be deferred until patient seems better able to benefit from it. C oncurrent ps ychotherapy with a psychiatrist while participating in dual-sex therapy is s ometimes recommended. E ach patient is interviewed individually early in the of treatment. A complete sexual history is obtained, is later reflected back to the couple to help them unders tand their present problem. T he individual also help the therapist understand the patients' lifes tyle and allow for sugges tions that fit into that lifes tyle.

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T reatment is s hort term and behaviorally oriented. exercises are prescribed to help the couple with their particular problem. S exual dysfunction often involves a fear of inadequate performance; thus, couples are specifically prohibited from any sexual play other than prescribed by the therapist. Initially, intercourse is interdicted, and couples learn to give and receive pleas ure without the pres sure of performance. exercises usually focus on heightening s ens ory to touch, s ight, s ound, and s mell. During these exercises, called s e ns ate focus couple is given much reinforcement to less en anxiety. T hey are urged to us e fantas ies to dis tract them from obses sive concerns about performance, which is s pectatoring. T he needs of both the dysfunctional and the nondysfunctional partner are cons idered. If partner becomes s exually excited by the exercises, the other is encouraged to bring him or her to orgas m by manual or oral means . T his procedure is important to the nondysfunctional partner from sabotaging the treatment. Open communication between the partners urged, and the express ion of mutual needs is R es istances, such as claims of fatigue or not enough to complete the exercis es , are common and mus t be with by the therapist. G enital s timulation is eventually added to general body stimulation. T he couple is sequentially taught to try various pos itions for without necess arily completing the act and to use of stimulating techniques before they are permitted to proceed with intercours e. T he specific exercises vary with differing presenting complaints , and s pecial techniques are us ed to treat 2235 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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various dys functions. In cas es of vaginis mus, for the woman is advised to dilate her vaginal P.1930 opening with her fingers or with s ize-graduated vaginal dilators as part of the therapy. In cas es of premature ejaculation, an exercis e known as the s que e ze us ed to raise the thres hold of penile excitability. In this exercise, the man or the woman stimulates the erect until the earlies t s ens ations of impending orgas m and ejaculation are felt. P enile s timulation is then s topped abruptly, and the coronal ridge of the penis is forcibly squeezed for several s econds . T he technique is several times. A variation is the s top–s tart te chnique , in which s timulation is interrupted for s everal seconds but squeeze is applied. Masturbation to the point of orgasm raises the threshold of excitability to a more tolerant s timulation level. T he man is encouraged to on sensations of excitement rather than dis tract hims elf from them. T his makes him more familiar with his excitement pattern and lets him feel in control rather overwhelmed by s ens ations of arous al. C ommunication between the partners is improved because the man let his partner know his level of sexual excitement so she can s queeze the penis before the ejaculatory has s tarted. S ex therapy has been s uccess ful with premature ejaculators ; however, a s ubgroup of dysfunctional men may need pharmacotherapy as well. A man with s exual des ire dis order or erectile dis order sometimes told to masturbate to demons trate that full erection and ejaculation are poss ible. A woman with lifelong female orgas mic dis order is directed to 2236 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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masturbate, s ometimes us ing a vibrator. K egel's may be introduced to s trengthen the pubococcygeal muscles —that is , the woman is encouraged to contract abdominal and perineal mus cles during mas turbation coitus. W hen a man has erectile dis order, the woman be ins tructed to s timulate or tease his penis. T he s ame technique is us ed with men who s uffer from retarded ejaculation, with stimulation s ometimes involving a vibrator. R etarded ejaculation is managed by ejaculation initially and gradual vaginal entry after stimulation to the point of near ejaculation.

Treatment G oals T he overall goal of treatment is to initiate an proces s, to diminis h the fears of performance felt by sexes, and to facilitate communication in sexual and nonsexual areas . T herapy sess ions follow each new exercise period, and problems and s atisfactions (both sexual and nons exual) are discus sed. S pecific and new exercises geared to the individual couple's progres s are reviewed in each s es sion. G radually, the couple gains confidence and learns (or relearns ) to communicate verbally and sexually. Dual-sex therapy most effective when the s exual dys function exists apart from other psychopathology.

Hypnotherapy Hypnotherapists focus s pecifically on the anxietyproducing s ymptom—that is , the particular sexual dysfunction. S ucces sful use of hypnosis helps the gain control over the symptom that has been lowering self-es teem and disrupting ps ychological homeostasis. 2237 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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P atient cooperation is first obtained and encouraged during a s eries of nonhypnotic ses sions with the designed to develop a s ecure doctor–patient and a s ense of physical and ps ychological comfort on part of the patient and to es tablis h mutually desired treatment goals. During that time, the therapist the patient's capacity for the trance experience. T he nonhypnotic s ess ions als o permit the clinician to take a careful ps ychiatric history and do a mental status examination before beginning hypnotherapy. focus es on s ymptom removal and attitude alteration. In trance state, patients can entertain ideas incongruent their usual (nonhypnotized) perceptions of reality. are ins tructed in developing alternative means of with the anxiety-provoking situation (i.e., the sexual encounter). F or example, a woman with vaginis mus is given the posthypnotic s uggestion that she will feel no pain intercours e and will be able to relax the mus cles surrounding her vagina. If compliance with the is s ucces sful, s he can deal with the anxiety produced the sex act. S he is also taught new attitudes , s uch as entitled to sexual pleas ure. Under hypnos is , her fear or anger at sexual contact can be examined, and she how her emotions are expres sed by involuntary vaginal spas ms . S ome patients res pond particularly well to the us e of hypnosis and indirect sugges tion. T hese techniques them to retain a greater sense of control over their situation. T ypically, patients are ins tructed to conjure images and develop ideas antithetical to their dysfunctional respons es. F or example, a woman with 2238 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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arousal disorder may firs t agree to concentrate on that caus es her to salivate. S he is then told that, just as has made her mouth water by focusing on stimulating images, she can effect the lubricating respons e of her vagina by focus ing on images s he finds erotic or At the s ame time, the therapis t helps her deal with her anxieties about a positive sexual respons e. P atients also taught relaxing techniques to us e before sexual relations . With these methods to alleviate anxiety, the phys iological res pons es to s exual stimulation can more readily result in pleas urable excitation and discharge. Hypnos is may be added to a bas ic individual ps ychotherapy program to accelerate the impact of ps ychotherapeutic intervention.

B ehavior Therapy B ehavior therapists as sume that sexual dysfunction is learned, maladaptive behavior. B ehavioral approaches were initially des igned to treat phobias. In cas es of dysfunction, the therapist s ees the patient as phobic of sexual interaction. Us ing traditional techniques, the therapist sets up a hierarchy of anxiety-provoking situations for the patient, ranging from the leas t threatening to the mos t threatening. Mild anxiety may experienced at the thought of kis sing, and mass ive may be felt when imagining penile penetration. T he behavior therapis t helps the patient master the anxiety through a standard program of s ys tematic T he program is des igned to inhibit the learned anxious res ponse by encouraging behaviors antithetical to T he patient firs t deals with the least anxiety-producing situation in fantas y and progress es by steps to the anxiety-producing situation. Medication, hypnos is , or 2239 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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special training in deep muscle relaxation is sometimes us ed to help with the initial mas tery of anxiety. Ass ertivenes s training helps teach patients to express sexual needs openly and without fear. E xercis es in as sertivenes s are given in conjunction with sex and patients are encouraged both to make sexual and to refus e to comply with requests perceived as unreas onable. S exual exercis es may be pres cribed for patients to perform at home, and a hierarchy may be es tablis hed, starting with activities that proved mos t pleas urable and s ucces sful in the pas t. One treatment variation involves the participation of the patient's s exual partner in the des ens itization program. T he partner, rather than the therapist, pres ents the hierarchical items to the patient. In such situations , a cooperative partner is neces sary to help the patient gains made during treatment ses sions to s exual activity home. B ehavior therapy techniques have been particularly effective in treating women with s evere inhibition of excitement and orgas m when s uch feelings were accompanied by strong feelings of anxiety, anger, or disgust.

Group Therapy Methods of group therapy have been used to examine both intrapsychic and interpers onal problems in with sexual disorders . T he therapy group provides a support P.1931

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system for patients who feel ashamed, anxious , or about a particular sexual problem. It is a useful forum which to counteract sexual myths, correct and provide accurate information regarding sexual anatomy, physiology, and varieties of behavior. G roups for the treatment of sexual disorders can be organized in s everal ways . Members may all s hare the same problem, s uch as premature ejaculation; may all be of the same sex and have different sexual problems ; or groups may be compos ed of both men women who are experiencing different s exual G roup therapy may be an adjunct to other forms of therapy or the prime mode of treatment. G roups organized to cure a particular dysfunction us ually have behavioral approach. F or example, patients with anorgas mia may participate with others who have the same problem in a s hort-term, intensive group S exual his tories , feelings of inadequacy, and concerns about body image are shared. S pecific phys iological information, s ometimes with the aid of audiovisual materials , is presented to the group members . are given homework as signments (e.g., they may be instructed to mas turbate). A combination of group and group press ure helps s ome of the participants complete as signments they might otherwis e avoid. As short-term group process nears termination, members encouraged to talk about their experiences with their partners . G roups have als o been effective when compos ed of sexually dysfunctional married couples . T he group provides an opportunity to gather accurate information, provides consensual validation of individual 2241 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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and enhances self-es teem and s elf-acceptance. S uch techniques as role-playing and ps ychodrama may be in treatment. T hes e groups are not indicated for which one partner is uncooperative, has s evere or ps ychosis , or has a s trong repugnance for explicit audiovis ual materials or a s trong fear of groups.

Integrated S ex Therapy One of the most effective treatment modalities is the of sex therapy integrated with supportive, or ins ight-orientated ps ychotherapy. Adding ps ychodynamic conceptualizations to the behavioral techniques used to treat sexual dysfunctions allows treatment of patients with s ex dis orders ass ociated with other psychopathology. Also, this type of therapy is appropriate for patients with hypoactive desire Ins ight-oriented therapy helps them deal with problems their interpersonal relationships or intrapsychic conflicts that frequently are at the root of the problem. T he and dynamics that emerge in patients in analytically oriented s ex therapy are the same as thos e that ps ychoanalytic therapy—relevant dreams, fear of punis hment, aggress ive feelings , difficulty with trus ting the partner, fear of intimacy, oedipal feelings , and fear genital mutilation. T wo cas es follow that demonstrate s ome of these dynamics. A 34-year-old widow pres ented for therapy with a chief complaint of vaginis mus. Her marriage of 3 years , had been unconsummated, ended when her husband killed in a car accident. Approximately 1 year after s he 2242 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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her hus band, the patient became involved with a man. S he was very attracted to him and became highly aroused during their s exual encounters. Although s he could reach orgas m through manual or oral s timulation, she could not tolerate penetration. Although s he never cons idered therapy when s he was married, in s pite of husband's requests to do s o, she was motivated to help for her problem, because she felt s ure her lover leave his wife for her if they could share a more sexual experience. T he patient's vaginis mus res ulted partly from developmental conflicts. Her parents had been loving cons tricted people who came from different socioeconomic backgrounds . T heir values often and they frequently fought over their daughter as s he entered adoles cence. T he mother insis ted that she academic cours e in high s chool to prepare for college, whereas the father pushed a “more practical” business program. T he patient s ided with her mother and felt her father, whom s he had always perceived as cold, became more dis tant than before. S ome of her difficulties were due to unresolved oedipal problems ; both her husband and her lover were more 20 years older than s he was , and her lover (reflecting parental s ituation) was married to a woman who was succes sful than he was . In addition, s he had identified some of her mother's negative feelings about men. T he mother had once told the patient s he hoped that she would be spared marriage. V aginismus protected the patient from the clos eness with men that she wanted but unconsciously perceived as hurtful and dangerous . 2243 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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A 56-year-old man came for treatment because of an erectile disorder. In general, he functioned better in extramarital affairs than in his marriage. Although he his wife and cons idered her an attractive woman, he believed that she was not interes ted in s ex. He could achieve an erection with her, and he gradually s topped approaching her s exually. His wife felt deprived by their lack of s exual relations and frequently mas turbated. T he patient had been a sickly child, with a mother he described as devoted but s mothering. He remembered cuddling him in bed until he was 8 years old, and he that s he was inappropriately affectionate in general embarrass ed me”). At the s ame time, he remembered father as an earthy man and had a childhood of hearing his mother ask his father, “How could you, could you? ” T he patient believed it had been his res ponse to a sexual overture or act. In part, his derived from his unconscious oedipal ass ociations to wife, which made her taboo for him as a s ex partner. women to whom he res ponded had to be blatantly and s ignal their acceptance of him before he would risk advance. T herapy involved both individual sess ions the patient and joint s es sions with him and his wife. C ommunication, which had been s trained partly of the sexual distance between them, was encouraged, and a behavioral approach was us ed to reestablish phys ical interaction. Individual work focused on his ps ychological problems. T he dynamics and the emotional difficulties evident in these vignettes are seen every day by psychiatrists . P sychiatrists can readily abs orb the techniques of s ex therapy into their treatment armamentarium, just as 2244 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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have modified and absorbed any number of s pecialized techniques, from class ic analytical dynamic the us e of pharmacotherapy, group therapy and behavioral and other directive modalities . T he combined approach of individual and s ex therapy is by the general ps ychiatris t, who carefully judges the optimal timing of s ex therapy and the ability of patients tolerate the directive approach that focuses on their difficulties .

B iologic al Treatment Methods B iological treatments , including pharmacotherapy and surgery, have applications in s pecific cases of sexual disorder. Advances in biological treatment methods , particularly pharmacological methods of treating sexual dysfunction have s ignificantly augmented the catalogue P.1932 of therapeutic approaches . Most of the recent involve male s exual dys functions . C urrent s tudies are under way to tes t pharmacological treatment of s exual dysfunctions in women.

Pharmac otherapy A variety of drugs have been explored in the treatment sexual dysfunction. T he major new medications are oxide enhancers such as s ildenafil (V iagra); oral prostaglandin (V as omax); alprostadil (C averject), an injectable phentolamine; and a transurethral alpros tadil (MUS E ), all us ed in the treatment of erectile dis order.

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Nitric Oxide E nhanc ers Nitric oxide enhancers facilitate the inflow of blood to penis necess ary for an erection. T he phys iological mechanism of penile erection involves release of nitric oxide in the corpus cavernosum during sexual Nitric oxide activates the enzyme guanylate cyclase, increases cyclic guanos ine monophos phate and produces smooth muscle relaxation in the corpus cavernos um that allows the penile ves sels to dilate and admit blood. T he firs t drug developed, s ildenafil, the effect of nitric oxide by inhibiting the enzyme that degrades cyclic guanosine monophos phate. T hus , sildenafil augments the natural proces s involved in and maintaining an erection during s exual stimulation. drug takes effect approximately 1 hour after inges tion, its effect can last up to 4 hours . S ildenafil has no effect the abs ence of s exual s timulation. T he most common adverse events ass ociated with sildenafil are headaches, flus hing, and dys pepsia. sildenafil users s ee things in a blue tint for several after taking the medication; becaus e of this, airline have been prohibited from taking the drug so that this visual artifact does not interfere with s afe landings. T he of sildenafil is contraindicated for people taking organic nitrates. T he concomitant action of the two drugs can res ult in large, s udden, and s ometimes fatal drops in systemic blood press ure. T he U.S . F ood and Drug Administration (F DA) has posted 130 deaths in which sildenafil was listed as an as sociated medication and advis es caution in prescribing s ildenafil to men with a recent (6-month) his tory of myocardial infarction, life-threatening arrhythmia, significant hypotension or 2246 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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hypertens ion, cardiac failure, angina, or retinitis pigmentos a. However, the F DA has reiterated that it is safe drug. S ildenafil is not effective in all cases of dysfunction. It fails to produce an erection rigid enough penetration in approximately 50 percent of men who had radical prostate s urgery or in thos e with longstanding, ins ulin-dependent diabetes. It is also in certain cases of nerve damage. T wo new nitric oxide enhancers similar to sildenafil— vardenafil (Levitra) and tadalafil (C ialis )—have been developed. T adalafil has an effective therapeutic of 36 hours compared to s ildenafil and vardenafil, are effective for approximately 4 hours . Oral phentolamine has proved effective as a potency enhancer in men with minimal erectile dysfunction. It prove useful for men with cardiac problems , as contraindicated for men using organic nitrates, but it is currently approved by the F DA. Apomorphine is also tes ted as an oral remedy for erectile dys function.

A lpros tadil In contras t to the oral medications, injectable and transurethral alpros tadil act locally on the penis and produce erections in the abs ence of s exual stimulation. Alprostadil contains a naturally occurring form of prostaglandin E . P ros taglandins are composed of hydroxy fatty acids , and they have wide biological influences. Although some pros taglandins are vasoconstrictive, pros taglandin E 1 , found in alprostadil, powerful vas odilating agent, especially in local vascular areas, such as the corpus cavernos um of the penis. drug caus es direct s mooth mus cle relaxation of penile 2247 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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vess els and erectile tiss ue; this reaction lowers the res is tance of the corpus and significantly increas es flow to the penis. T he firm erection produced within 2 to minutes by increas ed blood flow may last as long as 1 hour. T reatment consists of the patient's self-injection alpros tadil into the corpus before coitus. T his technique easily taught and relatively painles s. Infrequent effects include penile bruising and changes in liver function test res ults , which are readily reversible when man s tops the injections. However, poss ible hazardous sequelae exist, including priapism and sclerosis of the small veins of the penis. Another s ubs tance being tried vasoactive intestinal polypeptide (V IP ). Intracavernous injection of V IP causes erection and has a parasympathomimetic effect. S ome res earchers that this substance, which has been found in the hypothalamus and the female genital organs, is the es sential factor in male and female arous al. In E urope, phenoxybenzamine (Dibenzyline) is us ed to produce erections by injection into the penis. S erious adverse effects include priapis m and pain accompanying the injection, and the drug is not allowed as a therapy in United S tates . Alprostadil can also be delivered via the urethra, eliminating the need for s elf-injection. S ome men prefer the local, nonsystemic effects of alpros tadil to oral sildenafil; others prefer s ildenafil becaus e it s eems like a nonpharmacologically aided respons e to them their partners. A small trial found a topical cream in alleviating erectile dysfunction. T he cream cons ists three vas oactive s ubs tances that are a mixture of ergot alkaloids. Alpros tadil is a us eful treatment for patients 2248 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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whom nitric oxide enhancers are contraindicated (e.g., patients who are taking nitrate-containing medication). is also of us e in patients who do not tolerate the side effects of other drugs. T he pharmacological treatments des cribed above are us eful in treatment of erectile dys function of various caus es: psychogenic, neurogenic, arterial insufficiency, venous leakage, and mixed. T he following cas e demonstrates the use of pharmacotherapy to treat dysfunction of ps ychogenic origin. Mr. B . and Ms. C . (his fiancée) presented for sex with Mr. B . having experienced erectile dys function for months, as well as a lifelong history of premature ejaculation. Mr. B . was a 42-year-old profes sional, and C . was a 38-year-old corporate executive. S he had been married; it was to be his s econd marriage. Mr. B .'s s exual his tory was remarkable for a late first (age 25) and a general s exual ins ecurity that with his profes sional confidence and social poise. Ms. was sexually res ponsive, in s pite of a history of anxiety attacks for which she had been treated in the pas t. early sexual activity together had been frequent and satis fying to both, in s pite of his prematurity. After a few months, however, s he began to complain about both premature ejaculation and the secrecy of their relations hip. Although Mr. B . was legally separated they became involved, he was worried about divorce negotiations if his spouse learned about his new relations hip. T reatment revealed that he found the in their relations hip exciting. T he two were treated with integrated s ex therapy, a 2249 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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combination of behavioral and insight-oriented techniques, and made s ubs tantial progress . T hey succes sfully controlled the premature ejaculation by practicing the s queeze technique (i.e., forcibly the coronal ridge of the penis P.1933 before ejaculation to increas e the threshold of penile sens itivity). In genital-cares sing s ess ions. Mr. B .'s returned, and he could maintain a good erection to with manual and oral s timulation. However, he to los e his erection when he attempted vaginal penetration. It was decided to s upplement with intracavernos al injections of alpros tadil (s ildenafil not yet available). Ms. C . was pres ent when he was instructed in the injection technique and s upported the proces s. Mr. B . was delighted with the res ults, and, month of pharmacologically ass is ted coitus , he succes sfully achieved penetration without ass is tance. C urrently, he has coitus once a week, with occasional of s ildenafil rather than intracavernos al injection when is feeling s tres sed. T he availability of a medication to his erectile problem significantly relieves his anxiety. E rectile dysfunction of psychological or mixed origin should not be treated by medication alone, even the dysfunction can be corrected pharmacologically. drugs should be used in conjunction with, not as a replacement for, s ex therapy. In s ome cas es, erectile dysfunction serves as a defens e against uncons cious conflicts that mus t be faced when the s exual symptom removed as result of medication. In some cas es , the 2250 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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patient deals with his conflicts by s imply not us ing the medications prescribed for his erectile problem. Also, patients in long-standing or marital relations hips the cooperation of their partners for this treatment to be effective. Although most women are very to their partner's des ire for treatment, several concerns occur with some frequency: the element of romance is important part of sexual interaction for many women, pharmacological as sistance of erections may eliminate that s ens e of romance; the woman, or the couple, may bemoan the lack of s pontaneity when part of the s ex act; and s ome women feel deprived of feedback about their des irability. J oint s es sions help couple cope with thes e is sues .

S ildenafil Us e in Women T he phys ical s ign of s exual excitement in women is lubrication. T hat lubrication is a trans udate believed to res ult from increased vasoconges tion of the extens ive capillary net in the vaginal walls. T he same mechanism—vasoconges tion—res ults in erection in man. R es earchers believe that sildenafil may facilitate blood flow in women jus t as it does in men and, thus , women with inhibited excitement of ps ychological or phys iological origin a pharmacological remedy for their dysfunction. S ome reports suggest that women find it preferable to apply sildenafil in a cream base to the labia, and vagina. However, as in men, treatment may need to be combined with psychological modalities to be effective. R ecognition of sexual excitement may be more for women than it is for men. F or example, in s tudies of 2251 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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res ponse to pornography, men and women underwent phys iological measurements of excitement after visual stimuli. In these studies, men were more accurate in correlating their s ubjective sense of arous al (i.e., than were women (i.e., lubrication).

Other Pharmac ologic al Agents Numerous other pharmacological agents have been to cure the various sexual disorders. Intravenous methohexital sodium (B revital) has been us ed in desensitization therapy. Antianxiety agents may have some application in tense patients, although these can also interfere with the sexual res ponse. T he side of antidepress ants, particularly the S S R Is and tricyclic drugs, which include delayed orgasm, have been us ed prolong the s exual respons e in patients with premature ejaculation. T his approach is particularly useful in refractory to behavioral techniques or who may have phys iologically determined premature ejaculation. T he of antidepres sants has been advocated in the patients who are phobic of sex and in those with a posttraumatic stress disorder (P T S D) after rape. T he taking s uch medications must be carefully weighed agains t their poss ible benefits. B romocriptine (P arlodel) us ed in the treatment of hyperprolactinemia, which is frequently as sociated with hypogonadis m. S uch cases first worked up to rule out pituitary tumors. a dopamine agonist, may improve sexual function impaired by hyperprolactinemia. Y ohimbine is an α-adrenergic receptor antagonis t that may cause dilation of the penile artery and improve erections . R ecreational drugs, including cocaine, 2252 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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amphetamines, alcohol, and cannabis , are cons idered enhancers of sexual performance. Although they may provide the us er with an initial benefit because of their tranquilizing, disinhibiting, or mood-elevating effects, cons istent or prolonged use of any of these substances impairs s exual functioning. G ins eng has been reported to have androgenic effects. One report described the case of a mother who large amounts of gins eng during her pregnancy, in androgenization of the neonate, who was born with pubic hair and enlarged testes. Other drugs that have been us ed by women to alleviate arousal dysfunction include oral phentolamine, topical prostaglandin E , oral oxytocin, ginkgo biloba, and ps ychos timulants , including caffeine. Many of these have not been approved for treatment of female sexual dysfunction and must be prescribed with caution. Dopaminergic agents have been reported to increas e libido and improve sex function. T hos e drugs include Ldopa, a dopamine precurs or, and bromocriptine, a dopamine agonis t. T he antidepres sant bupropion has dopaminergic effects and has increas ed sex drive in patients. S elegiline, an MAOI, is s elective for MAO B dopaminergic. It improves s exual functioning in older persons.

Hormone Therapy Androgens increas e the sex drive in women and in with low testosterone concentrations . W omen may experience virilizing effects , s ome of which are (e.g., deepening of the voice). In men, prolonged use 2253 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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androgens may produce hypertens ion and prostatic enlargement. T estosterone is most effective when parenterally; however, effective transdermal are available. Oral preparations are ass ociated with increased ris k of hepatotoxicity. G onadotrophin-releas ing hormone (G nR H), also known luteinizing hormone -re le as ing hormone (LHR H), the releas e of luteinizing hormone, which increas es tes tos terone s ecretion in both s exes. G nR H is used as inhalant in E urope. It s timulates des ire and increas es potency. B ecause G nR H is released normally in a fas hion, portable infus ion pumps have been developed that s imulate pulsatile delivery. An excess of G nR H suppress es estrogen and tes tos terone; thus , the therapeutic us e of G nR H is limited by a narrow window. Women who use estrogens for replacement therapy or contraception may report decreas ed libido; in s uch combined preparation of es trogen and testos terone been used effectively. E strogen its elf prevents thinning the vaginal mucous membrane and facilitates T es tos terone is given to women around the world in form of tablets, implants, patches , and creams. In the United S tates , methyltestosterone pills and creams are the primary methods of adminis tration. T es tos terone is primarily adminis tered to (occurring surgically or naturally) women, but deficiency als o exis ts in premenopaus al women. P.1934

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Mrs. M. presented for therapy alone with a chief of pain on intercours e dating from the onset of menopaus e 14 months before coming for treatment. husband knew of her visit but did not accompany her, he was away on one of many routine and frequent business trips. S exual intercours e was infrequent becaus e of his travel s chedule, but their s ex play was varied and, menopaus e, Mrs. M. had enjoyed sex. Mrs. M. found sexual interactions with her hus band gratifying. S he strong libido and would masturbate when Mr. M. was away. Mrs. M. was on oral hormone replacement therapy, had helped but had not eliminated the pain she had intercours e. In cons ultation with her gynecologis t, the occasional us e of hormone cream was added to her treatment regimen. Additionally, s he was instructed to vaginal dilators routinely when Mr. M. was away. T his not for purposes of masturbation, which for her clitoral s timulation, but for routine stretching of the vagina. Nonhormonal vaginal cream was prescribed for the couple to use with intercourse. T he combination of oral hormone replacement therapy, vaginal creams, the routine us e of vaginal dilators served to eliminate M.'s pain. S he was diagnosed with dyspareunia, type. P heromones are sexual s cents that are found in and may be present in humans. T hey produce dramatic sex-seeking behavioral patterns in animals (e.g., male following female deer in estrus , mounting behavior in primates). Human pheromones are believed to be acting fatty acids pres ent in vaginal s ecretions and 2255 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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sweat. In one s tudy, women were cons is tently more attracted to items impregnated with a chemical derived from male sweat (α-andros tenol) than to control items . another study, the sweat of women was preserved in underarm pads they changed daily, and the date each was worn was correlated with the women's menstrual cycle. A second group of women was as ked to smell pads as they were rubbed above their upper lips , knowing what they were and recognizing no s cent but alcohol pres ervative us ed on the pads . Depending on whether they were exposed to pads from the early or part of the first group's (the wearers) menstrual cycle, second group (the s niffers ) saw their own menstrual shortened or lengthened. T his area is still being res earched.

A ntiandrogens and A nties trogens E strogen and proges terone are antiandrogens that been used to treat compuls ive s exual behavior in men, us ually in s ex offenders. Medroxyprogesterone acetate (Depo-P rovera), us ed primarily as a contraceptive in women, inhibits the secretion of gonadotrophins. It is us ed in men with compuls ive s exual behavior to reduce libido by tes tos terone levels. C yproterone acetate is a strong antiandrogen used in E urope to treat sex offenders. At dosages of 100 to 200 mg a day, the sex drive within 2 weeks . T amoxifen (Nolvadex) is used to treat breast cancer has antiestrogenic properties . In some women, libido may result from the unopposed testosterone C lomiphene (C lomid) is an ovulatory s timulant us ed in 2256 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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women with ovulatory mens trual cycles des iring pregnancy. C lomiphene increases release of pituitary gonadotrophins , and s ome women may report libido. Neither of these drugs, however, is used as a treatment for decreased libido in women.

Mec hanic al Treatment Approac hes S teal S yndrome In male patients with arteriosclerosis (especially of the distal aorta, known as L e riche's s yndrome ), the be los t during active pelvic thrus ting. T he need for increased blood in the gluteal mus cles and others by the ilial or hypogas tric arteries takes blood away from the pudendal artery and, thus, interferes with blood flow. R elief may be obtained by decreas ing thrusting, which is also aided by the woman-superior position.

Vac uum P ump V acuum pumps are mechanical devices that patients without vas cular disease can us e to obtain erections. blood drawn into the penis after the creation of the vacuum is kept there by a ring placed around the base the penis . T his device has no advers e effects, but it is cumbersome, and partners must be willing to accept its us e. S ome women complain that the penis is redder cooler than when erection is produced by natural circums tances , and they find the process and the res ult objectionable. A vacuum pump with the marketing name E ros was devis ed for women to precipitate a clitoral erection. It 2257 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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works s imilarly to the vacuum pump used to create erections in men, although no band is placed around clitoris once erection is obtained. T he pump is not neces sary for intercours e to occur; it was devised to enhance female excitement, but its effectivenes s has been s tudied rigorously.

S urgic al Treatment Male P ros thes es S urgical treatment is infrequently advocated, but improved penile prosthetic devices are available for with inadequate erectile res ponse who are res is tant to other treatment methods or who have medically deficiencies. T here are two main types of prosthesis: a semirigid rod pros thesis that produces a permanent erection that can be positioned close to the body for concealment and an inflatable type that is implanted its own res ervoir and pump for inflation and deflation. latter type is des igned to mimic normal phys iological functioning. P lacing a penile prosthes is in a man who lost the ability to ejaculate or to have an orgas m as a of medical caus es will not res tore those functions. Men with pros thetic devices have generally reported satis faction with their s ubs equent s exual functioning, their wives report much less satis faction. P res urgical couns eling is strongly recommended so that the couple has a realistic expectation of what the pros thes is can their s ex lives . P os tsurgical counseling may als o be neces sary to help the couple adapt to their ability to have intercourse. T hey may experience a high level of anxiety if their sex life had been inactive for a prolonged period before surgery. P ros thetic devices 2258 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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been ass ociated with severe advers e effects, including perforation, infection, urinary retention, and persistent pain. S ome s urgeons are attempting revascularization of the penis as a direct approach to treating erectile res ulting from vascular disorders . S uch s urgical are indicated in patients with corporal s hunts that allow normally entrapped blood to leak from the corporal spaces, leading to inadequate erections (steal Limited reports exis t of prolonged success with the technique. E ndarterectomy can be of benefit if occlusive dis eas e is respons ible for the erectile dysfunction. Another medical treatment being s tudied for erectile disorders is electros timulation at the base of the penis . Initial reports indicate minimal phys ical discomfort in patients receiving this therapy. However, respons e to treatment is incons istent, and a problem exis ts in terms maintaining erections . At the present time, the seems to have no benefits.

F emale P roc edures S urgical approaches to female dysfunctions include hymenectomy in the case of dys pareunia in an unconsummated P.1935 marriage, vaginoplas ty in multiparous women complaining of les sened vaginal sens ations, or freeing clitoral adhesions in women with inhibited excitement. S uch s urgical treatments have not been carefully 2259 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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and s hould be considered cautious ly.

Outc ome Demons trating the effectiveness of the varieties of sex therapy is just as difficult as ass ess ing the outpatient ps ychotherapy in treating other problems . As with other dis orders, the more severe the ps ychopathology ass ociated with a problem of long duration, the more adverse the outcome is likely to be. Masters and J ohnson first reported positive res ults for behavioral treatment approach in 1970. T hey studied failure rates of their patients (defined as failure to revers al of the basic s ymptom of the presenting dysfunction). T hey compared initial failure rates with 5year follow-up findings for the same couples. Although some have criticized their definition of the percentage presumed success es , other s tudies have confirmed the effectivenes s of their approach. T he most difficult treatment cas es involve couples with severe marital discord. C ases involving problems of intimacy, excess ive dependency, or excess ive hostility also complex. Other challenges are pos ed by patients impulse dis orders, unres olved homos exual conflicts , or fetishis tic defens es. P atients phobic of sex also pres ent treatment difficulties , as do patients diagnos ed with lifelong dys functions . Des ire disorders are particularly difficult to treat. T hey require longer, more intensive therapy than s ome other disorders , and their outcomes very variable. When behavioral approaches are used, empirical that are s upposed to predict outcome are more easily 2260 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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is olated. Using these criteria, for instance, couples who regularly practice as signed exercises appear to have a much greater likelihood of s ucces sful outcome than do more resis tant couples or those whos e interaction sadomas ochis tic or depres sive features or blame and projection. F lexibility of attitude is als o a positive prognostic factor. Overall, younger couples to complete s ex therapy more often than older couples . C ouples whos e interactional difficulties center on their problems , such as inhibition, frus tration, or fear of performance failure, are also likely to respond well to therapy. In general, methods that have proved effective singly combination include training in behavioral s exual skills, systematic desensitization, directive marital counseling, traditional ps ychodynamic approaches, group therapy, and pharmacotherapy. Although most prefer to treat a couple for sexual dysfunctions, treatment of individual persons has als o been s ucces sful. T he frequency of sess ions is not a significant factor in treatment T hus, whether patients have intens ive daily therapy period of 2 weeks , weekly therapy, or biweekly therapy appears to have little effect on the outcome of Als o, the use of one therapist to treat a couple instead dual-sex cotherapy team is nearly as effective and more practical. P atients s een today are frequently older when they present for therapy, more informed about s ex, and likely to have dis orders of mixed etiology than were seen in the mid-1970s . Moreover, numerous new biological treatments are now available for into s ex therapy treatment programs . T oday, a 2261 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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treatment regimen and an eclectic approach to s exual disorders will res ult in a favorable outcome in the great majority of cas es.

S UG G E S TE D C R OS S Homosexuality is discus sed in S ection 18.1b, are dis cuss ed in S ection 18.2, and gender identity disorders are dis cus sed in S ection 18.3. S exual covered in S ection 18.4. T he neuropsychological and neurops ychiatric as pects of HIV infection are covered S ection 2.8. C ouples therapy is discus sed in S ection and biological and other pharmacological therapies are discuss ed in C hapter 31. T he phys ical and s exual children, including inces t, is covered in S ection 49.3.

R E F E R E NC E S Araoz DL: Uses of hypnos is in the treatment of ps ychogenic s exual dys functions . P s ychiatr Ann. 1986;16:102. Ass alian P , Margoles e H: T reatment of induced s ide effects. J S e x Marital T he r. 1996;22:3. B rady J P : B ehavior therapy and s ex therapy. Am J P s ychiatry. 1976;133:896. C hes sick R D: T hirty unres olved ps ychodynamic questions pertaining to feminine ps ychology. Am J P s ychothe r. 1988;42:86. *Delgardo P L, McG auey C A, Moreno F A, Laukes C , G elenberg AJ : T reatment s trategies for depress ion 2262 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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sexual dys function. J C lin P s ychiatry. 1999;17:22. E llis A. S tudie s in the P s ychology of S ex. New Y ork: P res ton Hous e; 1936. F ederman DD: P erspective: T hree facets of sexual differentiation. N E ngl J Me d. 2004;350:323–324. G oldstein I, Lue T , P adma-Nathatan H, R os en R , WD, W icker P A: T he sildenafil study group, oral in the treatment of erectile dys function. N E ngl J 1996;338:1397. Herman J , LoP iccolo J : C linical outcome of sex Arch G e n P s ychiatry. 1983;40:443. K egeles S M, Adler NE , Irwin C E : S exually active adoles cents and condoms : C hanges over one year knowledge, attitudes and use. Am J P ublic He alth. 1988;78:460. K oppelman M, P arry B L, Hamilton J A, Alogna S W , Loreaux P L: E ffect of bromocriptine on affect and in hyperprolactinemia. Am J P s ychiatry. K oren G : Maternal gins eng us e as sociated with androgenization. J AMA. 1990;264:2866. K rafft-E bing R . P s ychopathia S exual. Munich: S eitz; 1984. *Laughman E , G agnon J , Michael R , Michaels S . 2263 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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Ame rica. C hicago: University of C hicago P res s; Leitenberg H, Detzer M, S rebnik D: G ender in masturbation and the relation of masturbation experience in preadoles cence and/or early to sexual behavior and s exual adjus tment in young adulthood. Arch S ex B ehav. 1993;22:87. Linet OI, Ogrinc F G (for the Alpros tadil S tudy E fficacy and safety of intracavernosal alpros tadil in with erectile dysfunction. N E ngl J Me d. Loosen P T , P urdon S E , P avlou S N: E ffects on modulation of gonadal function in men with gonadotropin-releas ing hormone antagonis ts . Am J P s ychiatry. 1994;151:271. MacLaughlin DT , Donahoe P K : Mechanisms of S ex determination and differentiation. N E ngl J Me d. 2004;350:369. *Masters W H, J ohns on V E . Human S e xual B os ton: Little, B rown; 1970. *Masters W H, J ohns on V E . Human S e xual B os ton: Little, B rown; 1970. P adma-Nathan H, Hells trom WJ G , K ais er F E , Lue T F , Nolten W E , Norwood P C , P eters on C A, R , T am P Y , P lace V A, G es undheit N (for the Urethral S ystem for E rection [MUS E ] S tudy G roup): T reatment of men with erectile dys function with 2264 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/18.1a.htm

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transurethral alpros tadil. N E ngl J Me d. 1997;336:1. *P urnine DM, C arey MP , J orgensen R S : G ender differences regarding preferences for s pecific heteros exual practices . J S e x Marital T he r. R hoden E L, Morgentaler A: R is ks of testosteronereplacement therapy and recommendations for monitoring. N E ngl J Me d. 2004;350:482. *R iley AJ : Life-long absence of sexual drive in a as sociated with 5-dihydrotes tos terone deficiency. J Marital T he r. 1999;25:13. *R osen R C , Lane R M, Menza M: E ffects of S S R Is function: A critical review. J C lin P s ychopharmacol. 1999;19:67. *S adock V A. T he treatment of ps ychos exual dysfunctions: An overview. In: G rins poon L, ed. P s ychiatry 1982. T he Ame rican P s ychiatric Annual R e vie w. W ashington, DC : American P res s; 1982. S adock V A. G roup ps ychotherapy of ps ychos exual dysfunctions. In: K aplan HI, S adock B J , eds . C omprehe ns ive G roup P s ychothe rapy. B altimore: Williams & W ilkins ; 1983:286. S eagraves R T , S eagraves K B : Human s exuality and aging. J S e x E duc T he r. 1995;21:88.

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S emans J H: P remature ejaculation: A new S outh Me d J . 1956;49:353. S hrainer-E ngel P , S chiavi R : Lifetime individuals with low s exual des ire. J Ne rv Ment Dis . 1986;174:646. S tein DJ , Hollander E , Anthony DT , S chneier F R : S erotonergic medications for sexual addictions, and paraphilias. J C lin P s ychiatry. 1992;53:267. S ternbach H: Age as sociated tes tos terone decline in men: C linical is sues for ps ychiatry. Am J P s ychiatry. 1998;155:10. T hase M, R eynolds C , G lanz L, J ennings J R , S weitz K upper DJ , F rank E : Nocturnal penile tumes cence in depres sed men. Am J P s ychiatry. 1987;144:89. Waldinger MD, Hengeveld W H, Zwinderman A, B : E ffect of S S R I antidepress ants on ejaculation: A double-blind, randomized, placebo-controlled study with fluoxetine, fluvoxamine, paroxetine and J C lin P s ychopharmacol. 1998;189:274. Wiley D, B orts W M: S exuality and aging—us ual and succes sful. J G e rontol. 1996;51:22.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > 19 - E ating Disorder

19 E ating Dis orders Arnold E . Anders en M.D J oel Yager M.D. E ating dis orders are disorders of eating behavior primarily from an overvaluation of the desirability of weight loss that result in functional medical, and s ocial impairment. T hese dis orders repres ent dysfunctional, emotional, cognitive, and behavioral strategies for coping with is sues in development, mood disturbances , interpersonal relations hips, and conflicts, becoming s elf-sustaining illnes ses , us ually in context of overvalued beliefs internalized from sociocultural norms promoting the benefits of thinnes s shape change. Des pite their often innocuous, culturally syntonic origins, eating disorders have undoubtedly present in various forms for thousands of years , but prevalence has increased s ubs tantially since the T hey now present as common serious clinical E ating dis orders have some of the highest rates of premature mortality in ps ychiatry—up to 19 percent within 20 years of ons et among those initially requiring hospitalization. T he syndrome bulimia nervosa was firs t described as part of the eating disorders spectrum only 1979, but hindsight s uggests it has been present as anorexia nervosa, often occurring below the level of common recognition becaus e of the lack of vis ible 2267 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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starvation. T he official recognition of binge-eating is even more recent, although forms of compulsive overeating have been recognized throughout his tory. A few principles concerning eating disorders will guide discuss ion. F irst, eating dis orders are syndromes, of symptoms that have a fairly predictable cours e and sometimes well-es tablis hed treatments, but they are unders tood at the fundamental level of a specific etiology. S econd, as with some other ps ychiatric diagnosing eating disorders involves imposing limits on what are dimens ional features , such as weight loss and attitudes toward weight and s hape. Although eating disorders as formally defined by the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ) afflict approximately 3 to 5 percent of the female population approximately one-third as many men, s ubs yndromal forms of eating disorders are widely present and caus e great distress , es pecially in the quality of life of who struggle to achieve the widespread overvalued for thinnes s in women and lean muscularity in men. F urthermore, eating dis orders are culture-bound with varying prevalence according to s ocial norms in different cultures and countries—a vas tly different situation from schizophrenia or manic-depres sive whos e rates of prevalence are ess entially uniform the world. T hird, eating disorders rarely pres ent as sole diagnostic entities ; they are almos t always by significant comorbid disorders on Axis I and Axis II. C linicians have made rapid progress in earlier of eating disorders , and several evidence-based treatments have been validated. F amilies , teachers , 2268 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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athletic and dance coaches, and clinicians are all more aware of thes e disorders than they were before the 1980s when anorexia nervosa firs t became a media and the syndrome of bulimia nervos a was just widely publicized. B efore this time, anorexia nervosa, es pecially, was cons idered a rare and obs cure times dismiss ed as a willful and voluntary fad, afflicting upper-clas s white girls . Anorexia nervosa before 1980 only slowly recognized, if at all, usually after extensive “rule-out” medical inves tigations. T he death of the K aren C arpenter in 1983 represents a watershed in awarenes s, as her death from anorexia nervosa on public cons ciousnes s the presence and serious ness the disorder. 

DE F INIT IONS

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NOS OLOG Y

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E P IDE MIOLOG Y

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E T IOLOG Y

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V ULNE R AB ILIT Y : P R E DIS P OS ING F AC T OR S

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P R E C IP IT AT ING F AC T OR S

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S US T AINING F AC T OR S

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INIT IAT ING AND S US T AINING

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DIAG NOS IS AND C LINIC AL F E AT UR E S

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DIAG NOS T IC C OMOR B IDIT IE S

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LAB OR AT OR Y E XAMINAT ION AND C LINIC AL P AT HOLOG Y DIF F E R E NT IAL DIAG NOS IS 2269

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C OUR S E AND P R OG NOS IS

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T R E AT ME NT OF E AT ING DIS OR DE R S

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S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > DE F INIT ION

DE FINITIONS P art of "19 - E ating Dis orders " T he two major categories of eating dis orders are nervos a and bulimia nervos a, but partial and syndromes abound, and transitions from one to form of these dis orders —for example, from anorexia nervos a to bulimia nervosa, or full syndromes to subclinical s yndromes—is common. T he term anorexia nervos a is derived from the G reek for “loss of appetite” and a Latin word implying nervous origin. T he words us ed to label anorexia nervosa, and eating dis orders in general, vary greatly from language language, with rich implications . T he G erman term for anorexia nervosa, puberte ts maigres ucht (thinness of adoles cents), captures only a portion of the dis order but, in some ways, is a clearer term linguis tically than anorexia nervosa, the term now embedded in the language. T he F rench have called anorexia nervosa anorexie mentale (mental anorexia) and anorexie (hysterical anorexia) and define eating disorders as “disorders of alimentation.” Anorexia nervosa is a syndrome characterized by three 2270 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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es sential criteria. T he first is a s elf-induced s tarvation significant degree—a be havior. T he s econd is a drive for thinness and/or a morbid fear of fatness —a ps ychopathology. (T he es sential psychopathology tightly linked to overvalued beliefs , primarily the overvaluation of thinnes s. T he drive for thinnes s ps ychopathological motif has been emphas ized more Americans , beginning with Hilde B ruch, whereas the morbid fear of fatness , the phobic avoidance of normal weight, has been emphasized more by the B ritish.) T he third criterion is the presence of medical s igns and symptoms resulting from s tarvation—a phys iological s ymptomatology. (In the pas t, amenorrhea for three or more months consecutively was s pecifically required. A sounder approach is to document significant general medical symptomatology secondary to s tarvation rather than only reproductive hormone abnormality). Anorexia nervos a is often, but not always, ass ociated with disturbances of body image, the perception that one is distress ingly large des pite obvious medical starvation. distortion of body image is dis turbing when pres ent, but not pathognomic, invariable, or required for diagnos is . P.2003 more s ummary integrative transdiagnos tic theme in all anorexia nervosa subtypes and subsyndromal variants the highly disproportionate emphas is placed on as a vital s ource, s ometimes the only source, of selfes teem, with weight, and to a les ser degree, shape, becoming the overriding and consuming day-long preoccupation of thoughts , mood, and behaviors . T wo s ubtypes of anorexia nervosa exis t with much 2271 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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and frequent transitions between them, especially from the res tricting subtype to the binge and/or purge In the class ic his torical form of anorexia nervosa, approximately 50 percent of cas es , food intake is res tricted (us ually with attempts to cons ume fewer than 300 to 500 calories per day and no fat grams ), and the patient may be relentles sly and compuls ively with overus e athletic injuries. In the second s ubtype, and/or purge, patients alternate attempts at rigorous dieting with intermittent binge or purge episodes , with the binges , if pres ent, being either s ubjective (more the patient intended, or due to social press ure, but not enormous) or objective. P urging repres ents a compens ation for the unwanted calories , most often accomplis hed by self-induced vomiting, frequently by laxative abuse, les s frequently by diuretics, and occasionally with emetics. S ometimes repetitive occurs without prior binge eating, after ingesting only relatively few calories. T he term bulimia nervos a derives from the terms for hunger” in G reek and “nervous involvement” in Latin. B ulimia nervosa repres ents in many ways a failed at anorexia nervos a, sharing the goal of becoming very thin, but occurring in an individual less able to s ustain prolonged semi-starvation or s evere hunger as cons istently as clas sic res tricting anorexia nervos a T hese eating binges provoke panic as individuals feel their eating has been out of control. T hey experience significant panic-laden conflict between their phys iologically driven eating behavior from hunger, on one hand, and the deep-seated desire to be thin on the other hand, with the anxiety heightened by the 2272 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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morbid fear of fatnes s. T he unwanted binges, creating ps ychological and phys ical distress , in turn lead to secondary attempts to avoid the feared weight gain by variety of compens atory behaviors, s uch as purging or excess ive exercise. Later, the binges tend to be more typically initiated by dysphoria and often become intractable at that point. Occasionally, a bulimia patient begins directly by purging, often after media information describes purging in detail, s ometimes after inappropriate teaching efforts focusing on s ymptoms , after receiving a “tip” from a friend s uggesting that purging is a quick way to lose weight. B inge epis odes (defined as repeated epis odes of overeating large quantities of food that is generally of dense caloric content rapidly and us ually privately, to guilt, anxiety about becoming fat, low s elf-es teem, frequently gas tric distress ) are behaviors shared several eating disorder s ubtypes . R egular binge and/or purge epis odes may occur with low body weight (in case it is class ified as a subtype of anorexia nervos a), normal weight individuals (mos t typically bulimia or in overweight persons as manifes tations of bingedisorder (without any compens ation). In bulimia compens ation for binge epis odes is carried out mos t commonly by purging through self-induced vomiting or laxative abuse (approximately 80 percent of cases ), a s econd subtype of bulimia nervosa (20 percent), it is carried out by “other compens ation”—us ually even stricter dieting or heroic exercise or both. P atients who binge eat but do not compens ate in any after binge eating are often medically overweight or obese, generally somewhat older (30s to 50s), and are 2273 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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likely to be male as female. T hes e patients meet binge-eating dis order, an eating dis order subtype currently considered a res earch diagnos is within eating dis orders not otherwise specified, a category logically cons tituting a third subtype of bulimia nervosa, not a res idual or “atypical” category. In general, presenting with bulimia nervosa for s pecialized differ from thos e untreated in the community, where of nonpurging s yndromes equal thos e of the purging forms. T he term binge , ess ential for the diagnosis of bingesyndromes, pres ents challenges in definition, although these may be more pertinent for res earch purposes for actual clinical practice. T he exact dis tinction s ubje ctive binge (eating more than one ostens ibly or physiologically requires, even if a s mall amount) and objective binge (eating what anyone would cons ider to abnormally large amounts [often 2,000 to 5,000 food that is usually sweet and high in fat; food is eaten quickly to the point of medical and/or ps ychological distress , often in private, and is mos t times as sociated secrecy or s hame) is undecided, as they blend into other. S ubsyndromal eating dis orders and variants that lack required diagnostic feature of the current criteria are cons idered to belong to the category of eating dis orde r otherwis e s pecifie d. T his category is overly large, often representing 30 to 50 percent of admis sions to experienced eating disorder programs . P atients with eating dis order not otherwis e s pecified are no less ill no les s respons ive to treatment than those with or bulimia nervos a, but the category is confus ing in its 2274 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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terminology and implication. C urrently, approximately percent of patients with eating dis order not otherwis e specified would fit into a slightly revised, more based scientific approach to diagnos is of anorexia primarily, and bulimia nervosa to a less er extent. Understanding definitions of eating disorders requires appreciating the concept of overvalued beliefs . many clinicians alternately view the ps ychopathology underlying the abnormal eating of eating-disordered patients as being either obsess ive-compuls ive in deriving from delusional beliefs, neither concept adequately captures or repres ents the characteristic es sential ps ychopathology s een most commonly in disorders . Overvalued beliefs, which are behind most of world terrorism, are als o the driving force behind eating dis orders. O ve rvalued beliefs are defined as culturally normative beliefs that have been ass igned disproportionate and ruling pass ion in an individual's and come to dominate that individual's thinking, emotions , and behaviors . T he behaviors res ulting from these overvalued beliefs are, at their extremes , ris ky life threatening, whether the behaviors are dangerous the individual (anorexia nervosa) or to others T hese beliefs are not fixed and fals e, as are beliefs delus ions, nor are they ego-dystonic thoughts or as required for a diagnos is of obsess ive-compuls ive disorder (OC D). T hinking about losing weight is normative in American s ociety. However, regulating every waking moment and mood around the overriding importance of slimnes s and how to achieve it ps ychopathological category bes t described as an overvalued belief. Unders tanding the nature and 2275 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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of overvalued beliefs seems es sential for treating disorders in a comprehensive and enduring manner. Using this functional definition of eating disorders — abnormalities of eating behavior driven by overvalued beliefs that lead to medical, s ocial, and ps ychological cons equences—eating dis orders have a long his tory. R oman practice of gorging and vomiting in “purgatoriums” at fancy dinners was not an eating disorder, but s imply culturally condoned gluttony. to real eating disorders were P.2004 the fas ting practices of the G nostic sect of C hris tian the fourth century who s elf-starved because of the that material objects , including food, were evil. In the practice of their as ceticis m, they spent years on top of pillars in the desert consuming very little food, to the of severe self-starvation. During the Middle Ages , were generally treated as s econd-clas s citizens, with exception of those demonstrating exceptional holines s. F emale holiness in that era was mos t commonly by denial of the body through chastity, self-denial, and, es pecially, fas ting to the point of emaciation. In these instances, the patterns of res trictive eating became sustaining and ego-syntonic, immune to pleas or change from thos e around, forming the core of lifelong identities , even if life was s hortened by these acts. R eas onable attempts to as sign eating disorder through biographical analysis to his torical figures such Lord B yron are interes ting exercis es, but thes e are dis tinctly less s ecure than thos e based on early reports of s pecific cas es . R ichard Morton, physician to 2276 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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court of E ngland, des cribed two cas es in 1689—a boy a girl—that conformed reasonably well to current diagnostic criteria for anorexia nervos a. T hese two were young people with “cares of the mind” who took to fas ting and were noted to s uffer emaciation without medical causation. Although more contemporary medical identification of anorexia nervosa was hinted at in several reports from phys icians in the early 1800s , it was most clearly almos t at the same time, by S ir W illiam G ull in London Dr. C harles Las égue in F rance in the 1860s and phys icians described cases of self-starvation, primarily upper-clas s young girls , but “occasionally seen… in at the same age,” “distinguishing them clearly from with medical causation.” S ir W illiam described anorexia nervos a with the clarity pos sible only in an era in which treatments were les s available and time for clinical observation was greater. In his words , “T he want of appetite is, I believe, due to a morbid mental state.” He prescribed “food… adminis tered at intervals varying invers ely with the exhaustion and emaciation. T he inclination of the patient mus t be in no way cons ulted. patient should be fed at regular intervals and by persons who would have moral [i.e. psychological] control over them, relations and friends being generally the wors t attendants .” T he keen obs ervation may s till applicable in certain instances. Laségue captured the dilemma of a family of anorexics, noting that the patient was not res pons ive to either “entreaties or menaces ,” sound couns el to families and phys icians . T he s ocial isolation of these patients was captured as well: “the circle within which 2277 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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revolved the ideas and s entiments of the patient more narrowed… what dominates in the mental is … almos t a condition of contentment truly pathological… she is not ill-pleas ed with her condition.” He anticipated the future warning of Hilde B ruch to letting patients quickly “eat their way out of hos pital” by cautioning that “as a general rule we must look forward a change for the better only taking place s lowly.” In the late 1800s, anorexia nervosa was temporarily confused with postpartum pituitary necros is, leaving a lasting, even if dis proved, as sumption that s ome abnormality of endocrine function was implicated in the origin of anorexia nervosa. E arly in the 20th century, the pendulum of etiological as sumptions s wung toward early, primitive hypothes es, leading to searches for ps ychoanalytic themes, s uch as “fear of oral impregnation,” and then attempts to work through thes e s exual conflicts with ps ychoanalytic methods . A much more contemporary, ps ychodynamically oriented approach was initially formulated by Hilde B ruch in the 1950s . In the 1960s, modem era of phenomenological description and pragmatic treatment of anorexia nervosa relatively free theoretical bias was initiated in E ngland by G erald Arthur C ris p, P ierre B eumont, and others . R us sell described bulimia nervos a in 1979, using the ne rvos a to unite the two forms of the eating dis orders spectrum—the self-starving syndrome of anorexia and the newly recognized binge–purge disorder— ps ychopathologically. B ulimia nervosa was initially described as “an ominous variant of anorexia nervosa,” later descriptions incorporated the s yndrome of bulimia 2278 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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nervos a at normal weight. T he recognition of bulimia nervosa was hidden for a number of reasons, including the shame and secrecy sufferers, who were reluctant to reveal these symptoms even while being treated for other related comorbid disorders , such as depress ion; the seemingly normal weight of most bulimic patients; and the lack of for help. T he “night-eating binge s yndrome,” by often unremembered binge eating while still in s ome stage of s leep, is even more difficult to diagnos e, but increasingly is recognized as a true variant. Des pite the relatively recent formal des cription of bulimia nervosa, evidence-based treatment s trategies have emerged quickly and have proven more effective than thos e for anorexia nervosa. T he recent his tory of eating disorders has focused on several areas , including (1) better delineation of the noncompens ating binge-eating disorder, (2) clearer descriptions of the prevalence and syndrome characteristics of eating disorders in men, and (3) recognizing the contributions of genetic and other predis pos ing neurobiological factors interacting with sociocultural norms . Only recently has there been recognition that the overvalued beliefs driving men with eating dis orders may vary cons iderably from thos e women. It is almos t entirely in men that a s till-evolving diagnostic s ubtype—a mirror image of anorexia called re vers e anorexia nervos a —is found, the distorted perception that one is too thin, too small, and not muscular enough despite even heroic and outwardly s ucces sful efforts at mus cular development. His torical trends in food availability have s hifted 2279 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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significantly. In the 18th and 19th centuries , food was readily available only to the prosperous . In general, was les s social press ure for extreme thinness , except upper-clas s families in which women corseted merciles sly to achieve impos sibly thin waists . B y the 20th century, fatty, palatable foods were available to populations in Western countries , and, paradoxically, fat foods became particularly cheap and available for many low-income populations . Obes ity has become more prominent among all social clas ses, particularly poorer populations . C oncurrently, press ures to be thin, weight control efforts , and eating disorders as clinical problems have become increasingly ass ociated with affluent s ocieties. It has been hypothesized that there always been a small number of cas es of anorexia that are primarily genetic in origin, and this core group been augmented s ubs tantially by the influence of sociocultural norms that mandate thinnes s, res ulting in current prevalence of anorexia nervos a, which blend of genetic and sociocultural factors . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > NO S O LOG Y

NOS OL OGY P art of "19 - E ating Dis orders " Nos ology, the art and s cience of class ification, remains challenging in eating disorders for several reasons. disorders are, firs t of all, culture-bound dis orders primarily within cultures that promote s pecific norms for body weight and shape. T heir core features are 2280 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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uniform acros s cultures , but, unlike s chizophrenia, their prevalence varies widely acros s cultures . S econd, disorders are bes t des cribed as s yndromes, not as fundamentally P.2005 unders tood dis eases with proven etiologies and mechanisms. Questions regarding the etiology and pathophys iological mechanisms of eating dis orders are still hotly debated without clear agreement as to the relative contributions of ps ychos ocial and biomedical factors . In general, a multifactorial caus ation is C omplexities in class ification of eating disorders can be appreciated by recognizing the different names us ed anorexia nervosa in different languages and over time. Although the term anorexia ne rvos a derives from S ir William G ull's pres entation to the clinical s ociety of in 1873, this appellation represents only one attempt at capturing the nature of the dis order by a name an etiology. Many countries now use the term anorexia ne rvos a but, for the es sential meaning of the disorder, rely on the prevailing criteria listed in either DS M-IV -T R the tenth revis ion of the Inte rnational S tatis tical C las s ification of Dis e as e s and R e late d H ealth 10). Although labeling the self-starving form as anorexia nervos a is, for now, a fait accompli, the propriety of this term is in question, as the dis order does not result from true “anorexia,” or los s of appetite, especially at the in contras t to the anorexia of cancer or acquired deficiency syndrome (AIDS ). No abnormality of brain mechanism mediates any initial los s of appetite, 2281 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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the proces s leading to the full s yndrome of anorexia nervos a; appetite los s occurs only in the s evere s tate emaciation, sus tained perhaps by ketos is, but the of medical anorexia is quite variable. T he term ne rvos a is embedded in the E nglis h language, until there is consensus for a more us eful descriptive E nglis h phras e. T he term bulimia nervos a better the core behavioral feature of that syndrome. E ven the location of eating dis orders in the DS M-IV -T R has changing views on clas sification. In third edition of the DS M (DS M-III) and the revised third edition of the DS M (DS M-III-R ), eating disorders were clas sified under disorders of childhood or adolescence, perhaps, in contributing to previous underdiagnos is of later-onset cases. It was only in DS M-IV -T R that eating disorders moved to a s eparate and independent section. T he case could be made that all s ubtypes of eating disorders could be most usefully regarded as part of an overarching unitary s yndrome—simply, eating in view of the common natural his tory of trans itions one s ubtype of eating disorder to another. A transdiagnos tic approach appreciates the s hared underlying features of all eating dis orders—an overvaluation of thinness or s hape change, sus tained abnormal eating behavior, and functional impairment medically, socially, and ps ychologically. A approach also can shape an integrative treatment approach to all eating disorders , with layered additional specifics for each subtype. T here is als o merit, retaining s ome identity among the several eating variants bas ed on differences in predis position and cours e. T he “lumping” versus “splitting” approaches to 2282 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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clas sification of eating dis orders both have merits and drawbacks . Ultimately, a more scientific approach to clas sification must await more fundamental of etiology and mechanism. P revious efforts to class ify eating dis orders as mood disorders have been found wanting becaus e disorders “breed true,” without evolving into mood disorders or other dis orders . Attempts to unders tand eating disorders as primary forms of OC D have also faltered. T hey have res is ted clas sification as ps ychotic disorders , des pite hints at this etiology in earlier before more rigorous modern definitions of such as the U.S .–U.K . s tudy of schizophrenia. incompletely unders tood, eating disorders , as a unitary group or as separate s ubtypes , are clearly dis tinct ps ychiatric disorders not s ubsumed into any other ps ychiatric disorder. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > E P IDE MIO LOG

E PIDE MIOL OGY P art of "19 - E ating Dis orders " E pidemiology concerns the prevalence and incidence disorder, as well as the sum of factors as sociated with onset and course of that disorder. T he thornies t is sues related to accurate epidemiology of eating disorders been threefold: (1) the changing definition of what cons titutes an eating dis order, (2) the previous presentation of eating dis orders by their phys ical 2283 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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cons equences in forme frus te s as medical disorders , the lack of recognition by health profes sionals until recently of even clear cas es of eating disorders widespread lack of clear diagnostic criteria and reliable as sess ment methods, especially for the cases in males , minorities, and matrons . T he is sue for determining the epidemiology of eating disorders , as with a number of other disorders , is where to draw the line s eparating the large majority of women and men who are merely diss atisfied with their weight and s hape from thos e who have the full syndromes. S eventy percent of young women, by highschool age, not only des ire thinnes s, but als o practice dieting behavior. W ith young men, equal dis satis faction with body s ize and s hape reigns , but the des ire to weight in the form of lean mus cle mass matches the to los e weight. It is s imply normative for mos t women, increasingly for men, to at leas t give lip service to the to los e weight. Defining eating dis orders epidemiologically involves problems s imilar to thos e that occur when defining hypertens ion, another dis order that involves using somewhat arbitrarily imposed categories —presumably built on s tatistical probabilities of current and future impairment and risk—to separate clinically s ignificant cases from others . A helpful trend in general medicine been to move from hypertensive versus not or diabetic versus not diabetic cases to the s pectrum of normal to prehypertens ive to clear clinical With these caveats and examples in mind, there is cons ens us that approximately 1 percent of young have class ic anorexia nervosa and that 2 to 4 percent 2284 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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young women meet criteria for bulimia nervos a as in DS M-IV -T R . T he healthiest end of the spectrum is composed of individuals with normal eating and no preoccupation with weight or shape (approximately 15 percent; “normal controls” are difficult to find for on eating behavior), and then there are thos e who are simply preoccupied with weight and body image (70 percent of the general population), and finally there are distinctly dis ordered individuals with partial or full disorders interfering with normal development or daily life. Approximately 20 percent of college women experience trans ient bulimic symptoms at some point during their college years, and approximately 5 percent have mild forms of anorexia nervos a. Likewise, approximately 17 percent of high s chool boy wrestlers meet s hort-term criteria for an eating dis order during active s ports s eas on. Although the number of college students with eating disorders remains relatively the specific individuals who have an eating dis order on admis sion to college are not always the individuals who have features of an eating dis order on graduation. T ransient eating disorder symptoms are common. T he lifetime prevalence of individuals with an eating disorder is approximately three times that of current prevalence. Much argument has taken place about whether eating disorders are increas ing in incidence. bulk of studies s uggest a true increase in new cases, es pecially of bulimia nervos a, recognizing that the current prevalence rates probably represent a combination of actual new cases and better recognition previous ly undiagnosed cases. P.2006 2285 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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T he larges t background epidemiological factor predis pos ing to eating disorders is a culture that values slimnes s and, in the cas e of men, lean muscularity. preoccupation can only take place in large numbers in population when there is s ufficient food to make poss ible, and, concomitantly, when social norms stigmatize overweight individuals . T here is little ps ychological purchase to be gained from selfin a poor, developing country in which starvation is common. As a society becomes more prosperous , with increased availability of densely caloric foods (fats and sugar), and increas ingly values s limness and lean muscularity, eating disorders increase in prevalence, starting with a few individuals who are perhaps predis pos ed, such as appears to be the case in days , and progres sing to a much larger contemporary population who come to see dieting as a seemingly obligatory rite of pas sage to a s tate of thinnes s to be mandatory for success or happines s. Obes ity is much more common in lower- than uppersocioeconomic clas ses in American s ociety, and stigmatization of obes ity is common, sugges ting that, although anorexia nervos a is becoming more widely distributed among cultures and social clas ses, s ome women s till s ee anorexia nervos a as a badge of upperstatus . However, this thesis does not hold for bulimia nervos a. R ecent studies s uggest that bulimic symptomatology is equally pres ent in all clas ses . E ating dis orders are among the most gender-divergent disorders in ps ychiatry, but the divergence is 2286 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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narrower than previous ly believed. P revious estimates the ratio of men to women for eating dis orders were typically 1 in 20 to 1 in 10. E xcellent recent communitybased epidemiological s tudies , however, found a ratio two women to one man for the combination of full- and partial-syndrome anorexia nervosa, and a ratio of three one for bulimia nervosa. T his s tudy s ugges ts that a large unidentified population men with eating dis orders exists in American s ociety that the gender ratios present in clinical s ettings do not reflect actual community prevalence. T he trend for men during the 1970s to follow women in increas ingly slimnes s appears to have been reversed in the 1980s, perhaps because of the increasingly common media pictures of emaciated gay males with AIDS that began appearing in the media at that time. S ince then, in both the gay and heterosexual male communities, there has been an increasing value placed on lean mus cularity than on thinness alone, with the ideal in the gay community being more lean mus cularity rather than the caricature of huge muscular development. B eing a gay man is a documented ris k factor for developing an disorder, but the mediating variable relates to the ideal body image of virtually impos sible phys ical perfection, the sexual orientation or behavior of the man. R ecently, clinicians have come to recognize a s till incompletely defined but clinically s ignificant dis order, occurring primarily in men, that is in many ways the mirror image typical anorexia nervos a, called re vers e anorexia, (linguistically ugly, albeit descriptive), body dys morphic dis order (most common), or, most s ensationally, the complex. In these disorders , which are often 2287 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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by steroid abuse, men perceive that they are still too in size or too thin, despite huge objective muscle development. T his variant of life-dominating body dysmorphic dis order is characterized by a des ire for impos sibly low body fat along with huge, clearly muscle mas s. B inge-eating dis order appears in approximately 25 of patients who s eek medical care for obes ity and in 50 75 percent of thos e with s tage III obes ity. It is in s ome the most subtle eating dis order and the lates t to be described because of patients ' lack of dramatic purging behavior, seemingly blending in with obes ity is erroneously, but commonly, attributed to lack of will. Although eating disorders have been des cribed in ranging from prepubertal ages to those in the ninth decade of life, peak ons ets most commonly occur in early and late teens. E xtremely early cases —in those younger than 5 to 7 years—almos t certainly repres ent patterns of abnormal eating behaviors that differ from anorexia nervosa and bulimia nervosa and are due to caus es, such as medical or neurological conditions . may als o represent childhood behavioral express ions anger, defiance, and fear or may represent attempts to control family dynamics , such as occurs with breath holding. S adly, s ome emaciated young children without obvious medical illness may s uffer from parental deprivation of food (Munchausen syndrome by proxy). Lastly, finicky appetites can be taken too serious ly by worried parents. Although worries about weight and shape, with res ulting dieting behaviors, are being seen earlier ages, true anorexia nervos a and, less bulimia nervosa, as defined here, do not occur below 2288 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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age at which children can internalize fat phobias or overvalue social norms of slimnes s. A type of imitative eating dis order occurs in young children who mirror abnormal eating behaviors s een in parents , such stepping on a scale frequently or trying to induce after a meal. A final epidemiological theme is that eating dis orders rarely s een as solitary psychiatric disorders . T hey are almos t invariably ass ociated with two to four additional comorbid diagnos es on Axis I and Axis II of DS M-IV es pecially mood, anxiety, obsess ive-compuls ive, body dysmorphic, and s ubs tance abus e disorders on Axis I personality vulnerabilities and disorders on Axis II. Anorexia nervosa, restricting subtype, is usually with C lus ter C personality dis order, whereas bulimia nervos a is more likely to occur with C lus ter B traits or disorders . T he probability of having s ome diagnosable personality dis order is significantly greater in with eating dis orders than it is in the general T he cours e and prognosis of any given case is strongly influenced by these comorbid conditions , particularly nature and intensity of any pers onality disorders or preexisting mood disorders , anxiety dis orders , or Mood dis orders are es pecially common in bulimia with es timates of 50 to 70 percent comorbidity being typical. C aus al relations hips and interactions , including poss ibility of some s hared vulnerabilities between disorders and eating dis orders, are complex and controvers ial. In approximately equal numbers does depres sion precede bulimia nervos a, bulimia nervosa precede depres sion, and the two conditions appear concomitantly. C las sic s tudies have documented that 2289 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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emotional blunting, social is olation, and frank may result from s evere weight los s alone. T able 19-1 summarizes some of the epidemiological factors eating disorders .

Table 19-1 E pidemiologic al R is k Fac tors R elated to E ating C ultural: S ocietal endorsement of weight loss dieting Gender: W omen > men (2:1 to 3:1 in community; 10:1 to 20:1 in clinical series ) Age: P eaks occur at early and late teen years , onset can be prepubertal through 8th decade. Prevalenc e: Anorexia nervosa, approximately young women; bulimia nervos a, 2–4% of young women (full s yndromes, DS M-IV -T R /IC D-10) Family dis orders : E ating dis orders, affective disorders , obesity Family patterns : E nmes hed or disengaged S oc ioec onomic clas s : Anorexia, pos sibly ↑ social class ; bulimia, independent of s ocial clas s

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Pers onality role: ↑ probability of a personality disorder; anorexia, ↑ with C lus ter C ; bulimia, ↑ C lus ter B Prior ps ychiatric dis turbanc e: C hildhood and adoles cent anxiety, mood, and obs es sivecompuls ive disorders Pubertal age: ↑ with early puberty, especially pubertal obesity, for girls Monozygotic to dizygotic ratio: 3:1 Monozygotic twin c oncordanc e: ≥ 50% R ural vs . urban: ↑ with move from rural to setting S exual orientation: ↑ with gay orientation; poss ibly ↓ with les bian orientation Medic al c omorbidity: P os sible ↑ with type I diabetes mellitus (controversial) Prior phys ic al, emotional, or s exual abus e: Nons pecific ↑ in all ps ychiatric dis orders, not specifically eating disorders Premature mortality: 0–19% on 10- to 20-yr up after hos pitalization (medical causes , clos ely 2291 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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followed by s uicide); anorexia nervosa plus dependent diabetes mellitus ↑ mortality 10 times either anorexia or diabetes alone Voc ational, avocational ris ks : B allet, modeling, amateur wres tling, vis ual media roles, sports (female gymnas tics, figure s kating), sports (jockey, cross -country running, lightweight crew)

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > E T IOLO G Y

E TIOL OGY P art of "19 - E ating Dis orders " C urrent etiological thinking about eating dis orders involves s everal principles and an integrating F irst, eating disorders are disorders of eating behavior. other factors may be pres ent (overvaluation of body image dis tortion), but, without abnormal eating, there is no diagnosable dis order. E ating dis orders represent in s ome ways a “highjacking” of normal neurobiologically regulated eating behaviors , which become distorted and overridden until the abnormal eating pattern becomes autonomous , res ponding to the continued drive for thinness and the neurobiological conditioning about normal weight. S econd, although 2292 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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analogy may eas ily P.2007 be overdone, s imilarities exist between eating and drug abuse in that abnormal eating, whether selfstarvation or binge–purge behaviors, produce immediate emotional changes that include initial relief dysphoria and production of excitement but res ult in more dysphoria, a vicious circle. T hird, biological theories are popular and are being actively res earched, no convincing evidence yet exis ts that disorders derive primarily from preillness s tructural or functional abnormalities of the brain; eating disorders , however, do res ult in profound consequences to the not neces sarily all fully revers ible. T he s earch for brain abnormalities as the caus e of eating dis orders is unders tandable but may prove too simplis tic. A more complex, multifactorial etiological approach may better account for current data. G enetic contributions are certainly involved, es timated from 40 to 60 percent, but less so in a deterministic manner, as with Huntington's chorea or even bipolar dis order, and more likely in a contributory manner, by increas ing the pres ence and strength of risk factors , such as pers evering, s ens itive, fearful, or impuls ive personality traits , or through more easily dis rupted regulation of s erotoninergic when dieting occurs. T hus, eating dis orders may pres ently be best conceptualized as probabilistic, as overdetermined disorders with multiple contributing causes, none of which—besides dieting behavior—is now known to be absolutely ess ential. T he most compelling perspective 2293 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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recognition that eating disorders probably derive from a clus ter of predis pos ing vulnerability factors (imagine kindling wood) reacting to precipitating events , those occurring during vulnerable “windows” in development (the match for the fire to start), and are maintained by s ustaining social, psychological, and biomedical reinforcements (the wind, oxygen, and lack rain that keep the fire burning). E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > V ULNE R AB ILIT Y : P R E DIS P O S ING

VUL NE R AB IL ITY: PR E DIS POS ING FAC TOR S P art of "19 - E ating Dis orders " It is doubtful that individuals who are not predis pos ed with typical known ris k factors can develop true eating dis orders, even with dieting behavior. F or an extroverted young woman with an internal rather external locus of control who grew up in a balanced, supportive family, who poss es ses high ass ertiveness , self-accepting body image, is average in weight, and no family history of affective dis order or obes ity is a doubtful candidate for an eating disorder, even if she practices brief dieting to meet job (e.g., modeling) or avocational (e.g., ballet) requirements.

B iologic al Vulnerability B iological theories of the etiology of eating disorders began hundreds of years ago and culminated in the 2294 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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1800s with the pronouncement that anorexia nervos a caus ed by postpartum pituitary necros is . Although this theory was soon disproved, a variety of s ubsequent theories have been advanced focus ing on putative biological underpinnings—for example, the hypothes is that s ome predis pos ing hypothalamic abnormality evidenced by amenorrhea. However, convincing have demons trated in volunteers willing to starve thems elves to 15 percent or more below their normal weights that virtually all the endocrine abnormalities characteristic of anorexia nervosa are abs ent before starvation, only appear as weight declines , and return normal when weight is restored. S everal lines of evidence s uggest genetic vulnerability, including high rates of familial trans mis sion. T win demonstrate a high concordance in monozygotic twins, approximately three times higher than in dizygotic suggesting that both genetic and ps ychos ocial contributions are operative. Monozygotic twins are documented to have a 50 to 80 percent concordance for eating disorders . E xactly what is being inherited remains controversial. G enetic factors definitely contribute, probably through multiple effects on temperament, cognitive s tyle, pers onality, moodregulating tendencies , s et points for weight, and predis pos itions toward phys ical activity. R es trictinganorexia nervosa, in contrast to bulimia nervosa, may require a s pecific genetic endowment of perseverance, sens itivity, perfectionis m, and low impulsivity to allow development of s us tained food restriction and maintenance of a severely starved s tate, impos sible for most people who are offered options to eat. Impuls ive 2295 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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extroverted personality s tyles increase the probability binge eating–purging dieting cycles . P ersonality, a heritable variable, plays a major role in the probability developing any eating dis order and its specific subtype. T he identification of genetically derived animal models anorexia nervosa is als o intriguing. T ake, for example, sow” disease. During breeding experiments , sows that s tarved themselves produced thinner hogs. Active searches are under way to identify genes that may contribute to the development of models, including research on knock-out gene models, increasing or decreas ing genes related to fear and avoidance. T he complexity of the tas k of identifying specific genetic contributions to eating dis orders is enormous. T o date, more than 200 genes have been identified that contribute to eating, activity, and weight regulation alone in simple s pecies, with new regulatory genes or gene interactions s uch as daf-2 cons tantly described. P.2008 C ontemporary theories have pointed to putative mechanisms, largely bas ed on observations that individuals with anorexia nervosa have abnormal cerebrospinal fluid (C S F ) serotonin levels when ill, that may not completely revers e on partial weight gain. date, no firm data are available s howing that s erotonin abnormalities exis t in vulnerable populations before the onset of an eating dis order. However, thes e hints have stimulated s tudies into the pos sibility that variations in genetically mediated s erotonin regulation may be important predisposing factors, perhaps increasing 2296 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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vulnerability to stress ful situations , a more indirect and interactive mechanism of diathes is interacting with during vulnerable periods . Although molecular genetic research of thes e disorders in its infancy, promis ing areas for inves tigation have already pointed to the potential importance of serotonin mechanisms, among others . G enetically interesting loci and polymorphis ms have been as sociated with genes the 5-hydroxytryptamine type 1B (5-HT 1B ), type 2A (5HT 2A ), and type 2C (5-HT 2C ) receptors , uncoupling 2 (UC P 2) and 3 (UC P 3), beta-type estrogen receptor, hS K C a3 potass ium channel, and human agouti protein. illus trate, a polymorphism in the coding region of the for the 5-HT 2C receptor s ubtype resulting in a cysteine serine s ubs titution has been reported in 23.7 percent of adoles cent girls reporting weight los s compared to 7.7 percent of normal-weight girls . In studies of the human agouti-related protein gene (related to an orexigenic neuropeptide), two alleles have been found to be in complete linkage disequilibrium and are s ignificantly enriched in anorectic patients (11 percent; P = .015) compared to controls (4.5 percent). S everal large-scale linkage and ass ociation s tudies are under way. T o areas of particular interes t have been identified on at chromosomes 1, 2, and 13. B ut, on the whole, the percentage of occurrence explained by thes e s pecific genetic ass ociations is still quite s mall. P opulation suggest that genetic factors may, overall, contribute approximately 50 percent or more to the appearance of anorexia nervosa and bulimia nervosa. T heories regarding potentially preexisting functional or structural brain dys functions have been proposed, but, 2297 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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yet, no convincing preexisting abnormalities have been revealed or replicated. More research in this area can expected with the availability of s ophisticated imaging technology, with the goal of eventual pros pective of the brain imaging and neurobiological functioning of individuals who later develop eating disorders . T he most notable biological vulnerability factors are related to dieting and its attendant undernutrition. its elf is a major s tres sor to the nervous s ys tem, one for which the typical individual is evolutionarily prepared multiple mechanis ms to defend life in the s etting of famine, but it is nonetheles s stres sful in that it involves rearranging virtually every as pect of cognition and metabolism.

Temperament, P s yc hologic al, and S oc ial Vulnerability F amily trans mis sion repres ents a major vulnerability for eating disorders , with a family his tory of eating disorders , affective spectrum disorders , anxiety OC Ds , and obes ity contributing approximately equally. Mood dis orders are approximately four times more common in families of eating-disordered individuals in the community at large. T he exact mechanism by this family his tory predis pos es to eating disorders is unknown. Mood and anxiety disorders and OC Ds in childhood the early appearance of perfectionistic pers onality traits appear to be major vulnerability factors for the development of eating disorders , es pecially anorexia nervos a. In young girls with s haky self-es teem, teas ing family or friends, or comments and directives from 2298 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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authority figures (doctors , nurses , teachers , coaches) regarding need to change weight and shape contribute vulnerability. Not uncommonly, children are weighed in clas s or by a s chool nurse for no credible reas on, with frequent long-term distress res ulting. Overall, twin suggest that approximately 17 to 46 percent of the variance in both anorexia nervosa and bulimia nervos a be accounted for by nons hared environmental factors . V ocational and avocational interes ts interact with other vulnerability factors to increase the probability of developing eating disorders . In young women, participation in strict ballet s chools increases the probability of developing anorexia nervos a at least sevenfold. In high s chool boys , wres tling is ass ociated a prevalence of full or partial eating-disordered during wrestling season of approximately 17 percent, a minority developing an eating disorder and not improving s pontaneous ly at the end of training. these athletic activities probably s elect for and persevering youth in the firs t place, press ures regarding weight and shape generated in thes e s ocial milieus reinforce the likelihood that these predis pos ing factors will be channeled toward eating dis orders. T he influence of family functioning s tyle as a potential predis pos ing factor remains controvers ial. No s ingle, specific family functioning style appears to be either a neces sary or sufficient requirement for developing an eating dis order. As in mos t psychiatric disorders , family dysfunctional styles appear to act as nons pecific vulnerability factors and also hamper recovery. routine blaming of families or the ass umption that they caus ative factors for an eating dis order in a child has 2299 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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receded along with the invidious concept of the “schizophrenogenic” mother or the autis m-promoting parents . G iven the presence of other vulnerability enmes hed families that provide youth little room to individuate may be more likely to foster the emergence adoles cents with anorexia nervosa. S o-called negative expres sed emotion in families, in which blame and criticis m are heaped on the patient by other family members, may add cons iderable nons pecific s tres ses other vulnerabilities . T rauma aris ing from childhood or adoles cent phys ical, emotional, or s exual abus e clearly contributes to the likelihood that thes e abus ed individuals will later some ps ychiatric dis order, but not specifically an eating disorder. T here is no evidence that s exual abuse alone major cause of bulimia nervos a. T he unscientific of ass uming that sexual abus e underlies bulimia and us ing “recovered memories” to support this theory have produced much suffering and malpractice. Of when pres ent, a s exual abus e history requires and s ympathetic attention and decisions about “uncovering” versus “working through” techniques, with expert guidance. T he extent to which media simply mirror society or play active roles in contributing to societal overvaluation of thinness and dieting and the increased prevalence of eating dis orders remains controvers ial. R ecent studies from F iji sugges t that the introduction of popular television programs highlighting slimnes s and stigmatizing obes ity launched wides pread dieting behavior and new eating-disordered cases in that were previously unconcerned with thes e is sues . 2300 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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R acial and ethnic factors per se offer no protection or predis pos ition to eating dis orders. T he only conferred by s pecific racial or ethnic groups is related the degree to which thos e groups promote weight los s shape change. A gay orientation in men is a proven predis pos ing factor, not becaus e of s exual orientation sexual behavior per se, but becaus e norms for albeit muscular slimnes s, are very strong in the gay community, only s lightly lower than for heteros exual women. In contrast, a lesbian orientation may P.2009 be slightly protective, as les bian communities may be more tolerant of higher weights and a more normative natural distribution of body shapes than their female counterparts. T he potential contribution of ins ulin-dependent as a predis pos ing factor to eating disorders remains uncertain. T he largest studies s uggest no actual eating dis orders in young individuals with type I but data are controvers ial, and the presence of insulindependent diabetes mellitus in a patient with anorexia nervos a may dis guise the eating disorder, and it complexifies treatment. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > P R E C IP IT AT ING F AC T O

PR E C IPITATING FAC TOR S P art of "19 - E ating Dis orders " 2301 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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Although no single predis pos ing factor is necess ary or sufficient by itself to lead to an eating disorder, the likelihood that an eating disorder will occur seems to be related to the number and s everity of predisposing risk factors . In almos t all patients , a s ympathetic and history will reveal one or a s mall number of events (often engraved indelibly in the patient's that interacted with thes e predisposing factors to the illness when the patient reacted to the event(s) with dieting behavior—us ually with food res triction, often exercise in addition, and rarely with initial purging only. approximately 95 percent of cas es , the eating dis order precipitated by dieting. In approximately 5 percent of cases, initial weight loss may be inadvertent accident requiring jaw wiring, flu, ulcer, etc.), but after some weight loss occurs for medical reas ons , s ocial or s elf-observation with a scale or mirror soon the des irability of the weight los s, and the patient now actively directs further weight loss by voluntary dieting. E ven less common is an iatrogenic onset, but this happens in teenagers . Once eating dis order patients firmly internalized a morbid fear of fatness based on overvalued belief in the neces sity for s limnes s, the is locked in until it becomes, in practice, autonomous self-perpetuating. F urthermore, blending exces sive exercise with dieting behavior appears to create a particularly risky combination. In another animal model activity anorexia, rats that are simultaneous ly food res tricted and given unrestricted access to an exercis e wheel often run themselves to death rather than eat. Numerous events have been identified as frequent precipitating factors for eating dis orders. T he mos t 2302 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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common include events around puberty, es pecially if puberty is early and accompanied by higher-thanbody weight and the individual is sensitive to criticis m. R epugnance toward menses and s exuality in general is historically recognized to predis pos e to anorexia Many patients can identify the specific place, time, and content of the teasing, criticism, or even wellremarks about weight that launched the eating T hese defining moments remain clearly etched in the individual's mind, usually accompanied by feelings of shame or humiliation and followed by determination to reduce body weight. After much contemplation of the hurtful remarks or comparison with others who are thinner, the future eating-disordered patient growing dis satisfaction with body image, and dieting or without intens e phys ical activity begins in earnest. Depending on the temperament, pers evering traits, and impulsivity of the individual, the subtype of the eating disorder is generally predictable. A move to a new location, changes in schools, social or academic competition with peers , romantic disappointments , family illnes s or death, and the urging coaches , teachers, or phys icians to los e weight are all common precipitating factors . S exual abuse may be a precipitating event for a number of ps ychiatric including eating disorders. F amily discord, the ons et of mood dis order leading to a s elf-critical and worsened image, or spurts of weight gain from any s ource may stimulate dieting behavior as a means of increasing sens e of pers onal control, s us taining factors for weight loss attempts . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins

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> T able of C ontents > V olume I > 19 - E ating Dis orders > S U S T AINING F AC T O

S US TAINING FAC TOR S P art of "19 - E ating Dis orders " Most individuals who initiate severe dieting and experience various degrees of subclinical eating symptoms do not go on to develop full-blown, eating dis orders meeting full diagnostic criteria. Many serious dieters experience early, trans ient eating symptoms and either retreat to intermittent or subs yndromal s ymptoms or s top the abnormal eating behaviors completely as a learning experience. T he sustainers of sustained eating disorders involve a combination of external social reinforcements and internal, psychological, or physiological reinforcers. S ocial praise commonly provides external for further weight los s in s elf-critical, self-doubting, perfectionistic, pers evering individuals who have lost some weight through dieting or exercis e or both. S uccess ful weight los s may offer the first s ense of internally effective s elf-control when the proces s of puberty is overwhelming, when childhood is mourned, when adulthood appears unattractive and fearful, and when perfectionis tic tendencies prove inadequate for challenges of adolescence. Anorexia nervosa is an implicitly sanctioned pseudos olution to the exis tential challenges of adolescence. W ith rigid control of weight, the proces s s eems to be more controllable. After significant weight has been los t through dieting or purging, attempts at healthy eating may, in fact, 2304 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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uncomfortable medical s ymptoms in the s hort run, such gastric bloating or fluid retention, that, in turn, lead to renewed dieting bas ed on the experience that normal eating is painful and imposs ible. T he exact which altered phys iological process es sus tain eating disorders are only s peculative. T hey putatively involve changes in opioids , neuropeptides , serotonin, leptin, ghrelin, cholecystokinin, neuropeptide Y , and other neurobiological molecules involved in the regulation of eating, hunger, satiety, and body weight. Negative express ed emotion in families may contribute poor prognosis by offering anorexia nervosa as a moderator of disturbing family emotions and anorexia can act as a regulator of family dynamics , unconsciously reinforcing its role as a neces sity for in certain families . F actors that s us tain anorexia and bulimia nervosa differ to s ome extent. In some instances, bulimia nervos a appears to repres ent failed attempts at res tricting anorexia nervos a in individuals have les s perseverance and less perfectionism than who purely restrict. In respons e to severe hunger, eating is naturally compensatory, and it is more likely to occur when dietary dis cipline is not s us tainable, particularly in individuals with impulsive traits . In other instances, binge eating initially occurs in res ponse to frus tration and dysphoric moods in attempts to quell or soothe these distress ing emotional states . P urging episodes , s imilarly, may offer brief periods of like states that temporarily remove the individual from other plaguing negative thoughts and moods . W hat appears to sustain bulimia nervosa is that binges and purges become elaborated into all-purpos e 2305 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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for dealing with dys phoric states of any kind. After us ed repeatedly to deal with hunger and dysphoric bingeing and purging behaviors simply become habits . B iochemically, animal s tudies sugges t that intermittent, excess ive s ugar intake may induce mechanisms endogenous P.2010 changes in opioid regulation, and thes e process es may also contribute to sustaining binge-eating behavior. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > INIT IAT ING AND S US T AIN P S Y C HO P AT HOLO G Y

INITIATING AND PS YC HOPATHOL OGY P art of "19 - E ating Dis orders " Anorexia nervosa often appears to serve as a longstrategy for coping maladaptively with maturational including press ures to develop a personal identity, and with difficult situations in family and social functioning. E ating dis orders of adoles cent onset are mos t ps eudosolutions to core challenges of adolescence as delineated by E rik E rikson—in other words , the of developing a coherent pers onal identity rather than experiencing role diffus ion. S ome early adoles cents rudely s urprised when coping mechanis ms they had previous ly been us ing to s ucces sfully contend with 2306 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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preadoles cent is sues of work and tas k completion no longer adequately manage adolescent challenges and chaos . In res pons e, some of the more s ens itive, perfectionistic, and compuls ive adoles cents may identities oriented around having anorexia nervosa. succumb to one type of “quick fix” for developing an adoles cent identity, devoting themselves to becoming thin or, in the case of boys , lean and mus cular. T he motivations behind eating dis orders are always in that they involve attempts to deal with the process of development, emotions , family dynamics, social relations hips , and internal s elf-regulation. Although early psychoanalytic theories regarding fear oral impregnation and other historically fanciful formulations appear irrelevant, if not quaint, more ps ychodynamic theories seem more applicable to disorders , es pecially thos e based on object relations self-ps ychology. However, they still remain more to systematically operationalize and have not yet been adequately validated. T herapies based on thes e formulations have been propos ed and may have but, at least in research circles, they have not yet the wider support accorded to cognitive-behavioral therapies or interpersonal therapy. P sychodynamic conflicts almost certainly contribute to eating disorders as predis pos ing and sustaining but adequately elucidating these phenomena has remained methodologically hard to pin down. K ey ps ychodynamic components vary from patient to family to family, and between genders . A relatively appealing, although not firmly proven, hypothes is is clus ter of ps ychodynamic themes is caus ally 2307 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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the majority of eating dis orders. F or example, and exis tential fears are very commonly involved with eating dis orders, and res tricting-type anorexia nervos a seemingly provides es cape from onrushing negative visions of the emerging s exuality and other biological social challenges of adoles cence. C oncurrently, other psychodynamic themes concern sens itive personalities deal with childhood narciss is tic injuries, seeking s afety and avoiding injury from phys ical, emotional, and sexual abuse through s elfstarvation and disappearing into “nothingness ,” from the material world. G ender-as sociated ps ychodynamics reveal that boys not only fear the exis tential anguis hes of adolescents, but als o fear far beyond medical reality, perhaps more than girls do. B oth bingeing and purging offer short-term s olutions problem s olving (or problem avoidance) before they insidiously turn into long-term s ources of medical and ps ychological distress . Despite being ego-dystonic in individuals , bulimic symptoms have to be unders tood coping mechanisms, albeit ineffective ones , for dealing with real is sues in mood regulation, such as anxiety, depres sion, anger, boredom, loneliness , and ennui; interpersonal relations ; s elf-protection; family and continued worries over body weight. Later-onset dis orders differ thematically from those earlier onsets. F or example, older adult men may slim to increas e their s exual desirability to extramarital partners , enhance their upward mobility at work, or improve their image in vis ual media. S ome men s lim to become more acceptable to gay partners. Later ons et women may represent attempts at emotional s elf2308 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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regulation when previously unres olved iss ues present thems elves , s uch as fractured relations hips, perceived of attractiveness , or feelings of ineffectivenes s or lack control. Although much dis agreement pervades unders tanding of eating disorders , the phenomenology eating dis orders, especially the core ps ychopathology involving overvalued beliefs in the des irability of weight loss for some reas on, has not changed s ince its first description. T he ps ychopathology of eating dis orders involves overvalued beliefs , but the content of these overvalued beliefs may differ in different cultures . A chronic and s ustained eating disorder is as much a as an “enemy.” E ating dis orders may satisfy human needs, albeit in a manner that ultimately fails , simultaneously provides a “profes sion,” an identity, and organizing principle for daily life. B as ically, overvalued beliefs reflect the ps ychology of the fundamentalis t zealot—in the cas e of eating-disordered patients, thes e beliefs are centered around s hape, weight, and fear of in society. T hey may take on religious tones in some individuals that hearken back to earlier eras when as ceticism was praised. G enerally, the overvalued ideas are not entirely to challenge with evidence-based ps ychological and do not generally attain the level of incorrigible, unfals ifiable truth of fixed delusions . R ather, they are fluid with time. Depending on the patient's level of and motivation to change, the ability to objectively on thes e overvalued ideas s hifts . Ultimately, recovery requires the capacity to sense these ideas as intrus ive unwanted, as ps eudosolutions rather than failures . T he 2309 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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core abnormal beliefs of eating dis orders have the potential for being challenged and discarded in favor of adaptive coping skills and healthy methods of internal regulation. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > DIAG NOS IS AND C LINIC AL F E AT U

DIAGNOS IS AND C L INIC AL FE ATUR E S P art of "19 - E ating Dis orders " T he diagnosis of an eating dis order is straightforward can be confidently accomplished with moderate knowledge and experience by directly identifying the eating dis order through the ps ychiatric his tory and status examination, without extens ive medical Anorexia nervosa is present when (1) an individual voluntarily reduces and maintains an unhealthy degree weight loss or fails to gain weight proportional to (2) an individual experiences an intens e fear of fat and/or a relentless drive for thinnes s des pite medical starvation; (3) an individual experiences starvation-related medical symptomatology, often, but exclusively, abnormal reproductive hormone but also hypothermia, bradycardia, orthostasis , and severely reduced body fat s tores; and (4) the behaviors ps ychopathology are present for at leas t 3 months . A distorted body image is common but not ess ential or invariable in eating disorders . When patients are asked how other people see them, they almos t always 2310 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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acknowledge that they are objectively too thin to others but insis t that they perceive themselves as fat. the initial illness wears on, more ins ightful patients recognize their thinness but persis t in remaining phobically avoidant of healthy weight. T he term atypical anorexia P .2011 nervos a has been applied to patients who recognize thinness , in contras t to thos e with typical anorexia nervos a, who insist that their body image distortions represent objective fact. T hese are not truly atypical only more ins ightful individuals . P rognos tically, thos e recognition of their extreme thinnes s have better res ponses to treatment and more favorable outcomes because they are not cons tantly fighting an inaccurate view of thems elves as heavy. In mos t patients, body weight is tightly tied to s elf-es teem. E ven when patients intellectually appreciate that their weight is within the normal range, the conviction that they weigh more than they desire leads to plummeting s elf-es teem and fears even thin-normal weights as being too fat. Where s elf-induced s tarvation and the core drive for thinness or fear of fatness exis t, a diagnos is of nervos a can be confidently made. Medical disorders be pres ent as consequences of starvation by food res triction and other methods of weight los s (especially purging) or may be incidental or preexisting findings , they are never primary causes when the core ps ychopathology is present and dieting was s elfIn thes e cas es, delaying the diagnosis of eating while waiting for extens ive workups to rule out a 2311 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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gastrointestinal, neurological, endocrine, or other suspected underlying medical disorder to account for weight loss or purging behavior is contraindicated. tes ting delays treatment and harms patients. Although the contemporary DS M and IC D approaches ps ychiatric diagnosis, in all of their s erial iterations, represent vas t improvements over previous vague and impres sionistic approaches to diagnosis, they are both works in progres s, with the criteria for various disorders varying from mos tly s cientific in origin to substantially based on minority opinions . Over the years , new and changing opinions have produced different criteria regarding how much weight loss , for example, is for anorexia nervos a to be diagnosed. T he third edition the DS M (DS M-III) required a weight of less than 75 of “normal.” In contras t, DS M-IV -T R requires les s than percent of a healthy weight, achieved either by weight or failure to increase weight along with normal growth. T he DS M-IV -T R requires amenorrhea, thereby excluding men, and ignores studies dis proving the value of amenorrhea. T he s pecific weight-loss of les s than 85 percent of a healthy weight is also problematic at best and uns cientific at wors t. T he decrement from a prior, us ually normal, weight to an unhealthy, s ignificantly lower weight by dieting, and/or purging is the key concept, not the attainment of specific percentage of some population average. weight, like height, is bell shaped in its natural a s elf-induced los s from 120 percent of a population weight, or an “ideal” weight, to 90 percent of that norm can be as indicative of anorexia nervosa as a reduction from a normal 90 percent of ideal weight to 84 percent 2312 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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that ideal. P s ychobiologically, anorexia nervosa is whenever a decrement from a s elf-sustaining “set a s ubstantially lower weight caus es s tarvation-related medical symptomatology. R elegating cas es in which final weight is not les s than 85 percent of “expected” weight to the category of eating disorders not otherwise specified is s cientifically disproved and a s ource of the overly large and unneces sary number of eating not otherwis e s pecified diagnos es , which are confusing clinically because of the implied “atypicality,” and often refused reimbursement because of the as sumption that they are not as s erious. T he diagnos tic C riterion A for anorexia nervosa in DS M-IV -T R for amount of weight for a diagnosis of anorexia nervosa gives 85 percent of expected weight as an exemplia gratia, but the number taken as an absolute requirement, not s imply an A young woman who weighed 20 percent above the average weight but was otherwis e healthy, functioning well, and working hard on a rural farm, left home and entered university. S he joined a sorority, started to perceive hers elf as fat compared to her sorority s is ters , started to diet, and reduced weight to 90 percent of the “ideal weight” for her age and gender. At her point of maximum weight los s, s he felt cold, dizzy, apathetic, morbidly afraid of becoming fat. S he started to restrict food choices even more, exercised compuls ively, and herself as s till in need of further weight loss . Her periods became lighter and briefer but did not cease. was not taking oral contraceptives . Although, using s trict DS M-IV -T R criteria, s he would be diagnosed as having an eating dis order not otherwis e specified because she did not reach less than 85 2313 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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“expected weight” and had s ome menstrual clinical experts would diagnos e her with incontestable anorexia nervosa. S he meets all of the core clinical ps ychopathological and behavioral criteria for anorexia nervos a. S he responded to standard treatment for anorexia nervosa. Anorexia nervosa has been divided into two the food-res tricting category and the binge-eating or purging category. In the binge-eating or purging little objective binge eating may actually occur. S ome patients purge after only eating s mall amounts of food. Overexercis ing and perfectionistic traits are common in both types . T able 19-2 lists current diagnostic criteria anorexia nervosa according to DS M-IV -T R . T able 19-3 shows the s lightly different, but s ubs tantially similar, criteria of IC D-10.

Table 19-2 DS M-IV-TR Diagnos tic C riteria for Anorexia Nervos a A. R efusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body less than 85% of that expected, or failure to make expected weight gain during period of growth, leading to body weight les s than 85% of that expected).

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B . Intens e fear of gaining weight or becoming fat, even though underweight. C . Dis turbance in the way in which one's body weight or shape is experienced, undue influence body weight or s hape on s elf-evaluation, or denial the seriousness of the current low body weight. D. In pos tmenarcheal women, amenorrhea, i.e., absence of at least three consecutive menstrual cycles . (A woman is cons idered to have if her periods occur only following hormone, e.g., es trogen, administration.) S pe cify type:    R es tric ting type: during the current episode of anorexia nervosa, the pers on has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the mis us e of laxatives , diuretics , or enemas )    B inge-eating or purging type: during the episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., s elf-induced vomiting or the misus e laxatives, diuretics, or enemas)

F rom American P sychiatric As sociation. 2315 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 19-3 IC D-10 Diagnos tic C riteria for Anorexia Nervos a Anorexia nervos a A. T here is weight loss or, in children, a lack of gain, leading to a body weight at leas t 15% below the normal or expected weight for age and height. B . T he weight los s is s elf-induced by avoidance “fattening foods .” C . T here is s elf-perception of being too fat, with intrus ive dread of fatnes s, which leads to a selfimpos ed low weight threshold. D. A wides pread endocrine dis order involving the

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hypothalamic-pituitary-gonadal axis is manifest in women as amenorrhea and in men as a los s of interes t and potency. (An apparent exception is persis tence of vaginal bleeds in anorexic women who are on replacement hormonal therapy, most commonly taken as a contraceptive pill.) E . T he disorder does not meet C riteria A and B bulimia nervosa. C omments T he following features s upport the diagnos is but not es sential elements : s elf-induced vomiting, induced purging, excess ive exercise, and us e of appetite s uppress ants or diuretics . If ons et is prepubertal, the sequence of pubertal events is delayed or even arres ted (growth in girls, the breas ts do not develop and there is a primary amenorrhea; in boys, the genitals remain juvenile). W ith recovery, puberty is often normally, but the menarche is late. Atypic al anorexia nervos a R es earchers studying atypical forms of anorexia nervos a are recommended to make their own decis ions about the number and type of criteria to be fulfilled. 2317 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion.

B ulimia nervosa is pres ent when (1) episodes of binge eating occur relatively frequently (twice a week or for at leas t 3 months; (2) compens atory behaviors are practiced after binge eating to prevent weight gain, primarily self-induced vomiting, laxative abus e, or abus e of emetics (80 percent of cas es ), and, less commonly, severe P.2012 dieting and s trenuous exercise (20 percent of cases ); weight is not s everely lowered as in anorexia nervos a; (4) the patient has a morbid fear of fatnes s and/or a relentles s drive for thinnes s and/or a disproportionate amount of self-evaluation depends on body weight and shape. When making a diagnosis of bulimia nervosa, clinicians should explore the poss ibility that the patient has experienced a brief or prolonged prior bout of anorexia nervosa, present in approximately half of nervos a patients . T ables 19-4 and 19-5 list the DS Mand IC D-10 criteria for bulimia nervos a.

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Tables 19-4 DS M-IV-TR C riteria for B ulimia Nervos a A. R ecurrent epis odes of binge eating. An binge eating is characterized by both of the following:    (1) eating, in a discrete period of time (e.g., any 2-hour period), an amount of food that is definitely larger than most people would eat a s imilar period of time and under similar circums tances    (2) a s ense of lack of control over eating during episode (e.g., a feeling that one cannot s top or control what or how much one is eating) B . R ecurrent inappropriate compensatory in order to prevent weight gain, such as s elfvomiting; misuse of laxatives , diuretics, enemas , other medications; fasting; or excess ive exercise. C . T he binge eating and inappropriate behaviors both occur, on average, at least twice a week for 3 months. D. S elf-evaluation is unduly influenced by body shape and weight. 2319 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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E . T he disturbance does not occur exclusively episodes of anorexia nervos a. S pe cify type:    Purging type: during the current episode of bulimia nervosa, the person has regularly self-induced vomiting or the misus e of laxatives, diuretics , or enemas    Nonpurging type: during the current episode bulimia nervosa, the person has us ed other inappropriate compensatory behaviors, such as fas ting or exces sive exercis e, but has not engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 19-5 IC D-10 Diagnos tic C riteria for B ulimia Nervos a

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A. T here are recurrent epis odes of overeating (at least twice a week over a period of 3 months) in which large amounts of food are consumed in periods. B . T here is pers istent preoccupation with eating a s trong desire or a sens e of compulsion to eat (craving). C . T he patient attempts to counteract the effects of food by one or more of the following:    (1) self-induced vomiting    (2) self-induced purging    (3) alternating periods of s tarvation    (4) us e of drugs s uch as appetite s uppress ants, thyroid preparations, or diuretics ; when bulimia occurs in diabetic patients, they may choose to neglect their insulin treatment D. T here is s elf-perception of being too fat, with intrus ive dread of fatnes s (usually leading to underweight). Atypic al bulimia nervos a R es earchers studying atypical forms of bulimia 2321 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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nervos a, such as those involving normal or body weight, are recommended to make their decis ions about the number and type of criteria to be fulfilled.

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion. T he eating dis orders not otherwise specified category broad and best used where identification of the core ps ychopathology is lacking or where behaviors differ subs tantially from requirements for anorexia nervosa or bulimia nervosa (T able 19-6). F or example, eating not otherwis e s pecified may properly describe patients who show only occasional binges or purges, repeated short epis odes of severe dieting, chewing and s pitting food as the predominant form of disordered eating, or binge eating in a s emi- or unaware s tate during sleepwalking episodes .

Table 19-6 DS M-IV-TR Diagnos tic C riteria for E ating Dis order Not Otherwis e S pec ified

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T he eating dis order not otherwis e s pecified is for dis orders of eating that do not meet the for any s pecific eating disorder. E xamples include 1. F or females , all of the criteria for anorexia are met except that the individual has regular mens es. 2. All of the criteria for anorexia are met except despite s ignificant weight loss , the individual's current weight is in the normal range. 3. All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compens atory mechanisms occur at a frequency less than twice a week or for a duration of less months. 4. T he regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., selfvomiting after the consumption of two cookies ). 5. R epeatedly chewing and s pitting out, but not swallowing, large amounts of food. 6. B inge-eating dis order: recurrent epis odes of eating in the abs ence of the regular use of inappropriate compens atory behaviors of bulimia nervosa. 2323 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

E xperts are currently working on sugges ted for the current criteria for future editions of the DS M IC D to better account for current knowledge about such is sues as variability of impairment as sociated with degrees of weight loss , variability of mens trual function, male phys iology, binge-eating dis order, and nightsyndromes, among others . B ecaus e s hame is prominent in eating-disordered symptoms are often concealed, and some diagnos tic detective work may be needed to elicit the diagnosis. Although the bigges t reason for failing to diagnos e an eating disorder is the failure to as k pertinent ques tions, patients s ometimes deny eating disorders , es pecially bulimia nervosa at normal weight, even when clinicians inquire directly about them. C oncealed bulimia nervos a may be s uspected in the presence of loss of dental gastroesophageal reflux disease in a young pers on, abrasions on the knuckles (from s elf-induced vomiting), and puffy cheeks or upper-neck soft tiss ue in otherwis e thin or normal-weight individuals (resulting from parotid and s alivary gland hypertrophy). Others may report the presence of vomitus in the home in the absence of 2324 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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gastroenteritis or food poisoning, finding unexpected laxatives or diuretics , or habitual departure to the bathroom immediately after meals. Unexpected tes ts that rais e s us picion include unexplained low potas sium and, occas ionally, bizarre findings , s uch as toothbrush in the s tomach on X -ray. Many young individuals with eating disorders are to or ambivalent about presenting thems elves for diagnostic ass es sment, fearing that they will be forced gain weight agains t their will or that they will be additionally shamed and s corned. C ollateral from parents or other clos e persons is extremely and s hould be sought when an eating disorder is suspected. T he most commonly overlooked categories of patients with eating disorders are men, matrons, and minorities , largely because clinicians rarely think of eating disorder diagnoses when as sess ing thes e populations . Men be as ked about desire for muscularity, fear of being too small, concern with body image from the wais t up (in contrast to women, who are primarily concerned with wais t down), and use of s teroids to enhance weight and desired s hape. Among older patients, especially thos e with ons et in 40s and 50s, mixtures of true eating dis order may coexis t with s eparate medical or psychiatric T he core diagnostic features confirm or reject the diagnosis of an eating dis order. S imilarly, eating should not be excluded from cons ideration in P.2013

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with borderline low or mild mental retardation or in the developmentally impaired. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > DIAG NOS T IC C OMO R B IDIT

DIAGNOS TIC P art of "19 - E ating Dis orders " T he diagnostic challenges of eating disorders are only partly addres sed when a s pecific eating disorder is identified, because, in the large majority of cas es, comorbid psychiatric dis orders accompany the eating disorder, with two to four separate additional diagnos es on Axis I or II of DS M-IV -T R commonly seen. In identifying Axis I mood, anxiety, obsess ive-compuls ive, and s ubs tance abus e disorders and Axis II pers onality vulnerabilities and dis orders, the temporal relationship these dis orders to the eating disorder s hould be noted. Mood dis orders that precede eating disorders differ significantly from thos e that first occur after the eating disorder is initiated. Mood dis orders s tarting before disorders usually require separate and s pecific whereas thos e s tarting in the wake of an eating often improve on their own during recovery from the eating disorder. In the s etting of an eating dis order, vulnerable personality traits may be amplified into what appear to be primary personality dis orders but are secondary personality dis turbances. As with Axis I disorders , how personality traits vary in relation to the onset of the eating disorder influences the prognosis of the Axis II component. P remorbid obsess ional traits , for 2326 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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example, may appear to be full-blown obsess ivecompuls ive s tates when an individual is malnourished may improve with weight res toration—this differs from conditions in which frank obses sional s ymptoms were present in childhood before the eating dis order. T able 19-7 s hows data from one of several s tudies that have documented the high comorbidity of Axis I in one s tudy of hos pitalized eating-disordered patients. Although the specific percentages vary with studied, the high comorbidity is common.

Table 19-7 Frequenc y of C omorbid Axis I Diagnos es in E ating Dis orde S ubgroups B ingeE ating and R es tricting- P urging T ype T ype Anorexia Anorexia Nervosa Nervosa

B ulimia Nervosa

Any affective disorder

57%

100%

100%

Intermittent

29%

44%

25%

Diagnos is

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depres sive disorder Major depress ion

57%

66%

100%

Minor depress ion

0

11%

0

Mania/hypomania

0

33%

25%

Any anxiety disorder

57%

67%

50%

P hobic dis order

43%

11%

0

P anic dis order

29%

22%

0

G eneralized anxiety dis order

14%

11%

50%

Obsess ivecompuls ive disorder

14%

56%

50%

Any subs tance 14% abuse/dependence

33%

50%

Drug

14%

22%

0

Alcohol

0

33%

50%

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S chizophrenia

0

0

0

Any codiagnos es

71%

100%

100%

3 or more codiagnoses

71%

100%

100%

No. of (x ± S D)

2.3 ± 2.5

3.8 ±

3.2 ± 1.5

F emale

100%

89%

100%

S ingle

71%

89%

100%

Age (x ± S D)

23.6 ±

25.0 ± 6.4

19.8 ± 5.6

S D, s tandard deviation. Well-diagnosed s chizophrenia is rarely s een together a typical eating disorder, although, in rare cas es , it may cooccur as a statis tical coincidence. T he phras e “perceptual distortion of delusional proportion,” us ed in older literature to describe body image dis tortions in eating-disordered patients, is a reminder that borders between delusional perceptions and s trongly held body image distortions, P.2014 2329 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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obses sional beliefs, and uns hakable overvalued ideas not been definitively clarified and that additional is neces sary to further illuminate thes e dis tinctions. F or example, there is a high comorbidity of anorexia with body dys morphic disorder—es timated at 20 percent—in which patients additionally have preoccupations regarding specific body parts not to weight or s hape in particular. B ody dys morphic occurs in delus ional and nondelusional forms , on the extent to which the obs ess ions are ego-alien recognized as unrealis tic or the extent to which the individual firmly believes that the obses sional concerns realis tically jus tified. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > LAB OR AT OR Y E X AMINAT ION AND P AT HOLO G Y

LAB OR ATOR Y AND C L INIC AL P art of "19 - E ating Dis orders " P athophys iology in eating dis orders res ults from (1) the amount and rate of starvation, (2) the means used to produce weight los s (dieting alone, with or without over exercising, self-induced vomiting, laxatives , diet pills, diuretics ), and (3) binge eating. E ating dis order die from either the medical consequences of starvation (cardiac mus cle loss and arrhythmia, s ometimes hypokalemia) or suicide. T he phys ical examination include height; pos tvoiding weight in a simple hospital 2330 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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gown obs erved for hidden weights ; vital signs , with particular attention to pulse rate and orthostatic blood press ure changes ; a complete examination of skin, and s ubcutaneous fat (noting the degree of starvation); neurological examination (which is , in general, normal); and a photograph of the patient if notably thin. Laboratory tes ts are helpful for as sess ing the s everity eating disorders and their medical consequences, but for chasing after obscure nonps ychiatric etiologies. It should be remembered that anorexia nervosa patients may die with completely normal laboratory tes t res ults . Abnormal laboratory findings document the presence pathophys iological proces ses and may als o be helpful enhancing motivation. P hys iological meas ures can be divided into thos e that reflect nons pecific cons equences of s tarvation and that are generally selfameliorating, such as mild bradycardia, and thos e that require urgent medical intervention, such as a QT interval on electrocardiogram (E G G ) or marked hypokalemia. Medical specialist consultation s hould be regularly used in the comanagement of thes e patients . T able 19-8 lists s uggested laboratory tes ts for patients anorexia nervosa or bulimia nervos a, with judgment regarding the full extent of workup for individual based on weight loss , severity of illness , s ubtype, and comorbidity. F or example, laboratory s tudies in nervos a binge-eating and purging type and bulimia nervos a often include determination of electrolytes and serum amylase, which are more likely to be abnormal these disorders than in the res tricting type of anorexia nervos a. T he elevated levels of amylase derive from salivary gland rather than pancreatic s ources , unles s 2331 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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alcoholism is comorbidly present. W here abnormal amylase is found, fractionation can identify the origin salivary, although this is us ually unneces sary in clinical practice.

Table 19-8 S ugges ted Laboratory S tudies for Patients with E ating Dis orders All    C omplete blood count (anemia is frequent)    E lectrolytes    B lood urea nitrogen, creatinine    T hyroid-stimulating hormone, free thyroxine    E lectrocardiogram    T otal protein and prealbumin    F asting glucos e    Amylas e if purging occurs    S erum phosphate 2332 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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B ulimic s yndromes    In addition to above, amylas e (fractionated if abnormal to determine parotid/salivary gland vs . pancreatic origin) If amenorrhea > 3 mos    B one mineral density (dual energy X -ray absorptiometry) In men with weight loss    T estosterone

P atients who have been abus ing diuretics require renal function tests . Many malnouris hed patients with nervos a develop a euthyroid sick s yndrome, in which decreased levels of thyroid-stimulating hormone (T S H), total thyroxine (T 4 ), and total triiodothyronine (T 3 ) may seen, free T 4 and free T 3 are us ually unchanged, and revers e T 3 (rT 3 ) is elevated. G enerally, thes e endocrine abnormalities repres ent energy-cons erving of starvation that improve spontaneously with T hey do not require immediate treatment but are to be followed with a repeat determination in approximately 3 weeks to determine if improvement occurs with Low estrogen and proges terone levels in anorexia are as sociated with the energy-cons erving role of 2333 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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hypothalamic hypogonadis m; low levels of luteinizing hormone and follicle-stimulating hormone are als o contrast to elevated luteinizing hormone and folliclestimulating levels resulting from failing ovaries , as in postmenopaus al patients. In men, tes tos terone levels decrease in proportion to weight loss . A man with anorexia nervos a is not fully res tored to a normal weight until testosterone is in the normal range, provided no other causes, such as congenital testicular insufficiency, exis t. T he res toration normal testosterone is a neces sary but not s ufficient criterion to as sess adequate weight improvement in When drug abus e is s uspected, urine and blood are indicated. A fair number of teenage girls using stimulant drugs, such as methamphetamine, do s o to control appetite and promote weight los s in addition to seeking excitement. S tool tests for the pres ence of phenolphthalein may reveal occult, nondisclosed abuse. B one mineral dens ity should be regularly ass ess ed in initial workup of patients with anorexia nervos a or nervos a with a his tory of amenorrhea in women or loss with low testosterone in men. B ecaus e has been ass ociated with negative calcium balance, loss of s keletal calcium in the range of 4 percent per many eating dis order patients have s ignificant bone mineral deficiency—us ually osteopenia but severe as os teoporos is —by their late teens and early twenties , with bones similar to those of elderly women. Osteopenia occurs when bone dens ity is one standard deviation below mean age-adjus ted scores ; occurs when bone dens ity is at least two and a half 2334 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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standard deviations below these scores . T hes e cannot be as ses sed by phys ical examination. DualX-ray absorptiometry (DE XA) s cans entail very low radiation, are relatively inexpensive, and are helpful in alerting patients to the realis tic medical consequences their disorders and in guiding clinicians ' concerning nutrition and participation in high-impact activities. T he mechanis ms of osteopenia/osteoporos is anorexia nervosa are more complex than in postmenopaus al os teoporos is , and treatments us eful in postmenopaus al women do not neces sarily help in anorexia nervosa. E strogen s upplementation in nervos a has been shown to offer no benefit in bone mineral dens ity while the patient is still low in weight. P.2015 Ovarian sonograms , preferably trans vaginal, can be particularly us eful in as sess ing individuals who have adopted (and for whom early growth charts are unavailable) or have grown substantially and when a healthy target weight is uncertain. Ovarian changes in a dose–res ponse relationship to the degree of starvation. Multiple small follicles are present when an individual is extremely starved; several s mall cys ts polycys tic, not abnormal polycys tic) are seen with weight restoration. W hen a woman is clos e to normal mens truation, a s ingle dominant cys t is pres ent. T hus, status of the ovarian follicles may be a useful guide to amount of weight res toration indicated. Healthy targe t weight, defined as the weight at which ovulation can spontaneously occur, is achieved when weight is approximately 5 lb greater than the weight at which a 2335 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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single dominant cys t can be present. On the average, weight at which mens es reoccur is approximately 92 percent of healthy weight for an individual woman. T he structural and functional neuropathology of nervos a is increasingly well documented by magnetic res onance imaging (MR I), computed tomography (C T ), functional MR I (fMR I), pos itron emis sion tomography and s ingle photon emis sion C T (S P E C T ) scans . total brain volume and s ulcal complexity and increas es brain ventricular size are us ually seen, but normal brain structural studies may als o be s een in s ome very malnouris hed patients. T he neuropathology of anorexia nervos a revers es substantially with refeeding and gain. However, although white matter deficits recover, gray matter changes resulting from s tarvation may not completely return to normal, even many months after weight restoration. T hes e abnormalities are often in corresponding deficits s een in neurops ychological tes ting. Approximately 40 percent of typical anorexia nervos a patients score in an abnormal range on two or more neuropsychological tests in standard batteries , suggesting that thes e patients may have difficulties cognitive-behavioral therapies and other in these s tates. T he extent to which long-term improvement in neuropsychological abnormalities may occur in proportion to weight restoration and ces sation binge–purge activity over a prolonged period of stability not yet clear. F unctional imaging s tudies have unusual degrees of temporal lobe vascular flow in adoles cent anorexia nervos a patients, with abnormalities after weight res toration in some patients , but these studies await extension, replication, and 2336 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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confirmation. In usual clinical practice, neuroimaging is neces sary, but, in patients with atypical features, if other findings sugges t that a brain lesion may be present, imaging studies may be of value. Laboratory tes ts s hould not be us ed to frighten However, many individuals with anorexia nervosa, es pecially those who minimize or deny its s erious nes s, benefit from frank dis cus sions of laboratory S ympathetically shared res ults from bone mineral and other laboratory examinations may help patients reass ess and take their dis orders more serious ly. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > DIF F E R E NT IAL DIAG NO

DIFFE R E NTIAL DIAGNOS IS P art of "19 - E ating Dis orders " Differential diagnos is per se is not generally difficult a full his tory and mental state examination indicate findings of an eating disorder and the core ps ychopathology is present. It has been s ugges ted that eating dis orders primarily repres ent indirect manifestations of mood dis orders, but this hypothesis been robus tly rejected by s everal sources of evidence, including family s tudies . On their own, mood dis orders lack a drive for thinnes s and a morbid fear of fat, but depres sion may produce significant weight loss , lack of appetite, and many of the nonspecific symptoms of loss , s uch as irritability, apathy, and fatigue. B ecause disorders commonly cooccur within eating disorders, 2337 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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starting either before, coincident with, or after their their presence needs to be carefully delineated, and time cours e and temporal sequence relating thes e disorders must be noted. Most commonly, depress ive symptoms emerge gradually after the eating disorder started and almos t never have melancholic or features. S ome s tudies sugges t a higher-than-expected of type II bipolar illness in both anorexia nervosa in and bulimia nervosa. P atients with bulimia nervos a who concurrent seasonal affective dis order and patterns of atypical depres sion (with overeating and oversleeping low-light months ) may manifes t seasonal worsening of both bulimia nervos a and depres sive features . In these cases, binges are typically much more severe during months. B right light therapy (10,000 lux for 30 minutes , early AM, at 18 to 22 inches from the eyes ) may be a component of comprehens ive treatment of an eating disorder with seas onal affective dis order. S imilarly, anxiety dis orders may be pres ent before or accentuated during the emergence of eating disorders . E ating dis orders thems elves do not conform either to generalized anxiety or to panic dis order diagnostic although thes e are frequent comorbid syndromes . In instances, a case might be made that anorexia nervos a subs tantially results from a phobic anxiety disorder fear of fatness as the core of the psychopathology). confusion may occur in which previously unrecognized choking episodes and food avoidance result in weight loss due to fear of recurrent choking, a form of specific phobia. C areful his tories may elicit previous episodes of choking on food, often in childhood, that 2338 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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not previously recalled and may be confirmed by a A s mall number of patients, usually s ocially phobic, sens itive personalities, fear vomiting in public, based on previous experiences . S uch fear of los ing in public may lead to s ubstantial food inhibition, but individuals manifest the core ps ychopathology of anxiously anticipating uncontrolled vomiting rather than primarily des iring thinness or fearing fatnes s. actual vomiting episodes , in the form of ps ychophys iological reactions , often do occur in the context of specific types of social phobias, such as fright and performance anxieties . E ating dis orders have been identified primarily as Although OC D as an Axis I comorbidity may occur in 25 percent of patients with anorexia nervos a, eating disorders are s eparate dis orders. B y definition, OC Ds involve ego-alien thoughts or behavioral urges that are res is ted, but the process of resis ting generates anxiety. S elf-starvation in anorexia nervosa is us ually, at least initially, ego-syntonic and based on overvalued beliefs the benefits of weight los s rather than on ego-alien thoughts and behaviors, such as excess ive handor checking behaviors. More likely to be pres ent in anorexia nervosa than Axis I OC D as a state are compuls ive traits and obsess ive-compuls ive disorder, marked by perseverance, perfectionis m, inflexibility, and emotional hypersens itivity in the face of failure or disappointment with performance. In body dysmorphic dis order, obsess ions focus on specific parts, not on the body as a whole or on weight or S ubstance abuse, es pecially of s timulants , can subs tantial weight los s. T he use of s timulants by eating 2339 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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disorder patients may be us efully divided into cases in which the s timulants are used primarily to promote loss and those in which substances are used for experiences or mood improvement. Alcohol abus e is more common in bulimia nervosa than in res trictinganorexia nervosa. When present, it may dis inhibit and allow the individual to eat s ome otherwis e impermis sible calories or releas e underlying hunger dysphoria, res ulting in binge behavior followed by purging. P.2016 Among bulimia nervos a patients , a substantial perhaps 15 percent—have multiple comorbid impulsive behaviors , including s ubs tance abus e, and lack of control thems elves in such diverse areas as money management (resulting in impulse buying and shopping) and sexual relations hips (often resulting in pass ionate attachments and promiscuity). T hey exhibit self-mutilation, chaotic emotions , and chaotic s leeping patterns. T hey often meet criteria for borderline personality dis order and other mixed pers onality and, not infrequently, bipolar II disorder. Occasionally, delus ional dis orders or other ps ychotic conditions as sociated with fear that food is being poisoned may result in food avoidance, but the diagnosis is usually not difficult. Although clinicians who are not familiar with eating disorders often confus e eating dis orders with primary gastrointestinal or endocrine medical diagnoses , s uch confusion almost always disappears when core 2340 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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ps ychopathology is ass ess ed. In more than 60 cas es National Ins titutes of Health, where extens ive medical laboratory examinations were made, not a s ingle individual was later found to have a primary medical for his or her weight los s when core eating disorder ps ychopathology was present. T his principle has been confirmed in several thous and additional cas es . coincidental medical dis orders may be pres ent—for example, a higher-than-expected incidence of irritable bowel s yndrome occurs in patients with anorexia F urthermore, eating dis orders may certainly produce profound medical consequences in many cases , s uch compress ion of the superior mesenteric arteries in emaciated patients resulting in s ignificant intermittent abdominal pain and s ymptoms of small-bowel (W ilkie's s yndrome) or the s uperior mes enteric artery syndrome (T able 19-9). However, the medical symptomatology is never the cause of the eating In occas ional cas e reports about brain tumors misdiagnos ed as anorexia nervos a, the nonspecific loss , amenorrhea, and apathy seen in s uch cases are accompanied by self-induced s tarvation or a morbid of fatness .

Table 19-9 Potential Medic al C ons equenc es of E ating Dis order and S ys tem Affected

C ons equence 2341

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Anorexia nervos a

 

   V ital signs

B radycardia, hypotens ion marked orthos tatic changes , hypothermia, poikilothermia

   G eneral

Muscle atrophy, los s of body

   C entral system

G eneralized brain atrophy enlarged ventricles, cortical mas s, seizures, abnormal electroencephalogram

   C ardiovas cular

P eripheral (s tarvation) decreased cardiac diameter, narrowed left ventricular wall, decreased res ponse to demand, s uperior mes enteric artery s yndrome

   R enal

P rerenal azotemia

   Hematologic

Anemia of s tarvation, leukopenia, hypocellular bone marrow

   G as trointes tinal Delayed gastric emptying, 2342 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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gastric dilatation, decreased intes tinal lipas e and lactase    Metabolic

Hypercholesterolemia, nonsymptomatic hypoglycemia, elevated liver enzymes , decreased bone mineral dens ity

   E ndocrine

Low luteinizing hormone, low follicle-stimulating hormone, low estrogen or testosterone, low/normal thyroxine, low triiodothyronine, increas ed revers e triiodothyronine, elevated cortis ol, elevated growth hormone, partial diabetes ins ipidus , increased prolactin

B ulimia nervos a and binge-eating and type anorexia nervos a    Metabolic

Hypokalemic alkalosis or acidosis, hypochloremia, dehydration

   R enal

P rerenal azotemia, acute and chronic renal failure

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   C ardiovas cular

Arrhythmias , myocardial toxicity from emetine (ipecac)

   Dental

Lingual s urface enamel los s, multiple caries

   G as trointes tinal S wollen parotid glands, elevated serum amylas e gastric distention, irritable bowel s yndrome, melanos is coli from laxative abus e    Mus culos keletal C ramps, tetany E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > C O UR S E AND P R O G NO

C OUR S E AND PR OGNOS IS P art of "19 - E ating Dis orders " T he cours e of eating dis orders is extremely varied in duration and s everity. T hey are truly spectrum es pecially bulimia nervosa. S ome broad pers pectives concerning the natural history of the eating dis orders as follows . Outcome reports des cribing the natural of eating dis orders depend greatly on how the are defined. Using a fairly rigorous definition of nervos a that includes a his tory of hos pital care, high mortality rates have been reported, with studies 2344 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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up to 19 percent death rates in patients who received relatively little posthospital care on 20-year follow-up. Other studies , from centers using very structured treatment programs to full weight res toration and with intens ive group and family psychotherapy, document premature deaths on 10- to 15-year follow-up. Although this s tudy excluded dropouts from treatment it represents the best results publis hed in patients than 18 years . S ome s tudies s uggest that death rates among young women with anorexia nervosa may be as much as 12 times higher than age-matched community comparis on groups and up to twice as high as other female ps ychiatric populations. Death in chronically ill relaps ed patients occurs in a s teady progress ion, in proportion to the number of years out of hos pital. Most recent outcome studies involve follow-up after form of treatment. No data currently exist on which treatment methods res ult in the lowest morbidity and highes t rates of global improvement. T he best cons isting of no deaths and complete abs ence of disorder s ymptoms in 70 percent of patients on followwere found in adoles cents initially treated with inpatient acute treatment in a multidis ciplinary program followed by 4 years of intens ive relaps e prevention emphasizing carefully conducted, evidence-based, informed psychotherapy. F ollow-up studies of anorexia nervos a patients that encompas s a broad range of initial s everity, and s ubs equent chronicity reveal that, overall, approximately 30 percent are well, 30 percent partially improved, 30 percent are chronically ill, and 10 percent have died. Many continue to have chronic anxiety, and pers onality disorders . 2345 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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Long-term s tudies show higher-than-expected subs equent rates of an as sortment of medical among those with adolescent eating dis orders. Of increasing concern and only recently documented is fact that long-term os teopenia and osteoporosis are commonly found even in young anorectic patients. T he sobering implication is that thes e female patients will enter the postmenopausal P.2017 phase, even if they return to normal gonadal function, amounts in the “bone bank” insufficient for the additional decline after menstrual function ceas es. Of concern is the demonstration that es trogen is res toring bone density in s tarved patients . T he wors t outcome of any eating disorder involves a combination anorexia nervosa and type I diabetes mellitus , with this group accounting for a dis proportionately high number deaths on follow-up. Mortality for patients with type I diabetes and anorexia nervos a is 34.8 percent compared to 6.5 percent for type I diabetes alone and percent for anorexia nervosa alone. A common finding on follow-up is the trans ition from anorexia nervosa to bulimia nervos a—seen in 50 of bulimia nervosa cas es —but the oppos ite transition occur, and many patients move in and out of complete partial syndromes of these dis orders. An encouraging finding s uggests that, on long-term follow-up, it is completely pos sible for many intens ively treated adoles cents to show complete cure with the absence of any diagnos able eating disorder on follow-up years T hese findings are cons is tent with other s tudies , 2346 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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suggesting that, in general, young age of onset and treatment intervention to attain and maintain full weight res toration are ass ociated with better prognos is. T he best prognostic s igns in anorexia nervos a for excellence in outcome are completely normal weight at discharge from acute treatment, intensive follow-up by experienced teams, les s rather than more ps ychiatric comorbidity, les s severe decreas e in weight at shorter duration of illness , and average age of ons et in early to mid-teens rather than very young age or ons et later than 25 years . Malenes s by itself confers no ris k for poor outcome. Men with some degree of sexual fantas y or activity before anorexia nervosa have a outcome. B ulimia nervosa is a more variable dis order than nervos a in its s everity, comorbidity, and treatment outcome. Although much more recently described than anorexia nervosa, it has been better studied because higher prevalence, its lack of severe weight loss hospitalization, and the relative eas e of completing outpatient treatment s tudies comparing and contrasting ps ychotherapeutic and pharmacological interventions. general, bulimia nervos a is characterized by higher partial and full recovery compared to anorexia nervos a. noted in the treatment section, treated cases fare much better than untreated cases . Untreated cases tend to remain chronic or may show small but generally unimpres sive degrees of improvement with time. In a year follow-up study of patients who had previous ly participated in treatment programs, the number of who continued to meet full criteria for bulimia nervosa declined as the duration of follow-up increas ed. 2347 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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Approximately 30 percent continued to engage in recurrent binge-eating or purging behaviors. A history subs tance use problems and a longer duration of the disorder at presentation predicted wors e outcome. Depending on definitions, 38 to 47 percent of women were fully recovered at follow-up. Often, the type of ps ychiatric comorbidity defines the outcome of treatment more than the illnes s its elf. clus ter analysis s tudies have s uggested three coherent prototypes based on eating disorder symptoms and personality profiles : a high-functioning or perfectionistic group with reasonably good prognos is , a cons tricted or overcontrolled group for which the condition is us ually chronic, and an emotionally dysregulated or undercontrolled group leas t likely to recover. F or among patients with bulimia nervos a, those with impulsive behaviors and borderline personality have much less likelihood of s ticking with treatment recovering than those with no s ignificant comorbidity or only mild depres sive symptoms . Malenes s has not proved to be a predictor of advers e outcome in either anorexia nervosa or bulimia nervosa. Among men, as in women, the best outcomes occur in adoles cents with good sexual adjustment for their age before the onset of illness , with s upportive families , have had les s initial weight loss and less ps ychiatric comorbidity. B inge-eating dis order, s till in a process of definition, appears to have les s mortality on follow-up than nervos a. Long-term outcome s tudies related to s pecific methods of treatment are lacking, but early studies are encouraging. S evere obesity augurs worse health 2348 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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outcomes , es pecially clas s II obesity (body mass index and clas s III obesity (body mass index of more than E ven less well-defined in outcome is reverse anorexia, which overlaps with the newly defined s pectrum of dysmorphic dis orders in men. T he outcome of ps ychiatric comorbidity in eating disorders is variable. T he res pons iveness or of comorbid Axis I mood and anxiety dis orders and depends largely on whether thes e s yndromes the ons et of eating disorders or occurred in their wake. S evere mood and anxiety disorders and OC Ds exis ting before the eating disorders generally remain long-term problems requiring s pecific additional treatment, but, even without s pecific treatments for them, obsess ive depres sive s ymptoms often improve s ubs tantially when weight is restored to normal in anorexia nervosa and when bulimia nervosa abates . T he most common outcome after weight recovery and behavioral improvement for vulnerable pers onality traits worsened starvation, s uch as perfectionism, perseverance, and avoidance, is the return to preillnes s levels. F or all disorders , the greates t ris k of relaps e occurs in the first months after s ucces sful treatment. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > T R E AT ME NT O F E AT ING DIS OR

TR E ATME NT OF E ATING DIS OR DE R S P art of "19 - E ating Dis orders " 2349 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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T he four es sential components of treatment are s ound principles, evidence-based practices (to the extent that studies have been published), a s pectrum of care appropriate to the intensity of illnes s, and a s killed multidis ciplinary team for serious cas es. T he core treatment goals for all eating disorders are and transdiagnos tic: (1) attaining and maintaining a normal, healthy, individualized, stable body weight; (2) stopping all abnormal eating behaviors, such as food res tricting, binge eating, or purging, and ass ociated abnormal behaviors, especially compulsive exercis e; dismantling the core overvalued beliefs and unhealthy cognitive “schemas ” of automatic cognitive distortions, replacing them with healthy, balanced views of s elf (not primarily dependent on body weight or shape) and the capacity for emotional and behavioral s elf-regulation; treating the comorbid conditions , ps ychiatric and and (5) planning for ongoing relaps e prevention for approximately 5 years after acute improvement. T he methods of treatment include medical, nutritional, ps ychotherapeutic, behavioral, and pharmacological components. T reatment planning requires matching the intens ity of treatment to the s everity of illnes s. After outpatient comprehens ive ass ess ment, patients will be referred to appropriate levels of intens ity of care, from medical/pediatric intensive care units for the medically uns table; s pecialty eating disorder inpatient units for the majority of serious cases of eating step-down or s tep-up to partial hospital (full-day) programs —to long-term res idential community where needed or to outpatient treatment for les s cases; or relaps e prevention. T reatment of s evere disorders usually requires trans itions between several 2350 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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steps in the s pectrum, with steps up and s teps down according to respons e to the initial location of Outreach and prevention programs in school and community s ettings round out res ources . P.2018 S tudies s how that outcomes are generally better for patients treated in specialty eating dis order units than general ps ychiatry units that lack specialty programs are considerably better for anorexia nervosa cas es to full normal weight.

Treatment of A norexia Nervos a Inpatient care is indicated not only for physiological abnormalities , but also to provide 24-hour treatment, management, and containment for the intensively ingrained behavioral abnormalities , such as s tarving, compuls ive exercising, and purging, which often have failed to respond to even full-day programs. At weights below 20 percent less than healthy, except under circums tances , most patients require inpatient care; es pecially if the eating disorder is recurrent or with significant psychological or medical comorbidity. E ven full day or partial hospital programs may not adequate containment to produce recovery but are increasingly us ed in the s pectrum of care. C ontroversy exists concerning the propriety and us e of treating treatment-reluctant patients on an involuntary basis through legal commitment. Approximately 10 to percent of cas es in large treatment programs require involuntary treatment. In life-threatening cases , involuntary treatment is appropriate when pers uas ion 2351 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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alone fails to get the patient to agree to accept S tudies s how that involuntarily committed patients approximately the s ame outcomes as voluntarily committed patients during acute hospitalization, almost always subsequently appreciate the intervention, and rarely pers is t in feeling angry or litigious . R eluctance of some third-party payers to authorize ongoing care for s everely ill anorexia nervos a patients presents a formidable challenge to patients, families , clinicians . As lengths of stay have decreas ed for nervos a due to insurance res trictions, relapse rates increased. E ffective state and federal parity laws , as judicial decis ions, may help. A federal dis trict court– decis ion ruling that medical benefits s hould be made available to patients with anorexia nervosa until they 85 percent of healthy weight has been underutilized as precedent for access ing medical benefits for the as sociated with anorexia nervos a. T he judge reasoned malnutrition is a medical diagnos is and that medical benefits, regardless of the cause of a medical dis order, legally mandated. T ypical anorexia nervos a patients can transition to hospital from inpatient care at 85 percent of healthy weight, but exceptions occur. T hose with chronic and repeated bouts of illness , comorbid diabetes, or s evere comorbidities on Axis I and Axis II may require higher weights and more prolonged inpatient s tays. T he difference between partial hospital and inpatient care is the length of treatment during the 24-hour day, not the intens ity of treatment or the adequacy of a multidis ciplinary staff. S hort-term s ucces sful treatment appears directly related to the number of hours per day 2352 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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and number of days per week of containment and treatment. G oing from 5 to 4 days per week in day programs has resulted in approximately 25 percent effectivenes s. R egarding exceptions to hospital care, research is under way to examine the effectivenes s of s upervis ed family-based outpatient treatment, in which highly motivated, involved, carefully instructed, and clos ely supervis ed parents may supervis e the refeeding of adoles cent patients—the so-called Maudsley model, protocolized and often s ucces sful. Data from these may influence treatment practices in the future.

Weight R es toration T he initial s hort-term goal is to res tore patients fully, and promptly to the ideal healthy range as s pecified in population weights for age, height, and gender or the weight at which there is a 50 percent chance of return mens es for adolescent girls. T he ultimate goal, not achieved during initial inpatient or partial hospital treatment, is to res tore each person to biological for women, the weights at which they will menstruate ovulate without artificial inducements and, for men, the weights at which normal s exual physiology and returns . Accordingly, some patients will not achieve normal biological function until they reach higher than they desire. T he concept of a bell-shaped of heights is widely accepted, but s imilar acceptance is lacking by many clinicians and mos t eating-disordered patients for body weights. Methods of achieving weight res toration vary, but available evidence s uggests that nursing-supervis ed 2353 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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refeeding of normal food in appropriate amounts and composition as directed by a dietitian promptly and res tores weight. F or women receiving inpatient care, approximately 3 lb per week are res tored and, for men, to 4 lb per week; up to 2 lb per week are res tored in hospital programs . In outpatient treatment, a minimum weight res toration of 1 lb per week is readily achievable with motivated patients. Although nasogas tric feedings are not ordinarily recommended or endorsed, s ome adoles cent medicine and pediatric programs use overnight gas tric gavage to supplement, but not oral feedings in an effort to achieve desired weights efficiently. Hyperalimentation by central venous lines is us ually contraindicated and often fraught with s evere medical complications. F ailure to fully restore weight adversely affects future outcome. Hunger, even in mildly underweight patients, often s erves to trigger binge-eating episodes . In patients above 70 percent of healthy weight can s tart at 1,500 calories per day, which can be increas ed 500 per day every 4 days during inpatient or partial hos pital treatment or each week in outpatient care. T ypically, women require a maximum of 3,500 calories per day, men may need 4,000 calories or more. T hese levels of energy intake are varied according to individual and medical complications, the mos t common of which are refeeding edema, gastric bloating, and, invariably, cons tipation. Any goal of less -than-fully-normal weight subs tandard. R efeeding hypophosphatemia is an occasional finding even in purely food-res tricting nervos a patients during treatment and requires

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Other Treatment G oals and T he treatment challenge of eating dis orders is enabling patients to s tart eating normally and s top compulsive exercise, binge eating, purging, and other behaviors . E vidence sugges ts that the most effective to change abnormal behaviors , whenever pos sible, is completely interrupt them from the beginning of treatment and replace them with healthy alternatives .

Medic ation When experienced eating dis order inpatient units comprehensive care for anorexia nervos a, adding ps ychotropic medications —specifically, selective serotonin reuptake inhibitors (S S R Is) or atypical antips ychotics —appears to offer no added advantage typical cas es . F urthermore, low-weight patients are likely to experience medication side effects, particularly from tricyclic antidepress ants (T C As ). S everal contribute to the s ens itivity of malnouris hed patients to medications —for example, depletion of body protein, particularly albumin, can increas e the percentage of unbound or free drug in blood, and depletion of body can decrease the volume distribution of fat-soluble medications , leading to increases in s teady-state levels. T he use of thes e medications in other s ettings more treatment-res is tant cases has not been fully explored. W hen s evere major depres sion, anxiety disorders , or OC D precede the ons et of anorexia P.2019 nervos a, concurrent pharmacological treatment of conditions may be helpful. On occasion, antianxiety 2355 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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medications may enable patients to deal with the anticipatory anxiety of confronting meals. T wo studies have demons trated that S S R Is are not more effective placebo in decreasing depress ive symptomatology or improving weight restoration in s tarved anorexia patients during nutritional rehabilitation. It is not clear whether the atypical neuroleptics play any role in treatment of eating dis orders, or whether they provoke ego-dystonic appetite and the metabolic syndrome. (50 to 100 mg elemental zinc) has been s hown to more rapidly improve weight res toration in anorexia nervos a. Once weight has been res tored, fluoxetine (P rozac) been s hown to reduce relapse in anorexia nervos a, compared to placebo, all other factors being equal. Of caution, one outpatient s tudy found that adoles cents anorexia nervosa los t weight on citalopram (C elexa) ps ychotherapy vers us ps ychotherapy alone.

Ps yc hotherapies In addition to restoring weight and interrupting eating and exercis e behaviors , treatment requires addres sing the core psychopathology of the eating disorders . P sychotherapies aimed at modifying and altering core pathological beliefs and other contributing ps ychopathological iss ues are key elements of Available evidence strongly favors treatments based on cognitive-behavioral therapies , similar to those robustly demonstrated to be effective in bulimia nervosa, but well proven in anorexia nervos a becaus e of the status of starved patients and the ethical of random as signment to no ps ychological treatment. Additional alternative ps ychotherapeutic interventions 2356 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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based on interpers onal therapies , family therapies , or ps ychodynamically informed ps ychotherapies — particularly thos e us ing s elf-ps ychology and “focal analytical” approaches —may als o be beneficial. S imply changing the abnormal behaviors through behavioral contingencies of reward and punis hment has been disproved as being effective for more than the s hort as it ess entially lets patients “eat their way out of without change in the overvalued beliefs and distorted cognitions. T he core of ps ychotherapeutic treatment is succes sfully engaging and relating to patients , their own self-awarenes s and motivation for change persuading and helping them to recognize, challenge, replace their overvalued beliefs regarding the of weight loss and their phobic fear of fatness with acceptance of healthy, normal, individualized body weights and the skills for s elf-regulation. F or patients with anorexia nervos a, s tudies show that involvement is es sential for good outcomes , with elements of family education, counseling, instruction, therapy incorporated into treatment. Individual, group, and family contexts for ps ychotherapy are all effective, the blend of these contexts is decided on a or age-appropriate bas is .

Treatment of B ulimia Nervos a P sychiatric hos pitalization is only occasionally the treatment of normal-weight patients with bulimia nervos a. E xceptions are the presence of intractable symptoms producing s ignificant physiological repeated failure to respond to competent outpatient treatment, suicidality, and the presence of complicating comorbidities, especially borderline personality 2357 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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subs tance abus e, and mood dis orders. F ifteen percent recent and less severe cases of bulimia nervosa have res ponded to four s es sions of ps ychoeducation emphasizing healthy nutrition with relief of bulimic symptoms and behaviors . Up to 20 percent res pond to guided self-help programs us ing profes sionally manuals , ps ychoeducation, and cognitive-behavioral principles. F or the average, moderately severe cas e of bulimia nervosa, cognitive-behavioral therapy has been clearly documented as an effective treatment that is superior to other forms of psychotherapy or ps ychopharmacology alone. Of concern is the fact that relatively few clinicians have currently received training in cognitive-behavioral ps ychotherapy s kills . C ognitive-behavioral therapy has been effective in both individual and group formats, with s hort-term reported by 40 to 50 percent of cas es treated with cognitive-behavioral therapy and s ymptom reduction to less er degree reported in higher percentages. If show little res ponse to cognitive-behavioral therapy approximately eight sess ions, s tudies suggest that an S S R I will improve outcome. At times, other ps ychotherapies , es pecially interpersonal may be mos t us eful. P s ychodynamically informed ps ychotherapies have not yet been well studied for bulimia nervosa, but experienced clinicians value ps ychotherapeutic tactics derived from ps ychodynamic perspectives , particularly relational therapies, s elfps ychology, and focal analytic therapies. E nhancing motivation is a key early treatment element. Antidepress ants have been s hown to be effective for symptom reduction in bulimia nervosa, with 2358 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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approximately 60 percent experiencing some s ymptom reduction. However, their use as a s ole therapy is not adequate to effectively treat most patients , as relatively few patients become abstinent of binge eating and purging on medication alone, and most relapse if the medication is discontinued. F luoxetine has been the extensively s tudied, and higher doses —60 to 80 mg day—appear to be more effective than the 20- to 40per-day traditional antidepres sant dose if there are components. In addition, T C As and monoamine inhibitors (MAOIs ) have been effective, although more problematic due to s ide effects and potential for suicide by overdos e. S urpris ingly, res ults using fluvoxamine (Luvox) have not been better than B upropion (W ellbutrin) is relatively contraindicated due an increas ed ris k for seizures in patients with bulimia nervos a. In practice, if results from the initial trials are inadequate, clinicians have found that trying several medications in sequence yields better res ults. If res ults are beneficial, a minimum of 6 months a year on medication is sugges ted, preferably in conjunction with C B T . S tudies in which bulimic patients have been treated both evidence-based ps ychotherapy and conjoint ps ychopharmacology s how small but important over cognitive-behavioral therapy alone and, over pharmacology alone.

C ognitive-B ehavioral Therapy C ognitive-behavioral therapy for bulimia nervosa of s everal phas es . T he firs t focuses on educating about bulimia nervos a, helping them to increas e the 2359 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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regularity of eating and res is t urges to binge or purge, part, through careful self-monitoring and recording. T he second phas e us es various s tructured procedures and homework as signments to help patients broaden their food choices and identify and correct dys functional attitudes, beliefs, and avoidance behaviors . Next, are taught to identify interpersonal stress ors and deal more effectively with them by employing more adaptive coping s tyles. F inally, after s ymptoms have abated, prevention s trategies are us ed to reduce the likelihood relaps es by anticipating and preparing for s tres sful situations and s etbacks likely to be encountered in the future. A lis t of guided self-help cognitive-behavioral therapy–oriented workbooks for patients and clinicians appears in the reference list. P atients with difficult-to-manage multiimpulsive bulimia nervos a are currently being treated with combinations dialectical behavioral P.2020 therapy, intensive psychotherapies, and medications . C ontrolled s tudies are under way to examine the effectivenes s of s uch treatment approaches for these patients.

Treatment of B inge-E ating B ecaus e binge-eating dis order and nonpurging bulimia nervos a clearly overlap, systematic res earch on bingeeating dis order has been des igned based on of bulimia nervosa and non–binge-eating forms of and current treatment recommendations derive from information from all of these fields. G eneral treatment 2360 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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principles s ugges t that binge-eating behavior s hould be addres sed before weight reduction for obesity is attempted. T reatment of the binge-eating behaviors is us ually bes t accomplis hed via treatment with cognitivebehavioral therapy, and s ome s tudies show that, for control of binge-eating behaviors , medications add little well-conducted cognitive-behavioral therapy. However, because only approximately 50 percent of patients stop binge eating after cognitive-behavioral therapy and because the addition of antidepres sants has been to increas e weight los s and s ometimes increase rates when added to cognitive-behavioral therapy, the addition of antidepres sant medication is often us eful. In addition to cognitive-behavioral therapy, interpersonal therapy has also shown effectivenes s for binge-eating disorder. A randomized clinical trial s howed that both therapies administered in group settings were similarly effective in achieving binge-eating recovery (73 to 79 percent posttreatment and 62 to 59 percent at 1 year). S ymptoms of binge eating per se appear to benefit medication treatment with s everal different S S R Is, desipramine (Norpramin), imipramine (T ofranil), and, recently, topiramate (T opamax). Open studies s ugges t inositol and sibutramine (Meridia) may be us eful. Most, not all, s tudies s how that medication added to behavioral therapy is much more effective than medication alone. Older s tudies showed that high-dose S S R I treatment (e.g., fluoxetine at 60 to 100 mg) often initially res ulted in weight loss . However, the weight was ordinarily short lived, even when medication was continued, and weight always returned when was stopped. 2361 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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T reatment of the obesity ass ociated with binge-eating disorder requires both nutritional modification with reduction and an increas e in aerobic exercis e. F or obesity, especially class III, medical s upervision and, occasion, gastric surgery are required.

S elf-Help G roups E vidence indicates that self-help groups —often laycan be beneficial for those who have a variety of and ps ychiatric disorders. S ome reports s uggest that malnouris hed anorexia nervosa patients may have difficulty participating in groups and that advers e cons equences of group participation may include competition for being the thinnes t patient and learning new maladaptive, “pro-anorexia” techniques. T here is general agreement that groups can be helpful for nervos a. A spectrum of profes sionally mediated to lay-led groups exis ts. Although data are sparse, some reports indicate that a subpopulation of patients with bulimia nervosa and binge-eating dis order find organizations s uch as Overeaters Anonymous (OA) to helpful (with experience varying from group to group individual to individual). F or the treatment of moderate obesity, organizations such as W eight W atchers can extremely helpful and are free of common fads or fixes .”

R elaps e Prevention R is k of relaps e is most common the first several years recovery. Ongoing treatment requires attention both to preventing relaps e and to enhancing the development and adaptability of recovering patients. In 2362 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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addition to monitoring for signs of s ymptom return, clinicians attempt to guide patients to work toward developing age-appropriate behaviors and mature skills ; satis fying involvement in s chool, work, and social relations hips ; and an identity bas ed on healthy core rather than on an eating dis order. Major challenges individuals whos e identities have centered around their eating disorders and who cannot imagine life without anorexia nervosa or bulimia nervosa. In relapse work, common cris es can be anticipated, s uch as the return to school, family, holidays involving food, special occasions, complexities in relations hips, moves , and unexpected disappointments. P revention requires building alternative coping skills and methods of stress reduction so that s tres sors do not automatically trigger regress ion to maladaptive, ineffective eating dis order– related modes of reaction. Methods include ongoing ps ychotherapy incorporating basic elements of behavioral therapy, as well as interpersonal and other ps ychotherapies . T he focus remains on continuing weight and eating behaviors and moderate exercis e. weight-res tored anorexia nervos a patients in follow-up, patients receiving fluoxetine—averaging 40 per day—experienced les s weight los s and fewer of depress ion and rehospitalization in the subsequent than those not receiving medication. T he clinicians who are most effective with eatingdisordered patients combine nonposs es sive warmth; freedom from controlling or hierarchical relations hips based on power; a s ound knowledge of technical ps ychotherapeutic s kills , normal human development, family dynamics , and sociocultural influences; an 2363 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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unders tanding of the neurobiology of food and weight regulation and the medical symptomatology of eating behaviors ; and the capacity to work as a team member leader. Although objectively not important, the gender the therapist may be subjectively very important to individual patients . S pecific training in eating disorders confers clinical advantages. G enerally well-trained clinicians who lack s pecific training with eatingpatients do not necess arily do well with thes e patients . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > S UG G E S T E D C R OS S -R E F E R

S UGGE S TE D C R OS S R E FE R E NC E S P art of "19 - E ating Dis orders " S ome of the specific syndromes that can be ass ociated with eating disorders are found in C hapter 13 on mood disorders , in C hapter 14 on anxiety dis orders , in on somatoform disorders, in C hapter 11 on s ubs tancerelated dis orders, in C hapter 21 on impulse-control disorders not els ewhere clas sified, in S ection 24.6 on endocrine and metabolic disorders , and in S ection 7.4 typical signs and symptoms of ps ychiatric illnes s. P ers onality disorders are dis cuss ed in C hapter 23, and relations hip between eating disorders and feeding in childhood, rumination, and pica are dis cus sed in 41. Other areas that relate to this chapter include cons ultation-liais on psychiatry (S ection 24.11), problems (C hapter 25), ps ychodynamic therapy 2364 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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30.1), and psychiatric treatment of infants, children, adoles cents (C hapter 48). S ections on genetics and ps ychiatry (S ection 1.18), psychopharmacology 31), and family therapy (S ection 30.5) provide more detailed background to unders tanding eating dis orders. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 19 - E ating Disorders > R E F E R E NC

R E FE R E NC E S Agras W S , Apple R F . O ve rcoming E ating Dis orde rs W orkbook: A C ognitive -B ehavioral T reatme nt for Nervos a. New Y ork: Academic P res s; 1999. Agras W S , W alsh B T , F airburn C G , W ilson G T , HC : A multicenter comparis on of cognitivetherapy and interpersonal psychotherapy. Arch G e n P s ychiatry. 2000;54:459–465. P.2021 *American P s ychiatric Ass ociation W ork G roup on E ating Disorders : P ractice guideline for the patients with eating disorders (revision). Am J P s ychiatry. 2000;157(1 S uppl):1–39. Andersen AE , ed.: E ating dis orders. P s ychiatr C lin Am. 2001;24(2). Attia E , Haiman C , W als h B T , F later S R : Does augment the inpatient treatment of anorexia Am J P s ychiatry. 1998;155:548–551. 2365 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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B achar E , Latzer Y , K reitler S , B erry E M: E mpirical comparis on of two ps ychological therapies . S elf ps ychology and cognitive orientation in the of anorexia and bulimia. J P s ychothe r P ract R es . 1999;8:115–128. B aran S A, W eltzin T E , K aye W H: Low discharge and outcome in anorexia nervos a. Am J P s ychiatry. 1995;152(7):1070–1072. B ergh C , E riks son M, Lindberg G , S odersten P : serotonin reuptake inhibitors in anorexia nervos a. L ance t. 1997;348(9023):339–340. B irmingham C L, G oldner E M, B akan R : C ontrolled zinc s upplementation in anorexia nervosa. Int J E at Dis ord. 1994;15:251–255. C olantuoni C , R ada P , McC arthy J , P atten C , Avena C hadeayne A, Hoebel B G : E vidence that excess ive sugar intake causes endogenous opioid dependence. O bes R es . 2002;10(6):478–488. Dare C , E is ler I, R us sell G , T reasure J , Dodge L: P sychological therapies for adult patients with nervos a: a randomised controlled trial of outpatient treatments . B r J P s ychiatry. 2001;178:216–221. Devlin B , B acanu S A, K lump K L, B ulik C M, F ichter Halmi K A, K aplan AS , S trober M, T reas ure J , DB , B errettini W H, K aye W H: Linkage analys is of anorexia nervosa incorporating behavioral 2366 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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Hum Mol G e net. 2002;11(6): 689–696. de Zwaan M, R oerig J . P harmacological treatment, evidence and experience in ps ychiatry. In: Halmi M, eds . E ating Dis orders . V ol 6. W orld P s ychiatric Ass ociation, J ohn W iley (in pre s s ). E as twood H, B rown K M, Markovic D, P ieri LF : in the E S R 1 and E S R 2 genes and genetic to anorexia nervos a. Mol P s ychiatry. 2002;7(1): 86– *E is ler I, Dare C , R uss ell G F M, S zmukler G I, le Dodge E : F amily and individual therapy in anorexia nervos a. A 5-year follow-up. Arch G e n P s ychiatry. 54:1025–1030. F airburn C . O ve rcoming B inge E ating. New Y ork: G uilford; 1995. F airburn C G , C ooper Z, Doll HA, W elch S L: R is k for anorexia nervosa: three integrated cas e-control comparis ons . Arch G e n P s ychiatry. 1999;56:468– F airburn C G , Norman P A, W elch S L, O'C onnor ME , HA, P eveler R C : A prospective study of outcome in bulimia nervosa and the long-term effects of three ps ychological treatments . Arch G e n P s ychiatry. 1995;52:304–312. F airburn C G , W elch S L, Doll HA, Davies B A, ME : R isk factors for bulimia nervosa: a communitybased case-control s tudy. Arch G e n P s ychiatry. 2367 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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1997;54:509–517. G arfinkel P E , Lin E , G oering P , S pegg C , K ennedy S , K aplan AS , Woodside DB : S hould amenorrhoea be neces sary for the diagnos is of nervos a? E vidence from a C anadian community B r J P s ychiatry. 1996;168(4):500–506. G arner DM, G arfinkle P E , eds . Handbook of E ating Dis orde rs . 2nd ed. New Y ork: G uilford; 1977. G ordon I, Las k B , B ryant-Waugh R , C hris tie D, C hildhood-onset anorexia nervosa: towards a biological substrate. Int J E at Dis ord. 1997;22 165. *G rice DE , Halmi K A, F ichter MM, S trober M, DB , T reasure J T , K aplan AS , Magistretti P J , B ulik C M, K aye W H, B errettini WH: E vidence for a susceptibility gene for anorexia nervosa on chromosome 1. Am J Hum G ene t. 2002; 70(3):787– Howard W T , E vans K K , Quintero-Howard C V , WA, Anders en AE : P redictors of s ucces s or failure transition to day hos pital treatment for inpatients anorexia nervosa. Am J P s ychiatry. 1999;156 1702. Hu X, Murphy F , K arwautz A, Li T , F reeman B , G iotakis O, T reasure J , C ollier DA: Analys is of microsatellite markers at the UC P 2/UC P 3 locus on chromosome 11q13 in anorexia nervosa. Mol 2368 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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2002;7(3):276–277. J ohns on J G , C ohen P , K asen S , B rook J S : E ating disorders during adolescence and the ris k for and mental disorders during early adulthood. Arch P s ychiatry. 2002;59(6):545–552. K eel P K , Mitchell J E , Miller K B , Davis T L, C row S J : term outcome of bulimia nervosa. Arch G e n 1999;56:63–69. K endler K S , Maclean C , Neale M, K es sler R , Heath L: T he genetic epidemiology of bulimia nervos a. Am P s ychiatry. 1991;148:1627–1637. Lambe E K , K atzman DK , Mikulis DJ , K ennedy S H, Zipurs ky R B : C erebral gray matter volume deficits weight recovery from anorexia nervosa. Arch G e n P s ychiatry. 1997;54(6):537–542. Levitan R D, K aplan AS , Mas ellis M, B asile V S , Lipson N, S iegel G I, Woods ide DB , Macciardi F M, K ennedy S H, K ennedy J L: P olymorphis m of the serotonin 5-HT 1B receptor gene (HT R 1B ) with minimum lifetime body mass index in women bulimia nervosa. B iol P s ychiatry. 2001;50(8):640– Lock J , le G range D, Agras W S , Dare C . T re atme nt for Anore xia N ervos a. New Y ork: G uilford P res s; Mitchell J E , F letcher L, Hans on K , Mus sell MP , C ros by R , Al-B anna M: T he relative efficacy of 2369 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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and manual-based self-help in the treatment of outpatients with bulimia nervosa. J C lin P s ychopharmacol. 2001;21:298–304. *P almer R L, B irchall H, McG rain L, S ullivan V : S elffor bulimic disorders : a randomised controlled trial comparing minimal guidance with face-to-face or telephone guidance. B r J P s ychiatry. 2002;181:230– P ierce DW , E pling F W: Activity-based anorexia: a biobehavioral perspective. Int J E at Dis ord. 485. P iran N, K aplan AS , ed. A Day Hos pital G roup P rogram for Anorexia Ne rvos a and B ulimia Ne rvos a. Y ork: B runner/Mazel; 1990. R atnasuriya R H, E is ler I, S zmukler G I, R uss ell G F : Anorexia nervosa: outcome and prognos tic factors 20 years. B r J P s ychiatry. 1991;158:495–502. R obb AS , S ilber T J , Orrell-V alente J K , V aladezE llis N, Dadson MJ , C hatoor I: S upplemental nasogastric refeeding for better s hort-term outcome hospitalized adolescent girls with anorexia nervosa. J P s ychiatry. 2002;159(8):1347–1353. S afer DL, T elch C F , Agras W S : Dialectical behavior therapy for bulimia nervosa. Am J P s ychiatry. 2001;158:632–634. S chmidt U, T reasure J . G e tting B e tter B itE by B itE : 2370 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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S urvival K it for S uffere rs of B ulimia Nervos a and E ating Dis orders . London: P s ychology P res s; 1993. S trober M, F reeman R , Lampert C , Diamond J , K ay C ontrolled family s tudy of anorexia nervosa and nervos a: evidence of s hared liability and partial syndromes. Am J P s ychiatry. 2000;157:393– S trober M, F reeman R , Morrell W : Atypical anorexia nervos a: separation from typical cases in cours e outcome in a long-term prospective study. Int J E at Dis ord. 1999;25(2):135–142. S ullivan P F : Mortality in anorexia nervos a. Am J P s ychiatry. 1995;152(7):1073–1074. T reasure J L, Owen J B : Intriguing links between behavior and anorexia nervos a. Int J E at Dis ord. (4):307–311. T reasure J , S chmidt U. Anore xia N ervos a. C linical E vide nce 7. London: B MJ P ublishing G roup; 162. V annatta J B , C agas C R , C ramer R I: S uperior artery (W ilkie's) syndrome: report of three cas es and review of the literature. S outh Me d J . 1976;69 1465. V illapiano M, G oodman LJ . E ating Dis orders : A C hange: P lans , S trategie s , and W orks he ets . New B runner-R outledge; 2001. 2371 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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V ink T , Hinney A, van E lburg AA, van G oozen S H, S andkuijl LA, S inke R J , Herpertz-Dahlmann B M, Hebebrand J , R emschmidt H, van E ngeland H, Ass ociation between an agouti-related protein gene polymorphis m and anorexia nervosa. Mol 2001;6(3):325–328. Walsh B T , Agras W S , Devlin MJ , F airburn C G , K ahn C , C hally MK : F luoxetine for bulimia nervosa following poor respons e to psychotherapy. Am J P s ychiatry. 2000;157:1332–1334. Watson T L, B owers W A, Anders en AE : Involuntary treatment of eating disorders . Am J P s ychiatry. (11):1806–1810. Wes tberg L, B ah J , R as tam M, G illberg C , Wentz E , J , Hellstrand M, E rikss on E : Ass ociation between a polymorphis m of the 5-HT 2C receptor and weight in teenage girls. Neurops ychopharmacology. (6):789–793. Wes ten D, Harnden-F ischer J : P ers onality profiles in eating dis orders: rethinking the distinction between axis I and axis II. Am J P s ychiatry. 2001;158 Wilfley DE , W elch R R , S tein R I, S purrell E B , C ohen S aelens B E , Dounchis J Z, F rank MA, Wis eman C V , G E : A randomized comparison of group cognitivebehavioral therapy and group interpers onal ps ychotherapy for the treatment of overweight individuals with binge-eating dis order. Arch G e n 2372 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/19.htm

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P s ychiatry. 2002;59(8):713–721. *Wolk S L, Devlin MJ . S tage of change as a predictor res ponse to ps ychotherapy for bulimia nervos a. Int J Dis ord. 2001;30:96–100.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > 20 - S leep Dis order

20 S leep Dis orders Wallac e Mendels on M.D. In traditional psychiatric practice, a complaint about the cons equences of the illness often leads to dis covery of underlying disorder. T hus, a patient who comes in to office because of difficulties at the job, or with his or spous e, may be found to have a previously depres sion. In a s imilar manner, the search for sleep dis orders us ually begins with a complaint about cons equences, usually insomnia or daytime J ust as an important as pect of helping the patient problem at first appeared to be job-related is to give a specific treatment for an underlying condition, s o, in treating s leep complaints, one must first recognize and give specific remedies for underlying proces ses. T his chapter reviews the pathophysiologies of s leep, emphasizing those likely to be seen in ps ychiatric B efore beginning, it should be mentioned that, of there are many other fascinating as pects of s leep that only pas sing relevance to the clinical s leep disorders presented here and, hence, are not covered in detail. Among thes e is the continuing mys tery of the ultimate functions of sleep. Like most drive behaviors, sleep probably has multiple functions, jus t as breathing, for instance, facilitates gas exchange but, in addition, 2374 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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a mechanism for speech and more complex behaviors, such as playing a mus ical ins trument. S o, too, s leep have originated to serve some bas ic need, on which are additional functions . F rom an evolutionary point of view, the observation that it involves a loss of cons cious nes s, which, at face value, makes an organism vulnerable to the dangers of the environment, suggests that its beneficial functions are important Among thos e that have been propos ed are energy cons ervation, res toration of cellular energy stores , emotional regulation, cons olidation of memory, and preservation of context in which to organize memory of new stimuli. As with the enigma of the functions of sleep, the nature dreaming is beyond the current s cope of this chapter. summary, interes t in s leep and dreaming as aspects of health goes back to the earlies t times . T he E gyptian Imhotep, who may be the earliest recorded physician in history and who was later wors hipped as a god hims elf, incorporated te mple s lee p in his treatment regimen in third millennium B C . B y P tolemaic times , many temples had sanatoria in which patients slept; it was believed that, while they dreamed, they were and healed by the res ident deity. In ancient G reece, Asclepius as ked his patients to sleep on the floor in his temple (although one wonders how comfortable this might be, given the proximity of the native snake population from which his symbol, and, ultimately, the badge of the medical profess ion, was derived). In both cases, patients were encouraged to talk about their dreams , which were likely influenced by the the temple setting and the religious beliefs of patient 2375 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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priest. T heories of functions of dreams in modern times are ranging from views that they repres ent manifestations unconscious conflicts or mechanisms for as similating stress ful events or that they represent a delirium-like P os itron emis sion tomography (P E T ) studies of rapid movement (R E M) sleep s ugges t that there is activation the pontine brains tem, as well as limbic and paralimbic cortical structures mediating emotional res ponses, accompanied by a reduction in activity of dors olateral prefrontal cortical structures regulating executive and mnemonic cognitive process es . T wo clinical s leep disorders ass ociated with dreaming, nightmares and terrors, are discuss ed later in this chapter. 

P R IMAR Y AND S E C ONDAR Y S LE E P

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P R IMAR Y INS OMNIA

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C IR C ADIAN R HY T HM S LE E P DIS T UR B ANC E S

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P E R IODIC LIMB MOV E ME NT S Y NDR OME

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R E S T LE S S LIMB S S Y NDR OME

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S LE E P -DIS OR DE R E D B R E AT HING

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NAR C OLE P S Y

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IDIOP AT HIC HY P E R S OMNIA

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P AR AS OMNIAS

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S UG G E S T E D C R OS S -R E F E R E NC E S

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > P R IMAR Y AND S E C O NDAR Y S LE E P

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PR IMAR Y AND S L E E P DIS OR DE R S P art of "20 - S leep Dis orders " S leep may, of course, be dis turbed as a consequence some other disorder. In the example us ed previous ly, a patient reported ins omnia as a res ult of depress ion. S imilarly, sleep may be disturbed owing to pain or discomfort from a medical illnes s. In terms of the fourth edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-IV -T R ), s uch cases are be s e condary s lee p dis orders . In contras t, primary dis orders res ult from conditions inherent to the mechanisms by which sleep is regulated. Although this us eful clinical distinction in organizing one's thoughts about a specific patient, ultimately, thes e two are les s clear. In the case of s leep disturbance due to depres sion, for instance, it is pos sible that fundamental alterations in biogenic amine metabolis m that alter states may als o lead to s leep disturbance. T he manifestation of primary sleep dis orders may als o be strongly influenced by nonsleep conditions . in children, for ins tance, often comes out during stress or family disturbance. Although secondary sleep disturbances are not the focus here, sleep in affective disorders is dis cuss ed for the reas ons given previous ly, the increased rate of ins omnia during periods of stress is mentioned in pass ing. Indeed, severe trauma, as that faced by thos e who survived the Holocaust, 2377 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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as sociated with reports of altered sleep and dreaming decades. E xternal stimuli can, of course, als o disturb as is reflected by the observation that the rate of prescriptions for sleeping pills (hypnotics) rises in areas surrounding major airports . On the other hand, the frequency of reported insomnia is approximately the in urban and rural areas , reflecting the univers ality of disturbance in basic s leep mechanisms and, perhaps dispelling the fantasy held by city dwellers of bliss ful country life. T he DS M-IV -T R divides primary s leep disorders into dys s omnias and paras omnias . T he dyss omnias, quantity or timing of sleep, are, in turn, divided into ins omnia and hype rs omnia. Insomnia is a perceived disturbance in the quantity or quality of s leep, which, depending on the s pecific condition, may be as sociated with dis turbances in objectively meas ured sleep. F orms insomnia include the primary ins omnias and circadian rhythm sleep dis turbances . P.2023 Hypersomnias represent conditions that are clinically expres sed as excess ive sleepiness . Again, this not as s harp in practice as this class ification s ugges ts. S ome circadian s leep disorders , s uch as delayed phase syndrome, for ins tance, may present as a of ins omnia at night, as well as morning s leepiness . S imilarly, periodic leg movement dis order may pres ent a complaint of insomnia or hypersomnia. P arasomnias abnormal behaviors during s leep or the trans ition between sleep and wakefulness . Often, they reflect the appearance of normal s leep proces ses at inappropriate 2378 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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times . In a s ens e, they are analogous to s exual in which a fundamentally normal, but often minor, in the context of overall s exual behavior comes to dominate and to disturb other as pects of s ex. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > P R IMAR Y INS O MN

PR IMAR Y INS OMNIA P art of "20 - S leep Dis orders "

Inadequate S leep Hygiene A common finding is that a patient's lifestyle leads to disturbance. T his is us ually phrased as inade quate hygie ne, referring to a problem in following generally accepted practices to aid sleep. T hese include, for keeping regular hours of bedtime and arous al, avoiding excess ive caffeine, not eating heavy meals before and getting adequate exercis e. F or example, a patient might come to clinic complaining of difficulty getting off to sleep. A closer examination of his history revealed he got home from his commute at 7:00 P M, ate a hasty dinner, kiss ed the kids goodnight, did s ome work for a hours, and then was s urprised to find that he could not sleep. In this case, the problem (or one of them) was his life no longer contained an evening in which to relax and to prepare for s leep. Alternatively, a school teacher might spend the evening grading papers and then find hims elf or herself wide awake at bedtime. In this case, intervention might be to teach him or her better timemanagement s kills to use during the daytime, so that 2379 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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or her evening will be free for relaxation. A patient who complains of awakening after only a few hours might out to be a dis co aficionado, whose extremely irregular bedtimes have disrupted the rhythm of s leep and In this case, guidance in keeping more regular hours be important. A variation on this problem is the patient whos e work and s ocial activities lead him or her to progres sively more sleep deprived as the week he or s he then cras hes and s leeps in on the weekends. Again, education about the importance of keeping relatively regular hours would likely be us eful. T wo caveats are in order when helping to educate a patient about s leep hygiene. T he firs t is that these are general principles and are not applicable to all patients . general, for ins tance, napping is discouraged, except in elderly and debilitated patients , but a s mall group of insomniacs may actually s leep better at night when take brief daytime naps . T he second is that when trying modify a patient's behavior, it is us ually better to focus one or two changes at a time, rather than ass aulting her with a panoply of desired changes , which can acros s as overwhelming. In a way, this is a s pecific general principle: When a tas k s eems so large as to be daunting, it can help to break it down into individual doable pieces.

P s yc hophys iologic al Ins omnia P sychophys iological ins omnia typically presents as a primary complaint of difficulty in going to s leep. A may des cribe this as having gone on for years and denies that it is as sociated with s tres sful periods in his her life. A typical comment is “I don't unders tand it; 2380 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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are actually going pretty well for me right now. If I could just get over this problem in going to s leep.” Often, the patient seems to be focused on the sleep disturbance how it is affecting his or her life. While lying in bed sleep, the patient typically ruminates about is sues on her mind, often thinking through the battles of the preceding day or planning s trategies for problems to be faced tomorrow. He or s he typically says that he or s he works at going to s leep and feels frustrated that his or efforts are not rewarded. C haracteris tically, the patient describes s leeping better when away from home. as ked, the patient reports that he or s he can fall as leep when not trying to, for ins tance, when watching A typical story is that the patient is dozing in the living room in front of the television; the s pouse then comes and wakes him or her up, s aying that it is time to go to bed. T hen, when the patient gets into pajamas and into bed, he or she feels wide awake and unable to It is thought that patients with ps ychophys iological insomnia have developed a conditioned s tate of heightened arousal that has become as sociated with act of going to bed or the environment in which s leep typically occurs —the bedroom. T he genes is of this conditioned respons e is not always certain, but, often, after getting to know the patient, one dis covers that the sleep dis turbance began after some emotionally event, which the patient has long since forgotten or he or s he no longer as sociates with the s leep difficulty. typical his tory would be that, s ome years before, the patient had an ups etting breakup with a girlfriend or boyfriend. In the s hort term, of cours e, he or she experienced sleep difficulty as part of a grief or 2381 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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reaction. In many individuals , the emotional ups et gradually works its way through in the next few weeks , and, as things s ettle down, s leep returns to normal. In these individuals, however, the emotional ups et but the s leep problem persists and s eems to take on a of its own. T he patient becomes worried about the poor sleep and works hard to overcome it. Over time, the original ass ociation with the traumatic event is One model of ps ychophys iological insomnia s uggests it can be cons idered to have three components —a predis pos ition, a precipitating cause, and factors that maintain the sleep dis turbance. Little is known about these patients may be more vulnerable to sleep disturbance. T he maintaining factors, however, appear include the excess ive worry about poor sleep. It is a bit like F ranklin R oos evelt's remark that “the only thing have to fear is fear itself.” In this case, the worry about sleeping becomes one of the caus es of poor s leep. In effect, the patient as sociates the act of entering the bedroom or going to bed with an uncomfortable condition generating anxiety and heightened arous al, which are incompatible with s leep. (B ecaus e of the res ponse on entering the bedroom, the patient reports that he or s he s leeps better when in a s trange environment—such as a hotel room—than when at home.) Often, he has found that, in most areas of life, working harder leads to rewards, so he tries even sleep; s adly, this is one of the few areas in which trying hard does not work and may, indeed, complicate the problem. When a patient with psychophysiological ins omnia has sleep study, the polys omnogram (P S G ) usually 2382 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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objectively disturbed sleep with a relatively long sleep latency (the time from when the lights are turned out sleep ons et), shortened total sleep time, or frequent awakenings during the night. W hen as ked in the to estimate how long it took him or her to fall asleep how long he or s he s lept, the patient is us ually fairly accurate. T his finding of good concordance between objective and s ubjective meas ures of sleep is crucial to distinction between psychophysiological insomnia and sleep state mis perception. T reatment of ps ychophys iological insomnia is us ually oriented to decathecting the powerful emotional focus that the patient has placed on his s leep problem, reducing the tendency to work hard at going to s leep, and removing conditioned respons e of anxiety and heightened that has become ass ociated with the act of trying to go sleep. P.2024 It s hould be noted that the kind of conditioned seen in these patients is a special cas e of a seen in many different areas of medicine. One example the cancer patient who becomes naus eous while to the chemotherapy clinic. F inally, it s hould be remembered that, although ps ychophysiological may be a dis order in its own right, many patients a conditioned arousal and anxiety res pons e as a complicating factor on top of ins omnia owing to some other reason. A patient whose sleep is dis turbed due to pain or who has the sleep difficulty ass ociated with depres sion, for instance, may begin to worry about his or her s leep and may develop an arousal 2383 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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res ponse when entering the bedroom. T his illustrates a broader problem, which is that, in evaluating patients chronic ins omnia, one often discovers multiple caus es , each of which needs to be treated.

S leep S tate Mis perc eption R ecognition of sleep state misperception (als o known s ubje ctive ins omnia) arose in respons e to a common— often frustrating—clinical phenomenon. A patient would present at the sleep center describing s leeping only for or 2 hours each night and, in colorful terms, would describe the agony of lying in bed awake for endles s hours. S hortly after the lights are turned out in the laboratory, the patient closes his or her eyes and lies with the quiet, regular res pirations of s leep. T he electroencephalogram (E E G ) appears that of a normal sleeper. In the morning, when the doctor enters the bedroom, the patient opens his or her eyes and, with bewildering sincerity, s ays “S ee doctor, I told you I wouldn't s leep a wink.” Later, when the P S G is analyzed, the s tudy indicates a relatively normal night's sleep. In contras t, the patient's morning estimate of the previous sleep des cribes a poor night, which contrasts sharply with these polygraphic res ults . T his is different from the morning report of a patient with conditioned insomnia, a report which s hows good concordance with the sleep recording. S ubjective insomnia, then, is characterized by a diss ociation between the patient's experience of and the objective polygraphic meas ures of sleep. T he ultimate cause of this dis sociation is not yet although it appears to be a specific case of a general 2384 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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phenomenon s een in many areas of medicine. One example is the sensation of dys pnea. On the one hand, can s ee patients with severe chronic obstructive pulmonary disease (C OP D) and markedly poor blood who report no trouble breathing; in contrast, an apparently healthy young man with normal pulmonary function tests can come in reporting a sensation of not being able to get enough air. S imilarly, in the gastrointestinal (G I) literature, there are reports of a variation in the s ubjective recognition of a s ens ation of satiety when the s tomach is distended, and it is thought that at least one aspect of the complex phenomena led to obesity is that s ome obese patients have recognition of this s ens ation of s atiety. One hint at the genes is of s ubjective insomnia comes a landmark study by L. J . Monroe, who reported that, poor s leepers were awakened in early stage II sleep, said that they felt that they had previous ly been awake, contrast to good s leepers , who believed that they had been asleep. T his s eemed to s uggest that some may have a different s ubjective experience of sleep wakefulnes s than good sleepers. T his disturbance appear to be due to being light sleepers, as a group, are no more eas ily arous ed by an auditory stimulus than good sleepers. T his phenomenon has been explored in terms of the way that hypnotic medication may act to improve s leep. T he author and colleagues found that, after receiving a placebo, insomniacs tend to report that they had been awake, as ked after being awakened from nonrapid eye (NR E M) s leep by an auditory tone. After receiving a hypnotic, such as zolpidem (Ambien) or flurazepam 2385 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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(Dalmane), however, the same patients respond like sleepers , s aying that they believed that they had been as leep. T his sugges ts that one as pect of the which hypnotics act may be that they have a cognitive effect; that is , they change a patient's perception of whether he or she is awake or as leep. S uch a cognitive action may help explain why, clinically, many hypnotics seem to offer a great deal of relief to insomniacs (at acutely), whereas drug-induced increas es in E E G such as total s leep time, are often relatively modes t (in review, the mean increase in total sleep induced by a variety of hypnotics was approximately 30 minutes). underlying phys iological bas is for this disorder remains unclear. One promis ing hypothesis is that at least insomniacs are in a s tate of hyperarous al, which is supported by data indicating that they may have metabolic rate. One common mistake in dealing with patients with subjective insomnia is to tell them that (bas ed on the polygraphic data) there is nothing wrong with their T here is always a temptation to do this, with the hope the patient will be relieved to hear this good news. In practice, telling the patient that he or s he is sleeping normally flies in the face of his or her experience, and likely leads to alienating him and losing his is better—although harder—to respect the patient's symptom, explaining that there is a dis parity between what he or she is experiencing and what the polygraph seems to be showing.

Idiopathic Ins omnia Among primary ins omnia patients, there remains a 2386 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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that appears to have neither a conditioned s leep disturbance nor a dis sociation between s ubjective experience and polygraphic data. T hey are class ified having idiopathic ins omnia. T ypically, a his tory of going to s leep or of awakening during the night goes to childhood or even infancy, and the patient's is confirmed by the sleep study, which may show an increased s leep latency, decreas ed total s leep, or arousals . T here have been many hypothes es to genes is of this dis turbance, including the poss ibility there may be a dysregulation of biogenic amine metabolism, alterations in basal forebrain function, an altered res ponse to γ-aminobutyric acid type A benzodiazepine receptor activity, or reduced levels of endogenous s leep-promoting substances. theories have s uggested that thes e patients failed to a normal erotization of s leep as infants or that they received conflicting mes sages from their mothers as to safety of sleeping alone. F inally, before examining iss ues of therapy, it s hould mentioned that primary ins omnia is probably not the as light sleep or sleep deprivation. As mentioned previous ly, there is significant evidence that a group, do not awaken in res ponse to an auditory tone more easily than good s leepers . Moreover, they are not excess ively sleepy during the daytime, at leas t as by the Multiple S leep Latency T est (MS LT ); indeed, if anything, they may be hyperaroused. tes ting s tudies s uggest that their pattern of deficits is different from that typically seen in s leep deprivation. Ins omniacs do not s eem to es timate time differently good s leepers . T hus, it appears that the problem of 2387 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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insomnia is more complex than first meets the eye, and solutions for it are probably different from merely increasing the number of minutes of E E G -meas ured

Treatment T reatments for ins omnia include nonpharmacological pharmacological approaches. P.2025

Nonpharmac ologic al Treatments Nonpharmacological treatments include some general recommendations for all patients and more specific behavioral and cognitive approaches. G eneral s lee p hygie ne principles are s ummarized in 20-1. As mentioned previously, it is important to remember that thes e are general guidelines, and they not fit all patients . When presenting these to a patient, us ually better to help him or her focus on only one or of thes e principles at a time and to work s lowly through the entire lis t, rather than making global recommendations that may feel overwhelming. It also be noted that, although it has long since become of the accepted tradition in lectures on sleep dis orders begin with sleep hygiene, there are minimal long-term outcome data to s upport its use.

Table 20-1 S leep Hygiene

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Maintain regular hours of bedtime and arising. avoid a lifes tyle of progres sive s leep deprivation during the week and then cras hing on the weekends. Do not eat heavy meals near bedtime. A light in contras t, may be helpful. In general, it is best to avoid napping during the daytime. (E xceptions are made for the elderly or debilitated.) E xercise daily. T his is best in the late afternoon early evening. E xercise later in the evening may disturb s leep. Minimize caffeine intake and cigarette s moking within 8 hrs of bedtime. Do not look at the clock during the night. If an clock is needed, put it in a drawer by the bed, s o it can be heard but not s een. If there is something that is worris ome while lying bed, write it down on a piece of paper and to look at the paper in the morning. Let it go until then. Make the bedroom comfortable. In general, it is better to be slightly cool than to be too warm. 2389 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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Do not us e alcohol to help in going to sleep.

Among specific behaviorally oriented therapies is control, developed by R ichard B ootzin. It sugges ts that important cause of s leep disturbance is that the patient has come to as sociate behaviors that are incompatible with sleep with the act of trying to go to sleep and the setting in which s leep is to take place. T he goal, then, remove all behaviors from the bedroom, except sleep loving. T hus , the patient is instructed to conduct all activities in another room. F or example, it would not be appropriate to have a s mall des k at which one pays household bills in the bedroom. S ome couples with children retreat to the bedroom as one of the few that they can have a fight behind clos ed doors . if a patient comes to as sociate the bedroom with the having frank dis cuss ions with the spous e, this does not sleep. F inally, it is important that the patient not come think of the bedroom as a place of discomfort. F or this reason, he or s he is told that whenever he or she finds hims elf lying in bed unable to sleep, he or s he s hould up, go in another room, and not to return to bed until he or s he feels ready to sleep. S le e p re s triction therapy, developed by Arthur 2390 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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addres ses the concern that one of the factors that maintains a s leep disturbance is the relatively sleep res ulting from the patient s taying in bed for unnecess arily long periods . In practice, the patient is to keep a sleep diary for, perhaps , 2 weeks and to to the office. T here, the patient and therapis t the average time that the patient is in bed each night the average amount that he or s he estimates is spent as leep. If, for ins tance, the patient estimates that he or is in bed 9 hours nightly but s leeps only 5 hours, he is instructed to stay in bed only 5 hours and to continue to keep the s leep diary. W hen his subsequent es timates sleep time indicate that he has been asleep 85 percent the 5 hours , the duration in bed is increased to 5.5 again, this is increased in 0.5-hour intervals each time es timated s leep ris es to 85 percent of the time in bed. E ventually, the patient's time in bed approaches more conventional amounts, while s leep efficiency is Although s timulus control and s leep res triction addres s different as pects of the factors that maintain poor should be noted that, like most behaviorally oriented therapies, they s hare many qualities. T ypically, they performed with what P eter Hauri and others refer to as co-s cie ntis t mode l. T his approach avoids the s ituation which the therapist is an authority figure who dispens es knowledge or instructions to a patient who is a pass ive recipient. R ather, the therapist s ays , in effect, “We are experts in certain parts of the common problem that we have before us . I am an expert in the principles of regulation but know less about you. Y ou, on the other hand, are the person most knowledgeable about your behavior and habits. Let's work together, then, and 2391 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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bring our own expertis e to this problem that we face together.” T he therapist encourages the patient to take active role in the proces s, rather than pass ively guidance. In part, this is in res ponse to the observation that insomniacs often have a pass ive view of their affliction. F rom the patient's perspective, it can s ound the heavens had inexplicably opened up and s truck her down with this affliction, which, from his or her perspective, has no relationship to events in his or her present or pas t life. One goal of thes e therapies is to encourage the patient to take a much more active and to be actively engaged in the resolution. T his giving well-earned credit to the patient when there is improvement. Another method of encouraging active involvement in previous ly mentioned therapies is to negotiate with the patient what an acceptable outcome would be. B efore beginning treatment, the therapist considers poss ible outcomes . He might ask the patient what he or she to gain from therapy. If the patient gives an high expectation, the therapist might s ay s omething this: “It s ounds like the best thing that could happen would be that you would come here for two or three and, from then, on you would s leep perfectly for the your life. I wis h this would happen, but it doesn't s eem likely to me that s uch a miraculous cure will take place. the other extreme, probably, the wors t thing that might happen would be that you would come weekly for a and improve only, let's s ay, by 5 percent. W e need to balance, somewhere in the middle, that each of us will agree is likely and that would be acceptable.” B y negotiating s uch an outcome, the therapist helps dispel 2392 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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unrealistic expectations and helps the patient take a active role in the proces s. C ognitive -be havioral the rapy (C B T ) emphasizes the dysfunctional thoughts in the maintenance of primary insomnia. It sugges ts, for ins tance, that incorrect (e.g., that there is nothing one can do about poor sleep that one night of poor s leep has disastrous may lead to anxiety that perpetuates the disorder and insomniacs tend to have more emotion-oriented coping strategies to s tres sors . It has been reported that as few six weekly s es sions can modify a patient's beliefs and this change correlates s ignificantly with P S G meas ures reduced wakefulnes s and improved s leep efficiency at month follow-up. It has als o been demons trated to aid discontinuation of benzodiazepines in older with benefits evident for up to 1 year. O the r behaviorally orie nted the rapie s have been dealing with insomnia, although, unlike the former, they lack long-term efficacy s tudies. In s ys te matic by reciprocal inhibition, the patient is as ked to cons truct hierarchy of s ituations that, in his or her experience, as sociated P.2026 with poor sleep. T his preliminary part of the treatment often s eems useful in itself, as the ins omniac patient's tendency is often to s tate that the sleep dis turbance is as sociated in any way with events in his or her life. In meantime, the patient is taught a basic relaxation technique, s uch as J acobsonian muscle relaxation. the hierarchy is cons tructed, the patient is asked to visualize the lowes t ranking s ituation as sociated with 2393 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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sleep (e.g., going to bed the night before a trip) and to pair this vis ualization with the relaxation respons e. When this is s ucces sful, he or she moves up the ladder the second leas t stress ful s ituation, and s o on. T he to des ens itize the patient to these experiences , s o that, when they occur, they carry less anxiety. In pas sing, it s hould be mentioned that, when working with the patient to construct the hierarchy and dealing with his or her s tatement that events in his or her life do not seem ass ociated with poor s leep, a technique sometimes used in the ps ychotherapy of pain patients be us eful. In the cas e of pain management, a cancer patient, for ins tance, says , in effect, “My pain comes cancer; what can you, as a ps ychiatris t, do about something like that? ” T he therapist's respons e can be as k the patient whether his or her pain is exactly the every day or whether it is worse some days , and it is some days. T ypically, a patient agrees that the severity vary on different days . T hen the therapis t suggests that “our job, then, is to see what is different about the good days and the bad days.” An analogous process can be when dealing with sleep dis turbance. In paradoxical inte ntion, the patient is as ked to try not sleep. As he or she finds out how difficult it is to s tay intentionally, he or s he comes to recognize the potency homeostatic s leep regulation. T he therapist can then suggest to the patient that his or her body will not allow him or her to mis s too much sleep. Other techniques on breaking up the ruminative thought process es that typically occur while an insomniac lies awake in bed. presumably the mechanism by which the old folk of counting s heep may have s ome benefit. A more 2394 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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way of achieving this end is us ed in cognitive focus ing, which the patient prepares in advance a s eries of reass uring thoughts and images on which he or she is as ked to concentrate, s hould he or s he wake up during night. Other techniques emphas ize s omatic relaxation, including muscle relaxation procedures , and electromyographic (E MG ) biofeedback. In general, efficacy has been minimal.

R E L A TIONS HIP B E TWE E N THE R A P IE S T he relation of nonpharmacological and approaches for chronic insomnia also needs to be cons idered. T he limited number of s tudies comparing two have been inconsistent. T hos e in favor of nonpharmacological therapy report improvement in 70 80 percent of patients and suggest that it takes longer show benefit initially but that the effects are more T hose in favor of medication point to the generally cost and als o emphasize that, in the major s tudies of nonpharmacological therapy, only a s mall number of potential patients s creened for the projects agreed to participate in the fairly rigorous programs and that patients drop out. Indeed, some of the s tudies showing long-term efficacy of nonpharmacological approaches present data only for thos e who completed the trial and appeared for follow-up. S imilarly, studies examining the efficacy of combining pharmacological and nonpharmacological treatments have been inconsis tent, ranging from thos e showing potentiation to at leas t one s uggesting that the use of medication may inhibit the effectivenes s of behavioral 2395 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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therapies. In the absence of conclusive data, the impres sion is that the two are not mutually inconsistent and, indeed, may aid each other. F or example, if a is given a s upply of medicine s ufficient for us e two or times a week, the therapist may inquire on which nights the patient took the medicine and may try to determine what was different about these days that led the patient be concerned that he or s he might not s leep at night. S imilarly, when as ses sing how deeply a patient slept us ing a behavioral technique, the therapis t may use the medicine as a kind of benchmark, as king how the night in comparis on to the medication night. A more answer as to whether combined therapy is more efficacious than either approach alone awaits the performance of appropriate outcome s tudies .

Pharmac ologic al Treatments P harmacological agents for primary ins omnia are cons idered elsewhere in this volume and hence are not discuss ed in detail here. S ome broad comments about their use are in order, however.

US E IN A C UTE VE R S US C HR ONIC INS OMNIA V irtually all pres cription hypnotics are efficacious for insomnias due to upsetting events or change in environment (e.g., a night in the hospital or on a trip). general, s hort-acting agents may be more des irable, because they improve s leep on the firs t night, whereas long-acting agents , s uch as flurazepam, may not show clear benefit until the s econd or third night of adminis tration. Hence, most therapeutic is sues are with 2396 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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the management of chronic primary ins omnia, which is focus here. In pas sing, some therapists believe that the of sedatives or hypnotics after ups etting experiences not be des irable, becaus e they might prevent the from process ing the recent events and working through the problems facing him or her. T he counterargument been that, if a patient gets a good night's sleep, he or may be more alert and effective in dealing with the next day.

L ONG -A C TING VE R S US S HOR THY P NOTIC S T he original benzodiazepine s edative-hypnotics, s uch flurazepam, chlordiazepoxide (Librium), and diazepam (V alium), were relatively long-acting agents , with active metabolites showing half-lives of 50 to 100 hours or F lurazepam, the first benzodiazepine s pecifically for sleep, rapidly replaced the older barbiturates in the 1970s and is representative of the mos t widely us ed for the following decade. It came to be recognized, however, that flurazepam and related compounds had several s ignificant limitations , s pecifically, that they did reach full potency until the second or third night and because of their long half-lives , they als o caus ed sedation. T he later introduction of the short-acting triazolam (Halcion) (half-life of 2 to 5 hours ) seemed to correct both of thes e problems , but concerns arose along with thes e benefits, it might have introduced a difficulty, namely, increased memory disturbance. In addition, it was thought by s ome to lead to more discontinuation sleep dis turbance than the longeragents , which were, in effect, self-tapering. Newer nonbenzodiazepine hypnotics , including zolpidem (half2397 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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life of 2.6 hours) and, later, zaleplon (S onata) (half-life hour), appear to be relatively free of daytime sedation, on the first night, and have les s s ignificant memory At the time of this writing, the short-acting zolpidem is far the mos t widely prescribed prescription hypnotic in United S tates . Overall trends for drugs given with the intention of improving s leep, however, s how a 10-year decline in prescription hypnotics and an increas e in the us e of sedating antidepress ants . Unless daytime s edation is s pecifically des ired (as it in s ome cases of ins omnia secondary to anxiety), acting agents are probably the treatments of choice. most significant limitation is the trans ient appearance discontinuation sleep dis turbance with the short-acting benzodiazepines, and even this is ameliorated by half dose for two or three nights before stopping the medication. Another is sue that arises is whether the half-life of zaleplon may make it more des irable, specifically for those cas es of insomnia in which the difficulty is primarily in going to s leep, as it has minimal effects on total s leep time. T his s hort duration of action may als o lead to new methods of administration, it may be us eful to give it during the middle of the night when the patient awakens .

L ONG -TE R M A DMINIS TR A TION Although chronic ins omniacs experience sleep disturbance for months (by definition) and, often, for prescription hypnotics are officially recommended for periods of time, P.2027 2398 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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generally 7 to 10 days. T he main concern about longus e has been that tolerance might develop, a view founded in s tudies of long-acting benzodiazepines in 1970s . More recently, a growing body of s tudies that examine the nonbenzodiazepine zolpidem in nightly for 6 months has shown no evidence of tolerance, as open-label studies of zaleplon for as long as 1 year. E szopiclone, which is under review for approval for us e at the time of this writing, has been reported to maintain efficacy for 6 months. If these studies be borne out, it seems likely that the wides pread view hypnotics are effective only in the s hort term will need be recons idered.

A L TE R NA TIVE A DMINIS TR A TION S TR A TE G IE S T raditionally, most studies of hypnotics have been on nightly adminis tration of medicine, although, in practice, many patients take thes e compounds T he minimal data that are available, which include us e quazepam (Doral) and triazolam every other night or zolpidem in nonnightly us e for 8 weeks , have that these may be viable alternative s trategies. T he half-life of zaleplon (1 hour) has led to a new approach adminis tration as well—the notion that the patient can take the medication when he or she awakens during night, rather than the traditional approach of taking bedtime in anticipation of later sleep difficulty. T he only caveat to this practice is that, even with the s hort halfit is recommended that the patient take zaleplon only if or s he plans to remain in bed for an additional 4 hours.

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HY P NOTIC S A number of studies have indicated that, although insomniacs infrequently go to their doctors for help, are a treatment-seeking group. Indeed, as many as 40 percent cons ume alcohol, over-the-counter (OT C ) hypnotics, or both to aid their sleep. T he former is undes irable, becaus e it expos es them to the ris k of abuse, and it is relatively ineffective as an oral hypnotic owing to dis turbed s leep toward the next morning. T he latter, usually antihis tamines , s uch as diphenhydramine (B enadryl), have significant daytime sedative may impair daytime functioning, and are relatively ineffective as nighttime hypnotics. In addition to laboratory s tudies , which are minimal and conflicting, a survey of pers ons in the community by the C ons umer's Union indicated that many fewer considered them “very helpful” compared to thos e who took prescription hypnotics. Many ins omniacs take me latonin and herbal remedies sleep. Although melatonin has clock-res etting that may make it helpful in treating sleep dis turbance to jet lag or irregular s leep cycle dis turbances in the its us efulness in primary ins omnia is a matter of controvers y. Among the few well-controlled laboratorybased studies is one indicating that 1 and 5 mg of melatonin given at 11:30 P M to healthy volunteers had significant effects , whereas dos ing at 6:30 P M, before endogenous s ecretion occurs, did alter sleep. Higher (5 mg) may even dis turb sleep and, when given in the daytime, may impair performance on s uch measures tracking and reaction time. Its safety als o is an is sue, particularly its actions at melatonin receptors in the 2400 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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vasculature of the coronary and cerebral arteries. In melatonin has been reported to caus e vasoconstriction the middle cerebral artery and reduced cerebral blood flow. T he C ons umer's Union s tudy mentioned found that pers ons taking melatonin ranked it “very helpful” much les s frequently than pres cription and gave it the rating “not at all helpful” more frequently than any other treatment. V ale rian derivatives , taken from the root s tock of officinalis , are repres entative of herbal preparations for sleep. It is lis ted in pharmacopoeias in some E uropean countries , although, in practice, it is us ed primarily in medicine. T here is s ome rationale for its us e, as one of components, the lignan hydroxypinores inol, interacts the benzodiazepine receptor. Although its use as a sedative goes back to ancient actual s tudies evaluating its benefits are limited and mixed res ults. S tudies in elderly poor s leepers and ps ychophys iological insomniacs s howed no effects on sleep latency or wake time, although slow wave s leep increased. A s ingle s tudy of a mixture of valerian and hops given to P S G -screened ins omniacs s howed improvement in s leep latency, wake time, and sleep efficiency, as well as improved subjective reports, after weeks. On the pos itive side, there appears to be no daytime residual effects on several tes ts . In the las t 2 years , a combination of valerian and hops has entered the U.S . marketplace as an OT C agent manufactured by a major pharmaceutical hous e, and how it will be received remains to be s een. Antide pre s s ants are often used to aid s leep; the one by far the mos t widely pres cribed for this purpos e is 2401 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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trazodone (Des yrel), the number of pres criptions for are approximately the same as thos e for the leading prescription hypnotic, zolpidem. Des pite this widespread use, there are few s tudies evaluating its poss ible benefits. A multicenter s tudy found that reported that it had some benefits for s leep, although than those of zolpidem. T wo recent sleep laboratory studies found that 100 mg given for one night had no benefits in dys thymic patients complaining of s leep disturbance, although it improved sleep in patients with major depress ion. Its us efulnes s may be limited by its effects, which include aggravation of ventricular arrhythmias, QT interval prolongation, and priapis m. the limited data about its effectivenes s, the reasons its widespread us e are not entirely clear, although, certainly, ease of prescribing (unlike pres cription hypnotics, it is not a clas s IV res tricted agent) may be factor. Mirtazapine (R emeron) is sometimes pres cribed sleep, although its benefits are often offset by daytime sedation. B lood dyscras ias appearing in roughly one in 1,000 patients should also be considered in weighing ris k to benefit ratio of its us e in nondepres sed patients.

NE W HY P NOTIC C OMP OUNDS T he last few years have s een the development of hypnotic compounds that are neither benzodiazepines nonbenzodiazepines acting at the G AB A A receptor. Although none is approved for commercial at the time of this writing, it s eems likely that s ome will appear in the next few years . Among thes e compounds melatonin receptor agonists (the goal of which is to achieve the pos sibly sedative effects of melatonin with more desirable s ide effect profile), neurosteroids, 2402 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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antagonis ts to serotonin receptor s ubtypes, and P antagonis ts . New methods of adminis tration, an intranas al spray of antihistamines , are being cons idered. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > C IR C ADIAN R H Y T HM S LE E P

C IR C ADIAN R HYTHM DIS TUR B ANC E S P art of "20 - S leep Dis orders " T he presence and consis tency of the circadian throughout evolution indicate its vital biological In mammals , many tis sues have the capability of behavior, but the fundamental pacemaker is located in suprachiasmatic nuclei (S C Ns ) in the anterior hypothalamus. As described by C harles C zeisler and others , the S C N pacemaker can be considered to have fundamental characteris tics: phas e, amplitude, period, res etting capacity. T he latter, in which the inherent rhythmicity of S C N cells is coordinated with external cues indicating whether it is day or night, is made by input from a s ubs et of retinal ganglion cells that us e neuromodulator melanops in. T he output ultimately reaches the pineal gland, where it influences the melatonin. T he S C N, in turn, is sensitive to melatonin, which decreases its waking s ignal. Melatonin, previous ly as a pos sible s edative-hypnotic, has been hypothes ized to have two main functions: resetting the S C N pacemaker with information about daylight and 2403 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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promoting proces ses as sociated with sleep. V arious as pects of thes e circadian proces ses can go awry, in several clinical s tates that can be manifes ted as insomnia or hypersomnia.

Delayed S leep-P has e S yndrome In delayed s leep-phase syndrome, the circadian operating in a delayed, but stable, relations hip to the night cues of the external world. Hence, a patient complains of being unable to fall asleep until perhaps to 3:00 AM, as it is only then that his circadian s ys tem a point P.2028 reached by the general population at 11:00 P M to midnight. In the morning, the patient has a difficult time getting up until late morning or complains of in the morning, because it is only then that the system reaches a s tate that is expres sed in most individuals at 8:00 or 9:00 AM. A s leep s tudy begun midnight shows a long s leep latency (often as long as 2 3 hours ) but then a relatively normal sleep pattern and total s leep time. T he patient often s ens es that his or sleep is relatively normal, although altered in timing. when taking a history, one can s ay “I know, of cours e, you have many constraints on when you can s leep and up—your job or schoolwork, for ins tance. B ut if you live a life in which you go to bed as late as you like, up when you feel ready, do you think your s leep would okay? ” T he patient us ually says that he or she would just fine under those circumstances. S imilarly, one can if there was ever a time in his or her life in which he or 2404 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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could choos e his or her hours of s leep, and, if s o, how he or s he do? Often, he or she says , yes, when he or was in college, he or s he would stay up late and sleep into the morning and felt well and energetic during that period. Many of these patients are drawn to jobs in they can choos e their own hours of sleep and waking, instance, working from home as freelance computer programmers. F or most, however, the constraints of working world lead to dis tres s. Originally, delayed s leep-phase syndrome was hypothes ized to aris e from a decreas ed ability of the res etting capacity of the pacemaker, s uch that from the retina was only partially success ful in coordinating the daylight–night signal from the external world with the inherent rhythmicity of the S C N. More recently, the pos sibility that thes e are patients with unusually long cycle periods has been sugges ted. focus on the role of the patient's behavior in the this s yndrome. T he firs t major therapy for delayed sleep-phase was chronotherapy, in which the patient is instructed to shift his or her hours of s leep and waking progress ively later each night, until he or s he has moved around the clock to a point at which he or s he has a more bedtime. (It may s eem paradoxical to as k him or her to a progress ive delay in his or her sleep to adjust to the earlier bedtime; this is done because it takes the inherent period of the pacemaker, which is slightly longer than 24 hours.) Once the patient has achieved her new earlier bedtime, one has to emphas ize the importance of faithfully keeping these new hours ; only few nights of going to bed later can dis rupt the newly 2405 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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es tablis hed pattern. In practice, it is difficult to keep the patient doing this . Many a therapis t has heard the come in with poor s leep again, giving elaborate explanations as to why he or she had had to stay up the last s everal nights (e.g., “my friend in C alifornia jus t divorced, and she keeps calling me to talk, at all Indeed, one could speculate that the many reas ons patients give for s hifting back to a much later bedtime represent logical rationales for obeying a biological impulse. In any event, the difficulty in having a patient move his or her sleep time around the clock and the difficulty in maintaining the new hours led to the quest new approaches . An alternative approach for managing delayed sleepphase syndrome is bright-light therapy. In this case, the patient is expos ed to bright artificial light in the early morning. V arious commercial fluores cent lights can be us ed for this purpose, and typical treatments might be minutes or more at 3,000 to 10,000 lux. T his res ults in phase advance of the pacemaker, s uch that the s leep– waking signal is res et to more traditional hours . T his is generally benign and effective therapy, although one should be aware of the rare poss ibility of phototoxicity retinal receptors, particularly in the macula, or of s olar retinopathy.

A dvanc ed S leep-P has e S yndrome Advanced sleep-phase syndrome is similar in principle delayed s leep-phase syndrome, except that, in this the rhythm of s leep and waking is advanced relative to traditional hours of bedtime and aris ing. T hus, it is manifest as sleepines s early in the evening and then 2406 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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awakening in the early morning hours with an inability go back to s leep. It is particularly common in the who have a phas e advance of approximately 1 hour in terms of their temperature and melatonin rhythms . T his condition can be treated by adminis tering bright light in the early evening, res ulting in a phase delay of the pacemaker, s uch that the s leep–wake s ignal is in concert with traditional hours for bedtime and aris ing.

Non–24-Hour S leep–Wake C yc le In a non–24-hour s leep–wake cycle, a patient may intermittent insomnia that periodically recurs . It is found in blind individuals and res ults from a complete failure of the resetting mechanis m of the pacemaker. patient then begins to live with a propens ity to have a sleep–wake rhythm with the inherent and uncorrected period of the internal pacemaker, approximately 24.15 hours. In a world in which day and night follow a 24.0cycle, this means that the patient's propensity for sleep cons tantly s hifting forward relative to what would be appropriate to his or her s urroundings . T he res ult is or s he experiences ins omnia, which is periodically exacerbated when his or her internal rhythm is most phase with the environment and which improves as he she moves more in phas e with his s urroundings . adminis tration has been demonstrated to be us eful in regulating sleep in thes e individuals .

S hift Work S hift work can induce s leep disturbances , as well as difficulties , including accidents due to s leepiness during nighttime working hours and, in more extreme cas es, a 2407 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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s hift-work s yndrome characterized by G I and disorders . A common experience among night shift workers is to come home in the early morning, to go to bed feeling exhausted, to s leep only 2 to 3 hours, and awaken feeling unrefreshed but unable to continue sleeping. T he treatments for s hift work are complex vary with the type of work schedule (s hift work is , of a general term that can include a wide variety of schedules: fixed work on an evening s hift, cycling shifts from day to evening to night s hifts, and so on). V arious strategies , including napping before going into work in the evening or taking a s cheduled nap nighttime work hours, may be helpful. Us ing bright light night and avoiding light during the day have been propos ed. It may be helpful, for instance, for a nightworker driving home in the morning to wear as not to get a large light exposure immediately before going to bed. It has been demonstrated that us ing circadian principles to design indus trial work schedules can reduce absenteeism and medical difficulties. T reatment with melatonin has been found to be less succes sful than timed bright light expos ure in aiding adjus tment to shift work.

J et L ag J et lag s leep disorder is s imilar to that of s hift work in it repres ents a dys synchrony between one's internal wake rhythm and that of the external world; in this however, the dyss ynchrony results from rapidly one's location to a new environment. After wes tward travel, one is phas e advanced relative to the that is , one wants to go to bed earlier and to get up than what is appropriate for the new location. E as tward 2408 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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travel res ults in being phas e delayed relative to one's surroundings—the P.2029 tendency is to s tay up later and to get up later than needed. A number of strategies have been proposed dealing with jet lag. One can, for ins tance, slowly adjust the new hours before leaving on the trip. B efore wes tward, for instance, one can progres sively go to later and get up later while s till at home. S pecial diets been propos ed, but their effects s eem relatively Maximizing light expos ure during the new daytime and minimizing light during the new nighttime are helpful, there is evidence that timed melatonin adminis tration aid adjus tment. In jet lag and s hift work, the use of acting hypnotics can aid s leep at the new bedtime, but there is no evidence that this leads to more rapid adjus tment to the new time schedule. A number of inves tigators and pharmaceutical houses are trying to develop chronobiotics , medications that help res et the pacemaker, although none has yet reached the prescription drug market with this indication.

Irregular S leep–Wake R hythm Irregular sleep–wake rhythm is characterized by shifting hours of s leepiness and wakefulnes s. It is an affliction of dis co aficionados and others who a highly irregular schedule, although it is s ometimes in pers ons who have had tumors or other pathology of hypothalamus. T reatment is organized around altering behavior, encouraging the patient to keep regular bedtime and aris ing and to avoid napping. 2409 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > P E R IODIC LIMB MOV E ME NT

PE R IODIC L IMB S YNDR OME P art of "20 - S leep Dis orders " P eriodic limb movement syndrome (P LMS ) (als o nocturnal myoclonus ), along with res tles s legs would be cons idered to be in the dys s omnia not s pecifie d category in terms of the DS M-IV -T R . A with P LMS is neurologically normal while awake but, during sleep, manifests periodic s tereotyped of the limbs (usually the legs ). T hese movements extension of the toes , as well as flexion of the ankle knee. T he patient is us ually unaware that thes e movements occur, although the bed partner may be too aware. T he res ult of these events is us ually although hypersomnia may als o appear. P LMS is as sociated with renal dis eas e, as well as iron vitamin B 12 anemia; some investigators believe that it is exacerbated by tricyclic antidepress ants, although are differing views on this is sue. T he disorder tends to problem of middle age in both s exes, with increasing frequency with advancing age. C hildhood cas es have reported, and there is s ome evidence that it is with attention-deficit/hyperactivity disorder (ADHD). It is not clear whether the sleep dis ruption ass ociated with movements leads to s leepiness , manifested in children hyperactivity, or whether both res ult from a common 2410 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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underlying etiology. P eriodic limb movements (P LMs) commonly s een in sleep studies of narcoleptics . One found a P LM index of greater than five in 61 percent of obstructive sleep apnea (OS A) patients; the P LMs and disordered breathing events had different periodicities, however, sugges ting that they have different T he ultimate etiology is uncertain, although it has been hypothes ized that it res ults from hyperactivity in some areas of the s pinal column, particularly in the and cervical segments , triggered by a poorly supras pinal sleep-related mechanis m. Although most authors emphasize the role of the P LMs in disrupting sleep, others speculate that they are, in fact, respons es sleep that is disturbed for s ome other reason. T his view would explain the high frequency of P LMs in narcoleps y, which is characterized by multiple in nocturnal s leep, and in s leep apnea, in which s leep disturbed by arous als res ulting from dis ordered events. Others have questioned whether the frequent appearance of P LMs in end-stage renal disease is as sociated with the sense of dis turbed s leep in these patients. On the P S G , P LMs are 0.5 to 5.0 seconds in duration occur every 20 to 40 s econds (F ig. 20-1) during NR E M s leep. Often, they are accompanied by a K or brief arousal signal in the E E G channels of a P S G . C linicians differ as to whether to count only thos e that accompanied by E E G evidence of arous al or to count P LMs regardles s of E E G cons equences. A diagnosis P LMS requires a P LM index of at least five per hour.

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FIGUR E 20-1 E xample of periodic leg movements as seen on the polysomnogram. C Z-02, electroencephalogram channel; E C G , E MG , electromyogram; LOC , left electrooculogram; right electrooculogram. T he traditional treatment for P LMS has been (K lonopin) in doses of 0.5 to 2.0 mg per day. this often brings a s ubjective s ens e of improved sleep the patient but is us ually P.2030 not as sociated with decreased numbers of P LMs on P S G . T his has sugges ted to s ome investigators that mechanism of action of clonazepam may be to the arousal res ponse to the movement. E ffectivenes s often limited by the complaint of daytime sedation, has led many clinicians to administer shorter-acting benzodiazepines. Another approach is to adminis ter doses of L-dopa (Larodopa), although others are 2412 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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to do this becaus e of the poss ibility of bringing out movement disorders or dopaminergic psychosis . no specific evidence is known, s ome clinicians believe the need for medications is reduced over time if enter s tres s -management programs or s imilar anxietyrelieving programs. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > R E S T LE S S LIMB S S Y NDR

R E S TL E S S L IMB S P art of "20 - S leep Dis orders " R es tles s limbs syndrome (R LS ) (also known as E kbom s yndrome ) is an uncomfortable subjective s ensation of limbs , usually the legs, sometimes described as a crawly” feeling or as the s ens ation of ants walking on skin. It tends to be worse at night, and (in contrast to claudications) is relieved by walking or moving about. It appears as a cause of s leep initiation insomnia, as the patient may find it difficult to lie still in bed, needing to up to relieve the dis comfort. T he ultimate cause is unknown, but it appears often in pregnancy, iron or vitamin B 12 deficiency anemia, and renal dis eas e. T here are no specific findings on the P S G , although often s ees increased movement artifact on the E MG channel before sleep ons et. Mos t patients with R LS have P LMS , although most patients with P LMS do not R LS . T he firs t s tep in treatment is looking for anemia and treating it, if found. B enzodiazepines are relatively 2413 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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ineffective. T he off-label use of L -dopa and carbidopa (S inemet), bromocriptine (P arlodel), and pergolide (P ermax) is often helpful. In rare patients who are affected, the off-label use of narcotic analges ics can when other treatments have been tried and have failed. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > S LE E P -DIS OR DE R E D B R E AT

S L E E P-DIS OR DE R E D B R E ATHING P art of "20 - S leep Dis orders " S leep-disordered breathing may pres ent as or ins omnia. OS A, the most common and relevant for this chapter, is characterized by periods of obstruction of the upper airway during s leep, resulting decreases in arterial oxygen s aturation and a trans ient arousal, after which res piration (at least briefly) normally. It tends to occur in patients who snore the majority of s norers do not have s leep apnea) and res ults in a s ens ation that sleep has not been Many, although by far not all, patients are overweight, it appears more frequently in patients with s maller jaws true micrognathia, acromegaly, and hypothyroidis m. S tudies of the upper airway sugges t that, as a group, patients have s maller airways than normal s leepers , there is a great deal of overlap. Medical cons equences include cardiac arrhythmias, s ys temic and pulmonary hypertens ion, and decreased s exual drive or function. exact relationship of obesity, OS A, and hypertens ion is 2414 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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matter under inves tigation, s ome arguing that hypertens ion is a consequence of OS A, whereas believe that OS A and hypertens ion can best be viewed difficulties arising from a common etiology, including obesity. It tends to be an illness of middle age, men, but can occur at any age, including children. On the P S G , episodes of OS A in adults are multiple periods of at leas t 10 s econds in duration in nasal and oral airflow ceas es completely (an apnea) or partially (a hypopnea), while the abdominal and ches t expansion leads indicate continuing efforts of the diaphragm and acces sory muscles of res piration to air through the obs truction (F ig. 20-2). T he arterial P.2031 saturation drops, and, often, there is a bradycardia that may be accompanied by other arrhythmias , such as premature ventricular contractions . At the end, an reflex takes place, seen as a waking signal and motor artifact on the E E G channels . At this moment, sometimes called the bre akthrough, the patient can be observed making brief restless movements in bed. T he patient then returns to sleep, with normal respirations . T hese events can occur in NR E M or R E M s leep, the us ually more frequent, the latter usually more s evere. Different laboratories require different numbers of to make a diagnosis , usually five or ten disordered breathing events per hour of s leep. Many laboratories a s cale of the number of dis ordered breathing events hour to class ify OS A as mild, moderate, or severe. clas sification based solely on the frequency of events be les s helpful than firs t s upposed, as the true s everity 2415 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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should include consideration of the degree of arterial oxygen s aturation, the presence or abs ence of cardiac arrhythmias, and other factors .

FIGUR E 20-2 E xample of an obstructive sleep apnea on the polys omnogram. C Z-O2, electroencephalogram channel; E C G , electrocardiogram; E MG , LOC , left electrooculogram; R OC , right C entral s leep apnea (C S A), which tends to occur in the elderly, res ults from periodic failure of central nervous system (C NS ) mechanis ms that s timulate breathing. original teaching was that OS A results in a complaint of excess ive sleepines s, whereas C S A is manifes t as but later case s eries have emphas ized that either may appear in either dis order. T he P S G features of similar to those of OS A, except that, during the periods apnea, a ces sation of res piratory effort is s een in the 2416 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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abdominal and ches t expansion leads. S everal features of OS A and C S A are s ignificant in ps ychiatric practice. T hese include decreased ability to concentrate, decreas ed libido, memory complaints , and deficits in neuropsychological tes ting. Many or even patients have dysthymic features , and, although many patients manifes t OS A and major depress ion, it is not certain that this occurs more often than would be s een chance. One study has indicated that, among OS A patients, thos e with a history of treatment for affective disorder s how greater decrements in ventilatory meas urements . Although s ys tematic data are minimal, many clinicians have the impres sion that, in cases of refractory depress ion, if OS A is found and treated, the depres sive s ymptoms may improve. tes ting indicates that mos t, but not all, deficits can be relieved by treatment. P atients s ometimes awaken from apneas with a of being unable to breathe, and thes e epis odes need to distinguished from nocturnal panic attacks. In taking a history, it s hould be noted that perhaps one-third of patients with daytime panic attacks also have thes e episodes during sleep, but it is rare to have panic purely at night. S imilar awakenings can occur in cases paradoxical vocal cord movement, but, in this s ituation, there is us ually a history of trauma or s urgery of the S leep apnea episodes also need to be dis tinguished nocturnal laryngospasm, in which patients report that are unable to s peak or can only whis per for a few after awakening. Another reas on for awarenes s of s leep-disordered breathing in ps ychiatric practice is that patients who 2417 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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complain of ins omnia and who have unrecognized may develop res piratory depress ion if given mos t traditional hypnotics. T he benzodiazepines have s uch res piratory depres sant qualities that their effects are clinically insignificant in persons with normal on the other hand, they can significantly exacerbate and other ventilatory dis orders. T his appears to be particularly true of the longer-acting agents . S tudies of short-acting agents have been mixed, and one s tudy suggested s light improvement in C S A. T he newer nonbenzodiazepines appear to s hare thes e respiratory depres sant qualities , although in milder form. T he important thought to keep in mind is that, if a patient sleep dis turbance appears overs edated in the daytime after being given a hypnotic, there s hould be at least cons iderations: (1) that this represents daytime sedation as a direct effect of the drug or (2) that the has exacerbated previously unrecognized sleep apnea. When a sedative is needed for patients with s leep one can give low dos es of s edating tricyclic antidepres sants (an off-label use), as they do not res piration and may have mild s timulatory effects . daytime anxiolytic is desired, it s hould be noted that buspirone (B uS par) does not appear to adversely res piration. In addition to OS A and C S A, some patients are found have mixed-type apneas, in which the early part of the disordered breathing event appears central in nature there is an absence of res piratory effort), whereas the part of the event appears obstructive. C linically, there little or no difference between what is s een in this form and what is seen in OS A. Upper airway resistance 2418 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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syndrome (UAR S ) is an interesting condition in which patient manifests the s leepiness , fatigue, and other features of OS A, but the P S G fails to reveal s pecific events. More elaborate testing with meas ures of intraes ophageal pres sure (a s urrogate for intrapleural press ure) reveals that, owing to increas ed upper res is tance, the patient mus t generate much greater negative pres sures to produce airflow. T reatment with continuous positive airway pres sure (C P AP ) has been shown to improve daytime alertness and other T he major treatments for OS A are C P AP and surgical approaches. C P AP is performed by administering room at low press ures (us ually les s than 15 cm of water through a nasal mask or small cus hioned nasal during s leep. It is remarkably effective acutely and has advantage of s paring the patient from a surgical procedure, although it carries the dis advantage that it must be used for long periods of time, or even the of the patient. A B elgian s tudy has indicated that 70 to percent of patients who try C P AP accept it, and 90 of them (us ually those who derive subjective benefit initially) continue to use it in the long term. Devices that automatically titrate and deliver the correct pres sure been developed; initial data indicate that they may be better tolerated, although the degree of improvement in daytime sleepines s is approximately the same as for conventional C P AP . Minor complications of C P AP irritation of the eyes from air leaks around the mask nasal drynes s or congestion. In rare cases , pneumomediastinum or pneumocephalus can occur. Alternative devices for treating OS A include tongueretaining devices or systems for advancing the 2419 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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T heir effectivenes s remains under investigation. T he original s urgical treatment for OS A was chronic tracheotomy, which is extremely effective (and may be gold s tandard of effectiveness ). T he concerns , of are that it is, in s ome s ens es , a disfiguring procedure, it requires maintenance, and that it can have complications , s uch as infection. Later, a modified procedure, the uvulopalatopharyngoplas ty (UP P P ) was developed, in which portions of the uvula and s oft are removed and the upper airway is widened. Its advantage is that (if success ful) it is a one-time (in contras t to the continuing need to us e C P AP ), but disadvantage is that it is a major surgical procedure requiring hospitalization and a certain amount of initial discomfort. More importantly, even in the bes t of hands , the success rate, in the range of 60 to 70 much lower than that of C P AP . R are complications can include changes in the voice and nasal regurgitation of liquids when s wallowing. A number of more surgical approaches , including mandibular or s elective widening of s pecific portions of the airway, performed as well, P.2032 although s election procedures to determine which is likely to benefit from which procedure are still under inves tigation. F or patients with s noring without s leep apnea, an outpatient laser-based technique (las eruvuloplasty [LAUP ]) is available. Medical remedies for s leep apnea are of limited benefit and probably should be considered treatments of choice. P erhaps the best s tudied is off-label use of 2420 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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protriptyline (V ivactil), 5 to 20 mg, which decreases sleep (which is usually as sociated with the more apneas ) and increases geniogloss us muscle tone. Its benefits are often limited by its anticholinergic side Low dos es of medroxyprogesterone acetate (P rovera) (again, an off-label use) may have beneficial effects, although, in rare cases, apneas may be exacerbated to uneven stimulation of the diaphragm and access ory muscles of res piration. Other compounds that have tried experimentally but are les s widely us ed are the label use of fluoxetine (P rozac) and buspirone. Lownasal oxygen has had mixed results ; it is generally of benefit in uncomplicated s leep apnea, although it is indicated in cases of apnea complicating other conditions. In addition to thes e s pecific procedures, a number of general precautions and behavioral interventions be us ed in all patients. C ertainly, weight loss should be encouraged in all obese patients, and, in extreme gastric s urgical procedures can be considered. weight loss can widen the upper airway and can lead to proportionate reduction in required C P AP press ure. patient should be encouraged to learn not to s leep on or her back and to avoid alcohol and drugs that are res piratory depres sants . He or she should be about driving, as OS A patients have been found to higher rate of automobile accidents . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > NAR C OLE P S

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P art of "20 - S leep Dis orders " Narcolepsy is a condition characterized by excess ive sleepiness , as well as auxiliary s ymptoms that the intrus ion of as pects of R E M sleep into the waking It typically begins in the teens or 20s but can occur or later. Once it appears, it is a lifelong condition. T he attacks of narcoleps y repres ent epis odes of irresistible sleepiness , leading to perhaps 10 to 20 minutes of after which the patient feels refreshed, at leas t briefly. helping s eparate sleep attacks from daytime other caus es , it is helpful to ask about epis odes of that have appeared at unus ual or inappropriate times, instance, during intens e conversations or s ex. In to sleep attacks , patients develop one or more symptoms, usually over the course of the next few after the appearance of the s leepiness . T he most of thes e is cataplexy, the s udden onset of weakness of weight-bearing muscles , lasting for a minute or les s occurring in ass ociation with the express ion of emotion, such as anger or laughter. (C ataplexy should be distinguished from catalepsy, the waxy flexibility of the limbs in catatonic schizophrenia.) C ataplectic episodes may be as mild as a sudden s ens ation of needing to sit down or may be so severe that the patient collaps es helpless ly to the ground. Often, the patient remains during the epis ode, although vis ual hallucinations may appear in longer ones lasting more than 1 minute. symptoms include sleep paralysis or hypnagogic hallucinations . T he former is characterized by a brief period of paralys is that occurs as the patient is drifting to sleep or awakening in the morning. Hypnagogic 2422 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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hallucinations are vivid dream-like experiences that when the patient is drifting off to sleep or is in the of awakening in the morning (hypnopompic hallucinations ). S leep paralysis and hypnagogic hallucinations can be accompanied by a s ens ation of a weight on the ches t and anxiety. T heir appearance in narcoleps y, in combination with sleep attacks and cataplexy, s hould be distinguis hed from occas ional episodes in the abs ence of daytime sleepines s, which occur as is olated events in persons without narcoleps y. S ome patients des cribe epis odes that are s uggestive automatic behavior, in which they have done things , s uch as putting dis hes in the clothes washer, for which they have no memory. T hes e probably represent actions taken during a period of sleepines s, which are later recalled. F inally, and somewhat paradoxically, sleepy individuals typically complain of difficulty with nighttime sleep, which is characterized by frequent awakenings . On the P S G , sleep is indeed dis turbed, with frequent arousals , and, often, there are significant numbers of periodic leg movements . T he diagnosis is made from a specialized daytime sleep recording, the MS LT , in patient is given four or five opportunities to s leep for as long as 20 minutes, at 2-hour intervals acros s the day. mean time to fall as leep is calculated, and it is whether the patient has marked sleepines s (usually defined as a mean s leep latency of less than 5 addition to s leepiness , however, during these naps , the narcoleptic patient typically shows two or more of R E M s leep, a phenomenon that is unlikely in other conditions of excess ive s leepiness . T his obs ervation of 2423 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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ons e t s le ep is diagnostic, as well as sugges tive, of the pathophys iology of narcoleps y, which appears to the intrus ion of as pects of R E M sleep (muscle atonia dreams ) into wakefulness . Hence, cataplexy and sleep paralysis can be s een as repres enting the atonia that occurs in R E M, whereas hypnagogic hallucinations an expres sion of the dreaming that is characteristic of Although there is s ome unders tanding of this dysregulation of R E M s leep in narcoleps y, the pathophys iology is s till being inves tigated. An with certain genetic human leukocyte antigen (HLA) markers has been found, but these can also occur in as ymptomatic individuals. T he child of a narcoleptic is approximately 20 times more likely to have narcoleps y than the general population, but there is no s imple Mendelian mode of trans mis sion. R ecent work that the sleepiness of narcolepsy may result from abnormalities in the function of the neuromodulator orexin/hypocretin in the hypothalamus. Occas ional of a narcoleps y-like condition (secondary narcoleps y) been reported in patients with various C NS including children with s uprasellar tumors and hypothalamic obes ity. T he medical treatment of narcolepsy is oriented to the target s ymptoms. F or the s leepiness , the traditional treatment has been the us e of s timulants , such as amphetamines. T olerance may appear, and s ome believe that the use of weekly drug holidays decreases likelihood. More recently, modafinil (P rovigil) has been found to increase wakefulnes s, while demonstrating a more benign s ide effect profile than the traditional analeptics. C ataplexy is us ually respons ive to the 2424 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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antidepres sants. In this off-label use, compounds such imipramine are given in much lower dos es than are for depress ion, for example, 50 mg, and the patient shows improvement within one or two nights. Other tricyclics , s uch as protriptyline, and s elective serotonin reuptake inhibitors (S S R Is ), s uch as fluoxetine, may cataplexy in this off-label use. In addition to medical treatments, a number of and educational interventions are important in narcoleps y. B ecause patients often awaken refreshed brief naps , it is helpful to work with the patient, or both to arrange for periods of s cheduled sleep the day. S ymptoms are us ually exacerbated during deprivation, which should be avoided. T he of narcolepsy are such that patients have often not achieved as much in life as their intelligence and drive might otherwise have produced; often, they have been told by teachers and employers that they are lazy, fact, they are pathologically s leepy. Not s urprisingly, experiences can lead to poor s elf-es teem, which can further inhibit the P.2033 patient's ability to achieve. Hence, education about the disorder and reass urance, for the patient and family, be important. Many patients with narcoleps y are dys thymic. In number of clinicians comment on the s imultaneous occurrence of major depress ion and narcoleps y, but population s tudies indicate that thes e are common illness es, and their coexis tence appears no more often than would be expected by chance. In ps ychiatric 2425 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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it is als o important to dis tinguis h between hypnagogic hallucinations and visual hallucinations from other and to consider narcoleps y in the differential diagnos is when hearing about a patient who exhibits episodes are sugges tive of automatic behavior. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > IDIOP AT HIC HY P E R S OM

IDIOPATHIC P art of "20 - S leep Dis orders " Idiopathic hypers omnia is a condition characterized by excess ive s leepiness and naps from which the patient not awaken refres hed. T he MS LT confirms significant sleepiness , without evidence of R E M ons et s leep Nocturnal s leep s tudies show no characteris tic pattern, although s low wave sleep may sometimes be elevated. us ually begins in young adulthood and becomes a condition lasting a lifetime. S ome cases appear to be familial and are as sociated with specific HLA antigens, whereas others begin after viral infections, and a group develops thes e symptoms but has neither family history nor postviral status . T reatment is empirical, involving use of amphetamines or other T here are also re curre nt hype rs omnias that appear in distinct episodes weeks apart. An example of these is K leine-Levin syndrome, us ually found in male and characterized by periods of sleepines s and eating. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > P AR AS OMNIA

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PAR AS OMNIAS P art of "20 - S leep Dis orders " P arasomnias, abnormal behaviors during sleep, are divided into forms as sociated with s low wave sleep or sleep. T he former includes s leep terror and disorder, whereas the latter includes nightmare and R E M behavior disorder.

S leep Terrors S leep terrors are epis odes in which a child awakens confused and upset, with marked autonomic seen clinically as rapid pulse and diaphores is . T here is report of dreaming, and, eventually, the s eemingly inconsolable child returns to s leep, with no memory of event in the morning. T he P S G shows that thes e appear out of s low wave s leep, and the overall night have hypersynchronous delta activity. S leep terrors occur in as much as 3 percent of children and tend to away in adoles cence.

S leepwalking Dis order S leepwalking disorder tends to occur between 4 to 8 of age and, like night terrors , tends to dis sipate in adoles cence. E pisodes occur out of slow wave sleep; during them, patients appear confused and disoriented. rare cases , they may become violent if arous ed, but, us ually, they can be guided back to bed. T his benign condition needs to be distinguished from the rarer, but more clinically s ignificant, problem of nocturnal 2427 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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Although a clinical E E G is the ultimate way of distinguishing thes e two dis orders, some features of history are of help: (1) P atients with sleepwalking return to bed, whereas those with s eizure dis order may awaken in the morning in another room. (2) Although it good practice to help protect sleepwalkers from harm, they rarely injure thems elves ; in contrast, the with seizure disorder may have a his tory of falling down the stairs or walking into a window. (3) T he sleepwalker can usually be guided back to bed, whereas the patient is not res ponsive to guidance during the If an epis ode is captured on the polygraph, it is s een as awakening and motor artifact appearing during s low sleep. If a patient with night terrors or sleepwalking not have an epis ode during a particular s leep one s uggestive piece of evidence is the presence of arousals out of s low wave s leep, which are fairly uncommon in the abs ence of a paras omnia. Night terrors and sleepwalking are benign conditions, treatment cons is ts primarily of educating and the parents . Although both can be exacerbated by of stress or s leep deprivation, in childhood, neither is as sociated with psychiatric illness . S ome cas es of sleepwalking may be induced by medication. Medical intervention is rarely needed for typical night terrors or sleepwalking. In difficult cas es, some clinicians try the label use of benzodiazepine sedatives, which decreas e slow wave s leep.

Nightmares Nightmares are vivid dreams that become more anxiety producing, ultimately resulting in an 2428 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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awakening. T hey can occur occasionally in as much as half of children in the range of 3 to 6 years of age. In contrast to night terrors , the child is not confus ed, does not exhibit the mass ive autonomic s igns, and des cribes having had a scary dream. Nightmares in children are as sociated with psychiatric illness ; in contrast, approximately one-half of the roughly 1 percent of who experience frequent nightmares are found to have disorders , including borderline pers onality and schizophrenia. Nightmares are sometimes brought out R E M-suppress ing drugs, in which cas e, the treatment gradually dis continue the medication, if pos sible. S ome authors s uggest that nightmares occur more frequently persons with certain personality traits, including thos e with thin boundaries and more creative individuals . is no widely accepted medical intervention.

R E M B ehavior Dis order R E M behavior disorder is characterized by episodes of complex, often violent, behavior and is thought to represent a patient acting out his or her dreams . It is common in older men, and there is often a history of a small s troke or other C NS ins ult in the last months or It may also appear as an early event in the evolution of P arkins on's dis ease. If an episode is captured on the polygraph, it shows motor artifact appearing out of sleep. If a patient with R E M behavior dis order does not have an epis ode while in the laboratory, the sleep may s how a failure of the normal hypotonia of the bearing muscles during R E M s leep. In cats, a that is s uggestive of R E M behavior dis order can be induced by les ions of the areas s urrounding the locus ceruleus , a brainstem noradrenergic center. T he initial 2429 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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was that the clinical disorder repres ents a malfunction the des cending pathway to the s pinal cord, which produces atonia during R E M; its prevalence in the and in parkinsonian patients has sugges ted that there be a more complex etiology involving alteration of function in pontine areas , including the nucleus pedunculopontine, where integration of sleep–wake regulation with locomotor s ys tems takes place. T he widely us ed treatment for R E M behavior disorder is the label administration of clonazepam.

S leep Dis turbanc es in P s yc hiatric Dis orders S leep disturbances in ps ychiatric disorders are the chapters of this volume devoted to the specific disorders . S everal epidemiological s tudies have the as sociation of ins omnia and ps ychiatric disorder; indeed, one s uggests that if a person with no known complains of insomnia at initial interview and does so again at 1-year follow-up, he or s he is almost 40 times likely as the general population to have a diagnosable ps ychiatric disorder. In the sleep center s etting, approximately one-third of pers ons coming in complaining of ins omnia are found to have a disorder, which is major depress ion in approximately half the cases. T here are als o s everal studies affectively normal insomniacs have a much higher rate subs equently developing major depres sion in the next several years . It is not yet known whether therapeutic interventions for the ins omnia will reduce this increased ris k. P.2034 2430 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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P erhaps 80 percent of patients with major depres sion complain of insomnia. R oughly 10 percent of patients des cribe hypersomnia, and this usually those with atypical or bipolar depres sion. S leep studies major depress ion reveal some combination of sleep latency, s hortened total s leep, and increased arousals during the night. S low wave sleep is us ually reduced. In addition, a number of features of R E M characteristic: (1) T he firs t R E M episode often occurs minutes or less after s leep onset (a s hort R E M subs tantially earlier than the roughly 90- to 110-minute R E M latency s een in asymptomatic normal young (2) ins tead of the normal progres sion in duration of episodes acros s the night, they are all of roughly equal length; and (3) the first R E M episode may have a particularly high number of eye movements . T he s hort R E M latency has been interpreted by s ome to be a biological marker of depres sion. T he underlying pathophys iology behind the short R E M latency is not P os sible interpretations are that it is a consequence of heightened s ens itivity of muscarinic cholinergic that it represents an altered ratio of cholinergic activity adrenergic activity in the brainstem, or that it is a cons equence of a poss ibly phas e-advanced os cillator the circadian regulatory system. A number of inves tigators have s uggested that s leep disturbance is more than an epiphenomenon resulting from depres sion and may instead be involved in its genes is. S upport for this notion comes from the observation that s everal manipulations of s leep (total or partial sleep deprivation or R E M sleep deprivation) 2431 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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represent potent (although time consuming and not always practical) treatments for depress ion. In treating sleep dis turbance in depres sed patients, several therapeutic options are available. One approach is to change to a more sedating antidepres sant, for from imipramine (T ofranil) to amitriptyline (E lavil). the S S R Is and newer mixed-action agents , this could done by changing, for ins tance, from fluoxetine or paroxetine (P axil) to the sedating mirtazapine. (In using the latter, however, one s hould be aware of the rare, potentially s erious , blood dys crasias that can appear.) antidepres sant is of clinical benefit but dis turbs s leep, can happen with fluoxetine, s ome clinicians add low of trazodone, although, in rare cas es , confusional can result. T here are s ome data to sugges t that initially adding the newer nonbenzodiazepine hypnotics to the antidepres sant regimen can give symptomatic relief for the depres sed patient's poor s leep, although this is sue still under investigation.

P os ttraumatic S tres s Dis order P os ttraumatic stress dis order (P T S D) patients typically describe poor s leep, and, indeed, the DS M-IV -T R incorporates two as pects (nightmares and a state manifes ted as ins omnia) in the diagnos tic criteria. study of car accident victims sugges ts that thos e who persis tent insomnia and daytime sleepines s for months after the trauma are more likely to later develop P T S D. Many patients complain of difficulty initiating and maintaining sleep, and s ome have anxiety dreams . Increased R E M dens ity and elevated arous al from R E M have been reported. In general, however, laboratory findings have been inconsistent, and 2432 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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interpretation is complicated by not fully cons idering comorbid psychiatric conditions . C linically, many of patients als o have major depress ion and are receiving various antidepress ants . T here are s ome data to that the off-label use of the anticonvulsant gabapentin (Neurontin) or the α1-adrenergic antagonis t prazos in (Minipres s) may improve their s leep. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > S UG G E S T E D C R OS S -R E F E R

S UGGE S TE D C R OS S R E FE R E NC E S P art of "20 - S leep Dis orders " T he basic s cience of s leep is discus sed in S ection Mood dis orders are covered in C hapter 13, and anxiety disorders are dis cus sed in C hapter 14. Light therapy, deprivation, and s leep delay are discuss ed in S ection and s leep disorders among the elderly are discus sed in S ection 51.3b. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 20 - S leep Dis orders > R E F E R E NC

R E FE R E NC E S Antrobus J . T heories of dreaming. In: K ryger MH, Dement W C , eds. P rinciple s and P ractice of S le e p Me dicine . P hiladelphia: WB S aunders; 2000:472– B aillargeon L, Landreville P , V erreault R , G regoire J P , Morin C M: Discontinuation of 2433 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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benzodiazepines among older ins omniac adults with cognitive-behavioural therapy combined with gradual tapering: A randomized trial. C MAJ . 2003;169:1015–1020. B as siri AG , G uilleminault C . C linical features and evaluation of obs tructive s leep apnea-hypopnea syndrome. In: K ryger MH, R oth T , Dement W C , eds. P rinciple s and P ractice of S le e p Medicine. WB S aunders; 2000:869–878. B ootzin R R : S timulus control treatment for ins omnia. P rocee dings of the 80th Annual C onve ntion of the Ame rican P s ychological As s ociation. 1972;7:395– C aps oni S , S tankov B M, F raschini F : R eduction of regional cerebral blood flow by melatonin in young rats . Neuroreport. 1995;6:1346–1348. C ons umers Union: Overcoming insomnia. R eport. 1997;62:10–13. C zeisler C A, Duffy J F , S hanahan T L, B rown E N, J F , R immer DW , R onda J M, S ilva E J , Allan J S , Dijk D-J , K ronauer R E : S tability, precision, and nearhour period of the human circadian pacemaker. 1999;284:2177–2181. Dawson D, V an Den Heuvel C J : Integrating the of melatonin on human phys iology. Ann Me d. 1998;30:95–102.

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G illin J C , Dow B M, T hompson P , P arry B , T andon B enca R : S leep in depres sion and other psychiatric disorders . C lin N euros ci. 1993;1:90–96. Hobs on J A, S tickgold R , P ace-S chott E F : T he neurops ychology of R E M s leep dreaming. 1998;9:R 1–R 14. *J ames S P , Mendels on W B : Herbal preparations for sleep. S le e p H ypnos is . (in pre s s ). J ames S P , Mendels on W B : T he us e of trazodone as clinical hypnotic: A critical review. J C lin P s ychiatry. pre s s ). K rys tal A, W alsh J , R oth T , Amato DA: T he efficacy and safety of eszopiclone over s ix months nightly treatment: A placebo-controlled study in patients with chronic ins omnia. S le e p. 2003;26 [S uppl]:A310. Mendels on W B . Human S le ep: R es e arch and New Y ork: P lenum P res s; 1987:1–436. *Mendelson WB . Do studies of s edative/hypnotics suggest the nature of chronic insomnia? In: J , G odbout R , eds. S le e p and B iological R hythms : Me chanis ms and Applications to P s ychiatry. New Oxford Univers ity P res s; 1990: 209–218. Mendels on W B . Drugs which alter s leep and s leeprelated res piration. In: K una S T , ed. S le e p and 2435 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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in Aging Adults . New Y ork: E ls evier S cience; *Mendelson W B : E ffects of flurazepam and the perception of s leep in ins omniacs . S le e p. 1995;18:92–96. Mendels on W B : T he relationship of sleepiness and blood pres sure to res piratory variables in obs tructive sleep apnea. C he s t. 1995;108:966–972. Mendels on W B : Are periodic leg movements with clinical s leep disturbance? S le e p. 1996;19:219– Mendels on W B . Hypnotics: B asic mechanisms and pharmacology. In: K ryger MH, R oth T , Dement W C , P rinciple s and P ractice of S le e p Medicine . WB S aunders; 2000:407–413. Mendels on W B . Ins omnia. In: C onn's C urre nt P hiladelphia: W B S aunders ; 2001:31–34. Mendels on W B , C arus o C . P harmacology in sleep medicine. In: P oceta J S , Mitler MM, eds . S le e p Diagnos is and T re atme nt. T otowa, NJ : Humana 1998:137–160. Mendels on W B , G arnett D, G illin J C , W eingartner H: experience of insomnia and daytime and nighttime functioning. P s ychiatr R es . 1984;12:235–250. *Mendelson W B , J ames S P , G arnett D, S ack D, NE : A ps ychophysiological s tudy of ins omnia. 2436 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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R es . 1986;19:267–284. Monroe LJ : P sychological and physiological between good and poor s leepers . J Abnorm 1967;72:255–264. *Morin C M, C ulbert J P , S chwartz S M: Nonpharmacological interventions for ins omnia: A meta-analysis of treatment efficacy. Am J 1994;151:1172–1180. Morin C M, R odrigue S , Ivers H: R ole of stress , and coping s kills in primary ins omnia. P s ychos om 2003;65:259–267. P elayo R , G uilleminault C . Narcolepsy and daytime sleepines s. In: P oceta J S , Mitler MM, eds. Dis orde rs : Diagnos is and T re atme nt. T otowa, NJ : P res s; 1998:95–116. P rovini F , V etrugno R , Meletti S , P lazzi G , S olieri L, Lugares i E , C occagna G : Motor pattern of periodic movements during s leep. Neurology. 2001;57:300– R ay J D. C ults. In: R edford DB , ed. T he Ancie nt Oxford, UK : Oxford University P ress ; 2002:61–91. S chweitzer P K , W als h J K : T en-year trends in the pharmacologic treatment of insomnia. S le e p. 1998;21:247(abst). S pielman AJ , S askin P , T horpy MJ : T reatment of 2437 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/20.htm

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insomnia by res triction of time in bed. S le e p. 1987;10:45–56. S tone B M, T urner C , Mills S L, Nicholson AN: activity of melatonin. S le e p. 2000;23:663–669. T urek F W , Dugovic C , Zee P C : C urrent the circadian clock and the clinical implications for neurological dis orders. Arch Neurol. 2001;58:1781–

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified > 21 C ontrol Dis orders Not E ls ewhere C las s ified

21 Impuls e-C ontrol Dis orders Not E ls ewhere C las s ified Harvey R oy Greenberg M.D. T he category of impuls e -control dis orders , not s pecifie d, includes impulse-related conditions that are subs umed under other diagnos tic categories in the fourth edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-IV -T R ). T he expansion of this chapter over earlier discuss ions in K aplan and C omprehe ns ive T e xtbook of P s ychiatry reflects an awarenes s that thes e disorders , taken together, for a s ubs tantial proportion of ps ychiatric illnes ses. T he feature common to this group is the repeated to res is t an intens e impulse, drive, or temptation to perform a particular act that is obvious ly harmful to s elf others , or both. B efore the event, the individual usually experiences mounting tens ion and arousal, but not cons is tently—mingled with cons cious pleas ure. C ompleting the action brings immediate gratification relief. W ithin a variable time afterward, the individual experiences a conflation of remors e, guilt, s elfand dread. T hes e feelings may s tem from obscure unconscious conflicts or awarenes s of the deed's 2439 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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on others (including the poss ibility of serious legal cons equences in s yndromes such as kleptomania). S hameful s ecretiveness about the repeated impuls ive activity frequently expands to pervade the individual's entire life, often s ignificantly delaying treatment. S igmund F reud declared that artists discovered the Oedipus complex long before ps ychoanalys is. Analogous ly, powerful portraits of impuls e-ridden personalities were drawn by S ophocles and W illiam S hakes peare, long before 19th century F rench J ean-E tienne E squirol described patients whose impulsiveness demonstrated “all the features of elevated to the point of delirium.” S ince E squirol, of impuls e control have eluded definitive let alone effective means of treatment. In contemporary nosology, the category of impuls e dis orders not e ls ewhe re clas s ified entered the third of the DS M (DS M-III) in 1980. B y DS M-IV -T R , this syndromes has been expanded to encompass gambling, trichotillomania, kleptomania, intermittent explosive dis order, pyromania, and impulse-control disorders not otherwise specified. T he latter address es syndromes waiting in the wings for definitive inclusion exclusion. T he category of habit and impuls e dis order in the 1992 tenth edition of the Inte rnational S tatis tical Dis e as es and R e late d H ealth P roble ms (IC D-10) is analogous to the DS M-IV -T R 's impuls e -control not els e whe re s pecifie d. Intermittent explos ive dis order not mentioned per se in the IC D-10 schema. Habitual of alcohol or drugs , as well as addictive or otherwis e pathological sexual and eating disorders , is specifically 2440 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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excluded.

Table 21-1 IC D-10 Diagnos tic C riteria for Habit and Impuls e Dis orders Pathologic al gambling    A. T wo or more episodes of gambling occur period of at least 1 year.    B . T hese epis odes do not have a profitable outcome for the individual but are continued despite personal dis tres s and interference with personal functioning in daily living.    C . T he individual describes an intense urge to gamble which is difficult to control and reports he or s he is unable to s top gambling by an effort will.    D. T he individual is preoccupied with thoughts mental images of the act of gambling or the circums tances surrounding the act. Pathologic al fire s etting (pyromania)    A. T here are two or more acts of fire s etting

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apparent motive.    B . T he individual describes an intense urge to fire to objects , with a feeling of tens ion before the act and a feeling of relief afterward.    C . T he individual is preoccupied with thoughts mental images of fire s etting or of the surrounding the act (e.g., abnormal interes t in fire engines or in calling out the fire s ervice). Pathologic al s tealing (kleptomania)    A. T here are two or more thefts in which the individual s teals without any apparent motive of personal gain or gain for another pers on.    B . T he individual describes an intense urge to with a feeling of tension before the act and a of relief afterward. Tric hotillomania    A. Noticeable hair los s is caused by the persis tent and recurrent failure to resist impulses pull out hairs .    B . T he individual describes an intense urge to out hairs, with mounting tension before the act a s ense of relief afterward. 2442 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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   C . T here is no preexis ting inflammation of the and the hair pulling is not in res ponse to a or hallucination. Other habit and impuls e dis orders    T his category s hould be used for other kinds of persis tently repeated maladaptive behaviors that not secondary to a recognized psychiatric and for which it appears that there is repeated to resist impuls es to carry out the behavior. T here a prodromal period of tension with a feeling of releas e at the time of the act. Habit and impuls e dis order, uns pec ified

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion. T he IC D-10's habit and impuls e disorders are by repeated acts with no clear rational motive that be controlled by the patient and are us ually harmful to interes ts of s elf and others. IC D-10 s tates the caus es these conditions are unknown, further ass erting that are only grouped together because of broad des criptive similarities , “not because they are known to share any other important features .” 2443 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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Over the pas t several decades , numerous studies have probed the complex phenomenology and etiology of impulse-control disorders . C onsiderable progress has made in conceptualization and treatment. Divers e, apparently disparate, conditions are now widely to have common epidemiological, genetic, neurobiological, and therapeutic features. T hes e are shared not only within the group, but often with other serious psychiatric illness es (notably depres sive and addictive disease) as well. Interconnections are and vary enormous ly from one impulse-ridden patient another. T he blurring of diagnos tic boundaries between control disorders and other Axis I and Axis II conditions often cited in the literature and regularly challenges the clinician. S tudies sugges t that a s ignificantly high comorbidity exists between the impuls e-control subs tance abus e disorders , affective dis orders, compuls ive disorder (OC D), and obs es sive-compuls ive personality dis order. Other important comorbid include borderline personality, antisocial personality, narcis sistic pers onality disorders; one or another type pathological aggres sion; attention-deficit disorder; disorders ; and paraphilias. F rom a genetic perspective, family histories of with impulse-control problems are replete with depres sion, bipolarity, substance abus e, and disorders . Mutatis mutandis , the family trees of patients with the latter problems often reveal a s tatistically meaningful presence of one or another impulse-control disorders . Neurobiological res earch sugges ts that compromis ed 2444 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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frontal lobe function may contribute to the dis inhibition some impulse-disordered patients. S imilarities in serotoninergic and other neurotrans mitter have als o been dis covered across the entire spectrum impulse disorders . Improvement with s elective reuptake inhibitors (S S R Is ), mood regulators, and antagonis ts points to common neurobiological between the impuls e-control s yndromes, which are variably dis played in their comorbid illness es. F rom a behavioral and cognitive viewpoint, whatever other origins of impulse-control disorders may be, the frequent repetition of impulsive behavior s ui ge ne ris is regarded as a major caus e of its installation within the ps yche. B ehavioral s trategies useful in treating abuse dis orders and obs ess ional states have been to a gamut of impuls ive behaviors with reas onable succes s. G iven this intricate web of intersections in etiology and treatment, researchers have attempted to ascertain “figure in the P.2036 carpet,” a central organizing schema for the impulse disorders that may also explain the link between them their comorbid conditions. One theory pos tulates a cons tellation of obs e s s ive -compuls ive s pectrum with varying degrees of overlapping features in each between three subgroups : (l) impulse-control disorders , disorders of phys ical appearance and sensation (e.g., dysmorphic dis order and hypochondriasis ), and (3) neurological disorders hallmarked by repetitive bursts tics, spasms, or other pathological movements (e.g., 2445 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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T ourette's s yndrome and S ydenham's chorea) (F ig. 21-

FIGUR E 21-1 Obs ess ive-compuls ive-related dis orders. (F rom Hollander E , K won J H, S tein DJ , et al.: compuls ive and s pectrum dis orders: Overview and of life is sues. J C lin P s ychiatry. 1996;57[S uppl]:3, with permis sion.) It has been further s ugges ted that the s yndromes the obsess ive-compuls ive s pectrum could notionally be located along an axis according to the approximate that each dis order is driven by risk avers ivenes s on the hand (compulsive s yndromes ), or risk seeking syndromes) on the other (F ig. 21-2). P s ychological contributing factors aside, the amplitude of ris k seeking ris k avoidance may be mediated by s erotonin, with neurotransmitters playing a les ser part.

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FIGUR E 21-2 C ompulsivity-impulsivity dimens ion. Hollander E : T reatment of obsess ive-compuls ive with S S R Is. B r J P s ychiatry. 1998;25[S uppl]:7, with permis sion.) Another important line of inquiry s tems from the cons picuous comorbidity of impuls e-control disorders with unipolar and—most notably—with bipolar illness 2447 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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(common features of bipolarity and impuls e-control difficulties include pleasurable and dangerous onset in adolescence or early adulthood, episodic chronic cours e, similar abnormalities in and improvement with mood s tabilizers and S S R Is) 21-3).

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FIGUR E 21-3 Hypothesized relations hip between compuls ivity, impulsivity, unipolarity, and bipolarity a s ingle dimens ion. T he compuls ivity-unipolarity end of spectrum is characterized by harm-avoidant behaviors, inhibited thinking and behavior, ins ight into of symptoms , resis tance to impulses and behaviors , absence of pleas ure. T he impulsivity-bipolarity end of spectrum is characterized by harmful behaviors , disinhibited or s pontaneous thinking and behavior, little insight into dangerousness of symptoms , little impulses and behaviors , and pleasurable feelings. IC D, impulse-control disorder; OC D, obsess ive-compuls ive disorder. (F rom McE lroy S , et al. Are impulse control disorders related to bipolar disorder? C ompr P s ychol. 1996;37:229, with permis sion.) P.2037 On this bas is, a clas s of affe ctive s pe ctrum dis orders been hypothes ized that embraces affective, obs ess ive, impulsive dis orders. T hes e conditions are notionally 2449 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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located on an inferred axis according to their different degrees or combinations of compulsivity and or impuls ivity and bipolarity. T he schema elegantly accounts for patients pres enting a perplexing mixture impulsivity and obsess ion (these liminal cases would be situated at the midpoint of the axis ). S uch formulations are neither definitive nor mutually exclusive. T hey are best contemplated as touchs tones, signifying that the truth about the deep s tructures of the impulse-control disorders is finally being glimpsed, as through a glas s darkly. T he increas ing volume and sophistication of research will s urely s hed more light on these intriguing maladies. F reud famously predicted that ps ychiatry's future would manifest a s wing of the pendulum between ps ychodynamically and somatically oriented theories about mental illnes s. C urrent research into impulsedisorders overwhelmingly explores their materiality— neurobiology, heredity, and ps ychopharmacology. In context of this lates t oscillation, the astute clinician will neglect psyche for s oma. One's attentivenes s to loading and s erotonin fluctuations should not preclude receptivenes s to the impulsive patient's inner world, to past trauma, and to dysfunctional family and s ocial circums tances . T here is, after all, a s earch for and meaning embedded within the molecules of human beings . 

P AT HOLOG IC AL G AMB LING



T R IC HOT ILLOMANIA 2450

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

K LE P T OMANIA

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P Y R OMANIA

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INT E R MIT T E NT E XP LOS IV E DIS OR DE R

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

IMP ULS E -C ONT R OL DIS OR DE R S NOT S P E C IF IE D S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified P AT HOLO G IC AL G AMB LING

PATHOL OGIC AL P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified" P athological gambling is the mos t common impuls e disorder in this category. It afflicts several million Americans , cons tituting a major, increasing public problem; hence, s ignificant space is devoted to it here.

His tory Archeological and anthropological research bear tes timony to the ubiquity of gambling, normative and pathological, in every time and place. G ambling may well have had religious origin: P erhaps attempts to divine the will of the G ods or F ates gave way to betting on more tangible outcomes. Wagering on the speed and strength of man or beas t arguably dates back to human prehis tory. Dice have found in the tombs of E gypt. E ncamped soldiers of 2451 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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upended chariots and bet on the turn of their wheels . ancient C hines e are s aid to have staked digits or limbs games of chance, the American Mojave Indians risked wives, and the G ermanic barbarians of J ulius C aesar's wagered life or freedom. P redeces sors of modern card games , craps , and gaming machines go back several hundred years to s everal thousand years . E very gambling was wildly popular in R enais sance and E nlightenment E urope. Des pite the P uritan ethic, the gamut of E uropean gambling quickly found favor the firs t American colonists , es pecially horse racing. As the American frontier expanded, gamblers followed farmer, the rancher, and the entrepreneur. G ambling flouris hed in the marginal milieus of cattle towns and mining camps, on Mis siss ippi riverboats , and in the and s alons of major cities . B y the mid-19th century, gambling had es tablis hed an increasingly ominous as sociation with criminal elements in wes tern towns eastern cities. C orruption of law enforcement officials politicians inevitably accompanied the consolidation of gambling interes ts. A powerful gangs ter and gambler coalition was forged by the 1930s and 1950s , with gangland muscle and cash backing illegal gambling legitimate busines ses behind the s cenes . In the las t two decades , major entertainment in Las V egas , Atlantic C ity, and Native American have reaped vaster profit from legitimate gaming than from their mob antecedents. C orporate s trategies are increasingly—and s ucces sfully—aimed at low-stake, family gambling. T he new wave of gaming is further by states and churches with straitened budgets . gambling Web sites are plentiful: T his global casino 2452 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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well prove to be the greates t source of gaming revenue history. T he current total take of legal and illegal es timated to be at least 0.5 trillion dollars yearly. T he chaotic life and times of the pathological gambler have proven perennially fertile ground for artis ts . One the most powerful and clinically accurate depictions of disorder is found in F yodor Dos toevs ky's novella, T he G amble r, based on the author's own descent into hell.

Nos ology P athological gambling was first des ignated as a diagnostic entity in DS M-III. P arameters were revis ed revis ed DS M-III (DS M-III-R ), redefined yet again for and es sentially retained in DS M-IV -T R . T he current definition emphasizes the afflicted individual's overwhelming preoccupation and obsess ion with gambling, tolerance and withdrawal in the progres s of condition, difficulty in controlling gambling activity and chas ing behavior, the us e of gambling to alleviate dysphoric emotional s tates, and the devas tating impact gambling on vocation, social, and family life. IC D-10 delineates pathological gambling as a “disorder frequent, repeated epis odes of gambling that dominate the patient's life, to the detriment of s ocial, material, and family values and commitments .” Like IV -T R , IC D-10 notes the patient's obs ess ive with and inability to control gambling P.2038 behavior, as well as the emergence of pathological gambling under s tres s. An alternate term, compuls ive 2453 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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gambling, is mentioned but is dismis sed, “because the behavior is not compulsive in the technical s ens e, nor the disorder related to obs ess ive-compuls ive neuros is .” S pecifically excluded from the IC D-10 category are gambling epis odes ; gambling for excitement or profit by those “likely to curb their habit when confronted with heavy loss es, or other adverse effects ”; and gambling sociopathic personalities .

E pidemiology Although comprehensive worldwide s tatistics have yet be compiled, excellent local s tudies all point to a 3 to 5 percent rate of problem gamblers in the general population and an approximate 1 percent rate of individuals meeting the requirements for pathological gambling. In the United S tates, the combined population of and pathological gamblers is es timated at 5 million. combined loss es run into the billions , with an average individual indebtednes s of $30,000. W ealthy gamblers with the means to s ustain a huge habit may hundreds of thous ands or even millions of dollars. C ollateral loss es due to time away from work, total unemployability, and eros ion of s avings as a result of gambling are s taggering. T he typical patient in treatment studies is a white man from a comfortable economic background, 35 to 50 of age. However, s urveys of more extensive populations indicate that pathological gambling cuts acros s every ethnic, clas s, age, and occupational (according to anonymous casino pers onnel, physicians 2454 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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amongst their most cons is tent heavy players and As every type of gambling has become increasingly access ible over the past few decades, the rate of and pathological gambling has ris en s pectacularly, es pecially in locales with legalized gaming. E scalation been noted in the poor, notably poor minorities; adoles cents ; elderly retirees; and women. One out of pathological gamblers is now female: It has been suggested that women are gambling more becaus e an increased presence in the workplace gives them more cash. T hese groups are all s till greatly unders erved regard to res earch and treatment. F amily histories of pathological gamblers s how an increased rate of s ubs tance abus e (particularly and depres sive dis orders. A parent or influential the patient often has been a problem or pathological gambler. T he family circle is likely to be competitively materialistically oriented, evincing intense admiration money and as sociated symbols of s ucces s. In this compuls ive gambling has been called the dark side of American dream.

C omorbidity S ignificant comorbidity occurs between pathological gambling and mood dis orders (especially major depres sion and bipolarity) and s ubs tance abus e (notably alcohol and cocaine abus e and caffeine and nicotine dependence). C omorbidity als o exis ts with attention-deficit/hyperactivity disorder (ADHD) (particularly in childhood), various personality dis orders (notably narciss is tic, antis ocial, and borderline disorders ), and other impuls e-control disorders . 2455 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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many pathological gamblers have obsess ive traits, full-blown obsess ive-compuls ive disorder is uncommon.

E tiology C ons iderable differences in precipitating factors are discovered from one patient to another and within the pathological gambler's lifetime as well. T he disorder— others in its class —is best conceptualized not as a monolithic entity, but as a condition encompas sing subs ets of dys functional behavior with diverse of divers e etiologies. F or decades, E dmund B ergler's compuls ive los e r dominated ps ychoanalytic res earch. B ergler as serted the pathological gambler is a pathological narciss is t, res ents the loss of childhood megalomania and bears a profound grudge agains t parents and other authority figures for reining in inflated infantile omnipotence. Aggress ion directed against sundry agents of occasions guilt and an intens e need for punis hment. pleas ures of gambling are related to the joy of rebellion; the pain of gambling is related to the certain expectation of punishment. E ventually, the anguis h of is eroticized and elaborated into a chronic masochistic stance, wherein the patient savors victimhood, relishes injus tice collecting, and revels in self-pity and s purious righteous indignation. B ergler's views have largely been s uperseded by more nuanced formulations , notably by R alph G reens on and succes sors . G reenson believed that pathological gratified multiple pregenital and genital conflicts, rooted in oral-receptive, anal-sadis tic, and, especially, oedipal 2456 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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strivings . G reenson was one of the first clinicians to speculate that gambling might defend against affect. Hearkening back to the pos sible theological origins of gambling, the pathological gamblers' relentles s to play compris es a kind of s pilt religion, betokened by host of s upers titions and rituals pitched at beating the odds. Analytical therapy often reveals a covert, fear of death, s uggesting that thes e patients may be courting the erratic favors of Lady Luck in aid of the ultimate score—winning over mortality its elf. Many studies indicate that the makeup of most pathological gamblers does not conform to tidy ps ychoanalytic paradigms. R esearch efforts have been directed at elucidating other causes —none of which neces sarily negates the importance of ps ychological factors . T he family history of problem gambling in pathological gamblers has already been mentioned. T win studies further s ugges t that the dysfunctional gambler, bes ides identifying with a gambling relative, may have inherited genetic potential for the illnes s. B ehavioral-cognitive s tudies conceptualize pathological gambling as a learned, dis as trous habit. Many pathological gamblers exhibit exquis ite sensitivity a gamut of reinforcers directly or indirectly related to wagering. An example of direct or primary the slot-machine jackpot's lure of high magnitude of return for a low-re s pons e , s upposedly small, (ignoring cumulative loss ). An example of indirect or secondary reinforcement would be the “comps ” offered 2457 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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casinos , s uch as s pecial room rates and free drinks. casino design and management s uggest an elegantly sinis ter deployment of virtually every behavioral to encourage betting over one's head. C ognitive s tudies indicate that many pathological gamblers are prone to characteristic cognitive biases distortions. T hes e include discounting the sum of many small bets made at great cost toward achieving a big such as a jackpot; magnifying one's own s kills while minimizing the talents of others ; los ing s ight of the amount of gambling time neces sary to make up loss es; selectively privileging memories of wins over los ses; the absolute conviction that a chain of los ses heralds impending win (the s o-called gambler's fallacy). P romis ing recent research has probed the the pathological gambler, although more questions been raised than answered. P atients with lesions in a neural system whose pathways involve the (V M) prefrontal cortex, amygdala, and other s tructures show denial or unawarenes s of various problems for common-sens e judgments . T his type of injury also seems to predis pos e patients to pursue actions with term rewards but long-term negative consequences. T he V M regulatory s ys tem is believed to activate somatic markers, which then provide covert or overt signals heralding the P.2039 need for appropriate decis ion making. Inves tigators speculate that s ubs tance abus ers and, poss ibly, pathological gamblers , who have analogous problems 2458 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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seeking short-term gratification over long-term pain, have a lack of warning makers due to dysfunction of V M regulating apparatus. V arious studies s ugges t that complex, articulating neurotransmitter dysregulation may exist in gamblers , similar to abnormalities in s ubs tance and patients with other behavioral and impuls ive problems . Imbalances in serotoninergic, noradrenergic, and dopaminergic mediation have all been pos tulated subvert the mechanisms underpinning appropriate behavioral arous al, initiation, dis inhibition, and reward reinforcement. In normal subjects exposed to high-ris k and low-ris k gambling experiments , individuals who preferred stimulus -rich environments cons is tently s ought long wagering more to win more. One conjectures that— the presence of other predisposing factors —such might eas ily be attracted to social and even gambling. Much has been written about one or another culture's supposed gambling predilections —the E nglis h, for sports ; T exans, for high-stakes poker. T hese notions largely anecdotal and, often, frankly prejudicial. As the entire United S tates is experiencing an unparalleled explosion of legal and illegal gambling, regardles s of bettor's race, creed, or national origin. A connection has definitely been establis hed between arrival of a cas ino and the ris e of pathological gambling the surrounding area, with a lag of approximately 3 to 5 years before the increase occurs . At leas t mos t casinos situated s ome distance away from mos t American 2459 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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or cities . S adly, the greater access ibility of other betting opportunities , such as bingo games, lotteries , and offparlors where none exis ted before, may well activate a legion of problem gamblers who never knew they had a problem. T he destructive potential of ever more Internet gambling looms es pecially ominous .

Diagnos is , C ours e, and P rognos is T he typical individual meeting the DS M-IV -T R criteria pathological gambling (T able 21-2) is in his or her midto 40s , married or divorced, and vocationally strong gambling interes t has frequently paralleled his her ordinary life s ince adolescence or young adulthood. C ontrary to B ergler's theories , the potential s ufferer has excellent gaming knowledge and s kills and may be reasonably cons is tent winner.

Table 21-2 DS M-IV-TR Diagnos tic C riteria for Pathologic al A. P ersis tent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following:    (1) T he patient is preoccupied with gambling preoccupied with reliving pas t gambling experiences , handicapping or planning the next venture, or thinking of ways to get money with which to gamble). 2460 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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   (2) T he patient needs to gamble with increasing amounts of money to achieve the desired excitement.    (3) T he patient has had repeated unsuccess ful efforts to control, to cut back, or to s top gambling.    (4) T he patient is res tles s or irritable when attempting to cut down or to stop gambling.    (5) T he patient gambles as a way of es caping problems or of relieving a dysphoric mood (e.g., feelings of helples sness , guilt, anxiety, and depres sion).    (6) After los ing money gambling, the patient returns another day to get even (“chas ing” one's loss es).    (7) T he patient lies to family members , others to conceal extent of involvement with gambling.    (8) T he patient has committed illegal acts , s uch forgery, fraud, theft, or embezzlement, to finance gambling.    (9) T he patient has jeopardized or lost a relations hip, job, or educational or career opportunity because of gambling. 2461 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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   (10) T he patient relies on others to provide to relieve a desperate financial situation caused gambling. B . T he gambling behavior is not better accounted by a manic epis ode.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. In the setting of life stress or a big win or without caus e, the previous ly success ful gambler begins to fall behind. Instead of s topping and cutting loss es, he or begins to chas e — spending ever more time and expanding his or her wagering repertoire to include multiple gaming opportunities. Over s everal months to years of chas ing loss es, he or she becomes embroiled es calating, tightening, and frightening s piral of options , which inevitably extend outside gambling its elf. and family resources are raided, loan s harks are us ed, criminal enterprises are undertaken, although us ually last recourse. Male gamblers commonly turn to embezzlement, scams , and credit card fraud; women be drawn into pros titution. When every option is exhaus ted, the pathological is exposed, often to the horrified s urpris e of s ignificant others . T he experience is devastating: B ankruptcy, 2462 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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imprisonment, and even suicide may follow. However, expos ure can have a pos itive outcome through the out, s uch as a rescue by family or friends paying off or remiss ion of indebtednes s by bank, bookmaker, or shark. Once expos ed, some pathological gamblers get help quit betting. Unfortunately, the patient more often bored and restless , begins as sociating with other gamblers , commences wagering, and soon is engaged chas ing anew. Many pathological gamblers undergo repeated episodes of spiraling, exposure, bail-out, and relaps e, with gradual deterioration of personal relations hips and career until, at the end stages of the illness , their lives lie in utter ruin. Morris C hafetz's class ification of re active and addictive alcoholism us efully applies to many pathological gamblers . T he re active gambling type has a s table, productive s ocial and vocational life. His or her normal gambling behavior typically involves one or two modalities but periodically s hades over into binges of compuls ive play, often precipitated by obvious external stress ors . T he patient keeps recovering his or her us ually without treatment, until he or she los es control definitively. T he addicted pathological gambler, on the other hand, intens ely involved with every aspect of gambling and out of control much earlier. B y his or her 20s, gambling pervades every aspect of an idios yncratic, marginal lifes tyle, hallmarked by chronic instability in work and social relations hips. One emphasizes that prolonged spirals of pathological gambling by a healthier reactive type eventually produce a deteriorated end-stage 2463 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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picture that is indis tinguishable from that of the type. R egardless of typology, a craving for action is central behavior of most pathological gamblers. Although they may ascribe their driven modus vivendi to an obvious need for cash, the arousal afforded by action its elf them ever deeper into the gaming vortex, or, once up, action s ustains them as an independent attraction. Action may s pin out of a gaming situation's peculiar ambiance—for example, the steamy milieu of the race track, polluted by rumor and fals e report, or the eternal glittering daylight of the casino with the seductive click P.2040 of a roulette wheel and the jingle of slot machines. T he action high can be found far from ordinary gambling locales , in bowling alleys , bars, and legal and illegal parlors in which any form of play can be ins tantly arranged. In time, the harried search for ever more sources of financing itself becomes part of the action. R egardless of s ocial background, ethnicity, or many pathological gamblers exhibit s trikingly similar personality traits . T hey tend to be intelligent (although deeply intellectual) and overconfident to the point of abrasivenes s. T hey are perennial optimis ts, deniers , rationalizers . B y turns, they are touchingly loyal or insensitive—notably when chas ing. T hey poss es s an gallows wit and appear s uperficially quite gregarious are often inwardly beset by profound feelings of lonelines s. T hey do not eas ily express their feelings ; indeed, they may be so unable to get in touch with an 2464 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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inner life as to be cons idered alexithymic (a feature of patients with other impulse-control disorders ). B oth pathological and success ful profess ional typically evince a curious grandios e elitism. T hey are absolutely certain that they “know the s core” about gambling, as well as life in the wider world—for which gambling is held as a dog-eat-dog metaphor. T he pride pathological gamblers in their idios yncratic vocation, at its dis as trous end s tage, is es pecially poignant, the enormous suffering entailed. T he cours e of the pathological gambler is often for the wors e by comorbid conditions, notably abuse and affective illnes s. T he easy acces sibility of and alcohol in gambling environments often disinhibits the pathological gambler, res ulting in wilder play, or the heavy burden of indebtednes s precipitates depres sion, which, in turn, triggers off more gambling binges. Many pathological gamblers are paradoxically hypochondriacal and dreadfully neglectful of their well-being. T hey eat poorly and often excess ively, are sleep deprived and underexercis ed, and are exces sive cons umers of caffeine and nicotine. Hard statis tics are lacking, but anecdotal evidence s uggests that they may more vulnerable than general populations to hypercholes terolemia, cardiopulmonary disease, and peptic ulcer.

Differential Diagnos is P athological gambling s hould be distinguis hed from the social gambling practiced in one form or another by a majority of the population (es timated at approximately 2465 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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percent). Normative gambling is based on the desire relaxation and profit, the inherent pleasure in variety of ego functions , ris k taking in a controlled and the satis faction of other obscure, pos sibly conflictrelated, drives . Unpathological gamblers us ually play designated occasions , with a notion of predetermined acceptable loss es . T heir pleas ure is highly predicated the companionable s ocial milieu that gambling offers. F or profess ional gamblers , play is bus iness —often one many busines ses . C ontrary to the conception of the glamorous high roller, profes sionals usually avoid the limelight to avoid taxes. T hey know s pecific games thoroughly, are prepared to take requis ite risks, coolly acknowledge the losing s treaks that come with the territory, and are prepared to weather them without control. However, reactive profes sional gamblers— a les ser extent, s ocial gamblers —may s lip into pathological gambling, often in the context of s ome environmental s tres sor. Acute s ubs tance abuse, notably acute alcoholis m, may precipitate a gambling bout in an individual without signatures of pathological gambling. G ambling binges are occasionally seen in the context schizophrenic's delusional s ys tem (e.g., being that G od has told one to wager one's life's s avings in saving mankind). E xces sive wagering may occur manic phase of bipolarity, in patients not otherwis e inclined to gamble. T he relationship between bouts of gambling and viciss itudes of mood is more problematic in 2466 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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gamblers with comorbid affective illness —es pecially hypomania and mania. T he latter often s eem wired to universe, like the manic, and fairly crackle with tension they purs ue their dizzy dance over the abyss . Y et, they return quickly to a more temperate state of mood once play has ceased, may be reactively elated after a win, appropriately depress ed after a loss . In any case, most pathological gamblers wager chronically whether high, low, or relatively euthymic, with or without obvious precipitating cause. It is moot whether mood swings precipitated by biological dys function per s e can gambling. T he antis ocial pers onality frequently pres ents with collateral gambling behavior that reflects the inherent criminality and lack of empathy. He (or, les s she) does anything poss ible to win and is often a cheater. Loss stimulates blame rather than remorse may precipitate violent retaliation. Unlike antis ocial gamblers , the majority of pathological gamblers have a better work record, a more stable family life, and a moral set before the disruptions caused by chronic begin. When they commit crimes or s cams , it is out of desperation, with a humiliating loss of pride, in a lasteffort to get money to cover loss es or to keep on gambling. Unlike the morbid ego-alien preoccupations the obs es sive-compuls ive patient, the pathological gambler's overweening preoccupation with play is, in cases, completely ego-syntonic.

Treatment V irtually every mental health modality has been the pathological gambler. F or decades, the res ults 2467 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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ungratifying, and relapse rates were high. B etter unders tanding of the patient's psychology and neurobiology now contributes to improved outcomes . C hances for success hinge on careful individualizing of treatment for each cas e. C ombined approaches are us eful. Mos t pathological gamblers make difficult regardless of the type of therapy. Like adoles cents — they much res emble—they rarely s eek help on their and, indeed, may bitterly oppos e treatment. T hey are us ually forced into cons ultation after many years of gambling, after expos ure precipitates an ultimatum that the gambler gets help or s uffers divorce or prosecution, example. T he pathological gambler's enormous pride, formidable denial, lack of introspection, impatience, and incurable optimism all militate agains t the formation of a working alliance in psychoanalytically oriented therapy (as well other therapies ). B es ides their gambling, patients often present a hos t of s erious problems and s ymptoms — depers onalization, hypochondrias is, obesity, panic and profound depres sion—that do not yield readily to talking therapies . P athological gamblers expect magical interventions are likely to leave when miracles are not forthcoming. may go through the motions of patienthood and yet remain inwardly convinced that a turn in luck and adequate funding will provide the s olution to their problems . T hey are notably contemptuous about gambling inexpertis e. T he therapis t who is a gambling can occasionally us e ignorance to good advantage by having the client teach him or her the ropes . P sychotherapy with a pathological gambler is likely to 2468 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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stormy—marked by miss ed ses sions , relaps es , and financial crises leading to disruption or ces sation of treatment. T hes e patients especially require a tolerant, noncritical attitude. With their testy pride and razorintuition of rejection, they do not remain long in an atmos phere with the smalles t tincture of moralizing or contempt. F irm but kind limit s etting, which may include payment at each ses sion, is often neces sary. G reater res ponsibility in handling fees can be an important of improvement. T he attractivenes s of group techniques for pathological gamblers is not s urprising, given their extravers ion. family, and couples P.2041 therapy have all been helpful. T he distress ing impact of gambling on significant others often becomes clearer registers more potently on the patient in family than in individual therapy alone. G amblers Anonymous (G A) is an international s elf-help organization adminis tered by abs tinent pathological gamblers , with branches in nearly every large city and many small towns acros s the world. G A is run along step lines analogous to Alcoholics Anonymous (AA), similar collateral groups for relatives , which are worthwhile when a pathological gambler refuses help. C lients are encouraged to confront their problems in company of others thoroughly acquainted with every and twis t of chasing. S pons ors can be provided; financial res titution is a crucial as pect of treatment. Unfortunately, the G A drop-out rate is high, especially first-time clients and when G A (or individual therapy, 2469 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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that matter) is the sole s ource of help. Once deemed ineffective, medication now figures regularly in the treatment of many pathological S tudies indicate stabilization of affect and modification aberrant gambling behavior with mood s tabilizers lithium [E skalith]) and antidepress ants (notably S S R Is clomipramine [Anafranil]). Improvement is mos t likely in dual diagnos is patients with s ignificant comorbid illness . T he close relationship of pathological gambling drug and alcohol addiction has led to treatment trials the opioid antagonis t naltrexone (R eV ia) to specifically block gambling urges, with a measure of success . E ducational, behavioral, and cognitive strategies the pathological gambler's inherent pragmatism— particularly in patients who are highly resistive to analytically oriented treatment. S imple instruction about their condition by an instruction manual and class work has enabled many patients to s top or to reduce gambling. More intricate cognitive-behavioral aim at undoing the habituating impact of s pecific gambling milieus and decreas ing or redirecting the for action. P atients are instructed in relaxation decrease tens ion, to identify s pecific gambling triggers , and to substitute gambling with competing rewards , for example. G ambling programs are especially us eful in as saying coordinating multiple modalities ; these are s teadily increasing acros s the United S tates . T reatment of the pathological gambler us ually takes place in an setting. However, it may be necess ary to break a debilitating gambling cycle by hospitalization, using a of several days to weeks to organize an effective 2470 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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outpatient treatment plan. Intriguingly, hospitalized pathological gamblers may s how s igns of physiological, well as emotional, distress analogous to hos pitalized addicts undergoing detoxification. G iven the gambler's chronically poor health habits , many patients need a complete phys ical examination, appropriate laboratory studies, and thorough evaluation of and exercise status .

G ambling and the L aw S tate and federal legal systems are still primarily concerned with the punis hment of pathological rather than their rehabilitation. S ome 60 percent of pathological gamblers commit illegal acts over their careers . T hese crimes are overwhelmingly bouncing checks, financial scams , and prostitution. It is generally appreciated that incarceration can become a dis guised bail-out, forestalling or eliminating requirements for res titution. P rison life itself is often with gambling, for cigarettes , drugs, and other items services . E xperts believe that rather than jailing mos t gamblers outright—particularly the majority without antis ocial pathology—the offender s hould be offered option to dis continue gambling, to make restitution, and to undergo some form of treatment as a condition of probation. T o date, a few states have actually s et up agencies programs to deal with pathological gambling—even as most states have been quick to allow lotteries , race and casinos to replenis h their coffers . It is the height of hypocris y for powerful gaming interes ts, backed by the 2471 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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powers that be, to tell the pathological gambler to “bet with your head, not over it,” while failing to redress the ps ychological disas ters that they are facilitating. F rank was a 32-year-old busines sman whose uncle compuls ive horse player. His maternal grandmother committed s uicide with sleeping pills. He was an avid player and sports bettor s ince his early teens , taking in being a s mall but s teady winner. F rank found formal education boring and dropped out of college in his fres hman year to take over his father's appliance store. expanded the bus iness to a chain of electronic outlets. Over the next decade, he pros pered, married happily, had three children, and lived in s ubs tantial During the s ame time, F rank's inveterate gambling increased. B es ides his weekly poker game and sports betting, he enjoyed occasional S aturday outings with his poker buddies to a casino that had opened at a nearby Indian res ervation. He mos tly broke even or sustained s mall loss es , but he was immens ely by several big s cores at blackjack and craps , games had not played much before. After his father's sudden death from a stroke, F rank traveling more often to the casino and s tarted playing higher stakes . S oon, he found himself betting then thous ands, of dollars on the turn of a card or the throw of the dice. T he size of s ports betting s imilarly increased. He vis ited the casino mos t weekends and weekday nights, lying about his whereabouts to colleagues and family. Within 2 years , F rank accumulated several million gambling debts. Now, he gambled not to win but to 2472 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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up—still fervently believing that “one s treak would put straight.” He invaded bus iness and personal finances, juggled accounts, charged his credit cards beyond the maximum limit, and borrowed money from loan s harks exorbitant rates. He had always s hielded his wife and family from his problem. P rofoundly depress ed, he cons idered killing himself in a car accident, so that “everyone would be taken care of.” He used cocaine to alleviate his despair. T he grim reality of F rank's indebtednes s and its cause unmas ked when his wife discovered that he had plundered the children's college funds to pay off a loan shark who had threatened to have his family killed. At she wanted to divorce him, but then her wealthy father intervened and bailed F rank out. He swore that he never gamble again, entered G A, and, within a few months, was back at the cas ino. S everal more epis odes of recovery and relapse did divorce and left F rank penniless . He finally entered a program for pathological gamblers , where he was diagnosed as also having atypical bipolar dis order. T reatment has included individual and group medication with an antidepres sant and mood regulator, family therapy (his wife is now willing to s ee him, but to live with him), and a program of restitution. He works a delicatess en clerk, has been abstinent for 6 months , says that “not a day goes by that I don't miss the E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified T R IC HOT ILL OMANIA

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TR IC HOTIL LOMANIA P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified"

His tory and Des c ription T richotillomania is a chronic dis order characterized by repetitive hair pulling, driven by escalating tension and caus ing variable hair loss that is us ually—but not visible to others . T he disorder was known at leas t as back as the 12th century. F ormation of trichobezoars — hairballs accumulating in the alimentary tract from hair pulling and s wallowing—was des cribed in the late 18th century. T he term trichotillomania was coined by a dermatologis t, F rancois Hallopeau, in 1889. P.2042 T richotillomania was once deemed rare, and little about was described beyond phenomenology. T he condition now regarded as more common. W ith a substantial increase in research, treatment has greatly improved the 1980s .

Nos ology T richotillomania was firs t recognized in the DS M-III-R . DS M-III-R clas sified trichotillomania as an impuls edisorder, chiefly because of the typical cycle of tension, the inability to res is t the urge to pull hair, and releas e and gratification afterwards . DS M-IV then specifically excluded hair pulling secondary to medical 2474 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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conditions or other ps ychiatric disorders from the diagnosis. T he criterion of s ignificant distress or impairment in s ocial, occupational, or other important of functioning was added and was s ubs equently maintained in DS M-IV -T R . IC D-10 class ifies trichotillomania under habit and dis orders , as a condition “characterized by noticeable loss due to a recurrent failure to resist impuls es to pull hairs, preceded by mounting tens ion and… followed by sens e of relief or gratification.” T he diagnosis s hould be made if “pre-exis ting inflammation of the s kin” exis ts if hair pulling occurs “in res pons e to a delusion or hallucination.” “S tereotyped movement dis order with plucking (F 98.4)” is also specifically excluded.

E pidemiology T he prevalence of trichotillomania may be because of accompanying shame and secretivenes s. diagnosis encompass es at leas t two categories of hair pullers differing in incidence, severity, age of and gender ratio. Other subsets may exist. T he potentially mos t s erious, chronic form of the us ually begins in early to mid-adoles cence, with a prevalence ranging from 0.6 percent to as high as 3.4 percent in general populations and with a female to ratio as high as 9 to 1. T he number of men may higher, becaus e men are even more likely than women conceal hair pulling. A chronic trichotillomania patient is likely to be the only or oldest child in the family. A childhood type of trichotillomania occurs equally in girls and boys. It is s aid to be more common 2475 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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than the adolescent or young adult syndrome and is generally far les s s erious dermatologically and ps ychologically. T he family history of trichotillomania patients is toward OC D and obs es sive-compuls ive personality disorder, anxiety and affective disorders (notably depres sive), and tics. Although a s trong his tory of trichotillomania has not been dis covered in family members, one study demonstrated a 25 percent rate of unspecified alopecia in relatives of childhood hair An estimated 33 to 40 percent of trichotillomania chew or s wallow the hair that they pull out at one time another. Of this group, approximately 37.5 percent develop potentially hazardous bezoars .

C omorbidity S ignificant comorbidity is found between and OC D (as well as other anxiety dis orders); syndrome; affective illnes s, es pecially depres sive conditions; eating dis orders ; and various pers onality disorders —particularly obs ess ive-compuls ive, and narcis sistic personality dis orders. C omorbid abuse dis order is not encountered as frequently as it is pathological gambling, kleptomania, and other

E tiology T he precis e caus es of trichotillomania are s till P sychoanalytically oriented theories cite childhood loss separation as precipitants . T he child-like appearance of some adoles cent patients resulting from hair pulling supposedly betokens the wish to regres s to an infantile state and to avoid the burgeoning pres sure of 2476 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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sexuality. E rotic, s adomas ochis tic, and s ymbolic masturbatory aspects of hair pulling have been in the analytical literature. T he frequent hair twis ting and hair patting of infants young children (often combined with thumb sucking) said to repres ent attempts to recuperate the abs ent mother's presence via the child's own body. Intriguing analogies may be drawn between human hair manipulation and various animal and avian grooming behaviors that appear to facilitate homeostasis, when alone, and s ocial bonding via mutual grooming. Under rubric, trichotillomania has a distinctively tactile, s elfsoothing quality for many patients . A s pecific family constellation has been described in a predominantly female cohort of adolescent and young adult patients with chronic trichotillomania. Although found in other psychiatric disorders , these family are peculiarly inflected by the role played by early experiences centered around hair and, later, by hair its elf. One parent, us ually the mother, is dominating and intrus ive. Her aggres sive facade conceals considerable and needines s. Often, her child has s hown anxious since infancy, pos sibly on a cons titutional bas is. and child become increas ingly embroiled in an intens e, hostile-dependent relations hip that interferes with the child's healthy s eparation. An uncanny mutual preoccupation with the beauty of the daughter's hair— styling and grooming—develops early on and may other family members . With the onset of trichotillomania during puberty, the 2477 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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mother's attempts to make her daughter stop pulling hair are countered by the youngster's s tubborn T his tangled partnership has been deemed a hairs ymbios is : T he s ymptom becomes a battleground for acting out conflicts over individuation. On tactful adult patients may reveal an earlier hair-pulling One emphas izes that the cons tellation is not in every cas e—or may exis t in a more benign version. C hronic trichotillomania may s hare biological features, well as comorbidity with obs es sional and affective T richotillomania and obsess ive-affective illnes s serotoninergic drugs. B ecaus e many chronic hair do not respond as robustly or at all to s erotoninergic agents , other neurobiological dysregulation could be implicated. F rom a cognitive-behavioral perspective, chronic hair pulling is an intensely s elf-reinforcing activity, acquiring an intense, habitual life of its own.

Diagnos is , C linic al F eatures , and C ours e C hronic trichotillomania is hallmarked by complex behaviors before, during, and after epilation (T able 21T he urge to pull customarily develops during solitary activity—relaxing, reading, and watching televis ion, for example. Alternately, it aris es in the context of anxiety frus tration related to external s tres s. S ome patients that antecedent tingling or burning s ens ations in the compel them to s eek relief by pulling.

Table 21-3 DS M-IV-TR Diagnos tic 2478 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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C riteria for Tric hotillomania A. R ecurrent pulling out of one's hair resulting in noticeable hair loss . B . An increas ing s ens e of tens ion immediately pulling out the hair or when attempting to res is t behavior. C . P leas ure, gratification, or relief when pulling the hair. D. T he disturbance is not better accounted for by another mental dis order and is not due to a medical condition (e.g., a dermatological E . T he disturbance causes clinically s ignificant distress or impairment in s ocial, occupational, or other important areas of functioning.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. A favorite private location is often used for hair pulling, es pecially the patient's bedroom or bathroom (the masturbatory connotation of these locales is obvious). 2479 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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prodromal period may las t for a few moments, but, commonly, tens ion builds over a longer time, until it cons umes the patient's thoughts , and epilation begins . T ension may be experienced as pleas urable or painful, meld of both. T he hair-pulling epis ode las ts minutes to several hours . Most patients pluck at a particular site—typically the crown or s ide of the s calp, with variable spread into adjacent areas in time (F ig. 21-4). B esides —or ins tead the scalp, hair may be pulled from the eyebrows, and pubic region (denuding the latter is a notable embarrass ment) (F ig. 21-5). Men pull hair from beards mous taches or from arm and leg hair growth.

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FIGUR E 21-4 E xample of plucking of the hair of the scalp due to trichotillomania. (S ee C olor P late.)

FIGUR E 21-5 E xample of plucking of the pubic hair due trichotillomania. T he hair root is a favored target of hair-pulling. P atients describe an idiosyncratic pleas ure in getting the root, particularly in s tripping P.2043 it away from a plucked hair. S ome state that they hear special popping sound or otherwis e know that the root has been extracted. T he hair is often nibbled and 2481 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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swallowed while pulling or after a s ufficient quantity of hair has been collated. T he root may be conspicuous ly savored. When the bout ends , pleas ure is s ucceeded by shame, remors e, and disgust—particularly over hair S hame and frus tration are es pecially intense when an is denuded that had been left alone for awhile, so that growth could take place. Hair los s from trichotillomania can be concealed from family and friends for a cons iderable time, as long as epilation is confined to a s mall area. C oncealment is maintained by careful combing, us e of hair extensions, wearing hats or kerchiefs on one pretext or another. Inevitably, los s becomes obvious to others , although patient does not easily admit its cause at home or in a doctor's office. T reatment for other alopecias is undertaken with a profus ion of remedies and healers, a firm diagnos is is finally made—us ually by a knowledgeable dermatologist. P ermanent ces sation of s evere trichotillomania after expos ure is the exception rather than the rule. T he is sometimes marked by little change in hair loss or gradual improvement, but, more often, frequent remis sions and serious exacerbations occur over many years . Using a wig is common; occas ionally, hair is from it, too. C hronic trichotillomania can be as sociated with permanent follicular damage and baldnes s. T he long-term ps ychological outcome of does not s imply hinge on the s eriousness of hair los s se. T he prognosis often depends on the extent to hair pulling is conflated with comorbid 2482 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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On its own, trichotillomania spins off abundant despair and diminis hed s elf-es teem. T hes e problems can with major depress ion, borderline or narciss istic personality problems, or eating dis orders to create a malignant feedback loop, with s ubs tantial deterioration quality of life. T he progres sion of childhood trichotillomania is us ually benign compared to the adolescent and young adult variety. A hair-pulling s ymbiosis is notably lacking in cases. E pilation is more akin to a transient habit, in duration and limited impact to the brief epis odes of phobic or compuls ive s ymptoms common in childhood. T he formation of a trichobezoar is always a potential complication in trichotillomania. Impacted hair can anemia due to nutritional deficiencies, intestinal obstruction, pancreatitis , peritonitis, small or large perforation, and, rarely, acute appendicitis. S ymptoms appear ins idious ly or acutely, depending on the and extent of the trichobezoar. P res enting problems include epigastric dis comfort as sociated with meals, altered bowel habits, weakness , weight los s, anorexia, nausea, and vomiting, with or without hematemesis. Weight preoccupation without a full-fledged eating disorder is commonly ass ociated with trichotillomania, particularly during adolescence.

Differential Diagnos is T rue trichotillomania should be dis tinguished from childhood or adolescent hair twirling and twisting actual hair plucking, which is found more frequently in girls than boys. 2483 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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Hair pulling can develop ex nihilo during an acute ps ychotic illness —schizophrenic or affective—as a res ponse to command hallucinations or a s pecific delus ional s ys tem or as a tangible express ion of the hyperbolic despair and s elf-loathing of ps ychotic depres sion. E pilation us ually ceases with remis sion of acute psychos is, although it may occasionally be noted chronic psychosis. P.2044 With its many ritualistic aspects, trichotillomania may difficult to differentiate from the ritualis tic behavior of OC D—particularly because one patient may harbor conditions. T richotillomania is driven by at leas t a modicum of pleasure seeking, whereas compulsive are chiefly directed at relieving intolerable anxiety and dread. T he us ually planned epilation of trichotillomania s hould distinguished from spasmodic mus cular and verbal tics T ourette's s yndrome. However, as noted, these may afflict the s ame patient. T richotillomania should be dis tinguished from factitious hair pulling in aid of receiving medical attention and sympathy. Alopecia due to other medical caus es mus t always be out when trichotillomania is s uspected. It is rare to find trichotillomania precipitated by or coexisting with alopecia.

L aboratory S tudies If necess ary, the clinical diagnosis of trichotillomania 2484 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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be confirmed by punch biopsy of the scalp. In patients with a trichobezoar, blood count may reveal a mild leukocytos is and hypochromic anemia due to blood Appropriate chemis tries and radiological s tudies should also be performed, depending on the bezoar's location and impact on the gas trointes tinal (G I) tract.

Treatment Most cas es of childhood trichotillomania respond well brief therapy, using s upport, s imple behavioral and is sue-focus ed s tres s management for family and patient, when neces sary. B y contras t, the treatment of s evere adolescent or trichotillomania is likely to be prolonged and arduous requires a combination of modalities . C linicians s hould aware that patients are deeply as hamed of their hair pulling, eas ily frightened, and intens ely denial prone. Many have avoided help for years. In teenagers with trichotillomania, res is tances are compounded by native oppos ition to adult intervention. An unpress ured, unintrusive s tance is especially helpful during the initial workup. Much comfort derives from simple education, from discovering that hair pulling does not make one weird or crazy and that others share the problem and s ucces sfully deal with it. P sychoanalytically oriented psychotherapy yields res ults. Improved understanding and esteem may lead improved relationships and educational and vocational succes s, although hair pulling itself persists s tubbornly. Individual therapy is especially problematic with embroiled in the tangled web of a hair-pulling E ffective work cannot proceed in the office when a 2485 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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is cons tantly being cajoled, bribed, or criticized vis à vis hair pulling at home. T he predictable repercuss ion of parental pers uas ion, however well intended, is what one youngs ter called “screw-you” hair pulling, further hair loss and reinforcement of a negative s elf-image. S ome s ort of intervention is needed in this setting by the primary therapist or a collateral therapist, if forging an effective working alliance with the patient precludes intensive contact with family members . Healthier families may require couns eling and s upport to weather the s tres s impos ed by a youngster's trichotillomania per s e. V irtually every clas s of ps ychotropic medication has directed at chronic hair pulling. S erotoninergic agents, particularly S S R Is and clomipramine, have figured prominently in recent years , reflecting inves tigation of relations hip between trichotillomania and OC D or disorder. C as e s tudies and anecdotal reports over controlled large-scale outcome s tudies . S ome patients do well and cons is tently maintain Others do not res pond at all, or an early robust fades over time. T ricyclics , lithium, and bus pirone (B uS par) have been along with or for augmentation of S S R Is . Improvement been occasionally reported with clonazepam (K lonopin) and monoamine oxidas e inhibitors (MAOI). P reliminary work indicates that the opioid antagonis t naltrexone be helpful in disrupting the rus h that is experienced in hair-pulling attacks . C ognitive-behavioral therapy has s hown increas ing promis e. F or instance, in habit reversal training (HR T ), 2486 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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therapist ass embles a package of individualized to address hair pulling, such as fostering awarenes s of specific affective and situational triggers, ins truction in relaxation and s topping techniques , development of competing res ponses, and the use of journals to progres s. Individual HR T is combined with HR T group meetings for teaching, as well as social s upport. As other modalities , relaps e after initial s ucces s is patients s hould be counseled to s ee pas t a temporary defeat. Anecdotal reports indicate some effectivenes s of on a s hort-term basis. Ignorance and shame about trichotillomania continue prevent patients from getting help. Awarenes s of the problem has been enhanced by local and national groups . K athy was a 24-year-old editor who had s uffered from trichotillomania since 17 years of age. T ypical hairbehavior began during junior year at a highly private high s chool in the s etting of increasing torment ruminations about not getting into the “right” college. plucked, chewed, and swallowed hair from the top and sides of her s calp, as well as her eyebrows . S he hair pulling from her family and friends , because she thought “I was going nuts.” S he finally blurted out her symptoms to a trus ted pediatrician during a routine visit. K athy's parents were profes sionals who made intense academic demands on all of their children; family life otherwis e not notably problematic. As a child, she was extremely critical of herself and afraid of failure. Her 2487 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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experienced mild periodic depress ion since college. brother developed obs ess ions and compulsions during late teens . B oth res ponded well to fluoxetine (P rozac). K athy had received analytic ps ychotherapy, behavioral therapy, and medication (recently fluoxetine and clomipramine) elsewhere. Although she made good progress psychologically, she was never able to pulling her hair long enough for it to grow back. S he wide circle of friends but still kept romance at arm's fearing that a potential lover would be frightened off if found out her “secret.” S he could not bring hers elf to replace the “ratty” wig that she had been wearing since late teens . “It makes me look dowdy,” she s aid, “but a new one would be like telling myself I'll never get K athy s ought treatment chiefly for regulation of her medication but quickly proved amenable to weekly ps ychotherapy s es sions . Her clomipramine was while s he explored the sense of damage and that made her fend off men who liked her. S he was helped by weekly meetings at a trichotillomania s upport group. After 6 months , her self-es teem had improved, had fewer bouts of hair pulling and had begun dating hesitantly. S he arrived at her las t sess ion dis playing an attractive new wig, s tating ironically: “It is n't my real yet, but at least it's better than my old rug.” E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified >

K L E PTOMANIA P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere 2488 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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C las sified"

Definition and His tory T he defining behavior of kleptomania is the repetitive theft of items that are us ually of little monetary value are not realistically needed. Increasing tens ion is experienced before s tealing. F eelings of relief and gratification during and after the act eventually give to guilt, remors e, and s elf-loathing, compounded by the fear of arres t. K leptomania is profoundly repugnant P.2045 to many s ufferers , inconsis tent with their otherwis e behavior and beliefs (T able 21-4).

Table 21-4 DS M-IV-TR Diagnos tic C riteria for K leptomania A. R ecurrent failure to resist impuls es to s teal that are not needed for personal us e or for their monetary value. B . Increasing s ense of tension immediately committing the theft. C . P leas ure, gratification, or relief at the time of committing the theft.

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D. T he s tealing is not committed to express anger vengeance and is not in res ponse to a delusion hallucination. E . T he s tealing is not better accounted for by conduct dis order, a manic epis ode, or antisocial personality disorder.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T he diagnosis of kleptomania was first coined in 1838 E squirol and C harles -C hretien-Henri Marc and was grounded on P hillipe P inel's earlier concept of a manie s ans de lire —insanity without delus ion or clouding of cons ciousnes s. E s quirol subsumed kleptomania under ins tinctive monomanias — conditions in which a s ingle, irre s is tible impulse was acted out. S ubsequent inves tigation during the 19th century was largely descriptive. P sychoanalytic exploration of single few cas es of kleptomania throughout the 20th century yielded valuable insights and s ome headway in S ince the 1980s, interest in kleptomania has increas ed, paralleling res earch into the psychobiology of other impulse-control disorders , as well as affective and obses sive illnes s. Nevertheless , no large cohort of 2490 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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kleptomania patients has been s tudied to date.

Nos ology K leptomania was mentioned pas s im in the first edition the DS M (DS M-I). It was omitted from the s econd the DS M (DS M-II), arguably because it was viewed as cons tituent s ymptom of other conditions, rather than a separate disorder. It was listed as a viable diagnos is in DS M-III and, subsequently, in DS M-III-R , DS M-IV , and IV -T R , with s everal changes along the way. DS M-III-R emphasizes that the stolen object is not for personal use. As sociated tens ion specifically occurs “immediately before committing the theft.” C riterion D DS M-III-R newly s tipulates that stealing “is not to expres s anger or vengeance” and is not a respons e delus ion or hallucination.” T he absence of planning and collaboration in connection with theft as a qualifier is dropped in DS M-III-R . C riterion D—“the s tealing is not to conduct disorder or anti-social pers onality thus reframed in DS M-IV : “T he stealing is not better accounted for by C onduct disorders , a Manic epis ode, Antisocial P ers onality Disorder.” DS M-IV -T R continues these exclusions . IC D-10 des ignates kleptomania as “pathological hallmarked by “repeated failure to resist impuls es to objects that are not acquired for pers onal use or gain. T he objects may be discarded, given away, or hoarded.” T he typical cycle of tens ion before s tealing, sens e of gratification during and immediately after, the act,” and the solitary nature of thefts are noted. despondency, and guilt” between episodes of s tealing “not prevent repetition.” E xcluded from the diagnos is 2491 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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recurrent acts of carefully planned s hoplifting for gain; organic mental dis order, in which payment for is overlooked “as a cons equence of poor memory and other kinds of intellectual deterioration”; and disorder with stealing.”

E pidemiology K leptomania was once thought to be extremely rare: instance, in a 1947 study of arres ted s hoplifters , less percent s howed evidence of the disorder. Many the field now believe that kleptomania is s ubs tantially underreported owing to the reluctance of ashamed patients to s eek help, as well as their not-unwarranted of pros ecution. F ailure to document kleptomania may als o s tem from of education or prejudice about the condition by law enforcement officials and health profes sionals. When kleptomania is seen as a criminal, rather than a is sue, many patients are s ure to be misdiagnos ed— written off—as antis ocial pers onalities , to be sanctioned. Although it is widely held that kleptomania is predominantly a disorder of women, the high female to male ratio (approximately 3 to 1) may reflect the fact more women seek or are compelled to use ps ychiatric services than men. F or ins tance, once under court supervis ion, a female s hoplifter is likely to be sent for a ps ychiatric evaluation, whereas a male offender is dispatched to jail. S everal of the kleptomaniacs described by Marc and E squirol were royals, s uch as K ing V ictor of S ardinia 2492 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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K ing Henry IV of F rance. A lion's s hare of interest in disorder is commanded by patients from favored backgrounds becaus e of the dis crepancy, absurd or poignant, between their wealth and power and the objects that they filch. Nevertheles s, there is no that kleptomania is a s pecial affliction of the rich. Limited data sugges t that higher rates of affective and obsess ive-compuls ive traits occur in first-degree relatives of kleptomania patients. F amilies als o may be pervaded by the s ame preoccupation with financial succes s and material acquis ition encountered in the relatives of pathological gamblers .

C omorbidity P atients with kleptomania are s aid to have a high comorbidity of major affective illnes s (usually, but not exclusively, depres sive) and various anxiety dis orders. Ass ociated conditions als o include other impuls edisorders (notably pathological gambling and shopping), eating dis orders, and substance abuse disorders , alcoholism in particular.

E tiology P sychoanalytic speculation about kleptomania has abundant relative to the s mall number of patients Analys ts conceptualize compuls ive s tealing as a highly overdetermined act, exquis itely balanced between gratification and punishment. S tealing is intended to res tore intraps ychic equilibrium and to redres s s undry childhood traumata, intrapsychic dis tortions , or both. syndrome has been interpreted as an attempt to rectify actual or perceived neglect and narciss is tic injuries of 2493 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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childhood via vengeful attack, to s tave off formidable feelings of low self-es teem through aggres sive and to gratify forbidden infantile sexual wis hes and masturbatory fantasies. W ith the omnipres ent threat of retaliation, s tealing often comes to poss ess a peculiar masochistic s izzle. T he stolen object has been construed as a talisman of recuperated loss acros s the s tages of child oral, anal, and genital. According to the developmental level of the patient's fixation, it may s ymbolize milk, breast, penis , or child. In some patients , compuls ive s tealing is strongly by the familial superego lacunae des cribed in and adolescent conduct disturbances by Adelaide and S amuel S zurek: An apparently upright, ethical projects uncons cious delinquent wishes on the child, proceeds to act out the dis avowed parental behavior. S ince the 1980s, analytical theories have been by s peculation on the neurobiology of kleptomania. T he significant comorbidity of the condition with affective disorders and obs es sive-compuls ive P.2046 pathology has been emphas ized, as well as the occurrence of affective dis order and OC D in clos e Although s ubs tantive confirmation is yet to come, kleptomania has been theorized as an obs es sivecompuls ive s pectrum dis turbance and affective disturbance. F rom a behavioral and cognitive perspective, stealing—like other impulse-control disorders —is 2494 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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powerfully self-reinforcing by virtue of its repetitive and highly ritualistic aspects.

C linic al F eatures and C ours e Most episodes of kleptomania seem to occur spontaneously and s uddenly, with little, if any, premeditation. However, deeper probing often reveals that theft ensued in the s etting of a recent s tres s —an argument with a busines s colleague or a lover's accompanied by frus tration, anger, and an ambiguous sens e of neediness . P atients report a mixture of dread and pleas ure before stealing. S ome feel agonizingly caught between the to relieve intolerable tension versus moral s cruples and fear of capture. Others plunge directly into action a moment's hes itation, es pecially when a well-defined pattern of s tealing has developed over repeated Most bouts of kleptomania take place in public, at supermarkets , and malls, for example. S tealing at parties or social events is less common. S tolen objects us ually have negligible value; in any case, they are not needed or could be easily afforded. T he items vary, or same object is stolen each time (es pecially undergarments ). S ome patients hoard and examine pilfered goods : T heir kleptomania poss es ses a fetishis tic as pect. More frequently, stolen material is hidden without s ubsequent attention; given away, out, or donated to charity by way of res titution; surreptitiously replaced at the point of origin; or with a jury-rigged explanation or with an admis sion of guilt and a plea for forgiveness . 2495 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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P atients are intens ely as hamed of s tealing and s trive mightily to keep it s ecret and under control. T hey avoid stores pilfered in the pas t; they even warn s tores in advance or ceas e s hopping altogether. P atients feel ps ychologically and morally when they are able to free thems elves of s tealing for a while; they feel devastated despairing when they backslide. K leptomania clas sically begins in late adoles cence to mid-20s, often emerges in the context of compulsive shopping, and can remain undetected for years (in one study, first involvement with the legal system occurred 35 years of age for women and at 50 years of age for S tealing bouts may occur s poradically, with quies cent periods, or may relentles sly escalate until the patient's inevitable arrest and pros ecution. E xpos ure precipitates crushing humiliation, akin to the trauma experienced by pathological gamblers when loss es are revealed. Although exposure us ually the individual to seek help, it may als o—as in the gamblers —provide an unhelpful bail-out, through deals struck with compas sionate store owners , res titution by patient or relatives, or adjudication for les ser offenses condition of treatment, and s o forth. K leptomania is likely to be a chronic illnes s, hallmarked repeated relaps es over decades. S tatistics on outcome lacking. B y anecdotal report, some patients find relief through therapeutic or s piritual intervention, or both; others simply burn out or continue s tealing indefinitely. Impris onment and s uicide to avoid incarceration are meaningful poss ibilities . T he cours e of kleptomania is decisively influenced by 2496 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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serious comorbid conditions. Individuals with shopping dis order often begin compuls ive s tealing the former condition easily shading over into the latter. E pisodes of kleptomania are als o precipitated by the disinhibiting influence of substance abuse. Although there is no cons istent kleptomania personality type, many patients manifest obsess ive-compuls ive narcis sistic tendencies . Lacunae in judgment about stealing may extend into other life areas. P atients experience genuine contrition and deeply fear arrest; they can als o appear strangely incapable of gras ping actual legal consequences of their actions and feel obscurely unempathic, wronged, and entitled vis à vis victims ' injured feelings : A woman pilfered her bes t friend's favorite paperweight during a party and then returned it the next day and revealed her kleptomania. S he was offended and angry because her friend did not immediately expres s what cons idered to be the proper degree of s ympathy and forgivenes s about her problem.

Differential Diagnos is E pisodes of theft occas ionally occur during psychotic illness , for example, acute mania, major depress ion ps ychotic features , or s chizophrenia. P sychotic stealing obviously a product of pathological elevation or depres sion of mood or command hallucinations or delus ions. T heft in individuals with antisocial personality dis order deliberately undertaken for personal gain, with some degree of premeditation and planning, often executed 2497 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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with others. Antis ocial stealing regularly involves the threat of harm or actual violence, particularly to elude capture. G uilt and remors e are distinctively lacking, or patients are patently ins incere. In contrast, kleptomania a s olitary activity, directed at property rather than and s tealing occas ions s hows of genuine remorse after event. S hoplifting has become a national epidemic. F ew shoplifters have true kleptomania; the majority are teenagers and young adults who “boost” in pairs or groups for “kicks,” as well as goods , and do not have a major ps ychiatric disorder. Acute intoxication with drugs or alcohol may precipitate theft in an individual with another ps ychiatric dis order without significant ps ychopathology. P atients with Alzheimer's dis ease or other dementing organic illness may leave a store without paying owing forgetfulness , rather than larcenous intent. Malingering kleptomania is common in apprehended antis ocial types, as well as nonantisocial youthful shoplifters. G iven a s ufficiently intelligent perpetrator, fictive vers ion can be quite difficult to dis tinguish from genuine disorder. E pisodes of s tealing are commonplace in childhood, for example, taking change from a parent's purs e or T he overwhelming majority of these are trans ient and reflect no serious ps ychological disturbance.

Treatment T he majority of patients avoid help until they become involved with the law, and some form of psychological 2498 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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as sistance is made a condition of remaining free. B y time, the dis order is likely to be entrenched, and corres pondingly difficult. C omplex therapeutic is sues often raised by the implied threat of pros ecution if treatment is not s ought or maintained. No controlled treatment studies of kleptomania have undertaken. Multiple modalities are common. S ucces s been reported on an anecdotal basis with various outpatient talking approaches, including group, and family work. Individual ps ychotherapy alone often insufficient to control acting out. Indeed, stealing may actually be precipitated by the trans ferential viciss itudes of insight-oriented treatment. P.2047 A panoply of behavioral and cognitive s trategies and medications have address ed kleptomania, with the anecdotal reports of s ucces s. Antidepres sants and stabilizers may be particularly helpful in cas es in which kleptomania clearly occurs against a background of affective illness . Naltrexone has shown s ome promis e specifically blocking the impuls e to steal. V ery few 12-step programs exist for kleptomania per arguably owing to tremendous s hame combined with unwillingness to go public, becaus e of fear of legal cons equences. Individuals with comorbid substance or gambling difficulties indicate that stealing is often remediated by AA and G A participation, even when choos e not to reveal their thieving. S ome nonabusing kleptomania patients claim that they have obtained simply by attending 12-step meetings without direct 2499 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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participation or s elf-revelation. Uncontrollable kleptomania can occas ionally be broken brief hospitalization, although securing insurance coverage pres ents a formidable problem. in a dual-diagnosis program that accepts patients with kleptomania is particularly helpful, if one can be found. An unwary therapis t can eas ily become overinvolved in the patient's attempts to avoid legal action. One does to remember that relaps es are common and must be with realis tically, while making authorities duly aware of the pathological nature of the problem. T he proces s of adjudication that is s o desperately feared by patients occasionally turn out to be an unexpected adjuvant to treatment. R egular check-ins with a competent, compass ionate probation officer can help s trengthen patient's impaired superego function. J ane was a 42-year-old, highly s uccess ful, single from a wealthy background. S he called herself a “shopyou-drop type” and had always been able to afford the expensive des igner clothing that she loved. S ince her “legit” shopping had been paralleled by “boosting” cheap panties and brass ieres from dis count s tores. not wear the s tolen items; indeed, s he cons idered them “sleazy.” S he could never bring hers elf to get rid of either and kept boxes filled with pilfered lingerie in a storage facility. J ane talked or bought her way out of trouble until her when s he was arrested while s tealing pantyhos e from same K -Mart for the third time in as many months. As a condition of probation, s he was ordered to s ee a ps ychiatris t. Her attendance was s poradic, and s everal 2500 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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more thefts occurred over the next 2 years . S he als o experienced substantial depres sion, which she tried to alleviate by heavy drinking. J ane finally began taking her problem serious ly after another arrest precipitated a s uicidal ges ture. S he keeping appointments regularly and cons ented to citalopram (C elexa) and naltrexone. S he believes that participation in an AA group for high-press ured has been at leas t as effective—if not more so—in controlling her s tealing. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified >

PYR OMANIA P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified"

Definition and His tory P yromania is defined as recurrent, deliberate fire (T able 21-5). C ontrovers y continues over whether the condition should be class ified under the impulsedisorders or, indeed, whether it compris es a s eparate entity at all.

Table 21-5 DS M-IV-TR Diagnos tic C riteria for Pyromania

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A. Deliberate and purposeful fire setting on more than one occasion. B . T ens ion or affective arousal before the act. C . F ascination with, interes t in, curios ity about, or attraction to fire and its s ituational contexts (e.g., paraphernalia, uses, and consequences ). D. P leas ure, gratification, or relief when s etting or when witnes sing or participating in their aftermath. E . T he fire s etting is not done for monetary gain, an expres sion of sociopolitical ideology, to criminal activity, to expres s anger or vengeance, improve one's living circums tances , in res ponse delus ion or hallucination, or as a res ult of judgment (e.g., in dementia, mental retardation, subs tance intoxication). F . T he fire s etting is not better accounted for by conduct dis order, a manic epis ode, or antisocial personality disorder.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. 2502 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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Like kleptomania, pyromania evolved out of P inel's concept of la manie s ans de lire — madness without delus ion or clouding of the sensorium, with substantive preservation of reasoning power. E arly 18th century F rench ps ychiatrists Marc and E squirol categorized pyromania as a monomanie ince ndiare — another of ins tinctive monomanias in which a patient acts out one irresistible impuls e.

Nos ology P yromania was mentioned pas s im in DS M-I and was omitted altogether in DS M-II, under the tacit that it did not merit consideration as a new diagnos is . It was so acknowledged for the firs t time in DS M-III; was categorized under impulse-control disorders , not elsewhere s pecified; and was described as a recurrent failure to resist to set fires, intense fascination with the setting of fires , and seeing fires burn. P rior to s etting the fire, there is a build-up of tension. Once the fire is under way, the individual experiences intens e pleasure or releas e. Although the fire-setting res ults from a failure to res is t an there may be considerable advance preparation. DS M-III-R redefined and otherwise modified s everal of DS M-III parameters . T he phrase “recurrent failures to 2503 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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impulses to set fires” was eliminated and was replaced “deliberate and purposeful fire setting on more than occasion.” C riterion C (“fas cination with”) elaborates further on ps ychological preoccupations related to fire setting. T he exclus ions of DS M-III's C riterion E were augmented to indicate that pyromania cannot be diagnosed if fire setting is clearly a res pons e to delus ions or hallucinations . T he revis ed C riterion F states that the diagnosis cannot be made when fire occurs in the setting of a manic epis ode, conduct or antisocial personality dis order. All DS M-III-R criteria pyromania are maintained in DS M-IV and DS M-IV -T R . T he IC D-10 characterizes pyromania as “multiple acts attempts at s etting fire to property or other objects, without apparent motive.” Incendiary activity is s aid to accompanied by tension and excitement over its Als o noted are pers istent preoccupations with firesubjects , fire-fighting equipment, and calling out the fire service. E xcluded from the diagnosis are fire s etting for obvious reas ons and fire setting by “a young person conduct dis order,” by “an adult with ‘sociopathic personality disorder,’” and by individuals with schizophrenia or organic ps ychiatric disorders .

E pidemiology No major study of pyromania has been conducted Nolan D. Lewis and Helen Y arnell's 1951 examination nonprofit incendiary cas es from the files of the National B oard of F ire Underwriters and since J . L. G eller's overview of adult pathological fire s etting. Only 3 to 4 percent—some 50 of the 1,594 fire setters —of the and Y arnell population fit DS M-IV -T R criteria 2504 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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P.2048 for pyromania. G iven the persis tent paucity of literature, as sertions about epidemiology and, indeed, any other as pects of pyromania are tentative. T he condition is supposedly rare. Mos t patients are with a male to female ratio of approximately 8 to 1. F ire setting by children and adoles cents continues to enormous problems , res ulting in s ubstantial damage to property and danger to life. More than 40 percent of arrested ars onists are younger than 18 years of age. stress es that few meet formal criteria for pyromania, although differential diagnosis is often difficult. B y anecdotal report, the families of pyromania patients show increased ps ychiatric problems , similar to the derangements of other impulse-control disordered patients, such as affective illness es ; substance abus e, particularly alcoholis m; and various personality

C omorbidity P yromania is significantly as sociated with substance disorder (es pecially alcoholism); affective disorders, depres sive or bipolar; other impulse control disorders, as kleptomania in female fire setters; and various personality dis turbances, such as inadequate and borderline pers onality disorders . Attention-deficit and learning disabilities may be cons picuously with childhood pyromania; this constellation frequently persis ts into adulthood.

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T he few in-depth explorations of pyromania have been conducted by ps ychoanalys ts. F reud famously inferred articulation between fire, ambition, and ure thral he als o theorized that pyromania repres ented a masturbatory equivalent. S ubs equent inves tigators describe fire setting and its related preoccupations as highly overdetermined activities expres sing repres sed childhood s exual or aggres sive drives, or both, aimed redress ing a panoply of real or perceived early the context of a dys functional, chaotic early family life. P yromania has been variously interpreted as a s triving exact revenge against rejecting, abus ive parents or adult figures, to acquire power in the context of chronic feelings of helples sness and inadequacy, or to master traumatic memories of the primal s cene. S ome young pyromania patients are s aid to act out projected, disavowed incendiary impulses of a parent or other member with superego lacunae. T here has been little research on the biological and cognitive-behavioral features of pyromania. T he lack reflects not only the disorder's inherent rareness , but an unwillingness to be identified that is even more formidable than the res is tance of trichotillomania and kleptomania patients. P reliminary studies hint at serotoninergic and other neurotrans mitter dysfunction, well as disordered glucos e regulation with the of a hypoglycemic trigger. Abundant clinical and phenomenological similarities between pyromania and other impuls e-control de s ire warrant the cons ideration of pathological fire as an affective s pectrum dis turbance or an obsess ive2506 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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compuls ive s pectrum dis turbance.

C linic al F eatures and C ours e A typical episode of pyromania begins with ris ing linked to thoughts of fire s etting. T ens ion often a dis tinctly erotic quality and may be accompanied by res tless nes s, headaches , palpitations, and tinnitus. Dis sociated feelings and alcohol intoxication before fire setting have been reported. In some cas es , preparation setting a fire is painstaking; in others , it is perfunctory. incendiary's pleasure over the conflagration derives several s ources : watching the flames themselves, may engender s exual arous al that is so intens e (pyrolagnia) as to lead to mas turbation, and watching activities connected with the fire, including the conflagration's es calating material devas tation, its on others, and, es pecially, the firemen's activities as go about extinguishing the blaze. P yromania patients often strongly identify with the firefighter's s trength and competence. In addition to lighting fires , they may undertake volunteer duties at firehouses or may become volunteer firefighters thems elves , then taking delight in putting out the that they have lit. W omen are les s likely to become involved with the firefighting community. Many patients prolong their idiosyncratic enjoyment by lingering in the vicinity of a fire that they have s et. It is the context of a perennial return to the scene or leave it that they are frequently apprehended by police or arson s quad detectives. T hey then regularly display striking denial, even after being pres ented with most damning evidence (unlike individuals with 2507 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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kleptomania, who readily confes s when caught). T ension drops after a fire-setting epis ode, and the may fall into a deep, relaxed sleep. T he overwhelming and remors e of individuals with kleptomania or trichotillomania do not seem to plague pyromania patients as consis tently. S ome even seem eerily toward the destruction that they have wrought. E pisodes of pyromania may occur s poradically, with prolonged impulse-free intervals . Other patients are afflicted by daily urges to set fire over many years . clinical impress ion is that a majority of fire-setting episodes occur at night—a time that offers greater poss ibilities for concealment and that may als o potent sexual and aggres sive ass ociations . A 28-year-old fire s etter said that he was tremendous ly aroused by the s ight of flames agains t the background black night sky. He remembered being awakened at 6 years of age by ominous noises coming from his sister's bedroom. He peeked through her open door was profoundly shocked—and arous ed—by the stark vision of her and a boyfriend, lit by a pool of bright lamplight, having pass ionate sex. P yromania usually begins in mid- to late adoles cence, earlier onset is not unusual. T he typical patient is said intellectually limited; comes from an underprivileged social background and a dysfunctional, violence-prone family; and often has s ignificant learning and handicaps in childhood. C hild or adoles cent fire s etting and preoccupations with fire may be unaccompanied other s ymptoms . P yromaniac behavior is more likely to 2508 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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part of a clus ter of petty delinquent behaviors that includes running away, truancy, and thieving, making primary diagnosis uncertain (vide infra). F ire setting at home frequently occurs in the youngster's room or the parental bedroom. If behavioral problems are s erious enough to require institutionalization, incendiary is likely to carry over to residential treatment centers , training s chools , and other in-patient settings , causing enormous problems. T he typical adult patient with pyromania suppos edly is vocational underachiever, has difficulty in s us taining relations hips , and may lead a marginal existence. this notionally average patient may compris e only one subtype, if the mos t common, of the condition. Other patients come from more s table families and exhibit achievement levels vocationally and socially. T heir life of fire setting remains a shameful secret. No definitive data about the cours e of pyromania exist. anecdotal evidence, some patients continually s et fires throughout their lives , despite repeated incarcerations , end up permanently imprisoned. Others persist in their setting P.2049 indefinitely, keeping it s urreptitious and limited enough avoid arres t. F or s till others , a gradual burnout of the disorder takes place in later decades. One s urmises the progres sion of pyromania is cons iderably inflected comorbid conditions , especially s ubs tance abus e and affective illnes s. Most self-immolations are obviously a function of 2509 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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ps ychos is or nonps ychotic social protes t. However, it seems reasonable to as sume that some pyromaniacs terminate their lives by setting fire to themselves, accidentally (particularly when intoxicated) or in the context of profound depres sion.

Differential Diagnos is Des pite the DS M-IV -T R 's exclus ionary criteria, it is extremely difficult to differentiate true pyromania from fire setting of other s yndromes , es pecially adoles cent conduct dis turbances. F ire setting in schizophrenia or manic-depres sive is clearly a function of flagrant thought disturbance, precipitated by command hallucinations or delusions. P yromania should not be diagnos ed if fire s etting is by acute intoxication with alcohol or other substances, lacking other parameters of the disorder. F ire setting in severe mental retardation or organic dementia clearly stems from impaired judgment based cerebral deficit: An 80-year-old man with Alzheimer's disease forgot he had left a cigarette burning on the edge of a night while looking for an as htray. T he cigarette fell into a was tebasket filled with combustible material, causing a major conflagration. F ire setting by individuals with antisocial dis order their criminal, unempathic, and remorseles s natures. Incendiary acts are clearly aimed at revenge, profit, or concealing a crime. T he triad of violence to animals , setting, and bedwetting in childhood is widely held to 2510 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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marker for particularly violent antis ocial behavior in adoles cence and adulthood. P yromania should be dis tinguis hed from s etting fires as means of political protes t or sabotage, of bringing attention to s ome pers onal wis h or need, or of gaining some other recognition in a nonpsychotic context. C hildren with no psychiatric disturbance may s et fires inadvertently as a function of ordinary experimentation. P laying with matches or lighters in this context is occasionally catastrophic but nevertheles s does not warrant a diagnos is of pyromania or other ps ychiatric disorder. Little is known about the profess ional arsonist or torch. Law enforcement sources s ugges t that career overwhelmingly male, pride themselves on their highly specialized expertis e, and—if only to avoid more prosecution—go to great lengths to ens ure that their does not cause physical harm. T he torch's criminality is usually confined to fire s etting, and he or she may not always fit the tidy paradigms of antis ocial pers onality disorder. One speculates that torches embody yet another s ubset of pyromania, in pathological incendiary impulses are rationalized and acted out under the aegis of doing a job for hire.

Treatment T reatment of pyromania continues to be problematic owing to a lack of a willing clientele, even when fire are incarcerated. Des pite anecdotal reports of s ucces s ps ychoanalytic methods , most pyromania patients are hardly apt candidates for ins ight-oriented therapy 2511 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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to their profound denial, heavy drinking, and an alexithymic inability to identify and to work through feelings. With s o little data available on any s ort of therapy, and definitive cure in s ight, one can only advocate the multimodal approach that is characteristic of treatment other impulse-control disorders : flexible deployment of various psychotherapies, cognitive and behavioral and drug intervention according to the unique presentation of each patient. C hildhood fire s etting mus t always be taken serious ly, es pecially when episodes are repeated, damage is subs tantial, the family structure notably is and the patient is substantially inarticulate. Under these circums tances , family therapy combined with individual treatment may be particularly helpful. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified > E X P LOS IV E DIS OR DE R

INTE R MITTE NT E XPL OS IVE DIS OR DE R P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified"

Definition Intermittent explosive dis order is characterized by repeated failure to resist aggress ive impulses, resulting punctate explos ions of aggres sion that cause serious 2512 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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phys ical harm or damage, or both, to property. T he eruption of violence is typically far out of proportion to precipitating s tres s (T able 21-6).

Table 21-6 DS M-IV-TR Diagnos tic C riteria for Intermittent Dis order A. S everal discrete episodes of failure to res ist aggres sive impuls es that res ult in s erious acts or destruction of property. B . T he degree of aggress ivenes s express ed the epis odes is gross ly out of proportion to any precipitating ps ychosocial stress ors . C . T he aggres sive epis odes are not better for by another mental dis order (e.g., antisocial personality disorder, borderline personality a psychotic disorder, a manic epis ode, conduct disorder, or attention-deficit/hyperactivity and are not due to the direct phys iological effects a s ubs tance (e.g., a drug of abuse or a a general medical condition (e.g., head trauma or Alzheimer's disease).

F rom American P sychiatric As sociation. 2513 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

C omparative Nos ology Intermittent explosive dis order arguably is the most controvers ial entity of this group. T he diagnos is out of several decades of debate about whether a syndrome consisting of repeated explosive episodes should be clas sified as a psychiatric illness in the firs t and, as suming this s yndrome exis ts, about where to it nos ologically. Investigators have particularly over whether a disorder s uch as this could be some kind of neurophys iological dysfunction, although still being s eparated diagnostically from other with obvious organically induced aggress ion. A patient meeting current DS M-IV -T R criteria for intermittent explosive dis order would have been diagnosed in DS M-I as a pas s ive -aggres s ive aggres s ive type . DS M-II replaced the latter with pe rs onality, which, in turn, was eliminated by DS M-III in favor of intermitte nt e xplos ive dis orde r. T he new diagnos is was advanced to account for with s o-called epis odic dyscontrol syndrome, in which sudden epis odes of violent behavior erupted without 2514 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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notable intervening psychopathology. A diagnosis of is olated e xplos ive dis order was also added to the salient feature was a P.2050 single epis ode of violent behavior with catas trophic cons equences. T he DS M-III vers ion of intermittent explosive disorder allowed for but did not require an organic etiology to s upport the diagnosis. It was noted that, in s ome cases , “features s uggesting an organic disturbance may be pres ent such as nons pecific E E G [electroencephalogram] abnormalities or minor neurological signs and symptoms thought to reflect subcortical or limbic system dys function.” T he was implicit, however, that psychosocial factors alone could cause the dis order. During the fashioning of DS M-III-R , intermittent disorder was , at firs t, deleted and then restored. T hose favoring elimination believed that repetitive violent outburs ts should not be s ubsumed within a dis crete ps ychiatric entity or thought that, when a substantive neurophys iological etiology could be proven, explos ive episodes would be bes t clas sified under the rubric of organic mental disorder. C oncern was voiced at that time—and s till exis ts today—about s tandardizing a nonorganic ps ychiatric diagnosis that could then be as a legal defens e in cases of violent crime. T he res tored DS M-III-R diagnosis reflected the final conclus ion of evaluators that psychosocial and environmental factors played a conclusive role in some cases of intermittent violent behavior. However, exclusionary category was created—organic 2515 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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syndrome, explosive type—to account for intermittent explosive cas es with a definitive history of central system (C NS ) dysfunction. DS M-IV and DS M-IV -T R retain the DS M-III-R 's explos ive dis orde r; eliminate organic pe rs onality explos ive type ; and redefine the exclusionary criteria: diagnosis now should not be made in the pres ence of manic epis ode, ADHD, and any “general medical (e.g. head trauma, Alzheimer's disease).” Intermittent explosive dis order is not recognized as a distinct diagnosis in IC D-10. It is mentioned under habit and impuls e dis orde rs (F 63.8), without s pelling specific parameters .

E pidemiology Intermittent explosive dis order is believed to be rare, although the condition may be underreported. T he few s tudies available indicate a male preponderance high as 80 percent. F amily his tories, particularly in firstdegree relatives, show a high rate of one or more comorbid mood disorders , anxiety dis orders, substance abuse dis orders, and impuls e-control disorders — intermittent explosive dis order its elf.

C omorbidity A major as sociation has been noted between explosive disorder and mood disturbances — bipolar disorder (more than 50 percent in one study). Meaningful comorbidity is also des cribed with anxiety disorders , substance abuse disorders, eating personality dis orders, attention-deficit disorder, and 2516 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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impulse-control disorders .

E tiology Although res earch has been limited, it is generally as sumed that intermittent explos ive dis order—like impulse-control disturbances —is caus ed by a varying confluence of ps ychos ocial and neurobiological factors. P atients regularly des cribe chaotic family backgrounds , with explosive behavior and verbal and phys ical abus e, often in the context of acute alcohol intoxication. Ide ntification with the aggre s s or is a common defense mechanism, in which the explosive violence of a parent clos e relative is internalized. T his sinis ter coping replicates the acts of s tormy violence to which patients have been expos ed during their formative years. S ituations that realis tically or symbolically evoke of early oppress ion and trauma may s park explosive episodes . T ypically, an acute s ens e of narcis sistic lowered self-es teem, and profound feelings of s hame humiliation are evoked: A 28-year-old man had been repeatedly brutalized by alcoholic mother throughout childhood and early adoles cence. He felt particularly humiliated when s he would s lap his face during frequent bouts of uncontrollable anger. One evening, while they were drinking at a local tavern, a friend playfully s lapped his cheek. T he patient s uddenly “saw red,” broke a beer over the man's head, and then mauled him severely. Modes t neurobiological studies point to pos sible deranged s erotonin neurotrans mis sion in patients 2517 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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identified with intermittent explosive dis order; low cerebrospinal fluid (C S F ) levels of 5acid (5-HIAA) in s ome impulsive, temper-prone and lowered levels of platelet s erotonin reuptake in patients with epis odic rage. A connection has also inferred between elevated C S F testosterone levels and aggres sive or openly violent behavior. P atients may show s oft neurological signs (e.g., of reflexes) and nons pecific E E G findings (e.g., diffus e activity). An element of genetic loading is s uggested by the fact that blood relatives are more likely to have characteristic outbursts of explos ive behavior adoptive relatives. In an overview of 27 cases, S usan L. McE lroy and colleagues concluded that intermittent explos ive could be class ified as an affective s pectrum based on the s trong comorbidity of bipolar disorder, a high familial rate of mood disturbances , disturbed circadian rhythms, and res pons iveness to thymoleptics .

C linic al F eatures , Diagnos tic C ons iderations , and C ours e An explos ive episode may be preceded by a period of es calating tension and aggress ive feelings or may a flas h with little or no inciting cause. T he attack itself is often accompanied by irritability, rage, mood elevation, increased energy, and racing thoughts. F eelings of diss ociation and depers onalization, without later for the event, are described. P hys ical s ymptoms may antedate or may occur during the outburst—for tingling, tremor, palpitations , ches t tightness , tinnitus , head press ure or headaches. After the episode, relief 2518 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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quickly followed by remors e, fatigue, and depress ion. A migraine-type headache may be carried over from the attack or may develop de novo. E xplos ive eruptions us ually las t approximately 10 to 20 minutes ; they may occur frequently, in clusters; or weeks to months may intervene before another episode. S ome patients no aggress ive tendencies between outburs ts, but the majority exhibit some type of chronic impulsive or aggres sive behavior. P atients are often perceived by others —and view thems elves —as perennially angry. experience s ubthre s hold s tates, in which serious aggres sion is headed off by exercising s haky control or engaging in less dangerous behavior—screaming, pounding a table, or punching a wall. Against the background of severe family dysfunction, the childhood individuals with intermittent explosive dis order is hallmarked by temper tantrums and s undry behavioral difficulties —stealing or fire s etting. T he youngs ter's problems are often compounded by defective attention, concentration, and hyperactivity. Intermittent explosive dis order characteris tically begins during late childhood to the early 20s , with a mean age onset of 18.3 years of age. C ourse is dependent on the frequency and severity of explosive episodes. S evere show poor s chool performance, employment problems , and s tormy interpersonal relationships . Divorce, injury self or others from fights and accidents (e.g., during of road rage), and sundry financial and legal problems (including incarceration) are common. Narcis sistic, obses sive, paranoid, or s chizoid personality traits may es pecially predis pos e patients to aggres sive outbursts. P.2051 2519 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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Although there is no extensive s tudy of outcome, the term history of the disorder may be epis odic or chronic. prolonged course with markedly deteriorated quality of life is likely when explos ive behavior occurs regularly, serious cons equences , in the pres ence of severe conditions—es pecially substance abuse disorders, disorders , and substantive character pathology. When intermittent explos ive disorder is s uspected, the patient must be pains takingly evaluated to rule out one the many medical or neurological conditions that can caus e aggres sive epis odes. A bas ic workup includes thorough neurological examination; blood chemis tries as say the poss ibility of diabetes , liver dis eas e, kidney disease, thyroid dis ease, syphilis , alcohol, and lead or poisoning; urinalys is with toxicology s creen; and s kull rays. F urther study may us e E E G , magnetic res onance imaging (MR I), computed tomography (C T ), and emis sion tomography (P E T ) scanning.

Differential Diagnos is DS M-IV -T R s tres ses that intermittent explos ive can only be diagnosed after all other medical and ps ychiatric caus es of intemperate aggress ion are absolutely ruled out. When it can be proven definitively that the aggres sive behavior is directly caused by a medical or organic condition (e.g., pos tconcuss ion syndrome), a diagnos is of pe rs onality change due to a ge neral me dical condition, aggre s s ive type , is made, than intermitte nt e xplos ive dis order. Aggress ive outburs ts are common in delirium and when the underlying caus e has been res olved. 2520 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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explosions are rarely s een in epilepsy, notably in and temporal lobe seizures. Aggress ion due to substance intoxication or withdrawal diagnosed by a his tory of abus e (not always easy to obtain), as well as by appropriate blood and urine Alcohol remains the mos t common cause of intoxicated aggres sive behavior. Amongs t s treet drugs, (P C P ) is es pecially known to precipitate extreme, behavior. Intermittent explos ive disorder can only be diagnosed in a violence-prone s ubs tance abus er if criteria of the former dis order are completely met. Aggress ive outburs ts as sociated with various disorders us ually have a more planned, premeditated quality. However, antisocial personality dis order and borderline pers onality disorder occasionally present serious, deliberate aggres sive acts, as well as unpremeditated violence. G iven the fulfillment of other criteria, intermittent explos ive disorder can then be diagnosed together with the requisite personality Attacks of anger as sociated with autonomic arousal tachycardia and flushing), related to terrifying feelings being out of control, can occur in major depress ive disorder and panic disorder. DS M-IV -T R allows the additional diagnosis of intermittent explosive dis order when aggres sive and destructive outbursts clearly do take place during periods of depress ion or a panic and other criteria are s atis fied. Aggress ive outburs ts as sociated with s chizophrenic or a manic psychotic state are obvious ly related to ps ychotic phenomena, such as command delus ions of pers ecution. 2521 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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Individuals with violent antis ocial tendencies may malinger s ymptoms of intermittent explos ive disorder to es cape punishment. Intentional violent behavior without any mental dis order distinguished by obvious motivation and hope for gain through aggress ive action. Dis play of anger in the context of frus trating life events , standard environmental press ures, or pos ttraumatic disorder (P T S D), precipitated by extraordinary stress , shows a res ponse appropriate to the cause of unlike the rage on little provocation that is intermittent explosive dis order. Amok is a culturally inflected eruption of exhibitionis tic violence. T he perpetrator, typically a man with no pattern of violence, s lashes or shoots at random often in a crowded public place, until he is subdued or killed. He appears to be in a dis sociated s tate; if he survives , he is amnes ic for the epis ode. T he practice of running amok is traditionally attributed to various southeas t Asian countries but has been reported elsewhere.

Treatment Most individuals with intermittent explos ive disorder do not seek treatment. Ins tead, they are compelled to get help by family pres sure or legal circums tances . P sychoanalytic ps ychotherapy is not likely to be undertaken and is problematic becaus e of the average patient's limited capacity for insight, brittlenes s of defens es , and alexithymia. A long-term s upportive relations hip combined with other modalities is generally 2522 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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more helpful. S imply knowing that one can call a concerned therapist when destructive impulses can greatly help a patient exert s uccess ful control. rage manageme nt s ess ions specifically directed at control are als o us eful. T he ps ychopharmacological treatment of intemperate aggres sion is s till in its infancy, and is largely single or small case studies . Improvement has been reported with divers e medications ; us ing drugs from than one clas s has become increasingly common. include anticonvulsants (e.g., carbamazepine phenytoin [Dilantin], gabapentin [Neurontin], [Lamictal]); antianxiety agents (e.g., benzodiazepines); mood regulators (e.g., lithium); β-adrenergic receptor antagonis ts (e.g., propranolol [Inderal]); and antidepres sants. S everal studies indicate that S S R Is reduce anger and irritability, with improvement rates as high as 60 percent. S olid res earch is clearly needed in area. When prescribing drugs of the benzodiazepine family buffer anxiety related to explosive behavior, the should be aware of their potential for caus ing and cons equent escalation of aggress ion in s ome (notably with clonazepam at higher doses). V arious cognitive-behavioral s trategies can help bring aggres sive impuls es under control. F or instance, deep relaxation is used in s ys tematic flooding of explosive s ituations to decreas e angry res ponses. After mastery of imaginal flooding, the patient uses neutralize anger in carefully graded real-life E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins

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> T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified > C ONT R OL DIS OR DE R S NOT OT HE R W IS E S P E C I

IMPUL S E -C ONTR OL DIS OR DE R S NOT S PE C IFIE D P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified" T he conditions within the category of impuls e -control dis orders not othe rwis e s pe cifie d do not s atis fy the for any of the previous ly mentioned impulse-control disorders or do not fit the paradigm of any other ps ychiatric disorder involving impulse-control problems described in the DS M-IV -T R (e.g., paraphilias and abuse dis orders) (T able 21-7).

Table 21-7 DS M-IV-TR Diagnos tic C riteria for Impuls e-C ontrol Dis order not Otherwis e S pec ified T his category is for dis orders of impulse control skin picking) that do not meet the criteria for any specific impulse-control disorder or for another mental disorder having features involving impuls e control described elsewhere in the manual (e.g., 2524 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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subs tance dependence or a paraphilia).

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T his heterogenous group includes compuls ive s exual behavior that is unclass ifiable elsewhere, compulsive and cuticle biting (onychotillomania), face picking, self-cutting and other P.2052 forms of s elf-mutilation, and compulsive buying. T he two s yndromes warrant further discus sion, becaus e compuls ive s hopping is now considered to be a major mental health problem, and delicate s elf-cutting to be on the ris e. A future DS M will pos sibly recognize or both as viable diagnostic entities to be listed with impuls e control dis orde rs not e ls e where s pe cifie d. IC D-10 contains two categories analogous to the DS MT R 's impuls e control dis orde rs not othe rwis e s pe cified. first—other habit and impuls e dis orde rs — disorders of “persis tently maladaptive behavior” that clearly not ass ociated with “a recognized psychiatric syndrome,” characterized by “repeated failure to res is t impulses to carry out the behavior,” prodromal tens ion, and “a feeling of releas e at the time of the act.” Intermittent explosive (behavior) disorder is the only 2525 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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listed in this group without comment. No criteria are and no examples are given for the s econd category— and impuls e dis orde rs , uns pe cified.

C ompuls ive B uying T he irresis tible compulsion to buy was well known to ancients . P etronius' S atyricon ironically delineates the insensate greed for acquisition that gripped wealthy R omans . Nineteenth century nosology termed the condition oniomania; it was als o clas sified as one of impuls ive ins anitie s . T he inordinate buying habits of wealthy addicts —like wealthy kleptomaniacs—has commanded public attention. However, like gambling, compuls ive buying cuts acros s the entire spectrum and is ominously on the rise. E stimates of prevalence range from 1 percent to as high as 5 the general population. Most patients —80 to 90 are female. C ompulsive buyers feel ris ing tens ion and excitement during a variable prodromal period and experience and s atis faction during a s hopping binge, followed by depres sive deflation. G uilty des pair may s eem related to ruinous overspending. Y et, many well-to-do excess ive buyers s till report agonizing postshopping remors e, s elf-loathing, and a terrible sens e of Most patients s hop alone, for thems elves . B uying vary in frequency, length, and duration. A typical bout several hours ; however, s ome patients describe s prees cons ume a day or s everal days . During intervening thinking is often invaded by fantasies about shopping, patients wrestle frantically for control. T hey may deliberately confine thems elves outside to store-free 2526 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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or may stay at home to quell their buying—where they tempted by catalogues and televis ion s hopping Items purchas ed are often related to personal clothes, perfume, makeup, and shoes . C lothing may be worn a few times or never at all and is hoarded. Male patients favor electronic and automobile equipment, hardware, or tools. However, es sentially any object for may be s ought obsess ively. Impulse purchas ing is common. C ompulsive buying gradually cons umes ever more of individual's time and money, with calamitous impact on vocational performance and social life: After several years of increas ing shopping binges , 35-year-old attorney, began attending weekend At first, she only bid on jewelry but soon became s o up in the action that she found herself impulsively bids on objects that she neither needed nor wanted. ran up more than $200,000 of debt and invaded res ources . Her marriage and friendships deteriorated. was hounded by loan s harks and considered killing yet s till kept attending auctions until s he was barred for failure to make good on her purchas es . S he sought only when threatened with bankruptcy, and her said that he wanted a divorce. T he similarity of compuls ive buying to the driven of pathological gambling and kleptomania is obvious. C omorbidity for kleptomania is es pecially high— frequently, but not exclusively, related to financial difficulties . Other significant comorbid conditions mood dis orders, s ubs tance abus e disorder, eating 2527 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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(bulimia in particular), OC D, attention-deficit disorder, various personality dis turbances . F amily histories are positive for mood, s ubs tance abus e, and impuls edisorders . C ompulsive buying usually begins in late adolescence develops insidiously, until it is unmas ked in the late 20s early 30s . T he cours e thereafter is epis odic and more favorable or chronic and severe, with attendant job bankruptcy, family dysfunction, divorce, and even or imprisonment. S erious comorbid pathology— related to bulimia, mood disorder, and drug abus e— militates for a poorer prognos is. T he etiology of the condition is multifaceted. P sychoanalysts s peculate that compulsive buying represents a complex s ymbolic restitution, variously redress ing low self-es teem, female cas tration anxiety (purchase equals penis ), fear of death, and depress ive emptines s, for example. B ehavioris t theory similarities between compulsive buying and other addictions regarding the intense reinforcement of repeated s hopping binges and the development of tolerance with the need for more purchas es to obtain relief, to name a few. Neurobiologists conjecture that compulsive buying may be yet another affective spectrum dis order or spectrum dis order by virtue of its phenomenology, its familiar comorbidity pattern, and its family his tory. Analogous dys regulation within the s erotoninergic and other neurotrans mitter s ys tems has been pos tulated not yet proven. It is commonplace that Wes tern society is intensely 2528 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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cons umeris t. E normous advances in the technology of cons umption, ever more sophis ticated advertis ing, and ubiquity of Internet marketplaces all combine to compuls ive buying in the afflicted and even, perhaps, create a legion of new s hopping addicts in those predis pos ed by chemis try, conflict, and character. With regard to differential diagnos is, compulsive and noncompuls ive s hoppers feel energized and happy buying. T his transitory well-being s hould not be with the prolonged elation propelling the febrile purchasing of bipolarity, accompanied by other manic stigmata. Devotees of unpathological so-called s hopyou-drop s prees occasionally overspend but do not as frequently and are not obs ess ed with s hopping, nor does purchas ing have the pervasive des tructive impact characteristic of the compuls ive buyer. However, shopping may insidiously escalate into compulsive S us picions on this score warrant the clinician's deeper exploration of shopping behavior and shopping-related preoccupations. T here have been no large-scale treatment s tudies of compuls ive buying. C ase reports s uggest that a combination of therapies is favored and more effective than a single modality. S ucces s has been achieved ps ychoanalytically oriented and supportive therapy, as well as cognitive techniques, for example relaxation imaginal work. T he res ults of pharmacotherapy are ambiguous; variable improvement has been reported antidepres sants, mood s tabilizers , anxiolytics, and antips ychotics , and combinations thereof. Debtors Anonymous (DA) meetings or other self-help groups proven effective in controlling buying impulses, alone 2529 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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combined with other therapies .

Delic ate S elf-C utting T he term de licate s e lf-cutting was coined by P aul P ao 1969 to delineate a s yndrome of precis e self-mutilation, predominantly afflicting adolescent and young adult women, which exhibits the hallmarks of other impuls econtrol disorders . Its prevalence has not been but many clinicians P.2053 believe that the s yndrome is not rare and has been increasing s ignificantly. T he condition is characterized by shallow, meticulous cutting into the s kin, us ing a razor blade or sharp knife, often in a series of s lices . T he most favored locations the wris t and lower arms. C utting elsewhere, such as breasts, abdomen, pubic area, is s aid to be as sociated even more s erious psychopathology. C utting is not a suicidal act but is connected with the releas e of tens ion and anger, with or without the attempt to stabilize frightening feelings, such as fragmentation. B orderline personality dis order is arguably ass ociated more cons is tently with delicate self-cutting than is the case with any other impulse-control disorders . significant comorbid conditions include OC D, affective disorder, diss ociative or depersonalization dis order, dysmorphic dis order, and eating disorders. F amilies extraordinarily dysfunctional, with high rates of affective and anxiety dis orders. Most theories about etiology derive from 2530 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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work. A s ubs tantial number of patients have illness , injury, or abus e by family members in Analytical investigators describe difficulties in affective regulation, with early failure to internalize appropriate soothing mechanis ms ; chronic anxiety about ego disintegration, loss of control, and maintaining ego boundaries ; disturbances in body image; and intense of sexual arousal and vaginal sensations. B izarre and frightening as s elf-cutting appears, to the patients thems elves , it is a profoundly reparative means for res toring psychic equilibrium. Little is written about the neurobiological and behavioral features of delicate s elfcutting. T he condition may qualify as an obs es sive spectrum dis order or affective s pectrum disorder (es pecially the former), with poss ible dysregulation of several neurotrans mitter s ys tems. B ehaviorists s tres s formidable reinforcing potential of the s ymptom, based the immense relief it provides . Delicate s elf-cutting typically begins in early around menarche. P atients may hide the disorder for adroitly concealing their wounds with long-sleeved clothing. T he condition is episodic in s ome patients , away with time. T he outcome is far more problematic behavior is firmly entrenched as a coping strategy, particularly when delicate s elf-cutting is as sociated with severe borderline pers onality disorder and mood disorders . In chronic cas es , dysfunction and marginalization of life is extens ive, with multiple hospitalizations and s uicidal tendency. R egarding differential diagnos is, single or multiple attempts in major depres sive dis order may be with delicate s elf-cutting; the former diagnosis is made 2531 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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the bas is of the obvious guilt-ridden intention to kill or, least, to injure ones elf, as well as obvious ly depress ed mood and vegetative symptoms. S elf-mutilation in schizophrenia is often bizarre (e.g., castration and enucleation) and is res ponsive to command or delusions . Malingered cutting, notably encountered in prisoners or psychiatric inpatients with no previous (es pecially adoles cents ), has an obvious, manipulative purpos e or can occur during an epidemic of copy-cat acting out. T he wris t cutting and other s elf-mutilations mentally retarded or autis tic institutionalized patients the complex intraps ychic symbolic meanings of self-cutting. Lesch-Nyhan s yndrome is a rare X-linked reces sive disorder that usually presents with the hallmark of severe, involuntary s elf-mutilation, occasionally including s elf-cutting. As sociated with the disease are cognitive impairment, choreoathetosis, and hyperuricemia. Mos t patients are male. S uccess has been reported in treating delicate selfwith ps ychoanalys is . Ins ight-oriented therapy is not to undertaken lightly with these patients and is often prolonged and stormy, with a s ubs tantial ris k of transferential dis tortions . Anecdotal reports note improvement with S S R Is , mood regulators , and various cognitive-behavioral techniques. Whatever treatments are us ed, delicate s elf-cutters make enormous emotional demands on the therapist because of their uns hakable need for attention, even they push help away. T oo much involvement may be 2532 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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perceived as a frightening intrusion by a patient whos e sens ibility is also finely tuned to the least hint of and who is prone to act out in either case. B alanced compass ion is requis ite. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified > C R OS S -R E F E R E NC E S

S UGGE S TE D C R OS S R E FE R E NC E S P art of "21 - Impulse-C ontrol Disorders Not E ls ewhere C las sified" As abundantly des cribed, many other disorders are comorbid with the impulse-control disorders , may with impulsive features, and may be contemplated as alternatives during differential diagnos is . T he reader is therefore directed to discuss ions of OC D (C hapter 14); mood dis orders, notably bipolar dis order (C hapter 13); anxiety dis orders (C hapter 14); and s ubs tance abuse dependency dis orders (C hapter 11; also, s ee S ection for a discus sion of conditions as sociated with eating dis orders, notably bulimia (C hapter 19); disorders , notably fugue states (C hapter 17); disorders , notably antis ocial and borderline personality disorders (C hapter 23); paraphilias , compuls ive sexual behavior, and sexual addiction (C hapter 18); and neurological and medical conditions as sociated with impulsivity (dementias, S ection 10.3). E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins

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> T able of C ontents > V olume I > 21 - Impuls e-C ontrol Dis orders Not E ls ewhere C la ss ified >

R E FE R E NC E S B audamant M: Description de deux mass es de trouvee dans l'es tomac et les intestines d'un jeune garcon age de 16 ans. His t S oc R oy Me d. B lack DW : C ompulsive buying: a review. J C lin P s ychiatry. 1996;57[S uppl]:50. B laszcynski A. O ve rcoming C ompuls ive G ambling: Help G uide Us ing C ognitive -B ehavioral T echnique s . London: R obins on; 1998. B rady K T , Myrick H, McE lroy S : T he relationship subs tance use disorders , impulse control dis orders, pathological aggres sion. Am J Addict. 1998;7:221. B rower C , S tein DJ : T richobezoars in case report and literature overview. P s ychos om 1998;60:658. C hambers R O, P otenza MN: Neurodevelopment, impulsivity, and adolescent gambling. J G ambl S tud. 2003;19:53. *C hris tenson G A, C row S J : T he characterization treatment of trichotillomania. J C lin P s ychiatry. [S uppl]:42. C hris tenson G A, F aber R J , de Zwaan M, R aymond S pecker S M, E kern MD, Mackenzie T B , C ros by R D, S J , E ckert E D, Mus sel MP , Mitchell J F : C ompulsive 2534 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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buying: descriptive characteristics and ps ychiatric comorbidity. J C lin P s ychiatry. 1994;55:5. C ohen IJ , S tein DJ , S imeon D, S padaccini E , R osen Aronowitz B , Hollander E : C linical profile, and treatment his tory in 123 hairpullers: a survey J C lin P s ychiatry. 1995;56:319. *C rockford DN, el-G uebaly N: P athological critical review. C an J P s ychiatry. 1998;43:43. C unningham-Williams R M, C ottler LB : T he epidemiology of pathological gambling. S emin C lin Neurops ychiatry. 2001;6:155. Dannon P N: T opirmate for the treatment of kleptomania: a cas e s eries and review of the C lin Neuropharmacol. 2003;26:1. Dickers on MG , Hinchy J , E ngland S : Minimal and problem gamblers : a preliminary inves tigation. J G ambling S tudie s . 1990;6:87. Doctors S . T he s ymptom of delicate s elf-cutting in adoles cent females : a developmental view. In: S C , Looney J G , S chwartzberg AZ, S oros ky AD, eds. Adoles ce nt P s ychiatry: De ve lopmental and C linical S tudie s . V ol 9. C hicago: University of C hicago 1981:443. *Durst R , K atz G , T eitelbaum A, Zis lin J , Dannon K leptomania: Diagnos is and treatment options . C NS 2535 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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Drugs . 2001;15:185. E squirol E . Me ntal Maladie s : A T re atis e on Ins anity. P hiladelphia: Lea and B lanchard; 1845. F elthous AR , B ryant S G , W ingerter C B : T he intermittent explosive dis order in violent men. B ull Acad P s ychiatry L aw. 1991;19:7l. *G eller J L: P athological fires etting in adults. Intl J P s ychol. 1992;15:283. G eller J L, B ertsch G : F ire-setting behavior in the histories of a s tate hos pital population. Am J 1985;142:465. G rant J E , K im S W , P otenza MN: Advances in the pharmacological treatment of pathological gambling. G ambl S tud. 2003;19:85. *G reenberg HR , S arner C A: T richotillomania: and s yndrome. Arch G e n P s ychiatry. 1985;12:482. P.2054 Hollander E , B egaz T , DeC aria C : P harmacologic approaches in the treatment of pathological C NS S pe ctrums . 1998;3:72. Hollander E , K won J H, S tein DJ , B roatch J , Himelein C A: Obs es sive-compuls ive and s pectrum disorders : overview and quality of life iss ues . J C lin 2536 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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P s ychiatry. 1996;57[S uppl]:3. K ammerer T , S inger L, Michel D: T he incendiaries : criminological, clinical and psychological s tudy of 72 cases. Ann Me d P s ychol. 1967;1:687. K euthen NJ , O'S ullivan R L, S prich-B uckmins ter S : T richotillomania: current is sues in conceptualization and treatment. P s ychothe r P s ychos om. K im S W, G rant J E : T he ps ychopharmacology of pathological gambling. S emin C lin Ne urops ychiatry. 2001;3:184. Lejoyeux MJ , Ades J , T ass ain V , S olomon J : P henomenology and ps ychopathology of buying. Am J P s ychiatry. 1996;153:1524. Leong G B : A psychiatric study of persons charged ars on. J F ore ns ic S ci. 1995;37:1319. Lesieur HR , R os enthal R J : P athological gambling: a review of the literature. J G ambling S tudies . Lewis ND, Y arnell H: P athological firesetting (pyromania). Nerv Me nt Dis Mon. 1951;82:8. Lion J R : T he intermittent explosive dis order. Ann. 1992;22:64. Mans ueto C A, T ownsley-S ternberger R M, T homas A, G oldfinger-G olomb R : T richotillomania: a 2537 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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comprehensive behavioral model. C lin P s ychol R e v. 1997;17:567. Marc H: C ons iderations medico-legales s ur la monomanie et particularement incendiare. Ann Hyg P ubl Me d L e g. 1833;10:367. McE lroy S L, Huds on J I, P ope HL J r, K eck P E J r, T he DS M-III-R impulse control dis orders not clas sified: clinical characteristics and relations to ps ychiatric disorders. Am J P s ychiatry. McE lroy S L, K eck P E J r, P hillips K A: K leptomania, compuls ive buying, and binge-eating dis order. J C lin P s ychiatry. 1995;56:14. McE lroy S L, P ope HG J r, K eck P E J r: Are impuls e disorders related to bipolar dis order? C ompr 1996;37:229. McE lroy S L, S outullo C A, DeAnna B A, T aylor P J r, P E : DS M-IV intermittent explos ive dis order: a report 27 cases . J C lin P s ychiatry. 1998;59:203. P ao P : T he syndrome of delicate s elf-cutting. B r J P s ychol. 1969;42:195. P etry NM, Armentano C : P revalence, ass ess ment, treatment of pathological gambling: a review. S erv. 1999;50:1021. P etry NM, R oll J M: A behavioral approach to 2538 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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unders tanding and treating pathological gambling. S emin C lin Ne urops ychiatry. 2001;6:177. P otenza MN: T he neurobiology of pathological gambling. S emin C lin Ne urops ychiatry. 2001;3:217. R eis t C , Nakamura K , S agart E , S okolski K N, Impulsive aggres sive behavior: open-label treatment with citalopram. J C lin P s ychiatry. 2003;64:81. S punt B , DuP ont I, Lesieur H, Liberty HJ , Hunt D: P athological gambling and subs tance mis use: a of the literature. S ubs t Us e Mis us e . 1998;33:2535. S tein DJ , Hollander E , Liebowitz MR : Neurobiology impulsive behavior and the impuls e control Neurops ychiatry C lin N euros ci. 1993;5:9. S tein DJ , S imeon D, C ohen LJ , Hollander E : T richotillomania and obses sive-compuls ive disorder. C lin P s ychiatry. 1995;56[S uppl]:28. S ylvan C , Ladouceur R , B oisvert J M: C ognitive and behavioral treatment of pathological gambling: A controlled study. J C ons ult C lin P s ychol. T avares H, Zilberman ML, el-G uebaly N: Are there cognitive and behavioural approaches s pecific to the treatment of pathological gambling? C an J 2003; 48:22. T oneatto T : C ognitive pathology of problem 2539 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/21.htm

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S ubs t Us e Mis us e . 1999;34: 1593. Winchell R M: T richotillomania: pres entation and treatment. P s ychiatr Ann. 1992; 22:84.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > 22 - Adjus tment Dis orders

22 Adjus tment Dis orders J effrey William K atzman M.D. Oladapo Tomori M.D. T he diagnostic category of adjustment dis orders is us ed among clinicians in practice. It is one of a few diagnostic entities in which an external stres sful event linked to the development of s ymptoms. T he event involves financial, legal, or relationship difficulties or a medical diagnosis. T he adjustment dis order cons truct often criticized for a lack of s cientific support, and there few controlled s tudies of the adjustment disorders in literature to date. T he diagnosis of adjus tment disorder s trays from the general phenomenological approach of the revised edition of the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ). T he diagnos is provides little in way of observable symptom criteria. Instead, it etiological model linking a s tres sor to s ymptom T his model is unique to adjus tment disorder, posttraumatic s tres s disorder (P T S D), and most other cases , the focus of the DS M-IV -T R is on symptom sets to es tablis h a diagnosis , not on linkages . T he linkage of an environmental stress or and symptom formation is cons is tent with paradigms used many clinicians, and this may account for some appeal 2541 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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this diagnos tic category. T he development of s ymptoms as a res ult of difficult events is widely considered part of the general human experience. F or this reas on, the diagnosis is often seen far les s s tigmatizing than other ps ychiatric disorders as symptoms develop in respons e to an event and are short-lived. T his idea was validated with a study of adoles cent and child psychiatrists through a s urvey the DS M-IV -T R work groups . F ifty-five percent of those who res ponded to the s urvey indicated that they us ed adjus tment disorder diagnosis to avoid stigmatization patients. F urthermore, the diagnos is is not viewed by medical ins urance carriers as a preexisting illnes s in same way that other diagnos es are. C linicians often diagnosis to protect patients for future applications for medical, life, and disability insurance. Des pite the clinical appeal of this category of adjus tment disorders have been seen as problematic number of reas ons . T he diagnostic criteria des cribe a syndrome in which a stres sful event leads to the development of a symptom complex. However, within diagnostic construct, there are no criteria to qualify the stress or for an adjus tment disorder in any way. the symptom complex that develops has been criticized lacking s pecificity. T he temporal course between the stress or and the development of s ymptoms lacks scientific evidence. F urthermore, it is difficult in clinical practice to link an event to the development of a complex. T hese is sues have raised questions with the diagnosis in general and have, no doubt, contributed to the lack of academic investigation. P erhaps the dilemma in considering this diagnos tic category 2542 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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the question as to why s ome individuals develop symptoms in response to a stress ful event, whereas do not. When clinicians us e this diagnosis to avoid or to attempt to link environmental experiences with symptom development, the potential for erroneous treatment decisions is quite real. One notable s tudy in area examined the concordance rate of diagnoses from medical house staff officers with later psychiatric cons ultations. In fact, 50 percent of inpatients with adjustment disorder by medical house staff were diagnosed with delirium by a ps ychiatric consultant. 

DE F INIT ION

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HIS T OR Y

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C omparative Nos ology

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E P IDE MIOLOG Y

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E T IOLOG Y

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DIAG NOS IS AND C LINIC AL F E AT UR E S

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DIF F E R E NT IAL DIAG NOS IS

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C OUR S E AND P R OG NOS IS

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T R E AT ME NT

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F UT UR E DIR E C T IONS

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S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > DE F INIT ION

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DE FINITION P art of "22 - Adjustment Dis orders " T he adjus tment disorders are a diagnostic category characterized by an emotional res ponse to a stress ful event. T ypically, the s tres sor involves financial is sues , medical illnes s, or a relationship problem. However, event may qualify by current diagnos tic criteria. T he symptom complex that develops may involve anxious depres sive affect or may present with a disturbance of conduct. T here is little specificity to qualify thes e symptoms other than an excess of what would be expected from the particular stress or or a s ignificant or occupational impairment. B y definition, the must begin within 3 months of the s tres sor and must within 6 months of removal of the stress or. If the complex is less than 6 months in duration, it is deemed acute. S ymptoms las ting beyond 6 months of the initial event are coded as a chronic adjus tment disorder. T he symptom complex must not qualify for another Axis I condition. A variety of s ubtypes of adjustment disorder identified in the DS M-IV -T R , varying on the particular predominant affective presentation. T hese include adjus tment disorder with depres sed mood, anxious mixed anxiety and depress ed mood, disturbance of conduct, mixed dis turbance of emotions and conduct, unspecified type. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > HIS T O R Y

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HIS TOR Y P art of "22 - Adjustment Dis orders " His torically, the DS M has held a place for a diagnostic category involving an acute ps ychological res ponse to environmental s tres sor. T he initial impetus for this through documentation of severe wartime s tres s s een World W ar II, as well as through the evolution of crisis intervention theory and practice. T he firs t edition of the DS M (DS M-I) in 1952 des cribed the category of s ituational pers onality dis order. W ithin this category the subtypes of gros s s tres s reaction, adult s ituational reaction, adjustment reaction of infancy, adjustment reaction of childhood, adjus tment reaction of and adjus tment reaction of late life. T he diagnosis was modified somewhat in the second edition of the DS M (DS M-II), which changed the to trans ie nt s ituational dis orde r. T his category was for “more or les s transient dis orders of any s everity (including those of psychotic proportions ) that occur in individuals without any apparent underlying mental disorders and that repres ent an acute reaction to overwhelming environmental stres s.” T he DS M-II similar P.2056 developmental s ubtypes to the DS M-I; however, the subtypes of gros s s tres s reaction and adult s ituational reaction were eliminated. T he s tipulation that this 2545 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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diagnosis not be us ed in the presence of another major ps ychiatric diagnosis was often ignored, with the of obscuring treatment recommendations. A large body literature also emerged ques tioning the use of this diagnosis in youth, which many argued was a time of inevitable turmoil and s ituational stress es . Anna F reud, example, stated that “upholding of a steady equilibrium during the adoles cent proces s is, in itself, abnormal.” C ritics als o pointed to the danger of using this adoles cence rather than noting more severe ps ychopathology, s uch as s chizophrenia or personality disorders . T he third edition of the DS M (DS M-III) introduced the diagnosis of adjus tme nt dis orde r. T he developmental periods of the earlier diagnostic s ys tems were Ins tead, the s ubtypes of adjus tment disorder were categorized based on the predominant affective experience. T hes e included adjus tment disorder with depres sed mood, anxious mood, mixed emotional features, disturbance of conduct, mixed disturbance of emotions and conduct, work inhibition, withdrawal, and atypical features . T he revis ed third edition of the DS M (DS M-III-R ) retained these diagnostic s ubtypes and an additional one involving physical complaints. T he III-R also specified that symptoms of an adjus tment disorder could not exceed 6 months . T he fourth edition of the DS M (DS M-IV ) modified the diagnosis of adjus tment dis order in s everal ways . T he subtypes of mixed emotional features , work inhibition, withdrawal, and phys ical complaints were eliminated. stress or was allowed to pers is t for an indefinite period time. A des criptor of chronicity was specified, whereby 2546 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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symptoms pers isting for longer than 6 months were deemed chronic. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > C omparative Nosology

C omparative Nos ology P art of "22 - Adjustment Dis orders "

DS M T he diagnosis of adjus tment disorder has been problematic on multiple levels and, at times , has been termed a was tebas ke t diagnos is . T he diagnos is that a s tres sor precede the development of a s ymptom complex. T he stress or criteria and the description of symptomatology are criticized in the literature. T he of the stres sor lacks s pecificity. T he time course to the development of s ymptoms is, in some s ens e, arbitrary has changed his torically. T he duration of the stress or is also highly variable from one clinical setting to the next. is extremely difficult in clinical practice to infer caus ality from the s tres sor to the development of s ymptoms . A clinician mus t then as sess whether an individual's symptoms are above and beyond what would be cons idered normal for that particular stress or. T he literature points to the potential subjective nature of this evaluation. Multiple authors have als o ques tioned the validity and reliability of the diagnosis and the overlap with other diagnostic categories. G iven the enduring nature of the diagnosis within the psychiatric diagnostic system, however, one mus t cons ider the function that 2547 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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entity s erves.

S tres s or C riteria T he DS M-IV -T R criteria for adjus tment disorder rely and foremost on the presence of a stress or. T he nature the stress or, however, is decidedly vague. T he DS Mstates only that the stress or is identifiable but makes mention as to what would qualify as a stress or. T his is contrast to other DS M-IV -T R diagnoses involving the presence of a stress or in which the nature of the event made more explicit. B ereavement, for example, death. P T S D requires a s tres sor involving a threat of a s erious injury to s elf or others , or a res ponse intens e fear, helples sness , or horror. F or an disorder, however, the only requirement is that a can be identified. T his leaves the clinician to determine whether any particular s tres sor could lead to the development of a stress res ponse. T he range in the and intens ity of stress ors is quite large, and one would reasonably believe that a divergent group of human experiences would lead to a s imilar ps ychological experience. S imilarly, the implication of the current criteria is that is an expectable reaction to a particular s tres sor. are left to determine what respons e might be to any identifiable event. A clinician can only have a subjective idea regarding an appropriate reaction to a given stress or. T his would s tem from the pers onal and culture of the individual examiner. F or example, a clinician whose wife died as a result of breas t cancer have quite a different idea of what an expectable ps ychological res ponse to the diagnosis is than a 2548 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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who has no pers onal experience with this particular disease entity. P erhaps most problematic is the notion of linear implied in the diagnosis of adjustment disorder. T he diagnosis implies a rather s implis tic model of cause effect. C ritics of this model, however, point to the complexity of interactions involved in the development a s ubjective experience. One author address es this eloquently when presenting different models of He ass erts that an event rarely involves mere linear caus ality. T he event can provide further feedback to elaboration of the original cause. More complex models caus ality mus t also be cons idered in the generation modification of symptoms . As a result of this complex interaction, an individual is frequently left with a set of symptoms and coping abilities that is different than the starting point.

Temporal C ours e DS M-IV -T R describes the onset of symptoms of disorder within 3 months of a s tres sor and the of symptoms within 6 months of the termination of the stress or. T here is some evidence to s upport the idea of symptom development closely following the time of the stress or. T wo s tudies have demonstrated the close temporal relations hip of stress or and s ymptom In one study of children with a new diagnos is of ins ulindependent diabetes, nearly one-third developed adjus tment disorders . T he highest risk period was in first month after diagnosis, and 31 of 33 children had developed s ymptoms within the firs t 3 months after the diagnosis of diabetes. In another s tudy of patients 2549 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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undergoing cardiac s urgery, patients developed symptoms immediately before surgery or within the firs t month after surgery. However, one could imagine that symptom formation in some individuals might come with considerable time T his idea is considered in the diagnosis of P T S D, be termed with de laye d ons e t, if symptoms pres ent 6 months or more from the time of the s tres sor. One anticipate that s uch a s imilar delay could occur for the stress of an adjustment dis order. T he literature the potential temporal variation in symptom formation from the onset of the s tres sor. One s tudy examined the timing and number of life events occurring in the year before the onset of emotional dis orders in school-aged children in an outpatient clinic. T hirty percent of cas es not develop s ymptoms until 6 months to 1 year after undes irable event. C hildren who experienced multiple negative life events were more likely to have les s time between stress or and s ymptom formation. T he diagnosis of adjus tment disorder s pecifies that the symptoms do not persist for more than 6 months once stress or—or its consequences —have terminated. It is extremely difficult for a clinician to gauge when a is no longer a stress or. In many cases , s tres sors this diagnos is do not go away. R ather, the meaning of stress or to the individual may change over time. Y et, it difficult to determine when a particular meaning changes for an P.2057 individual. T he literature supports the notion that emotional symptoms can linger for quite some time. 2550 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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study compared the long-term mental health effects in adults of two different community stress ors (the T hree Mile Island accident and wides pread unemployment to layoff). S ymptoms remained elevated for as long as months afterwards. In another study, 35 percent of and 66 percent of adolescents had enduring s ymptoms longer than 6 months from the time of the stress or. It is unclear, however, whether thes e data s how that an can lead to lingering res ponses or whether the event lingers and continues to impact an individual, therefore engendering ongoing emotional s ymptoms . T he DS M-IV -T R does make s ome allowance for this the designation of acute versus chronic adjustment disorders . T he des ignation of chronic is reserved for with symptoms lasting longer than 6 months in the context of ongoing s tres sors .

R eliability T he literature contains mixed information about the reliability of the adjus tment disorder construct. S tudies speak to the poor reliability of the diagnosis, given the vague diagnostic criteria. One study showed an agreement for adjus tment dis orders to be 0.05 (P = not significant) in a survey of ps ychiatris ts and us ing 27 child and adolescent cas e histories. T he the U.K . W orld Health Organization (W HO) s tudy of reliability of the ninth revision of the Inte rnational C las s ification of Dis e as e s (IC D-9) categories in adoles cents were consis tent with this. T he interrater reliability for adjus tment disorders was 0.23, lower than many other categories.

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Validity Des pite the poor reliability of the diagnosis , however, another body of literature des cribes the predictive and the discriminative us efulness of the diagnos is. T he predictive validity of the diagnos is of adjus tment was demons trated in a large study of adult inpatients . inves tigators s ought to determine whether patients with adjus tment disorder s hared a s imilar prognos is at 5 S eventy-nine percent of adults in the s tudy were well at year follow-up. T he diagnosis was not as predictive for adoles cents , with 57 percent well at 5 years. T he suggest that the good prognosis s hared by the adult cohort implies s pecific characteris tics of the group diagnosed with adjus tment disorder and that the diagnosis carries with it a prediction of recovery at 5 T his predictive validity, however, is not s hared by the cohort of children in the sample. F urther work has delineated other features that are to adjus tment dis order, when compared to major depres sion, s ugges ting des criptive validity. P atients diagnosed with adjus tment disorder had a lower of illness rating, a greater likelihood to improve in the hospital, a greater s everity of stress ors, better recent functioning, and more likelihood to be rated as at follow-up. A further s tudy found adjus tment disorder be a specific psychiatric dis order manifested mainly through depress ive s ymptoms as sociated with marital family problems . T he patients tended to display instability in the form of a pers onality disorder or interpersonal problems and tended to be in the age group. T heir problems were more rapidly s olved in the majority of specific ps ychiatric affective 2552 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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T his is consis tent with an earlier s tudy involving a 2,078 male Navy-enlis ted pers onnel diagnos ed with transient situational disturbance. T his proved to be a disabling diagnosis than any other ps ychiatric condition terms of chronicity, length of hospitalization, and ability return to a previous job.

C ultural P ers pec tives An interesting dis cus sion is pos ited regarding the us efulnes s of the adjus tment disorder diagnos is the lens of cultural anthropology. T his pers pective cons iders the evidence that most cultures have an named for a process whereby an individual is stress ed the point of s ymptom development. T his parallels the concept of a ne rvous bre akdown within a particular setting. In this s ens e, the adjus tment dis orders s hare features with other culture-bound syndromes , s uch as s us to, koro, and Arctic hysteria in that they all describe development of a set of s ymptoms after a particular stress or. T he particular cultural variety of adjustment disorder is affected by (1) the nature, intensity, and meaning of the stress or in ques tion; (2) the nature of modal pers onality configuration of the people which includes s tyle or rules, or both, about behavior emotional express ion; (3) idiosyncratic features of the in question; and (4) the meaning that adjustment has in the culture. T he individual is firs t treated within family and other social support networks . W hen this the event is inevitably medicalized in s ome fas hion. preservation of a diagnostic category of adjustment disorders in the DS M-IV -T R may point to this process . In W es tern cultures , clinicians often use the diagnos is 2553 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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adjus tment disorder as a means of communication to patients and third parties that the individual in ques tion res ponding to an outs ide event. T hird parties, including health and life insurance carriers, often look at this diagnosis as a nonrecurring phenomenon with a good outcome.

IC D-10 T he tenth edition of the IC D (IC D-10) als o contains a category of adjus tment dis orders . T he diagnos is is to the DS M-IV -T R entity in outlining the development of ps ychological symptoms following a s tres sor. However, IC D-10, the symptoms mus t appear within 1 month of stress or, instead of the 3-month temporal cours e of IV -T R . T he IC D-10 criteria share with DS M-IV -T R the requirement that s ymptoms mus t not persis t for longer than 6 months after the removal of the s tres sor. T he and DS M-IV -T R differ in their consideration of Whereas the DS M-IV -T R requires the s pecification of or chronic for all subtypes of adjus tment dis order, the 10 only refers to chronicity if the primary experience involved is a depress ed s tate. In this case, the prolonged depress ive reaction is used to des cribe symptoms las ting for as long as 2 years. T he IC D-10 states that symptoms of an adjustment disorder may be any of those found in the major neurotic, stres s-related, s omatoform, or conduct provided that the s ymptoms are not sufficient to qualify for the particular diagnos tic entity. It goes on to s pecify specific diagnostic s ubtypes of adjustment disorder on the nature, degree, and temporal course of involved. T hese subtypes track the DS M-IV -T R 2554 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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fairly well, in that they involve s ymptoms of depres sion, anxiety, and conduct. However, there are s ome is sues are unique to the s ubtypes of IC D-10. F or example, the IC D-10 subtype of adjus tment disorder with disturbance of other emotions is s omewhat s imilar to DS M-IV -T R category of mixed emotional features. However, this IC D-10 category is also us ed to code childhood regres sive reactions, including bedwetting thumb s ucking. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > E P IDE MIOLO G

E PIDE MIOL OGY P art of "22 - Adjustment Dis orders " F ew s tudies have examined the prevalence of disorder in community samples. One s tudy conducted two treatment sites sought to determine the frequency various Axis I diagnoses. Of 164 patients s een at a urban clinic, 88 percent met S tructured C linical for DS M-IV -T R (S C ID) criteria for an Axis I diagnos is , percent met criteria for two or more diagnoses. T here general concordance between clinical diagnoses and diagnoses from a S C ID. T he notable exception was in area of adjus tment dis orders . T he diagnos is of disorder far surpas sed any other diagnos is in the T he category of adjus tment disorders accounted for 54 P.2058 percent of all diagnoses made by a clinical interview. 2555 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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However, it accounted for les s than 4 percent of made by S C ID. A much larger s tudy of patients on entry to the Wes tern P sychiatric Institute clinical services involved a as sess ment of more than 11,000 individuals of all ages us ing a s emistructured ass es sment form and DS M-III criteria s heets. T en percent of the sample was found to have adjustment disorders , making it the second diagnostic category. In children and adolescents than 18 years of age, more than16 percent had disorders . In adults, the female to male ratio was approximately two to one. In children, there was only a slight preponderance of girls with the diagnosis. A further study examined the prevalence of adjus tment disorder among adults and children admitted to an inpatient psychiatric hos pital. T he particular hos pital served a predominantly middle-clas s white community approximately 900,000 individuals. Of the adults, 7.1 percent were admitted with an adjus tment disorder diagnosis, and 34.4 percent of the adolescents were admitted with an adjus tment disorder diagnos is . S tudies of patients in the medical setting point to the prevalence of adjustment disorders in the context of a medical illnes s. In a study of 107 patients with head neck cancers, 14 (12.1 percent) had a diagnosis of adjus tment disorder. In another s tudy of 55 women first recurrence of breas t cancer, 19 (35 percent) were diagnosed with adjus tment disorder. In a s tudy of 92 children diagnos ed with new-onset ins ulin-dependent diabetes mellitus , 33 (36 percent) of the children developed an adjustment disorder within 6 months of 2556 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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time of medical diagnosis . T he literature also dis cuss es the development of ps ychiatric s ymptoms after natural dis asters. In a multiple dis as ter s tudies us ing metaanalytical disas ter exposure was as sociated with a 17 percent increase in psychopathology. T his included s ymptoms depres sion, anxiety, s tres s, phobia, somatization, and drug us e, and global dis tres s. One prospective inves tigation coded victims ' res pons e to the 1993 floods in the United S tates . V ictims reported more depres sive symptoms after the events compared their counterparts who were not affected. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > E T IO LOG Y

E TIOL OGY P art of "22 - Adjustment Dis orders " C urrent knowledge regarding the relationship between stress ful life experience and the development of symptoms remains complex. Unres olved ques tions in the literature regarding the etiology of adjustment disorder. Many authors in the field of adjustment disorders the idea of linking a s ingle s tres sor with a s ymptom complex. T he model of a single s tres s exposure symptoms does not account for the complex array of symptoms that are s een in clinical practice. Although studies have as signed relative values to specific the methodology of s uch studies is controversial. Axis 2557 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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DS M-IV -T R , allowing a clinician to cons ider the a s tres sor in a multiaxial formulation, has been shown have poor reliability. As discus sed previous ly, if a does impact an individual, the model of linear caus ality less us efulnes s than other complex models of Another ques tion involves the interplay of temperament and environmental responsivenes s. C urrent ps ychoanalytic theory places tremendous importance the context in which an event occurs in cons idering the development of s ymptoms . T he lack of an attuned res ponse from others to s tres sors typically involved in adjus tment disorders may contribute to the disruption experienced. C urrent literature points to the importance of childhood experiences in the vulnerability to s ymptom formation res ponse to later life s tres s. E vidence from a variety of sources sugges ts that early experience with diminis hed control may foster a cognitive style characterized by an increased probability of interpreting or process ing subs equent events as out of one's control. T his may represent a ps ychological vulnerability to the development of anxiety. One s tudy examined 54 men experiencing an disorder as a res ult of conscription. S ubjects were adminis tered a S ymptom C hecklist 90 for a rating of ps ychological, behavioral, and s omatic complaints the last month. T hey were also given a self-report instrument that es timated the perception of parenting received in childhood during the first 16 years of life separate instrument that meas ured early separation anxiety. T he study concluded that abus ive and overprotective parenting received in childhood, as well 2558 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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early separation anxiety, were important factors for the development of adjus tment dis order in s oldiers. S tudies also demons trate that individuals with ongoing ps ychiatric s ymptomatology at the time of the stress or may be more prone to develop symptoms as a result of stress ful life event. In individuals after cardiac s urgery, prolonged adjustment dis order was correlated with preexisting mood s ymptomatology. In another study involving Is raeli children who suffered the loss of their fathers in war, preexisting conduct s ymptoms were correlated with poor adjustment. T he literature s uggests that the degree of exposure to stress ful life events may, to some extent, be influenced familial and genetic factors. T win studies have the degree to which thes e factors predispose one to expos ure to s tres s over the lifetime. One study of 2,000 twin pairs s howed a modest concordance for the likelihood of s tres s exposure. T his correlated more for monozygotic than dizygotic pairs . G enetic and factors each accounted for 20 percent of the variance stress exposure. A further s tudy demonstrated a role of genetics in the likelihood of developing P T S D after expos ure to traumatic events. T he s tudy s uggested symptom formation in res ponse to a stress may be some genetic control. T hes e s tudies point, to s ome to the role of temperament or biological predisposition the development of adjustment dis orders. T here is little in the literature regarding known changes in individuals with an adjus tment disorder. However, one important recent study examined neurochemical changes in individuals with an disorder after a suicide attempt. P latelet monoamine 2559 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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oxidase (MAO) activity was found to be significantly in patients compared to controls . Urinary 3-methoxy-4hydroxyphenylglycol (MHP G ) was higher in the patient group. P las ma levels of cortisol were s ignificantly the patient group as well. T he findings of higher urinary MHP G output and higher cortisol plas ma levels point to poss ible parallel activations of the noradrenergic and the hypothalamic-pituitary-adrenal axis at the time the attempt. T his is of particular interes t in a s uicide attempt in adjus tment disorders , which, by definition, stress -related conditions. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > DIAG NO S IS AND C LINIC AL

DIAGNOS IS AND C L INIC AL FE ATUR E S P art of "22 - Adjus tment Dis orders " P sychiatric taxonomy, for the mos t part, relies on the difficult task of ass ess ing qualitative and quantitative changes in behavior as principal illness criteria. T his difficulty is particularly apparent in the subthres hold disorders , such as adjustment dis orders. S ubthres hold disorders are often poorly defined and overlap with diagnostic categories. C riticis m of the adjus tment diagnosis has been around the inference and value judgment that may be required to make the diagnos is , well as problems with validity and reliability. B ecaus e diagnosis of adjus tment disorder is widely us ed in practice, it appears that iss ues of diagnostic rigor and 2560 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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clinical us efulness are at odds . A precipitating experience in the form of a s tres sful or life s ituation is the sine qua non for the diagnosis of adjus tment disorder. P.2059 It is characterized by the development of emotional or behavioral s ymptoms in the context of an identified ps ychos ocial s tres sor. T he symptoms vary widely in and s everity, and the pers on may not be aware of the stress or as being s ignificant. In contras t to other DS Mdisorders , the adjustment disorder criteria have no and s pecific s ymptom profile that defines the condition. T he premis e of an adjustment disorder is a res ponse to an identifiable s tres sor that results in the development of clinically s ignificant emotional or behavioral s ymptoms. T he implication is that, without precipitating event or situation, the adjus tment (or perhaps maladjus tment) res ponse might not have occurred. T he nature and severity of the s tres sor are specified. S uch a res ponse is viewed as pertinent if it occurs within 3 months of the ons et of an identifiable stress or. It is deemed clinically s ignificant if by marked distress in exces s of what would be given the nature of the stress or, or significant in social and occupational functioning. T he challenge the clinician, in these s ituations, is to differentiate a reasonable and expected res ponse to ps ychosocial stress ors from that which might indicate a diagnos is of adjus tment disorder. T he diagnos tic criteria for disorders define the contextual and temporal characteristics of a subthreshold respons e to a 2561 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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ps ychos ocial s tres sor; they do not apply if the s tres s related dis turbance meets the threshold for another specific Axis I diagnosis or is thought to be an of a preexisting Axis I or II disorder. Adjustment disorders may occur in any age group. studies have identified s chool problems as the most frequent precipitant in adoles cents , whereas marital problems are common in adults . S tres sors may be multiple, recurrent, or enduring events . As a result, temporal and caus al relations hips with s ymptoms are often uncertain. S everal studies have des cribed pres enting features of adjus tment disorders in clinical samples. In mos t depres sive s ymptoms have been most prominent. T wo studies from a mixed child and adult population depres sive mood in more than one-half of the study sample. Other s ymptoms noted in patients with adjus tment disorder were insomnia (53 percent), other vegetative s ymptoms and social withdrawal (29 and s uicidal indicators (29 percent). Depress ive s ymptoms appear to be characteris tic of adjus tment disorders in children and adults, although behavioral s ymptoms and mixed presentations are more frequently in children and adolescents. T hes e findings have been replicated in a number of s tudies following the University of Iowa study, which reported 87 percent of adults with adjus tment dis order had depres sive s ymptoms , compared to 63 percent of adoles cents . In contras t, 77 percent of adoles cents had behavioral s ymptoms, whereas 25 percent of adults C ommon symptoms of adjus tment disorders identified 2562 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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Wes tern P s ychiatric Ins titute s tudy included depres sed mood, low s elf-es teem, s uicidal behavior, increased activity, hypervigilance, impulsivity, and s ubstance us e. T hese symptoms may be ass ociated with other subthreshold mood and anxiety disorders that are not stress related, and it is unclear whether they are in the context of stress . In an attempt to better the symptom profile for adjustment disorders , two of youth who developed adjus tment disorders after the diagnosis of diabetes mellitus reported an average of symptoms: feeling sad, s uicidal ideation, pes simism, anhedonia, irritability or anger, and fatigue. S tudies of adjustment disorders using s tructured diagnostic instruments have reported high levels of comorbidity. In a mixed group of children and adults , approximately 70 percent of patients with adjus tment disorders had at leas t one additional Axis I diagnosis. However, comorbidity of adjus tment dis orders with Axis I dis orders was less than in dysthymic disorder or major depress ive disorder. T he degree of comorbidity be an important determinant of the level of impairment and ris k for poor outcomes in persons diagnos ed with adjus tment disorders . A recent study demons trates the potential efficacy of a screening instrument to identify patients with disorders . T his one-question instrument was applied to population of patients with a new diagnosis of cancer. study suggests that this brief screening ins trument is a valid tool to identify patients with potential adjus tment disorders and other diagnoses of depres sion. S everal studies have reported a s ignificant as sociation adjus tment disorders with suicidal ideation, particularly 2563 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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youth. In an urban hospital setting, 56 percent of all admis sions for suicidal behavior were clas sified as transient situational disorders using DS M-II criteria. age range was 15 to 24 years of age, with the majority cases being women. T hese findings underscore the s eriousnes s of disorders in a s ubs et of individuals ; s ubthres hold conditions may carry high morbidity, including the risk serious s elf-harm and death.

S ubtypes S ix subtypes of adjustment dis orders have been based on the predominant s ymptom presentation. IV -T R does not identify s pecific s ymptom profiles for of the subtypes; however, attempts have been made to more accurately des cribe them. Notable symptoms for individual adjustment disorder s ubtypes include the following: (1) in depress ed mood, depress ion, low self-es teem, and s uicidal indicators; (2) in anxiety, generalized anxiety, increased motor activity, and situational anxiety; (3) in disturbance of conduct, impulsivity, lack of ins ight, and violent behavior; and (4) mixed disturbance of emotions and conduct, exces sive alcohol ingestion, s uspicious ness , hos tility, defrauding behavior, and homicidal ideation. A recent publication s ugges ted a further potential of adjus tment dis order bas ed on a unique emotional res ponse to the s tres sor. T his concept, termed pos ttraumatic embitterme nt dis orde r, is characterized emotional res ponse of embitterment and feelings of injus tice after an exceptional, negative life event. T his be accompanied by thoughts of revenge and repeated 2564 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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intrus ive memories of the event. T he diagnosis of adjus tment disorders requires the cons ideration of the pers on's coping style, the details of the situation within which symptoms emerged, and s elfperception of the s tres sor's impact. T he clinician als o needs to appreciate the relations hip between the event and the onset, cours e, and expected outcome of symptoms. T he diagnos is of adjustment disorder less on well-circums cribed symptom clusters than the totality of the clinical picture as perceived by the T here are certainly patients for whom this category appropriate, for ins tance, high-functioning individuals experience mood or anxiety symptoms in res ponse to change of occupational status , loss of loved ones , and newly diagnos ed or ongoing medical conditions. In practice, however, the adjustment dis order category serves a nonclinical function and may not reflect the as sess ment of the clinician. A 48-year-old married woman, in good health, with no previous ps ychiatric difficulties , presented to the emergency room reporting that she had overdosed on handful of antihis tamines s hortly before s he arrived. described her problems as having started 2 months soon after her husband unexpectedly requested a S he felt betrayed after having devoted much of her 20year marriage to being a wife, mother, and S he was sad and tearful at times, and she occasionally difficulty s leeping. Otherwise, s he had no vegetative symptoms and enjoyed time with family and friends. felt desperate and suicidal after she realized that “he longer loved me.” After crisis intervention in the 2565 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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emergency s etting, she res ponded well to individual ps ychotherapy over a 3-month period. S he required benzodiazepines for anxiety during the period treatment. B y the time of discharge, s he had returned her bas eline function. S he came to terms with the poss ibility of life after divorce and was exploring her options under the circums tances . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > DIF F E R E NT IAL DIAG NO

DIFFE R E NTIAL DIAGNOS IS P art of "22 - Adjustment Dis orders " P.2060 A wide range of ps ychiatric disorders frequently occur the context of s tres sful life events. E tiological linkage of specific s tres sor to s ymptom formation, however, is a cons ideration only in the cas e of adjustment disorder, posttraumatic syndromes, and bereavement. T ypically, DS M-IV -T R phenomenological approach es tablis hes diagnostic thres hold us ing a combination of quality, quantity, and duration of s ymptoms . T he adjus tment disorder category is one of the few whose definition not include a specific profile of s ymptoms and signs . S ubsyndromal symptoms coupled with an identified ps ychos ocial s tres sor dis tinguis h adjustment dis order other Axis I disorders in DS M-IV -T R . T he adjus tment disorders have been des cribed by s ome authors as a transitional diagnos tic category, becaus e the level of 2566 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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symptomatology and impairment in adjus tment was found to be intermediate between a comparis on group of patients with a DS M-III problem-level and s pecific, above-threshold diagnos es . Other Axis I conditions are s tres s related but have an established diagnostic thres hold or have s ubthreshold symptoms are not neces sarily linked to s tres s. It is not clear that stress or criterion is specific enough to adequately discriminate between adjustment disorders and other subthreshold dis orders that are not linked to stress . R egardless of the s tres sor, a more specific Axis I as sumes precedence when appropriate criteria are satis fied. T he upper thres hold is thus established by criteria for the major s yndromes, whereas the lower threshold between adjus tment dis orders and other subthreshold dis orders is les s clear. T he presence of a stress or is a requirement in the of adjus tment dis order, P T S D, and acute stress P T S D and acute stress disorder have the nature of the stress or better characterized and are accompanied by defined cons tellation of affective and autonomic symptoms. In contrast, the stress or in adjus tment can be of any severity, with a wide range of poss ible symptoms. W hen the res pons e to an extreme stress or not meet the acute stress or pos ttraumatic dis order threshold, the adjustment disorder diagnos is would be appropriate. T he adjus tment disorder s ubtypes need to be distinguished from s ubthres hold types of the major mental disorders , the so-called not otherwis e s pecified (NOS ) categories . T he presence of an identifiable sets adjus tment dis orders apart from the NOS 2567 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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DS M-IV -T R . Interestingly, if the symptoms of disorder persist for more than 6 months after the or its consequences have resolved, the diagnos is have to change to the appropriate NOS category, if symptoms remain s ubthres hold, or a more s pecific Axis diagnosis. T he differentiation of adjustment dis order from a mood disorder due to a general medical condition is complex. Although the medical condition may be the obvious stress or, affective s ymptoms may aris e as a direct phys iological cons equence of some medical medical and other settings, care must be taken to distinguish between the reasonable and expected res ponse to ps ychosocial stress ors , which s ome have described as nonpathological reactions to stress , and inordinate res pons e that may suggest an adjus tment disorder. S ome authors have propos ed the concept of de moralization as a normal respons e to advers ity. Normative data on s tres sor respons e patterns are not available in any rigorous fashion; thus, inference and judgment continue to play a significant role in the diagnosis of adjus tment disorders . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > C O UR S E AND P R OG NO

C OUR S E AND PR OGNOS IS P art of "22 - Adjus tment Dis orders " His torically, adjustment disorder has been viewed as a transitional diagnostic category and, by definition, is not 2568 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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an enduring diagnosis. It is presumed that, without the occurrence of the stress or, the condition would not and that s ymptoms do not persist beyond 6 months the stress or or its cons equences have terminated. T he symptoms resolve or progress to a more s erious T he importance of age, pers onality type, social s upport systems , and comorbid conditions in modulating the cours e of adjustment disorders has been described by some authors . T here is s ome suggestion that persons unusually s evere s ymptoms may repres ent a previous ly compromis ed group. Attempts have been made by a number of investigators addres s the ques tion of whether an initial episode of adjus tment disorder predicts the s ubs equent development of more specific and severe pathology. Multiple studies have shown a fairly benign cours e for adults , with a lower likelihood of recovery in 5-year follow-up study at the Univers ity of Iowa s howed recovery rate of 71 percent in adults vers us 44 percent adoles cents . An additional 8 percent of adults were follow-up but had intervening problems , compared to percent of the adoles cent group. Almost 70 percent of adoles cent group was ill during the 5-year follow-up period, whereas les s than 30 percent of the adult group experienced psychiatric dis orders in the s tudy period. Although most of the adults developed major disorder and alcohol abuse, the adoles cents developed wider range of major psychiatric disorders , including schizophrenia, bipolar dis order, antis ocial pers onality disorder, drug abus e, and major depres sive dis order. C hronicity of s ymptoms and behavioral s ymptoms were the bes t predictor of poor outcome. T he adjus tment 2569 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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disorder s ubtype alone did not predict the follow-up diagnosis. Another study that s urveyed all adolescents receiving mental health treatment in a geographical found that 52 percent of those originally diagnosed as having DS M-II trans ient situational dis order continued ps ychiatric treatment at 10-year follow-up. One s tudy that looked at the cours e and prognosis of depres sive disorders in children and adolescents that adjus tment disorder with depres sed mood was not characterized by an increas ed risk for major depress ive disorder. It was not determined whether some of the children later developed disorders other than thos e in mood spectrum. A related s tudy of children diagnosed with adjustment disorder found that this diagnos is did increase the ris k for poor outcome when compared to a control group without an adjustment disorder diagnos is, but the two groups matched for comorbidity. T hese findings s uggest that some of the ris k for poor outcome reported in children and adolescents might be related comorbidity with other dis orders. T ypically, the diagnos es of major depres sion, schizophrenia, bipolar disorder, and substance us e are as sociated with a significant s uicide risk. However, individuals with adjustment disorder may als o carry a significant risk of s uicide. A recent s tudy of 119 with adjustment disorder indicated that 60 percent had documented s uicide attempts in the past, and 96 had been s uicidal during their P.2061 admis sion to the hospital. F ifty percent had attempted suicide immediately before hospital admis sion. 2570 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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diagnoses of substance abuse and pers onality disorder contributed to the suicide risk profile. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > T R E AT ME N

TR E ATME NT P art of "22 - Adjustment Dis orders " T he adjus tment disorders may present with symptomatology acros s multiple s ymptom domains ; there is no single treatment intervention approach for heterogeneous clinical manifestation of the disorder. T here has been little systematic study of the treatment individuals with adjustment disorder and other subthreshold conditions . Nonetheles s, adjustment dis orders are common in clinical practice, and attention to this and other subthreshold conditions may potentially fores tall the development of more severe psychiatric morbidity. T he clinician is often faced with the question of whether there is s ufficient psychiatric morbidity to warrant treatment intervention. T he treatment of individuals adjus tment disorder requires the careful as sess ment of nature and severity of symptoms, with cons ideration of ris k factors ass ociated with poor outcome, such as premorbid functioning and persistent s tres sors . It is es sential to understand the meaning of the s tres sor to patient and why it is ass ociated with the pres enting symptoms. T he primary goals of treatment are the relief of 2571 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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and the achievement of a level of adaptive functioning that is comparable to or, in s ome s ituations, better than the level of premorbid functioning. It is important to unders tand and to facilitate thos e factors that mitigate pathological res ponse to s tres s, as well as the patient's level of vulnerability and capacity for adaptation. T reatment interventions s hould be designed to the impact of the stress ors on day-to-day function and mobilize adaptive s tres s -coping mechanisms. S pecific treatment interventions that may be individuals with adjustment disorder include supportive ps ychological approaches and cognitive-behavioral ps ychodynamic interventions. C oncrete guidance with res olution of stress ors is often helpful. S hort-term treatment may be adequate for many patients; more extended treatment may be appropriate in in which individual characteris tics predispose the to s tres s intolerance. Depending on the level of acuity exis ting supports, cris is intervention and case management may be necess ary on a s hort-term basis preclude rapid progres sion and perhaps to avoid hospitalization. Individual ps ychotherapy tends to be supportive in nature, rather than exploratory. It is important to help the patient better understand the meaning of the stress or and why it may have overwhelmed his or her coping mechanis ms . F amily, couples, and group therapies may have us efulness , depending on the pres enting circumstances. A recent publication sugges ts the validity of a new form of ps ychotherapy, mirror therapy, for the treatment of patients with adjus tment dis order with depres sed mood a result of myocardial infarction. 2572 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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T here are hardly any s ys tematic clinical trials efficacy of pharmacological interventions in individuals with adjustment disorders . T here is plenty of less evidence from cons ultation-liais on and clinical s ettings suggesting that it is reasonable to consider the us e of medications to treat specific symptoms with adjustment disorders . T ypically, thes e are antidepres sants and anxiolytics . S elective s erotonin reuptake inhibitors (S S R Is ) have been found to be treating s ome subthreshold depress ive s yndromes and may benefit certain subtypes of adjus tment dis orders . number of s urveys looking at prescribing practices office-based physicians since the 1980s show a increase in the prescription of antidepress ants . It however, be emphas ized that ps ychosocial strategies remain the mains tay of treatment, with pharmacological intervention being a complementary treatment E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > F UT UR E DIR E C T IO

FUTUR E DIR E C TIONS P art of "22 - Adjustment Dis orders " C reating an interactive model that takes into account stress and res iliency factors that are respons ive to individual and cultural differences remains challenging. Ques tions abound regarding the adjustment dis orders; instance, what is the relationship between adjus tment disorder and other s tres s -related dis orders, such as and acute stress dis order? S hould s tres s -related be grouped together in the DS M, as in IC D-10? Are 2573 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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subtypes of adjustment disorders more appropriately conceptualized as minor disorders of mood, anxiety, behavior? S ome authors have sugges ted that a better of the adjus tment dis orders might require a radical T he choice may be that the diagnosis of adjus tment disorder is not based on a definition that lends its elf to rigorous investigation and thus should be recons idered that its pragmatic us efulness , despite methodological problems , should be recognized as a reas on for further study, particularly from the epidemiological and therapeutic viewpoints . T he latter option would require continued efforts to improve the s pecificity and of the diagnos tic category. F urther res earch mus t be be directed toward optimal treatment approaches us ing systematic clinical trials and rigorous cost–benefit analyses . Ultimately, the usefulness of a diagnostic category is largely dependent on the s trength of its prognos tic and therapeutic implications. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > S UG G E S T E D C R OS S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "22 - Adjustment Dis orders " Anxiety disorders , including P T S D, are discus sed in 14, and mood disorders are discus sed in C hapter 13. S uicide is presented in S ection 29.1 and C hapter 45. S eparation and divorce are covered in S ection 30.5 on 2574 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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couples therapy, S ection 24.9 on stress , and C hapter relational problems. B ereavement is dis cuss ed in 28.5, and phys ical abus e and s exual abuse are S ection 28.6. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 22 - Adjus tment Dis orders > R E F E R E NC

R E FE R E NC E S Akizuki N, Akechi T , Nakanishi T , Y oshikawa E , M, Nakano T , Murakami Y , Uchitomi Y : a brief screening interview for adjus tment dis orders major depress ion in patients with cancer. C ancer. 2003;97:2605. *Andreasen NC , Hoenck P R : T he predictive value of adjus tment disorders : A follow-up study. Am J P s ychiatry. 1982;139:584. Andreas en NC , Wasek P : Adjustment dis orders in adoles cents and adults . Arch G e n P s ychiatry. 1980;37:1166. B onelli R M, B ugram R : Additional A-criterion for adjus tment disorders ? C an J P s ychiatry. C as ey P , Dowrick C , W ilins on G : Adjus tment F ault line in the ps ychiatric gloss ary. B r J P s ychiatry. 2001;179:479. C horpita B F , B arlow DH: T he development of T he role of control in the early environment. P s ychol B ull. 1998;124:3. 2575 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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*Despland J N, Monod L, F errero F : C linical adjus tment disorder in DS M-III-R and DS M-IV . P s ychiatry. 1995;36:454. F abrega H, Mezzich J : Adjustment disorder and ps ychiatric practice: C ultural and historical as pects . P s ychiatry. 1987;50:31. F abrega H, Mezzich J , Mezzich A, C offman C : validity of the DS M-III depress ions. J Ne rv Ment Dis . 1986;174:573. G inexi E M, W eighs K , S immens S , Hoyt DR : Natural disas ter and depres sion: A pros pective investigation reactions to the 1993 Midwest floods . Am J P s ychol. 2000;28:495. G iotakos O, K onstantakopoulos G : P arenting childhood and early separation anxiety in male cons cripts with adjustment dis order. Mil Med. 2002;167:28. G onzalez-J aimes E I, T urbull-P laza B : S election of ps ychotherapeutic treatment for adjus tment dis order with depress ive mood due to acute myocardial infarction. Arch Me d R e s . 2003;34:298. G reenberg W M, R osenfeld DN, Ortega E A: disorder as an admiss ion diagnos is . Am J 1995;152:459. J ones R , Y ates W R , Williams S , Zhou M, Hardman 2576 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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Outcome for adjus tment dis order with depress ed mood: C omparis on with other mood disorders . J Dis . 1999;55:55. P.2062 J udd LJ , R apaport MH, P aulus MP , B rown J L: S ubsyndromal symptomatic depres sion: A new disorder? J C lin P s ychiatry. 1994;55[S uppl]:18. K endler K S , Neale M, K es sler R , Heath A, E aves L: study of recent life events and difficulties. Arch G e n P s ychiatry. 1993;50:789. K im K J , C onger R D, E lder G H J r, Lorenz F O: influences between stress ful life events and internalizing and externalizing problems . C hild De v. 2003;74:127. K ovacs M, G ats onis C , P ollock M, P arrone P L: A controlled prospective s tudy of DS M-III adjustment disorder in childhood. Arch G e n P s ychiatry. K ovacs M, Ho V , P ollock MH: C riterion and validity of the diagnosis of adjus tment disorder: A prospective study of youths with new-onset insulindependent diabetes mellitus. Am J P s ychiatry. 1995;152:523. K ryzhanovskaya L, C anterbury R : S uicidal behavior patients with adjus tment dis orders . C ris is .

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K ugaya A, Akachi T , K ouyama T , Nakano T , Mikami Okamura H, Uchitomi Y : P revalence, predictive and s creening for psychological dis tres s in patients newly diagnos ed head and neck cancer. C ancer. 2000;88:2817. Lewins ohn P M, R ohde P , K lein D, S eeley J R : into adulthood. J Am Acad C hild Adole s c P s ychiatry. 1999;38:56. Linden M: P os ttraumatic embitterment disorder. P s ychothe r P s ychos om. 2003;72:195. Looney J G , G unders on E K : T ransient s ituational disturbances : C ourse and outcome. Am J 1978;135:660–663. Margolis R L: Nonpsychiatric hous e s taff frequently misdiagnos e ps ychiatric disorders in general inpatients . P s ychos omatics . 1994;35:485. Okamura H, Watanabe T , Narabayas hi M, Ando M, Adachi I, Akechi T , Uchitomi Y : distress following first recurrence of disease in with breast cancer: P revalence and ris k factors. C ancer R e s T re at. 2000;61:131. S hear MK , G reeno C , K ang J , Ludewig D, F rank E , HA, Hanekamp M: Diagnos is of nonpsychotic community clinics. Am J P s ychiatry. 2000;157:581. S lavney P R : Diagnosing demoralization in 2578 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/22.htm

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ps ychiatry. P s ychos omatics . 1999;40:325. S naith R P : T he concepts of mild depress ion. B r J P s ychiatry. 1987;150:387. *S nyder S , S train J , W olf D: Differentiating major depres sion from adjus tment dis order with depress ed mood in the medical setting. G e n Hos p P s ychiatry. 1990;12:159. S palletta G , T roisi A, S aracco M, C iani N, P asini A: S ymptom profile, Axis II comorbidity and s uicidal behavior in young males with DS M-III-R depres sive illness es. J Affect Dis ord. 1996;39;141. S tolorow R D, Atwood G E . C onte xts of B eing: T he Inte rs ubje ctive F oundations of P s ychological L ife . T he Analytic P ress ; 1992:54. *S train J J , Newcorn J , W olf D, F ulop G . Adjustment disorder. In: Hales R E , Y udofsky S C , T albott J A, Ame rican P s ychiatric P res s T e xtbook of P s ychiatry. Was hington, DC : American P sychiatric As sociation P res s; 1994. S train J J , S mith G C , Hammer J S , McK enzie DP , B lumenfield M, Muskin P , Newstadt G , W allack J , A, S chleifer S S : Adjustment disorder: A multis ite of its utilization and interventions in the liais on psychiatry s etting. G e n Hos p P s ychiatry. 1998;20;139.

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T ripodianakis J , Markianos M, S arantidis D, Neurochemical variables in subjects with adjustment disorder after s uicide attempts. E ur P s ychiatry. 2000;15:190. V an der K link J J , van Dijk F J : Dutch practice for managing adjus tment dis orders in occupational primary health care. S cand J W ork E nviron He alth. 2003;29:478. *Woolston J L: T heoretical considerations of the adjus tment disorders . J Am Acad C hild Adole s c P s ychiatry. 1988;27:280.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > 23 - P ers onality Disorde

23 Pers onality Dis orders Dragan M. S vrakic M.D., Ph.D. C . R obert C loninger M.D. P ers onality disorder is a common and chronic dis order. prevalence is estimated between 10 and 20 percent in general population, and its duration is express ed in decades. T his means that at least one in every five to individuals in the community has pers onality disorder. Als o, many instances of violent and nonviolent crime large percentage of the pris on population are with underlying pers onality disorder. T hes e individuals have chronic impairments in their ability to work and to love; tend to be les s educated, drug dependent, single, and unemployed; and tend to have marital difficulties . T hey consume a large portion of community s ervices, social welfare benefits , and public health resources . Approximately one-half of all ps ychiatric patients have personality disorder, which is frequently comorbid with Axis I conditions. P ersonality disorder is also a predis pos ing factor for other psychiatric disorders (e.g., subs tance use, suicide, affective dis orders , impuls edisorders , eating disorders , and anxiety dis orders) in it interferes with treatment outcomes of Axis I and increases personal incapacitation, morbidity, and mortality of thes e patients. 2581 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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P ers ons with pers onality disorder are frequently aggravating, de manding, or paras itic and are generally cons idered to have poor prognosis . Alternatively, they be seductive or dependent and may elicit inappropriate blurring of profess ional boundaries, such as s exual or the urge to res cue. T hese patients challenge the of the physician's theoretical knowledge, clinical s kills , even pers onal maturity. In general, practitioners with narcis sism, high energy, and high tolerance are optimal treating patients with personality dis order. Many patients in s omatic medicine and neurology have personality disorder comorbid with their phys ical P ers onality factors have been as sociated with ris k for coronary artery disease, angina pectoris, contraction of human immunodeficiency virus (HIV ), ps oriasis, ulcerative colitis , and many other so-called ps ychos omatic diseases. On the other hand, many with pers onality problems who seek medical help frequently have negative workups and no medical explanation for their complaints . During the last several decades there has been a increase in clinical and res earch interest in pers onality disorder. After the introduction of explicit diagnostic criteria and the multiaxial diagnos tic s ys tem in the third edition of the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-III) in 1980, personality dis order has diagnosed more frequently and more s ys tematically. DS M criteria have been revised and standardized in subs equent editions of the DS M—the revis ed third of the DS M (DS M-III-R ) (1987) and the fourth edition of DS M (DS M-IV ) (1994). In addition, in 2000, the revis ed fourth edition of the DS M (DS M-IV -T R ) was published. 2582 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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multiaxial diagnos tic s ys tem means that personality disorder and mental retardation are class ified on Axis whereas all other mental dis orders are clas sified on T he availability of thes e two axes facilitates the of pers onality disorders , as it ens ures that personality disorder is not diagnostically overlooked even when it cooccurs with a clinically more prominent Axis I T he increased clinical recognition of pers onality probably reflects its increas ed pres ence in the general population. At the turn of the 20th century, when F reud was pioneering his unders tanding of human neuros es and neurotic problems were the dominant ps ychopathology of eve ryday life . At the time, the ps ychological tas k people were facing was to find acceptable ways to express their as ocial impulses, predominantly aggres sion and s exuality. Obvious ly, behavior codes of present s ociety differ s ubs tantially the ethical cons ervativis m at the turn of the century. Aggress ion and sexuality have become much easier to expres s in an ethically more liberal s ociety. Instead of struggling with morality, people of the 1990s are faced with questions of identity, meaning, and choice. Nowadays , one frequently encounters patients who help but cannot precisely des cribe their problems , who more disappointed than anxious , who struggle with questions of purpose rather than guilt, who are rather than inhibited; who feel empty rather than sad, who manifes t a peculiar inability to learn from as they tend to repeat maladaptive behaviors over and over again. Another pos sible explanation for the increas ed interest personality dis order is its pos ition s omewhere in 2583 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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minor and major ps ychiatric problems (e.g., adjus tment disorder vs. schizophrenia), which makes it interes ting wide variety of experts and s chools , ranging from sociodynamic to purely biological. As noted previous ly, pers onality disorder underlies susceptibility to many other ps ychiatric and medical problems . Accordingly, diagnos is and treatment of any ps ychiatric patient, as well as patients with problems , and prevention planning in many medical syndromes are inadequate without a s ys tematic to ass es sing and clas sifying pers onality. F inally, the development of ps ychiatry as a whole has generated an increased interest in personality dis order. E very s cience in its initial stages has a tendency to its s ubject as clearly as poss ible. Once s ufficiently developed, it naturally begins to recognize various and transitional forms . It is now clear that pers onality disorder repres ents a more or less s evere variation of normal personality, which ps ychiatry, owing to its own development, has begun to recognize. 

B AS IC DE F INIT IONS AND T E R MINOLOG Y

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C ONC E P T UAL AND P S Y C HOME T R IC IS S UE S

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P E R S ONALIT Y DE V E LOP ME NT : S E LF -OR G ANIZING P S Y C HOB IOLOG IC AL

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P E R S ONALIT Y DIS OR DE R

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INDIV IDUAL P E R S ONALIT Y DIS OR DE R S

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C LINIC AL AND P S Y C HOME T R IC IS S UE S

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E T IOP AT HOG E NE S IS OF P E R S ONALIT Y 2584

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

T R E AT ME NT

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S UG G E S T E D C R OS S -R E F E R E NC E S

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > B AS IC DE F INIT IO NS AND

B AS IC DE FINITIONS AND TE R MINOLOGY P art of "23 - P ers onality Dis orders " T he terms pe rs onality, temperame nt, motivation, and ps yche are often used interchangeably. T his is misleading and unjustified. T hes e concepts are to dis tinguis h them with more clarity.

P ers onality P ers onality is complex and unique: on the one hand, people differ greatly from one another in multiple components of behavior, P.2064 and, on the other hand, each person express es only their many potential lifestyles. T he common of all existing definitions of pers onality is that they are functional, that is, they focus on ques tions related to motivation and mental adaptation of the organism. S pecifically, G ordon Allport defined pe rs onality as the “dynamic organization within the individual of those ps ychophys ical systems that determine his /her unique 2585 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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adjus tment to his/her environment.” Allport elaborated on this definition by explaining that expres sion “dynamic organization” emphasizes that personality is an organized s ys tem (unitas multiple x) cons tantly evolving and changing. T he s yntax “within individual” means that personality is what lies behind specific individual's acts. T he term “ps ychophys ical” that personality is neither exclus ively mental nor exclusively neural, but a combination of the two. T he “determine” indicates that personality traits are determining tendencies that guide express ive and adaptive behaviors. T he express ion “unique the environment” has functional and evolutionary significance pointing to personality as a mode of and, more generally, adaptation, which is unique to individual. It has been widely accepted that pers onality develops through the interaction of hereditary dis pos itions and environmental influences. W addington's notion of canalization (or epige netic lands cape ) has been include the reciprocal necess ity of genetic endowment and environmental s timulation in the development of behaviors . G enetic differences account for one-half of the variance in mos t normally distributed temperament traits . Of the remaining 50 percent of the variance, 30 to 35 percent is explained by nonshared environmental effects (i.e., experiences that are unique the individual), and 10 to 15 percent is explained by meas urement error and nontrait s core fluctuations . C ontrary to the common belief, environmental that are shared by siblings (such as having the s ame parents , living in the s ame neighborhood, and going to 2586 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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the same s chools ) have little or no influence on differences in personality. Of note, adoption studies suggest s omewhat lower heritability of approximately percent for pers onality traits . T his reflects nonadditive genetic variance (e.g., higher-order interaction among alleles at each locus or among loci), which is the s ame monozygotic twins but contributes little to the res emblance of first-degree relatives. F rom the s tructural standpoint, personality can be decompos ed into temperament, character, and psyche. R oughly speaking, temperament involves bas ic character involves rational concepts about s elf and interpersonal relations , and the ps yche involves self-awarenes s and intelligence. S elf-awarenes s and intelligence influence pers onality development subs tantially, s o meas ures of temperament and provide an incomplete understanding of personality development. B as ic functions of personality are to feel, think, and to perceive, and to incorporate these into purpos eful behaviors .

Temperament T e mpe rame nt refers to the body's biases in the of conditioned behavioral responses to prescriptive phys ical s timuli. B ehavioral conditioning (that is , procedural learning) involves presemantic sensations elicit basic emotions , s uch as fear or anger, cons cious recognition, descriptive obs ervation, or reasoning. P ioneering work by Alexander T homas S tella C hess conceptualized temperament as the component (how) of behavior, as differentiated from motivation (why) and content (what) of behavior. 2587 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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concepts of temperament, however, emphas ize its emotional, motivational, and adaptive as pects . four major temperament traits have been identified: avoidance, novelty seeking, reward dependence, and persis tence. It is remarkable that this four-factor model temperament can, in retros pect, be s een as a modern interpretation of the ancient four temperaments : Individuals differ in the degree to which they are melancholic (harm avoidance), choleric (novelty sanguine (reward dependence), and phlegmatic (persis tence). However, the four temperaments are unders tood to be genetically independent dimensions that occur in all factorial combinations, rather than mutually exclus ive categories .

Ps yc hobiology of Temperament T emperament traits of harm avoidance , novelty re ward de pende nce , and pe rs is te nce are defined as heritable differences underlying one's automatic to danger, novelty, and various types of reward, res pectively. T hes e four temperament traits are closely as sociated with the four basic emotions of fear (harm avoidance), anger (novelty s eeking), attachment dependence), and ambition (pers is tence). Individual differences in temperament and bas ic modify the process ing of s ens ory information and early learning characteristics , es pecially as sociative conditioning of uncons cious behavior res ponses. T emperament is conceptualized as heritable bias es in emotionality and learning that underlie the acquis ition emotion-based, automatic behavioral traits and habits are obs ervable early in life and are relatively stable 2588 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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one's life s pan. E ach of the four major dimens ions is a normally quantitative trait, which is moderately heritable, observable early in childhood, relatively stable in time, moderately predictive of adoles cent and adult behavior. T he four dimensions have been shown to be homogeneous and independently inherited from one another in large, independent twin studies in the United S tates and Australia. T emperamental differences, are not stable initially, tend to stabilize during the and third year of life. Accordingly, ratings of these four temperament traits at 10 to 11 years of age were predictive of pers onality traits at 15, 18, and 27 years age in a large sample of S wedis h children. T he four dimensions have been repeatedly s hown to universal acros s different cultures , ethnic groups, and political s ys tems on every inhabited continent. In summary, these aspects of personality are called te mpe rame nt, because they are heritable, manifest life, are developmentally s table, and are cons is tent in different cultures . T able 23-1 s ummarizes contrasting of behaviors that distinguish extreme s corers on the dimensions of temperament. Note that each extreme of these dimens ions has specific adaptive advantages disadvantages, so neither high nor low s cores mean better adaptation.

Table 23-1 Des c riptors of Individuals Who S c ore High and Low on the Four Temperament Dimens ions 2589 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Des c riptors of E xtreme Variants

Temperament Dimens ion

High

Low

Harm avoidance

P es simis tic

Optimis tic

 

F earful

Daring

 

S hy

Outgoing

 

F atigable

E nergetic

Novelty s eeking

E xploratory

R es erved

 

Impulsive

Deliberate

 

E xtravagant

T hrifty

 

Irritable

S toical

R eward dependence

S entimental

Detached

 

Open

Aloof

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Warm

C old

 

Affectionate

Independent

P ers is tence

Indus trious

Lazy

 

Determined

S poiled

 

E nthus ias tic

Underachiever

 

P erfectionist

P ragmatist

T he component traits (facets ) for each of the four temperament dimens ion have distinct learning characteristics and correlate more strongly with one another than with other components of temperament. T hey s hare a common s ource of covariation that is and invariant regardless of changes in the environment and past experience. E ach of the four temperament dimensions has unique genetic determinants according family and twin s tudies, as well as studies of genetic as sociations with s pecific deoxyribonucleic acid (DNA) markers. T he four dimensions of human temperament clos ely to those obs erved in other mammals. Multiple levels in the phylogeny of learning abilities in animals invertebrates to man indicate that learning has multiple component proces ses that are hierarchically organized and interact extensively throughout development (F ig. 2591 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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1).

FIGUR E 23-1 A hierarchical model of learning. In F ig. 23-1, temperament corresponds to the sens ation, ass ociation, and motivation that underlie the integration of skills and habits based on emotion. F igure 23-1 is us eful to specify the hierarchical phylogenetic and ontogenetic organization of learning and its relevance to the concepts P.2065 of temperament and character, not to compare learning 2592 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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humans at a particular age to learning in lower animals. S pecifically, temperament and character are conceptualized on the bas is of two types of memory learning, which have been des cribed in humans and primates. T hese are called proce dural me mory (i.e., behavioral conditioning) and s e mantic me mory (i.e., term propos itional or declarative memory). (the emotional core of pers onality) involves procedural memory regulated by complex dis tributed circuits in the corticos triatolimbic s ys tem, primarily the sensory areas, the amygdala, and the caudate and putamen. P rocedural memory underlies ass ociative learning and involves presemantic perceptual proces sing of information and affective valence that can operate independently of abs tract conceptual or volitional proces ses. In contrast, semantic learning involves cognitive functions of abs traction and s ymbolization. T hese two s ys tems of learning and memory can be diss ociated functionally from one another and also from third memory system that is unique to human beings . Neurobiological s tudies of animals have been highly informative about the functional organization of brain systems underlying procedural learning and E xplicit animal models have been described based on extensive work in rodents and other nonprimates, providing hypotheses that are now being tested in humans P.2066 us ing modern techniques of brain imaging, neurochemis try, and neurogenetics. T he most comprehensive neurobiological model of learning in 2593 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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animals that has been s ys tematically related to the structure of human temperament is s ummarized in 23-2. T his model distinguishes four dis sociable brain systems for behavioral activation (novelty s eeking), behavioral inhibition (harm avoidance), social (reward dependence), and partial reinforcement (persis tence).

Table 23-2 Four Dis s oc iable B rain Influenc ing S timulus -R es pons e P Underlying Temperament B rain (R elated Pers onality Dimens ion)

Princ ipal R elevant Neuromodulators S timuli

B R

B ehavioral activation (novelty seeking)

Dopamine

Novelty

Ex pu

 

 

C S of reward

A ap

 

 

C S or UC S of relief of

Ac av

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monotony or punis hment  

 

 

Es

B ehavioral inhibition (harm avoidance)

γ-Aminobutyric acid

Aversive conditioning (pairing C S and UC S )

Fo of C

 

S erotonin (dorsal raphe)

C onditioned signals for punis hment, novelty, and frus trative nonreward

Pa av ex

S ocial attachment (reward dependence)

Norepinephrine

R eward conditioning (pairing C S and UC S )

Fo of ap C

 

S erotonin raphe)

 

 

P artial reinforcement (persis tence)

G lutamate

Intermittent

R to ex

 

S erotonin (dorsal

R einforcement  

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raphe)

C S , conditioned stimulus ; UC S , unconditioned s timulus . Adapted from C loninger C R : A s ys tematic method for cl description and class ification of personality variables. Ar P s ychiatry. 1987;44:573–588. T he ps ychobiology of harm avoidance, novelty reward dependence, and pers is tence is briefly the following s ections.

HA R M A VOIDA NC E Harm avoidance involves a heritable bias in the of behavior in respons e to signals of punis hment and frus trative nonreward. It is observed as fear of shyness , s ocial inhibition, pas sive avoidance of or danger, rapid fatigability, and pes simis tic worry in anticipation of problems even in situations that do not worry other people. Adaptive advantages of high harm avoidance are cautious nes s and careful planning when hazard is likely. T he dis advantages occur when hazard unlikely but still is anticipated, which leads to inhibition and anxiety. P eople low in harm avoidance carefree, courageous, energetic, outgoing, and even in s ituations that worry mos t people. T he of low harm avoidance are confidence in the face of danger and uncertainty, leading to optimistic and energetic efforts with little or no distress . T he 2596 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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disadvantages are related to unres pons iveness to or unrealis tic optimism, with potentially severe cons equences when hazard is likely. T he ps ychobiology of harm avoidance is complex. In animal s tudies , as cending s erotoninergic projections the dorsal raphe nuclei to the s ubs tantia nigra inhibit nigros triatal dopaminergic neurons and are ess ential conditioned inhibition of activity by s ignals of and frustrative nonreward. B enzodiazepines disinhibit pass ive avoidance conditioning by γ-aminobutyric acid (G AB A)–ergic inhibition of s erotoninergic neurons originating in the dors al raphe nuclei. T he anterior serotoninergic cells in the dorsal raphe nucleus intermingle with the dopaminergic cells of the ventral tegmental area, and both groups innervate the same structures (e.g., basal ganglia, accumbens, and providing opposing dopaminergic-serotoninergic influences in the modulation of approach and behavior. T he anterior s erotoninergic projections from dorsal raphe to s triatum, accumbens, amygdala, and frontal cortex are usually as sociated with serotonin (5-HT 2 ) receptors . Individuals who are high in harm avoidance and novelty seeking are expected to have frequent approach-avoidance conflicts, as seen in binging and purging in bulimia. More generally, behavioral inhibition (i.e., high harm avoidance) predis pos es individuals to anxiety, depres sion, and low self-es teem. E ffective antidepress ant treatment lowers scores in harm avoidance, but higher s cores in harm avoidance predict poorer respons es to including tricyclics and s elective s erotonin reuptake inhibitors (S S R Is). 2597 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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R ecent neuropsychological studies confirm that harm avoidance is as sociated with individual differences in clas sical aversive conditioning, whereas other of pers onality are uncorrelated (T able 23-3). Harm avoidance, not other dimens ions of temperament, is replicably ass ociated with potentiation of startle res ponses . Neurops ychological tests also confirm that harm avoidance is ass ociated with behavioral F or example, harm avoidance is as sociated with the validity effect (the P os ner tas k uses a detection time paradigm with dis crete presentation of simple stimuli in the periphery). C ues that correctly direct attention to the spatial location at which the target stimulus will appear are called valid cue s , whereas that direct attention to incorrect locations are called invalid cue s . In three large samples of healthy college students, those higher in harm avoidance have greater slowing of their reactions after invalid cues or les s from valid cues than others .

Table 23-3 R eported Ps yc hobiologic al C orrelates of Harm Avoidanc e Variable

E ffec t

Neuroanatomy (positron emiss ion tomography) 2598 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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   Medial prefrontal (left)

Increased activity (behavioral inhibition)

   Anterior (right)

Increased activity (s ens itivity to threat)

Neurops ychology

 

   Avers ive conditioning

G reater as sociative with punishment (r = .4)

   E ye-blink startle reflex

P otentiation of respons e avers ive stimulus (effect size = 1.9)

   P osner validity effect

G reater slowing of res ponses after invalid (r ≥.3)

   S patial delayed res ponse

B etter ability to delay res ponses after inges ting amphetamines (r = .5)

Neurochemistry

 

   P latelet s erotonin type 2 receptor

F ewer receptors (r = -.6)

   P las ma γaminobutyric acid

Lower level (r = -.5)

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Neurogenetics

 

   S erotonin transporter

G reater reuptake activity

R ecent functional magnetic resonance imaging (fMR I) studies found that healthy human volunteers who are in harm avoidance tend to have a greater volume of right anterior cingulate gyrus . T he correlation was 0.49 with the right, but not the left, anterior cingulate. individual differences in harm avoidance have been observed to be significantly negatively correlated with functional differences in activity in the medial prefrontal network at res t. T his includes significant negative correlations between regional blood flow and the score harm avoidance in paralimbic regions , s uch as the left parahippocampal gyrus and the left orbitoinsular and various neocortical regions in the frontal, parietal, temporal cortex. P os itron emis sion tomography (P E T ) the National Ins titute of Mental Health (NIMH) with 18 F deoxyglucose (F DG ) in 31 healthy adult volunteers a s imple continuous performance task s howed that avoidance was as sociated with P.2067 increased activity in the anterior paralimbic circuit, specifically the right amygdala and ins ula, the right 2600 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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orbitofrontal cortex, and the left medial prefrontal T his activation pattern corresponds well to the 5-HT 2 terminal projections of the dorsal raphe. However, 5has been measured only in platelets (T able 23-3). Higher plas ma G AB A levels have also been correlated low harm avoidance. P las ma G AB A has als o been correlated with other measures of anxiety proneness has been highly correlated with brain G AB A levels . a gene on chromosome 17q12 that regulates the expres sion of the serotonin trans porter has been found account for 4 to 9 percent of the total variance in harm avoidance in most, but not all, of the tests of this relations hip. T hese findings support a role for G AB A serotoninergic projections from the dors al raphe underlying individual differences in behavioral inhibition as meas ured by the trait of harm avoidance.

NOVE L TY S E E K ING Novelty s eeking reflects a heritable bias in the initiation activation of appetitive approach in response to approach to s ignals of reward, active avoidance of conditioned signals of punis hment, and escape from unconditioned punis hment (all of which are to covary as part of one heritable system of learning). Novelty s eeking is obs erved as exploratory activity in res ponse to novelty, impulsiveness , extravagance in approach to cues of reward, and active avoidance of frus tration. Individuals high in novelty s eeking are quick tempered, curious , easily bored, impulsive, and disorderly. Adaptive advantages of high novelty seeking are enthusiastic exploration of new and stimuli, potentially leading to originality, discoveries, 2601 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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reward. T he disadvantages are frequent and easy boredom, impulsivity, angry outburs ts , potential in relationships , and impress ionism in efforts. P ers ons in novelty s eeking are slow tempered, uninquiring, reflective, frugal, res erved, tolerant of monotony, and orderly. T heir reflectiveness , res ilience, systematic and meticulous approach are clearly advantageous these features are adaptively needed. T he reflect tolerance of monotony and lack of enthusiasm, potentially leading to prosaic routinization of activities. Mesolimbic and mesofrontal dopaminergic projections have been shown to have a crucial role in incentive activation of each aspect of novelty seeking in animals . example, dopamine-depleting les ions in the nucleus accumbens or the ventral tegmentum lead to neglect of novel environmental stimuli and reduce s pontaneous activity and inves tigative behavior. B ehavioral by dopaminergic agonists is dependent on integrity of nucleus accumbens but not the caudate nucleus . In human studies, individuals at ris k for P arkinson's have low premorbid scores in novelty s eeking but not other dimensions of pers onality, s upporting the importance of dopamine in incentive activation of pleas urable behavior. T he initiation and frequency of hyperactivity, binge eating, s exual hedonis m, drinking, smoking, and other s ubs tance abus e, es pecially are each ass ociated with high s cores in novelty T he ps ychobiological correlates reported for novelty seeking are s ummarized in T able 23-4. High s cores correlate with increased metabolic activity on P E T in cingulate cortex and left caudate. In addition, high seeking is ass ociated with decreased activity of the left 2602 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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medial prefrontal cortex, which is exactly the same as sociated with increased activity in individuals scoring high in harm avoidance. T his s uggests that medial prefrontal cortex may be an important site in the proces sing of approach-avoidance conflicts. In recent fMR I study found that high novelty seeking was correlated with increas ed volume of the left, but not the right, pos terior cingulate gyrus in healthy human volunteers .

Table 23-4 R eported Ps yc hobiologic al C orrelates of Novelty S eeking Variable

E ffec t

Neuroanatomy (positron emiss ion tomography)    Medial prefrontal (left)

Decreas ed activity (behavioral disinhibition)

   P osterior cingulate

Increased activity (behavioral activation)

   C audate (left)

Increased activity (behavioral activation)

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Neurops ychology    R eaction time

S lower to respond if not reinforced (neutral stimuli, = -.4)

   S timulus intens ity res ponses (N1/P 2 event-related potential)

Augmentation of intens ity of cortical to novel stimuli (r = .5)

   S edation

More easily sedated by diazepam (V alium) (lower threshold, r = -.3)

   R ey word list memory

Deterioration of verbal memory when excited (after inges ting amphetamine, r = .6)

Neurochemistry    Dopamine transporter

Higher dens ity obs erved striatum

   P latelet oxidase type B

Lower activity (as sociated with cigarette s moking)

Neurogenetics

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   Dopamine type 4 receptor

Ass ociation with exon 3 variant

   Dopamine transporter

G reater reuptake activity

E voked potential studies of stimulus intens ity confirm that novelty seeking is ass ociated with augmentation of s timulus intensity, particularly with stimuli. Novelty seekers are also sensitive to sedatives stimulants: T hey are eas ily overs edated by benzodiazepines and overs timulated by leading to deterioration in their information process ing. T heir reaction times are s low to neutral stimuli. T he as sociation of increas ed s triatal activity with high novelty s eeking is more s pecifically ass ociated with density of the dopamine transporter, P.2068 suggesting that novelty seeking involves increased reuptake of dopamine at presynaptic terminals , thereby requiring frequent s timulation to maintain optimal levels of pos tsynaptic dopaminergic s timulation. Novelty leads to various pleas ure-seeking behaviors, including cigarette smoking, which may explain the frequent observation of low platelet monoamine oxidas e type B (MAO B ) activity, because cigarette s moking has the 2605 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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of inhibiting MAO B activity in platelets and in brain. S tudies of candidate genes involved in dopamine neurotransmis sion (e.g., dopamine transporter and locus ) have provided evidence of as sociation with seeking and no other dimens ion of temperament. T he dopamine transporter, which is res ponsible for reuptake of dopamine and a major s ite of action of including s timulants like methylphenidate (R italin), is encoded by a gene locus on chromosome 5p. P olymorphisms at this gene locus are ass ociated with attention-deficit disorder and other dis orders related to variation in novelty seeking. Likewis e, polymorphisms the DR D4 locus have been as sociated with attentiondeficit disorder, opioid dependence, and other traits related to novelty seeking.

R E WA R D DE P E NDE NC E R eward dependence reflects a heritable bias in the maintenance of behavior in respons e to cues of s ocial reward. R eward dependence is characterized by sentimentality, social s ens itivity, attachment, and dependence on approval by others . Individuals high in reward dependence are tender hearted, s ens itive, dedicated, dependent, and sociable. One of the major adaptive advantages of high reward dependence is the sens itivity to social cues that facilitates affectionate relations and genuine care for others. T he related to s ugges tibility and loss of objectivity encountered with people who are excess ively socially dependent. Individuals low in reward dependence are practical, tough-minded, cold, s ocially insens itive, irresolute, and indifferent if alone. T he advantages of 2606 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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reward dependence are personal independence and objectivity that is not corrupted by efforts to pleas e Its adaptive dis advantage is related to s ocial detachment, and coldnes s in s ocial attitudes. Noradrenergic projections from the locus ceruleus and serotoninergic projections from the median raphe are propos ed to influence such reward conditioning (T able 2). In animals , s timulation of the noradrenergic locus ceruleus or its dorsal bundle or direct application of norepinephrine decreas es the firing rate of terminal neurons and increases their sensitivity to other so that targeted s timuli can s tand out from nontargeted stimuli. In humans , short-term reduction of norepinephrine release by acute infusion of the α2 presynaptic agonist clonidine (C atapres) s electively impairs paired-as sociate learning, particularly the acquisition of novel ass ociations . T he noradrenergic ceruleus is located at the same posterior level of the brains tem as the s erotoninergic median raphe, and these pos terior monoamine cells innervate structures are important to formation of paired as sociations, s uch the thalamus , neocortex, and hippocampus . Neurophysiological s tudies s how that the anterior temporal lobe decodes s ocial signals, such as facial and s ocial ges tures . C onsequently, individuals high in reward dependence are expected to be particularly sens itive in their s ocial communication, whereas those in reward dependence are expected to be socially T he ps ychobiological correlates reported about reward dependence are summarized in T able 23-5. As reward dependence is ass ociated with individual differences in formation of conditioned s ignals of 2607 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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T his is als o s upported by its as sociation with individual differences in paired as sociate learning.

Table 23-5 R eported Ps yc hobiologic al C orrelates of R eward Dependenc e Variable

E ffec t

Neuroanatomy (positron emiss ion tomography)    T halamus

Increased activity (facilitates sensory proces sing)

Neurops ychology    R eward conditioning

Increased as sociative pairing with rewards (r = .3)

   P aired as sociates

B etter learning of novel as sociations (r = .5)

   P osner validity effect

F as ter respons es after valid cues (r = -.4)

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Neurochemistry    Urinary 3-methoxyhydroxyphenylglycol

Less excretion of norepinephrine metabolite (r = -.4)

   P las ma cortisol

Higher morning cortisol when depres sed (r = .3)

   Urinary Harman

G reater excretion of indoleamine product in alcoholics high in dependence (r = .7)

Neurogenetics    S erotonin type 2C receptor

Allelic ass ociation size = 2)

High reward dependence is as sociated with increas ed activity in the thalamus , which is consis tent with about the importance of s erotoninergic projections to thalamus from the median raphe in modulation of communication. T his is further supported by the finding low levels of urinary 3-methoxy-4-hydroxyphenylglycol (MHP G ) with high reward dependence. High reward dependence is also as sociated with hypercortisolemia patients with melancholia but not in individuals who are not depres sed. 2609 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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P E R S IS TE NC E P ers is tence reflects a heritable bias in the maintenance behavior des pite frus tration, fatigue, and intermittent reinforcement. It is observed as industriousness , determination, ambitious nes s, and perfectionism. persis tent people are hard working, pers evering, and ambitious overachievers who tend to intens ify their in res pons e to anticipated reward and perceive and fatigue as a pers onal challenge. High persistence adaptive behavioral strategy when rewards are intermittent but contingencies remain stable. W hen the contingencies change rapidly, perseveration becomes maladaptive. Individuals low in persistence are inactive, unstable, and erratic; they tend to give up when faced with frustration, rarely strive for higher accomplis hments , and manifest a low level of perseverance even in res ponse to intermittent reward. Accordingly, low persistence is an adaptive s trategy reward contingencies change rapidly and may be maladaptive when rewards are infrequent but occur in long run. P ers is tence can be objectively meas ured by the partial reinforcement extinction effect in which pers is tent individuals are more res is tant to the extinction of previous ly intermittently rewarded behavior than other individuals who have been continuous ly reinforced. work in rodents s howed that the integrity of the partial reinforcement extinction effect depends on projections from the hippocampal subiculum to the nucleus accumbens. T his glutaminergic projection may be cons idered as a short circuit from the behavioral system to the behavioral activation system, thereby 2610 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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converting a conditioned s ignal of punis hment into a conditioned signal of anticipated reward. T his is probably dis rupted in humans by lesions of the orbitomedial cortex that may have a s pecific antipersistence effect of therapeutic benefit to some severely obs es sive-compuls ive patients. B ilateral cingulotomy, which reduces harm avoidance only, is effective in reducing persistent compuls ive behavior cingulotomy combined with orbitomedial lesions . P.2069 T hese findings in animals suggested that the regulation persis tence involved the ventral striatum, which the nucleus accumbens. T his has recently been tes ted humans and has been confirmed. Individual differences persis tence are s trongly correlated (r = .8) with meas ured by fMR I in a circuit involving the ventral striatum, orbitofrontal cortex and ros tral insula, and prefrontal and cingulate cortex (B rodmann's area [B A] S ubjects low in persis tence exhibited relative activity within this circuit, whereas those high in persis tence exhibited relative increases. P ersistence also correlated with apparent s election bias , such that subjects with high persistence scores made relatively pleas ant judgments at the expens e of neutral when viewing pictures from the International Affective P icture S ys tem (T able 23-6).

Table 23-6 R eported Ps yc hobiologic al C orrelates of Pers is tenc e 2611 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Variable

E ffec t

Neuroanatomy    Orbitomedial cortex

Dis connection reduces perseveration

Neurops ychology    G ambling style

P ers everation in bet s ize despite continuing loss es

   R ey word list learning

Learning without reinforcement (r = .5)

Neurochemistry    G lutaminergic connection

E ss ential for partial reinforcement extinction effecta

   S ubiculum to nucleus accumbens

 

Neurogenetics    S erotonin type 2C

Allelic ass ociation (effect 2612

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receptor

size = 2)

aP artial

reinforcement extinction effect is or increas ed res is tance to extinction after intermittent reinforcement.

Motivation S urvival and reproduction, the bas ic drives for all species , are expres sed in humans primarily through experiential derivatives, that is , affects and emotions. contrast to the limited motivational s pectrum of the drives , emotions have an independent motivational that makes them not only the primary motivational for many people, but als o the personality proces ses give meaning, at least to rational materialists, who up most of contemporary society. T emperament traits of harm avoidance, novelty reward dependence, and pers is tence, with their primary emotions of fear, anger, attachment, and ambition, are obs ervable early in development. in children has demons trated that, during the firs t months of life, fear and anger differentiate from the disposition to dis tress (a tendency to be become ups et autonomically arous ed eas ily and intensely). During period, which is characterized by active regres sive in the organization of neuronal circuits and density of synapses, especially in frontal, temporal, and limbic 2613 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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cortical areas , many other complex and s ocial human behavior emerge. T hes e new functions , are organized around an early s et of enduring and emotional dispositions referred to in this work as te mpe rame nt traits . A relatively limited s pectrum of emotions is as sociated with the four temperament traits (T able 23-7). Depending on whether a particular temperament trait is high or low, certain emotions tend dominate one's motivation, perception, and behavior.

Table 23-7 E ffec ts of Pos itive (+) an (-) R einforc ement on E motional S ta Temperaments  

Low S

High S c orers

Temperament Dimens ion +

-

Harm avoidance

Anxious (agitated)

Depress ed C heerful (retarded)

Novelty seeking

E uphoric

Angry

P lacid

R eward

S ympathetic

Dis gus ted

Aloof

+

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dependence P ers is tence

E nthus ias tic

S teadfas t

Uns table

As can be inferred from T able 23-7, the s ame external stimulus is likely to elicit responses via activation of multiple temperament dimens ions. F or example, novel unfamiliar s timuli elicit interes t in approach in to novelty s eeking, as well as inhibition of approach in proportion to harm avoidance. E ach temperament trait clearly involves an integration of multiple emotional that may be conflicting (competitive) or facilitatory (s ynergis tic). S uch s hared environmental effects mean the genetic and phenotypic structure of personality cannot be as sumed to be the s ame. T emperament involves a relatively s mall s et of as sociated with one's basic needs , for example, safety called primary motives ). E xces sive fear and anger, as sociated with temperament, are motivationally monopolistic and take over the personality by altering perception, learning, and behavior in a biased way. However, under normal circumstances, after survival are met, the goals of normally developing pers onality change to include not only the integrity of the physical self, but als o the integrity of the mental s elf (e.g., selfes teem). Normal pers onality development also adapts 2615 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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numerous social goals (e.g., education, occupation, family) and a rich s pectrum of secondary (social) (s uch as shame, pride, empathy, and compas sion). s e condary, s ocial, or growth motives are closely related to character development. S pecifically, basic emotions of fear, anger, and excitement are into more complex s econdary emotions, such as carefulnes s, as sertiveness , and joy, through the with increasingly more complex internalized concepts as sociated with character. E ven though s ome bas ic character components develop early in life, s uch as and confidence, it is the completion of s elf-object differentiation (“me” vs . “not me”) between 18 months 3 years of age that sets the s tage for the development character traits and secondary emotions , such as T he secondary emotions take over as primary of further character development and maturation. Of they are not as monopolistic as the basic emotions and thus motivate development of more flexible and adaptable personality traits. As s hown in T able 23-8, of the three character traits is ass ociated with a typical pattern of s econdary emotions .

Table 23-8 E ffec ts of Pos itive (+) Negative (-) R einforc ement on S tate of Three C harac ters  

High S c orers

Low S c ore

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C harac ter Dimens ion

+

-

S elf-directed

Hopeful

R es ourceful V ain

S ham

C ooperative

Loving

F orgiving

S cornful

R eve

P eaceful

G reedy

Mise

T ranscendent J oyful

+

-

P.2070 In conclusion, abnormal (deviant, immature) motivation derives from two or three dominant, monopolistic elementary emotional needs as sociated with s urvival. contrast, mature motivation develops after bas ic needs met, and the person is freed to experience numerous secondary motives for growth in character and in selfawarenes s. T his explains the motivational inflexibility poverty of deviant personality and accounts for all the motivational diversity and flexibility of mature

C harac ter C haracte r refers to the mind, that is , the conceptual personality. It involves individual differences in s elfconcepts and object relations that reflect pers onal and values. In other words, character is what a person makes of hims elf or herself intentionally. C haracter is 2617 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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rational and volitional. W hereas temperament involves basic emotions , s uch as fear and anger, character secondary emotions , s uch as purpos eful moderation, empathy, patience, and, in even more mature hope, love, and faith. As a res ult, character can be described as mental self-government, which involves executive, legislative, and judicial functions . In the discuss ion that follows , the concept of character is outlined bas ed on the seven-factor psychobiological model of pers onality. T he ps ychodynamic concept of character, which has contributed many illuminating clinical and theoretical formulations on the subject, is discuss ed in s ome detail as well.

Ps yc hobiology of C harac ter C haracter (or the conce ptual core of personality) higher cognitive functions , which include abs traction, symbolic interpretation, and reasoning. T hese higher cognitive functions are instantiated in complex networks in the brain, which involve encoding of schemas by the hippocampus with long-term s torage semantic memories in neocortex. S uch symbolic functions interact with temperament through cognitive proces sing of emotionally ridden sensory percepts regulated by temperament. T his temperament– interaction leads to the development of mature, realistic internalized concepts about the self and the external world. T he executive, legislative, and judicial functions mental s elf-government can be meas ured as three character traits, which are called s e lf-dire cte dne s s , coope rativene s s , and s e lf-trans cende nce , respectively. character traits are adaptive, but their low ends are advantageous because of a limited s pectrum of 2618 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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circums tances in which immaturity, especially low selfdirectedness and cooperativeness , means better adaptation than maturity. S elf-directedness quantifies differences in the competence of individuals . A highly self-directed self-sufficient, res ponsible, reliable, resourceful, goal oriented, and s elf-accepted. T he most advantageous summary feature of s elf-directed individuals is that they are realis tic and effective, that is, they are able to adapt their behavior in accord with individually chos en, voluntary goals . Individuals low in s elf-directedness are blaming, helpless , irresponsible, unreliable, reactive, unable to define, to s et, and to pursue meaningful goals . S uch poor executive function, manifes t as behavior and lack of internal guidance, is rarely advantageous to the individual. C ooperativenes s quantifies differences in the functions of individuals . Highly cooperative people conceptualize themselves as integral parts of human society. S uch highly cooperative pers ons are des cribed empathetic, tolerant, compass ionate, s upportive, and principled. T hes e features are advantageous in and s ocial groups but not in individuals who mus t live solitary manner. P eople who are low in are s elf-absorbed, intolerant, critical, unhelpful, and opportunis tic. T hey primarily look out for and tend to be incons iderate of other people's rights or feelings. S elf-transcendence quantifies individual differences in judicial functions of people. S elf-transcendence reflects the extent to which people conceptualize themselves an integral part of the univers e as a whole. S elf2619 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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transcendent individuals are described as judicious, insightful, s piritual, unpretentious , and humble. T hes e traits are adaptively advantageous when people are confronted with suffering, illness , or death, which is inevitable with advancing age. T hey may appear disadvantageous in most modern s ocieties in which idealism, modesty, and a meditative search for might interfere with the acquisition of wealth and P eople low in s elf-transcendence tend to be pragmatic, objective, materialistic, controlling, and pretentious. individuals appear to fit in well in mos t W estern because of their rational objectivity and materialistic succes s. However, they cons is tently have difficulty accepting s uffering, failures , personal and material and death, which leads to lack of s erenity and problems , particularly with advancing age. C ontras ting sets of descriptors that dis tinguis h the three character are s ummarized in T able 23-9.

Table 23-9 Des c riptors of Individuals Who S c ore High and Low on the Three C harac ter Dimens ions  

C harac ter

Des c riptors of E xtreme Variants High

Low

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Dimens ion

S elf-directed

R es pons ible

B laming

 

P urposeful

G oalles s

 

R es ourceful

P as sive

 

S elf-accepting

Wishful

 

Dis ciplined

Undisciplined

C ooperative

T olerant

Intolerant

 

E mpathic

Ins ensitive

 

Helpful

S elfis h

 

C ompas sionate R evengeful

 

P rincipled

Opportunistic

S elftranscendent

J udicious

P ragmatic

 

Ins ightful

Objective

 

Acquiescent

S keptical

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S piritual

Materialistic

 

Idealistic

R elativis tic

As shown in T able 23-9, high and low s corers in each character dimens ion are dis tinguis hed by behavior that arise from differences in concepts that are each internally cons istent but not logically falsifiable. F or example, people low in s elf-transcendence live in the material world, s keptical of whatever they cannot prove objectively and us e practically. In contras t, for highly transcendent individuals, the meaning of life goes material things and includes intuitive awareness of beautiful, true, and good, to which materialis ts may be insensitive. E ach s et of beliefs appears to be internally cons istent to those who hold them, who also regard approach to life as realistic. F urthermore, s piritual cannot prove a materialis t is wrong (at leas t not to the satis faction of the materialis t!), or vice vers a, becaus e has different intuitions of reality on which they base concepts . C haracter matures in a s tepwise manner in incremental shifts from infancy through late adulthood. T he timing rate of trans itions between levels of maturity are functions of antecedent temperament configurations, systematic cultural bias es , and experiences unique to 2622 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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individual, which depend on individual differences in episodic memory or intuitive P.2071 self-awarenes s that enables human beings to past experiences . T he developing character traits (i.e., newly internalized concepts about one's s elf and the external world) optimize adaptation of temperament early emotionality) to the environment by reducing discrepancies between one's emotional needs and favoring s ocial press ures . In F ig. 23-1, character corresponds to the process es of logic, cons truction, and evaluation of abs tract s ymbols that are based on conceptual repres entation of information and that are well developed only in some mature humans . T hes e proces ses are related to functions (predominantly logic), legislative functions (predominantly cons truction), and judicial functions (predominantly evaluation). R ecent fMR I res earch in healthy human volunteers by Debra G usnard and Marc R aichle has demonstrated strong correlation between directedness and a cortical circuit involving the medial prefrontal cortex, which is known to regulate executive function. E arlier work has s hown that markers of neocortical process ing, s uch as the P 300 related potential and contingent negative variation, are correlated with measures of character but not with temperament. Namely, s elf-directedness , but not temperament traits , correlates moderately with the evoked potential P 300 (r = .4; P <.002). Likewis e, cooperativeness correlates with the contingent variation (this was particularly obvious for the empathy 2623 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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subs cale, r = .4). Individuals with P arkinson's disease in temperament from others (they are lower in novelty seeking premorbidly) but not in character. T hes e and empirical observations as sociate character, but not temperament, to higher cortical functions in the central nervous s ys tem (C NS ). B as ic differences between temperament and character presented in T able 23-10.

Table 23-10 K ey Differenc es between Temperament (As s oc iative or Proc edural Learning) and C harac ter (C onc eptual or S emantic Variable Properties

Temperament

C harac ter

Awareness level

Automatic

Intentional

Memory form

P ercepts

C oncepts

 

P rocedures

P ropositions

Learning principles

Ass ociative

C onceptual

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C onditioning

Ins ight

R ole of in mental activity

P as sive

Active

 

R eproductive

C ons tructive

K ey brain system

Limbic s ys tem

T emporal cortex

 

S triatum

Hippocampus

F orm of mental representation

S timulusres ponse sequences varying additively in strength

Interactive networks (conceptual schema) varying qualitatively in configuration

Ps yc hodynamic C onc ept of T he ps ychodynamic concept of character derives from concept of de fens e mechanis ms . T he latter are defined automatic, unconscious psychological process es and emotional) that protect against anxiety generated intraps ychic conflicts and external s tres sors . All mechanisms are grouped into three levels , for 2625 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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mature (sublimation, anticipation, humor, and altruism), neurotic (centered around suppres sion), and immature (centered around splitting). P sychodynamic concepts (Anna F reud, Otto F enichel) define mature character as res idues of previous mature defense mechanis ms have become s table behavior patterns . In other words , normal character reflects one's capacity to pos tpone immediate gratification and to process internal needs through sublimation, anticipation, altruis m, and humor. B ehaviors reflecting these particular defense corres pond to the des cription of s elf-directedness (es pecially sublimation), cooperativeness (es pecially altruis m), and self-transcendence (es pecially P sychodynamic theories have also recognized that the not only protects from, but also s hifts, organizes, and reacts to, internal impulses and external s timuli. T he pattern of thes e integrative functions and the ways in which one combines various functions to s atis fy external and internal pres sures als o cons titute Again, ego-strength corres ponds to the description of directedness . P s ychodynamic theories describe two of character disorders : neurotic character and neuros is . Neurotic character traits are postulated to from neurotic defenses (e.g., suppres sion, reaction formation, projection, repress ion, and undoing), which have dis sociated from their original conflict and have become inflexible, pervas ive, and ego-syntonic traits of everyday behavior. Anna F reud called this inflexibility armor plating of character. As extensions of previous conflicts between one's emotions and oppos ing social press ures , neurotic character traits protect a pers on being involved in s uch s ituations again. F or example, excess ive scrupulousness , a frequently observed 2626 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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trait of obsess ive pers onalities , is a re action formation agains t their usually s trong aggres sive impuls es . B y rigidly hyperscrupulous , obsess ive pers ons protect thems elves from cons cious experience of aggress ion from intrapsychic conflicts that would have been by s uch an experience. C haracter neuros is is obs erved when an inflexible character trait interferes with healthy parts of F or example, character neurosis is present when cleannes s (an ego-syntonic character trait obs erved obses sive individuals) frequently interferes with the to interact freely with others (generated by healthy of obs ess ive personality) and, ins tead of being as natural, is perceived as frustrating. Of note, neuros is has been included in the tenth edition of the Inte rnational S tatis tical C las s ification of Dis e as e s and Health P roble ms (IC D-10) but not in the DS M-IV -T R . Individual differences in the maturity of defense mechanisms (i.e., normal, neurotic, and immature) tend covary with the severity of ps ychopathology (i.e., normality, anxiety dis orders, and pers onality disorder, res pectively). P atients with personality dis order favor certain immature defense mechanisms, which, in turn, shape their behavior style and clinical presentation. favorite defenses are, for example, projection for personality dis order, acting out for antis ocial disorder, and fantas y for s chizoid personality dis order. Note, however, that in addition to these favorite personality dis orders also us e other immature contributing to their irrespons ibility and tendency to blame others, for example. R eflecting thes e and s imilar observations about the importance of defens e 2627 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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mechanisms for the overall unders tanding of deviant personality, the DS M-IV -T R clas sification now enables clinicians to class ify the use of a particular, dominant defens e mechanism on Axis II. T he ps ychodynamic and the ps ychobiological of character traits is similar. B oth concepts underscore adaptive function of character in the overall adaptation one's emotional needs to the environment. However, two concepts differ in other etiological and as pects of character. T he ps ychobiological model individual differences in character as quantitative on the three character traits . In contras t to this dimensional approach, the psychodynamic concept distinguishes categorically between character subtypes (e.g., neurotic character is further divided into anal, and phallic) and dis crete character dis orders (i.e., characters and character neurosis). T he model underlines the cons cious nature of character, whereas the psychodynamic concept unders tands character traits, with the poss ible exception of anticipation, as predominantly unconscious process es . Most importantly, the ps ychodynamic P.2072 concept does not provide guidelines for further etiopathogenetic studies of character. However, the ps ychodynamic concept is an important treatment tool and is us ed to reveal and to revise conceptual bias es inherent in immature defenses and deviant character traits.

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P s ychology is literally the study of the ps yche , but this is frequently misunders tood. P s yche refers to a cons ciousnes s, s elf-awarenes s, or s pirit. More meas urable s cientific terms, individual variability in the ps yche can be measured in terms of differences in a person's level of intuitive s elf-awarenes s. S elfunique to human beings, but humans do s how variation their level of self-awarenes s in ways that have a s trong influence on sus ceptibility to personality dis orders or capacity for wisdom and well-being. In F ig. 23-1, involves the unique human proces s of s ymbolic which is based on intuitive s elf-awarenes s, leading to human invention of art, s cience, and s pirituality. T he growth of self-awarenes s is crucial to the development full coherence of pers onality, which is manifest as creativity, well-being, and wis dom.

Ps yc hobiology of the Ps yc he Detailed studies of human learning and memory have distinguished procedural, s emantic, and epis odic As des cribed in relation to temperament, procedural memory underlies as sociative learning and involves presemantic perceptual process ing of information from the physical s ens es that can operate independently of abstract conceptual or volitional process es , or both. In contrast, intuitive learning is bas ed on immediate recognition from a s ingle epis ode of observation. One of memory based on immediate recognition is of facts, which has been called s e mantic me mory or te rm de clarative me mory, as discus sed in relation to registration of cognitive schema underlying personality traits. T he second type of recognition memory is awarenes s of one's own intentions in a s patiotemporal 2629 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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context, which has been called epis odic me mory. In words , epis odic memory involves s elf-awarenes s and of events in a context that gives pers onal meaning to whe n and whe re of life experiences . Initially, this type recognition memory was defined in terms of materials tas ks , s uch as intentions (i.e., one's self in a context). S ubs equently, the concept of epis odic has been refined and elaborated in terms of awarenes s one's s elf, the sense of s ubjective time, and a state of s elf-awarenes s of the continuity in one's past, present, and future, which is different from dreaming or imagination. E . T ulving now des cribes episodic self-awarenes s or autonoe tic cons cious nes s , which is cons istent with other des criptions of ordinary human awarenes s, as bas ed on immediate recognition by the intuitive senses. E pisodic memory is also called to distinguish it from factual knowledge that has no personal context in space and time. T ulving notes that there is no evidence that such intuitive self-awarenes s present in any animal s pecies except human beings. P rocedural, semantic, and episodic memory can be functionally diss ociated from one another. F or individuals with P arkins on's dis eas e characterized by striatal lesions exhibit deficits in procedural learning but not in semantic or epis odic memory. Individuals with an amnes tic s yndrome, characterized by lesions in the temporal lobe, have deficits in semantic learning of facts but not in procedural learning or episodic cons ciousnes s. Individuals with amnes tic syndrome an anterograde amnesia for new facts but may have no deficit in their immediate s ense of s elf-awarenes s. lesions in the human hippocampus lead to deficits in 2630 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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awarenes s (that is, epis odic cons cious nes s or the recognition of one's s elf in a s patiotemporal context). E pisodic memory is subs erved by a widely distributed network of cortical and subcortical brain regions that overlaps with, but als o extends beyond, the networks subs erving other memory systems . K ey regions in this network include the hippocampus , regions of the prefrontal cortex, and the anterior cingulate. E ss entially, the human epis odic memory system acts mirror that provides spontaneous self-awarenes s to humans, whereas other primates require provis ion of external mirror even to recognize thems elves . T his mirroring function depends on hemis pherical specialization in the encoding and retrieval of Left prefrontal cortex is more involved in encoding episodic memories and retrieval of semantic memories , whereas right prefrontal cortex is more involved in the retrieval of episodic memories . T he episodic retrieval is a s tate of consciousness (in which a pers on is recollecting or remembering their pas t) and involves strong activation of s ites in the right prefrontal cortex weaker activation of s ites in the left prefrontal cortex medial anterior cingulate. T he experimental evidence that human beings have an intuitive form of learning and memory as the basis for unique capacity for self-awarenes s is now strong, but significance has yet to be widely appreciated. C urrent evidence suggests that the hippocampus and other of the epis odic memory s ys tem, such as prefrontal are neces sary for encoding of epis odic memories but for the acquis ition of factual knowledge. T he proces ses all s ensory information available to a person 2631 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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about one's external and one's internal milieu. this pan-sens ory information is constantly updated, allowing the regis tration and recall of ongoing life experiences in a personal context that is unique to individual. T he hippocampus is als o known to maintain plasticity throughout life, including the ongoing generation of new neurons as it adapts to ongoing experience. In contrast, long-term declarative such as factual knowledge and s elf-reported character traits, are stored in brain networks that show greater stability and less plasticity than the hippocampus . also some evidence for development of new neurons during adult life in thos e regions of the prefrontal cortex with which the hippocampus is clos ely connected as of the epis odic memory s ys tem. Likewise, character traits are static concepts , which are abstractions from which the s patiotemporal context has been reduced to a factual s tatement by a fixed choice eliminates the intentional flexibility inherent in selfcons ciousnes s. E s sentially, s elf-aware consciousness living with many pos sible outcomes that can be influenced, whereas factual knowledge is dead or like a collaps ed quantum wave function. T hes e findings about s elf-aware consciousness s uggest a poss ible explanation of the importance of factors that are unique the individual in personality development and of the subs tantial resistance to change of character and cognitive s chema when cognitive-behavioral or ps ychodynamic s trategies are us ed. T he plas ticity of episodic memory s ys tem and its role in s elf-awarenes s suggest a crucial role for growth in self-awarenes s as a means of experiential transformation of pers onality. 2632 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Development and As s es s ment of the Ps yc he E pisodic memory is a recently evolved memory system that appears to be unique to human beings, jus t as components of the epis odic network, such as prefrontal cortex, are recent evolutionary developments. As for a recently evolved function, episodic memory later than procedural or s emantic learning. C hildren younger than 4 years of age do not yet have a mature episodic memory s ys tem, s o people generally have no direct recollection of their past before 4 years of age. In contrast, bas ic emotions are present at birth, and s elfobject differentiation occurs between 18 months and 3 years of age. C . R obert C loninger has obs erved five dis tinct levels of intuitive awarenes s in human beings. T here is a of levels of awareness P.2073 that can be meas ured in terms of what are s ometimes called the innate human ide as or intuitions about be ing human nature . As sess ment requires an empathic unders tanding of the way in which another pers on is cons cious of being, freedom of will, beauty, truth, and goodness , which provide markers of a hierarchy of awarenes s. T hes e five as pects of cons cious nes s intuitive awarenes s of the world. T he awarenes s of and intentions are only two of the empirically levels of awarenes s. F or example, some patients with severe pers onality disorders complain of emptines s , which is a fearful 2633 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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of is olation, s eparatenes s, annihilation, or lack of S uch patients lack a s table awarenes s of their being, they are s ometimes des cribed as having a borderline of pers onality organization. T his is characterized by difficulty in s ublimation, intolerance of dis tres s, of reality testing, and poor self-acceptance. T heir sens e of being (i.e., lack of s piritual fullness , identity, vitality) makes them so emotionally unstable and that they often mutilate themselves or attempt suicide. Approximately 1 percent of people are deficient in their intuitive sense of being and experience life with a borderline organization chronically. Another 1 percent people experience s uch disorganization and emptiness intermittently under stres s. In contrast, the vast majority people have a well-developed awarenes s of being all time. T his level of awareness involves memory of with a s table s ens e of being, that is , without fear of annihilation. T his level of awarenes s is bas ed on the recognition and memory of facts , or what has been called s e mantic me mory. S econd, other people us ually have a hopeful their being but feel that they are s laves to extrinsic influences and trapped in time like a hell or prison from which they have no means of es cape. In other words , people have a lack of flexibility in their actions or little freedom of will. T he lack of awareness of freedom of intention (i.e., will) also dis torts the s ens e of a free flow time. T he lack of cons ciousnes s of free will in time has been described as chrone s the s ia in patients who have brain les ions in their epis odic memory s ys tem. E ven in people with no brain lesions , the lack of awareness of will can be pervas ive. F or example, some people are 2634 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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fatalistic materialists and claim that freedom of will is illus ion or something in which they are lacking. T heir intuition contradicts that of humanis ts and dualis ts who feel that rational respons ibility and freedom of will are what give human beings their dignity. Approximately 10 percent of people experience lack of freedom and the urgency of time commitments to external influences chronically throughout their lives . T his corresponds to traditional definitions of personality dis order, which involve lack of freedom or flexibility in adaptive In contras t, most people have a stable intuitive s ens e their freedom and responsibility for their intentions . generally, this level of awarenes s involves a person's awarenes s of his or her intentions in a pers onal spatiotemporal context. T his is the s econd of T ulving's intuition-based types of memories, but it does not the levels of human awarenes s. T hird, s ome people have no aes thetic s ens ibility. T hat some human beings have no intuitive s ens e of what is lovely or beautiful. It has been observed that those who had attained each level always had awareness of the levels but not the higher levels of consciousness . F or example, those with an awarenes s of beauty also had awarenes s of being and freedom but not necess arily awarenes s of truth or goodnes s. In other words, these indicators of consciousness define a hierarchy of levels awarenes s. It is s hocking to recognize that s ome with pers onality disorders have no recollection at any in their lives of feeling a s ens e of wonder and for the beauty of any poem, painting, or nature s cenes ! to understand what that means for the quality of their lives . W hen such unaware individuals see a rainbow, 2635 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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do not feel that it is beautiful or wonderful! T hey just phys ical colors and s hapes with no cons cious of beauty. T he complete absence of any sense of love beauty is rarely acknowledged, occurring in only approximately 3 percent of individuals, but many more show little intens ity in their appreciation of beauty. though they know what opinions are fashionable, it has little or no impact on their ordinary awareness . with an uns table s ens e of beauty are consequently unstable in their capacity for love and emotional in relationships . Approximately one-half of marriages in the United S tates end in divorce, which is an objective indicator of ins tability in the s ens e of what is beautiful loved. In contras t, the s table intuitive s ens e of what is beautiful and loved is characteris tic of the other half of general population, who have s ometimes been as romantics . In particular, aes thetic sensitivity is a developed intuitive sense in romantic poets and such as R alph Waldo E merson and Henry T horeau, romantic mus icians, s uch as F ranz S chubert. F ourth, still other individuals have a sense of being, freedom, and beauty at least s ome times in their lives never have any intuition of absolute truth. T his is individuals who des cribe thems elves as pragmatis ts or objectivis ts. S uch individuals als o are us ually agnostic atheis ts , because they have no intuition of their participation in a unity of cons cious nes s, which gives to what F reud called oceanic fe e lings and, hence, to Approximately 10 percent of individuals in the United S tates are atheists or agnostics , which is cons is tent recent nationwide G allup polls . According to G allup (2000), approximately nine out of ten (86 percent) 2636 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Americans believe in G od, but the majority do not feel institutional religions are adequately ins piring and satis fying their s piritual needs . E ight percent of do not believe in G od but believe in a univers al spirit or higher power. Only 5 percent of people are atheists also deny belief in a universal s pirit or higher power. Individuals who have attained each level always have awarenes s of the lower levels , but not the higher cons ciousnes s. F or example, individuals with a s ens e emptines s were also lacking in awarenes s of freedom, beauty, truth, and goodnes s. T hos e with an awarenes s truth also had awareness of being, freedom, and but not neces sarily an awareness of goodnes s. Hence, awarenes s of truth is an intuitive sense that is welldeveloped in elevated levels of consciousness . T he intuitive sense of truth is prominent in many scientis ts , such as P ierre T eilhard de C hardin and C arl R ogers. It even more fully developed in highly s elf-aware sages , as G eorg W ilhelm F riedrich Hegel, Leonardo da V inci, Mahatma G andhi, who viewed their lives as truth. F ifth, s till other individuals may have had a sens e of freedom, beauty, and truth at times in their lives but never had any intuition (i.e., direct awarenes s) of the intrins ic goodness of all things despite the perversions corruption that exist in the world. Unfortunately, this group includes nearly all people at times when they wonder about the exis tence and nature of evil or seek retribution and revenge agains t other human beings threaten or attack them or perhaps only frustrate them. Deep awarenes s of the universal unity of being and cons ciousnes s is required to love one's enemies . T he 2637 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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intuitive sense of goodnes s is well-developed only T here is a partial awareness of it in individuals who are highly developed in all three character traits , including self-transcendence, s uch as the American transcendentalis ts, such as E mers on and T horeau. However, a well-developed awarenes s of goodness only rarely, in wis e people s uch as P lato and G andhi. P.2074

P ers onality: A n Integrated View R ecent reports about complex and fundamental underlying neurophys iology, development, and phenomenology of personality provide powerful guidelines for the formulation of a comprehensive ps ychobiological model of personality as the coherent organization of the human body, mind, and s pirit. T he model integrates earlier phenotypic obs ervations about behavior with contemporary concepts bas ed on neuroimaging, biology of behavior, genetics, advances , and nonlinear modeling of normal and personality development. P ers onality is conceptualized a complex adaptive system involving a interaction among temperament, character, and T he coherent maturation of pers onality requires of humans ' natural unity of being, which, in turn, on the interplay of the procedural, s emantic, and systems of learning and memory (F ig. 23-2).

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FIGUR E 23-2 T emperament configurations. T hrough the interaction of temperament and character, different as pects of internalized concepts of the self the external world modify the s ignificance and the of sensory percepts and affects regulated by and vice versa. In other words , temperament regulates what a person notices , and, in turn, character modifies meaning, so that the salience and s ignificance of all experience depend on a person's temperament and character. In turn, the development of character is derivative of individual differences in intuitive s elfawarenes s. E ss entially, pers onality development on the joint interactions among three s ys tems of and memory. T hes e are called proce dural, s e mantic, 2639 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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epis odic me mory and are related to temperament, character, and ps yche, res pectively. T he leas t plas ticity temperament (procedural memory), and the most plasticity is in the psyche (episodic memory), with character (long-term declarative or s emantic memory) intermediate to the other two in its malleability. C ons equently, treatment efficacy depends s ubs tantially whether treatment is focused on temperament, or psyche. Medications and behavioral conditioning temperament, which us ually changes little beyond specifically conditioned s ituations. C ognitive and ps ychodynamic approaches s eldom eliminate or maladaptive cognitive schemas (i.e., trans form but may improve the management of conflicts by of prolonged treatment of more than 1 year. Only treatment focused on intuitive awareness is likely to to actual cure of pers onality disorder by transformation the level of intuitive awareness , and the evidence in support of this s uggestion in this chapter remains anecdotal. T hroughout this chapter, s pecific aspects of model are dis cuss ed in more detail. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > C O NC E P T UAL AND

C ONC E PTUAL AND PS YC HOME TR IC IS S UE S P art of "23 - P ers onality Dis orders "

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S ituation Debate P ers onality traits are neurops ychic structures with the capacity to render many s timuli functionally equivalent and to initiate and to guide equivalent (cons is tent) of adaptive and express ive behavior (Allport). the DS M-IV -T R defines pe rs onality traits as “enduring patterns of perceiving, relating to, and thinking about oneself and the environment,” that is , other people and the world as a whole. T he major value of pers onality therefore, lies in their us efulnes s in identifying regularities in an individual's behavior. T he stability of pers onality traits in time and acros s situations has been the central is sue in pers onality for decades, as it bears direct relevance to the whether internal dis pos itions or external s ituations determine behavior. T he pe rs on-ve rs us -s ituation was initiated in the early 1900s by two groups of (s ituationis ts vs. pe rs onologis ts ); the former viewed behavior as highly s ituationally s pecific, the latter behavior as centrally organized and purpos ive. As by E ps tein and O'B rien, the dilemma remained for decades , because it was not realized that behavior be situationally s pecific at the item level and cross situationally general at the aggregate level. S ingle behavior have limited reliability and generality. T hey be aggregated over s ituations and occas ions to reveal broad and s table traits , which allow accurate behavior tendencies (without having to s pecify the eliciting s ituations) but less accurate predictions of behavioral acts . On the other hand, global pers onality traits als o do not explain behavior completely, becaus e people do not 2641 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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exhibit unmodulated consistencies in behavior across and s ituations (complete invariance in behavior is as sociated more with psychopathology than with normality). B iogenetic factors influence how an adapts to experience, and the latter modifies adaptive tendencies. Hence, personality traits are not expected be fixed. T his current P.2075 unders tanding of traits differs from the cons ervative the 1980s . T he emerging cons ens us is an interactionist position allowing room for situational (external) and dispositional (internal) determinants of behavior in a variety of complex combinations .

P henotypic and Developmental P ers onality Models T he major difficulty in relating obs erved variation in personality to its underlying biological process es is that the obs erved phenotypic structure differs from the underlying biogenetic s tructure, because learning and environmental factors also influence phenotypic Observed phenotypic traits do not explain behavior but thems elves require etiological explanation. F actor can determine only the minimal number of behavior traits not their underlying caus ative factors. Hence, the phe notypic trait pers onality mode ls , which us ually factor analytically derived (e.g., Heinz J . tridimens ional model and P aul T . C osta's and R obert McC rae's five-factor model), account for much of the observed phenotypic variance but may not corres pond the underlying biogenetic process es . In particular, 2642 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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neuroticism is a compos ite of high harm avoidance and low self-directedness . However, harm avoidance and directedness have unique genetic determinants and regulated by different brain circuits. F or example, s elfdirectedness , but not harm avoidance, is strongly correlated with activity in the medial prefrontal cortex in fMR I studies during executive tasks and with the P 300 evoked potential. In contras t, de ve lopmental trait pers onality mode ls take account the underlying biological dispositions to observable behaviors and individual differences in res ponses to experience during pers onality T he most recognized dimensional models are those of Henrik S jobring, Marvin Zuckerman, and C loninger. Des pite some limitations, S jobring's developmental in the late 1940s is a heuris tic attempt to take res earch beyond the level of phenotypic observations factor analysis. T he model defines three dimensions of latent variation predisposing to personality: validity (i.e., the degree of energy available in adaptation to experience), s olidity (the cons is tency of adaptation), s tability (referring to the maximum potential of a pers on develop s killful habits in adapting to routine). T hese genetic dispos itions were postulated to be independent from one another and from the factor of general intelligence (referred to as capacity) and also to define one's s usceptibility to behavior dis orders. P ers onality has often been described in terms of a sequence of qualitatively discrete developmental and s tructural types . However, the frequent occurrence heterotypic individuals with intermediate or mixed features calls into ques tion the basic as sumption that 2643 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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personality s tructures are limited to a finite number of types that are qualitatively discrete and homogeneous . Likewise, it is becoming increas ingly clear that there is only variation in the rate and direction of pers onality development as a whole, but also as ynchrony and inconsistency among its major components that are reorganized through time. T he following section more general nonlinear quantitative theory of development that does not make the res trictive as sumptions about a finite number of qualitatively structural types. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > P E R S ONALIT Y DE V E LO P M F UNDAME NT ALS O F A S E LF -OR G ANIZING P S Y C H OB IO LOG IC AL C O M

PE R S ONAL ITY DE VE L OPME NT: FUNDAME NTAL S OF A OR GANIZING PS YC HOB IOL OGIC AL C OMPL E X P art of "23 - P ers onality Dis orders " Dragan M. S vrakic and colleagues formulated a quantitative model of normal and deviant pers onality development as a complex dynamic system that is s elforganizing and partly molded by familial and 2644 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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influences. T he model allows for nonlinear interactions among etiologically distinct components of pers onality. also accounts for the frequent, but not invariant, development of s tage-like periods of moderately stable personality configurations (s imilar to pers onality types ) punctuated by abrupt trans itions in which there are structural reorganization and emergence of new features. T he model is based on a s ophis ticated mathematical framework that can be implemented and tes ted with readily acces sible data. More recently, the developmental interactions among temperament, character, and ps yche have been able to be interpreted terms of interactions among procedural, semantic, and episodic systems of learning and memory. T he central ideas behind this model are the following: P ers onality is as a dynamic multidimensional comprised of more elementary operating (traits) that are organized in an interdependent way that is critical to carrying out a particular function. S uch a system is characterized by particular rules operation, for example, the principles of as sociative learning within the temperament function, long-term semantic learning within the character function, and episodic intuitive awarenes s within the ps yche function. T he satisfaction of s uch multiple res ults in nonlinear dynamics , which are of all systems involving growth and development in biology, neuroscience, ps ychology, and s ociology. S uch multidimensional dynamic systems are called complex adaptive s ys te ms . T he correlations observed among multiple 2645 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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traits can be us ed to explain the s pontaneous organization of s table multidimensional configurations (i.e., pers onality types ); these types develop in a stage-like fashion with s ucces sive of prolonged s tability punctuated by rapid However, the progres sion of each individual is because differences in intuitive awarenes s result in subs tantial variability that is unique to each T he model accounts for functional interactions multiple types of influence, including genetic family environment, s ociocultural norms, and experiences that are unique to each individual. B as ed on the s pecified basic differences between temperament and character (T able 23-10), plus variation in level of intuitive awarenes s, this model takes into account all as pects of information proces sing from ass ociative conditioning of habits skills to enculturation about goals and values within unique ps ychological context. P ers onality development is pres ented as a walk on an adaptive (or fitnes s) landscape with two or more hills (representing high adaptive values) s eparated by (representing low adaptive values ). F itnes s is defined ability to produce change in personality. In general, a complex system subjected to cons traints res ponds to these constraints by optimizing fitness , that is, by changes in personality. As change in personality is motivated by optimization of fitness , people most likely and most rapidly move in the direction of the greatest increase in adaptive value (i.e., the neares t hill). Once have reached the peak of the hill, they s tay there for a 2646 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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relatively long time, because they would first have to decrease fitness (i.e., descend into the valley) to find a with a higher peak (i.e., better adaptation). S uch development is called U s hape d. As noted, temperament and character traits are etiologically distinct but functionally related. S uch an interactive s ys tem has the property of being s elforganizing as a result of the collective dynamics among multiple components. In other words, the organism is spontaneously driven to find patterns of behavior that res ult in coherence of all information about the external and the internal milieu. F or example, harm avoidance interacts with novelty seeking and P.2076 reward dependence, inhibiting approach to novel and inhibiting s ocial attachments by increasing fear of unfamiliar and s ens itivity to social criticis m. cons istent negative correlations of harm avoidance novelty seeking and reward dependence have been In contras t, novelty seeking and reward dependence positively s ynergis tic, facilitating sociability and seeking social approval. S uch interactions influence the stability each of the eight pos sible multidimensional or profile s of temperament traits (F ig. 23-3), making more s table than others .

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FIGUR E 23-3 C haracter configurations. In the fitness lands cape, the valleys (or the adaptive minima) are unstable, because even s mall such as random events , drive the s ys tem away from points of the lowes t fitnes s. In contrast, hills (i.e., maxima) are s table, becaus e they act as attractors for lower points in the neighborhood. C onsequently, personality interactions tend to self-organize into such attractor s tate and to remain in that configuration in the absence of external press ure or maturational F or the understanding of the chronicity and treatment res is tance of personality dis orders , it is of critical importance to realize that a particular pers onality configuration may be highly s table, even though it may not be the mos t adaptive behavior poss ible for that 2648 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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individual. T his chapter is mainly concerned with patterns of of character traits as a function of relatively s table temperament traits and variation in the level of s elfawarenes s, as dis cus sed in the following s ections. T he three character traits interact to produce eight pos sible character configurations or profiles (F ig. 23-4).

FIGUR E 23-4 P ers onality: an integrated schema. Any change in these character configurations can be predicted from the initial temperament configuration, taking into account temperament–character and the effects of sociocultural norms , random events unique to the individual, social learning within the and genetic factors. However, whether there is change depends on s elf-awarenes s, which is unique to each 2649 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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individual and unpredictable, that is, underdetermined free. All these s ources of individual differences the likelihood for different s table character in the outcome. T he s ociocultural P.2077 norms can be additionally accounted for as the bias in development as sociated with demographic variables , s uch as s ubculture, gender, race, age, and occupation. T hes e norms and s ocial education in the family create environments that are supportive or oppres sive of s pecific character development. W ith all taken into account, it turns out that a single initial temperament configuration may lead to s everal stable character configurations ; this aspect of development is referred to as multifinality. T hes e are graphically repres ented in F igures 23-5, 23-6, and with four different initial temperament configurations their poss ible character outcomes .

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FIGUR E 23-5 Most probable character outcomes for adventurous antecedent temperament traits. C O, cooperativeness ; S D, s elf-directedness ; S T , s elftranscendence.

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FIGUR E 23-6 Most probable character outcomes for explosive (borderline) antecedent temperament traits . cooperativeness ; S D, s elf-directedness ; S T , s elftranscendence.

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FIGUR E 23-7 Most probable character outcomes for sens itive antecedent temperament traits. C O, cooperativeness ; S D, s elf-directedness ; S T , s elftranscendence. T hree dimensions of character (s elf-directedness , cooperativeness , and s elf-transcendence) are drawn three orthogonal axes, and each character represented by a point in this abstract s pace. E ight poss ible high–low combinations of three character dimensions are repres ented by the corners of the cube. 2653 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Observe that certain temperament types may and do ris e to several poss ible s table character outcomes , with a certain probability, a feature characteris tic of nonlinear systems . T he size of the bulging at a character configuration is proportional to the probability of that outcome. F igures 23-5, 23-6, 23-7 illus trate this adventurous (high novelty s eeking, low harm low reward dependence), explosive (high novelty high harm avoidance, low reward dependence), and sens itive (high novelty s eeking, high harm avoidance, reward dependence) temperament types. S imilar can be obtained for the remaining five temperament configurations. Individuals are born with one temperament profile with several poss ible character outcomes . T his multifinality reflects the fact that the lands cape in personality development has objective subjective components. F eelings and internalized concepts that are unique to the individual do influence evaluation of the objectively worthwhile goals and T he observed dis crepancies between the natural directions influenced by antecedent temperament traits and actually achieved character configurations point to the importance of external events, s uch as s ocial and random fluctuations in the final character outcome. As a res ult of the presence of points of high and low adaptive values in the fitnes s landscape, personality development is characterized by periods of relative stability alternating with more rapid trans itions to new adaptive levels . T he s ubs cale s tructure of the T emperament and C haracter Inventory (T C I) was formulated to s pecify character in terms of 15 steps of its development, as s hown in T able 23-11. 2654 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Table 23-11 S piral Movement of 15 S teps in Pers onality Development S teps

SD

CO

ST

T olerant vs. suspicious (trus tful vs. mistrustful)

—

TC I Tier 1    [1] C O1

—

   [2] S D1

R es pons ible — vs . blaming (res pectful vs . shameful)

—

   [3] S T1

—

—

Hopeful vs . demanding (moderate vs. indulgent)

—

—

TC I Tier 2    [4]

P urposeful

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S D2

vs . aimles s (nonviolent vs . aggres sive)

   [5] C O2

—

E mpathic vs . cruel (prudent vs . s cornful)

—

   [6] S T2

—

—

C ons cientious vs . unjust (fairnes s vs . defiant)

TC I Tier 3    [7] S D3

R es ourceful — vs . inept (benevolent vs .

—

   [8] C O3

—

G enerous vs . disagreeable (kind vs . hostile)

—

   [9] S T3

—

—

S piritual vs. materialistic (contemplative vs . greedy)

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TC I Tier 4 [10] S D4

S elfaccepting vs . vain (humble proud)

—

—

[11] C O4

—

— F orgiving vs . revengeful (compass ionate vs . callous )

[12] S T4

—

—

E nlightened vs . objective (patient vs. controlling)

TC I Tier 5 [13] S D5

C reative struggling (authentic vs .

—

—

[14] C O5

—

Integrity vs. unprincipled (well-being vs . unfulfilled)

—

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[15] S T5

—

—

C oherent vs . dualistic (virtuous vs . practical)

C O, cooperativeness ; S D, s elf-directedness ; S T , selftranscendence; T C I, T emperament and C haracter Inventory. T he 15 steps in character development are a ideal, corres ponding to the modal pathway that leads to full character development with high scores on all three character dimens ions, which is not optimal for Observe that success ive s teps in character form a s piral pattern, where each revolution around the spiral (presented as each of the five T C I tiers in T able introduces a new s et of developmental iss ues with the new s et of component facets of the three character traits. F urthermore, each revolution of the depends on different levels in a hierarchy of intuitive awarenes s. F or example, in early character during the firs t revolution around the s piral, a person encounters problems of trust versus mistrust, selfversus s hame, and moderation versus indulgence; are as sociated with s ocial acce ptance (first facet for cooperativeness ), re s pons ibility (first facet for selfdirectedness ), and s e lf-forgetfulne s s (first facet for s elftranscendence). T his depends s ubs tantially on a intuitive sense of being, whereas later developmental 2658 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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depend on the intuitive s ens es of freedom, and s till developmental tasks depend on beauty, truth, and goodness . As can be inferred from T able 23-11, as move along the s piral, people s ucces sively face new developmental tasks as sociated with new component facets in self-directedness , cooperativeness , and s elftranscendence. T his spiral pattern of character development provides P.2078 P.2079 an opportunity to correct de ve lopmental flaws that were made at any of the previous s teps within the s ame trait. F or example, as character develops around the s piral reach a new step of cooperativenes s (e.g., one gets in line historically with iss ues of and res ponsibility (als o s teps of cooperativeness , but encountered during earlier revolutions ) (T able 23-11). alignment facilitates retros pective revis ions of errors at these earlier developmental levels. T he poss ibility of re tros pe ctive he aling of old character errors is planning the psychotherapy of patients with pers onality disorders . Namely, when addres sing problems related certain developmental s tep, these patients are more susceptible to changes related to previous s teps within same character traits. T his 15-step developmental sequence is consistent prior qualitative des criptions of developmental stages J ean P iaget, F reud, and E rik E rikson (T able 23-12) but allows for the actual nonlinearity in development that depends uniquely in each individual on intuitive 2659 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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awarenes s.

Table 23-12 C omparis on of Diffe Des c riptions of Pers onality Develo Temperament and C harac ter Inventory Developmental S tep

J ean Piaget

   [1] C O1—trus t in reality

S igmund Freud

E ri E ri

S ensorimotor (reflexive)

Oral

T ru

   [2] S D1—selfres pect

S ensorimotor (enactive)

Anal (negativistic)

Au

   [3] S T 1—hope

S elf–object differentiation

E arly phallic

—

   [4] S D2— purpos efulnes s

Intuitive

Late phallic (exploratory)

Init

   [5] C O2— empathy

Operational (concrete)

Latency (conforming)

—

   [6] S T 2—

Operational

E arly genital

Ide

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cons cientious nes s (abstract)

(cons cientious work)

   [7] S D3— res ourcefulness

—

—

—

   [8] C O3— mutual helpfulness

—

Later genital (s ocial maturity)

Inti

   [9] S T 3— spirituality

—

—

—

[10] S D4—selfacceptance

—

—

—

[11] C O4— compass ion

—

—

Ge

[12] S T 4— patience

—

—

—

[13] S D5— authenticity

—

—

—

[14] C O5— integrity

—

—

Inte

[15] S T 5— coherence

—

—

—

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C O, cooperativeness ; S D, s elf-directedness ; S T , s elf-

C omputer simulations of the s elf-organized of character have been carried out beginning with initial temperament traits and taking into account all of previous ly mentioned contributing factors . T hese simulations found that children first increas e in selftranscendence (i.e., become imaginative and enjoy fantas y), then increas e in cooperativenes s (i.e., conforming and rule based), and only later increase in directedness (i.e., behavior becomes increas ingly selfreliant and autonomous). T his prediction is cons is tent the des cription of the stages of ego-development by Loevinger and her colleagues . T his early s equence not exclude the s ubs equent further development of character dimens ions in res ponse to demands of social roles with age or changes in self-awarenes s, or It is this subs equent development in res pons e to social pres sures that may explain adult selfand moral development, as des cribed by E rikson, Lawrence K ohlberg, and others . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > P E R S ONALIT Y DIS OR

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PE R S ONAL ITY DIS OR DE R P art of "23 - P ers onality Dis orders "

Normal vers us Deviant Normal pers onality is us ually defined (1) directly, us ing criteria of health ideals ; (2) indirectly, as the opposite to deviant personality; or, mos t frequently, (3) statis tically, behaviors that are most common in the given environment. T he dis tinction between normal and abnormal personality is inherently relative, as it relies arbitrary cut-off points on the continuum between two extremes (low and high) of any behavior. T his also context dependent, as the s ame behavior, in different situations, could be viewed as normal or maladaptive (e.g., invariant cautiousness , when danger unlikely, and the s ame trait, when danger is likely). However, relying s olely on the s ocial or s ituational to establish the diagnos is is problematic, becaus e personality dis order involves many noninterpers onal as well (e.g., narciss istic pers ons satis fy many aspects their grandios ity in fantas y). Here, pers onal deviance also does not reliably dis tinguis h between normal behavior and pers onality disorder (e.g., s ome are s ocially withdrawn without impairment in functioning or signs of personal suffering and distress ). other words, pers onal P.2080 and s ocial aspects are needed to fully account for the 2663 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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symptoms of personality dis order.

C las s ific ation of P ers onality T he leading clas sifications of personality dis order are Inte rnational C las s ification of Dis eas e s (IC D) of the Health Organization and the DS M of the American P sychiatric Ass ociation. T he clas sification of disorder in the ninth edition of the IC D relied on S chneider's book P s ychopathic P e rs onalities and his description of ten discrete socially deviant personality types . T he lates t edition of the IC D, IC D-10, publis hed 1987, corresponds more clos ely to the DS M system, however. Anglo-American concepts of personality originate in J ames P ritchard's des cription of moral which was later termed s ociopathy and which finally became antis ocial pers onality dis orde r in the second of the DS M (DS M-II) in 1968. However, other class ified personality dis orders in the DS M s ys tem can be traced the work of S chneider. T his chapter describes the T R clas sification of pers onality disorder. It is , however, descriptively s imilar to IC D-10, and, for practical much of the following section on DS M-IV -T R holds for 10 as well. A noteworthy exception is that IC D-10 schizotypal personality dis order on Axis I, among schizophrenic disorders , whereas DS M-IV -T R keeps disorder on Axis II, among personality disorders .

DS M-IV-TR C las s ific ation According to DS M-IV -T R , the critical criterion for distinguishing deviant pers onality traits is the pres ence (evidence) of long-term maladaptation and inflexibility that are manifested as s ubjective dis tres s or 2664 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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sociooccupational functional impairment, or both. DS MT R defines pe rs onality dis orde rs as An enduring pattern of inner experience and behavior deviates markedly from the expectations of the individual's culture. T he pattern is manifes ted in two (or more) of the following areas : cognition (i.e., ways of perceiving and interpreting other people, and events) affe ctivity (i.e., the range, intensity, lability and appropriatenes s of emotional res ponse) interpersonal functioning impulse control T he pattern is stable and of long duration and its onset be traced back at leas t to adoles cence or early It is inflexible and pervasive acros s a broad range of personal and s ocial situations and leads to clinically significant dis tres s or impairment in social, or other important areas of functioning. P ers onality disorder s ubtypes clas sified in DS M-IV -T R s chizotypal, s chizoid, and paranoid (C luster A); borderline , antis ocial, and his trionic (C luster B ); and obs e s s ive -compuls ive , de pe ndent, and avoidant In addition to thes e ten s tandard disorders , the DS Mclas sifies two disorders , pas s ive -aggres s ive and among crite ria s e ts and axe s provide d for furthe r s tudy Appendix B . T he DS M-IV -T R arranges categorical personality disorders into three clus ters , each sharing some clinical features : C luster A includes three with odd, aloof features , such as paranoid, schizoid, 2665 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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schizotypal. C luster B includes four disorders with dramatic, impulsive, and erratic features , s uch as borderline, antisocial, narciss is tic, and histrionic. includes three disorders sharing anxious and fearful features, s uch as avoidant, dependent, and obs es sivecompuls ive. S everal s tudies have s upported the validity of thes e clus ters , except that the s ymptoms for compuls ive disorder tend to form a separate, fourth clus ter. Note that the three dimensions underlying A, B , and C (i.e., detachment, impuls ivity, and corres pond clos ely to normal temperament traits (i.e., reward dependence, high novelty s eeking, and high avoidance, respectively), s uggesting that variation in temperament traits might be s ignificant in among the three clus ters of disorders . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > INDIV IDUAL P E R S ONAL IT Y

INDIVIDUAL PE R S ONAL ITY DIS OR DE R S P art of "23 - P ers onality Dis orders "

G eneral Diagnos tic G uidelines DS M-IV -T R introduces the following general guidelines the diagnosis of personality dis order. P.2081 Many of the features of various pers onality disorders may be s een during an epis ode of another mental 2666 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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disorder. T he diagnos is of personality disorder is made only made only when the features are typical of longfunctioning and are not limited to a dis crete epis ode of another mental disorder. Likewis e, when maladaptive behavior features are due to the direct ps ychological effects of a s ubs tance (e.g., various ps ychoactive subs tances , including medication) or a general medical condition, diagnosis of personality disorder is not warranted. J udgments about pers onality functioning mus t take into account one's ethnical, s ocial, and cultural background. P ers onality disorder s hould not be confus ed with acculturation after immigration or with the expres sion of customs and religious and political values that are characteristic of one's culture of origin. Diagnos is of s pecific pers onality disorder may be made children or adoles cents when observed maladaptive personality traits are pervas ive, persistent, and unlikely be limited to a particular developmental s tage or an episode of an Axis I dis order. T o diagnos e a disorder in an individual who is younger than 18 years age, the features mus t be pres ent for more than 1 year. T he only exception to this is antisocial personality which cannot be diagnosed in individuals who are younger than 18 years of age. C linical experience points to a potential s ex-bias in diagnosing personality dis orders. C ertain pers onality disorders are diagnos ed more frequently in men (e.g., antis ocial and schizoid), whereas some disorders are frequently diagnosed in women (e.g., borderline, histrionic, and dependent). E ven though it is likely that there exis t real gender differences in the prevalence of 2667 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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these dis orders, clinicians are cautioned not to certain personality dis orders in men and women of social s tereotypes about typical gender roles and behaviors . Observed maladaptive behavior traits must be that is , manifes t in a wide range of personal and s ocial contexts (i.e., at home, at work, and with family and friends ), not is olated as pects of the person's life. T he collection of data from collateral informants is thus cons idered critical to ensuring the high-quality as sess ment, diagnostic reliability, and validity. In addition to official diagnos tic criteria, DS M-IV -T R specifies a group of as s ociated features . T hes e not given in the form of explicit criteria (as their official counterparts) but rather as loos e descriptions of but fairly frequent, behaviors intended to help clinicians cases in which the diagnos is is not certain.

C lus ter A P ers onality Dis orders Paranoid Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of paranoid personality dis order are excess ive s uspicious ness and dis trus t of others as a pervasive tendency to interpret actions of others deliberately demeaning, malevolent, threatening, exploiting, or deceiving. Diagnostic features als o least four of the following: [black right-pointing arrowhead]Hypers ens itivity to and unforgivenes s of insults, slights, and rebuffs 2668 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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[black right-pointing arrowhead]Unwarranted tendency to ques tion the loyalty of friends or the fidelity of s pouse or sexual partners [black right-pointing arrowhead]R eluctance to in others because of unwarranted fear that the information will be us ed against them [black right-pointing arrowhead]P reoccupation with cons pirational explanations of and hidden or threatening meanings into benign events or remarks [black right-pointing arrowhead]Unwarranted tendency to perceive attacks on their character or reputation with angry reactions or counterattacks S ome of the as sociated features include [black right-pointing arrowhead]E xces sive need to self-sufficient and s trong sens e of autonomy [black right-pointing arrowhead]P ervas ive inability relax and to compromise [black right-pointing arrowhead]F requent involvement in legal disputes [black right-pointing arrowhead]F requently impress others as fanatics [black right-pointing arrowhead]T endency to form clos ed groups or cults cons is ting of people with beliefs [black right-pointing arrowhead]P eculiar ability to generate fear in others 2669 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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C OMP L IC A TIONS C omplications include brief reactive psychosis, in res ponse to s tres s.

C OMOR B IDITY T hese patients are at increas ed risk for major obses sive-compuls ive disorder (OC D), agoraphobia, subs tance abus e or dependence. T he mos t common cooccurring pers onality disorders are s chizotypal, narcis sistic, avoidant, and borderline. P aranoid personality dis order has been postulated to premorbid antecedent of delusional disorder, paranoid type.

IMP A IR ME NT Impairment is frequently only mild and typically occupational and s ocial difficulties.

S E X R A TIO According to DS M-IV -T R , this dis order is more diagnosed in men.

E P IDE MIOL OG Y P revalence rates of 0.5 to 2.5 percent in the general population, 10 to 30 percent for ps ychiatric inpatients , 2 to 10 percent for psychiatric outpatients are reported DS M-IV -T R .

F A MIL IA L P A TTE R N A ND G E NE TIC S S ome s tudies have demonstrated increased this personality dis order among relatives of probands 2670 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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chronic s chizophrenia and delus ional dis order, type.

DIF F E R E NTIA L DIA G NOS IS P aranoid personality dis order is dis tinguis hed from schizophrenia (es pecially paranoid type); delus ional disorder, paranoid type; and affective disorder with ps ychotic features bas ed on periods with positive ps ychotic s ymptoms, such as delusions and When a brief reactive psychosis with delus ions the clinical picture of paranoid personality disorder, this distinction is far more difficult. T he duration of the latter and its frequent ass ociation with s tress are us ually sufficient for differential diagnosis. P aranoid personality dis order is sometimes difficult to distinguish from the following pers onality disorders : [black right-pointing arrowhead]S chizotypal (which includes magical thinking, unusual perceptual experiences , oddities in s peech, appearance, and thought proces ses) [black right-pointing arrowhead]Obs ess ivecompuls ive, s chizoid, borderline, and histrionic (all with no prominent paranoid ideation) [black right-pointing arrowhead]Avoidant (which includes fear of embarrass ment) [black right-pointing arrowhead]Antisocial (which includes personal gains in antis ocial behavior) [black right-pointing arrowhead]Narcis sistic (which includes fear of having hidden imperfections and 2671 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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revealed)

S c hizoid Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of schizoid personality dis order are a pervas ive pattern of s ocial detachment and a restricted range of expres sed emotions in interpersonal settings beginning by early adulthood and present in a variety contexts , as indicated by four or more of the following: [black right-pointing arrowhead]Indifference to and criticis m [black right-pointing arrowhead]P reference for activities and fantasy (so-called loners ) [black right-pointing arrowhead]Lack of interest in sexual interactions P.2082 [black right-pointing arrowhead]Lack of des ire or pleas ure in clos e relations hips [black right-pointing arrowhead]E motional detachment, or flattened affectivity [black right-pointing arrowhead]No close friends or confidants other than family members [black right-pointing arrowhead]P leas ure in few, if any, activities S ome of the as sociated features include 2672 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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[black right-pointing arrowhead]Difficulty in expres sing anger, even in respons e to direct provocation, which contributes to the following features [black right-pointing arrowhead]Impress ion of flattened affect [black right-pointing arrowhead]P as sivity in adverse circums tances [black right-pointing arrowhead]S evere lack of skills

C OMP L IC A TIONS C omplications include very brief reactive ps ychos is , particularly in res ponse to s tres s.

C OMOR B IDITY T his pers onality disorder s ometimes appears as the premorbid antecedent of delusional disorder, schizophrenia, or, rarely, major depress ion. T he most common cooccurring personality dis orders are schizotypal, and avoidant.

IMP A IR ME NT Impairment includes frequently severe problems in relations . Occupational problems develop when interpersonal involvement is required; s olitary work sometimes favorably affects overall performance.

S E X R A TIO According to DS M-IV -T R , this dis order is more diagnosed in men and may caus e more impairment in 2673 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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them.

E P IDE MIOL OG Y P revalence rates varying from uncommon (DS M-IV 7.5 percent in the general population.

F A MIL IA L P A TTE R N A ND G E NE TIC S An increas ed prevalence among the relatives of with s chizophrenia or s chizotypal personality dis order been reported.

DIF F E R E NTIA L DIA G NOS IS S chizoid pers onality disorder is distinguis hed from schizophrenia, delus ional dis order, and affective with ps ychotic features bas ed on periods with positive ps ychotic symptoms , s uch as delus ions and in the latter. W hen a brief reactive ps ychos is the clinical picture of schizoid personality dis order, this distinction is far more difficult. T he duration of the latter and its frequent as sociation with stress are us ually sufficient for differential diagnosis. S chizoid pers onality disorder is distinguis hed from disorder and As perger's s yndrome by more s everely impaired social interactions and s tereotypical behaviors and interes ts in the latter two disorders . S chizoid is distinguished from the following pers onality [black right-pointing arrowhead]S chizotypal (which includes magical thinking, unusual perceptual experiences , oddities in s peech, appearance, and thought proces ses) [black right-pointing arrowhead]Avoidant (adequate 2674 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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emotionality in the latter, als o s ocial isolation due to the fear of embarras sment, not indifference) [black right-pointing arrowhead]Obs ess ivecompuls ive (adequate capacity for intimacy, sometimes exces sive isolation due to perfectionis m and workaholic attitudes) [black right-pointing arrowhead]P aranoid (which includes s uspicious ness , ideas of reference, and guarded facade)

S c hizotypal Pers onality Dis order C L INIC A L C R ITE R IA S chizotypal pers onality disorder is characterized by and interpersonal deficits as indicated by pervasive discomfort with reduced capacity for close well as cognitive and perceptual distortions and behavior (not s evere enough to meet criteria for schizophrenia). Diagnostic features als o include at five of the following: [black right-pointing arrowhead]Ideas of reference (not delus ions) [black right-pointing arrowhead]Odd beliefs and magical thinking (s uperstitiousness ; beliefs in clairvoyance; telepathy, als o known as s ixth s e ns e ; in children and adolescents, bizarre fantas ies or preoccupation) [black right-pointing arrowhead]Unusual perceptual disturbances (illus ions, including bodily illus ions 2675 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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sens ing a presence of a pers on nearby) [black right-pointing arrowhead]P aranoid ideation suspicious nes s [black right-pointing arrowhead]Odd, eccentric, peculiar behavior [black right-pointing arrowhead]Lack of close except family members [black right-pointing arrowhead]Odd thinking and speech without incoherence (e.g., vague, metaphorical, overelaborated, and s tereotypical) [black right-pointing arrowhead]Inappropriate or cons tricted affect [black right-pointing arrowhead]S ocial anxiety that does not diminis h with familiarity and that is as sociated with paranoid fears

P R E DIS P OS ING F A C TOR S E mpirical findings about this disorder are difficult to interpret, as there appear to be s everal clinical this dis order, with potentially differential relationships to the schizophrenic s pectrum. Adoption, family, and twin studies demons trate an increas ed prevalence of schizotypal features in the families of schizophrenic patients, especially when s chizotypal features were not as sociated with comorbid affective symptoms. S mall, anticipatory saccades that disrupt s mooth pursuit eye movement, hypothes ized to be a marker of genetic vulnerability to schizophrenia, have been also detected schizotypal and introverted personalities . T he nature of relations hip of this pers onality disorder and 2676 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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is still controvers ial, with some genetic s tudies not the relationship, and with s ome s tudies finding a of gradation in multifactorial liability from s chizotypal personality (mild), to broad schizophrenia (moderate), narrow schizophrenia (s evere).

C OMP L IC A TIONS C omplications include trans ient ps ychotic episodes, particularly in res ponse to s tres s. S ymptoms become s o s ignificant that they meet criteria for schizophreniform disorder, delusional dis order, and ps ychotic disorder.

C OMOR B IDITY More than one-half of these patients have had at leas t episode of major depress ion, and 30 to 50 percent major depress ion concurrent with this pers onality disorder. T he mos t common cooccurring personality disorders are s chizoid, paranoid, avoidant, and

IMP A IR ME NT Impairment typically includes occupational and social difficulties .

S E X R A TIO T he sex ratio is unknown; this disorder is frequently diagnosed in women with fragile X s yndrome.

E P IDE MIOL OG Y A prevalence rate of 3 percent in the general reported in DS M-IV -T R . E arlier reports sugges ted a between 2 and 6 percent. 2677 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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F A MIL IA L P A TTE R N A ND G E NE TIC S T here is an increased prevalence of this personality disorder among the first-degree relatives of probands schizophrenia. Also, there is an increased prevalence schizophrenia and other psychoses in the relatives of probands with s chizotypal personality dis order. T he disorder itself tends to aggregate in families (DS M-IV -

DIF F E R E NTIA L DIA G NOS IS S chizotypal pers onality disorder is distinguis hed from schizophrenia, delusional disorder, and affective with ps ychotic features based on periods with pos itive ps ychotic symptoms , s uch as delus ions and in the latter. W hen a brief reactive ps ychos is with complicates the clinical picture of schizotypal this dis tinction is far more difficult. P.2083 S chizotypal pers onality disorder is difficult to from the heterogeneous group of solitary, odd children whos e behavior is characterized by s ocial isolation, eccentricity, and peculiarities in language s een in disorder, As perger's s yndrome, and express ive and receptive-expres sive language disorder. disorders might be distinguished by the primacy and severity of the disorder in language accompanied by compens atory efforts of the child to communicate by other means and also by specialized language Autistic dis order and Asperger's s yndrome are distinguished based on more s everely impaired social interactions and s tereotypical behaviors and interests 2678 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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the latter two dis orders. S chizotypal dis order is distinguished from the following pers onality disorders : [black right-pointing arrowhead]S chizoid and paranoid (which rarely have magical thinking, perceptual experiences , or oddities in s peech, appearance, and thought process es) [black right-pointing arrowhead]Narcis sistic (with predominant s ens e of grandiosity, fragile s elfand fear of having hidden imperfections or flaws revealed) [black right-pointing arrowhead]Avoidant (which rarely has oddities in appearance and behavior; fear of embarras sment, not disinterest and detachment, caus es social avoidance and isolation) [black right-pointing arrowhead]B orderline (characterized by affective instability and stormy relations hips , as well as impulsive and manipulative behavior)

C lus ter B P ers onality Dis orders Antis oc ial Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of antisocial personality dis order are pervas ive disregard for and violation of rights of others occurring since 15 years of age and continuing into adulthood. A person has to be 18 years of age or older, there has to be evidence of conduct dis order before 15 years of age (conduct disorder involves a repetitive and 2679 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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persis tent pattern of behavior in which the basic rights others or major age-appropriate social rules are the examples include aggres sion to people or animals , both; destruction of property; deceitfulness or theft; and serious violation of rules). Diagnos tic features also at least three of the following: [black right-pointing arrowhead]F ailure to conform social norms (res ulting in frequent arres ts) [black right-pointing arrowhead]Deceitfulnes s, including lying and conning others for personal or pleasure [black right-pointing arrowhead]Impulsivity or failure to plan ahead [black right-pointing arrowhead]Irritability and aggres siveness , including repeated phys ical fights as saults [black right-pointing arrowhead]R eckless ness , with disregard for s afety of self and others [black right-pointing arrowhead]Irrespons ibility, indicated by the failure to honor financial or to s ustain consistent work behavior [black right-pointing arrowhead]Lack of remorse, indicated by indifference or rationalization of having hurt, mistreated, or stolen from others S ome of the as sociated features include [black right-pointing arrowhead]P romis cuity and inability to s ustain a monogamous relationship 2680 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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[black right-pointing arrowhead]Lack of empathy, cynicis m, and contempt for feelings , rights , or of others [black right-pointing arrowhead]Inflated and self-appraisal [black right-pointing arrowhead]Abusiveness and irrespons ibility toward children

C OMP L IC A TIONS C omplications include dys phoria, tension, low for boredom, depress ed mood, and premature, violent death.

C OMOR B IDITY T hese patients are at increas ed risk for impuls e control disorders , major depress ion, s ubs tance abus e or dependence, pathological gambling, anxiety disorders , and s omatization disorder. T he mos t common personality disorders are narcis sis tic, borderline, and histrionic.

IMP A IR ME NT Impairment is extremely variable and typically includes social difficulties .

S E X R A TIO According to DS M-IV -T R , this dis order is more (by a ratio of 3 to 1) diagnos ed in men.

E P IDE MIOL OG Y P revalence rates of 3 percent for men and 1 percent 2681 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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women in the general population and 3 to 30 percent in clinical s ettings , with even higher rates for forensic samples and substance abus ers, have been reported. noted in DS M-IV -T R , there has been s ome concern disorder may be underdiagnos ed in women, given the emphasis on aggres sive items in diagnosing conduct disorder. A high frequency of antisocial pers onality dis order is as sociated with low socioeconomic status and urban settings .

C OUR S E After 30 years of age, the most flagrant antisocial behaviors (promiscuity and crime) and the less severe behaviors and subs tance use tend to decrease.

F A MIL IA L P A TTE R N A ND G E NE TIC S Antisocial personality dis order is more frequent among first-degree biological relatives of probands with this disorder. B iological relatives of women with antisocial personality dis order are at increased ris k for the same disorder compared to biological relatives of men with antis ocial personality dis order. G enetic studies have suggested familial transmiss ion of antis ocial disorder, s ubs tance use, and s omatization disorder, former two being characteris tic of men, and the latter being characteris tic of women in the s ame family. Adoption s tudies have s hown that genetic and environmental factors contribute to the risk for this disorder. Adopted and biological children of parents with 2682 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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personality dis order are at increased ris k for this C onduct dis order (before 10 years of age) and accompanying attention-deficit/hyperactivity disorder (ADHD) increas e the likelihood of developing antisocial personality in adult life. C onduct disorder is more likely develop into antisocial disorder with erratic parenting, neglect, or inconsis tent parental discipline.

DIF F E R E NTIA L DIA G NOS IS Antisocial personality dis order is dis tinguished from bipolar disorder, manic, on the bas is of epis odic cours e and euphoric mood of the latter. Antisocial disorder is distinguished from the following pers onality disorders : [black right-pointing arrowhead]Narcis sistic (which rarely manifes ts s erious criminality, aggress ion, deceit and is characterized by excess ive need for admiration and envy of others ). [black right-pointing arrowhead]His trionic (which includes s eductiveness , attention seeking, superficiality, and rarely s erious criminality and aggres siveness ). [black right-pointing arrowhead]B orderline (which includes manipulativeness to gain nurturance and affective ins tability). C ontrary to the common belief that borderline pers onalities rarely commit crime, individuals with explos ive or borderline (high harm avoidance, high novelty s eeking, and reward dependence) frequently manifest antis ocial behaviors (s e condary ps ychopathy). S econdary ps ychopathy is distinguished from antisocial personality proper (or primary ps ychopathy), as the 2683 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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latter has a different temperament profile: high novelty seeking with low harm avoidance and low reward dependence, corres ponding to the adventurous temperament profile. [black right-pointing arrowhead]P aranoid (which includes s uspicious ness , guarded attitude, and, serious antis ocial behaviors ). [black right-pointing arrowhead]Adult antisocial behavior (with no personality pathology in the background). P.2084

Narc is s is tic Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of narcis sistic personality dis order are a pervas ive s ens e of grandiosity (in fantas y or in need for admiration, a lack of empathy, and chronic, intens e envy. Diagnostic features als o include at least of the following: [black right-pointing arrowhead]G randios e s ens e of self-importance and s pecialnes s [black right-pointing arrowhead]P reoccupation with fantas ies of unlimited s ucces s, power, brilliance, beauty, or ideal love [black right-pointing arrowhead]S ense of [black right-pointing arrowhead]Interpersonal exploitation, such as taking advantage of others to 2684 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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achieve own needs [black right-pointing arrowhead]Lack of empathy [black right-pointing arrowhead]E xces sive need for admiration and acclaim [black right-pointing arrowhead]Intens ive and envy [black right-pointing arrowhead]Arrogant and haughty attitude S ome of the as sociated features include [black right-pointing arrowhead]F ragile s elf-es teem (which exclus ively depends on external admiration) with hypers ens itivity to criticis m [black right-pointing arrowhead]High achievements more frequent than in any other pers onality [black right-pointing arrowhead]S trong feelings of shame and humiliation [black right-pointing arrowhead]E xhibitionis m (behavior motivated by the pleas ure of being at) [black right-pointing arrowhead]F ear of having imperfections and flaws revealed

C OMP L IC A TIONS C omplications include social withdrawal, depres sed dysthymic or major depres sive dis order in reaction to criticis m or failure.

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C OMOR B IDITY T hese patients are at increas ed risk for major and s ubs tance abus e or dependence (es pecially us e). T he mos t common cooccurring pers onality are borderline, antisocial, histrionic, and paranoid.

IMP A IR ME NT Impairment is frequently severe and typically includes marital problems and interpersonal relations hips in general.

S E X R A TIO According to DS M-IV -T R , this dis order is more diagnosed in men (50 to 75 percent of diagnosed men).

C OUR S E T he cours e is chronic. However, narcis sistic s ymptoms to diminis h after 40 years of age, when pes simis m develops .

E P IDE MIOL OG Y P revalence rates of 2 to 16 percent in the clinical population and less than 1 percent in the general population are reported in DS M-IV -T R .

P R E DIS P OS ING F E A TUR E S T here may be a higher risk for this personality dis order the offspring of narciss is tic parents who impart on their children an unrealis tic s ens e of grandiosity. In addition, most narcis sis tic persons are realis tically talented, beautiful, or highly intelligent, as these features serve 2686 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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the nucleus around which the sense of s pecialness is further organized.

DIF F E R E NTIA L DIA G NOS IS Narciss is tic personality dis order is dis tinguis hed from manic or hypomanic episode by the episodic cours e, euphoria, and functional impairments in the latter two. Narciss is tic personality is dis tinguis hed from the personality dis orders: [black right-pointing arrowhead]Antisocial exploitation is more driven by the wish to establish one's dominance than by material gains, his tory of conduct dis order, and no exces sive need for admiration) [black right-pointing arrowhead]B orderline (which includes unstable self-concept, chaotic behaviors , destructive ges tures , chronic anxiety, and rarely achievements) [black right-pointing arrowhead]His trionic (which includes capacity for empathy, emotional dis play, rarely, uns crupulous nes s and exploitation of [black right-pointing arrowhead]Obs ess ivecompuls ive (which includes inflexibility, detailoriented behavior, and social isolation, in addition perfectionism and the belief that others cannot do things as well) [black right-pointing arrowhead]P aranoid and schizotypal (which include sus piciousnes s and withdrawal)

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His trionic Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of his trionic personality dis order are pervas ive and excess ive s elf-dramatization, excess ive emotionality, and attention seeking. Diagnos tic features also include at least five of the following: [black right-pointing arrowhead]Inappropriate seductiveness or provocativenes s [black right-pointing arrowhead]E xces sive need to in the center of attention [black right-pointing arrowhead]R apidly s hifting and shallow express ion of emotions [black right-pointing arrowhead]S ugges tibility [black right-pointing arrowhead]P hysical us ed for attention seeking purpos es [black right-pointing arrowhead]Impress ionistic speech lacking detail [black right-pointing arrowhead]S elf-dramatization, theatricality, and exaggerated express ion of [black right-pointing arrowhead]R elations hips cons idered to be more intimate than they really are S ome of the as sociated features include [black right-pointing arrowhead]Difficulties in achieving emotional intimacy in romantic or s exual relations hips 2688 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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[black right-pointing arrowhead]C raving for excitement and s timulation [black right-pointing arrowhead]P romis cuity or complete sexual naiveté [black right-pointing arrowhead]Low tolerance for delayed gratification

C OMP L IC A TIONS C omplications include frequent suicidal ges tures and threats to coerce better caregiving. Interpersonal are uns table, shallow, and generally ungratifying. frequent marital problems secondary to the tendency to neglect long-term relations hips for the excitement of relations hips .

C OMOR B IDITY T hese patients are at increas ed risk for major somatization disorder, and convers ion disorder. T he common cooccurring disorders are narcis sis tic, antis ocial, and dependent.

IMP A IR ME NT Impairment is frequently only mild and typically personal romantic relationships .

S E X R A TIO T here s eems to be a general agreement that this occurs far more frequently among women. According DS M-IV -T R , the disorder might be equally frequent men and women.

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E P IDE MIOL OG Y P revalence rates of 2 to 3 percent in the general population and 10 to 15 percent for ps ychiatric and outpatients are reported in DS M-IV -T R .

F A MIL IA L P A TTE R N A ND G E NE TIC S T his dis order tends to run in families. A genetic link between histrionic and antis ocial personality dis order alcoholism has been s uggested.

DIF F E R E NTIA L DIA G NOS IS His trionic pers onality disorder is dis tinguis hed from the following personality dis orders: [black right-pointing arrowhead]Antisocial (which includes antis ocial behaviors and crime to gain power, or some other material gratification; history conduct dis order; no exces sive s elf-dramatization; no exaggerated emotional expres sion) [black right-pointing arrowhead]B orderline (which includes unstable self-concept, chaotic behaviors , destructive ges tures , chronic anxiety, and identity disturbance) [black right-pointing arrowhead]Narcis sistic (which includes fear of having hidden imperfections and revealed and a sens e of grandios ity and P.2085

Antis oc ial, Narc is s is tic , and 2690 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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S pec trum Narciss is tic, antis ocial, and his trionic personality qualify for the so-called s pectrum disorders. T he three disorders have been s hown to aggregate in the s ame family and to cooccur in the s ame person. distinguishable disorders may be referred to as dis orders , if they meet the two conditions previous ly mentioned. S pectrum disorders sometimes reflect differential express ion of the s ame liability. Antisocial, narcis sistic, and his trionic personality dis orders the spectrum in which proneness to impuls ivity and aggres sion (ass ociated with high novelty seeking) interferes with character development and maturity. E mpirical data show that s ymptoms of the three tend to group around impulsivity, aggres sion, and dramatic affects . A s pectrum disorder may als o reflect less deviant form of the other on an underlying liability scale. In that regard, the underlying antisocial increase in s everity as one proceeds from histrionic personality (manipulation via narciss is tic pers onality exploitation), and antis ocial pers onality (violent and property crime).

B orderline Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of borderline pers onality disorder are pervas ive and excess ive instability of affects, selfand interpersonal relationships , as well as marked impulsivity. Diagnostic features als o include at leas t the following: 1. F rantic efforts to avoid real or imagined 2691 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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(Note: Do not include suicidal or s elf-mutilating behavior covered in C riterion 5) 2. Uns table and intense interpers onal relations hips alternating between idealization and devaluation 3. Markedly and persis tently uns table s elf-image or of s elf 4. Impulsivity in at leas t two potentially s elf-damaging areas (s pending, s ex, substance abuse, binge and reckless driving) (Note: Do not include suicidal self-mutilating behavior covered in C riterion 5) 5. R ecurrent suicidal behavior, ges tures , threats , or mutilating behaviors 6. Ins tability of affect due to marked reactivity of mood 7. C hronic feelings of emptines s 8. Inappropriately intens e anger or difficulty controlling anger 9. S tres s-related, transient paranoid ideation or diss ociative s ymptoms S ome of the as sociated features include [black right-pointing arrowhead]T endency to undermine self when clos e to realizing a goal [black right-pointing arrowhead]F eeling more with nonhuman objects (pets and inanimate than in interpersonal relations hips

P R E DIS P OS ING F A C TOR S Numerous s tudies have pointed to early traumatic 2692 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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experiences in the etiology of this pers onality disorder. R ecently, a tripartite etiopathogenetic model, including childhood trauma, vulnerable temperament, and a of triggering events , has been formulated. Dynamic biological psychiatry agree that a combination of early traumatic events and certain biological vulnerabilities (mostly in the emotional domain) repres ent primary etiological factors for this disorder. F amilial aggregation borderline pers onality disorder has been repeatedly demonstrated.

C OMP L IC A TIONS C omplications include psychotic-like symptoms (hallucinations , body image distortions, hypnagogic phenomena, and ideas of reference) in res pons e to premature death or phys ical handicaps from suicide suicidal gestures , failed suicide, and self-injurious

C OMOR B IDITY T hese patients are at increas ed risk for major subs tance abus e or dependence, eating dis order bulimia), pos ttraumatic s tres s disorder (P T S D), and B orderline personality dis order cooccurs with most personality dis orders.

IMP A IR ME NT Impairment is frequent and s evere and includes job loss es, interrupted education, and broken

S E X R A TIO According to DS M-IV -T R , this dis order is more diagnosed in women (75 percent of diagnosed cases 2693 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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women).

C OUR S E C ours e is variable. It mos t commonly follows a pattern chronic instability in early adulthood, with episodes of serious affective and impuls ive dyscontrol. T he and the ris k of s uicide are the greatest at the young years and gradually wane with advancing age. In the fourth and fifth decades of life, these individuals tend to attain greater s tability in their relations hips and functioning.

E P IDE MIOL OG Y P revalence rates of 2 percent in the general percent for ps ychiatric outpatients , 20 percent for ps ychiatric inpatients , and 30 to 60 percent among patients with personality dis orders are reported in TR .

F A MIL IA L P A TTE R N A ND G E NE TIC S P hysical and sexual abus e, neglect, hos tile conflict, early parental loss or separation are more common in childhood histories of patients with this dis order. B orderline personality dis order is five times more among relatives of probands with this disorder than in general population. It als o increases familial risk for antis ocial pers onality disorder, s ubs tance abus e, and mood dis orders.

DIF F E R E NTIA L DIA G NOS IS B orderline personality dis order is distinguished from disorder, dys thymic disorder, and cyclothymia (with 2694 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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depres sion and mood swings mimicking borderline affective problems) bas ed on efforts to avoid abandonment, unstable relationships with alternating between idealization and devaluation, identity disturbance, impuls ivity in potentially s elf-damaging chronic feelings of emptiness , and inappropriately intens ive anger or difficulty controlling anger (these symptoms are rarely obs erved in mood dis order, dysthymia, or cyclothymia). B orderline disorder s hares many features and is difficult to dis tinguis h from all personality dis orders, frequently as an exclus ion based on typical clinical s ymptoms for other pers onality disorders . B orderline disorder is distinguis hed from identity problems (the latter is limited to a stage).

C lus ter C P ers onality Dis orders Avoidant Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of avoidant personality dis order are pervas ive and excess ive hypers ens itivity to negative evaluation, s ocial inhibition, and feelings of Diagnos tic features also include at least four of the following: [black right-pointing arrowhead]Avoidance of occupational activities that involve significant interpersonal contact because of fears of criticis m, rejection, or disapproval [black right-pointing arrowhead]Unwillingness to be 2695 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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involved with others unles s certain of being liked [black right-pointing arrowhead]R es traint in intimate relations hips because of the fear of being s hamed ridiculed [black right-pointing arrowhead]P reoccupation of being criticized or rejected in social s ituations [black right-pointing arrowhead]Inhibition in new social s ituations becaus e of feelings of inadequacy [black right-pointing arrowhead]R eluctance to take personal risks or to engage in any new activities, because they may prove embarrass ing P.2086 [black right-pointing arrowhead]V iews s elf as inept, personally unappealing, or inferior to others S ome of the as sociated features include [black right-pointing arrowhead]F earful and tense demeanor [black right-pointing arrowhead]F ear of blushing or crying in front of others in respons e to criticism [black right-pointing arrowhead]S ocial is olation accompanied by craving social relations and fantas izing about ideal relationships with others

C OMP L IC A TIONS C omplications include social phobia.

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C OMOR B IDITY T hese patients are at increas ed risk for mood and disorders (es pecially s ocial phobia, generalized type). most common cooccurring disorders are schizotypal, schizoid, paranoid, dependent, and borderline.

IMP A IR ME NT Impairment can be s evere and typically includes occupational and s ocial difficulties.

S E X R A TIO According to DS M-IV -T R , this dis order is equally men and women.

E P IDE MIOL OG Y P revalence rates of 0.5 to 1.0 percent in the general population and 10 percent for psychiatric outpatients reported in DS M-IV -T R .

C OUR S E F requently begins in childhood with shynes s and fear strangers and new situations . Dis figuring illness and shyness in childhood predis pos e children for this personality dis order.

DIF F E R E NTIA L DIA G NOS IS Avoidant personality dis order is difficult to distinguis h from s ocial phobia (many authors believe that these alternative labels for the s ame or s imilar condition). In social phobia, specific situations , rather than contact, are avoided. P anic dis order with agoraphobia manifests avoidance but usually after the onset of 2697 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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attacks. Avoidant disorder is distinguis hed from the following personality dis orders: [black right-pointing arrowhead]S chizotypal and schizoid (s ocial is olation of avoidant personalities is accompanied by the des ire for s ocial relations , not obs erved in s chizoid and schizotypal disorder) [black right-pointing arrowhead]P aranoid (which includes guarded attitude, preoccupation with meanings , and cons pirational explanations of [black right-pointing arrowhead]Dependent (which focus ed on being taken care of rather than on the of negative evaluation)

Dependent Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of dependent pers onality disorder are pervas ive and excess ive need to be taken care of that to clinging behavior, s ubmis siveness , fear of and interpersonal dependency. Diagnos tic features also include at least five of the following: [black right-pointing arrowhead]Difficulty in making everyday decisions without excess ive reass urance advice from others [black right-pointing arrowhead]Need for others to as sume res ponsibility for major areas of his or her 2698 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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[black right-pointing arrowhead]Difficulties disagreement with others because of fear of loss of support or approval. (Note: Do not include realis tic fears of retribution) [black right-pointing arrowhead]Lack of initiative [black right-pointing arrowhead]Unrealistic preoccupation with fears of being left to take care self [black right-pointing arrowhead]Urgent s earch for another relations hip as a s ource of care and when a clos e relations hip ends [black right-pointing arrowhead]E xtens ive efforts to obtain nurturance and support from others (to the point of volunteering to do unpleasant things) [black right-pointing arrowhead]Uncomfortable and helpless feelings when alone because of fears of being unable to take care of self An ass ociated feature includes [black right-pointing arrowhead]Low self-es teem self-doubt and s elf-defeating demeanor

C OMP L IC A TIONS C omplications include mood disorders , anxiety adjus tment disorder, and social phobia, as well as low socioeconomic s tatus , poor family, and marital functioning.

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T hese patients are at increas ed risk for major anxiety disorders , and adjus tment disorder. T he mos t common cooccurring disorders are histrionic, avoidant, and borderline.

IMP A IR ME NT Impairment is frequently only mild and typically interpersonal relationships and occupational if independence is required.

S E X R A TIO T his dis order is equally frequent in men and women IV -T R ).

E P IDE MIOL OG Y T his dis order is reported in DS M-IV -T R to be the mos t frequent of personality dis orders.

F A MIL IA L P A TTE R N A ND G E NE TIC S T here is no known familial pattern for this disorder. C hronic phys ical illness or separation anxiety disorder predis pos e for dependent personality dis order.

DIF F E R E NTIA L DIA G NOS IS Dependent disorder is dis tinguis hed from dependency seen in mood disorders , panic disorder, and and as a result of a general medical condition. disorder is distinguis hed from the following personality disorders : [black right-pointing arrowhead]B orderline (which includes unstable, stormy relations hips and the 2700 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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reaction to abandonment with rage, emptines s, and demands, as opposed to increas ing appeas ement submiss iveness seen with dependent pers onalities ) [black right-pointing arrowhead]His trionic (which includes gregarious flamboyance with active for attention) [black right-pointing arrowhead]Avoidant (which includes social is olation because of the fear of evaluation as oppos ed to clinging and s ubmis sive behavior of dependent pers onalities )

Obs es s ive-C ompuls ive Pers onality Dis order C L INIC A L C R ITE R IA T he hallmarks of obs es sive-compuls ive personality disorder are pervasive and include preoccupation with orderlines s, perfectionis m, and mental and control, at the expens e of flexibility, openness , and efficiency. Diagnos tic features als o include at leas t four the following: [black right-pointing arrowhead]P reoccupation with details, rules , lists , order, procedures, organization, schedules to the extent that the major point of is lost [black right-pointing arrowhead]P erfectionism that interferes with tas k completion [black right-pointing arrowhead]E xces sive devotion work and productivity to the exclus ion of leisure activities and friendships (not accounted for by 2701 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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obvious economic neces sity) [black right-pointing arrowhead] scrupulousness , and inflexibility about matters of morality, ethics , or values (not accounted for by religion or culture) [black right-pointing arrowhead]Inability to dis card worn-out or worthles s objects with no sentimental value [black right-pointing arrowhead]R eluctance to delegate tasks or work with others unless they exactly to his or her way of doing things [black right-pointing arrowhead]S tingines s (money viewed as s omething to be hoarded for future catas trophes ) [black right-pointing arrowhead]R igidity and stubbornness S ome of the as sociated features include [black right-pointing arrowhead]Decis ion-making difficulties when no strict rules or es tablis hed procedures dictate correct action P.2087 [black right-pointing arrowhead]Anger and when not able to maintain control of physical or interpersonal environment (anger is typically not expres sed directly) [black right-pointing arrowhead]E xces sive attentivenes s to their relative status in dominance– 2702 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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submiss ion relations hips [black right-pointing arrowhead]C ontrolled and res tricted emotional express ion and reserved style [black right-pointing arrowhead]F ormal and s erious quality of everyday relations hips

P R E DIS P OS ING F A C TOR S It has been repeatedly demonstrated that obs ess ivecompuls ive personality dis order and OC D frequently coexist. Obsess ions and compuls ions have been repeatedly linked to high central s erotoninergic which is as sociated with anxiety in general, s upporting hypothes is that obs es sions and compuls ions repres ent ps ychological and behavioral mechanisms reflecting underlying anxiety.

C OMP L IC A TIONS C omplications include dis tres s and difficulties when confronted with new situations that require flexibility compromise and myocardial infarction (s econdary to features typical of type A pers onalities , s uch as time urgency, hos tility, and competitivenes s).

C OMOR B IDITY T hese patients are at increas ed risk for major and anxiety dis order. T here is equivocal evidence for increased ris k of OC D.

IMP A IR ME NT Impairment is frequently severe and typically includes 2703 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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occupational and s ocial difficulties.

S E X R A TIO According to DS M-IV -T R , this dis order is twice as in men as in women.

E P IDE MIOL OG Y P revalence rates of 1 percent in the general population and 3 to 10 percent for ps ychiatric outpatients are reported in DS M-IV -T R .

F A MIL IA L P A TTE R N A ND G E NE TIC S S ome s tudies have demonstrated familial aggregation this disorder.

DIF F E R E NTIA L DIA G NOS IS Obsess ive-compuls ive personality dis order is from OC D based on true obs es sions and compulsions the latter. T his personality disorder is distinguis hed the following personality dis orders: [black right-pointing arrowhead]S chizoid (which includes lack of capacity for intimacy and social is olation secondary to emotional detachment, as oppos ed to devotion to work and discomfort with emotions ) [black right-pointing arrowhead]Antisocial (which includes material goals in antis ocial behavior and criminality as opposed to hypermorality of personalities ) [black right-pointing arrowhead]Narcis sistic (which includes s ens e of grandiosity, s elf-aggrandizement, 2704 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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exhibitionis m, and fear of having hidden and flaws revealed)

P ers onality Dis order Not S pec ified (NOS ) T his dis order is diagnos ed when the DS M-IV -T R dysfunctional personality (i.e., general criteria for a personality dis order) are met, but no specific criteria for any of the subtypes are obs erved. F or example, a may not meet criteria for any of the clas sified disorders may s till manifes t features from more than one disorder (mixe d pe rs onality dis orde r) which, together, distress or impairments in s ocial or profes sional functioning. T his category is als o us ed when the judges that a specific pers onality disorder that is not included in DS M-IV -T R is appropriate (e.g., depres sive personality or pass ive-aggres sive pers onality).

S ummary Des c ription of the DS MTR P ers onality Dis orders Qualitative features that are diagnostic of a personality disorder as clas sified in DS M-IV -T R are summarized in T able 23-13. C loninger has als o provided practical to detail thes e general features, s o that a clinician may decide whether a person has any personality disorder before proceeding to diagnose a s pecific cluster or category of illness . T he general features of all disorders are the character traits , whereas the clusters categories are determined by additional temperament features.

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Table 23-13 Qualitative C lus ters and S ubtypes of Pers onality Dis orders Ac c ording to the Americ an Ps yc hiatric C lus ter

S ubtype

Dis c riminating Features

Odd/eccentric

S chizoid

S ocially indifferent

 

P aranoid

S us picious

 

S chizotypal

E ccentric

E rratic/impuls ive

Antisocial

Dis agreeable

 

B orderline

Uns table

 

His trionic

Attention seeking

 

Narciss is tic

S elf-centered

Anxious/fearful

Avoidant

Inhibited

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Dependent

S ubmis sive

 

Obsess ive

P erfectionistic

Not otherwise specified

P as siveaggres sive

Negativis tic

 

Depress ive

P es simis tic

Adapted from American P s ychiatric As sociation. Diagnos tic and S tatis tical Manual of Me ntal 4th ed. T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000.

Dis advantages of DS M-IV-TR C las s ific ation In addition to problems s hared by all categorical personality, the DS M clas sification has its s pecific limitations . F irst, DS M-IV -T R is an etiologically atheore tical of pers onality disorder based s olely on descriptive derived from observations of prototypical cas es . T his atheoretical approach was expected to s timulate work the etiopathogenetic unders tanding of deviant clas sified as pers onality disorders . However, this has been the cas e. T he introduction of descriptive criteria in DS M-III has inspired extensive res earch of some bas ic ps ychometric as pects of the personality dis order 2707 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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but rarely has ins pired s tudies of etiology, underlying dynamics, or pathogenes is . Although this emphas is on ps ychometrics obviously reflects an attempt of this new field to delineate its s ubject, it is als o reflective of the purely des criptive approach, which provided no etiopathogenetic models or hypotheses for tes ting. F or example, the DS M criteria have been of little or no help developing the psychobiological model described here. S econd, the DS M-IV -T R describes as pathognomic for personality disorder maladaptive res ponse patterns are enduring, that is, appearing before adulthood with long-term duration. In practice, however, it can be to dis tinguis h long-term maladaptation that is indicative personality dis order from chronic personality changes caus ed by other factors, such as other mental (e.g., chronic depress ion) and long-term s ituational (e.g., job-related timidity), and by other medical (e.g., irritability ass ociated with hyperthyroidism). P.2088 T hird, the DS M-IV -T R definition of pe rs onality inherently imprecis e, as it requires that maladaptive behaviors caus e clinically significant subjective distress clinically s ignificant impairment in social and function, or both. S ubjective dis tre s s us ually pres ents self-es teem, anxiety, guilt, depress ion, and hypochondriasis. T hes e s ymptoms are frequently diagnosed as Axis I dis orders while the background personality dis order is overlooked. T he quantifier s ignificant is an arbitrary diagnostic element that can hardly be made objective. E ditors : S adock, B e njamin J .; S adock, V irginia A

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T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > C LINIC AL AND P S Y C HO ME T R IC

C L INIC AL AND PS YC HOME TR IC IS S UE S P art of "23 - P ers onality Dis orders "

E go-S yntonic and A lloplas tic of P ers onality Dis order P atients with personality dis order typically blame other people or unfavorable circumstances for their own problems . T his externalizing of res ponsibility is a result the following two characteris tics. F irs t, mos t of these patients perceive their own deviant behaviors as appropriate and adequate; in other words, their are ego-syntonic. T he exceptions to this are patients dependent and avoidant personality dis order. B oth disorders are characterized by prominent anxiety as sociated with maladaptive behaviors , and this caus es the patients to perceive their s ymptoms as disturbing, that is, ego-dystonic. S econd, patients with personality dis order try to others , not thems elves ; in other words, their attitude is alloplas tic. T he exceptions to this rule are patients with avoidant and schizoid pers onality disorder. Avoidant persons usually try to improve their own performance avoid negative evaluation by others . S chizoid are socially detached to the extent that they are usually indifferent to what others might do, think, or feel. 2709 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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P ers onality Dis order: S oc ial or Diagnos is ? One of the general DS M-IV -T R requirements for disorder is that maladaptive behavior “deviates from the expectations of the individual's culture.” T his requirement introduces a significant s ocial connotation what was meant to be a clinical clas sification. Indeed, clinicians frequently diagnos e pers onality dis order solely on the extent to which certain behavior is to the local s ociety. S ociocultural pres sures are always norm favoring, promoting phenotypes that fall within the range of accepted behavior norms . As shown later in the text, temperament profiles with high reward dependence a low incidence of diagnosed personality dis order, whereas thos e with high harm avoidance or high seeking, or both, increas e this ris k. In most W es tern societies, the normative phenotype is not the one with average personality traits (as one would expect, given adaptive flexibility of such configuration) but the one high reward dependence (high reward dependence means much eas ier conditioning of s ocially accepted behaviors than is the case with other two temperament traits). In a s imilar way, child psychiatry clas sifies three broad groups of mental disorders : One group is characterized high novelty seeking (e.g., ADHD and conduct one group is characterized by high harm avoidance depres sive and anxiety disorders ), and one group is characterized by low reward dependence (e.g., C hildren with thes e extreme temperaments are 2710 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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and treated to change their behavior, whereas children with high reward dependence (s ociable, attached, and dependent) are s electively permitted to develop with no corrective intervention. T his raises a question, which is beyond the s cope of this chapter, about the role of modern human society in engineering psychological profiles of its members . S uffice it here to s ay, biological adaptation appears to have become les s critical for survival than behavioral and s piritual adaptation. selection is not targeting humans' morphological anymore, but, rather, their personality features and awarenes s. T hrough its suppres sion of certain temperament traits and its modeling effects on development, modern human society appears to have important role in this proces s.

C ategoric al vers us Dimens ional A pproac h to P ers onality Dis order Medical diagnosis has historically been categorical, most clinicians tend to think categorically for two F irst, one of the most important functions of diagnos is prescribe appropriate corrective action, that is, T he decis ion whether a pers on is affe cte d or (s ick or not s ick) is functionally equivalent to the whether that pers on needs treatment (hence, diagnosis facilitates treatment decisions in practical S econd, categorical s ys tems simplify profess ional communication, as they describe prototypical cas es meet all or most of the diagnostic criteria. J ust one category, for example, antis ocial pers onality, can communicate a great deal of vivid clinical information about the patient. However, categorical descriptions convey useful information only about prototypical and 2711 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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severe cases but little or no information about atypical, mixed, or mild cas es.

C ategoric al Approac h T he categorical approach adopts the medical model that a personality dis order is pre s e nt or abs e nt that individuals are affe cte d or unaffe cte d. C ategorical models are optimal for discontinuous variables (e.g., marital s tatus and s kin cancer). However, when distinguishing characteris tics of a dis order are variants normality, s uch as pers onality traits , any categorical decis ion about the pres ence or abs ence of a disorder arbitrary. In other words, one of the major of categorical models of personality dis order is that es tablis h arbitrary cutoff points or thres holds for continuous behavior traits . T his becomes clear in mild cas es that are close to the cut-off point, which cannot be well class ified as affe cte d or unaffe cte d. In attempt to minimize this problem, DS M-IV -T R now clinicians to class ify maladaptive pe rs onality traits that not meet the threshold for a pers onality disorder on Nevertheles s, the categorical approach is not optimal patients who do not perfectly fit their pigeonhole in the clas sification, s o an additional was tebasket category atypical or mixe d cases has to be es tablis hed, and this often is used to des cribe most cases of pers onality disorder. F inally, the categorical approach does not es tablis h a pres criptive relations hip between diagnos is and treatment. R eflecting a significant overlap of diagnostic criteria for personality dis order subtypes , categorical s ys tems us ually yield multiple pers onality diagnoses for individual patients . In such cases, 2712 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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priorities are eas ily and frequently confus ed.

Dimens ional Approac h Dimens ional models define a number of graded and continuous behavior dimens ions and s pecify individual differences as quantitative variations along these dimensions . T hese models are optimal for features that vary quantitatively and that have different adaptive significance in different s ituations (such as personality traits). T hese models account for the fact that everyone multiple pers onality traits , more or les s prominent and adaptive, rather than being s imply pres ent or absent. eliminates the need for multiple and overlapping categorical diagnos es . B y quantifying one's position on continuous personality trait, dimensional models information about individual patients more than categorical models . P ers onality dimensions are as applied to the common atypical and mild cases as they to the rare prototypical and severe cases . Lastly, by dimensional system, one can easily manipulate mathematically complex data and can include many variables . P.2089 R es earch has s hown that normal pers onality traits tend generalize to pers onality disorders , indicating that traits may be conceptualized as extreme variants of normal, adaptive behaviors. Note, however, that dimensional models do not answer the ques tion of it about s ome traits that makes them dis orders. Natural breaks or points of rarity on the continuum of normal maladaptive pers onality traits have not been detected. 2713 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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extreme s tanding alone is not s ufficient to be dysfunctional (e.g., people with low reward can be well adapted in their environment). T o make more prescriptive of treatment and more compatible categorical diagnoses, dimens ional models have to introduce cut off points for continuous traits (which are always arbitrary) or, as proposed here, have to use probability estimates for categorical pers onality based on the s everity of measured personality traits.

Meas urement of P ers onality Dis orders S elf-R eport or Interview? Interviews are cons idered more reliable and valid diagnostic tools than s elf-reports for meas uring personality dis order, although no data for a definite advantage of one of these formats have been As many of these patients tend to be biased regarding their ego-syntonic deviant behaviors, interviewing the patient reduces this problem, because unclear, inconsistent, or defens ive responses can be clarified, the patient's demeanor and appearance can be On the negative side, interviews tend to be affected by systematic biases, ideological orientation, experience, rating idios yncrasies of interviewers . In self-reports , res ponse sets (e.g., careless inconsistency, and exaggeration) and validity items can be meas ured help in interpretation. R ecently, a set of performance scales, independent of the item content, bas ed on the observed regularities in the technical pattern of res ponding to questions has been defined. T hes e performance s cales are used to tes t the validity of s elf2714 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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reported pers onality traits . S pecifically, s elf-report to questions , regardles s of the content of the ques tions, tends to follow specific patterns that correlate with personality traits . F or example, the number of items that are otherwis e rarely found in the general population correlates with low reward dependence. performance s cales are used to predict scores on each the temperament and character dimens ions, which are then compared with self-reported, content-dependent scores on these same traits . S ubstantial s core between s ubje ctive and pe rformance -bas e d s cores on personality traits indicate s ignificant bias or intentional misrepres entation. F urther improvement of this basic might be accomplished by us ing neural networks to detect content-independent response patterns that typical of each pers onality trait. S elf-reports and interviews depend on the patient's accuracy, hones ty, and level of insightfulness . Hence, collection of data from collateral informants and expert ratings is us ually considered critical to ensuring highquality personality diagnosis .

S tate–Trait E ffec t Most Axis I dis orders have their less severe variants or representatives on Axis II (T able 23-14). T he s tate –trait distinction between s ymptoms reflecting long-term personality traits and those reflective of trans ient Axis I states can be difficult. Indeed, trans ient variation in emotional state can influence s elf-report and clinical evaluation of long-term personality characteris tics. T he susceptibility to such s tate effects has been for some categorical measures of personality 2715 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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T he state effect can be reduced, although not when subjects are repeatedly reminded to des cribe us ual, not their current, behavior, feelings, and contrast to categorical diagnos is , only thos e personality that underlie s usceptibility to depress ion anxiety, such as neuroticism and harm avoidance, tend covary with mood and anxiety s tates. Also, increases in anxiety or depres sion lead to mild and transient in self-directedness and cooperativenes s. person with no enduring pers onality disorder may act immaturely when depres sed or under s tres s. S elfof other dimens ional traits —novelty seeking, reward dependence, and pers istence, in particular—are largely independent from and unaffected by comorbid mood anxiety states.

Table 23-14 Phenotypic between Axis I and Axis II Axis I Dis orders : Major Variant

Axis II Dis orders : Minor Variants

S hared S ymptoms

S chizophrenia spectrum

S chizoid

Negative and positive

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S chizotypal PD

 

Delusional disorder

P aranoid

S us piciousness

Major depres sion

Depress ive PD

P ronenes s to depres sed mood; self-destruction

 

B orderline PD

 

C yclothymia, bipolar disorder, mania

Narciss is tic PD

Mood swings; impulsiveness

 

His trionic PD

 

 

Antisocial PD

 

Obsess ivecompuls ive disorder

Obsess ivecompuls ive PD

Hypochondrias is ; inflexibility

S ocial phobia

Avoidant

S hynes s; behavior

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P anic dis order with agoraphobia

Dependent PD

Dependency

P D, personality disorder.

C ategoric al Tes ts for Pers onality Dis order T he majority of categorical tes ts for personality are based on the DS M criteria and s hare all the and disadvantages of that polythetical categorical approach. In the DS M-III field trials , the interrater was 0.61 and the tes t-retest reliability was 0.54 for any personality dis order. T he reliability is us ually lower for individual s ubtypes than for the pres ence vers us of any pers onality disorder becaus e of the difficulty in distinguishing among the s ubtypes. Among the categorical self-reports , the two mos t frequently us ed are the P ers onality Diagnos tic Ques tionnaire (P DQ) and the Minnesota Multiphas ic P ers onality Inventory (MMP I) s cales for pers onality disorders (MMP I-P D). T he P DQ is a self-report vers ion the DS M-III-R criteria for pers onality disorders , along the impairme nt-dis tre s s s cale to quantify the impairment or subjective distress required by DS M In practice, this ins trument has been s hown to overdiagnose pers onality disorders when compared to 2718 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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expert clinical diagnosis . T he MMP I-P D scales were derived from the MMP I item pool to evaluate s ymptoms for DS M-III pers onality disorders . T he MMP I-P D scales are incorporated into so that, in addition to evaluating personality dis order other clinical s yndromes, clinicians and researchers also use other MMP I s cales (e.g., for lies , validity, and defens iveness ) for validity and response set analyses. Among the interviews that categorically diagnos e personality disorders , the most commonly us ed is the S tructured Interview for DS M-IV P ers onality Dis orders (S IDP -IV ). T he original S tructured Interview for Dis orders (S IDP ) was developed for pers onality described in DS M-III, and it has been regularly updated with each new DS M revision and edition (S IDP -R for III-R and S IDP -IV for DS M-IV ). T o increase its P.2090 validity, the S IDP -IV requires that ans wers for selected questions be obtained from a collateral informant. T his tes t can be combined with a 10-minute S IDP -IV s creen personality dis order, which can cons iderably reduce tes ting time in populations with many individuals who not have pers onality disorder. Other popular interviews for categorical class ification of personality dis orders include the S tructured C linical Interview for DS M-III-R P ers onality Dis orders R evised II), the Diagnostic Interview for P ers onality Dis orders (DIP D), and the P ers onality Dis order E xamination T he P DE is available in an international version from World Health Organization in several languages and 2719 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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diagnoses according to the IC D in addition to DS M-III-

Dimens ional As s es s ment of Dis orders His torically, pers onality has been studied and us ing dimensions or traits , and personality dis order has been s tudied categorically, as discrete entities of ps ychopathology. Hence, conceptual advances in the of normal behavior and personality have had little or no effect on research in the field of personality dis order vice versa. F or example, if the features as sociated with E ys enck's model of pers onality, that is , neuroticism, extrovers ion, and tough-mindedness , are combined, res ulting combinations do not corres pond clos ely to traditional categories of pers onality disorder. T he popular five-factor model of normal personality has been recently advocated to account for underlying dimensions of pers onality disorder as well. However, ability of the five-factor model to account for the underlying s tructure of personality dis order has been tes ted primarily in nonclinical s amples and normal individuals . T he few s tudies that tested the five-factor model in clinical samples showed that neuroticism, extrovers ion, and low agreeableness predict disorder s ymptoms. After controlling for age and depres sion (cons idered standard for high-quality personality diagnos is ), only high neuroticism and low agreeableness remained as significant predictors of personality dis order symptoms . T hes e two dimens ions define pe rs onality dis orde r in a nons pecific way, as a general predis pos ition to ps ychopathology (i.e., high neuroticism) accompanied by an antagonis tic behavior 2720 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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facade (i.e., low agreeableness ). In addition, tends to be confounded with nonspecific factors (s uch depres sion or anxiety), which reduce its ability to distinguish pers onality disorder, other ps ychopathology (e.g., mood and anxiety disorders ), and well-adjus ted individuals with high neuroticism. S everal lines of evidence s uggest that some common features, distinct from other forms of psychopathology that caus e personal dys function, characterize disorder s ubtypes clas sified in DS M-IV -T R as discrete categories . F or example, DS M-IV -T R arranges all personality dis orders into three clus ters (A, B , and C ), comprised of a number of pers onality disorder with similar clinical features. C lus ter A includes with predominantly odd and eccentric s ymptoms (e.g., paranoid and s chizoid personality dis order), C lus ter B includes subtypes with dramatic, erratic, and impulsive symptoms (e.g., his trionic, antis ocial, and borderline personality disorders ), and C luster C includes subtypes with fearful and anxious s ymptoms (dependent, and obses sive pers onality disorders ). T hese clusters represent three independent dimensions underlying personality dis order subtypes within each of the However, the ability of thes e three dimensions to discriminate s ubjects with and without pers onality disorder or to distinguis h between pers onality disorder subtypes has not been tested. Dimens ional tests of pers onality disorders are self-reports (except for T yrer's P ers onality As ses sment S chedule). T he mos t frequently us ed are the Millon Multiaxial Inventory (MC MI); the previous ly mentioned Neuroticis m E xtrovers ion Openness P ers onality 2721 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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(NE O-P I), which evaluates the five-factor pers onality model; and the T C I, which evaluates the s even-factor ps ychobiological pers onality model. T hes e tests have originally designed to evaluate normal personality (the NE O-P I), ps ychiatric patients (the MC MI), and normal deviant personality (the T C I). T he NE O-P I was previous ly vis à vis the homogeneity of its component traits and its us efulnes s in clinical work with personality disorder. T he other two tes ts are briefly discus sed T he MC MI-II (des igned to match DS M-III-R personality disorder categories) evaluates long-term behavior traits systematized as ten bas ic pe rs onality patte rns avoidant, schizoid, pass ive-aggres sive, narcis sis tic, antis ocial, hys terical, compuls ive, aggres sive, and selfdefeating) and three pathological pe rs onality dis orde rs (borderline, schizotypal, and paranoid). T he latter the severity of the ten basic personality patterns . T he also evaluates nine Axis I clinical syndromes . S ome suggest that MC MI-II tends to overdiagnos e personality disorder in comparis on to expert clinicians . A s tudy comparing the MC MI-II to the T C I pointed to a cons iderable overlap of MC MI-II measures of Axis I syndromes and Axis II personality dis orders. T he number of proposed dimensions that underlie personality ranges from 2 to 24 in the literature, in most models , it can be reduced to four dimensions (aloof, anxious, anankas tic, and adventurous ). T he number of underlying dimens ions and the content of dimensions that purport to describe personality and its disorders most efficiently are still vigorous ly debated. ambiguity arises because factor analys es of behavior unrelated individuals are always compatible with an 2722 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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infinite number of rotations of the inferred phenotypic factors . F ortunately, s tructural equation analys is of the caus es of individual differences in the resemblance in pairs varying in the degree of genetic relationship can specify a unique model of the genetic s tructure of personality. In what follows , the distinction between temperament and character is us ed to improve the etiopathogenetic understanding and the diagnosis of personality dis order. In the treatment section of the chapter, the concepts of temperament and character us ed to outline treatment guidelines for patients with personality dis order.

Temperament and C harac ter (TC I) T he T C I evaluates four major temperament dimensions (harm avoidance, novelty s eeking, reward and persis tence) and three major character dimens ions (s elf-directedness , cooperativeness , and s elftranscendence). E ach of these main temperament and character dimens ions is compos ed of component (or s ubscales ) to evaluate respons e patterns elicited by specific s timuli (e.g., harm avoidance is obs erved in different s ettings as worry and pes simis m or fear of uncertainty, s hynes s, or excess ive fatigability, or a combination of thes e). T he s even major dimensions their component traits are pres ented T able 23-15.

Table 23-15 Temperament and C harac ter Inventory S c ales and S ubs c ales 2723 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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T emperament    Harm avoidance (HA)       HA1: worry and pess imism vs. uninhibited optimism       HA2: fear of uncertainty       HA3: s hynes s with s trangers       HA4: fatigability and as thenia    Novelty seeking (NS )       NS 1: exploratory excitability vs. stoic rigidity       NS 2: impulsivenes s vs. reflection       NS 3: extravagance vs. reserve       NS 4: disorderlines s vs . orderlines s    R eward dependence (R D)       R D1: s entimentality       R D2: s ociability vs. aloofnes s

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      R D3: attachment vs. detachment       R D4: dependence vs. independence    P ersistence (P S )       P S 1: eagernes s of effort vs. laziness       P S 2: work hardened vs. spoiled       P S 3: ambitiousness vs . underachieving       P S 4: perfectionis m vs. pragmatism C haracter    S elf-directedness (S D)       S D1: res ponsibility vs . blaming       S D2: purpos efulnes s vs . lack of goal direction       S D3: res ourcefulness vs . helples sness       S D4: s elf-acceptance vs . self-striving       S D5: congruent s econd nature    C ooperativeness (C O)

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      C O1: s ocial acceptance vs . s ocial intolerance       C O2: empathy vs . s ocial dis interes t       C O3: helpfulness vs. unhelpfulness       C O4: compass ion vs. revengefulness       C O5: pure hearted vs. s elf-serving    S elf-transcendence (S T )       S T 1: s elf-forgetful vs. s elf-cons cious       S T 2: transpers onal identification vs. s elfdifferentiation       S T 3: spiritual acceptance vs . rational       S T 4: enlightened vs. objective       S T 5: idealistic vs. practical

T he T C I is a family of tes ts with s everal specialized designed for varying types of informants (s elf-report, ratings , and interviewers), varying age groups (7 to 14 years of age for the junior T C I and 15 years or age or for the adult T C I), scope of information (temperament character, or both), level of clinical detail (140 items for 2726 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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major dimens ions only or 240 items for multiple facets each dimens ion). T he tes t meas uring the temperament dimensions only was originally called the P ers onality Q ue s tionnaire (T P Q). In the T P Q, novelty seeking, harm avoidance, reward dependence, and persis tence were all meas ured, but pers is tence was originally s cored as a component of reward T he name of the tes t was changed to T C I when the character scales were added and when persistence recognized as a fourth, s eparately inherited dimension in twin studies in Aus tralia P.2091 and the United S tates . T he self-report version of the 240-item test available in true–false and five-point formats . Its psychometric properties are presented in T C I Manual. T he ability of the T C I to predict categorical diagnos es personality dis orders was clinically tes ted in samples of ps ychiatric inpatients and outpatients with and without personality dis orders and varying mood and anxiety C orrelation and regres sion analys es consis tently demonstrate that low scores on character dimens ions, es pecially self-directedness and cooperativeness , are as sociated with high symptom counts for any disorder, for each of the DS M clusters of personality disorder (T ables 23-16 and 23-17) and for each clinical subtype of personality dis order, with or without Axis I s yndromes and independent of age. As s hown in T able 23-17, the T C I character scales of s elfcooperativeness , and s elf-transcendence predict the number of pers onality disorder s ymptoms, after 2727 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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controlling for age, anxiety, and depres sion. C learly, scores on P.2092 character traits repres ent a core feature (common denominator) of all personality dis order clusters and subtypes .

Table 23-16 C orrelations betwee Temperament and C harac ter Inven S c ales and the Total Number of for Pers onality Dis orders and C lus C lus ter B , and C lus ter C Pers ona Dis order S ubtypes    

Inpatients (N = 136) Total Number Pers onality Dis order C lus ter C lus ter C lu Sx A Sx B Sx C S

Novelty

.22 c

.02

.44 a

–

Harm

.31 b

.23 b

.08

.4

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R eward dependence

-.14

-.37 a

-.08

-.

P ers is tence

0

-.07

.04

-.

S elfdirectedness

-.56 a

–.35 a

–.43 a

–.

C ooperativenes s

–.44 a

–.44 a

–.40 a

–.

.02

–.08

.03

.

S elftranscendence

S x, symptoms. aP

<.0001.

bP

<.001.

cP

<.01.

Table 23-17 S tepwis e Multiple R egres s ion

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Inpatients (N = 136) Total Number of Interview PD S ymptoms Predic ted by TC I (C ontrolling for Age and Depres s ion)  

Number of PD S ymptoms

 

Partial R 2

P

Age and depress ion

.35

.0001

Novelty s eeking

—

Ns

Harm avoidance

—

Ns

R eward dependence

—

Ns

P ers is tence

—

Ns

S elf-directedness

.13

.0001

C ooperativenes s

.03

.0076

S elf-transcendence

.02

.0376

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C umulative R 2

.18

.0001

Model R 2

.53

.0001

Outpatients (N = 109)

Total Number of S elf-R eport PD S ymptoms Predic ted by TC I (C ontrolling for Age, Depres s ion, and Anxiety)

 

Total Number of S ymptoms

 

Partial R 2

P

Age, anxiety, and depres sion

.45

.0001

Novelty s eeking

—

Ns

Harm avoidance

—

Ns

R eward dependence

—

Ns

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P ers is tence

—

Ns

S elf-directedness

.20

.0001

C ooperativenes s

.05

.0001

S elf-transcendence

.05

.0001

C umulative R 2

.30

.0001

Model R 2

.75

.0001

Ns, not significant; P D, pers onality disorder; T C I, T emperament and C haracter Inventory. In differential diagnosis , personality dis order subtypes distinguished based on temperament s cores without overlap, because each s ubtype correlates with the T C I temperament dimens ions in a unique way (F ig. 23-8).

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FIGUR E 23-8 C orrelations between individual disorder s ubtypes and temperament traits of harm avoidance (HA), novelty seeking (NS ), and reward dependence (R D). A, antis ocial; A c , antis ocial borderline; D, dependent; F , s elf-defeating; G , pas siveaggres sive; H, his trionic; N, narciss istic; O, obs es sive; paranoid; S , sadis tic; T , s chizotypal; V , avoidant; Z, T he previously mentioned results have important diagnostic and treatment ramifications for personality disorder, as discus sed in the following s ections.

DIA G NOS IS OF P E R S ONA L ITY 2733 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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C haracter and temperament traits delineate the core features and the distinguishing features of pers onality disorders (T ables 23-16 and 23-17; F ig. 23-8). P oorly developed character traits, especially s elf-directedness cooperativeness , are a common denominator acros s all s ubtypes of personality dis order and are diagnosis to predict categorical personality dis order symptoms (T ables 23-16 and 23-17). C linically, low character scores explain chronic difficulties in of respons ibility, the s etting of long-term goals , fragile es teem, and other features as sociated with low selfdirectedness that are so characteristic of individuals personality dis order. Usually, but not always , these patients are also uncooperative as well (i.e., opportunis tic, s elf-centered, s ocially intolerant, to others, and lacking in empathy, compas sion, or principles). High s elf-transcendence correlates with schizotypal and paranoid s ymptoms (depicting primary proces s thinking and fanaticis m, respectively) and with borderline, his trionic, and narciss istic symptoms proneness to dis sociation), much as predicted in F igure 4. In addition, recent data indicate that high selftranscendence might be an important component in susceptibility to ps ychos is (when other two character are low), or, on the other hand, it may predispose to creativity (when other two character traits are high). High self-directedness is not always protective agains t personality disorder. S ome narcis sistic and antis ocial persons can be s elf-sufficient, res ourceful, and but can s till be maladapted because of low cooperativeness (e.g., intolerance of others , revengefulnes s, and low empathy). 2734 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Once the probability for the pres ence of pers onality disorder is es tablis hed bas ed on character, traits are used for differential diagnosis. Membership in C lus ter A (aloof, eccentric pers onalities) is mos t clearly determined by low reward dependence (des cribed as social detachment). Members hip in C luster B erratic pers onalities ) is most clearly determined by high novelty seeking (described as impulsivity). Membership C lus ter C (anxious, fearful personalities) is determined high harm avoidance (described as fearfulnes s) (T able 16). R ecent data indicate that pers is tence predicts obses sive-compuls ive traits. Individual s ubtypes of pers onality disorder are distinguished based on their unique pattern of correlations with temperament traits without any (F ig. 23-8). In other words, clinical pres entation of personality dis order varies along four underlying dimensions , corres ponding to the four temperament of harm avoidance, novelty seeking, reward and persis tence (T able 23-18).

Table 23-18 Quantifiable (Dimens ional) Features of Pers onality Dis order C ons is tent features    Low s elf-directedness 2735 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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      Irres ponsible, blaming       No mature goals       R es ourceless , helpless       P oor s elf-es teem       Undisciplined    Low cooperativeness       Intolerant of others       Lack of empathy       Unhelpful       R evengeful       Unprincipled V ariable features    High pers istence (obsess ive-compuls ive only)    Low reward dependence (odd clus ter only)    High novelty seeking (erratic clus ter only) 2736 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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   High harm avoidance (anxious clus ter only)

T his model does not require arbitrary cut-offs for the presence or absence of personality dis order. disorder can be quantified in terms of degree of or probability of diagnos is can be estimated. As s hown T able 23-19, the probability for the presence or personality dis order bas ed on the s elf-directedness alone ranges from low (approximately 10 percent) to (approximately 95 percent) in clinical s amples .

Table 23-19 Predic tions of Pers onality Dis orders from S elfDirec tednes s S c ores  

 

S elfDirec tednes s

Predic ted Perc ent with

Obs erved with PD

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S cores

PD

f/N

%

44–39

13

4/18

22 ± 0.10

38–34

23

5/17

29 ± 0.11

33–30

33

4/16

25 ± 0.11

29–27

44

8/20

40 ± 0.11

26–23

55

8/19

42 ± 0.11

22–20

66

6/12

50 ± 0.14

19–16

70

14/16

88 ± 0.08

<16

85

17/18

94 ± 0.05

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3.37 + 0.13 (s elf-directedness score). f/N, frequency/number; P D, pers onality disorder.

T his model reconciles some aspects of categorical and dimensional approach to personality dis order. It seven temperament and character dimensions to for individual differences in behavior. T hese interact to create temperament and character (types , profiles, or configurations), which corres pond to categorical DS M subtypes of pers onality disorder (F igs. 3 and 23-4). In other words, this model is dimensional still can be us ed for categorical clinical diagnos is, each temperament and character compos ite profile corres ponds to one clinical category P.2093 of pers onality disorder (in practice, this is us eful for purpos es of description and prediction of cours e). E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > E T IOP AT HO G E NE S IS OF DIS OR DE R

E TIOPATHOGE NE S IS OF 2739 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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PE R S ONAL ITY DIS OR DE R P art of "23 - P ers onality Dis orders " Only a few etiopathogenetic models of pers onality disorder are available. Of thos e, the ps ychodynamic focus es on the effects of early traumatic experiences cons titutionally high dis pos ition to anxiety and anger, whereas the spectrum disorder hypothesis postulates a common etiology of personality syndromes with Axis I disorders . A growing body of evidence points to a nonlinear etiopathogenes is with multiple factors, s uch genetic, neurophys iological, learning, maturational, and cultural, which are fully incorporated into the ps ychobiological model of personality dis order.

S pec trum Dis order Hypothes is E choing E rnest K retchmer's work from many decades some experts s till cons ider subtypes of personality disorders as minor variants of major Axis I s yndromes. Indeed, most Axis I disorders have their les s severe or re pre s e ntative s on Axis II. F or example, represented by schizoid personality dis order, disorder is repres ented by paranoid personality social phobia is repres ented by avoidant pers onality disorder, cyclothymia is represented by the group of emotionally uns table C luster B personality dis orders, so forth (T able 23-14). T hese Axis I and Axis II dis orders are similar and are frequently differentiated based only on severity of their clinical presentation. T he 2740 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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nature of this Axis I–Axis II relationship has not been es tablis hed, as ide from the obvious s ymptomatic similarity. Axis II disorders might be predisposing premorbid features , or s ubclinical express ion of Axis I disorders . T heir common etiopathogenes is , however, is still an open ques tion. S o far, a close etiological relations hip has been s upported only for s chizotypal personality and the s pectrum of schizophrenia.

P s yc hodynamic Model of Dis order T he central idea behind this model is that pers onality disorder s ubtypes , clas sified as separate nosological reflect different behavioral express ions of the same deficit in personality. T he so-called borderline level of personality organization has been pos tulated to the nucleus s hared by most subtypes of personality disorder. As defined by Otto K ernberg, the borderline le ve l of pe rs onality organization is characterized by nons pe cific manife s tations of e go we akne s s (s uch as lack of control, lack of anxiety tolerance, and lack of potentials ), s pecific e go de fects (manifes ted as partially blurred s elf-object boundaries , mild to moderate proces s thinking, and periodically distorted reality partial object re lations (manifes ted as alternations all good and all bad perceptions of the s elf and external objects), primitive de fens e mechanis ms (centered splitting), and ide ntity dis turbance . In addition, an inadequately developed s uperego is sadistic (e.g., obses sive pers onalities ) or rigid in s ome but is absent in other areas, permitting conflict-free 2741 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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of impulses and behaviors. Immature defenses and a fragmentary self-concept are similar to the previously described borderline personality organization) are a normal early phase in mental development. In the cas e of pers onality however, this early developmental phas e pathologically persis ts in later periods . E tiologically, this pathological persis tence is pos tulated to reflect cons titutional factors (e.g., poor anxiety tolerance, high aggres sivity, and vulnerability to certain affects ) or environmental factors (e.g., early s eparation, loss of a parent, physical mental abuse, and neglect). According to the theory, s uch traumatic etiological generate aggres sively charged, negative of the self and external objects , which are incorporated into the internal world. T his , in turn, interferes with the crys tallization of the early ego, which normally occurs around positive, libidinally cathected representations of the self and external objects . In words , normal early motivation and growth are around pos itive primary emotions, particularly interest joy. It is the relative predominance of strong negative emotions , particularly anger and fear, that interferes normal development. As a consequence, primitive defens es (splitting and the related defenses), which are normally predominant in this early phas e of life, pathologically pers is t in the inner world and interfere normal development. More mature defens es, such as repress ion, require more energy for their operation splitting (e.g., repres sion requires at least as much for its P.2094 2742 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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operation as is contained in unacceptable impulses). In contrast, splitting s imply keeps oppos ite good and bad self-representations and object repres entations apart each other. As K ernberg pointed out, splitting and early ego weakness mutually perpetuate each other. B y protecting pos itive self-representations and object representations, that is, keeping them apart from their negative analogs , primitive defens es ensure at least development around positive experiences but interfere with neutralization of aggress ion and fear. T hese emotions and their related impulses (or a chaotic combination of pregenital and genital ones ) pers is t as dominant motivators of behavior and significantly interfere with normal pers onality development.

C ore of All P ers onality Dis order C linically, the borderline personality organization is observed as [black right-pointing arrowhead]C hronic freeanxiety [black right-pointing arrowhead]P olys ymptomatic neuros is (e.g., multiple phobias related to one's or appearance, bizarre convers ion s ymptoms, diss ociative reactions, and hypochondrias is ) [black right-pointing arrowhead]P olymorphous pervers e s exual trends (e.g., coexis tence of genital pregenital elements and bizarre forms of involving aggress ion) [black right-pointing arrowhead]P oor impulse 2743 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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and addictions [black right-pointing arrowhead]S hift toward primary proces s thinking (magical thinking and primitive fantas ies ) [black right-pointing arrowhead]P artially impaired reality testing Note, however, that the previously mentioned are not unique to individuals with borderline personality but are shared by other s ubtypes of pers onality J ames R eich and Allen F rances have shown that “the diagnosis of borderline pers onality organization is es sentially equivalent to the diagnos is of pers onality disorder (any s ubtype).” Likewise, a hierarchical cluster analysis of identical and fraternal twins , their siblings, their parents s howed that 12 DS M-IV -T R personality disorder s ubtypes can be grouped into eight heritable syndromes, which can be further aggregated into one group clos ely corres ponding to the previously borderline pers onality organization. C hris topher P erry and G eorge V aillant wrote: “J ust as pus, and callus formation are the body's physiological reactions to ins ults of disease, personality dis orders reflects pers ons ' efforts to heal thems elves .” Indeed, a personality dis order reflects a pers on's attempt to overcome its underlying fragility through maladaptive, purpos eful, behaviors . T hese maladaptive behaviors referred to as purpos e ful, because they compens ate fragility and pronenes s to decompensation as sociated with the borderline nucleus . P ers ons with personality disorder become less fragile, because the pers onality deviation (e.g., narciss ism) takes over as the principal 2744 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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motivator of behaviors, but more abnormal, because an already immature pers onality is further impaired by additional distortions of s elf-representations and object representations. T hese compensatory behaviors can have different symptomatic s et-up (e.g., avoidant, paranoid, schizoid, and dependent). Note that compensatory behavior s tyles help clas sify a s yndrome regarding its descriptive label (e.g., avoidant and antis ocial) but tell about the real character of the dis order underlying the descriptive label. C ompensatory behavior s tyles reflect internal factors (e.g., fearfulness causes avoidant symptoms) and external factors (e.g., s ocial class antis ocial behaviors ). In other words, depending on cons titutional and environmental factors, pers ons with borderline level of personality organization create the clinical picture of their personality dis order. A s ubgroup of borderline patients manifes t the core symptoms, for example, s tormy affects, vague identity, unstable relationships , in a rather s table way (s table ins tability). T hes e patients are fragile and prone to fragmentation but do not develop any compensatory behavior facade to protect their fragility. S ome of them can periodically mimic behaviors of any personality disorder s ubtype (avoidant, antisocial, and obsess ive) temporary, chameleon-like solution to their chronic internal problems . T he described compens atory proces s generates a twolevel personality structure with the dominant compens atory s elf-concept and the s plit-off real selfconcept. C ons equently, clinical express ion of disorder is dominated by overt, prototypical behaviors, 2745 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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a s et of s ubtle and covert s ymptoms and signs with the underlying borderline nucleus is regularly observed in the clinical picture. T hes e difficult-to-detect symptoms are overlooked in the DS M s ys tem as criteria of pers onality disorder. F or example, clinical presentation of narcis sistic pers onality is dominated by grandiose self, a deviant s elf-concept that generates unrealistic sense of one's specialnes s, entitlement, arrogance, and other prototypical narciss istic behaviors (included in the DS M-IV -T R description of this T he hidden real self of a narciss is tic person is through chronic feelings of inferiority, hypochondrias is , envy, and pess imism that are not included in the DS MT R description of this dis order, even though they accompany and sometimes even dominate clinical presentation of pathological narcis sism. S imilar overt cove rt clinical features have been establis hed for other personality dis orders as well.

S ome C onc eptual and Is s ues F rom the s tandpoint of its diagnostic validity, the borderline level of pers onality organization can be distinguished from the s chizophrenic spectrum but less reliably from affective s yndromes. C learly, the same immature personality proces ses that increase the susceptibility to deviant behaviors may also increase susceptibility to mood disorders . In many cas es, mood disorders and pers onality disorder are comorbid and be interwoven to the extent that no meaningful between them can be made (as implied in concepts of depres sive pers onality, hysteroid dysphoria, or 2746 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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characterological depres sion). An increas ing number of ps ychometric tes ts to improve the reliable meas urement of psychodynamic constructs available (e.g., the Defens e S tyle Ques tionnaire and previous ly mentioned K ernberg's S tructural Interview). satis factory diagnostic s tability and dis criminatory in patients diagnosed as borderline pers onality organization have been demons trated. T he ps ychodynamic and the ps ychobiological models define a common denominator (the core fe ature ), extends across discrete subtypes of personality syndromes. T his core feature is the borderline organization in the psychodynamic model and the developed character traits, mos tly self-directedness , in ps ychobiological model. S ymptomatically, low s elfdirectedness and borderline pers onality organization for all practical purposes, identical. F or example, individuals with low s elf-directedness are des cribed as blaming, helpless , irresponsible, and unreliable and as having no internal direction and having difficulties in defining and purs uing stable goals (rather, they tend to experience numerous s hort-term, frequently mutually exclusive, motives, none of which can develop to the of real pers onal s ignificance). It has been shown that self-directedness correlates highly with the use of immature defense mechanis ms , which are central in ps ychodynamic concept of borderline personality. E tiologically, both concepts pos tulate that excess ive negative emotionality, s uch as fear and anger (or high harm avoidance and high novelty s eeking), interferes developmental process es and increas es the P.2095 2747 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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ris k of personality dis order. C learly, the ps ychodynamic concepts can be incorporated into a comprehensive, ps ychobiological understanding of personality dis order.

P s yc hobiologic al S ummary of P ers onality Dis order P sychodynamic unders tanding of personality dis order, shown previous ly, was a us eful first s tep in the unders tanding of human behaviors. However, the ps ychodynamic model neither accounts for nor directions for expanding understanding of the full etiological complexity of personality disorder. In other words , as an etiological theory, the psychodynamic addres ses only a portion of the iceberg representing deviant behaviors. However, as a treatment tool, its unders tanding of emotional and cognitive process es behind deviant behaviors is effectively us ed in the of personality dis order, es pecially in reorganizing internalized concepts about the s elf and the external world. P s ychodynamic s trategies are an integral part of comprehensive psychobiological approach to the treatment of personality disorder. In contras t, modern ps ychobiology of behaviors an integrative, multifactorial, and developmental etiological model of personality and its disorders . T he ps ychobiological approach is based on four etiopathogenetic pers pectives —genetic, neurophys iological, learning, and phenomenological— which interact in a nonlinear way to produce differences in cognitive s tyles and behavior traits . P sychobiology of temperament and character traits is 2748 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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discuss ed throughout this chapter (see T ables 23-2, 23-4, 23-5, 23-6 for a review). Nonlinear s elfcharacter is dis cus sed in the section on development. Diagnos tic and treatment implications are dis cus sed in corres ponding sections . G enetic and environmental factors interact in complex ways to influence the ris k of personality dis order. genetic observations about twins, adoptees, and are explained by the hypothesis that there is inheritance of underlying personality dimens ions that influence the risk of personality dis order, rather than separate inheritance of individual personality dis order subtypes . As a reminder, more than one-half of the variance in the four major temperament traits is T hese temperament traits determine one's specific neurochemical process es , which, in turn, individual differences in bas ic emotions and influence early learning characteris tics. T hes e temperament have their dis sociable genetic, neurobiological, and phenomenological correlates (T ables 23-2, 23-3, 23-4, 23-6). T he antecedent temperament factors, along with systematic cultural bias es and random life events , influence character development, repres ented as internalized concepts about the self and the external world. As s hown in T able 23-20, various temperament types affect differentially one's risk of immature and personality dis order. S ome configurations, mos tly those with high reward dependence, are protective agains t personality dis order, whereas some increas e ris k (e.g., the explos ive or borderline profile with low reward dependence and high novelty s eeking and 2749 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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avoidance). C ontrary to the common belief, average on the temperament dimensions do not protect against maladaptation and immaturity. P eople with average temperament traits have an average (not a decreas ed) of pers onality disorder (T able 23-20).

Table 23-20 R elative R is k of Pers onality Dis order as a of Temperament Type in a from the General C ommunity Temperament C onfiguration N Type

Immature (%)

High ris k B orderline

NHr

39

72

Obsess ional

nHr

44

59

Antisocial

Nhr

25

48

P as siveaggres sive

NHR

30

40

Average ris k

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Average profile

—

15

33

Avoidant

nHR

30

17

S chizoid

nhr

31

16

His trionic

NhR

50

12

R eliable

nhR

36

6

T otal

—

300

33

Low ris k

Note: Lower case letters (h, n, r) and capital N, R ) indicate low and high values for traits. H, harm avoidance; N, novelty seeking; R , reward dependence. E xtreme temperament variants are not necess arily indicative of personality dis order. T hey are expected to as sociated with long-term personal, social, or impairments , or a combination of these, that warrant personality dis order diagnos is only when accompanied low character traits. In other words, poorly developed character is what makes some behavior traits 2751 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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and increases the ris k of personality dis order. An high in novelty seeking and low in harm avoidance may have an impulsive pers onality disorder if he or s he is self-directedness and cooperativeness , or may be an inquisitive scientis t without pers onality disorder if he or she is s elf-directed and cooperative. Mature character (i.e., mature concepts about one's self and the external world) optimize adaptation of temperament (i.e., bas ic emotionality) to the environment by reducing discrepancies between one's emotional needs and favoring s ocial pres sures. In pers onality disorder, character traits and extreme temperament mutually perpetuate each other. T he concepts of temperament and character are to decompose the s ymptoms of pers onality disorder the common features, shared by all personality and distinguishing features that permit the among pers onality disorder clusters and individual subtypes . T his is not poss ible for models that confound temperament and character. T his als o indicates that personality dis order reflects deviations in temperament and character, that is , in emotional and conceptual personality process es . E xtreme temperament traits and their as sociated emotions of fear, anger, and detachment are motivationally monopolis tic, that is, they persist as dominant motivators of behavior and interfere with character development and maturation. In s ome cas es, personality s tabilizes at this level of pers onality (this is obs erved as maladaptation). P ersonality represents a point of developmental s tability for many individuals , as it involves maladaptation, that is , deviant 2752 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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poor adaptation (but still some adaptation) to the local environment. In other words, pers onality disorder represents a s uboptimal developmental outcome, with es tablis hed, although maladaptive, personal and s ocial roles, support network, etc. T hese s uboptimal which are clearly maladaptive relative to the pos sible maximum for that individual, tend to be s table (to res ist change). T he s tability of outcomes that are not optimal (i.e., they are maladaptive relative to the global optimum pos sible for that individual) occurs because step in personality development mus t increase the P.2096 adaptive fitness of the organis m, s o that it is more succes sful in balancing multiple internal and external cons traints. In other words , the s earch for higher maxima is dis couraged by the necess ity of initially decreasing in overall fitness (the earlier mentioned Ushaped developmental pattern). B ehavior geneticists have demons trated that the effect sociocultural factors on personality appears les s than that of genetic factors, influencing succes s in adaptation rather than its form or personality s tyle. T his cons istent with recent findings about the importance of family and local culture in character development. environment does not influence temperament but explains approximately 35 percent of variability of character traits. Hence, ps ychos ocial dis organization in rearing environment of a child has a substantial on the ris k of pers onality disorders . T his is ess ential for preventive s trategies , as even temperament configurations with high risk of pers onality disorder 2753 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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be overcome in homes and communities that provide security and limits on behavior in a warm, manner, as well as encouraging s elf-directed choice the value of res pect for other people. P ers onality disorder is ass ociated with younger age. indicates maturation (i.e., remis sion of deviant with increasing age. In general, three dimens ions of personality change substantially with age. Novelty decreases with age by approximately 18 percent, s o older individuals become les s impuls ive (more less rule breaking (more orderly), and less quick (more s toical). C ooperativenes s increas es markedly in children during s chool age and then increases by 12 percent on average after 18 years of age. S elfincreases markedly in most people during adoles cence and young adulthood, increas ing on average by 9 after 18 years of age. T he decreasing prevalence of personality dis order with age is attributable to the increas ed development of directedness and cooperativeness with age. T he tendency for novelty seeking to decrease with age explains the finding that patients with impuls ive personality disorders show more improvement than with anxious or eccentric personality disorders . T he documented finding about change in deviant behaviors the remis sion of criminal behavior in individuals with antis ocial pers onality disorder. T hes e individuals nearly always remained impuls ive (high novelty s eeking), ris k taking (low harm avoidance), and aloof (low reward dependence) but became mature enough to maintain work and family life in a stable manner. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di

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C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > T R E AT ME N

TR E ATME NT P art of "23 - P ers onality Dis orders " Most individuals with personality dis order perceive their lifes tyles as normal and s eldom seek or accept T ypically, they s eek help when their maladaptive culminate in severe marital, family, and career for comorbid anxiety, depres sion, s ubstance abuse, or eating disorders . T emperament traits are primarily treated by pharmacological intervention. G iven the importance of as sociative learning in the development of some ps ychotherapeutic correction is poss ible, us ing behavioral techniques. Alternatively, drugs rarely induce changes in character, which is amenable to psychotherapeutic intervention. C haracter optimizes adaptation of temperament to the because it modulates the s alience of percepts and emotions , thereby reducing the maladaptive impact of extreme temperament traits. E xtreme temperament immature character traits are optimally treated simultaneously with combined ps ychotherapy and pharmacotherapy.

P s yc hotherapy It is hard to find a ps ychotherapeutic method that has been tried to treat personality dis order. E ach s chool of ps ychotherapy provides a s pecific unders tanding of behavior and a particular method of intervention. In 2755 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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practice, different schools are not mutually exclus ive overlap and complement one another. Dynamic ps ychotherapy address es the internal world of the patient's emotions and needs and treats s ymptoms as external manifes tations of internal motivations . therapy focus es on external manifestations (or and enables patients to change behavior or to achieve better control of their behaviors . C ognitive therapy patients correct their dis torted cognitive appraisal of the significance of environmental cues and their underlying core beliefs that lead to maladaptive behaviors. Humanistic approaches, by increas ing selfand cooperativeness , as sist patients in achieving and s ocial maturity in a form of altruis tic individualis m. one of the previously mentioned goals is invariably correct, and each orientation is expected to make a specific contribution to the overall efficacy of treatment. T his s eems to be es pecially relevant to personality disorder, where both the reduction of internal and the improvement of s ocial functioning are equally important. F or example, a combination of dynamic therapy (which is ins ight oriented) and cognitivebehavioral therapy (which is action oriented) efficiently helps patients trans form their insights into an actual behavior change. R ecently, dialectical behavior based on a biosocial theory that borderline symptoms reflect primarily a dysfunction of the emotion regulation system, has s hown effectiveness in reducing the core symptoms and improving the s ocial adjustment of borderline patients . A growing number of therapis ts are beginning to ignore ideological barriers dividing schools of ps ychotherapy and are attempting technical synthes is (eclecticism) and theoretical s ynthes is 2756 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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(integration) of various orientations (this is called integrative -ecle ctic ps ychotherapy). C ombinations of various orientations and formats and emphasis on team work are optimal in the of pers onality disorder. S ome bas ic rules and values strictly obs erved, however. P robably the mos t crucial is a s table therapeutic relationship with cons istency reliability of care. B ehavior and feelings are the primary focus of psychotherapy and are the principal language communication. T he therapist is active and uses highenergy confrontation and care (the rape utic pre s s ing). central mess age is always doing s omething with the patient, not s omething to the patient. T his way, the feels somewhat in control, which might keep him or her treatment. R eflecting their s plitting mechanism, these patients alternatively feel inferior and omnipotent, at others and self-destructive, sensitive to rejection but us ually provoking it. F lexibility in approach, but basic values, with creativity and readiness to step away from the rules to get out of thes e frustrating no-way-out situations is ess ential. Many of these patients can not tolerate feeling better, as this means that the therapis t succes sful. T hese and similar frustrative s ituations countertransference problems with a potential los s of profes sional objectivity; constant s upervision and a support network are therefore necess ary. One s hould in mind, however, that thes e patients are almost never good as they look when they are doing well and are never as bad as they look when they are not doing Of note, pure s upportive psychotherapy is rarely used personality dis order, becaus e it encourages exis ting coping s tyles (which are, by definition, maladaptive in 2757 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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personality dis order), and this often reinforces the problems of thes e patients. Modified s upportive (s upporting the motivation to change, not the coping mechanisms) can be us ed as the initial phas e of during the contract and trus t building phase. T he ps ychobiological approach is eclectic and these s trategies into a comprehensive treatment plan aimed at stimulating character development, primarily self-directedness and cooperativeness . P.2097 T he primary focus is changes in internalized the self and the external objects , that is, concepts self, society, and the world as a whole. T his is with cognitive methods (aimed at identifying and these concepts and their underlying emotions ) or with dynamic methods (aimed at stimulating maturation of internalized object relations), or, frequently, with a combination of the two. Dynamic and cognitive are complemented by behavior modification and experiential techniques , which are efficient in insights into actual behavioral changes . In the course of therapy, as character matures and new concepts and their ass ociated s econdary emotions develop, they neutralize extreme temperament traits their related basic emotions of fear and anger. change accordingly, from being primarily reactive, that steered by basic emotions and automatic responses regulated by temperament, to being primarily proactive, that is , s teered predominantly by s econdary emotions active s ymbolic cons tructs regulated by character 2758 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Prac tic al Is s ues P sychotherapy of pers onality disorder is a specific rather than a strictly defined method, becaus e the takes place cons tantly (during any and every kind of contact with the patient), not only during the ps ychotherapy s es sions proper. In fact, what is between the s ess ions may be critical for the outcome the treatment. W ith thes e patients , ps ychotherapy es sentially means reparenting, which, although demanding, leaves space for various types of interventions , s uch as education, help with real life problems , and encouragement. F requent s ess ions week) are needed to develop trus t and interactions complex enough to be us eful for diagnostic and purpos es. P atients with personality dis order are required to clarify their goals in treatment. T hes e may vary from s imple concrete (e.g., to reduce alcohol use) to more complex (e.g., to become independent) and ambitious (e.g., to able to love) but never general (e.g., to be happy). T he therapist evaluates each treatment goal and the likelihood of succes sful outcome. T here has to be least one area in which the therapist and the patient agreement regarding these goals. It is of critical importance to unders tand that not every patient with personality dis order can be helped to achieve his or goals . In general, most patients who have never had a meaningful relations hip with at leas t one person are likely to benefit from ps ychotherapy. Additional prognos tic factors are the patient's intelligence quotient (IQ), his or her ps ychological mindednes s (i.e., self-awarenes s), the training and competency of the 2759 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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therapist, and the compatibility of desired treatment with bas eline pers onality characteristics . As shown in F igures 23-5, 23-6 23-7, one temperament may lead to s everal, but not all, of the eight poss ible character outcomes. Obviously, s ome treatment goals, chos en by individuals with incompatible temperament traits, simply might not be achievable. In general, treatment outcomes are clas sified as ideal, optimal, or compromises. Ideal outcomes corres pond to concepts an ideally mature personality with a full development of three character traits. T hes e outcomes are not always poss ible, es pecially for patients with pers onality who usually have temperament configurations that are incompatible with high s cores on all character However, whenever poss ible, ideal outcomes are as the ultimate standard of maturity. More frequently, treatment is planned to enable the patient to achieve best poss ible adaptation for his or her given traits. T his is called an optimal characte r outcome . If, reason, optimal outcome cannot be achieved, the alternative is the s o-called compromise outcome that improves the patient's adaptation compared to the one baseline but does not achieve the optimal adaptation poss ible for that patient. F or patients who are unlikely to benefit from ps ychotherapy, s ymptom control might be achieved through pharmacological intervention only. In addition, many areas of everyday life, s uch as friends hips, relations hips , media, education, and valued life opportunities (e.g., stable marriage, work-related and religious conversion), increas e their chances for maturation. T he emergent changes are often sudden 2760 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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are as sociated with a new perspective on life and new goals and values, which cannot be achieved by logic, medication, or advice alone. At leas t initially, the therapy is s upplemented by as structuring of the patient's life as needed. T his may from directed behaviors , to day-hospital programs , to hospitalization. If complications occur, additional structuring is often needed, s uch as phone calls or sess ions. S tructuring, advice, and logic are not generate personality change but only to temporarily improve behavior control. As K ernberg noted, ps ychotherapy begins where common sens e ends. P rolonged s tructuring robs the patient of the to become more s elf-reliant or to learn from his or her failure to do s o. T hese patients us ually want psychotherapy “their way,” with many conditions and ultimatums. T hey rarely manifest a s trong pers onal motivation to change. In they frequently minimize or deny the existence of even serious problems , s uch as a s uicide attempt. T hese spots for the patient's own problems reflect the fact that these patients, s ince early age, have developed mechanisms to avoid dis turbing feelings and insights. Hence, they generally feel a much lower level of with their s ymptoms than would be experienced by a mature pers on in a similar s ituation. C onfrontations interpretations !) are us ed to increase the level of the patient's discomfort with his or her own s ymptoms, then improves their recognition of these s ymptoms and their motivation to change them. Of note, mos t of thes e patients tolerate confrontations well, provided that they trus t their therapis t. T hey need an extraordinarily high 2761 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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level of stimulation (s ometimes achieved through confrontations ) in any relations hip, including their T his hunger for s timuli us ually can be recognized in childhood and may be related to lack of stimulation (neglect) or extreme s timulation (abuse) by their caretakers . R es istance to change is strong in patients with disorder, whose symptoms reflect their attempt to overcome internal fragility through compens atory behaviors . T he achieved compens atory facade schizoid, antis ocial, etc.) is maladaptive but stable. In ps ychotherapy, thes e patients are expected to give up their purpos eful, if maladaptive, behavior traits. In the proces s, they temporarily become similar to the core borderline patients without any behavioral for their fragility. In other words, most patients with personality disorder first have to regress to a more primitive (but less deviant) level of personality organization and then develop more mature object relations and better-adapted personality traits . T his progres s ive re gres s ion or back-to-the -future s trategy directly from the already mentioned U-shaped developmental pattern, in which better adaptation can achieved only after an initial decreas e in current adaptation. E ach personality dis order subtype requires specific modifications and careful timing of this strategy addres s their distinguishing symptomatic facade and specific s ocial deviations . G roup therapy is generally considered us eful for personality disorders , as it expos es and treats their deviance. It is usually done in conjunction with therapy, and, often, individual therapy elaborates 2762 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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experiences from group s es sions.

P harmac otherapy A growing body of evidence demons trates that pharmacotherapy is at leas t equally important to ps ychotherapy P.2098 in the overall treatment of pers onality disorder. P harmacotherapy is (1) causal, aimed at correcting neurobiological dispositions to underlying deviant traits , or (2) symptomatic, aimed at correcting target of pers onality disorder.

C aus al Pharmac otherapy of Dis order T he central idea behind caus al pharmacotherapy is enduring personality changes may res ult from pharmacological manipulation of the underlying dispositions to deviant traits (als o called trait In other words , pharmacotherapy is expected to modify neurophys iological systems that regulate affects and learning s tyles. T his, in turn, is expected to reduce affective and learning process es and, ultimately, in cognitive and behavioral s ymptoms of personality disorder. In contras t to factor-analytically derived models , ps ychobiological models provide tes table guidelines for the pharmacological manipulation of the underlying neurochemical trait vulnerability. As noted previously, harm avoidance, novelty s eeking, and reward are pos tulated to reflect differences in the C NS 2763 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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serotoninergic, dopaminergic, and noradrenergic with implications for pharmacological management of these traits. P harmacological trials , bas ed on thes e similar pos tulates , might lead to what S ollof calls pharmacological dis s e ction of the underlying biological vulnerabilities . F or illustration, the following few of causal pharmacotherapy are provided: R es pons es to antidepress ants of different patients major depres sion can be predicted by their temperament to a s ubs tantial degree, not by the number, type, severity, or cours e of their symptoms. P atients who are highly sensitive to approval (i.e., who are high in reward dependence) most likely to improve on S S R Is. In contrast, those are highly fearful but not s ocially dependent are likely to improve on noradrenergic uptake inhibitors, such as des ipramine (Norpramin). C hildren with ADHD (who are high in novelty and low in dopaminergic activity) are efficiently treated with drugs that increase dopamine releas e, such as methylphenidate. C entral s erotoninergic mediation is important in obses sive-compuls ive behaviors , characterized by harm avoidance (postulated to reflect high serotonergic activity). T hes e behaviors are drugs that change serotoninergic system activity, as S S R Is. As noted by Liebowitz, cerebrospinal (C S F ) findings show high basal s erotoninergic in obs es sive patients who respond to s erotonin reuptake blockers, and normalization of s erotonin activity after chronic treatment (the treatment 2764 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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suppress es serotonin activity presumably by posts ynaptic s erotonin sensitivity). Most of the presented treatment s trategies are still tentative and experimental and need further tes ting. However, they are bas ed on modern biology of and provide guidelines that may potentially lead to a better unders tanding of biological vulnerabilities underlying deviant pers onality traits and to a more prescriptive relationship between diagnosis and of pers onality disorder.

S ymptomatic Pharmac otherapy of Pers onality Dis order P harmacotherapy cannot be us efully organized around individual s ubtypes of pers onality disorder for s everal reasons. F irs t, the efficiency of drug treatments is best evaluated at a symptom level, not at the s yndrome S econd, the target s ymptoms likely to res pond to particular drugs are not unique to any s ubtype but are shared by various s ubtypes of pers onality disorder. the state-trait effect tends to interfere with efficient evaluation of pharmacotherapy of personality which are frequently comorbid with mood and anxiety states . F ourth, some of the clas sified pers onality subtypes are heterogenous compos ites that can be subtyped into one or more s ubcategories, each requiring s pecific pharmacotherapy. P henotypic s imilarity between s ome Axis II and Axis I syndromes (T able 23-14) explains the attempts to treat patients with personality dis order with drugs proven efficient for the corres ponding Axis I disorders . 2765 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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common pathogenes is for the Axis I syndromes and corres ponding Axis II counterparts has not been es tablis hed, leaving open to ques tion the validity of treatments by analogy. S uch treatments are neither driven nor hypothesis testing, and none has proven efficient and long las ting for pers onality disorder. S ymptomatic treatments are s till the s tandard of care these patients. P harmacological intervention is us ually focus ed on acute symptoms (e.g., s uicidal tendency agitation), but an increas ing number of authors treatment of chronic pathology (e.g., impuls ivenes s and affective dysregulation) in addition to the acute treatments . In that regard, mos t authors agree that are three symptom domains that underlie chronic pathology of personality dis order. T hese include (1) aggres sion and behavioral dys control; (2) affective symptoms, anxiety, and mood dyscontrol; and (3) cognitive-perceptual distortions, including psychotic symptoms. T hese three chronic s ymptom domains clinically corres pond to the underlying temperament dimens ions and to DS M-IV -T R clus ters of pers onality disorder: novelty seeking and C luster B disorders correspond to aggres sion and behavior dyscontrol domain, high harm avoidance and C luster C disorders correspond to the anxiety and depress ion domain, and low reward dependence and C luster A disorders correspond to the domain of detachment, and cognitive disturbances. In other words, the identification of these chronic target symptom domains has narrowed the gap between and s ymptomatic pharmacotherapy of personality disorder. Of note, cognitive dis turbance s , as defined by 2766 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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most authors, refer to magical thinking, odd beliefs, illus ions, and chronic, low-grade psychotic symptoms observable primarily in the schizotypal pers onality disorder. Note that every personality disorder s ubtype manifests cognitive disturbances and a dis torted perception of reality because of the underlying learning and emotional biases. T hes e disturbances are called nonps ychotic thought dis order or partial los s of te s ting. T he interaction between biological and ps ychological factors in deviant behaviors is complex. F or example, disposition to aggress ion may caus e s plitting, which, in turn, prevents neutralization of aggres sion. One way to interrupt the feedback mechanis ms by which biology and psychology perpetuate each other is to combine drug treatment of the underlying biological vulnerability with ps ychotherapy of the as sociated ps ychological mechanis ms . Hence, pers onality optimally treated with combined pharmacotherapy and ps ychotherapy. P harmacological treatment of the four target symptom domains is nons pecific, as medications regularly affect target s ymptom domain and other s ymptom domains . T his nons pecificity may reflect many factors , such as equifinality phenomenon, in which s imilar behaviors derive from different underlying antecedents , or the nonspecific action profile of the drug, affecting s everal neurophys iological systems at the same time. More sophisticated, receptor-specific drugs might help some of the ques tions in this regard. In what follows, symptomatic pharmacological management of and impulsivity, mood dysregulation, and cognitive 2767 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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disturbances is des cribed in more detail. P.2099

A G G R E S S ION It is useful, although s ometimes difficult, to distinguish different types of aggress ion. T he most common form aggres sion occurs when a quick-tempered person is provoked by frus tration or threats. T his is called aggres s ion and is frequent in impulsive-aggres sive individuals . B iological correlates of impulsive and poor behavior inhibition include low C S F 5hydroxyindoleacetic acid (5-HIAA) and altered neurotransmis sion. Unprovoked aggres sion can occur patients with cerebral ins tability documented by an abnormal electroencephalogram (E E G ) (s o-called ictal aggres sion), regardles s of any as sociated pers onality P redatory aggres sion or cruelty involves hostile revengefulnes s and taking pleasure in victimizing often with intact impulse control; s uch predatory aggres sion is mos t frequent in individuals who are low cooperativeness , which is mos t likely in antisocial and borderline personalities. Lastly, organic-like impuls ivity and aggres sion are often accompanied by poor s ocial judgment. It is distinguis hed from other impulsiveaggres sive s yndromes by prominent dis tractibility, inattention, emotional lability, and high s omatic anxiety with panic and cardiorespiratory s ymptoms, often s een patients with frontal lobe lesions . Multiple double-blind trials have s hown that lithium (E skalith) reduces affective display and aggres sion in normal subjects and impulsive-aggres sive individuals. 2768 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Anticonvulsant mood stabilizers, such as (T egretol), valproates, lamotrigine (Lamictal), (Neurontin), tiagabine (G abitril), or topiramate reduce the intens ity and the frequency of unprovoked angry outbursts, improve behavior dys control, and anxiety and suicidal tendency in s ome patients, of normality of their E E G . Note the nons pecific effect of anticonvuls ant mood s tabilizers , which, in addition to target s ymptom domain of impulsivity, also affect other chronic s ymptom domains and acute manifestations. Anticonvulsants are recommended for ictal aggress ion because of frequent tolerance to anticonvulsive effects benzodiazepines. Double-blind trials have s hown that dopaminergic ps ychos timulants , s uch as methylphenidate, are in the treatment of inattentive and hyperactive adults are aggress ive, especially when the symptoms have in early childhood. C ons is tent with the pos tulated serotoninergic in impulsive aggress ion, antidepres sants (mostly beneficial for some chronically impulsive subtypes of personality dis order (e.g., borderline). In many cases, in addition to expected improvements in depress ed and impulsivity, als o nons pecifically improve affective lability, rejection s ens itivity, impuls ivenes s, selfand ps ychos is . Monoamine oxidas e inhibitors (MAOIs), such as tranylcypromine (P arnate), are effective in cases of hysteroid dys phoria with s omatic anxiety, and destructive impulsivity. T he organic aggres sion may res pond to imipramine (Norfranil), ps ychostimulants (e.g., methylphenidate), some of the novel cholinergic agonists (donepezil 2769 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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or galantamine [R eminyl]). β-B lockers have also been shown to reduce aggress ion and violence in patients dementia, brain injury, s chizophrenia, mental and organic brain syndrome. Low-dose new neuroleptics may be us eful in modifying affective or predatory aggress ion in some cas es. A of neuroleptics, from thioridazine (Mellaril) to (Haldol), have been used in dos es that are much lower than those for psychoses (full antips ychotic dosages generally not proven us eful). T he usefulness of new atypical neuroleptics for aggres sive behaviors has yet es tablis hed. In general, neuroleptics are us ed with and for a s hort term to avoid potentially irrevers ible movement s ide effects . Als o, dose adjustment is maintain compliance, becaus e patients with personality disorder poorly tolerate s ide effects . T here are s ome relative contraindications in pharmacological treatment of impulsivity and F or example, lithium (E skalith) should not be given to antis ocial pers ons without aggress ion and impuls ivity; it does not diminis h nonaggres sive antisocial behaviors (s uch as lying or s tealing). It is also poorly tolerated by anxious schizoid individuals . Likewise, and alcohol have disinhibiting effects on violence, conditioned avoidance behavior (loos en inhibitions ), further impair pass ive avoidance learning in impuls ive antis ocial pers ons . T he us e of benzodiazepines s eems appropriate only in nonaggres sive, dys social for example, s chizoid personalities. In s ome borderline patients, carbamazepine has been cons idered to be behaviorally toxic, because it s eemed to precipitate melancholic depres sion. 2770 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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MOOD DY S R E G UL A TION T arget s ymptoms in the domain of mood dysregulation include emotional instability, emotional detachment, depres sion, and dys phoria. E motional ins tability and mood swings are respons ive lithium and a spectrum of anticonvuls ants , for example lamotrigine, carbamazepine, gabapentin, tiagabine, or valproates . Low-dose neuroleptics, s uch as also have a mood s tabilizing effect. R ecently, a number novel antipsychotics have been approved for mood stabilization (olanzapine [Zyprexa] and quetiapine [S eroquel]). C alcium channel blockers (V erapamil) are sometimes useful. T ricyclic antidepres sants (T C As), amitriptyline (E lavil), increas e impulsivity, s uicidal tendency, and as sault in emotionally unstable patients with borderline features and depress ion. T hese paradoxical effects are unrelated to anticholinergic or sedating effects of T C As and are postulated to reflect cognitive and behavioral disorganization under catecholamine s tre s s (i.e., increas ed catecholamine with T C A treatment). E motional detachment, cold and aloof emotions , and disinterest in s ocial relations (chronic as ociality) are of s chizoid, schizotypal, and some antisocial and personalities . In cases in which s ocial withdrawal an underlying depres sion, antidepress ants (S S R Is or MAOIs ) may help. One s hould be cautious with T C As schizotypal personality dis order, for they may worsen ps ychos is . In many cas es, emotional detachment to atypical neuroleptics, s uch as ris peridone quetiapine (S eroquel), olanzapine (Zyprexa), 2771 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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(G eodon), and, es pecially, aripiprazole (Abilify), which reduce social withdrawal and other features of C lus ter A pers onality disorders with les s risk of extrapyramidal s ymptoms than with typical Atypical depress ion and dysphoria, frequently personality dis order, are rarely responsive to T C As , but rather to S S R Is or MAOIs . A lack of specificity of effect also seen with MAOIs and S S R Is in borderline several target symptom domains (impuls ivity, anger, hostility, mood reactivity, hypersomnia, and res ponding to thes e drugs . In fact, at leas t one-half of subjects with pers onality disorder and atypical wors en on T C As . In contras t, typical depress ive which may complicate any pers onality disorder, are treated with antidepress ants , including heterocyclics , in doses s uggested for Axis I major depres sion. neuroleptics are often efficient in treating the affective symptom domain. Low-dose trifluoperazine (S telazine) significantly reduces anxiety, suicidal tendency, depres sion, and rejection s ens itivity. Likewise, (F luanxol Depot) improves recurrent parasuicidal in C luster B patients (the s ame could not be for antidepress ants). T his nonspecific effect has been attributed to reduced depers onalization, improved obses sive rumination, decreas ed sense of P.2100 and decreased paranoid ideation—not improvement in the core s ymptoms of depres sion.

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anxiety. T his makes the s tate–trait distinction difficult— that is , it is not always clear whether a chronic state symptom (anxiety) becomes a stable personality characteristic or vice vers a. T hes e patients often with cognitive anxiety (i.e., anticipatory worrying) and somatic anxiety (i.e., concerns about bodily pains and ps ychophys iological reactions ). C ognitive anxiety is res ponsive to benzodiazepines, whereas s omatic more res ponsive to MAOIs and S S R Is . Again, benzodiazepines have a nons pecific effect, as they tend to improve hostility, s us piciousness , cognitive disturbance, and s leep in borderline patients . T hey can caus e s evere behavior toxicity as well. B uspirone and G AB A analogs have a potentially important role in treatment of anxiety ass ociated with pers onality S ome components of somatic anxiety, s uch as palpitations , diarrhea, and tremor, can be treated with blockers . S evere, ps ychotic-like anxiety res ponds to dose neuroleptics , es pecially atypicals.

C OG NITIVE -P E R C E P TUA L DIS TUR B A NC E S Acute, brief reactive psychoses may complicate mos t subtypes of personality dis order. T hese are treated symptomatically, according to accepted practices . In general, ps ychotic patients with disorder are likely to res pond to and comply with low doses of neuroleptics. Acute psychotic s ymptoms requiring medication may s ubs ide when environmental stress ors are brought under control, thus one s hould ready to lower the dose or to discontinue the S ome personality dis order subtypes , for example, 2773 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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borderline and s chizotypal, manifes t chronic, low-grade cognitive s ymptoms, such as nonps ychotic thought disorder (ideas of reference, magical thinking, odd fantas ies , and s uspicious ness ), unusual perceptual experiences (illus ions ), depers onalization, and eccentric behaviors . T hese chronic, low-level, ps ychotic-like symptoms res pond to low-dose neuroleptics , typical and atypical. S ometimes, chronic cognitive disturbances , s uch as mild ideas of reference suspicious nes s, may s ubs ide when the background emotional tension is reduced by anxiolytics. Neuroleptics also manifest a nonspecific effect, as they improve s everal target symptom domains in borderline and s chizotypal personalities. S pecifically, s ymptoms res ponding most clearly to low-dose neuroleptics are anger, hos tility, suspicious nes s, illusions , ideas of reference, anxiety, and obsess ive-compuls ive T he effect is mos t impress ive when symptoms are which lead some authors to s peculate that thes e drugs might be a nons pecific treatment for s ymptom s everity. T able 23-21 s ummarizes drug choice for various target symptoms of personality disorders .

Table 23-21 Pharmac otherapy of T S ymptom Domains of Pers onal Dis orders Target S ymptom

Drug of

C ontraind

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B ehavior dyscontrol

 

 

   Aggres sion/impuls ivity  

 

      Affective (hot temper with normal E E G )

L ithium

? B enzodiaze

 

S erotone rgic antide pres s ants

 

 

Anticonvuls ants

 

 

Atypical neuroleptics

 

      P redatory (hostility and cruelty)

Atypical ne urole ptics

B enzodiaze

 

Lithium

 

 

β-B lockers

 

      Organic-like aggres sion

Imipramine (T ofranil)

 

 

C holinergic agonis ts (donepezil

 

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[Aricept], galantamine [R eminyl])  

Anticonvulsants

 

      Ictal aggress ion (abnormal E E G )

C arbamaze pine (T e gretol)

Neurole ptic

 

P he nytoin (Dilantin)

 

 

V alproates

 

 

B enzodiazepines  

Mood dys regulation

 

 

   E motional lability

L ithium, lamotrigine (Lamictal)

? T C As

 

Atypicals (olanzapine [Zyprexa] and quetiapine [S eroquel])

 

   Depres sion

 

 

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      Atypical and dysphoria

MAO Is

 

 

S erotone rgic antide pres s ants

 

 

Neuroleptics (zipras idone [G eodon])

 

 

Lamotrigine

 

   E motional

Atypical ne urole ptics (que tiapine [S e roque l], ris pe ridone [R is pe rdal], olanzapine [Zypre xa], aripiprazole [Abilify])

? T C As

 

Zipras idone

 

Anxiety

 

 

   C hronic cognitive

S erotone rgic antide pres s ants

 

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MAO Is

 

B enzodiazepines  

 

G AB A analogs: gabapentin (Neurontin), tiagabine (G abitril)

 

   C hronic s omatic

MAO Is

 

 

β-B lockers

 

 

G AB A analogs: gabapentin (Neurontin), tiagabine (G abitril)

 

   S evere anxiety

Low-dose neuroleptics (atypicals)

 

 

MAO Is

 

P sychotic s ymptoms

 

 

   Acute and brief ps ychos is

Atypical ne urole ptics

 

 

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   C hronic and lowps ychotic-like symptoms

Atypical ne urole ptics

 

Note: Italics indicate drug of choice or major contraindic E E G , electroencephalogram; G AB A, γ-aminobutyric acid monoamine oxidase inhibitor; T C A, tricyclic antidepres s

P s yc hobiologic al Integration of Treatment T he presented psychobiological model distinguis hes components of personality that differ in terms of their etiology, pattern of development, and res ponses to ps ychotherapy and pharmacotherapy. T his provides a foundation for approaching diagnos is and treatment in way that can be generalized to all s ubtypes of disorder but that is s ens itive to differences among individual patients . B as ed on the establis hed structural and clinical characteristics of temperament and as well as pos tulated neurochemical characteris tics of temperament and character, pharmacotherapy and ps ychotherapy can be s ys tematically matched to the personality s tructure and s tage of character of each individual. T his is clearly a unique advantage other available models . As shown previously, development can be des cribed in terms of a s equence 15 character s teps, in which trans formations of 2779 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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values, and emotions occur as a result of complex interactions among heritable predis pos itions , social learning, and individual experiences (T able 23-11). step in development emerges as a consequence of a complex set of nonlinear facilitating and inhibitory influences. A hierarchical model of the different types of underlying problems occurring at each s tep in personality development is shown in T able 23-22. T his is into five levels , which corres pond to deficiencies in the hierarchy of intuitive s ens es (being, freedom, beauty, and goodness ), as described previous ly.

Table 23-22 Hierarc hic al Model Mental Order and Dis order on L evel of Pers onality Development C harac ter Defic its

As s oc iated Mental Health Features

Level 1 (deficient s ens e of being and    [1] C O1—mistrust

S elf-injurious behavior

   [2] S D1—doubt and shame

Hypochondrias is , fibromyalgia 2780

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   [3] S T 1—poor impulse control

E motionally uns table, hopeless

Level 2 (deficient s ens e of freedom and res ponsibility)    [4] S D2—

Unemployment, criminality

   [5] C O2—lack of empathy

P olys ubs tance abus e, irritable bowels

   [6] S T 2—no cons cience

Lack of charity and kindness

Level 3 (deficient s ens e of love and beauty)    [7] S D3—helpless and inept

S ocial insecurity,

   [8] C O3—

R es entment, lack of intimacy

   [9] S T 3—security seeking

Ungiving in attachments and loves

Level 4 (deficient s ens e of truth and faith)    [10] S D4—poor acceptance

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   [11] C O4— revengefulnes s

Hos tility and tens ion

   [12] S T 4—pride

Lack of faith

Level 5 (deficient s ens e of goodness and unity of being)    [13] S D5—

Mastery s eeking and perfectionism

   [14] C O5— unprincipled

Lack of wisdom and being

   [15] S T 5—dualistic

Lack of coherence and virtue

S ubscales are des ignated by S D (s elfC O (cooperativeness ), S T (s elf-transcendence), the number of the s ubs cale s hown in T able 23-11 through 5). P roblems at the firs t level are related to deficiency in intuitive awarenes s of being and the sense of personal permanence. T his is manifes t as difficulties in bas ic (s tep 1) and self-res pect (s tep 2), which are individuals who have a his tory of s exual or phys ical beginning in early infancy. P roblems at this first level of awarenes s lead to highly disorganized dis orders. 2782 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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According to T . B yram K arasu, such patients have characterized as having s evere borderline and disorders with dyadic de ficits , if they are arrested at (which leads to impairments in the s ens e of self along impaired mother–child relations), or dyadic conflicts , if are arres ted at s tep 2 (which leads to s everely object relations , such as difficulty of the child from the mother). S uch fundamental impairments predis pos e to vulnerability to psychosis. S lightly less impaired are patients with triadic de ficits , who are at s tep 3. An arres t at step 3 of level 1 leads to poor impulse control in addition to severe oedipal problems , such as a lack of capacity for intimacy and s ocial commitment. P roblems at the second level are related to a deficient sens e of intuitive awarenes s of freedom and Without self-awarenes s of their own freedom of will, patients have little sense of their own dignity as res ponsible and rational beings . C onsequently, they lack awarenes s of the dignity of others as rational T his leads to severe personality disorders with lack of purpos efulnes s and empathy. T hese individuals are described as having mild borderline and narciss is tic disorders characterized by problematic three-person mother–child–father) relations hips. According to patients who are arres ted at s teps 4 or 5 have triadic conflicts , which lead to mild oedipal conflicts , s uch as inhibited sexuality or impaired internalization of group values. S imilarly, patients at s tep 6 also are lacking in cons cientious nes s and a sense of fairnes s and justice their relations hips. Individuals with deficiencies of s elfawarenes s at level 2 have severe problems in working, 2783 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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socialization, and impulse control. P roblems at the third level are related to a deficient intuitive s ens e of love and beauty. C onsequently, these patients have s ubs tantial problems in their s ens e of emotional security and capacity for intimacy. S uch emotional insecurity is often manifest by jealous y, res entment, insecure attachments, and failure to stable friends hips and marriages. T his is typically as sociated with diagnos es of mood and anxiety Often, it is pos sible to recognize progress through level in terms of the sum of s elf-directedness and cooperativeness , which corresponds to the DS M-IV and F reud's notions of maturity of personality. T he fourth and higher levels involve progres sive steps cognitive and s piritual development among s ocially mature individuals seeking fulfillment of their s ens e of health and well-being. S uch overall personality can be meas ured by the s um of scores on all three character dimens ions, cons is tent with C arl J ung's the self-transcendent leader. T hes e higher levels of personality integration may be ass ociated with ps ychopathology at times of existential cris is .

Prac tic al S trategies As noted previous ly, character development depends the temperament configuration and prior development. T o take s uch information into account, reliable and systematic as sess ments are needed. Once the is in hand, P.2101 it provides efficient guidelines for comprehensive 2784 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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treatment planning specifically tailored for each patient. V arious poss ible character outcomes can be evaluated early in treatment by using nonlinear modeling to alternative outcomes depending on the bas eline conditions and applied interventions . As a general rule, pharmacotherapy is us eful in regulating temperament, whereas different ps ychotherapy techniques are to facilitate particular s teps in development (T able 23A multistep approach is needed, rather than trying to accomplis h all tasks with the s ame technique. T hese developmental observations indicate that the choice of techniques likely to benefit the patient on the stage of personality integration that is manifes t the time of treatment. A brief outline of this integrative ps ychobiological approach is given in T able 23-23.

Table 23-23 Multilevel Program Integrative Ps yc hobiologic al Treatment to Develop C oherenc e of Pers onality Level

Developmental S teps

Methods of Treatment

S upportive-realis tic therapy (to awaken intuitive sens e of being as s ource of hope)

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   [1] T rust in

Acceptance, trust building

 

 

E stablish supportive environment; antips ychotic medication, if

 

 

Detoxification, if needed

 

   [2] S elf-res pect

V alidation

 

 

Maintain safety and support

 

 

T each bas ic living skills and social interdependence

 

   [3] Moderation

Ins truction about temperament

      

      Hope

C ommunicate hope by trus t and optimism

 

 

T each brief exercises

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S et limits and for boundaries

C ognitive-behavioral therapy (to awaken intuitive sens e of freedom and subjective time, as a res ponsibility and kindness )  

   [4] Nonviolence

Anger management; no blaming

 

 

E ncourage res ponsibility

 

 

E xplore goals and role models and make a s earching personal inventory

 

 

Model problemsolving skills for analysis and

 

   [5] F lexibility

S eek freedom from past conditioning

      

      F orbearance

E ncourage helpfulness to

 

   [6] F airness

C ommunicate fairnes s and 2787

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by being fair and  

      K indnes s

Identification with role models

 

 

+ Objectively monitor treatment compliance

 

 

+ P harmacotherapy of impuls ivity, violence, and (e.g., lithium [E s kalith], carbamazepine [T egretol], valproates )

 

 

+ T reatment of comorbid

 

 

+ Deconditioning of poor impulse control by repetitive drills and homework

Nondirective dynamic-humanis tic-interpersonal therapy  

   [7] B enevolence

Nondirective

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discuss ion of for coping with problems , then encourage res ourceful s elfwilled action  

      R es ourcefulnes s Letting go of res entments and jealousy

 

   [8] Mutuality

Making amends , helping others

 

      S ocial

S haring, accepting help from others

 

   [9] E mpathy

E ncourage lis tening and being a friend

 

      F riends hip

Mindfulness meditation training

 

 

+ E ducation about character development

 

 

+ C ognitive analysis of fears and desires and their elicited 2789

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thoughts  

 

+ Antidepres sant medication, if

T ranscendence therapy (to awaken intuitive truth as s ource of faith)  

[10] S elfacceptance

Letting go of ambition to control self and others

 

[11] C ompas sion

Working at service others

 

[12] P atience

Listening to psyche (to grow in s elfawarenes s)

 

      F aith

Meditation on union in nature

 

 

+ Optional reading highly enlightened authors

Advanced coherence therapy (to awaken intuitive sens e of goodnes s and unity of being as source coherence)

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[13] C reativity

C ontinuous letting go of all s truggles

 

[14] W ell-being

C ontinuous and work at the service of others

 

      S erenity

 

 

[15] C oherence

C ontinuous awarenes s in all activities

T reatment is organized into five levels corres ponding to the five levels of s elf-awarenes s that were described previous ly. W ith res pect to personality dis order, of particular interes t are levels 1 and 2 and, s ometimes , 3. 1. T he firs t treatment level involves supportive and reality-based techniques that facilitate the of the intuitive s ens e of being and permanence. at this primitive level includes basic trus t building, validation, and teaching of bas ic living s kills . T he here is to ens ure the s afety of patients with s evere disorganization and des tructive impulses. T rust building and validation within s afe limits are bas ic components of all therapy and are es sential at this level, because patients are filled with all of the 2791 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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negative emotions, such as mos t patients whose temperaments are explosive (borderline) or whos e characters are severely immature P.2102 (melancholic or schizotypal). However, if the patient ps ychotic or prepsychotic, therapy may be limited supportive functions . S uch supportive function may require somatic therapies , s uch as therapy (E C T ) or high doses of antips ychotic medication. T he holding or reparenting aspects of ps ychotherapeutic environment are crucial at this level, including the therapist's being dependable, nonretaliatory, and compass ionate, des pite crises, and being able to provide a more optimistic unders tanding of the patient's needs and opportunities than the patient. T his allows the to build trust in reality and self-res pect. 2. T he second treatment level involves cognitivebehavioral techniques that help facilitate the awakening of the intuitive sens e of freedom of will personal respons ibility, which are fundamental to a sens e of human dignity and the capacity to work. level involves initial treatment of individuals with moderately s evere personality and mood disorders , such as most antis ocial, severe obses sional, or borderline patients. P harmacotherapy for labile and impulsivity, s uch as mood s tabilizers , and for hostility, s uch as low-dose neuroleptics, may be beneficial. Discuss ion of pers onality s tructure and emotional needs in such patients is focused on unders tanding of their temperament structure and 2792 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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basic emotional needs , along with education about mature ways of satisfying those needs . T his work on encouragement of res ponsibility for anger management and impuls e control. Also, encouragement of work to be more flexible and helpful to others is prominent at this level. Hatha or s ome other forms of nonviolent physical s kills training can be appealing methods for teaching control at this level, leading to enhancement of the sens e of res pons ibility and freedom from pas t conditioning. T here mus t be much patient repetition of practical problem-solving skills and by discus sion of attractive role models . T his makes cons tructive us e of such a patient's craving for pleas ure and power. 3. T he third treatment level is related to the the intuitive s ens e of love and beauty. W ork at this level involves nondirective dynamic, humanis tic, interpersonal techniques to fos ter increases in benevolence, res ourcefulness , generos ity, and intimacy in interpersonal relations hips. At this direction is counterproductive, becaus e the patient needs to internalize group values and to develop confidence in his or her self-willed action. and anxiety are common at this level and may be treated with antidepress ants , as needed, in combination with the nondirective therapy. T he standard s ix exercises of autogenic training are at this level, providing relaxation and preparation meditative exercis es at more advanced levels . 4. T he fourth treatment level is related to the of the intuitive s ens e of what is moral and true, as 2793 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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as the capacity for s piritual faith. T his level requires experiential and existential therapy techniques, as meditation on one's union in nature. the awakening of s piritual awarenes s (i.e., the becoming aware of itself) can be facilitated by encouraging the person to lis ten to his or her own ps yche in a state of calmnes s and effortles s, awarenes s. T his involves a conscious expans ion of self-concept to include a transpersonal (i.e., component in addition to the mind and body. Antidepress ant or antianxiety medication may be us eful at times of exis tential crisis but are us ed sparingly and transiently, becaus e s trong needed to promote the leaps of faith needed to transform conscious nes s and self-concepts . All this work is carried out in the context of a pers onal decis ion to let go of all s truggles , to work at the of others, and to let the mind become aware of R eading of ins piring literature, such as the works of P lato, Augus tine, or more recently, Alphonse de Lamartine, G andhi, and J iddu K ris hnamurti, may be us eful, but there s hould be no press ure to pus h the patient, because the path to coherence of cons ciousnes s mus t be freely and s pontaneous ly sought. 5. T he fifth level is related to the continuing of the intuitive s ens e of goodnes s and unity of T his does not really involve direction or even but more a relationship of facilitative friends hip with mutual res pect and s haring to minimize s elfand perfectionism, which are frequent s tumbling blocks at this level. Many individuals with s uch 2794 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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personality development are seldom impaired by ordinary s tandards but s eek as sistance to achieve superior character integration, emotional fulfillment, and healthy longevity. F inally, it is important to recognize that character traits only repres ent abs tract summaries of the way that a person us ually thinks , feels , and acts . T he levels of development des cribed in T ables 23-22 and 23-23 only represent the maximum levels of thought that a pers on has reached during his or her life; the levels repres ent point in the flow of thought at which a pers on is blocked or arres ted in development. In contras t, when ps ychotherapy is done, a dialogue is entered into with stream of consciousness of the person. T he ps ychotherapeutic dialogue is the meeting of the of the patient and the psyche of the therapis t in a relations hip. T he flow of thought may be observed in as sociation or by examining the s pecific thoughts that elicited by the patient's particular fears or desires at the moment. In any cas e, there mus t be flexibility in along with the thoughts that are important for the at the moment, rather than trying to reduce them to something frozen in a s tep in development that thought from its freedom of flow in time. Des criptions of temperament and character are useful for diagnos tic as sess ment and to help the patient begin to become self-aware. However, ultimately, progres s in treatment requires a shift to attend directly to the movement of thought, which is free and alive in cons cious nes s. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > S UG G E S T E D C R OS S -

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S UGGE S TE D C R OS S R E FE R E NC E S P art of "23 - P ers onality Dis orders " Adult antis ocial behavior is discus sed in S ection 26.2, personality dis order in elderly adults is dis cuss ed in S ection 51.3h, theories of P.2103 personality and psychopathology are discus sed in 6, and impuls e-control disorders are discus sed in 21. P s ychotherapy is dis cus sed in C hapter 30, and pharmacotherapy is dis cus sed in C hapter 31. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 23 - P ers onality Disorders > R E F E R E NC

R E FE R E NC E S Allport G . P ers onality: A P s ychological London: C onstable; 1937. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 3rd ed. Was hington, DC : AP A P ress ; 1980. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 3rd ed. R ev. Was hington, DC : AP A P ress ; 1987.

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American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. Was hington, DC : AP A P ress ; 1994. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. T ext Was hington, DC : AP A P ress ; 2000. B ayon C , Hill K , S vrakic DM, P rzybeck T R , Dimens ional as sess ment of pers onality in an sample: R elations of the systems of Millon and C loninger. J P s ychiatr R e s . 1996;30:341–352. *C loninger C R : A s ys tematic method for clinical description and clas sification of pers onality Arch G e n P s ychiatry. 1987;44:573–588. C loninger C R : A practical way to diagnos e disorder: A propos al. J P e rs Dis ord. 2000;14:99– P.2104 C loninger C R . Implications of comorbidity for the clas sification of mental dis orders: T he need for a ps ychobiology of coherence. In: Maj M, G aebel W, Lopez-Ibor J J , S artorius N, eds. P s ychiatric C las s ification. C hichester, UK : J ohn W iley and 2002:79–106. C loninger C R . F e e ling G ood: T he S cience of W e ll New Y ork: Oxford University P res s; 2004. 2797 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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C loninger C R . T he genetics and ps ychobiology of seven factor model of personality. In: S ilk K , ed. R eview of P s ychiatry. V ol 17. W ashington, DC : AP A (in pre s s ). *C loninger C R , P rzybeck T R , S vrakic DM, W etzel R . T e mpe rame nt and C haracte r Inventory: A G uide to Deve lopme nt and Us e . S t. Louis, MO: C enter for P sychobiology of P ers onality, W ashington 1994. C loninger C R , S vrakic DM: Integrative approach to ps ychiatric as sess ment and treatment. P s ychiatry. 1997;60:120–141. C loninger C R , S vrakic DM, P rzybeck T R : A ps ychobiological model of temperament and Arch G e n P s ychiatry. 1993;50:975–990. C os ta P T , McC rae R R . T he NE O P e rs onality Manual. Odes sa, F L: P sychological As sess ment R es ources ; 1985. E ys enck HJ . T he B iological B as is of P e rs onality. S pringfield IL: C harles T homas ; 1967. G underson J , P hilips C . P ersonality Disorders . In: HI, S adock B J , eds. C omprehe ns ive T e xtbook of P s ychiatry. 7th ed. B altimore: W illiams & W ilkins ; J offe R T , B agby R M, Levitt AJ , R egan J J , P arker T ridimens ional P ers onality Questionnaire in major 2798 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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depres sion. Am J P s ychiatry. 1993;150:959–960. J oyce P R , Mulder R T , C loninger C R : T emperament predicts clomipramine and desipramine res pons e in major depress ion. J Affect Dis ord. 1994;30:35–46. K ernberg O. B orde rline C onditions and P athological Narcis s is m. New Y ork: Aronson; 1975. Millon T . Manual for the MC MI II. 2nd ed. MN: National C omputer S ys tems; 1987. Mulder R , J oyce P : T emperament and structure of personality dis order s ymptoms. P s ychol Me d. 1997;27:99–106. *P erry C , V aillant G . P ersonality dis orders. In: S adock B J , eds . C omprehe ns ive T e xtbook of 5th ed. B altimore: W illiams & W ilkins ; 1989:1352– R eich J , F rances A: T he structural interview method diagnosing borderline dis orders. P s ychiatr Q . 1984;56:229–235. S chneider K . P s ychopathic P e rs onalities . London: 1956. S jobring H: P ers onality s tructure and development: model and its application. Acta P s ychiatr S cand 1973;244:1–204. *S vrakic DM, W hitehead C , P rzybeck T R , C loninger 2799 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/23.htm

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Dimens ional diagnosis of personality dis orders by seven factor model of temperament and character. G e n P s ychiatry. 1993;50:991–999. S vrakic NM, S vrakic DM, C loninger C R : A general quantitative theory of personality development: F undamentals of a self-organizing ps ychobiological complex. Dev P s ychopathol. 1996;8:247–272. T ome MB , C loninger C R , W ats on J P , Is aac MT : S erotonergic autoreceptor blockade in the reduction antidepres sant latency: P ers onality variables and res ponse to paroxetine and pindolol. J Affect Dis ord. 1997;44:101–109. *T ulving E : E pis odic memory: F rom mind to brain. R ev P s ychol. 2002;53:1–25. World Health Organization. Inte rnational of Dis eas es . 10th ed. G eneva: World Health Organization; 1987. Zuckerman M: T he ps ychobiological model for impulsive uns ocialized s ens ation s eeking: A comparative approach. Neurops ychobiology. 1996;34:125–129.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 24 - P s ychological F a ctors Affecting Medica l C onditions > 24.1: of P s ychos oma tic Medicine

24.1: His tory of Ps yc hos omatic Medic ine Harold I. K aplan M.D. P art of "24 - P sychological F actors Affecting Medical C onditions " E ditor's note: T he founding editor of this textbook, I. K aplan, M.D., had a long-standing interest in ps ychos omatic medicine and the history of ps ychiatry. wrote the section on the his tory of ps ychos omatic medicine for the firs t edition of this textbook and for subs equent edition thereafter until his death in 1998. following vers ion appeared in the sixth edition and is included here with minor changes made by the editors.

INTR ODUC TION P sychos omatic (ps ychophys iological) medicine has specific area of concern within the field of psychiatry for more than 50 years . It is imposs ible to trace its history, however, without immediately becoming involved with the idea of mindbody unity implied by the G reek words ps yche (breath, to breathe) and s oma (body). T he of mind and body and how they relate has been cons idered by all ages . T hat relations hip is reflected in various editions of the American P sychiatric Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs which, in 1980, deleted the nos ological term 2801 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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ps ychophys iological (or ps ychos omatic) dis orde rs and replaced it with ps ychological factors affe cting phys ical conditions . T hat change was ill advised and continued question about how ps ychic and somatic holism was to defined. T he American B oard of Medical S pecialties the American B oard of P sychiatry and Neurology a s eparate board to be called the Ame rican B oard of P s ychos omatic Me dicine to take effect in 2005. T hat decis ion not only recognizes the importance of the field but also brings the term ps ychos omatic back in us e. T o speak of mind and body is to s uggest that other twos omes, such as mindbody, are more often seen as oppos ites than as polarities: materialimmaterial, knownunknown, objectives ubjective, matterspirit, visibleinvis ible, and realunreal. It als o is not different the belief of the common pers on, held onto from often in contradiction to later-formed beliefs , that his or her ps yche precedes his or her embodiment and will survive his body's dis integration. Although often cited contributing a mindbody (ps yche vs . s oma) split to Wes tern civilization, the G reeks , through a s mall group their philosopher-scientis ts , tried to dignify matter and raise it to a position of equality with s pirit, even to the eminence of preexistence. T heir atomis ts believed that from the clas hing of original atoms came all matter. is preeminent, s pirit or matter, mind or body? How to depends, to a certain extent, on the resolution of that question.

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Prehis tory T he child of today has collected a small s torehous e of reliable information involving cause-and-effect relations hips , many concerned with the effect of wish will on his or her environment. C hildren know their and loves and how to move their fingers, which are part them, to get s omething for a more inclus ive s elf. T hey know that there is s ometimes light and sometimes darkness but have no idea why, although, as they culture teaches them why. F or the child of prehis toric times, the s torehous e of caus e-and-effect relationships was, however quickly expanding, s mall. S pirit was s till the prime force, the unseen but known power that controlled events as handedly and with as much determination as a dream overtakes one. B ecause the child of prehistoric times not wis h to die, to s uffer pain or weaknes s, or to be wounded, those happenings were attributed to the of an evil spirit or will. It could be the will of an enemy rival, the spirit of a violated place, the world-controlling spirits threatening him or her out of whims y, or the of the dead, angry at not receiving appropriate B ad things existed outs ide of the individual pers on and entered the body to attack. E ven death was not an indwelling potential, but a visitor who could s uddenly seen standing nearby during the moments before the stiffening of the body. Disease, in its more serious was the res ult of a body's being pos sess ed by an illintentioned s pirit. W ounds, however, were different. A hunter saw the enemy, the raised club, and the gas h or broken bone and lived through the course of healing; 2803 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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early began to notice what helped or hindered the of healing and began to collect a body of rational observation concerning wounds . Dis eas e remained spiritual; as soon as humans the necess arily s harp stone tools (circa 10,000 B C ), began to bore holes in the s kulls of s ick pers ons to let evil out (F ig. 24.1-1). T repanation did not always kill its patients; a good number recoveredaided, it is by the power of the personality of the operating or medicine man. At one time, the s haman exorcised disease-bearing demon by wrestling with him in the and defeating him. Later, the more rational medicine might rub the patient, remove an object from the body the patient by sleight of hand, or bleed him. Whatever healer's approach, he or she always gave the patient a renewed will to health by the power of s uggestion, in best tradition of the doctorpatient relationship. T hus did primitive people emphasize a holistic concept, rather a dichotomized psyche and s oma.

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FIGUR E 24.1-1 A trepanned Neolithic s kull found at Nogent-Les -V ierges . S hamans bored holes in the s kull evil spirits es cape. (C ourtes y of the B ettmann Archive, New Y ork.) P.2106

E gyptians E gypt's embalmers were a separated cas te of the hereditary pries thood; when they cut into the bodies of 2805 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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the dead to draw out, to was h, and to wrap in linen the intes tines, liver, and, usually, the kidney, they were leave the heart intact. F or there res ted the soul, the person's intelligence and emotions , his or her pers onal T he priest-phys icians of E gypt named many parts of body, but they referred to the nerves , mus cles, arteries, and veins by the s ame word and thought of those arrangements as channels in a branching system that connected the heart to the working parts of the eyes , fingers , testicles, and toes . T hrough those conduits pas sed air, water, s emen, and all the other neces sary s ubs tances , including the initial breath of which was s aid to enter through the right ear; the of death made its way into the body through the left Like earlier people, the E gyptians imagined death and disease to come into the body from the outside. disease was attributed to the s ame trinity as it had earlier people: the gods , spiritses pecially those of the deadand the evil wishes of humans. T hoth, Isis, her s on Horus, and the vizier Imhotep 2800 B C ), who was eventually deified as a healing god because of his medical knowledge, were all called on aid in exorcising bad s pirits , but E gypt's three class es famous phys icians, magicians , and pries ts of S ekhmentmany of them s pecialists in the dis eases of specific part of the bodydid not rely on the gods to do work. T hey compiled medical observations to aid thems elves and their descendants in diagnosis and treatment. In the E bers papyrus (copied circa 1600 B C older manuscripts), 877 s ections dealt with treatment specific complaints ; in only 47 of them did the writer bother to diagnose the dis eas e, ass uming that 2806 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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on the part of his readers. T he text proceeded in this manner: If you examine a man who s uffers from X, you may s ay it is X, and you may do for it x, x, or x. suggested included oral rites, manual rites, and drug doses . T he phys ician who chos e to us e a spell addres s the troubled organ directlyOh, failing eyes or might choos e manual rites and tie four or s even knots a thread or apply s aliva or mass age to the affected He might choos e to apply ointments or poultices of animal, vegetable, or mineral s ubs tances or choose the more expensive method of introducing drugs by recipe into the body, and he might do so with or without incantation. If the case looked incurable, he limit his actions to a comforting ritual and choose not to treat the patient furthera stand cons idered ethical. was a lot to choos e from, and the choice might be and effective, irrational and effective, or magical and ineffective. A different balance appeared in the roughly E dwin S mith papyrus , mainly a handbook for the treatment of wounds. As noted previous ly, in wounding, there is witnes s to the cause-and-effect connection; where cause is seen to be rational, treatment tends to so, too. Not s urprisingly, then, for the 48 wound cases described in the papyrus , only the rational treatments were sugges ted. P hysical surgery was developing out phys ical observations , pure magic became the for the otherwise incurable, and, in the middle ground internal and external medicine, various methods approaching body and mind were being tried.

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T he medical texts of the conglomerate S umerianB abylonian-Ass yrian civilization (circa 2500 to 500 B C ) remarkably s imilar to the contemporary but more texts of E gypt. If you see X, begin most texts, and they on to recommend the same kinds of treatments magic and reasonoral and manual rites and the prescription of fanciful or effective drugs. T he overall sens e, however, is that those texts are heavily toward magic, and no exis ting text is totally rational. T he sophisticated herb doctors of that civilization's hereditary pries thood could cons ult texts dealing with hundreds of vegetable and mineral drugs . Its surgical doctors were common enough to be warned by Hammurabi's laws that patients dying under their knives would be avenged with the amputation of the surgeon's hand. Its exorcists had, at the tips of their tongues, the names of 6,000 demons known to cause 6,000 different complaints: Idpa attacked the throat, attacked the neck, and s o on. Idpa and Utuq and their cohorts were address ed directly and urged to leave the body, after which the doctor would try to repair the damage. As did the E gyptian phys icians, when the parted from his demon-vacated patient, he left him or with an amulet to wear over the skin where the demon had been. T he ultimate s ource of disease might be the gods who sent pain as punis hment for ritual or moral error, the neglected and angered dead, the hand of a ghos t from an unburied body, an ill wind, sorcery purchased the pocket-book of a malevolent person, or the patient he or s he had committed a ritual or moral sin. a pers on in pain was disgraced and urged to look into 2808 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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or her s oul and to examine s ins until the charms of the priest freed him or her from sicknes s. Disease was of as having a caus e within the patient, rather than on him or her from the outs ide. T he sick man was a was the prevailing belief. T he patient prayed, and went to an exorcis t. Dis eas e in that connection ps ychos omatic in all its as pects .

J udeo-C hris tian Heritage F or the Hebrews , disease was predominantly the punis hment s uffered for the sin of having dis obeyed or His laws. I kill, and I make alive; I wound, and I heal, warned (Deuteronomy 32:39), and other healers in the form of doctors were scorned. F or group s in, there was group punishment of pestilence or plague. Dis obeying G od's law did have the direct result of less ening the community's degree of s anitation and hygiene, S abbath res t, abs taining from carnivorous animals , is olating lepers , and burying excrement in camp were some of the laws enforced by a pries thood that, in no way, was a body of public health officials trying to parasitic and epidemic disease. If thou wilt give ear to his commandments, and keep all statutes, I will put none of these dis eas es upon thee, I have brought upon the E gyptians : for I am the Lord healeth thee (E xodus 15:26). With laps es into E gyptian and As syrian demon belief, J ews generally upheld their laws and profited from their res pect for the power of contagion. P.2107 F or the sin of individual failure to obey G od, there was 2809 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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punis hment of individual dis eas e. If the priests were public health officials , the prophets, like the s hamans before them, who could also see the invis ible and know the unknowable, were more the recours e of the s ick could not, by thems elves , find a new heart. Like the E gyptians , the J ews considered the heart to be the intelligence and will. T hey believed the will and the to be interacting and bound together: Make you a new heart and a new s pirit; for why will ye die? (E zekiel S ongs were thought to s oothe the heavy heart, and pleas ant words were thought to sweeten the soul and heal the body. Overall, to make oneself right with G od to find oneself on the road back to health. P ersons like K ing As a, who gave up and turned to herbalis ts, were criticized until the time of the second century B C . B y the sick among the J ews were urged to pray and then go to a doctor, for the Lord created doctors, too. of Maccabean times would whisper the ancient into the ear of a patient as he or s he s wallowed his or medicine: If thou wilt give ear to his commandments I put none of these diseases upon thee (E xodus 15:26). J esus, too, s aw the body and the spirit as a whole: Whatever his prophetic healing powers may have does not appear to have thought of disease as a punis hment for disobedience to law but more as an imbalance within the patient, an imbalance correctable a psychic act of faith. In locating the origin of dis eas e squarely within the patient, at least in mos t cases , did not differ s o much from the G reek civilization that preceded and s urrounded him as he did from the E uropean C hris tians who s ucceeded him.

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Greeks Like the rest of the ancient world, the G reeks were impres sed by E gypt's medicine. When they eventually deified their As klepios (Aesculapius), a man of the 13th century B C who had spread a knowledge of bandaging and herbal medicines and who had also advocated the humane treatment of the insane, they identified him E gypt's more ancient Imhotep. T here are s cores of references in T he Iliad (eighth century B C , disputed) to wounds; as in E gypt, the pries t-phys icians of G reece pass ed on to their sons observations on wounds and diseases . T hey did so through the centuries at medical schools that grew up at C nidus, where diagnos is was specialty; at C os , where prognos is was featured; and C rotona. E ventually, that priesthood lost its that the status be inherited. It was the deities who brought disease, and it was they who brought healing; spirit and body were an unity. T here were scores of temples to As klepios by the fifth century B C (F ig. 24.1-2), and the patient coming to such an ins titution planned to stay a few days to a regime that progress ed from bathing, dieting, and touring the temple's display of testimonials through praying, reporting s ymptoms, and being examined, to sacrificing an animal and sleeping in its s kin or a T hat was the sleep of incubation, taking place on ground. During this s leep, the pries t-phys ician might to the patient and make suggestions ; if surgery was required, it might be done on a drugged sleeper by a wearing the robes of the god; or, perhaps, no interview took place, and the arrival of the god occurred only in dreams . B y is olation during the temple s tay, the patient 2811 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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was brought in touch with his or her emotions, with his her private spirit world, and perhaps reunified himself herself toward health. In the morning, his or her were interpreted by a pries t-phys ician, who pointed out elements of the dreams that could be us ed for Like other ancients, the priest-phys ician called believed in a relations hip between a life force and its housing, the body, and tried to cure the body by that force.

FIGUR E 24.1-2 As klepieion of E pidaurus in its pres ent status . T he labyrinthine structure of the tholos , where mental patients had to walk and to sleep to be able to reach the center. In the course of this highly s ymbolic proces s, they were healed by the god while dreaming. (F rom K ereny C . As kle pios . Arche typal Image of the P hys ician's E xis te nce. New Y ork: P antheon B ooks ; 2812 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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with permiss ion.)

Hippoc rates S on of a physician of Asklepios , Hippocrates (460 to B C ) s tudied medicine at C os . He probably wrote only the 60 books attached to his name, one of them with the often-misquoted phras e: Life is s hort, but [the] [of medicine] is long [in the learning]. T he learning took lifetime and involved obs ervation, hypothes is , and the study of tradition. Hippocrates hims elf selected from E gyptian and the G reek traditions , and he ceas eless ly observed and hypothesized. Hethat is to say, the authors of the Hippocrates books wove together a categorization of temperaments with contemporary categories of elements and qualities, producing a of dis eas e that a number of clinicians today take as a simplified statement of the workings of the endocrine system. Dis eas e originated within the body and was due not to spirits but to an imbalance in fluid matter. T hat could be related to or even caus ed by a similar in the patient's external environment. Hippocrates the visiting doctor to cons ider the altitude, the wind direction, the purity of water s upply, and the season of year before making any diagnos is . He pointed out that citizens of cities in particular environments would run to phlegmatic or sanguine temperaments as a reflection the city's coldness or heat. P hys ical or fluid imbalance could be caused by emotional ups et, too. Hippocrates reported that fear produced s weat and that shame 2813 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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brought on palpitations of the heart; he urged young phys icians to look at patients with kindly express ions never with impatience, because impatience could the return of health. He is s aid to have cured a king of intes tinal lesion by analyzing a dream. It was who wrote in order to cure the human body, it is to have a knowledge of the whole of things. Although he did not understand how amulets worked, admitted that they sometimes helped cure diseas es. was natural; to get that idea across to the family of a patient and to give hims elf credibility with them, the young doctor should be sure to predict death after viewing a new patient who showed s igns of its advent. If you cut into a head with a bad s mell and too mois t a brain, Hippocrates pointed out in S acred you plainly see that it is not a god but a dis eas e that the body. T he search for the location of the mind occupied the G reeks in a discus sion of the organ housing that and became temporarily complicated, but ultimately clarified, by a tendency to separate the functions of into various subdivis ions, s uch as life force, reason, cons ciousnes s, and the emotions . A hundred years Hippocrates , Heraclitus (535 to 475 B C ) had s tated soul or life force could not be contained in a particular organ, neither could the heart of the E gyptians nor the brain proposed by his predeces sor Alcmaeon (s ixth century B C ). Hippocrates cons idered the brain to be center of the s ens es and of reas on, but he agreed with others that a certain life force called P.2108 2814 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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pne uma was more basic. B ecause pneuma controlled brain, it was the ultimate s ource of intelligence and T he discuss ion was to continue.

Idealis ts vers us A tomis ts Walking in the academy at Athens, P lato (427 to 347 imagined an ideal world; each palpable bird and each tangible tree he s aw was but a copy of the ideal bird the ideal tree in a perfect preexis ting mental world. Like the Orphics , who felt the s oul to be reincarnated in succes sive bodies, and like P ythagoras (sixth century who regarded the psyche as an immortal s elf, P lato spirit as superior, a mas ter to the s lave, matter. As an idealist, he went agains t the tendency of the preceding generations to dignify and to study matter, developed the theories of Democritus , the atomis t (born 460 B C ). As expres sed much later by Lucretius in O n the N ature the Univers e (55 B C ), the creed of the atomists begins matter. Matter precedes ps yche and is what the world made of, its irreducible parts being called atoms , movement and chance collis ion, gave rise to the world is known. T he human being is made up of a multitude atoms ; when he or s he dies , the atoms go back into the world, whereas , once the lute is broken, the mus ic obtainable from its s trings is no more. In the capital of the G raeco-R oman world, As clepiades century B C ) founded a medical theory s temming from atomism. In his system, the s oul had no location but the convergence of all perception; dis turbances of the pass ions could caus e mental disease, whereas too cons triction or relaxation in the vacuum or space 2815 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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the gyrating atoms of the body caus ed phys ical In T imae us , P lato remarked that trouble in the soul bring trouble to the body, and, in C harmide s , P lato S ocrates, who had hims elf attributed the words to a king: As it is not proper to cure the eyes without the nor the head without the body, s o neither is it proper to cure the body without the soul. Aris totle (384 to 322 B C ) observed that the emotions of anger, fear, courage, and joy affect the body, and (first century B C ) pinpointed a dis turbance of the as one of the s ix major causes of paralysis. T he had gradually become a factor of mind or ps yche on attention was being focus ed.

G alen T he G reek physician G alen (130 to 200 AD) lived in where he attended the emperor Marcus Aurelius . looked on Hippocrates as an ancient, one from whom had learned and whos e techniques he attempted to reconcile with those of the P latonic idealists and with those of the atomistic materialis ts. In his compilation, G alen as sembled an eclectic and often confus ing summation of G reek medicine that was to be the foundation of E uropean medicine for 1,000 years to G alen s aw the brain as the center of s ens ation, motion, reason; it was a rational s oul. Like P lato, G alen named irrational subsouls . One was the energetic, irascible soul, located in the heart, and the other was the female s oul, situated in the liver. However, unlike P lato, G alen cons idered the three souls to be slaves, rather masters, of the body; material considerations of 2816 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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dampness , s tructure, and animal s pirits circulating in body ultimately determined how one felt and thought. S oul, therefore, was material or of the body. T he E gyptian vis ion of the breath of life entering the conduits of the body through the right ear and of body fluids thereafter circulating in those branching tubes been reconceived in a number of ways by the G reeks. S toics , who were atomists, divided the kingdoms of the living into plant, animal, and man. P lants grew, animals grew and moved about, and man grew and moved and thought. Air or pneuma drawn into the body was adapted to each of those three functions of man. G alen us ed that framework and sugges ted that inges ted food was converted into blood in the liver and sent out as natural s pirits through the veins, from which the spirits performed the function of growth. One vein brought natural spirits to the right ventricle of the heart. T here pass ed through the s eptum (not known to be a s olid of mus cle) into the left ventricle, where, during the expansion of diastole, they mixed ever s o s lightly with pneuma drawn from the lungs . As vital spirits , that was pus hed out of the heart during s ys tole and carried through the body by the arteries to monitor locomotion. S ome of the vital spirits were carried to the brain and, pass ing through a network of s pecial vess els , became animal (from anima, s oul) spirits capable of caus ing thought. Animal s pirits pass ed outward through the by way of the nerves. G alen reported that he began treating one cas e of depres sion with two causative poss ibilities in mind: the phys ical caus e of the overbalance of black bile and the ps ychic caus e of inordinate des ire. An erratic pulse in 2817 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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woman patient at the mention of the dancer P ylades caus ed him to choose the s econd alternative. He sometimes pres cribed herbals , such as opium, for emotional and phys ical complaints . R ather than embodying a single point of view, G alen can be cons idered an anthology of G reek medical opinion, offering to s ucceeding generations a view of holistic interplay between psyche and soma, an interplay that largely ignored as the tendency became, like that the G reeks, to emphas ize spiritual agents only in the etiology of disease.

Middle Ages T he E uropean tribesmen who finally occupied R ome brought with them a slighter tradition of medical observation. Although the works of many of the G reek Latin writers were trans mitted through the C hristian church, the Mediterranean's civilization of increasingly objective observation was run to ground by the return belief in spiritual powers , demons, witches, and sin. All those agents were accused of having produced during that period (500 to 1500 AD), and healing again became a spiritual iss ue. T he evil was within and sick person might consult a priest or the relics of a and promise to give up his or her own sin, lack of faith, evil impuls es in exchange for health. T he status of the phys ician fell. S ympathetic magic returned in the form amulets placed over the eye of the statue of a saint or eye-shaped talis man harbored by the patient with troubled vision.

R enais s anc e 2818 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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After 1,000 years of religious dominance, interes t in caus es and cures of disease returned during the R enais sance. During the R enais sance (1400 to 1650 the study of the material world renewed itself, but was more than elevated to a position of a proper s tudy balance with spiritit eventually became the dominant virtually only credited field. T hat dominance was in the study of human health, which was divided into flouris hing investigation of the body's structures and an atrophying s tudy of the emotions.

Des c artes and an Interac ting Duality After C opernicus (1473 to 1543 AD) and the suntheory of the universe, things as they appeared to be no longer things as they were. R ene Des cartes (1596 1650 AD) began his ques t for knowledge by formerly held beliefs and s tarting fresh. He dismis sed as sumption and came quickly into hims elf, to his mind its s elf-awarenes s, not to his s enses , which told him bit of wax was hard and yellow and made a noise when struck, because only a few minutes later the s ame wax, warmed by fire, was soft, dark, and no longer of producing s ound; the s ens es were not reliable. If stripped away all apparent or s ens ual terms of what was wax? A mathematician hims elf, Des cartes agree with the mathematicians and phys icists, who ran back to Lucretius and the atomists , that the es sential quality of the wax was the s ame as the es sential P.2109 of all matter; it was extendable and movable. He again of his own mind and its relationship to objects. 2819 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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C ould he be fooling himself a second time? C ould he casting onto wax his own mental s ens e of himself as extended and movable? P erhaps. W as there anything exis ting that was not a projection of his own mind? Des cartes decided, was the one thing man could not imagined. A man cannot s ens e himself to be eternal, immutable, omnipotent, or perfect, because he so obviously the oppos ite; those qualities, becaus e knows them, must then exis t outside man, in the in the pers on of G od. Having s atisfied himself as to the exis tence of spirit, Des cartes turned to matter. If G od is perfect, He does not deceive; if He does not deceive, then the world vis ible to the viewer is not a delus ion; it is real, although the relative realnes s of different kinds of sensual impress ions mus t be S pirit and matter are real, although s pirit precedes In the beginning, s piritual force without movement and extension created movement and extension, created hardnes s, yellowness , and the blue of the infinitely s oft C artesian dualism gave matter more importance than P latonic idealis m had but less importance than the atomists had given it. Descartes' followers occupied thems elves uns ucces sfully with examining the which matter that moves came into contact with mind; all concluded with Des cartes that soul and body the pineal gland. As materialism grew in strength, Des cartes' famous phras e cogito, ergo sum was being turned inside out into I am; therefore, I think.

19th and 20th C enturies In the 19th century, the mindbody schism spread to its furthes t division. T he 20th century witness ed a new 2820 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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attempt to view mindbody holis tically.

The C ell T he ultimate s oma became the cell; the diseased cell became the s ource of bodily disease. R udolf V irchow to 1902) made clear through laboratory work that has its origin in the dis ease of the cell. F irs t, he showed a change toward pathology takes place within cells ; then, a change in the structure of the cell and, lastly, physiological disorder can be s een in the that make up the tiss ue of an organ. Louis P as teur (1822 to 1895) als o s tudied the single is olated in his laboratory. T he temple of the future, according to P asteur, was to be the laboratory. Within framework of laboratory-based somatic medicine, no generalizations were produced from the growing list of observations made on the relations hip between psyche and s oma. Indeed, the thoroughly somatic or tenor of the times was s hown by scientis ts, such as Huxley (1825 to 1895), who believed that mental in thems elves had no caus al s ignificance but were the product of somatic activity.

S igmund F reud It was S igmund F reud (1856 to 1939) who brought and s oma back together, us ing memory as the of the psyche. He demons trated the importance of the emotions in producing mental dis turbances and disorders . His early psychoanalytic formulations the role of psychic determinism in somatic convers ion reactions . His contribution to a more holistic outlook beyond reintroducing the interrelationship of ps yche 2821 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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soma to reins tating the therapeutic doctorpatient relations hip, seen in the function of s haman and With transference and countertrans ference, F reud that relations hip out of the religious framework of hope and faith and into an intellectually understandable dynamis m. P icking up where the G reeks and R omans left off, F reud redignified the s tudy of the emotions as a separate s tudy and pointed to their relations hip with the soma in the new field of ps ychiatry.

E MOTIONS A ND C E L L TIS S UE Using F reud's ins ight, a number of workers in the early decades of the 20th century tried to expand the unders tanding of the interrelations hip of ps yche and soma. T he influence on adult organ tiss ue of various unresolved pregenital impulses was propos ed by K arl Abraham in 1927, the application of the idea of reaction to organs under the control of the autonomic nervous s ys tems was described by S andor F erenczi in 1926, the attaching of a s ymbolic meaning to fever and hemorrhage was sugges ted by G eorge G roddeck in and the poss ibility was suggested that troubled mental states translate into somatic activity that provides an underlying altered basis of activity, branching into a number of pos sible dis eas es. T wo trends were developing, one s uggesting that emotions led to specific cell and tis sue damage, and second holding that generalized anxiety created the preconditions for a number of not-neces sarily predetermined diseases. C ases of shell shock during War I and new endocrine s tudies provided the swell of interes t in theory evidenced in the 1930s . 2822 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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Inc orporation of S tres s along Pathways In 1950, F ranz Alexander believed that, if a s pecific stimulus or s tres s occurred, it express ed its elf in the specific res ponse of a predetermined organ. He the fight-or-flight alert of the body against s tres s, as reported by W . B . C annon in 1932, to the problem. Alexander s aw conflict as a s tres s and s uggested that, when conflict pres ents itself to a person, he or s he may suppress the stress and produce, through the voluntary nervous s ys tem, a reaction such as the conversion described by F reud. On the other hand, after stress , he or she may, through the autonomic s ys tem, his or her s ympathetic respons es alert for heightened aggres sion or flight or his or her parasympathetic res ponses alerted for heightened vegetative activity. P rolonged alertness and tension can produce phys iological dis orders and eventual pathology of the organs of the vis cera. F or ins tance, Alexander, using much of F reudian ps ychodynamics , postulated that, in a pas siveperson without s omeone to satisfy his or her stress is created. T hat particular s tres s may stimulate keep alert the paras ympathetic nervous system, which means that too much gas tric acid is s ecreted, and hypermotility results, all of which may lead to a peptic ulcer. Another dependent pers on with a different set may, in repres sing conflict, s timulate the parasympathetic overfunctioning through pathways leading to colitis or as thma. S till other dependent in seeking to move beyond dependency, incorporate stress ; s uch a move entails overs timulation of the 2823 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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sympathetic s ys tem, and the chronic alertness caus ed thereby produces migraine, hypertens ion, or arthritis . Alexander called thos e relations hips conflict Although many other workers us ed different specificity approaches, Alexander's C hicago P s ychoanalytic group has continued to s upport his original findings, dating back to the 1930s , and continues to publis h additional s upportive data. Although there is s ome validation of Alexander's there has been considerable disagreement on whether poss ible to demons trate the same s pecific conflicts in cases of the same dis eas e. It is als o ques tionable the conflicts postulated for one dis ease differ from as sociated with other diseases. In other words, it has been poss ible, thus far, to predict disease from conflict vice versa. In addition, it is highly doubtful whether specific ps ychological conflicts can be correlated or experimentally with specific physiological vegetative changes. Alexander's views have received s ignificant phys iological support from several hundred cas e reported in the literature. P.2110 A number of inves tigators have developed the pathway concept of cons tellations into other theories involving whole personality. T he ambitious, hard-driving man prone to coronary occlus ion, as described by F landers Dunbar in 1954, is no longer accepted as having predis pos ition enough to dictate death by coronary occlusion. However, he is not so different from the competitive, res tless , time-haunted, and coronarytype A pers on proposed by M. F riedman and R . H. 2824 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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R os enman in 1959. F riedman and others later listed phys iological characteris tics of their type A person: plasma triglycerides, high choles terol level, hyperins ulinemic respons e to glucose challenge, and levels of noradrenaline pres ent in urine. S imilarly, correlations between cancer proneness and who repres s and deny emotional s tres s and who are extremely s ens itive to loss have been found in some cohorts of cancer patients.

Nons pec ific Inc orporation of S tres s T here are, it seems , four general types of reaction to the normal reaction, in which alert is followed by an of defense; the neurotic reaction, in which the alert or anxiety is so great that the defense becomes the ps ychotic reaction, in which the alarm may be misperceived or even ignored; and the psychosomatic reaction, in which defens e by the ps yche fails, and the is translated into s omatic systems , caus ing changes in body tis sue. T he second trend in ps ychosomatic has been that of inves tigating what happens to a a nons pecific way when faced with s tres s; chronic can be studied by itself without being tied to s pecific pathway reactions or ps ychic cons tellations . In the 1950s, Harold W olff and S tewart Wolf observed chronic hyperfunction or chronic hypofunction in the vascular and secretory activities of the mucos a of the gastrointestinal (G I) and res piratory systems can pathology. Overfunctioning of the mucos a was by Wolff with hostility, and underfunctioning was correlated with fear or sadnes s. T he patient's entire reactive patterning and his or her life history account 2825 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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whether he or she reacts to stress by hyperfunctioning hypofunctioning. Other workers in the nonspecific group have demonstrated various poss ible mechanisms by which ps ychologically induced s tres s may cause organic in humans and animals . In 1950, Hans S elye thought the hypophyseal-adrenocortical axis res ponded to types of physical and ps ychic s tres s with hormonal changes that can ultimately caus e a variety of organic diseases , s uch as rheumatoid arthritis and peptic ulcer. S elye viewed s uch diseases as a byproduct of the attempt to adapt to stress from any s ource. E xperimental psychologis ts with a learning theory conception of behavior studied the effects of chronic unrelieved anxiety in humans and animals and found gastric hydrochloric acid production increas es under circums tances . B ecaus e s uch acidity is a precursor of peptic ulcer, they concluded that chronic anxiety, from any s ource whats oever, is the variable intervening between the behavioral and physical events involved in ps ychos omatic illness . Other animal experimenters success fully produced a variety of ps ychosomatic s ymptoms , such as certain res piratory conditions in animals , by experimentally creating s tres sful s ituations and inducing conflict. it can be as sumed that animals do not have a human being's capacity for symbolic thought, but because they do demons trate ps ychos omatic phenomena in to ps ychogenic s tres s, one wonders whether it is or practical to postulate the operation of specific ps ychological conflicts , which can hardly be meaningful 2826 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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an animal, in the etiology of s uch dis ease. If, on the promise of reward, a pers on can control his or heart rate, s ys tolic blood press ure, temperature, and rhythm frequency, as occurs in biofeedback res earchin short, more of the autonomic system's reactions than before suppos edwhere does the power of control of the body by the will actually end? If human beings show altered electroencephalographic (E E G ) patterns in res ponse to words, and if people who tend to conform social pres sure show a lower level of skin potential than those who do not, what is the exact boundary between an organism and its environment? T he control the autonomic nervous system through such was sugges ted by Neal Miller in 1969. P avlovian conditioning has been s tudied intens ively by S oviet neurophys iologists as a causative agent in disease. T here are a multitude of unans wered but questions in the field of ps ychos omatic medicine. factors , what one may call the outer ps yche , have come to the fore as an area of study.

S oc ial F ac tors In 1951, J urgen R ues ch, in studying communication between people, propos ed that psychos omatic are infantile in nature, because the s ick person, like the infant, expres ses his or her somehow uns peakable communication through his or her own viscera. T . H. Holmes and R . H. R ahe s howed that life cris es often precede illness and that there is s ome correlation the intens ity of the cris is and the length and the of the illness that follows ; the crisis ranked as the most intens e by s ubjects was the death of a spous e. Other 2827 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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suggested a giving-upgiven-up complex, in which a person feels powerless to change his or her or himself or hers elf and eventually los es the will to try, becoming mentally or phys ically ill, perhaps because of changes in the immunological and neuroendocrine systems . Lack of affective involvement with their love-objects, called ale xithymia, in ps ychos omatic patients has been suggested by J ohn C . Nemiah and P eter C . S ifneos . of telephone-company employees s howed that the workers who developed heart dis eas e were apt to be hampered by poss es sing only a high school education. Another s tudy among monks s howed a higher of myocardial infarction among men ris ing from a low socioeconomic s tatus than among those from a middleclas s background. T he duration of a s ickness may connected with the pers on's bas ic attitude toward being sick.

Toward a C larified Interac tion In reports on the disorders now clas sified as ps ychos omatic, there is a tendency to is olate what becomes of the s tres s produced by conflict. T he are often s een as unres olved holdovers from the pregenital period: dependence vers us independence res ultant tens ions leading to ulcer, riddance versus retention and resultant tensions leading to intestinal disorders , and express ion or s uppress ion of anxiety or and res ulting tens ions leading to cardiovascular and vascular headache. T he panic at feared object los s person with a high demand for s upport, leading to hyperthyroidism, and rheumatoid arthritis, is not, strictly 2828 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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speaking, a conflict. No discus sion of illnes s can fail to touch on terminal and the death that awaits everyone. T he organis m fail, but how? If not by direct violence or the ravages of parasitic and epidemic disease, then by the gradual deviations of cells and organic s ys tems from their activity. T he common pers on knows that one member his or her family takes the winter's virus into his or her res piratory tract, whereas another endures it as a stomach: to each his or her own s trengths and weaknes ses. A busload of people presents not only 40-odd lives , but also 40-odd deaths ; what percentage of them is hurried the effects of emotional res pons es on organ tiss ue is known. T he physician of today deals , like people of prehis tory, with the triad of death, disease, and K nowledge of their interrelations hip has increased, but time has not come when phys icians can s ay, as Hippocrates was wont to do, that the people who live at such an altitude in such a climate tend to such a body with such a chemical balance, and live in such a and die in such a manner. F or a s ummary of modern concepts of ps ychos omatic medicine, s ee T able 24.1-

Table 24.1-1 Major C onc eptual Trends in Ps yc hos omatic I. P s ychoanalytic 2829 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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   S igmund F reud (1900) S omatic involvement in conversion hys teria, which is psychogenic in origine.g., paralysis of an extremity. C onversion hysteria always has a primary ps ychic caus e and meaning; i.e., it repres ents the s ymbolic expres sion of an uncons cious conflict. It involves organs innervated only by the voluntary neuromuscular or the s ens orymotor nervous P sychic energy that is dammed up is discharged through physiological outlets .    S andor F erenczi (1910) T he concept of hysteria is applied to organs innervated by the autonomic nervous s ys tem; e.g., the bleeding of ulcerative colitis may be described as specific ps ychic fantas y. (Dis eas es , s uch as known today as ps ychos omatic diseases that only in organs innervated by the autonomic system.) F erenczi's interpretation of symptoms as convers ion reactions was the first application of the concept to diseases s uch as    S mith E ly J elliffe, G eorge G roddeck (1910) organic diseases, s uch as fever and hemorrhage, held to have primary psychic meanings ; i.e., they interpreted as convers ion symptoms that the expres sion of unconscious fantas ies .    F ranz Alexander (1934, 1968) P s ychos omatic symptoms occur only in organs innervated by the

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autonomic nervous s ys tem and have no s pecific ps ychic meaning (as does conversion hysteria) are end res ults of prolonged phys iological states , which are the phys iological accompaniments of certain s pecific unconscious repres sed conflicts. certain cons titutional organic predispos ing in addition to the ps ychic factors involved, ps ychic energy is discharged phys iologically. Alexander's obs ervations were s upported by Weiner's 1957 s tudy of peps inogen P res ented first conceptualization of the biops ychos ocial model.    Helen F landers Dunbar (1936) S pecific personality pictures are as sociated with s pecific ps ychos omatic diseases, an idea similar to Meyer F riedman's 1959 theory of the type A coronary    Helen Deuts ch (1939), P hyllis G reenacre T rauma during birth, infancy, and childhood predis pos es to adult ps ychos omatic disease.    Angel G arma (1950) P eptic ulcer has a specific ps ychological meaning. G arma's idea is an of S igmund F reud's conversion concept to an innervated by the autonomic nervous system. It is similar to S andor F erenczi's concept.    J urgen R uesch (1958) Importance of the between pers ons i.e., communication between the 2831 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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patient and the environment. A dis turbance in communication res ults in ps ychos omatic illness , regress ive type of communication. Developed concept of infantile pers onality as vulnerable to ps ychos omatic illness .    P eter S ifneos, J ohn C . Nemiah (1970) the concept of alexithymia. Developmental the capacity and the ability to expres s affect res ult in ps ychos omatic symptom C oncept of alexithymia modified later by S toudemire, who advocated the term emphasizing cultural influences on use of somatic language and s omatic symptom to express distress . II. P sychophysiological    W alter C annon (1927) Demonstrated the phys iological concomitants of some emotions and the important role of the autonomic nervous in producing thos e reactions . T he concept is on P avlovian behavioral experimental designs .    Harold W olff (1943) Attempted to correlate life stress (cons cious ) to physiological response, objective laboratory tes ts. P hysiological change, prolonged, may lead to s tructural change. He es tablis hed the bas ic res earch paradigm for the fields of psychoimmunology, ps ychocardiology, 2832 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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ps ychoneuroendocrinology.    Hans S elye (1945) Under s tres s a general adaptation syndrome develops. Adrenal cortical hormones are res ponsible for the phys iological reaction.    J ohn Mason (1968) Individualized emotional res ponses are the dominant factor in determining the magnitude of stress related physiological reactions and the role of intervening variables or key factors in regulating reactions to stress . Mas on's concepts pres aged R ichard 1984 emphasis on the person's cognitive stress ful s timuli as a critical factor determining reactions .    Meyer F riedman (1959) T heory of type A personality as a ris k factor for cardiovas cular T he concept has predominated much of ps ychos omatic res earch for the past 30 years . basic concept was introduced by Helen F landers Dunbar as early as 1936.    R obert Ader (1964) E stablished the basic and the res earch methods for the field of ps ychoneuroimmunology. III. S ociocultural

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   K aren Horney (1939), J ames Halliday (1948), Margaret Mead (1947) E mphas ized the influence the culture in the development of ps ychosomatic illness . T hey thought that culture influences the mother, who, in turn, affects the child in her relations hip with the childe.g., nursing, child anxiety transmis sion.    T homas Holmes , R ichard R ahe (1975) the severity and the number of recent stress ful events with the likelihood of disease.    J ohn C as sel (1976) P s ychos ocial factors can as either stres sors or buffers in determining vulnerability to dis eas e. IV . S ystems theory    Adolph Meyer (1958) F ormulated the ps ychobiological approach to patient as ses sment that emphasizes the integrated as ses sment of developmental, psychological, social, and biological aspects of the patient's condition. B as ic concept of the biopsychos ocial model in his approach.    Zbigniew Lipowski (1970) A total approach to ps ychos omatic disease is neces sary. E xternal (ecological, infectious , cultural, environmental), internal (emotional), genetic, somatic, and 2834 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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cons titutional factors as well as past and pres ent history are important and should be s tudied by inves tigators working in the various fields in they are trained.    G eorge E ngel (1977) C oined the term biops ychos ocial derived from general s ys tems theory and bas ed on conceptual ideas introduced much earlier by Alexander and Meyer.    Herbert W einer (1977) Integrative model of ps ychos omatic phenomena. He emphas ized the need not only to integrate biological, s ocial, and ps ychological factors contributing to dis eas e vulnerability but also to unders tand s uch at the genetic, molecular, and neurophys iological levels.    Leon E is enberg (1995) C ontemporary res earch demons trates that the mind/brain to biological and social vectors while being jointly cons tructed of both. Major brain pathways are specified in the genome; detailed connections are fas hioned by, and cons equently reflect, s ocially mediated experience in the world.

Adapted from Harold I. K aplan, M.D. P.2111 2835 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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P.2112

S UG G E S TE D C R OS S C hapter 30 discuss es the various psychotherapies that us eful in the ps ychological management of disorders . A general history of ps ychiatry appears in S ection 55.1.

R E F E R E NC E S Abraham K . S ele cte d P apers in P s ychoanalys is . Hogarth P ress ; 1927. *Alexander F . P s ychos omatic Me dicine : Its Application. New Y ork: W . W. Norton; 1950. Alexander F , F rench T M, P ollock G H. S pe cificity. V ol. 1: E xpe rime ntal S tudy and R es ults . C hicago: Univers ity of C hicago P res s; 1968. *Avila LA: G eorge G roddeck: Originality and His t P s ychiatry. 2003;14:83. B ahnson MB , B ahnson C B : E go defens es in cancer patients. Ann N Y Acad S ci. 1969;164:546. B eaumont W . E xperiments and O bs ervations on the G as tric J uice and the P hys iology of Dige s tion. NY : F . P . Allen; 1833. C affrey B : A multivariate analys is of 2836 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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factors in monks with myocardial infarctions . Am J Health. 1970;60:452. *C annon W B . T he W is dom of the B ody. New Y ork: Norton; 1932. Des cartes R . A Dis cours e on Me thod. London: Dent; Deutsch F : T he choice of organ in organ neuros is. P s ychoanal. 1939;20:1. Deutsch F : T hus speaks the body. T rans N Y Acad 1949;12:2. *Dunbar F . E motions and B odily C hange s . New C olumbia University P ress ; 1954. E neel G L. S election of clinical material in medicine: T he need for a new phys iology. Me d. 1954;16:368. F arrington B . G re ek S cience I and G re e k S cie nce If. London: P elican B ooks ; 1949. F erenczi S . F urther C ontributions to the T he ory and T e chnique of P s ychoanalys is . London: Hogarth 1926. F reud S . F ragment of an analysis of a cas e of S tandard E dition of the C omple te P s ychological S igmund F re ud. V ol 7. London: Hogarth P res s;

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F reud S . On narcis sis m: An introduction. In: E dition of the C omple te P s ychological W orks of F re ud. V ol 14. London: Hogarth P ress ; 1957:73. F riedman M, B yers S , R os enman R H: C oronaryindividuals (type A behavior pattern): S ome biochemical characteristics . J AMA. 1970;2:1030. F riedman M, R os enman R H: Ass ociation of specific behavior pattern with blood and cardiovas cular findings: B lood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary disease. J AMA. 1959;769:1286. G aldston I: P s ychosomatic medicine: P ast, pres ent, future. Arch Neurol P s ychiatry. 1955;74:441. G antt W H. E xperimental B as is for Ne urotic O rigin and Developme nt of Artificially P roduced Dis turbance s of B e havior in Dogs . New Y ork: P aul Hoeber; 1950. G reenacre P . T rauma, G rowth, and P e rs onality. W. W . Norton; 1953. G regerson MB : T he his torical catalyst to cure Adv P s ychos om Med. 2003;24:16. G rinker R . P s ychos omatic R e s e arch. New Y ork: W . Norton; 1953. G rinker R , R obbins F . P s ychos omatic C as e B ook. 2838 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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P hiladelphia: B lakis ton; 1954. G roddeck G . T he B ook of the Id. New Y ork: Nervous Mental Dis eas e P ublis hing; 1929. Halliday J L. P s ychos ocial Medicine : A S tudy of the S ocie ty. New Y ork: W . W. Norton; 1948. Hinkle LE J r, W hitney LH, Lehman E W: Occupation, education, and coronary heart dis eas e. S cience. 1968;161:1238. Holmes T H, R ahe R H: T he s ocial readjus tment scale. J P s ychos om R e s . 1967;11:213. Horney K . T he Neurotic P ers onality of O ur T ime . Y ork: W . W . Norton; 1937. Liddell H. T he role of vigilance in the development of animal neuros es . In: Hoch P , Zubin J , eds . Anxie ty. Y ork: G rune & S tratton; 1950:117. Lipows ki ZJ : P sychosomatic perspectives. C an As s oc J . 1970;15:515. Lipows ki ZJ : P sychosomatic medicine in a changing society: S ome current trends in theory and res earch. C ompr P s ychiatry. 1973;14:203. Lipows ki ZJ , Lips itt DR , Whybrow P C . Me dicine : C urre nt T re nds and C linical Applications . Y ork: Oxford Univers ity P res s; 1977. 2839 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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Lucretius . O n the N ature of the Unive rs e . Latham New Y ork: P enguin; 1951. Mahl G F : T he effect of chronic fear on gastric P s ychos om Me d. 1949;11:30. Mead M: T he concept of culture and the approach. P s ychiatry. 1947;10:57. Meltler C C . A H is tory of Me dicine . P hiladelphia: 1947. Miller NE : Learning of visceral and glandular S cience. 1969;163:434. *Nemiah J C , S ifneos P C . Affect and fantasy in with ps ychosomatic disorders . In: O Hill, ed. Mode rn T re nds in P s ychos omatic Me dicine . London: 1970:126. Novack DH: R ealizing E ngel's vis ion: medicine and the education of physician-healers. P s ychos om Me d. 2003;65:925. P lato. T he Dialogue s of P lato. London: C larendon 1871. R eeves J W . B ody and Mind in W es tern T hought. B altimore: P enguin B ooks; 1958. R ues ch J , B ates on G . C ommunication: T he S ocial 2840 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/24.1.htm

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of P s ychiatry. New Y ork: W . W. Norton; 1951. S elye H. T he P hys iology and P athology of E xpos ure S tre s s . Montreal: Acta; 1950. S igeris t HE . A H is tory of Me dicine . V ol 1. New Y ork: Oxford Univers ity P res s; 1951. S igeris t HE . A H is tory of Me dicine . V ol 2. New Y ork: Oxford Univers ity P res s; 1961. Wolff HG . T he mind-body relationship. In: B ryson L, An O utline of Man's K nowledge of the Mode rn Y ork: McG raw-Hill; 1960:123. Wolf S , W olff HG . Human G as tric F unction. New Oxford Univers ity P res s; 1943. Zilboorg G , Henry G W. A H is tory of Me dical New Y ork: W . W . Norton; 1941.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > 25 - R elationa l P roblem

25 R elational Problems Leah J . Dicks tein M.D. An adult's ps ychological health and sense of well-being depend to a s ignificant degree on the quality of his or important relationships—that is , on patterns of with one's partner and children, parents and s iblings, friends and colleagues. C los e relations hips acros s the cycle are relied on for personal growth, need fulfillment, and s upport. P roblems in the interaction between any these significant others mentioned may lead to clinical symptoms and impaired functioning among one or members of the relational unit. R elational problems can also exacerbate the course or complicate the of a ps ychiatric or other medical condition. C onvers ely, individual's other medical or ps ychiatric condition may provoke dysfunctional patterns of interaction with significant others. R elational problems that remain unrecognized and thus untreated often become chronic and progres sive, with increas ing impairment in the functioning of the couple, the family unit its elf, or other important relationships involved. R elationships have been the object of a growing of research s tudies . C ertain aspects of relational functioning have been extensively investigated. T hese include the relative frequency and patterning of the 2842 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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interactions between intimate partners (i.e., trust, approach-avoidance, problem s olving, communication deviance, behavioral control, coercive process es, interactions, and gender iss ues ). C ognitive elements, as interpersonal attributions and s chemas and the expres sion and regulation of emotional tension partners and in the family, have als o been studied. A remarkable continuity of attachment patterns in adult relations hips has been demons trated. R es earchers explored the development of partner relations hips, differences between dis tres sed and nondistress ed and predictors of divorce. Attempts have been made to clas sify relations hips on the basis of res ources rules established, roles played by the participants , and styles used in conflict res olution. Until the 1990s , few inves tigators developed a culturally oriented unders tanding of observed interaction patterns; thus , previous research findings have generally not been applicable across cultures. In addition, the field lacks a coherent unifying theoretical framework within which various lines of inves tigation can be integrated. F urthermore, many important theoretical contributions developed in the clinical practice of couples , family, dyadic therapy have not yet been empirically tested. R elational problems may be a focus of clinical attention when a relational unit is distress ed and dys functional or threatened with diss olution and (2) when the relational problems precede, accompany, or follow other or medical disorders . Indeed, other medical or symptoms can be influenced by the relational context the patient. C onvers ely, the functioning of a relational is affected by a member's general and other medical or 2843 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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ps ychiatric illnes s. R elational dis orders require a clinical approach than other disorders. Ins tead of primarily on the link between s ymptoms , s igns , and the workings of the individual mind, the clinician mus t also focus on interactions between the individuals involved and how thes e interactions are related to the general other medical or ps ychiatric s ymptoms in a meaningful way. 

DE F INIT ION

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E T IOLOG Y

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R E LAT IONAL P R OB LE M R E LAT E D T O A DIS OR DE R OR G E NE R AL ME DIC AL C ONDIT ION

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P AR E NT –C HILD R E LAT IONAL P R OB LE M

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P AR T NE R R E LAT IONAL P R OB LE M

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S IB LING R E LAT IONAL P R OB LE M

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R E LAT IONAL P R OB LE M NOT OT HE R W IS E

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S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > DE F INIT IO

DE FINITION P art of "25 - R elational P roblems" According to the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV re lational proble ms are patterns of interaction between 2844 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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members of a relational unit that are ass ociated with symptoms or significant impairment in functioning in or more individual members or with s ignificant impairment in the functioning of the relational unit itself. DS M-IV -T R distinguis hes five categories of relational problems . T he first category, relational problem related a mental or general medical condition, deals with the as sociation between relationships and health. T he categories focus on problems in s pecific relational parent–child relational problem, partner relational problem, s ibling relational problem, and relational problem not otherwis e s pecified. In addition, in B , DS M-IV -T R features the G lobal Ass ess ment of F unctioning (G AR F ) S cale (s ee T able 7.9-4), which the clinician to rate the degree to which a relational unit meets the needs of its me mbe rs . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > E T IOLO G

E TIOL OGY P art of "25 - R elational P roblems" P eople communicate not only about pers onal iss ues external events, but als o about their relationships . Interpersonal problems are generally related to interactions that deal with the various components and functions of the relations hip its elf. T he topics of thes e interactions (i.e., what they are about) are class ified in broad categories. It is hypothes ized that all close relations hips fundamentally deal with iss ues of (1) attachment; (2) ranking order, s tatus, and dominance; 2845 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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autonomy and territorial control; (4) gender and (5) boundaries and loyalties ; and (6) cognitive interpretations of the world. T he lis t is s omewhat and not exhaustive. E xcept for cognitive other iss ues can also be observed in interactions nonhuman primates.

A ttac hment A core iss ue in all close pers onal relationships is the es tablis hment and regulation of the affiliative between the participants . In a typical attachment interaction, one person s eeks more proximity and and the other reciprocates , rejects, or dis qualifies the reques t. A pattern is shaped through repeated Attachment behavior between an infant and its primary caregiver leads to the development of an attachme nt which is a relatively s table communication pattern exhibited in close relationships . Dis tinct attachment have been observed in children and P.2242 adults . Adults with an anxious -ambivale nt attachment tend to be obs ess ed with romantic partners , extreme jealous y, and have a high divorce rate. P eople with an avoidant attachment s tyle appear relatively uninvested in clos e relations hips, often feel lonely, afraid of intimacy, and tend to withdraw when there is stress or conflict in the relations hip. B reak-up rates are high. P eople with a s e cure attachment s tyle are highly inves ted in relationships and tend to behave without much pos sess ivenes s or fear of rejection.

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R anking Order Interactions that center on the acquisition of s tatus and dominance (i.e., on decision-making power and control over the partner) can be called ranking-orde r Although the bases of interpersonal influence are and difficult to s pecify, power and dominance are an is sue in close relationships . P eople tend to resent strategies of influencing to which they are particularly susceptible; for example, s ome partners are sensitive threats of withdrawal of affection, and others are to guilt induction. F unctional relations hips require a balance of power that is s atis factory to the participants and that facilitates conflict res olution rather than interactional gridlock. Acute power struggles us ually involve a perceived challenge to an existing dominance structure. An example of an es pecially dysfunctional exertion of power is the verbal or phys ical ass ault of a with suppos edly noncompliant behavior or of a spouse partner perceived as being insufficiently obs equious. V iolence is les s likely to occur in egalitarian

Territory P eople develop a sense of ownership over their own bodies , personal s pace and poss es sions, areas of res ponsibility, and the privacy of their minds. T erritorial interactions deal with pers onal autonomy and control res ources and center on the acquis ition, management, defens e of ownership rights . E ffective parenting gradual transfer of territorial control from the parents to the increasingly autonomous child. E s pecially the progres sive validation of children's s ens e of and control over their bodies (W ho can touch me? W ho 2847 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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controls my food intake? ). Iss ues of pers onal autonomy often increas e drastically in adoles cence. Many experienced by couples are about territorial iss ues , privacy, control over one's time, res pons ibility for tasks chores , financial control, and who makes final T he person who performs the quality control over an is cons idered the owner of the territory, which is why comments, advice, and criticis m are often resented. In healthy relations hips, each partner is able to relinquis h autonomy and territorial control at different times , particularly with acute stress and illnes s. P roblems when such dependency is not tolerated, but als o when systematically encouraged and maintained. territorial interactions are als o common in the work environment when a pers on's area of res ponsibility is expanded to an unmanageable level or when a colleague threatens it.

S exuality and G ender C ommunications that expres s gender role expectations that s ignal the presence or absence of s exual attraction a part of most close relations hips. S exual interactions center on the express ion of s exual interes t and on the management of s exual tens ion between potential partners . C ultural norms and individual maturity dictate the relationships in which s exual interactions are and those that must be kept des exualized. C learly, and older adults carry the res ponsibility of neutralizing sexual tension that can aris e in relations hips with Many sexual partner relations hips are challenged by differences in desire (with women's s exual drive being insis tent than men's ) and by the tas ks of s ynchronizing individual s exual rhythms and maintaining appropriate 2848 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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and res pectful s exual tens ion in the relations hip.

B oundaries and L oyalties R elationships are constantly influenced, beyond prior experiences , by other people, external pres sures, and partner's outs ide activities and experiences. A marriage can be undermined by an adulterous relations hip, as as by exces sive jealousy about a partner's emotional involvement with an outs ide pers on or activity. Loyalty conflicts involving one's s pouse or partner and one's of origin are common in the beginning of a marriage. is also often experienced as competing with the relations hip. E ven a general medical or psychiatric condition can be seen as a rival when the patient prefer the emotional involvement with symptoms and treatments to involvement with his or her partner. E very clos e relations hip has to define its boundaries (e.g., the acceptable degree of outs ide interference, as well as acceptable degree of each partner's involvement with outside elements ).

C ognitive Interpretations Humans live in a symbolic world: the world of the and nonverbal—that is , body languages , ideas , values, goals . A major s ocialization tas k of parents is this s ymbolic world to their children. One's s ense of belonging depends on the social validation of one's and interpretations of the world. One's s ens e of identity to a large degree, a s ummary description of how one been defined by others acros s the life cycle. world view, values, and beliefs tend to caus e conflicts. Differences in how a conflict is interpreted by 2849 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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participants tend to maintain it. A ps ychological mechanism that has cons is tently been found to create problems is that people tend to interpret their own behavior as s tate depe nde nt (a normal res ponse to the circums tances ) and their partner's behavior as trait de pendent (determined by s table character traits). cons istent finding is that of gender differences in about relations hips. W omen think about relations hips more and with more complexity than men do. T hey outwardly more dis tres sed about problems and have noted to be more likely to take action related to res olve them. C onceivably, women carry more than an equal of the respons ibility for relationships , because they are defined by s ociety as the relationship experts, and yet poss ess less power to invoke change. T hese interactions can take place without the appearing to pay cons cious attention to them. T hes e interactions often cons ist of an exchange of signals while the overt communication focus es on something completely different and s eemingly relations hip neutral. F or instance, while dis cus sing vacation plans , a couple may us e tone of voice and nonverbal mess ages to also exchange information who is going to be in charge. T hes e s ubtle exchanges confirm or challenge the existing power s tructure in the relations hip. If enough tension develops, the iss ue may brought to the forefront and discuss ed openly if the relations hip is bas ed on trust and respect for as well as for common foci of agreement. It is useful to distinguish between conflicts of intere s t conflicts of me aning. In conflicts of interes t, the agree on what the interaction is about, but each one 2850 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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pursues a different outcome. In conflicts of meaning, partners s ee the interaction from a different perspective and give it a different meaning. F or instance, one may have a need for intimate conversation; the other partner has had a rough day and wants to be left alone. T he firs t partner may experience the other's reluctance listen and talk as a refusal to engage in intimacy, that partner may experience the insistence to lis ten and talk as an insensitive invasion of privacy. S uch misunderstandings P.2243 can escalate and lead to distorted global interpretations the partner and the relations hip. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > R E LAT IONAL P R OB LE M R E LAT E D ME NT AL DIS OR DE R OR G E NE R AL ME DIC AL C ONDIT

R E L ATIONAL PR OB L E M R E L ATE D TO A ME NTAL DIS OR DE R OR GE NE R AL ME DIC AL C ONDITION P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of relational problem related to a mental disorder or general condition “should be us ed when the focus of clinical attention is a pattern of impaired interaction as sociated 2851 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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with a ps ychiatric disorder or a general medical in a family member.” S tudies indicate that satis fying relations hips may have health-protective influence, whereas relationship tends to be as sociated with an increas ed incidence of illness . T he influence of relational s ys tems on health been explained through ps ychophysiological that link the intens e emotions generated in human attachment s ys tems to vascular reactivity and immune proces ses. T hus , s tres s -related ps ychological or symptoms can be an express ion of family dys function. A person who feels ill first turns to the members of the family or to his or her partner. T heir opinions influence whether a pers on sees the s ymptoms as trivial or as a caus e for concern, as requiring home remedies or profes sional attention. T he family or partner als o participates, directly or indirectly, in the ongoing between patient and physician or other health profes sional, defining the type of medical problem that the patient is experiencing, how it s hould be dealt with, and what the family's or partner's role s hould be in managing the illnes s and s upporting the patient. T o a large extent, the ps ychological meaning of the illness the patient's cooperation and compliance with depend on the outcome of thes e relational interactions . F amily and partner relationship dynamics influence an individual's cours e of illnes s. C onversely, the illnes s of family member or partner influences the family's interactional dynamics . If the dis eas e proces s is chronic, an adjus tment of members' and partner's roles and respons ibilities is to be needed. T he patient's identification with the s ick 2852 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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and the concomitant regress ion and dis ability are influenced by the interpersonal dynamics of thos e involved. In some cases, the family or s ignificant other, both, joins with the patient in a s truggle against and others who appear to refus e to acknowledge the patient's disability and therefore to deny financial S ometimes , medical symptoms are recruited to play a meaningful role in the interactional dynamics of the relational unit (e.g., to stabilize the patient's family, to regulate clos eness and dis tance among family or to communicate information that cannot be openly expres sed). T he role of marital and family interactions in the ons et cours e of ps ychiatric dis orders has been extens ively studied, in particular, for mood and anxiety dis orders, schizophrenia, substance-related dis orders, eating disorders , and pers onality disorders . Attempts have made to link dis tinct family dynamics to s pecific On the other hand, the following outline provides a somewhat s implified and generalized s ummary of the observed interactions . At first, the ps ychiatric symptoms displayed by a family member or s ignificant other elicit concern and care. roles within the family are adjus ted, often with other members taking charge and ass uming some of the patient's duties and responsibilities. F amily members define the patient's problem, give advice, propose solutions , and encourage the patient to overcome the difficulties or to seek help, or both. W hen the patient to improve, however, the family members or partner feel increasingly frustrated. Indeed, ps ychiatric are often hard to live with, and they can undermine the 2853 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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family's and partner's energy and morale. T he mentally family member often behaves in a way that social interaction and increas es interpers onal conflict. extra efforts and tasks required of the other family members can often become more burdensome over In addition, s ignificant others may hold ps ychiatric patients more res pons ible for their own symptoms than they would general medical patients. As frustration mounts, the family members feel that they have limited options for dealing with their own feelings. T heir direct expres sion of anger, dis approval, and criticism is likely aggravate the ps ychiatric condition. On the other hand, family members and the patient's partner withdraw and exclude the patient from activities, the patient may feel neglected and abandoned. F inally, family members feel guilty about their feelings of frustration and try to compens ate for this with s elf-sacrifice, overprotection, overidentification with the patient. S uch overcompens ation indirectly express es the underlying hostility. T hese understandable family and partner adaptations represent behaviors that are rated high on s cales for hostility, criticis m, and overinvolvement, a constellation that has come to be known as expre s s e d e motion. E xpres sed emotion is a significant and robus t predictor relaps e in several psychiatric conditions , including schizophrenia and mood and eating dis orders. High expres sed emotion might also be as sociated with a wors ening of the course of Alzheimer's dis eas e and even play a role in general or other medical conditions , such as diabetes. T he interactional mechanis ms that account for the different express ed emotion res ponse 2854 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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styles of family members are unknown. T he relationship between family interaction patterns ps ychiatric illnes s is likely to be bidirectional. T here is suggestion that, when a vulnerable family member excluded or rejected and is treated with criticis m and overinvolvement, psychiatric s ymptoms may develop. instance, the ris k of developing depress ion has been to be ten times greater for individuals experiencing relations hip dis tres s than the risk for individuals in nondis tres sed relations hips. T he mechanis ms described previous ly do not s upport notion that families caus e mental illness or relapse. neither the res earch data nor the complex and nature of family interaction patterns warrants s uch a conclus ion. Y et, mental health profess ionals have, in past, neglected the families and s ignificant others of patients in the name of confidentiality and therapeutic alliance or blamed them for causing the illness . T he clinician mus t appreciate the dedication of most and s ignificant others, their need to be involved in treatment decisions that affect them, and the fact that they are entitled to as sistance with the considerable burden of caregiving. Indeed, families are the primary caregivers of the sick and the dis abled, and it is that one-half to two-thirds of the persistently mentally ill population live with families. C aregiving is s tres sful, the burden of caring for ill family members falls disproportionately on the women in a family. F amily members who live with a mentally ill relative report high levels of s tres s, anxiety, depres sion, and resentment. cite increas ed marital strain, disrupted social life, and hardship for s iblings . In recent years, research into the 2855 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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stress of caregiving and how to alleviate it has been initiated, partly in res ponse to the advocacy of s upport organizations , s uch as the National Alliance for the Mentally Ill. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > P AR E NT –C HILD R E LAT IONAL

PAR E NT–C HIL D PR OB L E M P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of parent–child relational problem should be us ed when the focus clinical attention is a pattern of interaction between parent and child (e.g., impaired communication, overprotection, inadequate discipline, neglect or P.2244 abuse) that is as sociated with clinically s ignificant impairment individual or family functioning or the development of clinically significant symptoms in parent child.

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P arents differ widely in sensing the needs of their S ome quickly note their child's moods and needs; are slow to respond. P arental res ponsivenes s in with the infant's temperament affects the quality of the attachment between infant and parent. A cons iderable body of res earch links an infant's attachment s tyle with social and emotional adjustment in childhood. S ecure ly attached children showed enhanced res ilience in a stress environment. Ins ecure children are more likely to anxious, aggress ive, and low on social competence. F urthermore, attachment-related factors , s uch as deprivation, major s eparations, los s of attachment and the development of dis organized-insecure attachment in res ponse to maltreatment, have been to be risk factors in the development of ps ychiatric disorders . R es earch on parenting s kills has isolated two major dimensions : (1) a permis sive-res trictive dimens ion and a warm-and-accepting versus cold-and-hostile A typology that s eparates parents on thes e dimensions distinguishes between authoritarian (res trictive and pe rmis s ive (minimally res trictive and accepting), and authoritative (res trictive as needed, but als o warm and accepting) parenting styles . C hildren of authoritarian parents tend to be withdrawn or conflicted; those of permis sive parents are likely to be more aggres sive, impulsive, and low achievers; and children of parents s eem to function at the highest level, s ocially cognitively. Y et, switching from an authoritarian to a permis sive mode may create a negative reinforcement pattern. T his interactional pattern s tarts with avers ive child behavior, s uch as whining or aggress ive 2857 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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hyperactivity, in response to ins istent parental “stop it.” T hen, the parent backs down, which rewards child for behaving avers ively. At this point, the child deescalates , thus reinforcing the parent's permiss ive attitude. S uch coercive process es have been with a child's lack of s elf-regulation, rejection by peers , later academic failure, depress ion, delinquency, and antis ocial behavior. S ubstantial evidence indicates that marital discord problems in children, from depress ion and withdrawal conduct dis order and poor performance at school. T his negative effect may be partly mediated through triangulation of the parent–child relationships . T riangulation refers to the process in which conflicted parents attempt to win the s ympathy and s upport of child, who is recruited by one parent as an ally in the struggle with the partner. T he term has also been used the proces s by which parents focus on a behavioral or general health problem of the child as a s trategy for defus ing marital conflicts . Marital discord can also the parent–child relationship in a direct way, as emotions begin to contaminate all family relations hips. instance, angry interactions between spous es have linked to negative affect in the relationship between and infant. T he parent–child relationship is greatly influenced by marital and family environment. Divorces and stress the parent–child relations hip and may create loyalty conflicts . S tepparents often find it difficult to as sume a parental role and may res ent the s pecial relations hip that exis ts between their new marital and the children from that partner's previous marriages. 2858 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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S ingle-parent families usually cons is t of a mother and children, and their relationship is often affected by financial and emotional problems . W omen who work outside the home out of need and to pursue jobs or careers often feel guilty about not having enough time with their children; yet, they are likely to s pend much time in child-rearing activities than fathers who als o outside the home. Normal developmental crises can also be related to parent–child problems . F or ins tance, adoles cence is a of frequent conflict, as the adolescent resists rules and demands increas ing autonomy, while s imultaneously eliciting protective control by displaying immature and dangerous behavior. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > P AR T NE R R E LAT IONAL P R O

PAR TNE R R E L ATIONAL PR OB L E M P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of partner problem should be us ed when the focus clinical attention is a pattern of interaction between spous es or partners characterized by communication (e.g., criticisms), 2859 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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distorted communication (e.g., unrealistic expectations), or noncommunication (e.g., withdrawal) that is as sociated clinically s ignificant impairment individual or family functioning, the development of symptoms in one or both partners . A partner relationship involves two people who have made a commitment to maintain their relations hip. Usually, the partners live together and have sexual relations with one another. Many partner relationships socially s anctioned by marriage. S eparation and rates have increased rapidly in Western s ocieties s ince 1960s . An unexpected announcement by one s pouse decis ion to divorce often elicits an acute relational which the partners desperately seek profess ional help. S ociologists have found that increases in the divorce correlate with meas ures of women's economic and ps ychological independence. A s uggested explanation that women are less willing to stay in unhappy or marriages to the degree that they are no longer forced do so for economic reas ons , as well as the fact that domes tic violence is now univers ally recognized as an too common occurrence and one that is not to be tolerated. Nevertheless , for most women, divorce s till severe economic cons equences , because they als o less for the s ame work as men and, too frequently, do receive the financial child s upport decreed by the court. Using observational methods , J ohn G ottman has criticis m, contempt, defens iveness , and stonewalling 2860 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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withdrawal from interaction) as interactive process es longitudinally predict which couples separate and T he best s ingle predictor is contempt, es pecially the contempt. F urthermore, there are gender differences ; women tend to s how more criticism than men do, and men s how more stonewalling. A cas cade has been propos ed in which complaining and criticizing leads to contempt, which leads to defens iveness , which leads withdrawal from the interaction. T hese same patterns probably als o occur in gay and les bian relations hips, although comparable data have not yet been reported. R elatively minor problems can escalate to levels as a res ult of unrecognized and yet natural interactional proces ses , s uch as the amplification of differe nce s and the polarization of ambivalence. S mall differences between partners, s uch as a s ubtle in sexual need, can amplify s pontaneous ly. T hen, gradually, the partner with the greater need may the only s exual initiator, overly focus ing on the other's sexual availability, whereas the other partner is likely to adopt a style of avoiding s ex and focusing on the first one's perceived or true sexual aggres siveness . T his preoccupation with one another's s exual des ire from the awarenes s of a pers on's own real needs , as person seems to always be “in the mood” and the other never. In a s pontaneous proces s of polarization, each partner express es an opposite position with regard to is sue about which they both feel ambivalent. An dilemma is thus externalized in the relationship. T he polarization of a couple's ambivalence about or about the decis ion to have children can als o lead to chronic emotional conflicts. 2861 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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Many partners expect the other to regularly provide of commitment. T his may res ult from personal or concerns about the true (real) power balance in the relations hip. Indeed, the pers on who is more P.2245 to and dependent on the relationship may feel when, and if, faced with divorce threats. Unfortunately, violent behaviors can be an attempt to deny and to exert power. B eing rejected by an intimate can elicit traumatic memories of pas t attachment experiences and can lead to impulsive suicide attempts to violence toward the partner, more often s een in the male partner, who is sex role s ocialized to maintain in relationships to be cons idered “a real man.” An iss ue with s pecial importance for partner relational problems is pas s ionate love , defined as a special state mind characterized by emotional dependence on the person one is in love with and by s ymptoms such as an intrus ive preoccupation with that pers on, an intense for reciprocity of feelings, idealization, and an uncanny ability to s ee hope even when there is none. F alling in can occur at any age and has been described in all cultures. Unrequited love can lead to depres sion, tendency, violence, and partner homicidal ideation, observed more often in men. In addition, dis tres s and alienation in one's primary relations hip put one more at ris k for falling in love with someone else. V iolence can be ass ociated with relational problems. A pattern of wife beating, however, indicates individual impulse-control problems , impaired s ocialization, being victim of child abuse, and, usually, alcohol and 2862 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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abuse, the latter enabling impulse dys control to Wife beating is found in every s ocioeconomic clas s and culture and at every income level. P regnancy is the ris k time for domes tic violence toward the woman. subjected to violence often res ults in depres sion and learned helpless nes s acros s the life cycle. W omen, as children, often are revictimized in adult significant relations hips . T he patient too often feels inhibited about divulging the s ecret of domestic violence and blames herself for its occurrence; thus , clinicians must develop an appropriate sensitivity to the poss ibility of spous al abuse, in which 5 percent of victims are men. patient, women and men, must be asked about experiences with violence across his or her life in the profes sional interview, regardless of sex, age, or socioeconomic, educational, racial, or faith E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > S IB LING R E LAT IONAL P R O B

S IB L ING R E L ATIONAL PR OB L E M P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of s ibling problem “should be us ed when the focus of clinical attention is a pattern of interaction between siblings , as sociated with clinically s ignificant impairment of functioning, or s ymptoms in one or more of the S ibling relations hips tend to be characterized by competition, comparis on, and cooperation. Intens e 2863 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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rivalry can occur with the birth of a child and may as the children grow up, compete for parental approval, and meas ure their accomplishments against one Alliances between s iblings are equally common. may learn to protect one another against parental or aggress ion. In hous eholds with three children, one tends to become closely involved with one another, leaving the extra child in the position of outs ider. P arents tend to be more empathetic with the child who has the s ame s ibling pos ition that they experienced. R elational problems can aris e when s iblings are not treated equally; for instance, when one child is being idealized, while another is cas t in the role of the family scapegoat. Differences in gender roles and expres sed by the parents can underlie s ibling rivalry. P arent–child relationships also are dependent on personality interactions . R es earch has shown that 30 percent of a person's personality is due to genetic T hus, this is sue must als o be cons idered when to understand and to explain parent–child and sibling relations hips . T he notion that a child's resentment at a parental figure or a child's own disavowed dark emotions can be projected onto a s ibling and can fuel intens e hate relationship is an interes ting hypothes is. As people grow older, they often desire to reconnect with sisters and brothers and, cons equently, may take great effort to resolve longstanding sibling conflicts. A child's general, other medical, or ps ychiatric always s tres ses the sibling relationships. P arental and attention to the sick child can elicit envy in the siblings . In addition, chronic dis ability can leave the 2864 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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child feeling devalued and rejected by s iblings , and the latter may develop a s ens e of superiority and may feel embarrass ed about having a dis abled s ister or brother. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > R E LAT IONAL P R OB LE M NO T S P E C IF IE D

R E L ATIONAL PR OB L E M OTHE R WIS E S PE C IFIE D P art of "25 - R elational P roblems" According to DS M-IV -T R , the category of relational problem not otherwis e s pecified “should be us ed when the focus of clinical attention is on relational problems clas sifiable by any of the s pecific problems above (e.g., difficulties with superiors and coworkers ).” P eople become emotionally involved in peer at school and work and in relationships with teachers, superiors , students, and employees. T hey develop intens ive friendships and engage in complex around avocational interes ts and goals. P eople, across life cycle, may become involved in relational problems with leaders and others in their community at large. In such relationships , conflicts are common and can bring about s tres s -related symptoms. Many relational problems of children occur in the setting and involve peers. Impaired peer relations hips be the chief complaint in attention-deficit or conduct disorders , as well as in depress ive and other 2865 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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disorders of childhood, adoles cence, and adulthood. R acial, ethnic, and religious prejudices and ignorance caus e problems in interpers onal relations hips. In the workplace and in communities at large, sexual is often a combination of inappropriate sexual inappropriate displays of abus e of power and and express ions of negative gender stereotypes, toward women and gay men, although als o toward children and adoles cents of both s exes. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > S UG G E S T E D C R O S S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "25 - R elational P roblems" C hild psychiatry is the subject of C hapter 32. C ouples family therapy are discuss ed in S ection 30.5. C hild and s exual abus e and neglect are dealt with in S ection 49.3. P hys ical and s exual abus e of adults is discuss ed S ection 28.6. S ection 18.1a deals with normal human sexuality and s exual dis orders. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 25 - R elationa l P roblems > R E F E R E NC

R E FE R E NC E S Amato P R , B ooth AA. G e ne ration at R is k: G rowing an E ra of F amily U phe aval. C ambridge, MA: Univers ity P res s; 2000:319. 2866 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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Anderson MA, G illig P M, S itaker M, McC los ky K , K , G rigsky N: “Why does n't she just leave? ” A study of victim reported impediments to her safety. J F am V iole nce . 2003;18:151–155. Aydin O, S ahin D: T he role of cognitive factors in modifying the intensity of emotional res pons es produced by facial express ions. P s ychol E duc. 2003;40:50–56. B elsky J , Y oungblade L, R ovine M, V olling B : marital change and parent-child interaction. J F am. 1991;53:487–498. *B erns tein AC . G ender in stepfamilies : Daughters fathers . In: S ilvers tein LB , G oodrich T J , eds. F amily T herapy: E mpowe rme nt in S ocial C ontext. Was hington, DC : American P sychological 2003. P.2246 *B orge L, Martins en E , R uud T , Watne O, F riis S : of life, loneliness , and lucid contact among long-term ps ychiatric patients. P s ychiatry S e rv. 1999;50:81. B urman B , Margolin G : Analysis of the as sociation between marital relations hips and health problems : interactional pers pective. P s ychol B ull. 1992;112:39. B utzlaff R A, Hooley J M: E xpres sed emotion and 2867 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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ps ychiatric relaps e. Arch G e n P s ychiatry. C hang T , Y eh C J : Using online groups to provide support to As ian-American men: R acial, cultural, gender, and treatment iss ues . P rof P s ychol R e s 2003;34:634–643. Davey A, E ggebeen DJ : P atterns of exchange and mental health. J G e rontol S e r B S oc S ci. 1998;53:86–95. Dicks tein LJ . Domes tic abuse as a ris k factor for and youth. In: S chetky DH, B enedek E , eds . C hild and Adole s ce nt F orens ic P s ychiatry. DC : American P s ychiatric P res s; 2001. Dres cher J , D'E rcole A, S choenberg E , eds . P s ychothe rapy with G ay Men and L e s bians : Dynamic Approache s . B inghampton, NY : T he P ark P res s/T he Haworth P ress , Inc.; 2003. *E dward J : T he loving side of the sibling bond: A for growth or conflict. Is s ue s P s ychoanal P s ychol. 2003;25:27–43. F letcher G J O, F itness J , eds . K nowledge S tructure s C los e R elations hips : A S ocial P s ychological Mahwah, NJ : E rlbaum; 1996. *G ottman J M. W hat P re dicts Divorce? T he B etwe e n Marital P roces s e s and Marital O utcomes . Hillsdale, NJ : E rlbaum; 1994. 2868 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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*G ottman J M. T he Marriage C linic: A S cie ntifically Marital T he rapy. New Y ork: Norton; 1999. G ottman J M, K atz LF , Hooven C . Me ta-E motion: F amilie s C ommunicate E motionally. Mahwah, NJ : E rlbaum; 1997. G reg A, Howe D: S ocial unders tanding, attachment security of preschool children and maternal mental health. B r J De v P s ychol. 2001;19:381–393. Haglund K : P arenting a second time around: An ethnography of African-American grandmothers parenting grandchildren due to parental cocaine J F am Nurs . 2000;6:120–135. Hazan C , S haver P R : Attachment as an framework for res earch on clos e relations hips. Inquiry. 1994;5:1. Higgins J , G ore R , G utkind D, Mednick S A, P arnas S chuls inger F , C annon T D: E ffects of child-rearing schizophrenic mothers : A 25-year follow-up. Acta P s ychiatr S cand. 1997;96:402–404. Hinde R A. R elations hips : A Diale ctical P e rs pe ctive . UK : P s ychology P res s; 1997. *K as low F W , ed. Handbook of R e lational Diagnos is Dys functional F amily P atterns . New Y ork: W iley; Lasenza S : S exuality: P sychoanalytic pers pectives . 2869 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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Marital T he r. 2004;30:53–56. Lefley HP , J ohnson DL, eds. F amilie s as Allies in T re atme nt of the Me ntally Ill: Ne w Dire ctions for Health P rofes s ionals . W ashington, DC : American P sychiatric P ress ; 1990. *Lewis J M: F or better or wors e: Interpersonal relations hips and individual outcome. Am J 1998;115:582. Looy HA. G ender and s exuality: C ons tancy and In: V ander S toep S W , ed. S cience and the S oul: F aith and P s ychological R es earch. Lantham, MD: Univers ity P res s of America, Inc.; 2003. *Lu L, Lin Y Y . F amily R oles and Happine s s in P ers onality and Individual Differe nce s . V ol 25. E ls evier S cience; 1998:195–207. Main M: Introduction to the s pecial section on attachment and ps ychopathology: Overview of the of attachment. J C ons ult C lin P s ychol. 1996;64:237. *Morrongiello B A, Hogg K : Mothers ' reactions to children mis behaving in ways that can lead to injury: Implications for gender differences in children's ris k taking and injuries. S ex R ole s . 2004;50:103–118. Nemeroff C B : Neurobiological cons equences of childhood trauma. J C lin P s ychiatry. 2004;65[S uppl 1]:18–28. 2870 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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O'Leary K D, C hristian J L, Mendell NR : A clos er look link between marital discord and depres sive symptomatology. J S oc C lin P s ychol. 1994;13:33. Oliver LE : E ffects of a child's death on the marital relations hip: A review. O me ga J Death Dying. 1999;39:197–227. P atterson G R , S toolmiller M: R eplication of a dual model for boys ' depress ed mood. J C ons ult C lin 1991;59:49. P erlmutter R A. A F amily Approach to P s ychiatric Dis orde rs . W ashington, DC : American P sychiatric 1996. P hares V . “P oppa” P s ychology: T he R ole of F athe rs C hildre n's Me ntal W e ll-be ing. W estport, C T : P ublis hing G roup Inc.; 1999:150. P ruchno R , R os enbaum J . S ocial relationships in adulthood and old age. In: Lerner R M, E as terbrooks eds. Handbook of P s ychology: De ve lopmental V ol 6. New Y ork: J ohn W iley & S ons, Inc.; 2003. *R iley S . Art therapy with couples . In: Malchiodi C A, Handbook of Art T herapy. New Y ork: G uilford P res s; 2003. S anford K : E xpectancies and communication in marriage: Dis tinguishing proximal level effects distal level effects. J S oc P e rs R e lations hips . 2871 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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402. S holerane G , P irooz MD, eds with LD S chwoer. of F amily and C ouple s T he rapy: C linical Was hington, DC : American P s ychiatric P res s, Inc.; S teinberg L: W e know s ome things: P arentrelations hips in retrospect and pros pect. J R e s 2001;1:1–19. *S wans on K M, K armali ZA, P owell S H, Miscarriage effects on couples ' interpers onal and relations hips during the firs t year after loss : perceptions. P s ychos om Me d. 2003;65:902–910. T s eung W , Hsu J . C ulture and F amily: P roblems T he rapy. New Y ork: Haworth P res s; 1991. Uebelacker LA, C ourtnage E S , W his man MA: of depress ion and marital diss atisfaction: marital communication style. J S oc P e rs 2003;20:757–769. V andervoort D, R okach A: P os ttraumatic syndrome: T he cons cious proces sing of the world of trauma. S oc B ehav P e rs . 2003;31:675–686. V erhuls t J : Limerence: Notes on the nature and of pas sionate love. P s ychoanal C ontemp T hought. 1984;7:115. V italiano P P , Y oung H, R us so J , R omano J , 2872 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/25.htm

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Amato A: Does express ed emotion in s pouses subs equent problems among care recipients with Alzheimer's disease? J G e rontol. 1993;48:202. Walzer S , Oles T P : Managing conflict after end: A qualitative study of narratives of ex-spous es . F am S oc. 2003;84:192–200.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 26 - Additional C onditions T hat Ma y B e a F ocus of C linical 26.1: Malingering

26.1: Malingering Mark J . Mills J .D., M.D. Mark S . L ipian M.D., Ph.D. P art of "26 - Additional C onditions T hat May B e a C linical Attention" E ven judged by the es oteric entries in this textbook, malingering is an odd condition and not a true diagnosis. F irst, despite its formal presence in nosology since the third edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-III), it more badness than madness . S econd, although a theme in forensic evaluations largely because s ome ps ychiatric symptoms are difficult to objectively verifymalingered pain is apparently far more common litigation than are malingered ps ychos is or malingered cognitive impairment. T hird, the his toric methodology of ps ychiatrylis tening to and observing one's patientsis ineffective in detecting malingering. Despite thes e anomalies, unders tanding malingering is a us eful for the psychiatric practitioner because malingering probes fundamental concepts that underpin psychiatric diagnosis and its approach to patients . Malingered ps ychiatric symptoms also reveal how nonpsychotic individuals imagine the s ymptoms of psychotic illness . F or the forensic ps ychiatris t, newly developed and widely circulated psychological tests have significantly 2874 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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honed the ability of forensic evaluators to detect malingering. S till, this ability attends best to the more flagrantly imagined psychiatric symptoms and the more fully elaborated cognitive impairments . T he in ps ychological tes ting require that the forensic practitioner become more familiar with this method of as sess ing malingering. F inally, malingering reminds psychiatrists to remain profes sionally humble, as they are accus tomed to attributing great value to their patients' s ubjective complaints . R arely do ps ychiatris ts fully cons ider the poss ibility that their patients are embellis hing their symptoms. T his behavior is often for a good reasonpsychiatrists perceive their patients' pain and to alleviate that pain. E ven when ps ychiatris ts cons ider poss ibility of symptomatic embellishment, their ability to detect that embellis hment is limited. P s ychiatry's strengththat is , its ability to lis ten to patientscan als o be downfall. If psychiatrists fail to recall that what they are being told is not necess arily true or accurate, they ris k furthering their patient's (or evaluee's ) misbehavior. C onvers ely, making an accusation of embellishment or outright feigning can rupture the therapeutic alliance beyond repair.

HIS TOR Y T he medical concept of malingering has its origins in philosophical dichotomy between reality and unreality, the ultimate express ion of which are questions about truth and falsity of life, generally. C entral to moral has been debate of the rightfulnes s or wrongfulnes s of person's deliberate us e of the capacity to deceive. At 2875 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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conceptual extreme is F riedrich Nietzche, writing in W ill to P owe r, there is only one world, and that world is false, cruel, contradictory, mis leading, sens eles s. At oppos ite philos ophical pole is Nicolai Hartmann, who argues in his E thics that any lie injures the deceived in his life; it leads him as tray. T he following example illus trates s ome of these is sues . Although perceived as the head of one of the mos t powerful mob families , the evaluee had nearly a 30history of making psychiatric complaints . T hese history of head trauma with a reported 50 percent loss meas ured intelligence, a history of s peaking nonsense public, and nearly a 20-year history of hospitalized ps ychiatric treatment on an almos t annual basis . of this very substantial history, this individual's was delayed years after his arrest on a variety of racketeering charges. Once indicted, his attorneys is sues of competence to s tand trial. T hus, his mental state became a crucial is sue early in proceedings and remained important throughout his T he prosecution asked to have the defendant a team including a psychiatrist/neuroimagis t, a neurops ychologist, and a forens ic ps ychiatris t. T he of this evaluation was that the prosecution's experts became convinced that the evaluee was elaborating symptoms of cognitive impairment. S till, those experts were not convinced that, des pite his elaboration, he did not have s ome very mild and not legally relevant impairment. T he defens e presented eight experts who opined about the defendant's multiple problems. Overall, they 2876 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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the defendant as having experienced clinically impairment from his days as a boxer, s chizophrenia had developed in his late 20s, and moderate disease that had developed over the previous few Once the court ruled that the defendant had s ufficient capacity to proceed to trial despite his purported impairments , the government pres ented cons iderable evidence of the defendant's ongoing role as the head his family. T hat evidence was sufficiently convincing the defendant was convicted on a majority of the brought agains t him. However, that led to a new inquiry into whether he was competent to have s entencing impos ed and what kind of facility would be bes t for him even the government's witness es had to admit, the defendant could be developing early cognitive P.2248 Again, the court found that the alleged problems were sufficiently great as to delay the impos ition of and the defendant was remanded to custody. T he defendant's family opined that he had been wrongfully convicted, and one of the major news documentary programs invited the defendant's forensic evaluators to discuss the ineptitude and zealotry of the government's experts. T he government monitored the defendant's behavior produced audio tapes of convers ations between him others . T he government has reindicted him, claiming the tapes reveal that he continued to run the family prison. At leas t one of the defendant's original experts , having heard selected portions of thos e tapes, now believes that the entire his tory of mental s tate 2877 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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abnormalities presented by the defendant was malingered. F urther, that expert has opined that the defendant manifes ted no cognitive impairment on the reviewed tapes . T o the extent that the history is accurate, it apparently reveals a cognitive attempt to fabricate psychiatric symptoms going back more than 20 and, probably, than 30 years . In medicine, the tens ion between truth and lies is evidenced in the conflict between malingering and its detection. Mental illness , because it is often difficult to objectively verify, is an age-old favorite of the T hat individuals might feign or produce illness or for gain of s ome kind or to avoid duty has been known since antiquity. T he G reeks cons idered malingering in military service to be analogous to forgery, and both offens es were punis hable by death. T he penalty was mitigated to forced public exposure for 3 days , wearing floridly female regalia. Ulys ses is s aid to have faked to avoid duty in the T rojan W ar, us ing such tactics as yoking a bull and a hors e together, plowing the and s owing salt instead of grain. In an early attempt at detection, the son of the K ing of Ithaca was placed in furrow, directly in the line of Ulyss es ' oncoming plow. If were truly mad, it was reasoned, he would take no the boy. However, Ulys ses s werved to avoid the boy, action that was considered proof that his madnes s was ploy. In the second century AD, G alen wrote a treatiseO n F e igne d Dis eas es and the De te ction of T he min which described R oman cons cripts who cut off thumbs or 2878 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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to ens ure unfitnes s for duty. In the 16th century, P aolo Zacchias , cons idered by many to be the father of medicine, wrote of madnes s, there is no dis eas e more easily feigned, or more difficult to detect. T ruth versus imposture was also dis cuss ed in T heodric B eck's 1823 E le me nts of Medical J uris prudence , the notable American text on the s ubject: In almos t every impos tors have sprung up who affect various maladies operate on the s uperstition or the curiosity of the short, then, is sues of malingering appear to be as old civilization.

DE F INITION A ND C OMP A R A TIVE NOS OL OG Y C ontemporary theoris ts share with their historical antecedents the cons truct that the fundamental characteristic of malingering is intentional falsity with incentive of gain of some kind. According to the revised fourth edition of the DS M (DS M-IV -T R ) T he es sential feature of Malingering is the intentional production of false or gross ly exaggerated phys ical or ps ychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining compens ation, evading criminal prosecution, or obtaining drugs. Under s ome circums tances , malingering may represent 2879 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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adaptive behaviorfor example, feigning illnes s while a captive of the enemy during wartime. Malingering s hould be s trongly suspected if any combination of the following is noted: (1) medicolegal context of presentation (e.g., the pers on is referred by attorney to the clinician for examination or is (2) evident dis crepancy between the individual's stress or dis ability and the objective findings , (3) lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen, and the presence of antis ocial pers onality disorder. Malingering differs from factitious dis order in that the motivation for the symptom production in malingering is an external incentive, whereas , in factitious disorder, external incentives are abs ent. E vidence of an need to maintain the sick role sugges ts factitious T his evidence is not present in malingering. F urther, malingering is differentiated from convers ion dis order other s omatoform dis orders by the intentional of symptoms and by the obvious, external incentives as sociated with it. In malingering, in contrast to disorder, s ymptom relief is not obtained by s uggestion hypnosis . T hus, malingering is distinguis hed from factitious disorder in its motivation: W hereas is prompted by a conscious desire to obtain external rewards or environmental outcomes , factitious disorder not. In the latter, a combination of intrapsychic needs manifesting themselves as a nearly irresistible des ire to as sume the s ick role is thought to motivate the deception of malady. 2880 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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T he problems of diagnos tic differentiation are obvious : person might malinger to obtain tangible rewards (such disability payments) as sociated with the s ick role, but might still enjoy the nurturing and care that s uch a role provides . A person with factitious dis order might be res is tant to returning thes e financial as pects of being while s till clinging to (and needing) the emotional gratification that a person with this disorder is crave. Differentiating malingering from the somatoform disorders (e.g., convers ion dis order) is eas ier in that somatoform disorders lack the volitional component of malingering. In the s omatoform disorders , an emotional conflict is thought to be unconsciously transformed into a physical manifes tation of some kind. external environmental outcome or reward is sought. R ather, the defensive makeup of the person somatoform disorder is believed to be more tolerant of manifest turmoil in obs ervable, extrapsychic form than unobs ervable, emotional upset. Whereas the various diagnos tic schemes us ed and internationally agree on the centrality of volitional deception to malingering, there is more controvers y whether malingering should be considered a mental disorder at all. T his is important because, in mos t civil litigation, only mental disorders are compensable. T R clas sifies malingering with additional conditions that may be the focus of clinical attention. T hus , if occurs in as sociation with such mental dis orders as antis ocial personality dis order, factitious disorder, or a somatoform disorder, the diagnostician is enjoined to cons ider thos e diagnos es primary. In fact, a diagnosis 2881 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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factitious disorder excludes a diagnosis of malingering. S till, as a V -code diagnos is , malingering is not s o much disorder as a kind of mis behavior.

Definitions of S ubtypes of It has been s uggested that malingering be cons idered as a dichotomous variable (a condition that is either present or abs ent), but as falling along a continuum in terms of (1) degree of intentionality, (2) degree of symptom exaggeration involved, and (3) degree of impairment (if any). In keeping with the concept of a continuum, the following definitions have been P.2249 P ure malingering: F eigning a disease or disability it does not exis t to any extent. P artial malinge ring: C onsciously exaggerating symptoms that really exist. F als e imputation: As cribing actual s ymptoms to a cons ciously understood to have no relation to the symptoms. Mis attribution: As cribing actual s ymptoms to a erroneously believed to have given ris e to them. misperception is often the product of unconscious proces ses that have interfered with reality testing, in its pure form, it does not cons titute malingering. the extent that the misattribution is consciously augmented (false imputation), malingering is at A female police officer filed a lawsuit against her former 2882 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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department alleging that s exual harass ment at the workplace and wrongful termination for whis tle-blowing had res ulted in ps ychiatric damages . P sychiatric of the cas e s uggested that, although the officer had a major depres sive dis order, the purported harass ment not caused it. Ins tead, the officer was found to have a borderline pers onality disorder. A series of interactions born of this dis order had given ris e to the tensions that ultimately resulted in her profess ional difficulties . Although the officer's borderline pers onality disorder did, to a great extent, cause her to distort and truly mis perceive the s equence of events leading to termination (mis attribution to her gender rather than to her profess ional failures ), the officer also invented episodes of haras sment, pointing to these fantastic as the specific origins of her (exaggerated) symptoms (false imputation and malingering). In addition to the various degrees of malingering, forms of malingering have been identified and defined: S imulation: F eigning symptoms that do not exis t or gross , cons cious exaggeration of preexis ting symptoms. S imulation has s ometimes been as faking bad and pos itive malingering. Dis s imulation: C oncealing or minimizing exis ting symptoms. Diss imulation has also been called good, negative malinge ring, and de fens ive ne s s . term is s omewhat confus ing becaus e it has been used to refer to medical faking in generalthat as a s ynonym for malingering. S taged e ve nts : C arefully planning, orchestrating, 2883 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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executing events, with the desired result being an actual injury or a credible explanation for a disability that will later be feigned. Data tampe ring: Altering diagnostic data or records simulate a disorder. S uch alteration might take the form of s elf-mutilation (to influence the outcome of phys ical examination), phys ical addition to or of substances from laboratory s pecimens (to the res ults of analys es performed on the or defacing or adjusting laboratory reports, instruments, and medicohistoricolegal documents. O pportunis tic malinge ring: E xploiting a naturally occurring event or preexisting medical condition for gain. Opportunistic malingering is distinguished partial malingering, which involves the of specific preexis ting s ymptoms. S ymptom inve ntion: F als ely and cons cious ly complaining of symptoms that are unrelated to any current or preexisting dis order or injury. An ins urance agency owner was apparently s truck by a rental-car company driver while in the process of another of the company's cars . T he victim reported that the car had run over his foot, causing his elbow to the windshield, followed by his head. A few days after the injury, on the fourth occas ion for which he had s ought medical attention, he reported, for the firs t time, symptoms cons is tent with pos tconcuss ive syndromeheadache, photophobia, difficulty concentrating, and memory loss . B ecause of these symptoms, he claimed he was incapable of continuing 2884 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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overs ee his agency. He s ought multimillion-dollar compens ation. S everal of the defendant's experts advised couns el that even if head trauma had occurred, given that there was loss of cons cious nes s, a concus sion could not have occurred. T hus , although tendernes s and headache be part of the s ymptom complex, increasing or longstanding difficulties with memory would not be Another expert opined that the phys ics of the accident made a head s trike virtually imposs ible. F inally, a the immediate posttrauma medical records revealed the injuries to the foot and elbow were minor and that there had been no complaints of head trauma. Independent ps ychiatric examination of the plaintiff revealed no anomalies in his his tory but unearthed odd complaints of paranoia, profound intoxication, interes t in tattooing, nons pecific threats of violence agains t others , and s elf-mutilation (he carved on his and forearms with a hunting knife in a way that led to significant scarring). T he forens ic ps ychiatris t, although aware of the noncorroborative date of the injury, was deeply troubled about the self-mutilation, provisionally opining that it was inconsistent with malingering. Only when the other experts pointed to inconsistencies in own arena was he comfortable rendering a diagnos is malingering. Defense couns el, who had been convinced that the accident as reported had been elaborated, later found witness es who testified that the entire injury had been falsified and that the plaintiff was desperate for money. cours e, the case then s ettled for nuisance value. 2885 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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E P IDE MIOL OG Y In the United S tates, malingering is not cons idered as a medical or ps ychiatric diagnosis. T herefore, traditional epidemiological cons iderations , s uch as the reliability diagnostic criteria and the validity of the diagnostic cons truct, are largely irrelevant. F urther, s ys tematic underreporting of malingering by health care hampers estimations as to the typical age of onset, s ex ratio, prevalence, or age-specific features. S everal underlie the reluctance of profes sionals to label malingerers and, ins tead, to refer to a vague lack of objective evidence in s upport of the patient's particular subjective complaints. Most clinicians were drawn to the mental health field of a desire to help others ; they find it distasteful, and a violation of the doctorpatient relationship, to call a a liar. C oncern over legal liability also inhibits the widespread labeling of malingering. Although expert tes timony about malingering, given in court and in good faith, is protected by immunity, a clinical label applied the outpatient office or emergency department often is not. F inally, physicians are concerned about the anger poss ibly, phys ical outbursts that might res ult if an individual's conscious attempts at deception are foiled his or her conscious s cheme to manipulate the s ys tem reward is dismantled. T hus , the method by which a in a clinical s etting is confronted is of paramount importance. Determining when it is necess ary to a client on his or her embellis hments depends on a thorough as sess ment of cos ts versus the benefits of confrontation. Indeed, in certain cas es, pacifying the patient by ignoring the embellishment may be of 2886 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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harm than benefit. After a decis ion P.2250 to confront is made, the clinician must direct much into exploring with the patient the reas ons behind the malingering. An exploration may notably help with diagnosis and, thus , have treatment implications . According to limited epidemiological data, it is that a person, on average, lies twice a day, although same pers on may be completely truthful at other times . 1 percent pres ence of malingering has been estimated among mental health patients in civilian clinical with the estimate rising to 5 percent in the military. In a litigious context, during interviews of criminal the es timated prevalence of malingering is much higherbetween 10 and 20 percent. B ut thes e are only es timates; there is no comprehensive empirical data for this information. S ome criminals are s killful liars , and the capacity to lie develops early; approximately 50 percent of children presenting with conduct disorders are described as bringing to the clinician s erious lying-related is sues. It reasonably be as sumed that, in civil laws uits, those involving child custody or evaluations pertaining civil commitment, a similar elevation of the prevalence diss imulation (faking good) would become apparent if appropriate data were amass ed. T hus, although no familial or genetic patterns have reported and no clear sex bias or age at ons et has delineated, malingering does appear to be highly prevalent in certain military, prison, and litigious 2887 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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populations and, in W estern s ociety, in men from youth through middle age. As sociated dis orders include disorder and anxiety dis orders in children and borderline, and narcis sistic personality dis orders in However, becaus e many behaviors have a genetic would be surpris ing if there were no familial patterns.

E TIOL OG Y Although no biological factors have been found to be caus ally related to malingering, its frequent ass ociation with antisocial personality disorder rais es the poss ibility that hypoarous ability may be an underlying metabolic factor. S till, no predis pos ing genetic, neurochemical, or neuroendocrinological forces are presently known. During the height of psychoanalytic influence, was cons idered to be a mental disease. K urt E is sler It can be rightly claimed that malingering is always a of a disease often more s evere than a neurotic disorder because it concerns an arres t of development at an phase. Although mos t analysts today accept the nondis ease concept of malingering, the malingerer is thought to be as controlled by the past as the neurotic except that the malingerer is unable to produce an neurotic s ymptom (the res ult of primitive ego and superego development). T he malingerer acts out cons ciously that which the neurotic is able to convert unconsciously. T he ps ychodynamic connection malingering and the s omatoform dis orders is a clos e At the other end of the etiological spectrum lie the theories of T homas S zas z, who has argued that malingering can be understood only in the context of 2888 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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sociops ychology of games, systems , and interactions. Malingering would be meaningles s in a s trictly situation limited to physician and patient. In fact, if it to emerge only in such a context, it would have to be cons idered factitious dis order. According to S zasz, malingering is a relevant concept only when the and patient are part of a larger s ocial s tructure and a player in a social game. T he patient is out to s core, is society. T he physician's job is to officiate the proceedings, to prevent cheating, and to minimize any unfair advantage. As s uch, the prudent ps ychiatris t approaches every evaluation with the as sumption that patient being evaluated may s tand ready to us e mental infirmity to achieve questionable ends . S ociocultural forces must be cons idered as etiologically relevant in any analysis of malingering behavior. studies showing marked differences in readines s to complain of illnes s among different ethnic groups have been criticized on methodological grounds, it is accepted that the culture of work, ethical res ponsibility, and duty to country in the form of military service (with potential for s elf-sacrifice) varies from s ociety to subculture to subculture, and epoch to epoch. How acceptable, condemnable, or laudable malingering may within a sociocultural context will accordingly vary.

DIA G NOS IS A ND C L INIC A L In his 1823 Me dical J uris prude nce , B eck described the contexts that have mos t s timulated malingering throughout his tory. Dis eas es are usually feigned 2889 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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one of three causesfear, s hame, the hope of gain. T hus , the individual ordered on service will pretend being afflicted with various maladies to es cape the performance of military dutythe mendicant, to avoid labour, and impos e on public and private beneficenceand the criminal, to prevent the infliction of punis hment. T he spirit of and the hope of receiving exorbitant damages, have also induced s ome to magnify s light ailments into s erious and illness . C ontemporary commentators have adduced eight patterns of malingering; however, thes e distinctions are less important than the common theme of s ymptom fabrication.

Avoidanc e of C riminal Trial, and Punis hment C riminals may pretend to be incompetent to avoid standing trial; they may feign ins anity at the time of perpetration of the crime, malinger s ymptoms to less hars h penalty, or attempt to act too incapacitated (incompetent) to be executed. T he following transcript from an E as t C oas t newspaper during the 1940s was quoted by Henry Davids on in the chapter on in his F ore ns ic P s ychiatry. 2890 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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X and Y who acted like mad in a murderous payroll robbery and like apes when brought to yesterday, were locked up out of the public gaze today to await their next appearance in court defens e lawyer contended that they were insane and they gave outward indications to the contrary. T hey walked into the courtroom with an apelike gait, arms hanging loosely, heads wabbling [s ic] from s ide to s ide with their chins held against their ches ts for pivots Attendants had to prod them along like animals . poked the fingers of his hand his mouth and gnawed them. Y ate pieces of paper from the X then rolled up a paper napkin and ate it. Y lowered his brow to the edge of the table and rubbed it like a hors e s cratching his on a post. X took a pair of s oiled underpants from his pocket and wrapped it around his neck. he licked it and wrapped it his head. At reces s, both had to be lifted from their chairs like sacks . T hey sloughed out of the room like apes

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Avoidanc e of Military S ervic e or of Partic ularly Hazardous Duties P ers ons may malinger to avoid conscription into the armed forces, and, once conscripted, they may feign to escape from particularly onerous or hazardous

Financ ial Gain Modern malingerers may seek financial gain in the undes erved disability ins urance, veterans' benefits, workers' compens ation, or tort damages for purported ps ychological P.2251 injury. In the chapter on malingering and as sociated syndromes in the s econd edition of Ame rican P s ychiatry, David Davis and J ames Weis s P unton's des cription of a malingerer, circa 1903: A man named Moffett described his cane and screw racket, in he us ed a specially prepared to loosen the floor screws on streetcars and railroad cars , which he would then pretend to stumble and then ins titute a for injuries s ustained. He stated that he made it a univers al rule employ the very bes t doctors, because he found, by that they were the most eas ily fooled, whereas the companies 2892 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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fleeced were better s atisfied with their opinions . In this he noted that he paid the bills promptly and willingly, even though at times he thought they were exorbitant, but this was done, he s aid, in order to them with the hones ty of his actions.

Avoidanc e of Work, S oc ial R es pons ibility, and S oc ial C ons equenc es Individuals may malinger so as to escape from vocational or social circums tances or to avoid the and litigation-related cons equences of vocational or improprieties . An owner of a previous ly success ful photographic equipment supplier declared bankruptcy in a way that government maintained was illegal. S ubsequently, the government indicted the defendant on various counts fraud. T he defendant's couns el maintained that the defendant was too depres sed to cooperate with him that, because of that depress ion, he experienced loss that made it imposs ible to understand what had occurred and, therefore, imposs ible to provide a meaningful defense. T he government's forensic ps ychiatris t evaluated the defendant to as certain the nature of his depress ion and to determine whether it caus ing cognitive problems. When asked early in his evaluation when his birthday 2893 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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he res ponded, Oh, what does it matter, it was in the 50s. S imilarly, when queried about where he was born, said, S ome place in Hungary. E ven when press ed for specifics, he refus ed to elaborate. Y et, at many points in his evaluation, he responded with complete, often detailed, information about transactions not related to those for which he had been indicted. It was the impres sion of the evaluator that the defendant's was malingering in a gros s and inconsistent fashion, incompatible with the kinds of decreas es in cognitive that occasionally attend major depres sion. S till, becaus e the evaluator had not brought tes ts for the evaluation, he was somewhat cons trained when it came to tes tifying as to bases for his He noted, however, that the defendant s at downcast throughout the trial and that, at least when s peaking to couns el, he answered monosyllabically. T his behavior appeared cons is tent with major depres sion (s omething had not observed). However, during a break, the ps ychiatris t observed that the defendant was in an animated conversation with a courtroom visitor. T his behavior appeared antithetical to his demeanor so the ps ychiatris t mentioned it to couns el. A witness then arranged to be pres ent at a subsequent conversation between the defendant and the visitor. he tes tified that the defendant was animated, engaged, and polys yllabic. T he defendant's motion to s ecure time for trial preparation was denied, and he was sentenced for the alleged frauds. Had the defendant's malingering not been detected, he might have delayed ultimate conviction or received a mitigating sentence referable to his claimed depres sion. 2894 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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Fac ilitation of Trans fer from Pris on Hos pital P ris oners may malinger (fake bad) with the goal of obtaining a transfer to a ps ychiatric hospital from which they may hope to es cape or in which they expect to do easier time. However, the pris on context may als o give to dis simulation (faking good); the pros pect of an indeterminate number of days on a mental health ward may prompt an inmate with true ps ychiatric symptoms make every effort to conceal them.

Admis s ion to a Hos pital In this era of deinstitutionalization and homeles sness , individuals may malinger in an effort to gain admis sion a psychiatric hospital. S uch institutions may be s een as providing free room and board, a s afe haven from the police, or refuge from rival gang members or drug cronies who have made street life even more unbearable and hazardous than it usually is. A robus t, neatly attired man presented to the emergency department in the early-morning hours . He stated that the voices were wors e and that he wis hed readmitted to the hospital. W hen the psychiatrist challenged him, obs erving that he had jus t been discharged that afternoon, that he routinely left the hospital in the morning and demanded rehos pitalization at night, and that, despite multiple hospitalizations, his reported his tory of hallucinations had been increasingly doubted, the man became belligerent. When the ps ychiatris t s till refused to admit him, the patient the ps ychiatris t's clothes , threatening him but inflicting 2895 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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harm. T he psychiatrist as ked the hospital police to him off the grounds . T he patient was told he could s eek readmiss ion to his regular ward during the day. S ubsequent contact with the patient's ward revealed their diagnos es were s ubs tance abus e and his apparent s chizophrenia appeared never to have an actual is sue in his treatment.

Drug-S eeking Malingerers may feign illness in an effort to obtain medications , either for personal us e or, in a prison as currency to barter for cigarettes , protection, or other inmate-provided favors. T he plaintiff, a woman in her late 20s, was injured while dancing at a club. Although her claim initially appeared bona fide, subsequent investigation cas t doubt on the mechanism of injury that s he claimednamely, that a misplaced electrical cord under a carpet caused her to T his was true, s he claimed, despite the fact that she be dancing in a particularly jerky manner that could easily caus ed problems without tripping. S ubsequently, she s ought medical and surgical for torn cartilage in her injured knee. However, des pite fact that the initial s urgery went well, s he kept reinjuring the knee with various slips . As a res ult, s he requested narcotic analges ics. A careful medical record review revealed that s he was obtaining such medications from multiple practitioners and that s he had apparently at least one prescription. In reviewing the case before binding arbitration, it was opinion of the orthopedic and ps ychiatric consultants 2896 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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although the initial injury and reported pain were real, plaintiff consciously elaborated her injuries to obtain desired narcotic analgesics.

C hild C us tody A final area in which malingering may be commonplace relates to litigation involving child cus tody and divorce. Minimizing difficulties or faking good for the s ake of P.2252 obtaining child cus tody can occur when one party accurately accuses the other of being an unfit parent to psychological conditions. T he accus ed party may compelled to minimize s ymptoms or to portray him- or herself in a positive light to reduce chances of being deemed unfit and los ing custody.

DE TE C TION OF MA L ING E R ING T he clinician mus t rely initially on interviewing s kills and history to detect malingering. Untrained observers do little better than chance in lie detection, and s ome studies have found police detectives do hardly better undergraduates in judging guilt vers us innocence. conceptual limitations , David R osenhan's study of malingerers faking psychosis as inpatients on a ward cas ts doubt on the ability of trained clinicians to differentiate real from feigned mental illnes s in certain contexts . Nevertheles s, several clues exis t, and, if properly they are us eful for the clinician who s us pects T he ps ychiatric conditions mos t likely to be malingered mental retardation, organic impairment, amnesia, 2897 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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ps ychos is , and posttraumatic res idua, including and posttraumatic s tress disorder (P T S D).

Detec ting Dec eption P erpetrators' urges to confess s eem greates t shortly they have trans gress ed; during this period, their guilt is apparently at its most burdensome and is as yet by mental defens e mechanisms. Memory has yet to be distorted, either cons cious ly or unconsciously. T hus , effort s hould be made to interview the criminal shortly after the event, often a crime. Malingering is harder to maintain as the evaluative interview becomes increasingly lengthy, becaus e of fatigue and a pull toward reality. T herefore, when malingering is s us pected, the clinical interview s hould long and detailed. S ometimes , the interview s hould be intentionally excess ively detailed. S uch a process more opportunities for the evaluee to feel his guilt and the obs erver to note inconsistencies. R es earch on lying and malingering has shown that liars often s peak in high-pitched voices , make errors of grammar, and make s lips of the tongue. S tudents who instructed to lie hes itate or pause while lying and tend make irrelevant, rambling, and negative comments; the negativity is thought to be related to guilt. T he pass ive voice is more common than the active, discrepancies between verbal and nonverbal express ion (blinking, dilated pupils, rubbing, or stroking of the self) are and answers may appear rehears ed, overly facile, and T he clinician's s us picion should be aroused if an interviewee makes too many spontaneous ass urances veracity, such as W ould I tell you a lie? or T o be 2898 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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hones t. P lanning a lie before the fact allows the liar to T hus, during the lie, he or s he requires fewer paus es words , phras es, or ideas ; has more control over tone of voice; and is able to project more confidently. P lanned are, cons equently, less easy to detect than thos e that unplanned. Among the mos t s ucces sful liars are thos e exaggerate their feigned s entiments by hamming; who have had s ome acting experience; thos e who are intelligent, creative, res ourceful, and have good and those who are smooth and practiced verbally. C ontrary to intuition and popular myth, facial and eye contact are generally poor indicators of truthfulnes s and may interfere with more s ensitive, but no means fully reliable, lie-detection modalities. One meas ured the ability to detect deception under three different conditions: (1) while watching and hearing a videotaped interview, (2) while listening to an audio recording of the interview but s eeing no visuals , and (3) while reading a transcript of the interview. Lis teners readers were far more s ucces sful at identifying than were watchers . T his s ugges ts that the vis ual cues during the interview serve primarily as distractions. At a fairly early age, children learn how to control their facial expres sions so as to conceal their emotions , refining skills through game playing and social interaction; the is particularly adept at deception. Liars do not necess arily make less eye contact, have eyes , s mile or gaze less , or adjust pos ture more than nonliars do. However, S igmund F reud's ass ertion that liar's unconscious guilt oozes out of every pore may at least be true below the neckline. A marked incongruity 2899 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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between calmness of face and tension, fidgeting, and active movement of the les s controllable arms , hands , and feet is a good reas on to s us pect deception. is not a common pattern.

Detec tion of S pec ific Malingered C onditions Malingered Mental Defic ienc y or R etardation Mental retardation is difficult to feign in the United largely because the educational s ys tem requires evaluations of intelligencesometimes called aptitude or ability. T ypically, the school s ys tem is paced at one year for each year of mental age on the S tanford-B inet Intelligence S cale, with the first grade adjusted to a age of 6. T hus , a s tudent who has completed the ninth grade s hould have a mental age of approximately 14 A s udden adult score more than 2 or 3 years out of line with that formula, in the context of prior school s cores cons istently adhering to the predicted pattern, should arouse suspicion. In addition, malingerers may mis s questions on ps ychometric tests while correctly more difficult ones. It is always useful to check vocational and military if mental deficiency is claimed, although they are not always revealing. T hese s ources may provide further corroborative or contradictory ins tances of formal intelligence tes ting, and a marked dis crepancy claimed capacity and historical accomplis hment would further caus e to s uspect falsity. T able 26.1-1 some clues to the detection of malingered mental 2900 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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deficiency or mental retardation.

Table 26.1-1 C lues to the of Malingered Mental Defic ienc y Mental R etardation 1. S triking dis crepancy between level of and level of intelligence 2. S triking dis crepancy between military and employment records and pres enting behavior and tes t performance 3. S triking dis crepancy between adult tes t performance and prior pattern of tes t 4. F ailure on easy items and s ucces s on difficult during evaluative testing 5. Incongruity of vocational and social with pres entation capabilities

Malingered C ognitive Dis orders A noteworthy dis crepancy reported between those who have dementia and those who are attempting to fake a cognitive disorder is the presence of marked in the former and its absence in the latter. If the 2901 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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malingering follows a traumatic injury (e.g., head or toxin exposure), a careful s tudy of the known effects that insult is necess ary before the physician can the claimed sequelae with the plaus ible ones . Most persons attempting to malinger feign fairly blatant and dramatic symptoms ; however, paranoia, morbid depres sion, s uicidal behavior, and gross forgetfulnes s not be reas onable outcomes of a specific class of injury. T he patient's performance before and after the alleged incident s hould be thoroughly analyzed, as s hould the patient's behavior in P.2253 all s pheres of function since the ons et of the alleged deterioration. A pers on who performs well s ocially and when at leis ure while claiming inability to work s hould suspected of malingering. T able 26.1-2 s ummarizes guidelines for the detection of malingered cognitive disorders .

Table 26.1-2 C lues to the of Malingered C ognitive 1. Lack of marked perseveration 2. Implausible s ymptom profile given reported

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3. P sychotic symptoms confused with cognitive impairments 4. Unimpaired function in social and recreational realms in the face of gros s dis ability

Malingered A mnes ia Amnes ia, probably the most common clinical presentation of malingering (except for malingered which is not usually malingered in the homicide claimed by 30 to 35 percent of perpetrators of is easy to feign and difficult to demonstrate. At leas t s ix pos sible causes have been suggested for amnes ia: (1) convers ion dis order, (2) psychosis, (3) alcoholism, (4) head injury, (5) epilepsy, and (6) malingering. B efore malingering is ascribed, the should review and eliminate the other five potential caus es. A good diagnostic battery s hould include res ults on s kull X -ray, head computed tomography magnetic res onance imaging (MR I), and electroencephalography (E E G ); normal findings on a neurological examination; a life his tory incons is tent either convers ion disorder or alcoholis m (or other of intoxication); and a clinical examination and his tory inconsistent with either alcoholic amnes ia (alcoholinduced pers isting amnes tic dis order) or alcoholic ps ychos is (alcohol-induced psychotic disorder). 2903 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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If thes e tests are negative, the clinician faces the more difficult task of amas sing evidencealbeit inferentialof malingering. Motivation is a key indicator. P revious amnes tic episodes without apparent motivational precurs ors lower the likelihood that the patient is malingering. S imilarly, a patient with histrionic traits is more likely to be experiencing true diss ociative amnes ia than one with primarily antisocial traits. T he timing of ons et and recovery and the correlation of the alleged amnestic epis ode with convenience are clues to the pres ence of malingering. G lobal amnesia somewhat more convincing than spotty, patchy, s elfserving amnesia. S potty amnes ia can be s een, for in a person who describes having difficulty with autobiographical memory (e.g., their date of birth, they are from, what age they got married) but has memory ability outs ide of autobiographical information. Additionally, there have been s everal reported of copycat amnesias after famous or highly publicized cases, s o an eye to recent sensational litigation is T able 26.1-3 s ummarizes s ome guidelines for malingered amnesia.

Table 26.1-3 C lues to the of Malingered Amnes ia 1. No history of amnes tic episodes

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2. Antis ocial pers onality traits more prominent histrionic personality traits 3. S potty, epis ode-specific amnes ia rather than global amnes ia 4. R ecent, widely publicized, suspicious ly familiar cases involving amnesia

In the context of forensic ps ychiatry and exculpation criminal blame, a claim of amnesia after s evere upset, as committing a murder, is a fairly common T o be useful in an insanity defens e, the claimed would generally have to have existed for an period before the criminal act and would have to have continued unabated throughout it; confusion regarding these sequencing iss ues caused the downfall of many malingerers.

Malingered P s yc hos is In ass es sing an apparently ps ychotic patient, the should obtain as much his torical and collateral as poss ible, es pecially if malingering is sus pected. Motivation, availability of coaching, and adherence of symptom picture to known disorder profiles are of us e as sess ing the plaus ibility of an evaluee's psychotic presentation. B eyond these initial as ses sments, a number of have been identified that, if present, raise the 2905 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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of malingering. Malingerers tend to overact their part, often mis takenly believing that the more bizarre they appear, the more convincing they are. T he historic example dis cuss ed earlier of the two ape-men is a point. S chizophrenic patients tend to be reluctant to discus s symptoms, particularly if they are in the throes of a persecutory delusional ps ychosis . On the other hand, malingerers may be anxious to call attention to their illness es and to whatever outlandis h belief s ys tems are attempting to feign. T he form of schizophrenic thinking (a formal thought dis order) is far more difficult malingerers to imitate than is its content. T hus, it is less likely that malingerers will mimic loose tangential or circums tantial reas oning than that they describe or act out odd beliefs. Uns ophisticated malingerers often confus e madness with dumbness , supposing that s illy or childlike responses go hand in with bizarre, delus ional experiences . S uch faulty juxtapos ition may be evident during clinical interviews and can be highlighted on ps ychological tes ting. Malingerers may claim the sudden onset of a delusion. R ealis tically, delusional symptoms usually take weeks , months, or years to develop. P sychotic individuals experiencing an acute epis ode are likely to act in direct accordance with their delusional system, whereas malingerers claim to have done s o only when s uch concordance is opportunistic. T he dis crepancy is less striking once the ps ychos is has become more longstanding, as the chronic s chizophrenic may not be as dramatic in acting on delus ional beliefs as a younger, acutely psychotic person. 2906 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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Malingerers are likely to contradict thems elves in their accounts of the illnes s, and thos e contradictions may multiply as the interview progres ses. T hey may be led as tray by leading ques tions that the examiner knows ps ychologically abs urd, and they may make mis takes questioned rapidly or directly confronted. S pecific questions about the ons et and progres sion of a are often most revealing becaus e, even if a symptom is malingered currently, its typical development may not appreciated. T heir symptoms may fit no diagnostic and, when caught in such a discrepancy, they may s ulk laugh from embarrass ment. Malingerers s ometimes attempt to take control of the interview, behaving in an intimidating and blus tery manner. T hey are likely to repeat ques tions or ans wer questions s lowly, working to give thems elves more fabricate convincing responses. T hey present as blameles s within their feigned illnes s, yet they are to have nonps ychotic alternative motives for their behavior, such as killing out of revenge or out of paraphiliac desire. As is true of the form of schizophrenic thinking, malingerers are unlikely to success fully imitate the signs of res idual s chizophrenia. B lunted affect, concreteness , and odd, s chizoid relatedness are presentations familiar only to the most talented malingerers. T able 26.1-4 s ummarizes s ome features malingered delus ions.

Table 26.1-4 Features of Malingered Delus ions 2907 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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1. Abrupt ons et and termination rather than development and hes itant abandonment 2. E agernes s to call attention to delusions and symptoms rather than reluctance to acknowledge them 3. B ehavior incons is tent with delusional content rather than reflective of delus ional content 4. T hought content gros sly disturbed in the face conventional and goal-directed thought process

P.2254 C riminal defendants attempting to malinger psychosis most frequently fake auditory hallucinations; thus , knowledge of the characteristics of general and detailed ques tioning into the nature of the claimed experience are mandatory if the clinician suspects malingering.

HAL LUC INATIONS T rue hallucinations tend to be as sociated with and are often a ps ychotic express ion of some need. Accusatory voices may repres ent unacceptable ps ychotic) guilt, horrifying creatures or threatening 2908 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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animals may repres ent unacceptable aspects of the personality, and the belief that one is giving off a foul may repres ent severe depres sion and s elf-deprecatory delus ion. Individuals with schizophrenia frequently report that voices speak directly to them or pass judgment on S chizophrenic hallucinations tend to be intermittent than continuous, and more than 50 percent of schizophrenic individuals eventually acknowledge that they may have imagined their hallucinations . S ome reveal that 66 percent of s chizophrenic patients have auditory hallucinations and 33 percent have vis ual hallucinations . T he visual hallucinations almost always accompany the auditory hallucinations. V is ual hallucinations tend to be in color and of normal-sized people. Olfactory and gustatory hallucinations have reported in acute epis odes of s chizophrenia; olfactory hallucinations are of unpleasant odors and are rare. E ighty-eight percent of s chizophrenic individuals report that auditory hallucinations come from outside the and 75 percent report that they hear both male and voices. T he mes sage is usually clear; it is vague only 7 percent of the time and is accusatory approximately third of the time. Approximately 30 percent of schizophrenic individuals ans wer the voices they hear. C ommand hallucinations , although clinically are ignored by true ps ychotic individuals up to 60 of the time. T hey are more likely to be obeyed if the is familiar to the hallucinator or if they are one element developed delus ional s ys tem. Most truly ps ychotic individuals have developed 2909 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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for coping with hallucinatory epis odes . C ommonly are changes of posture, distraction through activity or interpersonal contact, or ingestion of antipsychotic medication. Although the auditory hallucinations of truly ps ychotic pers ons tend to be general and basic, thos e malingerers are often s tilted, specific, and self-serving. Alcohol-induced psychotic disorder with hallucinations that follows the abrupt ces sation of previously high alcohol intake ordinarily produces vivid hallucinations . Although voices are extremely common, experience of noise, music, unintelligible voices, or tactile such as formication, are more frequent than in schizophrenia. S ubs tance-induced psychotic disorders generally involve unformed, indis tinct hallucinatory T able 26.1-5 s ummarizes s ome features of malingered auditory hallucinations .

Table 26.1-5 Features of Malingered Auditory Halluc inations 1. C ontinuous rather than intermittent 2. V ague, inaudible, or unintelligible rather than distinct 3. F ree-standing rather than as sociated with delus ions 2910 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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4. S tilted in language and specific in tone rather basic and general 5. R eported in the firs t person rather than in the person 6. Uncontrollable rather than susceptible to strategies for containment 7. Irres istible rather than s us ceptible to

Malingered P os ttraumatic In today's too often litigious society, the psychiatrist be as ked to determine the veracity of ps ychiatric or behavioral s ymptoms that a person claims resulted trauma, whether psychological or physical in nature. actual incidence of malingered ps ychological after phys ical injury is unknown, but one s tudy found 48 out of 50 cases of pos taccident neuros is had 2 years after the legal claim had been s ettled, and a G eneral Accounting Office follow-up study reported in 1980 that approximately 40 percent of individuals cons idered to be totally dis abled had no dis ability whatsoever 1 year after that declaration. S uch data suggest that such claims are rife with embellis hed symptoms. T hey also underscore the importance of cons idering malingering when evaluating s uch claims. Malingerers in personal injury cas es seldom feign 2911 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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ps ychos is . Much more common are claims of and, now that it has become widely publicized, of S uch ambulatory illness es allow malingerers to avoid res ponsibility and to escape from work, while sparing them the unpleas antness and the 24-hour s crutiny of hospitalization in a ps ychiatric setting. In attempting to distinguis h malingered from actual posttraumatic depres sion, it is helpful to determine signs and s ymptoms of depres sion not commonly to the lay individual. T he absence of diurnal variation, specifically early-morning awakening (as opposed to vague, generalized insomnia), of angry irritability, and diminis hed sexual interes t may sugges t imitation. S imilarly, the lack of a family history of the dis order or prior incidents is s us picious. P oss ibly mos t revealing of is a lack of depres sive withdrawal from enjoyable such as social and recreational activities , in the face of apparent total incapacity in avers ive domains, such as work. P T S D has become a particularly productive field for es pecially since the Department of V eterans Affairs publicized the P T S D criteria in the early 1980s and announced that any veteran meeting the criteria was eligible for governmental compens ation. In P T S D in pos ttraumatic depres sion claims , amas sing a picture of pretrauma functioning is crucial. Naturally, relation between the degree of the stress or and the alleged s ymptom clus ter, the temporal pattern, and any prior, concurrent, or s ubs equent symptoms and figure centrally in the evaluation. S ome s pecific clues to the malingering of P T S D exis t. patient with P T S D frequently focus es on the negative 2912 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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features of the dis orderthe emotional numbnes s, indifference, and social withdrawal. In contras t, the malingerer may be more impress ed by (and, therefore, hopes to impress more with) the expres sionistic of nightmares and flashbacks. In true P T S D victims, nightmares tend to vary in content while hewing to the cons tant themes of terror and helpless ness ; are more likely to report reexperiencing exactly the dream, often described as a videotape-like reliving of alleged trauma itself. S ome malingerers are about the nature of the true flashback experience, confusing it with and des cribing it as a benign pictorial memory. P articularly in P T S D, with its clearly criteria and entirely des criptive diagnos is, a textbookperfect pres entation s hould rais e greater sus picion presentation characterized by a vague, more symptom clus ter. T able 26.1-6 lists a P.2255 number of items s ugges tive of malingering of ps ychological distress after a traumatic incident.

Table 26.1-6 Fac tors S ugges ting Malingering of Ps yc hologic al Dis tres s after Trauma 1. Ass ertion of inability to work in the face of unimpaired capacity for pleasurable activity 2913 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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(recreation, social interaction) 2. S ubs cription to more obvious symptoms of publicized dis orders in the face of denial of more subtle features 3. S potty, ques tionable vocational his tory; to drift; fringe member of s ociety 4. E vas iveness during interview; unwillingness to concretely address a return to work, and s ocial expectation 5. G eneral presentation of sullenness , suspicious guardednes s, uncooperativenes s, or res entment 6. R efus al to comply with recommended or treatment procedures; avoidance of direct examination 7. History of disabling injuries and unusually frequent absences from work 8. T raits common to antisocial, narciss istic, borderline, or histrionic pers onality disorders 9. E nergetic and concerted purs uit of legal claim the face of alleged debility caused by depres sion posttraumatic s tres s disorder

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10. R efus al of employment s uggested as despite alleged dis ability 11. S elf-depiction in exces sively favorable and capable terms before alleged trauma and collaps e

Objec tive Tes ting F or centuries, objective measures , such as reactions , have been us ed to differentiate the conniving from the s incere. F or example, realizing that s tres s caus e a reduction in saliva production, the B edouins required conflicting witness es to lick a hot iron; the whos e tongue s tuck to the iron was adjudged to be the liar. S imilarly, in ancient C hina, individuals in conflict each required to chew on a ball of rice and then to s pit out; the person whos e ejected rice was drier was cons idered to be the charlatan. T he contemporary technique for measuring psychophysiological stress is polygraph. However, the polygraph is not foolproof; at best, it is 80 to 90 percent reliable, a fact that has many jurisdictions to forbid its use in forens ic T he polygraph seems best at detecting lying in anxious but hones t individuals ; it is, therefore, prone to falsepositive res ults . P articularly dis heartening is the empirically verified, that some practiced s ociopaths can beat the lie detector. Amobarbital (Amytal)sometimes mis takenly cons idered 2915 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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truth s erumand hypnotic techniques have also proved disappointing candidates in the s earch for objective evaluation. Approximately 50 percent of tes ted pers ons are able to maintain a lie under either of these techniques, and, in fact, some lies can actually become solidified under botched hypnotic circumstances. P sychological tes ting has increasingly proven the detection of malingering. B y far, the mos t widely ps ychological tes t for this purpose and the one with the broades t empirically validated data s et, is the Multiphasic P ers onality Inventory2 (MMP I-2). Among us eful validity indicators is the gauge known as the F K scale, obtained by subtracting the K raw score from the raw s core. Higher s cores on the F K index sugges t a likelihood that the s ubject is malingering overall. With K index of +10, one would be correct approximately percent of the time to ass ume that the entire MMP I-2 profile was malingered. Obvious ly, this is a significant indicator. C ons idered separately, both the F and K s cales can be further us e in evaluating an individual. T he F s cale has been proposed as an indicator of malingering, particularly when the s core approaches a t-score of above. T he F s cale is compos ed of items endors ed by than 10 percent of the population. T hus , s cores on this scale can inform a clinician about the frequency to odd, atypical items or s ymptoms are endorsed and, the likelihood of an individual faking bad. Nonetheles s, scores approximating 100 or above can s ignal not only invalid profile due to malingering but als o s imple uncooperativenes s, misunders tanding of the items, a for help from a patient who perceives the system as 2916 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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advers arial, or frank psychosis. T hus , gathering a background history of the patient, including vocational, and ps ychiatric histories , becomes even es sential in clarifying the reasoning behind an elevated score. T he F validity s cale itself has additional subscales that also be us eful indicators of malingering. T he F (b), or back scale, was des igned to as ses s a fake bad mode res ponding by containing additional items that have a endors ement frequency (i.e., les s than 10 percent of nonpatient adults ). On this scale, evaluees should roughly equivalent to the overall F score. Nevertheles s, high T -scores on the F (b) indicate either generalized pathology or an attempt to exaggerate his or her level symptomology. S imilarly, the F (p), or F subs cale, is yet another notable marker of malingering. T his s ubscale is composed of s ubtle items that are endors ed by nonpatients or those who have an obvious ps ychos is . T herefore, s cores on the F (p) scale can be as additional data to further evaluate a profile for faking bad. S cores on the K scale similarly tap into malingering, the oppos ite end of the continuum. Unlike the F scale, K s cale is compos ed of rather understated items difficulties that few individuals would deny. A significant score on the K scale, then, is a good meas ure of defens iveness and can identify individuals attempting present thems elves in a positive light. Higher scores on K s cale (a t-score of approximately 70 or above) that either the patient is attempting to des cribe him- or herself in an overly favorable manner and denying difficulties or that he or she is nay-saying (answering 2917 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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on all items ). F inally, the variable res ponse incons is tency (V R IN) true res ponse incons is tency (T R IN) scales offer a level of analys is of malingering potential. T he V R IN comprised of pairs of items that are s imilar or oppos ite content. T hus , high s cores on this scale sugges t indis criminate responding, which may be a res ult of malingering. S imilarly, the T R IN s cale is made up of items but only includes items that are oppos ite in T hus, a +1-point score would be generated on the scale for each oppos ite pair that the evaluee true to and a 1-point score would be generated for oppos ite pair that the evaluee answered false to. C ons equently, then, the T R IN is a good scale for inconsistencies in res ponses related to ans wering true false on all items. In summary, it has been sugges ted that the MMP I-2 be most fruitfully us ed if the F s cale (including the F [b] F [p]), K s cale, F K index, and V R IN/T R IN s cores are computed and the subject is then reinterviewed concerning the endors ed critical items. S uch an combination with a detailed background his tory, can further light on the reas oning that prompted the res ponse pattern. E ven without s uch reevaluation, the scale alone can be useful when the other sources of potential contamination can be eliminated. A further use of the MMP I-2 in the detection of malingering has involved an analysis of the ratio of versus obvious indicators of pathology endors ed. In an analys is , as in the setting of a clinical interview, malingerers are more likely to s ubscribe to blatant, indicators of pathology than to more subtle ones. Over 2918 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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time, new indicators of malingering are being and cons ultation with a knowledgeable ps ychologist is important if testing is to be fully used as a s ource in evaluating malingering. P.2256 T he plaintiff, a federal employee with a history of filing multiple claims alleging dis crimination at work, claimed be incapacitated from work because of recurrent symptoms of P T S D aggravated by his work as a fire suppress ion agent. T he defendant's ps ychiatric revealed a pleas ant and s eemingly cooperative man provided a history s imilar to that incorporated in his complaint. In the course of his evaluation, he was adminis tered an MMP I-2 that, when scored, revealed score of 120. T he ps ychiatris t used this information, other inconsistencies adduced during the discovery proces s, to opine that the plaintiff's symptoms of P T S D were malingered. Upon receipt of the ps ychiatris t's the plaintiff wrote a long diatribe complaining about the ps ychiatris t's lack of profess ionalism during his T his appeared to the ps ychiatris t to reflect the plaintiff's displeas ure with his malingering diagnosis. Ultimately, plaintiff, who had admitted during a detailed deposition examination that he had repeatedly lied in documents supporting his claims of dis crimination, s ettled his s uit nuisance value. B es ides the MMP I-2, other pers onality inventories can insight into an evaluee's propens ity for malingering. A and promis ing meas ure, known as the P ers onality As s es s ment Inve ntory (P AI), has fewer questions than 2919 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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MMP I-2 but allows graduated ans wers, which avoids forcing an evaluee to ans wer only true or fals e. It als o typically allows the test-taking proces s to be completed less than 1 hour. B ecause it provides an as sess ment of clos ely an individual's answers fit certain patternsfor example, malingeringit als o provides useful information about an individual's approach to an evaluation. Many forens ic evaluators find that us ing the two tests in conjunction is helpful. Other psychological tests provide a more focus ed exploration of a particular as pect of malingering. T he V alidity Indicator P rofile (V IP ) provides information cognitive malingering. Most evaluees complete it in than 1 hour; thus, like the P AI, it can be included as a s ingle daylong as sess ment. T he S tructured Interview R eported S ymptoms (S IR S ), developed by R ichard is an excellent instrument for as sess ing feigned T he R ors chach, although an excellent test, es pecially scored with the publis hed and validated E xner s ys tem, not an appropriate instrument for making the diagnosis malingering. S coring for that determination is generally cons idered too s ubjective, despite its power in dynamic is sues. Nevertheless , as noted els ewhere in section, s avvy malingerers appear to increasingly favor nonps ychotic diagnos es; thus, its us e may be circums cribed. Neurops ychological tes ting has been advanced as an the evaluation of head-injured patients. In one s tudy, Hals tead-R eitan B attery, which includes the W echsler Adult Intelligence S cale (W AIS ) and the firs t edition of MMP I, were adminis tered to 16 volunteer malingerers 16 nonlitigating patients with head injuries, and the test 2920 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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res ults were sent to 10 neuropsychologists for blind ratings . Although the overall levels of impairment were equivalent in both groups , the patterns of impairment were not. T he malingerers scored mos t poorly on the obvious items, whereas the injured individuals failed subtle ones. C ons idering the results of all three tes ts together, the neurops ychologists correctly clas sified percent of the malingerers and 94 percent of the nonlitigating injured patients. T hes e are dramatic and unders core the us e of neurops ychological in cases that rais e cognitive malingering is sues. T hus, although ps ychological and neurops ychological tes ting can be very helpful, they are neither infallible uniformly dispositive. S till, well-chos en psychological can be of enormous benefit in detecting malingering. R arely, however, is one test res ult so aberrant that it, its elf, confirms a malingering diagnosis .

DIF FE R E NTIA L DIA G NOS IS Malingering mus t be differentiated from the actual phys ical or ps ychiatric illness suspected of being F urthermore, the pos sibility of partial malingering, an exaggeration of existing symptoms, mus t be entertained. T here also exists the poss ibility of unintentional, dynamically driven misattribution of genuine s ymptoms (e.g., of depress ion) to an incorrect environmental caus e (e.g., to sexual haras sment rather than to narcis sistic injury). A middle-aged manager of a department s tore made error in his 23rd year of s ervice. When two department supervis ors one retiring and the other incomingdisputed 2921 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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the rightful ownership of a s eas onal bonus check, the manager did not contact upper management for a solution. An individual with clear-cut narciss istic personality dis order, the manager took matters into his own hands. He divided the check three ways, one-third going to each supervis or, and one-third going to T he manager was put on sus pension for inappropriate dispensation of company funds. T his epis ode was only the most serious of an series of poor decisions , and the company sugges ted the manager allow hims elf to be ps ychiatrically at company expens e. Outraged at the s uspens ion after these years of devoted s ervice and the suggestion that would do anything wrong, the manager instead quit his position and sued the company for race discrimination age discrimination. P sychiatric examination revealed a man with depres sion that was clearly the product of a narcis sistic wound who appeared utterly convinced of truth of the mis attribution of his misfortune, which had been dynamically driven outward. A diagnosis of malingering would have been as inappropriate in this as were the plaintiff's allegations of race- and agemotivated discrimination. It s hould als o be remembered that a real psychiatric disorder and malingering are not mutually exclus ive. A patient was admitted to a V eteran's Administration hospital with complaints consistent with P T S D. he denied auditory hallucinations , he was troubled by recurrent nightmares and frightening flashback experiences , both involving a terrifying event he had witness ed while serving with the infantry in V ietnam. 2922 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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T ime and growing trust in the therapist resulted in an admis sion by the patient that he experienced auditory hallucinations and had for years ; in fact, his history became, increas ingly, clearly that of Antips ychotic agents greatly relieved his s ymptoms. Ultimately, it was dis covered that the patient had never served in V ietnam, had never witness ed any lifethreatening trauma, and had never experienced or recurrent nightmares . He did, however, continue to benefit from profes sional antips ychotic medication and was dis charged with the correct diagnosis of paranoid schizophrenia. F actitious disorder, G anser's syndrome, and disorders (es pecially conversion dis order) can be with malingering. F actitious disorder is distinguis hed malingering by motivation (sick role versus tangible whereas the somatoform dis orders involve no volition. In conversion disorder, as in malingering, objective s igns cannot account for s ubjective and P.2257 differentiation between the two dis orders can be T able 26.1-7 lists s ome variables that may aid in distinguishing between thes e two conditions .

Table 26.1-7 Fac tors Aiding in Differentiation between Malingering and C onvers ion Dis order 2923 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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1. Malingerers more likely to be s uspicious , uncooperative, aloof, and unfriendly; patients with conversion disorder likely to be friendly, appealing, dependent, and clinging 2. Malingerers may try to avoid diagnostic evaluations and refuse recommended treatment; patients with convers ion dis order likely to evaluation and treatment, s earching for an 3. Malingerers likely to refuse employment opportunities des igned to circumvent their disability; patients with convers ion dis order likely accept s uch opportunities 4. Malingerers more likely to provide extremely detailed and exacting descriptions of events precipitating their illness ; patients with convers ion disorder more likely to report historical gaps , inaccuracies, and vagaries

G ans er's s yndrome, or the syndrome of approximate answers , is rare and described primarily in pris on populations. It involves the production of answers to questions that are relevant but not quite correct, such stating that the product of 7 4 is 29. It is clas sified in IV -T R as a dis sociative disorder not otherwis e has variously been regarded as a factitious disorder, a 2924 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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hysterical phenomenon, a psychotic dis order, and frank malingering. S everal s tudies of undergraduates to feign madness res ulted in the malingerers producing approximate ans wers s trikingly reminiscent of G ans er's syndrome. T hat finding lends credence to F rederick Wertham's famous 1949 as sertion that A G ans er a hypothetical pseudos tupidity which occurs almost exclusively in jails and in old-fas hioned G erman It is now known to be almos t always due more to cons cious malingering than to unconscious

C OUR S E A ND P R OG NOS IS Malingering pers ists as long as the malingerer believes apt to produce the desired rewards . In the abs ence of concurrent diagnoses , once the rewards have been attained, the feigned s ymptoms disappear. In s ome structured s ettings , s uch as the military or pris on units, ignoring the malingered behavior may result in its disappearance, particularly if an expectation of productive performance, despite complaints, is made clear. In children, malingering is mos t likely as sociated a predisposing anxiety or conduct disorder; proper attention to this developing problem may alleviate the child's propensity to malinger. Malingerers are unlikely to comply with disordertreatments that are offered. If they are confronted with their malingering directly, they are likely to s eek out doctors until they can find a phys ician who unwittingly complies with their manipulations. S ymptoms are likely abate only when the des ired outcome has been or when it becomes clear that the malingering is futile. that point, malingerers are likely to discontinue 2925 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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abruptly. However, as would be expected, the more the malingering has been reinforced, the more likely it is to recur. S ucces sful malingerers are apt to malinger repeatedly throughout their lives on jus t as many occasions as society, however unwittingly, rewards

TR E A TME NT It is obvious that malingerers do not wis h to be treated; the last thing they desire is to have their condition detected or diagnosed. T hey are cons cious ly the system in the hopes of achieving personal gain or benefit. S till, the appropriate s tance for the ps ychiatris t is neutrality. If malingering is suspected, a careful inves tigation s hould ensue. If, at the conclusion of the diagnostic evaluation, malingering s eems mos t likely, patient should be tactfully but firmly confronted with the apparent outcome. However, the reasons underlying rus e need to be elicited and alternative pathways to the desired outcome explored. C oexisting ps ychiatric disorders should be thoroughly ass es sed. Only if the patient is utterly unwilling to interact with the phys ician under any terms other than manipulation s hould the therapeutic (or evaluative) interaction be abandoned.

S UG G E S TE D C R OS S T he somatoform disorders , including convers ion are discus sed in C hapter 15; further differentiation of disorders from malingering may be found in that F actitious disorders are discuss ed in C hapter 16. Dis turbances of perception, including hallucinations , of experience, including delus ions, are discus sed in 2926 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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C hapter 8 on clinical manifestations of ps ychiatric disorders . S chizophrenia is dis cuss ed in C hapter 12, dementia is dis cuss ed in C hapter 10, and mental retardation is dis cuss ed in C hapter 34. Dis sociative amnes ia is address ed in C hapter 17. Depres sive are reviewed in C hapter 13. V arious personality and traits , including borderline, narcis sistic, histrionic, antis ocial personality dis order, are elucidated in 23. P s ychological and neurops ychological tes ting are addres sed in S ections 7.5, 7.6, and 7.7.

R E F E R E NC E S B agby R M, Nicholson R , B uis T : Utility of the subtle items in the detection of malingering. J P e rs As s es s . 1998;70:405. B as h IY , Alpert M: T he determination of malingering. Ann N Y Acad S ci. 1980;347:86. B eaber R J , Marston A, Michelli J , Mills MJ : A brief meas uring malingering in s chizophrenia individuals. Am J P s ychiatry. 1985;142:14781481. B eck T R . E le me nts of Me dical J uris prude nce . V ol 1. Albany, NY : W ebsters & S kinners ; 1823. B en-Avi I, R abin S , Melamed S , K reiner H, R ibak J : Malingering ass es sment in behavioral toxicology: why, and how. Am J Ind Med. 1998;34:325. *B utcher J N, Miller K B : P ersonality ass es sment in personal injury litigation. In: Hes s AK , W einer IB , 2927 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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Handbook of F ore ns ic P s ychology. 2nd ed. New Wiley; 1999. C arus o K A, B enedek DM, Auble P M, B ernet W: C oncealment of ps ychopathology in forensic evaluations : A pilot study of intentional and unins ightful dis simulators. J Am Acad P s ychiatr 2003;31(4):444450. C atton J . B ehind the S ce ne s of Murde r. New Y ork: 1940. C houinard MJ , R ouleau I: T he 48-P ictures T est: A alternative forced-choice recognition tes t for the detection of malingering. J Int Ne urops ychol S oc. 1997;3:545. Davids on HA. F ore ns ic P s ychiatry. 2nd ed. New R onald P ress ; 1965. Davis D, W eiss J MA. Malingering and ass ociated syndromes. In: Arieti S , B rody E B , eds. Ame rican Handbook of P s ychiatry. 2nd ed. V ol 3. New Y ork: B ooks ; 1974. DeP aulo B M, R os enthal R : T elling Lies . J P e rs S oc 1979;37:1713. E dens J F , G uy LS , Otto R K , B uffington J K , T omicic P oythress NG : F actors differentiating s uccess ful unsuccess ful malingerers. J P e rs As s e s s . 2001;77 (2):333338. 2928 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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E is sler K R . Malingering. In: W ilbur G B , W, eds . P s ychoanalys is and C ulture . New Y ork: International Univers ities P res s; 1951:218. E xner J E . T he R ors chach: A C omprehe ns ive 3rd ed. New Y ork: Wiley; 1993. F ord C V . L ie s ! L ie s ! L ie s !!! T he P s ychology of Was hington, DC : American P sychiatric P ress ; 1996. G oodwin DW, Alders on P , R os enthal R : C linical significance of hallucinations in psychiatric study of 116 hallucinatory patients . Arch G e n 1971;24:76. G riffin G A, G las smire DM, Henders on E A, McC ann II: redesigning the R ey screening tes t of C lin P s ychol. 1997;53:757. G roth-Marnat, G . Handbook of P s ychological 3rd ed. W iley, New Y ork; 1999. G uriel J , F remouw W : As ses sing malingered posttraumatic disorder: A critical review. C lin R ev. 2003;23(7):881904. *Hadjistavropoulos T . C hronic pain on trial: T he influence of litigation and compens ation on chronic pain s yndromes . In: B lock AR , K remer E F , eds. of P ain S yndrome s : B iops ychos ocial P e rs pe ctive s . Mahwah, NJ : E rlbaum; 1999. 2929 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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P.2258 Hall HV , P ritchard DA. Dete cting Malinge ring and Dece ption. Delray B each, F L: S t. Lucie P ress ; 1996. Hawk G L, C ornell DG : MMP I profiles of malingerers diagnosed in pretrial forensic evaluations . J C lin 1989;45:673. Larrabee G J : Detection of malingering us ing atypical performance patterns on s tandard tes ts . C lin Neurops ychol. 2003;17(3):410425. Lipian MS . S omatoform dis orders. In: P rice DR , Haley P R , eds . T he Ins ure r's Handbook of C laims . S eattle, WA: I.W. P ublications ; 1995:83. Lykken DT : T rial by polygraph. B ehav S ci L aw. Marcus E H: T he dilemma of the malingering patientlitigant. Am J F orens ic P s ychiatry. 1987;7:3. Mckinzey R K , R uss ell E W: A partial cros s -validation Hals tead-R eitan B attery malingering formula. J C lin Nue rops ychol. 1997;19:484. Merydith S P , Humphreys J K , E bener DJ : distortion of the 16P F by welfare recipients . J P e rs 1997;69:376. O'B ryant S E , Hilsabeck R C , F isher J M, McC affrey of the trail making test in the as sess ment of 2930 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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in a s ample of mild traumatic brain injury litigants . Neurops ychol. 2003;17(1):6974. Osimani A, Alon A, B erger A, Abarbanel J M: Use of S troop phenomenon as a diagnostic tool for malingering. J N eurol Ne uros urg P s ychiatry. P ollock P H, Quiley B , W orley K O, B as hford C : mental disorder in prisoners referred to forensic health services . J P s ychiatr Ment He alth Nurs . P rice J R . Malingering and s ymptom exaggeration. P rice DR , Lees -Haley P R , eds . T he Ins ure r's P s ychological C laims . S eattle, W A: I.W. 1995. R es nick P J : T he detection of malingered mental B ehav S ci L aw. 1984;2.21. R es nick P J : Malingering. J F ore ns ic P s ychiatry. R eynolds C R , ed. Dete ction of Malingering during Injury L itigation. C ambridge, MA: P erseus 1998. R ogers R . S tructure d Interview of R e ported (S IR S ). Odess a, F L: P sychological Ass ess ment 1992. *R ogers R , ed. C linical As s e s s me nt of Malingering As s es s ment. 2nd ed. New Y ork: G uildford; 1997.

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R ogers R , C ruis e K R : As ses sment of malingering simulation des igns: T hreats to external validity. L aw Hum B e hav. 1998;22:273. R ogers R , Harrell E H, Liff C D: F eigning neurops ychological impairment: A critical review of methodological and clinical cons iderations . C lin R ev. 1993;13:255. R ogers R , S alekin R T , G oldstein A, Leorand K : A comparis on of forens ic and nonforensic malingerers: prototypical analys is of explanatory models . L aw B ehav. 1998;22:353. R os enhan D: On being s ane in ins ane places . 1973;179:250. S chmand B , Lindeboom J , S chagen S , Heijt R , Hamburger HL: C ognitive complaints in patients whiplas h injury: T he impact of malingering. J Ne urol Neuros urg P s ychiatry. 1998;64:339. S chretlen D: T he use of psychological tests to malingered s ymptoms of mental disorders . C lin R ev. 1988;8:451. S iegler M, Os mond H: T he s ick role revisited. S tud Has tings C e nt. 1973;1:41. S mith G P , B urger G K : Detection of malingering: V alidation of the S tructured Inventory of Malingering S ymptomatology (S IMS ). J Am Acad P s ychiatry 2932 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/26.1.htm

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1997;25:183. S zasz T S : Malingering: Diagnos is of s ocial condemnation. Arch Neurol P s ychiatry. *T rueblood W , S chmidt M: Malingering and other validity considerations in neuropsychological evaluation of mild head injury. J C lin E xp 1993;15:578. Wang E W , R ogers R , G iles C L, Diamond P M, Wang LE , T aylor E R : A pilot s tudy of the P ers onality Ass es sment Inventory (P AI) in corrections: of malingering, s uicide ris k, and aggres sion in male inmates. B ehav S ci L aw. 1997;15:469. Wertham F . T he S how of V iole nce . New Y ork: 1949. *Williams R W , C arlin M: Malingering on the W AIS -R among dis ability claimants and applicants for vocational ass is tance. Am J F orens ic P s ychol. Ziskin J : Malingering of ps ychological disorders . S ci L aw. 1984;2:39.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > 27 - C ulture-B ound S yndrome

27 C ulture-B ound S yndromes Manuel Trujillo M.D. 

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DE F INIT ION C ULT UR E AND T HE DE V E LOP ME NT OF P S Y C HOP AT HOLOG Y

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E P IDE MIOLOG Y

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AS S E S S ME NT AND E V ALUAT ION

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C ULT UR AL F OR MULAT ION IN DS M

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C ULT UR E -B OUND S Y NDR OME S

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T HE R AP IE S

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P S Y C HOP HAR MAC OLOG Y

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S T ANDAR DS

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C ULT UR AL P R OF IC IE NC Y T HR OUG H T HE C AR E S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > DE F INIT IO

DE FINITION 2934 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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P art of "27 - C ulture-B ound S yndromes " T he term culture -bound s yndrome us ually denotes arrays of behavioral and experiential phenomena that to present thems elves preferentially in particular sociocultural contexts and that are readily recognized illness behavior by most participants in that culture. syndromes are commonly ass igned culturally explanations and interpretations that, in turn, generate set of culturally congruent remedies, us ually in the form healing rituals performed by someone to whom the community ass igns a therapeutic role. C ulture-bound syndromes tend to encompas s a wide range of ps ychological, s omatic, and behavioral manifestations. Ataque de ne rvios , a syndrome that is widely prevalent in Latin America, among U.S . and in other Latin and Mediterranean cultures , erupts a florid combination of anxiety symptoms , s omatic experiences , and erratic behavior. Its sufferers may experience intense heat ris ing from the chest, may many dis sociative s ymptoms , and may faint or s eize. observer may report out-of-control behavior, shouts screams , sobbing, trembling, and purpos eless motor behavior. Its victims may jump, run, or throw agains t walls or may enact random aggres sive acts suicidal gestures. Dis sociation seems to be at the core amok, a s yndrome observed in wide areas of Malays ia, Asia, the P acific, andles s oftenin P uerto R ico and the Navajo Indians . After an initial period of intense brooding and withdrawal, amok s ufferers enter a period diss ociation marked by motor automatis ms and of random violence with or without persecutory ideas 2935 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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amnes ia. A glos sary of primary symptoms present in culturedisorders was compiled by C . C . Hughes , who reports, decreasing frequency, the presence of s ymptoms of anxiety, apathy and withdrawal, angry and aggres sive behaviors , bizarre and unconventional complex motor behaviors (e.g., taking off clothing, thrashing about, shouting and swearing, and inappropriate dancing), depres sion, dis sociation, gas trointes tinal (G I) hallucinations , sleep disorders with parasomnias, and many others. A W estern clinician or res earcher trying to unders tand culture-bound syndromes might frame his or her quest with the following caveats : 1. All societies harbor individuals who exhibit acute chronic behavior that is at variance with the mores standards of the community and that becomes problematic for the individual or for other members the community, or both. All societies in the anthropological record hold explanatory for such behavior, as sign it a label, and attribute to meaning and value (acceptance or s tigma) as they prescribe a s ocial role (s upport or sanction) to the victims of such behavioral epis odes. T o the degree aberrant behavior earns the label of illness , all provide a vas t array of remedies aimed at its amelioration and confer s pecific benefits to those hold the s ick role. 2. S ocieties vary widely in the way in which they aggregate s ymptoms to construct and to label disorders , in the thres holds of tolerance for 2936 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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behavior, in the entitlements provided pers ons who fall ill, and in the proces s and systems that are designed for the care of the afflicted. T hese parameters thems elves (symptom aggregates, thresholds of tolerance, and s ys tems of care) are subject to cons iderable historical change. J us t in Wes tern societies, s ymptom aggregates have cons iderably during the 20th century. S uffice it to the rarity of presentations of grand hysterics in Wes tern clinics today as compared with their florid abundant presence in the era of J ean Martin Diagnos tic labels have changed as well; witnes s fate of the diagnos is of homosexuality, earlier regarded as a psychiatric condition s ubject to diagnosis and treatment in a social atmos phere of legal sanction and moral rejection, and now cons idered a normal variant of sexuality deserving equal and full protection in the various bills of rights and codes of law. C hanges in thresholds of have a more mixed record. P rogres s has to be in the reduction of the stigma attached to patients with schizophrenia earlier in the era of indus trialization. W estern communities, however, erect s ignificant barriers to thes e patients in terms their fuller reintegration to community living, employment, and valued social roles ; thus, the paradox observed in many outcome research that monotonously confirm the better outcomes of these dis orders in s o-called less advanced but tolerant and welcoming communities. 3. C linicians and researchers who operate in W es tern cultures and s ocieties tend to cons ider the Wes tern 2937 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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biomedical intellectual tradition (including the Diagnos tic and S tatis tical Manual of Me ntal [DS M] and the Inte rnational S tatis tical Dis e as es and R e late d He alth P roble ms [IC D]) as objective referent. As it were, the Wes tern edifice of diagnoses and treatment is unwittingly as cribed the value of the s o-called objective norm agains t which other ethnic labels are contras ted and evaluated. T his viewpoint permits W estern cons ider the psychiatric knowledge produced by cultures as culture bound. S cientific humility would compel phys icians to as k the question that, if all nosologies (and treatment systems ) are culture has the W estern s ys tem of aggregating s yndromes , producing labels , and as signing value and meaning emerged outside of the bounds of W es tern culture? more balanced view would invite examination of the cultural ass umptions under which the Wes tern of diagnos is and care operates. It might also the unique set of stress ors that give rise to s uch Wes tern disorders as anorexia nervosa, bulimia nervos a, chronic fatigue syndrome, and type A personality. 4. Ins ofar as ps ychiatric dis orders, whatever their biological determinants , find express ion through the final common pathway of pers onal beliefs and behavioral anomalies and dis turbances, all known societies have found ways to differentiate normal abnormal behavior (diagnos is ) and have devised to attribute caus ality and motivation to such (explanatory frameworks ). Likewise, all societies develop means for the treatment of s uch ailments 2938 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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(healing rituals and practices) and ins titutions for containment of those who fail to recover or attain limited improvement. P.2283 T hroughout his tory, ps ychiatric illnes ses have carried special intellectual, moral, religious , and, often, literary meanings and have been burdened with the heavy of social s tigma and destructive attributions of Malevolence, s in, pos sess ion by evil s pirits, the punis hment of implacable gods, and the like have all cast in the role of providing reass uring motives for the tragic fate of psychiatric illness , as they were discarded reasonable explanation for all of those behaviors cons idered more normal. In the context of W es tern medicine, ps ychiatry has evolved a model for the unders tanding and treatment of mental illnes s, the biome dical model, which emphas izes the concept of ps ychiatric disorders as naturalistic entities , each poss ess ing a s eparate and distinct structure and that can be clas sified, explained, and treated. T he presumes that the illnes s is located within the individual and is caus ed by a primary brain malfunction. for example, once explained by s pirit poss ess ion, and, such, reflecting a disturbance in the relations hip the patient and the world of s pirits , is seen by as a disturbance of brain function arising from of gene or neurotrans mitter functions. T hus , the current biops ychos ocial model that is prevalent in Wes tern ps ychiatry, aided by impress ive advances in molecular biology, psychopharmacology, and 2939 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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brain imaging, is heavily weighted toward the biological component of the equation. Unlike during the earlier of the 20th century, the model currently deemphasizes ps ychological and social variables of the equation, minimizing the etiogenic, pathogenic, and pathoplastic roles of psychological conflict and unconscious and of powerful s ocial is sues, s uch as s ocial standing, employment s tatus, s ocial role conflict, poverty, racial discrimination, and the like. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > C ULT UR E AND T HE P S Y C HO P AT HOLO G Y

C UL TUR E AND THE DE VE L OPME NT OF PS YC HOPATHOL OGY P art of "27 - C ulture-B ound S yndromes " T he rendition of the biops ychos ocial model currently in vogue holds that mos t, if not all, ps ychiatric dis orders represent the behavioral express ionunder certain environmental conditionsof presumed brain alterations undergirded by abnormal genes or abnormal gene expres sion. In this model, there are four pos sible steps the development of abnormal behavior and ps ychopathology: (1) genetic variations or and alterations in gene express ion, (2) abnormalities in brain phys iology, (3) class ical conflict s ituations aris ing within the mind, and (4) intensely advers e conditions. Although the model has rallied substantial 2940 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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support for the contributions of each of the levels described previously to the development of the clas sic ps ychiatric syndromes, it has not yet achieved scientific evidence (unquestioned markers) for any of them. T here is , furthermore, cons iderable ambiguity scientific controversy regarding the weight that each of these factors holds in the development of a particular disorder, as well as regarding the rules that govern the interrelations hip between genes , brain phys iology, personal psychology, and environmental stress ors. It is conclus ively known, for example, whichif anygenes are neces sary or sufficient for the development of schizophrenia, how they determine and alter brain phys iology to produce schizophrenia's characteristic behavioral alterations, or the pathways through which environmental and s ociocultural conditions suppress or facilitate the actual development of overt ps ychopathology. E qual ambiguity governs the model that creates the cons truct of illne s s . R ecent, well-conducted, epidemiological s tudies have establis hed that the presence of behavioral abnormalities; s ubjective such as anxiety and depres sion; and even psychotic symptoms in unselected community samples is more widespread than once thought. A study by J im van Os colleagues, publis hed in the Archive s of G ene ral in 2001, found an incidence level of 12.9 percent of ps ychotic symptoms , s uch as delus ions , hallucinations , persecutory beliefs , or experiences of thought interference, or a combination of thes e. T hes e s ubjects not fulfill criteria for a DS M-III-R diagnosis, had never sought help for their experiences, and reported no 2941 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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suffering or dysfunction related to the presence of their symptoms. Only approximately one-third of all the subjects who reported any ps ychotic s ymptoms met criteria for a psychiatric disorder. Little is formally known of the process es that govern aggregation of such s ymptoms and experiences into groupings or about the thresholds that determine their caus ing sufficient pers onal s uffering or community concern to trigger help-seeking behavior. Little is also known about the s ocial determinants of acceptance or rejection of s uch s yndromes or which pattern of help seeking, of the many available to individuals in all societies, is s ought by a particular s ufferer. T he culturally s yntonic s yndrome of taijin kyofus ho can fruitfully examined through the s teps defined T aijin kyofus ho, a common phobia in J apan, as first systematized by S homa Morita in the early 1920s a fear of interpersonal relations. Its sufferers exhibit anxiety centered on the potential violation of the crafted rules of s ocial interactions imposed on J apanese society by rapid urbanization that seems to been accompanied, in J apan, by the rapid rise of the kyofus ho s yndrome. T he sequence of the s ocial construction of illness can be described as follows : F irst, there is the exis tence of an attitude of enhanced awarenes s and preoccupation with the pres entation of the self that the development of timid, s hy, and humble behavior. the development of rapid, large-scale s ocial change (urbanization, for example) alters the lands cape of personal s pace, forcing wides pread contact with a number of people outside of the rigidly codified network 2942 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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of relationships formerly normative in more traditional J apanese social environments. T hes e new conditions exacerbate latent anxiety about one's impact on others putting the individual on s tage at all times , thus multiplying the opportunities for inappropriate or awkward interpersonal behavior. S uch a faux pas may subjectively experienced as a humiliating interpersonal offens e and perceived as evidence of pers onal failure. attendant anxiety and preoccupation with one's own behavior may reach s uch prevalence and intensity that prompts s ociety to confer on thes e patients the label of abnormal (beyond the acceptable thres hold) and to cons ider such behavior sociodystonic. T he final s tep in sequence requires s ociety to develop therapeutic strategies to alleviate the fate of such patients . T he of the suffering is probably not equally dis tributed in the general population. Here, like in many other s ocially shaped conditions, many variables may modulate the appearance and outcome of the full s yndrome. T hos e people who are temperamentally predis pos ed to s hy anxious behavior may show earlier or more s evere the illnes s. S uch may also be the cas e for people who experienced significant lack of support or blatant emotional deprivation through their development. C onvers ely, it is known that high intelligence, extens ive education, and belonging to dens e s ocial networks frequently act as protective factors .

C ultural P s yc hiatry C ultural ps ychiatry can be defined as the body of knowledge that aims to define the impact of culture on the diagnosis and treatment of mental and to provide guidance for the design and 2943 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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implementation of culturally competent s ys tems of C ultural ps ychiatry engages the universality and the divers ity of human experience and s trives to illuminate impact of culture on the vulnerability, pathogenes is , phenomenology, subjective experience, course, and outcome of ps ychological disorders . P.2284 C ultural ps ychiatry is a truly interdisciplinary endeavor draws from many other basic and applied dis ciplines . S ocial, cultural, and medical anthropology lend insights regarding how particular social worlds are ordered and how such order is dis rupted in res pons e to historical change. It supplies descriptions of people's behavior in particular ecologies , native views of health and illness , descriptions of native healing rituals and s ys tems . Of particular importance for the understanding of culturebound syndromes , cultural anthropology may help agains t what Arthur K leinman has called the category fallacy: the application of a category (a ps ychiatric example) that is valid in one cultural context to another cultural context without regard for the rich s ymbolic and interactional soil in which a particular human behavior embedded. F rom s ociology and medical s ociology, ps ychiatry draws an understanding of the relationship mental disorders to s uch variables as economic employment and occupational opportunities , demography, and the s ocial conditions that promote social affiliation or disaffiliation. E pidemiology is central cultural ps ychiatry ins ofar as it provides data about differential incidence and prevalence of ps ychiatric disorders in different populations and may help track 2944 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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emergence of new clinical entities under rapidly social conditions . W itnes s the sudden emergence of disorders , including frank bulimia, in certain isolated societies after the s udden introduction of W estern television programs. Although no longer as intensely cultivated, cros s-cultural developmental has helped elucidate the role of culture in the development of personality traits. S uch analysis can facilitate the unders tanding, for example, of the development of an intens e and powerful male identity the P apua New G uinean S ambian tribe, des cribed by G ilbert Herdt, through the repeated and ritualized cultivation of malenes s, and it can als o illuminate the prevalence of antisocial traits in inner city ecologies are characterized by expos ure to poverty, domes tic violence, s ocial dis organization, and family breakdown. T he history of cultural ps ychiatry parallels the growth of clinical ps ychiatry. E mil K raepelin and S igmund F reud figure prominently in both. K raepelin, for example, for the development of a s ubs pecialty of ps ychiatry: comparative psychiatry (ve rgle ichende ps ychiatrie ), observation of differential pathoplas ty between his G erman patients and the J avanese and other patients whom he obs erved during a lecture tour through As ia. F reud wondered about and ultimately as serted the universality of the oedipal situation, however filtered experience may have been through context-specific renditions . As it turned out, this original link between anthropology and psychoanalysis continued a fruitful dialogue through the work of R uth B enedict, Margaret Mead, and other workers, such as B ronis law Abram K ardiner, R alph Linton, and many others . T he 2945 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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two decades have seen a veritable explos ion of in cultural ps ychiatry, including innovative theoretical work (K leinman and Lawrence K irkmayer), propos als (Lloyd H. R ogler and P eter G uarnacia), and observations and ethnographic des criptions (S pero Mans on on Native Americans and Monica McG oldrick P edro R uiz on inner city His panics ). R ecent advances cross -ethnic ps ychopharmacology augur well for the methodological rigor, as well as for practical

C ulture T he ambiguity of the term culture is as vast as the of definitions propos ed: More than 160 are recorded in E nglis h s ocial science literature. However difficult to define, everyone seems to know what culture means intuitively develops a holis tic view of it and a universe referents: meanings, values , mores , and traditions , es sential to individual and group identity. T he end this process is a relatively unified world view easily among members of a group. F or clinical ps ychiatric purposes, the best definition be the one provided by the National Institute of Mental Health's C ulture and Diagnos is G roup: C ulture refers to meanings , values and behavioral norms that are and transmitted in the dominant society and within its social groups. C ulture powerfully influences cognition, feelings and self-concept as well as the diagnostic and treatment decisions . T wo aspects s tand out from this definition for their potential import in the development of On the one hand, culture influences cognitions , and s elf-concept, thus exerting powerful influence on 2946 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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central mediators of health and pathology. C ulture als o influences the presentation of distress , the diagnostic proces s, and treatment decisions, thus becoming a partner in the therapeutic therapistpatient relations hip. F inally, culture represents a normative framework that shapes behavior and molds identity and accomplis hes such aims by defining normality and deviance, preferred values and behaviors while pros cribing and sanctioning others. S uch sanctions may promote or healthy adaptations.

R ac e and E thnic ity T he terms culture , race , and ethnicity are often used interchangeably and with cons iderable lack of E ven when us ed in the s cientific literature, the terms such lack of precise boundaries that their us e has to be cons idered colloquial. R ace is most often us ed to human groups s haring phenotypically compelling characteristics (e.g., s kin color and eye morphology) are often interpreted to mean strongand widespreadgenotypic homogeneity. In fact, no such genotypic homogeneity has been described for any group, and the genetic variability between individuals of the same race may be larger than that between of different races. Des pite race's lack of significance in denoting a genotype, and probably because it is s o outwardly it may be a s ource of cons iderable s uffering for if the social context discriminates between people on basis of racial characteris tics and ascribes value to one to the detriment of another. R acially based is thus a source of considerable human s uffering for 2947 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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victim and may become a difficult obstacle in the path toward a healthy sense of pers onal value and identity. R es earchers have noted the distortions that can be in the diagnos tic process of patients of another race. In United S tates , African Americans have been s hown, for example, to be overdiagnos ed with s chizophrenia and underdiagnosed with bipolar and other mood dis orders. V arious factors have been called to account for this variance, including cultural distance between patient examiner; misinterpretation of interpersonal and nonverbal behavior, s peech, vocabulary, and and misinterpretation of the presenting s ymptom P recis ion in the differential diagnos is of s chizophrenia from mood disorders is of extreme importance in terms prognos is and treatment, as well as in the recognition treatment of preventable s ide effects . T he term ethnicity, denoting a s hared s ens e of identity, common ancestry, and s hared history and beliefs , is increasingly gaining ascendance among cross -cultural res earchers because of its heuris tic value. It denotes is sues of clinical import: the development of personal identity, socialization, and group affiliation so often derailed or arrested by ps ychopathology. Likewis e, in multicultural s ituations, ethnicity and ethnic identity can be, and should be, carefully explored in the clinical situation. S uch iss ues as key ethnically shaped developmental experiences , participation in rituals and rites of pass age, relative adherence to family roles , religious obs ervance, s tyles of dres s, dating and many others are often prone to evoke guilt, selfdoubt, family conflict, and other forms of psychological distress or dys function. 2948 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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As directed by the DS M-IV -T R , the ethnic or cultural identity of the individual should be a key factor in the development of a patient's P.2285 cultural formulation and should als o be s ys tematically evaluated in the clinical proces s. K ey determinants , gender identity, s exual orientation, language clas s description, and religious and s piritual beliefs , to be ass ess ed as the clinician formulates the cultural dimensions of the patient's pres enting problem.

C ulture and P s yc hopathology In an earlier paper, the author described as an tas k of cultural psychiatry the description and of the pathways through which culture affects ps ychopathology and described the following: 1. G enerating ps ychopathology by presenting stress es that tax the individual's ps ychological life behavior. C hronic s ocial conditions, such as unemployment, and pervasive racism, cons is tently generate high rates of dis tres s and the populations exposed to them. 2. R educing psychopathology by enacting protective factors against external or internal s tres sors . In this regard, J avier I. E s cobar, among others , has called attention to the low prevalence for mos t ps ychiatric disorders among low-acculturation Mexican Americans and recent Mexican immigrants, which be due to a protective effect of their traditional culture's emphasis and pervasive use of s upportive 2949 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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extended family networks . 3. P romoting or modulating s ocial change, thus increasing or reducing the psychological s tres ses as sociated with change. 4. Affecting the onset, pathoplas ty, course, and of conventional ps ychiatric s yndromes, such as schizophrenia or bipolar disorders . 5. Affecting the tolerance for certain behavioral, subjective, and clinical s ymptoms or unus ual states and thus promoting the pathogenic is olation healing integration into the wider s ocial group of the individual displaying such signs and symptoms . 6. P atterning culture-specific idioms of dis tre s s , sanctioned ways for individual or group express ion subjective dis tres s.

C ulture and S ymptom E xpres s ion It is a known phenomenon that culture affects the freedom with which patients acknowledge to to family members, and to clinicians the nature and of perceived subjective experiences and bodily dysfunctions. T he E pidemiological C atchment Area study, for example, appeared to confirm that P uerto reported somatic symptoms out of proportion to the of the population, res ulting in a higher mean number of somatization s ymptoms in the Diagnostic Interview S chedule. Although a later analysis indicated that mos t the variance could be accounted for by the undetected presence of ataque de nervios , the less on nevertheless remains: Not only does culture affect the expres sion of 2950 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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distress by patients, but it may als o affect the of unfamiliar expres sions of s uffering by clinicians. Although the us e of rating s cales and interview facilitates the accurate collection of addres sed the clinician operating acros s the language and cultural barriers must be aware that these ins truments cannot capture those symptoms that, whatever their are not reported in the s cale. R es ults from the International P ilot S tudy of showed that, s urprisingly, the reliability of s ymptoms collected through patient reports (such as the pres ence hallucinations and delusions ) was higher than that of signs observed by the clinicians (problems with affect) the historical data (social relations , work his tory) by various other means. An accurate and mental s tatus examination remains the cornerstone of clinician's work.

A c c ulturation Acculturation, the proces s by which people originating from certain cultures (guests ) migrate, interact, and ultimately ass imilate into another culture (host), is a proces s of great mental health interest and is more s o in a century of great migratory currents. In according to W illiam Davis , only approximately 300 people (approximately 5 percent of the global still retain a strong identity as members of an culture, rooted in his tory and language and by myth memory to a particular place. V igorous intercultural interaction is thus the norm more than the exception in world immersed in the process of globalization. A host factors and variables governs this proces s and dictates 2951 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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impact on the individual. T he relative opennes s and tolerance and the prevailing expectations of the host society are viewed as determinant. In the United example, the waves of immigrants of the late 19th and early 20th centuries encountered expectations of quick as similation to and internalization of the mores and customs of the host society: the me lting pot metaphor. Immigrants arriving after W orld War II, aided by improvement in communication and travel tended to preserve more of their native languages and cultures and more ongoing contact with their lands of origin. At the level of the individual, acculturation denotes the proces s by which people change their behaviors , attitudes, and life goals as a res ult of exposure to a different cultural system. Insofar as this proces s affects parameters critical to the development of a valued selfconcept and of the s ocial efficacy necess ary to this process presents notable risks to the subject's health. At a minimum, the proces s of acculturation represents an additional stress or for the individual and or her family. More recent concepts of acculturation support four outcomes for such a proces s: 1. Ass imilation, by acquiring the behaviors and values the hos t culture with minimal participation and endors ement of beliefs and practices of the former one. 2. Integration, which requires a comfortable balance behavior and values originating from both cultures, leading to practical adaptation and a valued s ens e 2952 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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ethnic identity. 3. S eparation, whereby the s ubject retains his or her traditional identity and shows reluctance to accept most behaviors and values from the new culture. 4. Marginalization, whereby the s ubject neither maintains a strong allegiance to his or her native culture nor incorporates the values predominant in or her new environment. T he resulting fragile identity and brittle s ocial support network impose a serious burden of stress on the individual and may impair his or her mental health. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > E P IDE MIO LOG

E PIDE MIOL OGY P art of "27 - C ulture-B ound S yndromes " T he last few decades have witness ed the production of significant res earch illuminating diverse as pects of cultural practice. Of great interest for those res pons ible the organization of ps ychiatric care are the ongoing findings of psychiatric epidemiology acros s cultures. C laims have repeatedly been made that African His panics , As ians, and other minorities experience levels of ps ychological distress and dis order than the mains tream population. Although the scientific s tatus of those claims remains uns ettled, a large portion of the alleged ethnic differences dis appears when age, socioeconomic s tatus , and education are controlled for. 2953 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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T he National Institute of Mental Health's C atchment Area S tudy found few ethnic differences in rate of DS M-IV diagnos es after it controlled for socioeconomic conditions. Lifetime rates for phobic disorder were significantly higher among African res pondents, with young His panics s howing a higher prevalence of alcohol abus e. Other studies conducted P.2286 by the Ins titute for Health S tatis tics demonstrated that, despite s imilar demographic characteris tics, the prevalence of major depress ive dis order for mainland P uerto R icans was significantly higher than for is land P uerto R icans . F rom the s tandpoint of the policy maker, however, minority status is often linked to economic, social, and educational dis advantages . T hese parameters , with the many s tres sors ass ociated with racial and minority status and the los ses and uncertainties of the migratory experience, may dras tically increas e the rate distress , symptoms, or diagnoses. T he planner and organizer of ps ychiatric services needs to be attuned to pockets of ris ing ris k in the target population. of underus e of mental health s ervices, repeatedly in minority populations , s uch as Asians , may lead the culturally competent mental health planner to interventions des igned to counter the effect of the cultural values and attitudes that inhibit s elf-referral. T he epidemiological literature, fortunately, does not only bad news. F ollowing the recommendations of J . E scobar, researchers and policy makers s hould als o become more cognizant of the potential benefits of 2954 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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as cription to an ethnic minority s tatus. F or example, Mexican Americans with low acculturation s tatus are reported to dis play low prevalence for mos t psychiatric disorders . Whatever the protective factor (social perhaps ), it s hould be identified and targeted for blending into preventative s trategies and interventions . If all organized s ys tems of ps ychiatric care ought to be sens itive to population-based program planning, the mandate is all the more compelling for those serving minority populations, for they confront stress factors and adaptive challenges with potential pathogenic impact and for which preventive strategies may be desired. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > AS S E S S ME NT AND

AS S E S S ME NT AND E VAL UATION P art of "27 - C ulture-B ound S yndromes " E ntry into the s ys tem of care always requires a comprehensive as sess ment process of which the status examination and the dynamic formulation are features. Additional medical and ps ychological tes ts frequently requested to aid in diagnosis and treatment planning. B oth process es are fraught with complexities and the potential for distortions when conducted acros s the language and cultural barriers . Authors such as Del C astillo and Luis R . Marcos have reported thes e distortions for His panics , although reaching opposite 2955 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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conclus ions as to whether ps ychopathology, evaluated acros s the language barrier, is as sess ed as greater interviews are conduced in the patients' native or in their secondary language. On the basis of clinical s tudies, Marcos has recommended s teps that clinicians may take to correct for those dis tortions . T he neces sity to evaluate, concurrently with the diagnostic interview, parameters s uch as the patient's language dominance, language proficiency, and language preferences , as well as the as sess ment of the patient's place in the acculturation s pectrum, can eas ily be transformed into guidelines for the evaluation of acros s the language barrier. T he quality and outcome this process can then be tracked through continuous quality-improvement activities. S ys tems of care can develop s imilar guidelines for the and interpretation of ps ychological tests . C linical must be encouraged when applying to a particular group norm derived from another group. Additional is sues, s uch as differential validity, reliability, measurement equivalency, and test bias, complicate the tas k of drawing clinically valid when us ing ps ychological ins truments whose ps ychometric properties are derived from a particular ethnic population to as sess the clinical status of a of another population group. A gold s tandard in this regard is the development, for a given population, of culturally s yntonic psychological tests . F or Hispanics , example, G ius eppe C onstantino has developed the Me-A-S tory (T E MAS ) tes t, a projective tes t cons is ting vivid colorful pictures that portray situations involving typical conflict in urban s ituations. T he test achieves 2956 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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significant interrater reliability, internal consistency, and predictive validity. As more of these instruments available, culturally competent s ys tems of care may to develop guidelines for their us e that guard agains t perpetuation of bias. In the absence of ethnicityvalidated tes ts , such systems may encourage the us e relatively culture-free instruments (B ender-G estalt and P orteus -Maze, for example) and widely trans lated s elfrating scales , s uch as the symptom checklist-90 and Zung S elf-R ating Depres sion S cale. Wes termeyer, others , has demonstrated that self-rated s cales and ps ychiatris t-rated s cales have shown s trong reliability cross -culturally. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > C ULT UR AL F OR MULAT IO N

C UL TUR AL FOR MUL ATION DS M P art of "27 - C ulture-B ound S yndromes " A glos sary of culture-bound syndromes , included in IV -T R 's broad cultural offering, allows diagnosticians to cons ider them as alternative or complementary entities in many cases. T he clinician is als o invited, the requirement of the cultural formulation, to systematically explore his or her patient's cultural the perceived causes or explanatory models that the individual and the reference group us e to explain and to seek its treatment, the cultural factors related to ps ychos ocial environments and levels of functioning, 2957 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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most importantly, the cultural elements of the between the individual and the clinician. T he ends with overall cultural as sess ment for diagnos is and care, which enjoins the clinician to note how cultural cons iderations specifically influence diagnosis and T he adoption by DS M-IV of cultural cons iderations , including the cultural formulation, represents an unques tionable achievement in creating a minimum worldwide standard of cultural adequacy. In practice, however, the outline is infrequently us ed, even in of care with heavy representation of ethnic minorities patients and providers. Organizers of psychiatric care a s ignificant opportunity for movement toward cultural adequacy by introducing the completion of the cultural formulation as a bas ic cultural competence standard in their facilities ' quality improvement process . P ayers regulators can be encouraged to monitor compliance to require increas ing levels of completion. Academic medical centers and res idency training programs , required by their chartering organizations to promote cultural competence, can s erve a key function in the diss emination of models of cultural as sess ment the training proces s. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > C ULT UR E -B O UND

C UL TUR E -B OUND S YNDR OME S P art of "27 - C ulture-B ound S yndromes " 2958 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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T he AP A's glos sary lists and describes briefly s ome of best-studied culture-bound syndromes and idioms of distress that may be encountered in clinical practice in North America.

A mok A diss ociative episode characterized by a period of brooding followed by an outburs t of violent, aggres sive, homicidal behavior directed at people and objects. T he episode tends to be precipitated by a perceived s light insult and s eems to be prevalent only among men. T he episode is often accompanied by persecutory ideas, automatis m, amnes ia, exhaus tion, and a return to a premorbid state after the episode. S ome instances of may occur during a brief psychotic epis ode or the ons et or exacerbation of a chronic psychotic T he original reports that used this term were from Malaysia. A similar behavior pattern is found in Laos, P hilippines, P olynes ia (cafard or cathard), P apua New G uinea, and P uerto R ico (mal de pe lea) and among Navajo (iich'aa). P.2287

L os s B urton-B radley reports the following case from which illus trates an epis ode of amok after s evere bereavement: In 1846, in the province of P enang, Malaysia, a elderly Malay man suddenly s hot and killed three and wounded ten others. He was captured and brought 2959 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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trial, where evidence revealed that he had suddenly his wife and only child, and, after his bereavement, he became mentally disturbed.

Interpers onal Ins ults Another cas e reported by B urton-B radley, from his New G uinea s tudy, illustrates the role of intolerable as precipitants of amok: T his patient was a healthy young adult man, who came from the Hinterlands of Abau, C entral Dis trict. At time of the act, he was working with a building gang on F ergus on Is land. He was a foreigner to his work mates , of whom called him an Abau bush piga grave ins ult. night, at approximately 6:30 P M, the others were in dormitory reading or lying down, when the patient in with a 12-inch bus h knife and suddenly attacked going from bed to bed hacking at them with the knife, mostly in the vicinity of the head and neck. S ix died, or later, some with terrible wounds , their heads being almos t chopped off. F inally, another man in the vicinity heard the nois e and came in with a rifle and one T he amok attempted to attack him, was fired at, and did not ceas e attacking. He was then put out of action the butt of the rifle and died. Another interesting ques tion relating to the boundaries the amok s yndrome has been rais ed by the C anadian inves tigator Arboleda-F lorez. His analys is of three American cas es of mass , random s hootings and perpetrated by young men led him to ass ert the universality of amok behavior. T here are two points of viewthe particularis tic and the universalis tic 2960 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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perspectives . T he particularis tic pers pective posits the exis tence of a culture-bound syndrome, amok, that is defined by a particular phenomenology: the clas sic episode of frenzied, random killing triggered by a significant emotional cris is , preceded by a period of brooding and followed by amnesia. T he subject, in this view, is mos t often ps ychologically average but a s ocial milieu of shared beliefs and expectancies amok. T he universalis tic perspective argues that amok not a culture-bound s yndrome, but a syndrome that be found in any culture that undergoes rapid s ocial change, s tres sing vulnerable, alienated individuals their coping limits and leading them to des perate of pers onal as sertiveness . Whereas the incidence of in underdeveloped or developing countries has decreased, occurrences of s udden mas s violence in indus trial s ocieties appear to be rapidly increas ing. Arboleda-F lorez reported three s uch cases: the the T ower, the Memorial Day Man, and the C algary S niper. T hree young men (ages 22 to 25) chose murderous rampages as final expres sions of their despair. T he three had lived quiet, res tricted social had acted in respons e to actual or perceived and s hared pers onal histories punctuated by family dysfunction, epis odes of violence, and ps ychiatric and personality dis orders. Additionally, workplace shootings have become increasingly common in North America. According to Handgun F ree America, there have been more than 100 deadly workplace s hootings over the 15 years alone.

A taque de Nervios Ataque de ne rvios is an idiom of dis tres s that is 2961 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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reported among Latinos from the C aribbean but recognized among many Latin American and Latin Mediterranean groups. C ommonly reported s ymptoms include uncontrollable shouting, attacks of crying, trembling, heat in the ches t ris ing into the head, and verbal or phys ical aggress ion. Dis sociative seizure-like or fainting epis odes, and suicidal ges tures prominent in s ome attacks but abs ent in others . A feature of an ataque de nervios is a sense of being out control. Ataque s de nervios frequently occur as a direct res ult of a s tres sful event relating to the family (e.g., of the death of a clos e relative, a s eparation or divorce from a spouse, conflicts with a spouse or children, or witness ing an accident involving a family member). may experience amnesia for what occurred during the ataque de ne rvios , but they otherwise return rapidly to us ual level of functioning. Although des criptions of ataque s de ne rvios most closely fit with the DS M-IV description of panic attacks, the as sociation of mos t ataque s de ne rvios with a precipitating event and the frequent absence of the hallmark symptoms of acute of apprehension distinguis h them from panic dis order. Ataque s s pan the range from normal expres sions of distress not as sociated with having a mental disorder symptom presentations as sociated with the diagnosis anxiety, mood, dis sociative, or somatoform disorders . In a community study in P uerto R ico, 16 percent of 1,000 people interviewed reported having had at leas t distinct episode of ataque de nervios . Almos t 75 patients regis tered in community mental health clinics New Y ork and B os ton als o reported having least one episode of the syndrome in their life. S uch 2962 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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reports were us ually not produced spontaneously but were elicited only after careful s crutiny on the part of clinician, rais ing the question of how many other bound syndromes are miss ed under the conditions of a conventional ps ychiatric interview anchored in the decis ion tree flowing out of the s tructure of DS M-IV -T R . Detailed phenomenological portraits of the s yndrome have been developed by P eter G uarnacia us ing representative samples of affected individuals . T he full syndrome profile may display symptoms repres enting alterations of bodily sens ations (chest tightnes s and suffocation, heart palpitations , trembling, shortness of breath), emotional expres sion (anger, fear, express ion, suicidal feelings and ges tures), and dis rupted cons ciousnes s (fainting, los s of cons cious nes s, diss ociation, derealization, blurring of vision). F inally, motor and behavioral dys control (screaming, s houting, crying uncontrollably) and verbal or physical lend the s yndrome its clas sic or characteris tic

C omorbidities R es earch on the comorbid relationship of ataque de to other DS M-IV -T R ps ychiatric disorders shows a very rate of comorbidities . Up to 63 percent of ataque de patients in a P uerto R ican s ample met criteria for ps ychiatric diagnosis, with anxiety and affective representing the most common comorbidities . V arious inves tigators reported that the presence of s pecific symptoms may predict the comorbid diagnos is ; for example, the prominent presence of fear (and bodily s ens ations ) links with comorbid anxiety and disorders , whereas the pres ence of overt anger and 2963 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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aggres sive behavior s eems to favor the affective comorbid pathway. Drawing from ps ychoanalytic conceptualizations , anxiety may repres ent a s ignal of presence of unacceptable impulses, whereas the of anger and aggres sion may lead to an aftermath of and depres sion.

B ilis and C olera (A ls o R eferred to Muina) T he underlying caus e of bilis and colera is thought to strongly experienced anger or rage. Anger is viewed among many Latino groups as a particularly powerful emotion that can have direct effects on the body and exacerbate exis ting symptoms. T he major effect of to dis turb core body balances (which are unders tood balance between hot and cold valences in the body between the material and spiritual aspects of the body). S ymptoms can include acute nervous tens ion, trembling, screaming, s tomach disturbances , and, in severe cases, los s of consciousness . C hronic fatigue res ult from the acute epis ode.

B oufe Dlirante B oufe dlirante is a syndrome obs erved in W est Africa Haiti. T his F rench term refers to a s udden outburst of agitated and aggres sive behavior, marked confusion, ps ychomotor excitement. It may P.2288 sometimes be accompanied by vis ual and auditory hallucinations or paranoid ideation. T hese episodes res emble an epis ode of brief psychotic disorder. 2964 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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B rain F ag B rain fag is a term initially us ed in W est Africa to refer condition experienced by high school or univers ity students in respons e to the challenges of schooling. S ymptoms include difficulties in concentrating, remembering, and thinking. S tudents often state that brains are fatigued. Additional somatic symptoms are us ually centered around the head and neck and pain, pres sure or tightnes s, blurring of vision, heat, or burning. B rain tiredness or fatigue from too much is an idiom of dis tres s in many cultures and resulting syndromes can resemble certain anxiety, depres sive, somatoform disorders .

Dhat Dhat is a folk diagnostic term used in India to refer to severe anxiety and hypochondriacal concerns with the discharge of semen, whitish dis coloration of urine, and feelings of weakness and exhaus tion. It is to jiryan (India), s ukra prameha (S ri Lanka), and s hen(C hina).

Falling Out or B lac king Out E pisodes of falling out or blacking out occur primarily in the s outhern United S tates and in C aribbean groups . are characterized by a s udden collaps e, which occurs without warning but s ometimes is preceded by feelings of dizziness or s wimming in the head. T he individual's eyes are us ually open, but the person inability to see. T he person us ually hears and what is occurring around him or her but feels powerless move. T his may corres pond to a diagnosis of 2965 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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disorder or a diss ociative dis order.

G hos t S ic knes s A preoccupation with death and the deceased as sociated with witchcraft) frequently observed among members of many American Indian tribes . V arious symptoms can be attributed to ghos t s ickness , bad dreams, weakness , feelings of danger, loss of fainting, dizzines s, fear, anxiety, hallucinations, los s of cons ciousnes s, confusion, feelings of futility, and a suffocation.

Hwa-B yung (A ls o K nown as WoolHwa-B yung) Hwa-byung is a K orean folk s yndrome that is literally translated into E nglis h as anger s yndrome and is to the suppres sion of anger. T he s ymptoms include insomnia, fatigue, panic, fear of impending death, dysphoric affect, indigestion, anorexia, dyspnea, palpitations , generalized aches and pains, and a a mass in the epigas trium.

K oro K oro is a term, probably of Malaysian origin, that refers an episode of sudden and intens e anxiety that the (or, in women, the vulva and nipples) will recede into body and pos sibly caus e death. T he syndrome is in south and eas t Asia, where it is known by a variety local terms, such as s huk yang, s hook yong, and s uo (C hines e); jinjinia be mar (As sam); or rok-joo occasionally found in the W es t. K oro at times occurs in localized epidemic form in east Asian areas . T his 2966 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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is included in the s econd edition of the C hines e C las s ification of Me ntal Dis orde rs (C C MD-2). Although the term and the s yndrome were firs t to the W estern biomedical literature by B lonk in 1895, report depended on the description given to him by an informant, himself a sufferer of koro. T wo years later, V ors tman reported two cas es , at leas t one of them witness ed by him. J ames E dwards provides the description of this report: A C hines e patrol officer induced V ors tman to him to a village in the S ingtan district to provide aid to a member of the native elite. T he patient was in bed, surrounded by a retinue and with an old man sitting at the foot of the bed. Having no information the patient's s ymptoms during the preceding days , V ors tman's examination and ques tioning failed to yield much ins ight into the man's problem. V ors tman that alcohol abuse, a common native habit, was the background for this cas e. T he C hines e official who accompanied V ors tman related to him that, for the las t days , the patient's penis had withdrawn into his and, as a preventive meas ure, the old man at the foot the bed had been gripping his master's obstinate limb. knowing the local term for the dis eas e, V orstman the term koro from B lonk's report. R . B ernstein and A. G aw have propos ed a definition of and advanced criteria for the diagnos is , recommending inclusion in the DS M. T he es sential feature of this disorder is a complaint of genital 2967 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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retraction with fear of impending death, occurring where culturally sanctioned beliefs of folk or pathology are present. men, the mos t common is that of the penis s hrinking into the abdomen and resultant among females, the s hrinking of the labia or breasts and death. T he person may appear be in a state of acute dis tres s attempt to pull his penis , have family members or friends hold onto the penis , or use clamps or strings tied to the penis to retraction. T he complaint is always accompanied by panic, fear, or anxiety. T hese authors propose the following diagnostic criteria: A feeling of overwhelming panic ass ociated with sens ation of or belief in genital retraction. A fear of impending death, s hould the genitals be allowed to fully retract. A tendency to prevent retraction by holding onto penis , enlis ting help in doing so from friends or relatives , or using devices attached to the penis . Aside from the belief and its ramifications , behavior not obvious ly odd or bizarre. T he individual has never met criteria for any Axis I 2968 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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disorder, other than somatoform dis order, and it cannot be es tablished that an organic factor and maintained the disturbance. S pe cify type: In/not in a c ultural c ontext S ingle/epidemic c as e S ubjective ideas of genital change may be more in the general population and among other psychiatric disorders than generally realized. One s tudy reported 20 percent of a male s chizophrenic s ample concerns about changes in the size of their genital although these experiences seemed to repres ent overvalued ideas or delusions without the distinct characteristics of the koro disorder. T he fact that genital retraction symptomatology has reported in as sociation with stimulant abuse (amphetamines) and heroin withdrawal, as well as in context of epileptic confus ional states , cerebral brain tumors , and other alterations of brain physiology, should prompt physicians confronted with a complaint genital retraction to carefully rule out the presence of organic pathology. T he presence of s omatic and concern merits a differential diagnosis of disorder, undifferentiated s omatoform dis order, or dysfunction not otherwise class ified. T he presence of anxiety and panic merit a differential diagnos is of panic disorder.

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L atah is hypersensitivity to s udden fright, often with echopraxia, echolalia, command obedience, and diss ociative or trance-like behavior. T he term latah is of Malaysian or Indones ian origin, but the syndrome has been found in many parts of the world. Other terms for condition are amurakh, irkunii, ikota, olan, myriachit, me nke iti (S iberian groups ); bah ts chi, bah-ts i, P.2289 and baah-ji (T hailand); imu (Ainu, S akhalin, J apan); mali-mali and s ilok (P hilippines). In Malaysia, it is more frequent in middle-aged women.

L oc ura L ocura is a term us ed by Latinos in the United S tates Latin America to refer to a s evere form of chronic ps ychos is . T he condition is attributed to an inherited vulnerability, the effect of multiple life difficulties , or a combination of both factors. S ymptoms exhibited by persons with locura include incoherence, agitation, auditory and vis ual hallucinations , inability to follow of social interaction, unpredictability, and poss ible violence.

Mal de Ojo Mal de ojo is a concept widely found in Mediterranean cultures and els ewhere in the world. Mal de ojo is a phrase translated into E nglis h as evil e ye . C hildren are es pecially at risk. S ymptoms include fitful sleep, crying without apparent cause, diarrhea, vomiting, and fever child or infant. S ometimes adults (especially women) the condition. 2970 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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Nervios A common idiom of distress among Latinos in the S tates and Latin America. A number of other ethnic have related, although often s omewhat dis tinctive, of ne rve s (s uch as ne rvra among G reeks in North Nervios refers to a general state of vulnerability to life experiences and to a s yndrome brought on by life circums tances . T he term ne rvios includes a wide of symptoms of emotional dis tres s, somatic and inability to function. C ommon symptoms include headaches and brain aches, irritability, s tomach disturbances , s leep difficulties , nervousness , easy tearfulnes s, inability to concentrate, trembling, tingling sens ations, and mareos (dizziness with occas ional like exacerbations). Nervios tends to be an ongoing problem, although variable in the degree of disability manifested. Nervios is a broad syndrome that spans range from cas es free of a mental disorder to res embling adjustment, anxiety, depres sive, somatoform, or ps ychotic dis orders . Differential depends on the cons tellation of symptoms the kind of s ocial events that are ass ociated with the and progres s of ne rvios , and the level of dis ability experienced.

P ibloktoq P ibloktoq is an abrupt dis sociative epis ode by extreme excitement of as long as 30 minutes ' and frequently followed by convuls ive seizures and lasting as long as 12 hours . T his is obs erved primarily arctic and s ubarctic E s kimo communities, although regional variations in name exist. T he individual may 2971 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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withdrawn or mildly irritable for a period of hours or before the attack and typically reports complete for the attack. During the attack, the individual may tear his or her clothing, break furniture, s hout obs cenities , feces , flee from protective s helters , or perform other irrational or dangerous acts.

Qi-G ong P s yc hotic R eac tion Q i-gong is a term des cribing an acute, time-limited characterized by diss ociative, paranoid, or other or nonpsychotic symptoms that may occur after participation in the C hines e folk health-enhancing of qi-gong (meaning exercise of vital energy). vulnerable are individuals who become overly involved the practice. T his diagnosis is included in the C C MD-2.

R ootwork R ootwork is a set of cultural interpretations that as cribe illness to hexing, witchcraft, sorcery, or the evil another pers on. S ymptoms may include generalized anxiety and G I complaints (e.g., naus ea, vomiting, and diarrhea), weakness , dizziness , the fear of being and, s ometimes , the fear of being killed (voodoo R oots, s pells , or hexes can be put or placed on other persons, causing a variety of emotional and problems . T he hexed pers on may even fear death until root has been taken off (eliminated), usually through work of a root doctor (a healer in this tradition), who also be called on to bewitch an enemy. R ootwork is in the southern United S tates among African American E uropean American populations and in C aribbean societies. It is also known as mal pues to or brujeria in 2972 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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societies.

S angue Dormido (S leeping B lood) S angue dormido is found among P ortugues e C ape Is landers (and immigrants from there to the United and includes pain, numbness , tremor, paralys is , convuls ions, s troke, blindness , heart attack, infection, miscarriage.

S henjing S huairuo (Neuras thenia) In C hina, s henjing s huairuo is a condition characterized phys ical and mental fatigue, dizziness , headaches, pains , concentration difficulties , sleep dis turbance, and memory loss . Other symptoms include G I problems, dysfunction, irritability, excitability, and various signs suggesting dis turbance of the autonomic nervous In many cas es, the symptoms would meet the criteria DS M-IV -T R mood or anxiety disorder. T his diagnosis is included in the C C MD-2.

S hen-K 'uei (Taiwan); S henkui S he n-k'ue i or s henkui is a C hinese folk label des cribing marked anxiety or panic s ymptoms with accompanying somatic complaints for which no phys ical cause can be demonstrated. S ymptoms include dizziness , backache, fatigability, general weakness , insomnia, frequent and complaints of s exual dys function (s uch as ejaculation and impotence). S ymptoms are attributed to excess ive s emen loss from frequent intercours e, masturbation, nocturnal emiss ion, or pass ing of white, turbid urine believed to contain semen. E xces sive loss is feared becaus e of the belief that it repres ents 2973 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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loss of one's vital es sence and can thereby be life threatening.

S hin-B yung S hin-byung is a K orean folk label for a s yndrome in initial phas es are characterized by anxiety and somatic complaints (general weaknes s, dizzines s, fear, insomnia, and G I problems ), with subsequent and poss ess ion by ances tral s pirits.

S pell A s pell is a trance s tate in which individuals with deceased relatives or with s pirits. At times , this as sociated with brief periods of personality change. culture-specific s yndrome is seen among African Americans and E uropean Americans from the southern United S tates . S pells are not considered to be medical events in the folk tradition but may be mis construed as ps ychotic epis odes in clinical s ettings .

S us to (Fright or S oul L os s ) S us to is a folk illness prevalent among s ome Latinos in United S tates and among people in Mexico, C entral America, and S outh America. S us to is also referred to es panto, pas mo, tripa ida, pe rdida de l alma, or chibih. is an illnes s attributed to a frightening event that the soul to leave the body and res ults in unhappiness sicknes s. Individuals with s us to also experience strains in key social roles . S ymptoms may appear any from days to years after the fright is experienced. It is believed that, in extreme cases, s us to may result in T ypical symptoms include appetite disturbances , 2974 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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inadequate or exces sive s leep, troubled s leep or feeling of sadnes s, lack of motivation to do anything, feelings of low self-worth or dirtiness . S omatic accompanying s us to include muscle aches and pains , headache, stomachache, and diarrhea. R itual healings focus ed on calling the soul back to the body and the person to restore bodily and s piritual balance. Different experiences of s us to may be related to major depres sive dis order, posttraumatic s tres s disorder and s omatoform disorders . S imilar etiological beliefs symptom configurations are found in many parts of the world.

Taijin K yofus ho T aijin kyofus ho is a culturally distinctive phobia in some ways res embling s ocial phobia in DS M-IV . T his syndrome refers to an individual's intense fear that his her body, its parts, or its functions displease, are offensive to other people in appearance, P.2290 odor, facial express ions, or movements. T his syndrome included in the official J apanese diagnostic s ys tem for mental disorders .

Zar Zar is a general term applied in E thiopia, S omalia, S udan, Iran, and other North African and Middle societies to the experience of spirits poss ess ing an individual. P ersons poss es sed by a s pirit may diss ociative epis odes that may include s houting, hitting the head against a wall, s inging, or weeping. 2975 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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Individuals may s how apathy and withdrawal, refus ing eat or to carry out daily tasks, or may develop a longrelations hip with the poss es sing s pirit. S uch behavior is not considered pathological locally. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > T HE R AP IE

THE R APIE S P art of "27 - C ulture-B ound S yndromes " Much knowledge has accrued about the applications of standard, ps ychoanalytically bas ed psychotherapy to populations and ethnic backgrounds, other than whites Wes tern origin. T o the repeated obs ervation that ethnic communities are accepted for psychotherapy treatment lower rates and drop out earlier than their mainstream counterparts, researchers and clinicians have provided bounty of adaptations ranging from preparations for ps ychotherapy to s ubs tantive framework modifications. T he most daring s tep in this continuum is the development of culture-specific therapies empirically derived from culture-specific behavioral features. J os S zapocznick has, for example, developed and model of family therapy for Miami's C uban families by empirically derived values prevalent in that such as s trong familial affiliation and a preference for hierarchical family s tructures . While encouraging openness to s uch technologies, systems of care s hould establish s tandards and that aim to obtain clinical and functional outcomes 2976 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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equivalent to the mains tream s tate-of-the-art efficacy studies, equally avoiding, promoting, and discouraging particular approaches until unques tionable evidence of efficacy and effectivenes s is developed. C ognitive and cognitive behavior therapies may some modicum of freedom from cultural bias to the degree that cognitive therapists work with the s pecific pathogenic beliefs of the patient, whatever the cultural origin of s uch beliefs. Its application to minority populations experiencing anxiety and depres sive may be an area of promis ing cros s-cultural res earch. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > P S Y C HO P HAR MAC O LO

PS YC HOPHAR MAC OL OGY P art of "27 - C ulture-B ound S yndromes " A rich lode of research findings mus t be codified by systems of ps ychiatric care that aim to improve the practice of ethnic ps ychopharmacology. G uidelines include (1) factual knowledge about differential pharmacogenetics and pharmacodynamics and (2) relational knowledge regarding the impact of giving or withholding medications . E xpectations about the us e of medications , as well as (3) the parallel us e of herbs, which is widespread in many cultures , are by culture-specific beliefs about caus ation of illnes s recovery and may need active inquiry by the clinician. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > S T ANDAR D

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S TANDAR DS P art of "27 - C ulture-B ound S yndromes " Over the las t few decades , largely through the efforts multiple cultural advocacy organizations , there has significant growth of guidelines and standards guide the behavior of clinicians working cross T he efforts of the AP A in addres sing cultural in DS M-IV -T R have already been noted. Its P ractice G uidelines for the P s ychiatric E valuation of Adults als o includes cons iderations for s ociocultural diversity, encourage clinicians to adopt a nonjudgmental attitude toward the patient's culturally mediated explanation of illness and encourage the use of culturally competent cons ultants and the aid of s tructured interviews , questionnaires, and rating s cales, thus incorporating guideline knowledge reviewed earlier about the distortions to which the evaluation of patients through cultural barrier is subject. T he American P s ychological Ass ociation has publis hed own G uidelines for P roviders of P sychological S ervices E thnic, Linguistic, and C ulturally Diverse P opulations , which encourages practitioners to recognize ethnicity culture as s ignificant parameters in unders tanding ps ychological process es and pres cribes an attitude of res pect for client's values and beliefs . P res criptions for cultural competency for systems of care have been compiled by the C hild Development C enter at G eorgetown University and by the Divis ion of Mental Health and S ubstance Abuse of S an F rancisco's 2978 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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Department of P ublic Health, among others. T he Mental Health S ervices has developed a set of C ultural C ompetence S tandards in Managed Health C are for F our Unders erved/Underrepres ented R acial/E thnic G roups . T hese standards are noteworthy including guidelines for all levels of the s ys tem of care: policy making, top and middle management, front-line staff, consumers and their families , and community stakeholders . T he s tandards require the care system's driven awarenes s of community health and mental disparities, invoke explicit demonstration of cultural competence through various as ses sment and es tablis h s pecific targets and benchmarks for outcomes , s uch as improving access to care, benefit design, process of treatment planning, and clinical and functional outcomes of care. It requires culture-specific knowledge of the clinical is sues mos t frequent in the patient's cultural background, such as s ymptom and s ymptom expres sion that are characteristic of the patient's cultural reference groups and the culturesyndromes ass ociated with them. T ools for monitoring cultural competence in health care are als o appearing. A noteworthy example is the to monitor providers' cultural competence, which was developed by the Latino C oalition for a Healthy T he project attempted to define dimensions of culturally competent health care practices through the efforts of culturally competent phys ician panels, s upplemented review of external expert cons ultants . T he project developed s everal tools , s uch as a culturally competent patient satis faction s urvey and a provider s elfsurvey, an instrument intended to be us ed as a guide 2979 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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detect areas of knowledge or s kills in which additional training may be useful to the clinician. In summary, the las t few decades have seen a ris e in the diversity of the U.S . population, with large numbers of monolingual immigrants making their way this country from non-Wes tern countries . Awarenes s regarding immigrant and ethnic minority health is also growing, together with knowledge regarding the broad impact of culture on health and mental health, the specific pathways for this influence through impact on epidemiology, ass ess ment, diagnos is , and treatment. However extensive in theory, and despite increasing availability of s tandards and guidelines that may guide the behavior of ps ychiatric care this body of knowledge is only s lowly making its way to the clinicianpatient interaction. Only a small minority of mental health clinicianpatient interactions taking place the vast health care system of the United S tates are culturally adequate, and a far smaller percentage can said to be culturally competent. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > C ULT UR AL P R O F IC IE NC Y T HE C Y C L E OF C AR E

C UL TUR AL PR OFIC IE NC Y THR OUGH THE C YC LE OF C AR E P art of "27 - C ulture-B ound S yndromes "

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C ulturally compe te nt organizations are defined as that govern the practice of their clinicians through the incorporation into their treatment guidelines of the growing body of evidence made available by cultural res earch. R ogler has developed a conceptual that organizes mental health res earch (in his cas e, for His panics ) into an experimentally valid sequence of that parallel a patient's path while s eeking and an episode of care. In R ogler's framework, research, P.2291 teaching, and other forms of cultural clinical evidence be arranged into five phas es that aim to represent the patient's cours e through the cycle of care, beginning the emergence of the emotional problem (phas e one ), through culturally mediated help-seeking efforts (phas e two), to diagnosis and ass es sment (phas e thre e ). denotes the patient's experience with therapeutic interventions , and the cycle ends (phas e five ) with the patient's reintegration to the community. P sychiatric care organizations would do well to conceptualize their approach to patient care using this framework. T his would allow them to develop a determining and making available to clinicians unique demographic and epidemiological s ervice area characteristics and needs at one end of the cycle one ) and to carefully monitor the clinical and functional outcomes of care at the point of community (phas e five ). T he protection of continuity of care would much des irable by-product of organizing care and about care along the same five-phase continuum. 2981 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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P has e One P roblems, and potential res ponses to them, ass ociated with phase one are summarized in T able 27-1. large portion of alleged ethnic differences in the prevalence of ps ychiatric dis orders disappears when studies are controlled for age, s ocioeconomic s tatus, education, the fact s till remains that some differences remain. African Americans , for example, have been to have a higher 6-month prevalence rate for cognitive impairment, drug abus e, panic attacks , and phobias whites or His panics.

Table 27-1 Phas e One: of Mental Health Problems Minority Population C harac teris tic s

Potential Mental S ys tem Approac hes

Demographics as sociated with increased ris k

P opulation-based approaches to case finding: primary prevention

Inferred increas ed incidence, and level of

E arly cas e finding, immediate identification through linkages : 2982

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primary health sources Migration-induced s tres s    V ia loss of status

Outreach to immigrant social s ervices system

   V ia loss of support

 

   Acculturation

Acculturation therapy

B ecaus e of the impact of advers e s ocioeconomic conditions, such as poverty, employment difficulties , immigration status, ethnic communities have demographic features as sociated with increased ris ks . Dohrenwend and others have demons trated that the of all ps ychiatric dis orders in the lowest s ocioeconomic levels is approximately 2.5 times the rate in the highest level. T his 2.5-to-1.0 relationship extends beyond diagnostic categories to basic dimensions of mental health, such as anxiety, depress ion, self-es teem, and functional adaptation. S ys tems of care s erving such high-ris k populations ongoing process es for determining unique communitybased needs. F or this purpos e, they ought to use all available methodologies, such as health and s ocial databases , community forums , and available epidemiological data. T hes e data can guide proactive population-based approaches to cas e finding, early 2983 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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identification, and, pos sibly, prevention efforts,

P has e Two Help-seeking behavior, after an individual experiences mental health problem, is a proces s s ubject to great culturally based differences. T hresholds for pain and dysfunction, tolerance for deviations from norms, perceptions of s tigma, and availability of alternative res ources to cope with ps ychological distress shape when and where of the process of help-seeking cons ultation. Help-seeking factors may affect the us e mental health services by minorities. Hispanics, for example, have been found to underus e outpatient ps ychiatric programs and nonpublic psychiatric while having high rates of us e of public inpatient Data on African American patients s how a disproportionately high rate of admis sion to all types of inpatient facilities . T hese patients may enter health treatment s ervices at later s tages in the cours e of their illness than their white counterparts. T able 27-2 s hows reported use trends for ethnic and potential approaches to counter the negative effects of existing use and continuity patterns. competent systems of care need to develop policies track use patterns , addres s its dis parities when found, aim to obtain clinical and functional outcomes as clos e poss ible to thos e reported by s tate-of-the-art efficacy studies. T he working group on C ultural C ompetence in Managed Mental Health C are includes among its for cultural competence for managed care the following:

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Table 27-2 Phas e Two: HelpS eeking B ehavior Minority Population C harac teris tic s

Mental Health S ys tem

Underus e of mental programs in outpatient and private psychiatric services

P rimary prevention, outreach program

 

Links with primary care providers

Overuse of public inpatient services

F amily ps ychoeducation programs

   Alternative resource theory

Integration of folk healing s ys tems

      F amily

P sychoeducation

      F olk healer network

User-friendly intake systemflexible appointments

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   B arrier theory

 

      C ultural: health

C ommunity-based, culturally s yntonic services

      B elief systems

 

      Ins titutional barriers

Use of bilingual, bicultural s taff

T he Health P lan s hall develop maintain a database which s hall track utilization and outcomes the four groups across all levels care, ensuring comparability of benefits, acces s, and outcomes. T he Health P lan s hall also and manage databases of social and mental health indicators on the covered population for the four groups and the community large.

P has e Three T he cultural challenges of ass es sing patients across language and cultural barriers have been discus sed at 2986 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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length earlier. B ecaus e of the robus tnes s of the findings and the importance of adequate diagnos is and as sess ment to treatment planning and care outcomes , area is mature for vigorous interventions by culturally competent health care organizations . At a minimum, ethnic minority client should have a cultural formulation completed as part of the intake ass es sment. Agencies should also es tablish guidelines covering the us e of ps ychological tes ting of language and acculturation as sess ment and a process of differential diagnosis that encourages explicit cons ideration of culturally idioms of distress and culture-bound syndromes . T able 3 lists the res earch evidence and potential approaches correct detected dis tortions .

Table 27-3 Phas e Three: Mental Health As s es s ment R es earch Findings

C ulturally C ompetent Approac hes

P sychological tes ting bias

Use of trans lated and validated instruments

P rojective tes ting bias

C orrection of bias 2987

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C linical ass es sment of ps ychopathology

S ys tematic language as sess ment

 

S ys tematic acculturation as sess ment

   Increas ed mis diagnos is

Ins titutional knowledge about as sess ment problems

   Increas ed ascription of ps ychopathology

 

Use of revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs cultural approach

 

 

   Differential diagnosis for culture-bound syndromes

 

   S ystematic us e cultural formation

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P has e F our High attrition rates after the initial therapeutic contacts have been repeatedly reported for His panics , As ians , African Americans, rais ing many questions about the appropriatenes s of traditional ps ychotherapeutic for thes e populations and about the effectiveness of standard application. In respons e to this s ituation, res earchers have devis ed multiple strategies ranging efforts to provide a few preparations for ps ychotherapy sess ions and culturally derived modifications of the ps ychotherapeutic frame to the development of syntonic therapies . Many pres criptions are als o available in the clinical and res earch literature for the integration into mainstream treatments P.2292 of the patient's native concepts of illness , as well as healing practices. Agencies providing s ervices to s ignificant numbers of ethnic minority patients need to develop guidelines for their therapy process to direct clinicians as to when how to integrate folk therapies into their treatment. decis ions need to be mediated by the ongoing of the patient's language competence, acculturation status , and voiced preference.

P has e F ive T he patient's reintegration into his or her community of origin is the ideal outcome of treatment and a main of the community ps ychiatry movement. T he ideal is 2989 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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unfortunately obs erved more in the breach than in the fulfillment. Disruptions to the continuity of care are overwhelming to mainstream and minority populations . Little, if any, systematic data exis t regarding ethnic minority indicators of reintegration success , s uch as rehospitalization rates and rates of resumption of personal, or profes sional role s tatus . P s ychiatric care organizations need to take the lead in developing benchmarks and encouraging s trategies of aggress ive outreach. T able 27-4 s pells out iss ues that need to be cons idered cross -cultural practice and res earch. Access to participation in specialized psychiatric and services ought to be emphasized to counter the of many minority patients to s eek services provided in strictly medical s etting and on a sporadic bas is rather in a mental health s etting on a continuous bas is .

Table 27-4 Phas e Five: Pos ttreatment Adjus tment and C ommunity R eintegration R es earch Findings

C ulturally C ompetent Approac hes

R ehospitalization rates

C ulturally realistic 2990

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discharge planning Difficulty in ass umption of community, family, work role functions , as function of sociodemographic status

   Network involvement

 

   F amily involvement

 

   E xtensive use of ps ychoeducation

 

   E ducation to continuous rather than periodic use of health care

Network functioning (s mall, clos e increas ed for rehos pitalization)

 

E xpres sed emotionrole of ps ychoeducation

Motivate family

 

Maintain contact with folk network

Low use of pos ttreatment services

User-friendly, community-based

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services    B arrier theory, health services

 

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > S UG G E S T E D C R O S S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "27 - C ulture-B ound S yndromes " P opulation genetics is covered in S ection 1.17, and mental health in S ection 3.7, and anthropology and cultural psychiatry in S ection 4.1. C linical ps ychiatric disorders are covered in C hapter 8. International psychiatric diagnos is is dis cus sed in 9.2. C ulture-bound syndromes with ps ychotic features covered in S ection 12.16f. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 27 - C ulture-B ound S yndromes > R E F E R E NC

R E FE R E NC E S American Medical Ass ociation. C ultural C ompetence 2992 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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C ompendium. C hicago, 1999. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. Was hington, DC : American P sychiatric As sociation; 1994. American P s ychiatric Ass ociation. American Ass ociation practice guidelines for the psychiatric evaluation of adults . Am J P s ychiatry. 1995;152 [S uppl]:6578. *American P s ychological Ass ociation. American P sychological As sociation G uidelines for the of psychological services to ethnic, linguis tic, divers e population. Am P s ychol. 1993;48:4548. B elkin G S : Hard ques tions in court: C ulture and ps ychiatry on trial. C ult Me d P s ychiatry. B hugra D, Mas trogianni A, Maharajh H, Harvey S : P revalence of bulimic behaviours and eating in schoolgirls from T rinidad and B arbados . P s ychiatry. 2003;40:408428. *B luestone H, V ela R M: T rans cultural as pects in the ps ychotherapy of the P uerto R ican poor in New Y ork C ity. J Am Acad P s ychoanal. 1982;10:269. C alifornia Mental Health Directors Ass ociation. C ompete ncy G oals , S trate gie s and S tandards for Health C are to E thnic C lients . S acramento, C A: 2993 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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Mental Health Directors Ass ociation; 1995. C omas-Diaz L. C linical G uide line s in C ros s -C ultural Health. New Y ork: W iley; 1988. C ons tantino G , Malgady R G , R ogler LH. T e chnical Manual: T he T E MAS T e s t. Los Angeles: Wes tern P sychological S ervices; 1988. C ons tantino G , Malgady R G , R ogler LH, T s ui E : Dis criminant analys is of clinical outpatient and public school children by T E MAS . A thematic apperception tes t for His panics and B lacks. J P e rs As s e s s . 1988;52:670678. C ros s T L. T owards a C ulturally C ompe tent S ys te m Was hington, DC : T echnical As sistance C enter. G eorgetown University C hild Development C enter; 1989. C ultural C ompe te nce S tandards in Manage d Me ntal Health C are for F our Unde rs e rve d/Unde rre pre s ente d/R acial/E thnic C enter for Mental Health S ervices ; 1997. Del C astillo J : T he influence of language upon symptomatology in foreign-born patients. Am J P s ychiatry. 1970;127:242244. *Derogatis LR , C ovi L, Lipman R S : S ocial class and as mediator variables in neurotic s ymptomatology. G e n P s ychiatry. 1971;25:3140. 2994 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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Dohrenwend B P , Dohrenwend B S , G ould MS , Link Neugebauer R , W uns ch-Hitzig R . Me ntal Illne s s in Unite d S tates . New Y ork: P reeger; 1980. E scobar J I: Immigration and mental health: W hy are immigrants better off? Arch G e n P s ychiatry. F aison W E , Arms trong D: C ultural aspects of in the elderly. J G e riatric P s ychiatry Ne urol. 2003;16:225231. G aw A, ed. C ulture, E thnicity and Mental Illne s s . Was hington, DC : American P sychiatric P res s; 1993. G uarnaccia P , R ogler HL: R esearch on culturesyndromes: new directions. Am J P s ychiatry. 1999;156:13221327. K eel P K , K lump K L: Are eating dis orders culturesyndromes? Implications for conceptualizing their etiology. P s ychological B ull. 2003;129:747769. K leinman A. R ethinking P s ychiatry: F rom C ultural C ate gory to P e rs onal E xperie nce . New Y ork: F ree 1988. Marcos LR , Alpert M, Urcuyo L, K es selman M: T he of interview language on the evaluation of ps ychopathology in S panis h-American patients. Am J P s ychiatry. 1973;130:549553. Marcos LR , T rujillo M. C ulture, language and 2995 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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communicative behavior: T he psychiatric of S panish Americans. In: Duran R P , ed. L atino and C ommunicative B e havior. Norwood, NJ : Ablex P ublis hing; 1981. Mezzich J E , K leinman A, F abrega H, B arron DL, C ulture and P s ychiatric Diagnos is : A DS M-IV Was hington, DC : American P s ychiatric P res s; 1996. P arzen MD: T owards a culture-bound insanity defens e? C ult Me d P s ychiatry. R egier DA, Myers J K , K ramer M: T he NIMH E pidemiological C atchment Area P rogram. Arch P s ychiatry. 1984;91:934941. R ogler LH, Malgady R G , R odriguez O. His panics Me ntal H ealth: A F rame work for R es e arch. Malabar, R obert E . K rieger P ublishing C ompany; 1989. R uiz P . C ros s -cultural psychiatry. In: Oldham J , R iba eds. Annual R evie w of P s ychiatry. V ol 14. DC : American P s ychiatric P res s; 1995. R uiz P , ed. E thnicity and P s ychopharmacology. Was hington, DC : American P sychiatric P res s; 2000. S imons R C , Hughes C C , eds . T he C ulture -B ound S yndromes . Dordrecht, the Netherlands : R eidel P ublis hing C ompany; 1985. S zapocznick J , S copetta MA, K ing OE : T heory and 2996 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/27.htm

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practice in matching treatment to the s pecial characteristics and problems of C uban immigrants . J C ommunity P s ychol. 1978;6:112. *T irado M. T ools for Monitoring C ultural Health C are . S an F rancisco, C A: Latino C oalition for Healthy C alifornia. T rujillo M. C ultural P sychiatry. In: S adock B J , eds. K aplan and S adock's C ompre hens ive T e xtbook P s ychiatry. 7th ed. P hiladelphia, P A: Lippincott & W ilkins ; 2000. Wes termeyer J : T wo self-rating scales for among H-mong refugees: Ass ess ment in clinical non-clinical s amples . J P s ychiatr R es . *Y ee T T . G e ne ral P rinciple s for Des igning and C ulturally C ompe te nt P rograms . S an F rancisco, C A: Department of P ublic Health. Divis ion of Mental and S ubstance Abus e; 1993. Zung W F : A s elf-rating depress ion scale. Arch G e n P s ychiatry. 1975;12:6370.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 28 - S pecial Areas of Interes t > 28.1: P s ychiatry and Medicine

28.1: Ps yc hiatry and R eproduc tive Medic ine S arah L . B erga M.D. B arbara L . Parry M.D. J ill M. C yranows ki Ph.D. P art of "28 - S pecial Areas of Interes t" T he phys iological proces ses as sociated with mens trual cycling, pregnancy, postpartum, and menopaus e occur within the context of a woman's ps ychological and interpersonal life, interfacing with ps ychos ocial functioning throughout adolescence, adulthood, midlife, and late life. R eproductive events proces ses have both phys iological and ps ychological concomitants. T he fields of ps ychiatry and reproductive medicine are jus t beginning to elaborate the multiple mechanisms by which psyche and s oma interact to determine a woman's gynecological and psychological function. F or instance, premenstrual dys phoric mood, cognitive, and behavioral changes that occur in as sociation with the menstrual cycleexemplifies a somatops ychic disorder in which biological changes occurring in the s oma trigger changes in ps ychological state. In contrast, functional forms of hypothalamic anovulation repres ent a ps ychos omatic illness that originates in the brain but alters s omatic functioning. 2998 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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Unfortunately, traditional medicine s eparates the treatment of reproductive events and proces ses from of psychological functioning. T his imposed dichotomy between mind and body undermines the unders tanding and treatment of both reproductive and ps ychiatric dysfunction in women. F or example, postpubertal are approximately twice as likely as men are to major depress ion, with depres sion rates peaking during female reproductive years. Y et, few obs tetricians in the United S tates routinely screen for depress ion among patients. Hence, depres sion during pregnancy and the postpartum period often goes unidentified and undertreatedleading to negative cons equences for both the woman and her children. In keeping with a biops ychosocial model, this chapter highlights the bidirectional interactions between psyche and s oma related to women's reproductive functioning. T aking a developmental approach, key concepts about reproductive physiologyranging from early sexual differentiation to menstrual phys iology and gonadal cess ation ass ociated with menopauseare incorporated each section. T he overall aim is to illustrate how the interaction between reproductive process es and ps ychos ocial events manifests as ps ychiatric or gynecological dis orders and how recognition of these interactions can improve our approach to both gynecological and ps ychiatric treatments.

R E P R ODUC TIVE DE VE L OP ME NT Fetal and Neonatal Development T he sex of an embryo is determined during the 2999 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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proces s. T he normal chromos omal contribution of the oocyte (egg) is 23 (including an X chromos ome), and sperm contributes 23 (including an X or a Y T he translation of gonadal sex into phenotypic sex depends directly on the type and s ecretory activity of gonad formed and on the res ponsiveness of target in the developing fetus to gonadal products . T he fetal tes tes begin to s ecrete tes tos terone and mllerianinhibiting s ubs tance (MIS ) toward the end of the firs t trimes ter. If s ecretion is absent or compromis ed or if fetal tiss ues are androgen insensitive, a spectrum of incomplete mas culinization ensues. Also, excess expos ure at this time from maternal or fetal s ources , as occurs in fetal congenital adrenal hyperplasia, can partially masculinize a female fetus. S exual differentiation of the central nervous system is believed to depend on the presence or absence of circulating levels of testosterone. T he fetal testes begin secrete testosterone in the late firs t trimes ter in to placental human chorionic gonadotropin (hC G ), whereas the fetal ovary does not. T he organizational effects of tes tos terone on the developing C NS are to depend primarily on in situ aromatization (the conversion of androgens to estrogens by the enzyme aromatase) of testosterone to es tradiol. In contras t, es trogens from fetal or placental sources do not cross bloodbrain barrier and are not thought to imprint the developing C NS . Also, testosterone may bind directly (without convers ion to estradiol) to androgen receptors the C NS . T he behavioral consequences that early to testosterone have on the developing brain are not but gender asymmetries may reflect central 3000 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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key brain areas with high aromatas e activity (which, can convert testosterone to estradiol) and those with androgen receptors . In the nonhuman primate brain, androgen receptors are located in the hypothalamus, amygdala, and prefrontal vis ual and somatosens ory cortices . T he as ymmetry in exposure to tes tos terone present in early neonatal life. In late pregnancy, gonadotropin s ecretion is res trained by placental production; when that res traint is lost at the time of gonadotropin s ecretion ris es dramatically in both boys , but not in girls , the gonadotropin rise is followed an elevation of testosterone concentrations to adult T hus, by 2 years of age, the brains and bodies of girls boys have been expos ed to dramatically different of sex s teroid s ecretion. T he degree to which genderrelated behavioral as ymmetries are accounted for by differences in hormone exposure is open to debate, clearly, a mechanism for inducing differences exists . In summary, the fetal s ex steroid exposures exert organizational effects on the fetal C NS .

Puberty In humans , the postnatal gonadal hiatus involves the desynchronization and suppres sion of the gonadotropin-releas ing hormone (G nR H) puls e by undetermined central mechanis ms that are largely gonad independent. P uberty, the pos tnatal P.2294 res umption of gonadal activity, is also a centrally proces s that depends on synchronization of the releas e of hypothalamic G nR H. G nR H neurons are 3001 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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endogenously puls atile and active during fetal and neonatal life. In experimental conditions with primates , entire pubertal proces s can be initiated and completed simply by providing exogenous puls es of G nR H or by stimulating the dormant G nR H neurons with excitatory amino acids . Although prenatal exposure to sex has organizational effects on the developing brain, the reinitiation of gonadal activity during puberty is viewed exerting primarily activational influences on the brain behavior. R ecent neuroimaging data s uggest, however, that there are further s exually dimorphic organizational effects as well.

Gender T he phenotypic s ex of an individual depends on chromosomal s ex and on expos ure and target tiss ues to endogenous and exogenous s ex G e nde r refers to the s elf-image and sex-role identity of person. G ender is determined not only by exposure res ponsiveness to sex s teroids, but als o by and behavioral patterns that are learned in early from parental, familial, and s ocietal models. G ender develops acros s the life cycle in respons e to and biological life events . Notions of gender direct career, and other behavioral choices and may depart biological options . F or example, a woman with mlle rian age ne s is has ovaries but no uterus and vagina. Her childbearing and sexual options are cons trained biologically, yet her sens e of gender-appropriate may drive her to purs ue a heteros exual relations hip motherhood via s urgical and technological advances. Although gender is influenced by cultural expectations, 3002 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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each individual understands and res ponds to these expectations differently. T o s afeguard gender development, ps ychiatris ts and psychologis ts mus t unders tand the medical and technological options available to individuals with dis orders that alter phenotypic s exual development, and pediatricians , internists , and gynecologists must be mindful of the ps ychological effects of thes e dis orders . Honesty is important, but physicians mus t convey information in a sens itive fashion. T he clinical objective is to maintain a flexible minds et to facilitate and s upport appropriate developmental choices. Dis orders of sexual development in phenotypic girls generally present at birth or at the time of expected puberty. Adre noge nital s yndrome can be caus ed by congenital adrenal hyperplas ia in female fetus es ; the adrenal secretes exces s androgens , which then masculinize the external genitalia and, pos sibly, the In female infants, the mas culinized genitalia are usually recognized in the delivery room. S urgery to reduce size and create or widen the vaginal introitus may be neces sary at a later date to restore the external appearance. However, the internal reproductive tract is normal, and puberty generally occurs around the time if adrenal replacement therapy is adequate. medical and surgical interventions, concerns over for sexual function may emerge, particularly in late adoles cence or young adulthood. T urner's s yndrome (XO gonadal dys genesis) may be recognized at birth becaus e of the ass ociated phys ical stigmata, whereas XX gonadal dysgenes is us ually at puberty. F rom a reproductive pers pective, the two 3003 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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conditions are similar in that the ovaries do not contain res ponsive oocytes due to premature atres ia of failure of germ cell migration. Donor oocytes allow the option of pregnancy. Other dis orders of sexual development include feminization and its variants , in which the gonads are tes tes , but the fetus is phenotypically female because a defect in the androgen receptor confers androgen insensitivity. B ecaus e the testes are normal, they MIS and mlle rian re gre s s ion (regres sion of the anlage would develop into the uterus and tubes) occurs. T he vagina ends blindly, and the presenting complaint is us ually primary amenorrhea. T he larche (onset of development) occurs at the normal time becaus e, at puberty, the testes s ecrete testosterone, which then is aromatized to es tradiol, which s timulates the growth of breast tis sue. Orchiectomy (removal of the testes) is recommended after puberty to avoid the risk of gonadoblastoma, unless there is partial androgen sens itivity, in which case it is performed earlier to the pubertal development of hirs utis m and partial masculinization. T here are many types of androgen receptor defects spectrum of clinical presentations . S ome individuals phenotypically like men and may present with infertility secondary to azoos permia or oligospermia. A related disorder occurs when there is an inefficiency of the enzyme 5-α-reductase, which converts tes tos terone to dihydrotes tos terone (DHT ); DHT is required for full masculinization of the external genitalia. B oys with a deficiency of that enzyme may look phenotypically or incompletely masculinized at birth. At puberty, 3004 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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masculinization, including phallic enlargement, may develop as the increased tes ticular s ecretion of tes tos terone partially overcomes the enzyme and more dihydrotestosterone is made. F ertility is preserved in this condition, so it is prudent to rear the as a male if pos sible. Neonatal treatment with dihydrotes tos terone may help to masculinize the genitalia. X Y gonadal dys gene s is is caus ed by a s treak gonad to secrete tes tos terone and MIS generally, the uterus, tubes , and vagina are pres ent. T his condition is when thelarche and menarche do not occur. A can confirm the XY chromos omal status. B ecause the gonads are inactive hormonally, they should be before puberty to avoid the risk of malignant degeneration. E xogenous hormone replacement is required to stimulate puberty and cause the of s econdary s exual characteris tics. If donor oocytes available, pregnancy is poss ible after in vitro and embryo transfer. T elling a young adolescent and parents about the diagnos is can be difficult, but it is to be honest, particularly because surgery will be to remove the gonads. A clinician who deals with patients with disorders of development must have a clear unders tanding of the phys iology of s exual differentiation, including that of the brain, as well as a sensitive perspective on the among gender, sexuality, and reproductive capacity.

E arly S exuality T he behavior of children can be understood by acknowledging the s exual motivations that, until 3005 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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F reud's time, had been ass umed to be quies cent until adoles cence. T he fact that incest, sexual abus e, and sexual taboos that may occur in childhood have aftereffects , even in adult life, bespeaks the importance childhood s exuality in establis hing healthy In puberty, the overriding influence on s exuality is the dramatic change in the hypothalamic-pituitary-gonadal axis that occurs in both males and females at that time. Major hormonal changes , combined with the iss ue of identity diffusion, contribute to the characteristic in relationships , particularly between male and female peers and between adolescents and their parents. In adulthood, one of the major indicators of maturity is capacity to establish healthy s exual relations hips. is in harmony with other components of the s elf and others , sexuality is an integral component of the adult character.

Adoles c enc e C arol G illigan noted in her longitudinal studies of girls before and during adoles cence that there appears to marked decline in s elf-es teem occurring after puberty. P readolescent girls exhibit a s ens e of self-confidence belief that they can influence the course of events in lives . During adolescence, that s elf-es teem and belief their own efficacy appear to diminis h. Adolescent girls generally expres s less confidence in their abilities to P.2295 change the world around them, accompanied by a of intimidation and pas siveness . 3006 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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B efore puberty, boys are more vulnerable than girls are depres sive illnes s. Over the cours e of adoles cence, however, a dramatic shift occurs, with girls displaying a precipitous rise in depress ion rates that far outstrips negligible (if exis tent) increas e displayed by adoles cent boys . B y age 15, girls are twice as likely as boys are to experienced a lifetime epis ode of major depres sion. gender difference pers ists for the next 35 to 40 years , es sentially spanning female reproductive years . T he predominance of depres sion in women and the adoles cent onset of this gender difference have now replicated cross -nationally. Indeed, the gender in lifetime rates of major depres sive disorder is to be one of the most robus t findings in the field of ps ychiatric epidemiology. Negative life events and chronic ps ychos ocial stress ors known to place individuals at risk for major depres sive episodes . A number of theories about the gender difference in depress ion point to the fact that women more likely than men are to experience certain types of traumatic life events, s uch as phys ical or sexual abus e, chronic life stress ors, such as s ingle parenthood, discrimination in the workplace, or financial adversity. general, however, such theories fail to account for the adoles cent onset of the gender difference in Indeed, growing evidence indicates that puberty may sens itize girls to the depress ogenic effects of life S pecifically, postpubertal women appear to be at heightened ris k for experiencing depres sion when with social s tres sors , s uch as conflicts, breaches , or within interpersonal relationships . R ecent theories have s ought to explicate pertinent 3007 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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biological and ps ychosocial factors that may interact to sens itize women to the depres sogenic effects of interpersonal life stress . Men and women tend to different interpersonal goals and pers onal s elf-views. Women tend to focus on relations hip intimacy and, thereby, to develop a strong affiliative style in their relations hips , as well as a sense of s elf in connection others . Men, in contrast, tend to focus on is sues of individuation and ass ertiveness within s ocial and to develop an agenic and autonomous s ens e of T he proces s of gender role development is likely the res ult of interactive biological and social process es . Although gender role socialization may begin well puberty, s ocial pres sures to conform to stereotypically feminine vers us masculine gender roles likely intensify during the adoles cent transition, as the development of secondary s ex characteris tics make adolescents look like adults and they begin to engage in greater levels of cross -sex interaction and dating. Importantly, hormonal changes in the reproductive neuroendocrine axis at puberty may potentiate and interact with this proces s to promote an adoles cent intensification of gender-based behaviors . S ome have s peculated that increase in testosterone in boys and the attendant aggres siveness , often directed at girls, contribute to a change in girls ' behavior during adoles cence. A large proportion of s elf-es teem in girls tends to be based on sens e of fulfillment in relationships , whereas s elfboys is largely attributable to a s ens e of achievement work, activities , and sports . T herefore, changes in relations hips between the sexes during adoles cence affect girls and boys differently and have different 3008 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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cons equences for their mental health. T he need in dominance in relations hips, precipitated by surges in tes tos terone at puberty, may contribute to, and be a prerequisite for, a sense of s elf-es teem and s elf-worth. contrast, pas sivity in girls relative to this dominance in boys may be required to maintain the relations hip, is girls' major source of self-es teem. T hus , changes in reproductive neuroendocrine axis in girls and boys at puberty may s et the s tage for alterations in the power balance of relations hips , which may affect the pers on's sens e of self, s elf-es teem, and mental health. in a s tudy of hormone replacement given to adoles cent boys and girls with delayed puberty, testosterone precipitated aggress ion in boys, whereas es trogen provoked aggress ion in girls. T his finding would that es trogen, per s e, is unlikely to be the cause of the increased depres sion and loss of self-es teem observed adoles cent girls . However, thes e researchers also that, whereas tes tos terone treatment was related to perceptions of athletic abilities in boys , es trogen was related to s elf-perceptions of romantic appeal and clos e friends hips in girls . Neurohormonal process es ass ociated with regulated by female reproductive hormones may contribute to the intensification of affiliative behaviors observed in girls at puberty. R ecent theories have implicated the hypothalamic neurohormone oxytocin in facilitating such affiliative behaviors as maternal and adult pair-bond formation in mammalian females. Oxytocin is known to s timulate s uch female functions as milk ejection during lactation and uterine contractions at parturition and appears to be critically 3009 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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regulated by estrogen and proges terone. S . E . T aylor et al. have argued that the oxytocincaregiving s ys tem may lie at the core of a uniquely biobehavioral res ponse to s tres s. F or decades , the flight res pons e has been regarded as the prototypic of the human s tres s respons e. His torically, however, a majority of exis ting human res earch examining the neuroendocrine parameters of the fight-or-flight has been bas ed on s tudies of men, largely because of unknown and potentially confounding effects of cyclic variations in female reproductive hormones on neurohormonal stress res pons es . T hese res earchers propos ed the exis tence of a uniquely female respons e stress , which they have termed the te nd-and-be frie nd re s pons e . B ecause mammalian females typically bear greater role in the care and protection of young res ponses to stress that promote fighting or fleeing via sympathetic and hypothalamic-pituitary-adrenal (HP A) activation may not be the most adaptive. F or example, such a fight-or-flight res pons e may be compromised by female reproductive roles (e.g., pregnancy) and may endanger the s afety of offs pring under her care (e.g., a fleeing res ponse that res ults in the abandonment of defens eless offspring). Ins tead of fighting or fleeing, quieting and tending to the needs of offspring when under s tres s and affiliating with other adults to promote the protection of ones elf and one's offs pring may represent a more adaptive female res pons e to environmental threats . B ehavioral evidence in humans supports gender-linked differences in affiliation and, specifically, affiliation under conditions of s tres s. T aylor et al. posit that the biobehavioral mechanism 3010 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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behind the tend-and-befriend res ponse is bas ed on the oxytocin-mediated caregiving system that, for women, serves to decrease sympathetic and HP A respons es to stress , while s imultaneous ly promoting affiliative res ponses . T he concept of a uniquely female res ponse to s tres s would have broad implications for unders tanding of s tres s sensitivity, stress res ponses , ris k of ps ychopathology in women. F urther research is needed, however, to test this provocative model.

ME NS TR UA L C YC L E S Mens trual Phys iology Mens trual cyclicity res ults directly from ovarian E ach ovarian cycle starts with the development of a or cohort of follicles , one of which becomes dominant. follicles are composed of an oocyte surrounded by granulosa cells , which, in turn, are s urrounded by theca cells . As shown at the top of F igure 28.1-1, follicular development is initiated by the hypothalamic release of G nR H at a puls e frequency P.2296 of approximately one pulse every 90 minutes . G nR H stimulates the release of the pituitary gonadotropins, luteinizing hormone (LH), and follicle-stimulating (F S H). In turn, LH s timulates ovarian theca cells to synthes ize and secrete androgens ; F S H induces cell development, including the enzyme aromatase, converts the thecally produced androgens to the presence of a constant G nR H pulse frequency of 3011 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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pulse each 90 minutes , the secretion of LH and F S H in follicular phase will be regulated primarily by es tradiol feedback at the level of the pituitary. R ising es tradiol concentrations s uppres s F S H, thereby limiting the of follicles that become mature oocytes capable of ovulating.

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FIGUR E 28.1-1 S chematization of the human mens trual cycle. E 2, es tradiol; F S H, follicle-stimulating hormone; G nR H, gonadotropin-releas ing hormone; LH, luteinizing 3013 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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hormone; P , proges terone. As illustrated in the middle panel of F igure 28.1-1, es tradiol concentrations ris e exponentially to exceed a critical thres hold and remain elevated for at least 36 which is the pattern one fully mature follicle produces , LH s urge is triggered and ovulation (releas e of the from the follicle sac) ensues approximately 36 hours T hereafter, granulos a cells transform into secreting luteal cells , and the ovulated follicle, then, is referred to as the corpus luteum, which secretes proges terone. F igure 28.1-1 displays the levels of LH, F S H, es tradiol, proges terone throughout the menstrual cycle and corres ponding follicular events. T he target tis sues for ovarian s teroids include the endometrium, whos e developmental s equence is illustrated along the bottom panel, and the hypothalamic G nR H puls e generator, frequency, as indicated in the top right panel, is s lowed dramatically by the combination of estrogen and proges terone s ecreted during the postovulatory or phase of the mens trual cycle. T his inhibition of G nR H followed by decreased secretion of LH and F S H s o that new follicular development is prevented until the luteum regres ses . As proges terone concentrations G nR H pulsatility increas es , and gonadotropin, F S H, s ecretion rises . T he phases of the mens trual be termed follicular and luteal in reference to ovarian events or prolife rative and s e cre tory in reference to endometrial events. 3014 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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It is generally ass umed that regular mens trual cyclicity intervals of 25 to 40 days s ignals ovarian cyclicity and ovulation, but, as illus trated in F igure 28.1-2, that as sumption is erroneous. A normal luteal phase has a length of more than 11 days and midluteal of progesterone secretion that exceed 10 ng/mL (30 nmol/L). T he woman whose hormonal levels across a mens trual cycle are depicted in the bottom two panels F igure 28.1-2 had a 39-day cycle. However, this cycle luteal phase whos e adequacy, with a length of 16 days a peak progesterone concentration of 19.1 ng/mL, be doubted. In contras t, the woman whose hormonal concentrations are s hown in the top two panels had an overall cycle length of 25 days. Although her estradiol levels rose to almost 300 pg/mL, the elevation in and LH was not followed by a rise in proges terone secretion. T hus, she had bleeding when her es tradiol concentration fell, but the cycle was anovulatory.

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FIGUR E 28.1-2 Daily concentrations of luteinizing 3016 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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hormone (LH), estradiol (E 2), and proges terone (P ) obtained in two women from the ons et of one epis ode mens trual bleeding to the next. As thes e examples demons trate, mens es and cycle interval cannot be us ed to determine if a woman is not ovulatory or if the luteal phas e was normal. T he clinician who is linking a P.2297 ps ychological state to a reproductive event must know how to determine the pres ence or abs ence of gonadal activity. Ovarian activity can be es timated by weekly es tradiol and progesterone concentrations from the ons et of one epis ode of mens trual bleeding to the next. T esticular activity can be es timated from one or random determinations of testosterone. T hes e as sess ments may not detect subtle compromise of gonadal function that may impair fertility, however, and further cons ultation with an appropriate specialist may needed. Mens trual cycles can be expected to become more regular with advancing gynecological age (time since first menses ) and, in the absence of pathology, generally remain regular until 5 to 10 years before menopaus e. During the perimenopausal years , ovarian function is characterized by higher es tradiol and lower proges terone s ecretion. Ovarian function does not gradually decline but rather becomes erratic and unpredictable, with the potential for exposing the brain and s oma to large fluctuations in hormone 3017 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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Premens trual S yndrome P remens trual s yndrome and the related condition, pre me ns trual dys phoric dis orde r, are s omatops ychic conditions that occur in res ponse to the expected fluctuations in sex s teroids as sociated with ovulatory mens trual cycles. P remens trual syndrome and premenstrual dys phoric dis order are not viewed by all identical disorders . P remenstrual dys phoric dis order is listed as a diagnos tic category for further s tudy in the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ). T hes e changes disturb psychological functioning in women. In contrast, functional hypothalamic arises in the ps yche and affects the s oma. In dysphoric disorder, menstrual cycles are hormonally normal, and the s oma is preserved at the expense of ps yche. F rom an evolutionary perspective, women are accustomed to periodic pregnancy and lactation. T here may be unappreciated physical and emotional cons equences from inces sant ovulation; recurrent hormonal periodicity may trigger mood dis orders in women with predis pos ing inherent vulnerabilities .

Func tional Hypothalamic F unctional hypothalamic anovulation or amenorrhe a is cons equence of a nonorganic reduction in G nR H that res ults in reduced pituitary secretion of gonadotropins and s ubs equent anovulation. P reviously referred to as idiopathic or ps ychoge nic amenorrhe a in ps ychiatric literature, functional hypothalamic is a diagnos is of exclus ion. T his implies that the capable of res ponding to appropriate gonadotropin 3018 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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of either endogenous or exogenous origin; that there no structural abnormalities of the thyroid, adrenal, pituitary, or brain; that the use of drugs , including antips ychotic medications , does not account for the suppress ion of G nR H; and that the patient is not Neuroimaging may be needed to es tablis h that there no s ignificant anatomical lesions of the brain or T wo major questions concerning the pathogenesis of functional hypothalamic anovulation remain F irst, the peripheral and central s ignals that disrupt pulsatility are poorly understood. S econd, how do behavioral, cognitive, and personality variables activate the neural systems to disrupt G nR H s ecretion? and patients alike wonder what lifes tyle variables or contribute to this type of ovulatory dysfunction and what pharmacological and nonpharmacological interventions should be considered. T he idea that psychogenic stress can induce dysfunction in women was formally introduced in 1946. T he best biochemical evidence in support of the that s tres s impairs G nR H release in women with hypothalamic amenorrhea is the consistent that the activity of the HP A axis is increas ed. F or prospective study found that young American women who developed trans ient amenorrhea while s tudying in Is rael had higher urinary cortisol concentrations on than did thos e whose menses remained regular. T here appears to be a doserespons e relations hip the type, s everity, and number of stress es on one hand the proportion of women who develop anovulation on other hand. B iological and ps ychological may confer resis tance or s ens itivity to various 3019 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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E xercise, low weight and weight loss , affective and disorders , various personality characteris tics s uch as perfectionism and unrealis tic expectations , drug use, variety of external and intrapersonal stress es have linked to the development of anovulation. Mos t women with functional hypothalamic anovulationwhen carefully evaluateddis play more than one of thes e traits or behaviors . R ecent evidence sugges ts synergism metabolic s tres sors that s uppress the hypothalamicpituitary-thyroidal axis, such as excess ive exercis e and nutritional res triction, and psychosocial challenges that activate the HP A axis . T hus, multiple chronic stress ors more likely to induce functional hypothalamic than is a single larger magnitude s tres sor. R ecovery is poss ible if res ponse patterns to ongoing ps ychos ocial demands are developed that are les s activate the central and metabolic process es that pulsatile G nR H releas e. T he current standard of other than observation, is to offer pharmacological interventions , s uch as oral contraceptives or hormonal replacement, if fertility is not des ired and ovulation induction if fertility is s ought. However, pharmacological intervention alone does not lead to spontaneous recovery and cannot be expected to ameliorate stress -induced alterations in central neurotransmis sion and hypothalamic function or to revers e ongoing metabolic derangements secondary to exercise or weight los s. F or instance, bone accretion not proceed apace in the face of metabolic even if exogenous hormone replacement is given in supraphys iological doses . Although women with functional hypothalamic anovulation frequently do not 3020 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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meet DS M-IV -T R criteria for eating dis orders or disorders , all of thes e s tates are characterized by cortis ol secretion, which alone can alter thyroid secretion and action and alter metabolism and central s ignals . T hus, it is not s urprising to find that with amenorrhea due to decreased G nR H drive, of cause, have lower bone mineral density. pharmacological intervention alone may mas k of psychological dysfunction and forestall the development of more effective respons e patterns. Als o, ovulation induction may place low-weight women with functional hypothalamic amenorrhea who conceive at for premature labor and intrauterine growth retardation. F etal neuropsychological development may be compromised by the concomitant pres ence of hypothalamic hypothyroidism (s ick euthyroid or hypercortis olemia if ovulation is pharmacologically induced. If the parenting s kills of women with functional hypothalamic are impaired by ongoing stress , their children may be at risk for poor psychosocial C learly, treatment s trategies need to cons ider that and mild ps ychological dysfunction can play an role in the genesis of this form of anovulation. If an disorder is recognized, specialized ps ychiatric indicated. P sychobiological characteris tics can predispose a to chronic activation of central neural proces ses in res ponse to commonplace events . G lobal dysfunction, including inhibition of G nR H puls atility, can res ult. Although identifying the P.2298 3021 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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neuromodulators that mediate the development and maintenance of the disruption of G nR H is of academic interes t, clinicians must make s ure that all other caus es of anovulation and amenorrhea have been excluded before recommending psychological, or behavioral interventions.

FE R TIL ITY A ND INF E R TIL ITY Gametogenes is G ame toge ne s is , the production of oocytes and s perm, occurs as a result of puberty. G ametogenesis is the minimum phys iological requirement for fertility. In women, the ovary mus t have oocytes that respond appropriately to gonadotropin input with the maturation of an oocyte that is ovulated. In men, the testes mus t able to manufacture normal s perm capable of the layer of granulosa cells surrounding the oocyte and then fusing with the outer oocyte cell wall, the zona pellucida. T he fallopian tube must be capable of oocyte capture, and the density of s perm in the fallopian tube must be s uch that there is juxtaposition of s perm and oocyte. T he s perm must be able to negotiate the layers granulosa cells surrounding the oocyte (cumulus) and with the outer cell membrane of the oocyte (zona pellucida) to release the paternal deoxyribunucleic acid (DNA) into the oocyte cytoplasm. T hereafter, the tube must be capable of timely transfer of the fertilized or zygote to the primed endometrium of the uterus . Implantation mus t occur, and normal fetal development must ens ue for the pregnancy to continue. In the of medical intervention, the customary manner in which ovulated oocytes are fertilized is via coitus or sexual 3022 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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intercours e.

Human S exual R es pons e It has been s aid that the mos t important sexual organ the brain. T his truis m is meant to emphasize the role of des ire and comfort in mediating s exual and expres sion. B rain centers mediate libido in a way. Other brain centers influence the selection of partners and the circums tances under which sexual longings are express ed. Hormones made by the and tes tes , s uch as es trogens and androgens, bind in certain brain centers and increas e s exual interest. and how this s exual interest gets express ed as depend on a number of factors, including general and well-being, the availability of a partner, a s ens e of what is appropriate, and prioritization of this interes t above other interes ts and obligations. One of the major aims of s ocial and cultural institutions is to channel or direct s exual interest in a manner that minimizes outcomes , s uch as sexually transmitted diseas es, while ensuring that children will be born and pros per. S exual interes t can be inhibited by any number of negative emotions , including anger, fear, worry, and dis like, and a marked decline in health or hormones . J ust like other personality factors, sexual interes t, or libido, has a spectrum, with some people having more and others S exuality is the term used to refer to a person's gender identity, feelings, sexual orientation, and attitudes, and distinct from the expres sion of s exuality and sexual behavior. T he human sexual res ponse has been described as a with four s tagesexcitement, plateau, orgas m, and 3023 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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res olution. T he s exual respons e cycle is not s imply a mechanical chain of events, however; it involves biological respons es to ps ychological and s ens ory T hus, the trans ition from one s tage of the human res ponse to another is not automatic, even if it is stereotypical. T he human s exual respons e also important biological events . F irst, there must be vasoconges tion, a process in which an increased of blood concentrates in the tis sues of the genitals and female breas ts. S econd, mus cle tone mus t increase. these two process es to take place, the nervous s ys tem must function appropriately and there can be no significant peripheral nerve impairments. If these biological process es cannot take place becaus e of illness , a person may have s exual feelings, but these feelings may not lead to a class ical s exual respons e, as vaginal lubrication or full penile erection. V aginal lubrication in women and penile erection in are the most noticeable s igns of the excitement phase. women, this phase als o involves internal vaginal and nipple erection. In the plateau phas e, the outer portion of the vagina swells, and the external as pects the female genitalia, the labia, thicken and change to a darker color because of vasoconges tion. In men, the increase in s ize and are pulled up agains t the body. A called a s e x flus h may develop on the upper torso. In sexes, orgas m involves a s eries of muscular that then diminis h in intens ity and rapidity. In women, there are muscular contractions of the outer portion of vagina, the uterus , and the anal s phincter. In men, begins with contractions in the pros tate and seminal vesicles, which caus e ejaculation. During the res olution 3024 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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phase, the changes revers e to an unarous ed s tate. but not women, have a refractory period after orgas m which ejaculation and orgasm cannot occur. In women, the orgas mic res ponse is the same, regardles s of there is manual s timulation of the clitoris or penile insertion, although the tempo of the s exual res pons e vary depending on the type of stimulation. Aging may be ass ociated with changes in s exuality. Although s exual interest declines to some degree with aging, older men and women who live together are sexually active than thos e who are not in a relationship B ecaus e women tend to live longer than men do, many elderly women will be without partners and will have limited opportunities for sexual express ion, even if drive is pres ent. In men, significant changes in and ejaculation occur with aging. As a man ages , it takes more s timulation to achieve an erection. In the plateau phase of s exual excitement is longer and not end in ejaculation. W hen ejaculation occurs, the of expulsion of s emen and the intens ity of ejaculation lower. After ejaculation, the erection res olves more and the refractory period increases. Many of these start to occur when men are in their 20s , and ageas sociated changes s hould be anticipated and viewed normal.

S exual Dys func tion in Women S exual dysfunction can be due to psychological, anatomical, and medication-related causes. T hes e are not mutually exclus ive. P s ychological causes inhibited sexual desire, which can be generalized or specific to one partner. If loss of libido is s pecific to one 3025 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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partner, then the prognos is for recovery is good. If has always been low and is generalized, it is unlikely to change. Loss of interes t in a given partner is difficult to res tore, unles s it is a temporary res ponse to an event or iss ue that can be addres sed in some mutually satis factory way. E vents , s uch as childbirth, that alter image and self-identity in both men and women may affect relationships , libido, and the human sexual in a variety of ways . B ecaus e relations hips are by their nature ever changing, it is to be expected that the relations hip will change with time; however, that need not be for the worse. T he intimacy inherent in relations hips requires continual renewal, so sexual relations hips by nature may be vulnerable to the viciss itudes of life and aging. Decreased libido leads to les s s exual arousal and uns atisfactory s exual contact for one or both partners. If neither partner the sexual relations hip as es sential, then these developments may not threaten the s tability of the relations hip, but, if there is a mis match in outlook, alterations in libido and sexual express ion may the foundation of the relations hip. Hormonal changes can affect both libido and the reproductive tract. Loss of estrogen with menopause or from s urgical removal of the ovaries can lead to los s of vaginal lubrication. Intercourse may be painful, or, typically, there may be les s s exual sensation and P.2299 decreased arousal. T his may or may not decrease satis faction within the relations hip. Anatomical reasons for s exual dys function include 3026 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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congenital malformations of the reproductive tract and res ults of surgery or childbirth. W hen extensive surgery performed that involves the external female genitalia, sexual dys function may be due to loss of s ens ation unavoidable injury to nerves, from pain at the s urgical from loss of hormones if the ovaries were removed, an altered sexual self-image, from fear or hes itation in partner, or from any combination of these factors . P sychiatric conditions often impact s exuality and behavior. T ypically, depres sion and anxiety s uppress and s exual performance. Organic conditions , s uch as endometriosis , ovarian and pelvic infections , can caus e painful intercourse and sexual dys function. Diabetes can lead to nerve injury thus, sexual dysfunction due to reduced s ens ation. neurological conditions and alcohol use disorders can impair s exual respons ivity. V aginis mus refers to a condition in which the muscles around the outer third of the vagina have involuntary spas ms in res ponse to attempts at vaginal penetration. Although this condition is generally thought to be ps ychological, women with vaginis mus typically enjoy foreplay and can become sexually arous ed and have orgasms. T he male partner may develop erectile dysfunction in respons e, particularly if he becomes impatient or feels guilty. Anorgas mia, or orgas mic dys function, refers to the to achieve an orgas m. T his is not always viewed as a problem by women who report it. Anorgas mia is to be the mos t common s exual dysfunction, but it mus t viewed in the context of each partner's des ires and expectations . T herapy is generally not success ful when 3027 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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primary motivation for s eeking medical intervention is satis fy the male partner. T he male partner may feel sympathetic, but he als o may feel threatened, as many partners as sume res ponsibility for the other's sexual satis faction. A mis match in libido or expectations can more distress ing than an identified problem. Dys pareunia, or painful intercours e, can result from atrophy due to inadequate estrogen expos ure, from endometriosis, from pelvic infections, from other anatomical conditions , or from lack of s exual Medications that may interfere with s exual res pons ivity sexual interest include antidepres sants, combined hormonal, progestin-only contraceptives such as levonorgestrel implants (Norplant) and medroxyprogesterone (Depo-P rovera), and G nR H C ontraceptive agents and G nR H agonis ts likely act by altering hormone concentrations . In general, proges tins diminis h libido and s exual respons ivity, and es trogens increase both. Antidepres sants decreas e s exual drive res ponsivity by acting on important brain centers . S elective serotonin reuptake inhibitors (S S R Is) have as sociated with decreas es in orgas mic function and less en s exual interes t. F or S S R Is with s horter halfas sertraline (Zoloft) and paroxetine (P axil), it may be poss ible to reverse the effects on sexuality without interfering with the antidepress ant effect by taking weekend drug holidays . S ome antihypertens ives als o as sociated with diminished s exual drive or s atis faction. clos e temporal link exis ts between the s tart of treatment and decreas ed s exual drive or may be worth cons idering another medication, if a alternative exis ts. 3028 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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Appropriate treatment depends on an accurate Organic or anatomical causes must be considered and require medical or surgical remedies . T he us e of may be helpful for women with vaginis mus. B ehavioral therapies, such as s ensate focus exercises, strategies for anxieties , relaxation training, training, and directed mas turbation have been alone or in combination. Depending on the couples couns eling and interpersonal therapy may be recommended. T he success of treatment depends on diagnosis.

Infertility Infertility is es timated to affect 10 to 20 percent of all couples. W ith the advent of sophisticated techniques both diagnosing and treating the caus es of infertility, many couples who might have remained childles s in a previous era or adopted a child to build a family can have biological children. C ommon causes of infertility include endometrios is , impaired s permatogenesis, damage to fallopian tubes or the vas deferens from infections or sterilization procedures, and ovulatory dysfunction or anovulation. T he bas ic infertility can involve a s emen analys is, hysterosalpingogram or sonohys terogram, hormonal s tudies , endometrial and diagnostic laparoscopy to define poss ible or causal factors (T able 28.1-1). Ovulation and adequacy can be monitored by obtaining serial blood samples or performing an endometrial biops y. In spermatogenesis is difficult to ass ess , because the takes 70 to 90 days to complete and the morphological features of sperm that can be as sess ed by a standard semen analysis do not correlate well with function (i.e., 3029 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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ability to fertilize a human oocyte). Diagnostic and a s eemingly endless array of treatment can easily provoke tension, indecision, and in the couple with infertility.

Table 28.1-1 Tes ts in the Infertili Workup Pos s ible

Tes t

C omments

Anovulation

B as al body temperature chart

P atient mus each mornin

 

E ndometrial biops y

Office procedure in late luteal

 

S erum proges terone

S ingle or multiple bloo tes ts

 

Urinary ovulation detection kit

Home us e a midcycle to time

 

Ultrasound

V is ualize ovarian follic

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and their rupture Anatomic disorder

Hys terosalpingography X-ray in proliferative phase to de intrauterine contours an tubal patenc

 

S onohysterography

T ransvagina ultras ound examination with ins tillat of saline into uterine cavit define conto

 

Diagnos tic

V iew extern surfaces of internal structures

 

Hys teroscopy

V is ualize endometrial cavity direct

Abnormal S emen analys is spermatogenesis

Normal valu >20 million/ 2 mL volum

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60% motility  

P os tcoital tes t

Midcycle tim to look at spermcervic mucus interaction

Immunological disorder

Antisperm antibodies

Male semen

Azoos permia

T es ticular biops y

Determine eligibility for intracytopla sperm inject

 

S emen analys is for fructos e

Determine if deferens are patent

Adapted from B eckmann C R B , Ling F W , B arzensky B M O bs te trics and G yne cology for Medical S tudents . W illiam Wilkins , B altimore; 1992. T he sens e that the window of opportunity is narrow can engender panic; a woman's age correlates well with fecundity, and treatment success declines s harply after 37, even when ovulation occurs regularly. Although fertility als o declines with age in men, the decline is 3032 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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gradual until age 50, and fertility may persist beyond 60. T he offs pring of older mothers have an increased chromosomal trisomies , particularly tris omy 21. An increase in autos omal dominant conditions has been reported in the offs pring of older P.2300 fathers . Of the identifiable causes of infertility, approximately 40 percent are thought to be due to factors , 40 percent to female factors , and 20 percent to both. Anovulation is the mos t common cause of in women. Approximately 20 percent of men with suboptimal s emen parameters have microdeletions of long arm of the Y chromos ome in a region thought to a critical role in spermatogenesis . Approximately 10 to percent of infertile couples have unexplained infertility, which means that there is no identifiable caus e. T he degree to which psychogenic or lifes tyle factors role in infertility is controversial. C ouples s hould not be told their infertility is related to stress unless there is documented evidence of sperm dysfunction, ovulatory dysfunction, or s exual dysfunction. However, because lifes tyle variables, s uch as tobacco exposure, alcohol cons umption, drug us e, exces sive exercis e, weight gain, and psychogenic stress , can compromis e reproduction, it is worth reviewing lifes tyle factors with couple and informing them of the potential adverse cons equences of these factors in a s upportive manner. P sychogenic variables can interfere with coital and reduce the likelihood of conception and can the central hypothalamic-pituitary drive to the gonad compromise the quality and quantity of gametes 3033 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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produced. S tandard interventions were once limited to res torative surgery and gonadal s timulation, but they now include variety of as sisted reproductive techniques, including in vitro fertilization with embryo transfer (IV F -E T ) and intracytoplas mic s perm injection (IC S I). In ass is ted reproductive techniques , the ovaries are generally hypers timulated to produce at leas t three or four follicles from which the oocytes can be retrieved S perm and oocytes are then mixed and supported in to promote fertilization. If fertilization occurs , the ovum or zygote is trans ferred to the recipient's uterus . chance of implantation if three or more zygotes are transferred is generally around 50 percent, but it can lower if fewer embryos are available or if the woman is over age 38. Approximately 25 percent of implantations (as evidenced by a trans iently elevated serum β-hC G concentration) are not sustained. T he likelihood of a succes sful full-term pregnancy increases dramatically if fetal cardiac activity is obs erved approximately 2 after mis sed menses (i.e., 4 weeks after the gamete or embryo transfer). T he main indication for as sisted reproductive procedures is failure to conceive with conventional interventions . In some ins tances , the reproductive impairment is so s evere that conventional interventions are unlikely to offer s uccess and an reproductive procedure is recommended primarily. IC S I us ed when there is failed fertilization during a previous procedure or when too few s perm exis t for IV F . G amete intrafallopian trans fer (G IF T ) is a form of reproduction with s imilar rates of success in which 3034 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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four oocytes are mixed with s perm and placed into the fallopian tube during a laparoscopy. F ertilization occurs the tube and, thus , is not obs erved. IV F -E T has largely supplanted this procedure because G IF T requires a laparoscopy and general anes thes ia and becaus e pregnancy res ults are not better than with IV F -E F . When it is not pos sible to correct underlying causes , subs titutions are poss ible. Not only are donor s perm available, s o too are donor oocytes and s urrogate who will ges tate the embryo of another couple. can be cryopres erved indefinitely and potentially transferred to a biologically unrelated recipient or to the woman herself years after menopause. T reatments for infertility are expens ive and consume time and energy. A s ens e of ps ychological and invas ion is common. Infertile men and women may feel angry, damaged, or guilty. S tudies s uggesting a link between ovarian cancer and infertility further increase anxiety and psychological turmoil. T he potential for husbands and wives to res pond differently to the experience of infertility and its treatments , particularly of the ass is ted reproductive technologies, can customary adaptation patterns and lead to decompensation. E ven s ucces sful infertility treatment poses challenges . Ass is ted reproductive technologies a 25 to 30 percent chance of twins and an almos t 1 chance of triplets. If quadruplets or more res ult, the must grapple with the option of selective reduction. A multiple pregnancy increas es fetal and maternal risks, as congenital abnormalities and preterm labor. F urther, multiple ges tation complicates postpartum adjus tment and carries a lifelong parenting challenge. T here is 3035 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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evidence that children born to previous ly infertile are viewed by their parents as s pecial. T hese parents have trouble s etting limits or may be overly protective. Whether or not it is treated, infertility can produce a of ps ychological reactions . R es ponses depend on personality attributes , including adaptability, cultural expectations , s upport s ys tems, knowledge about reproductive process es , and the attitudes of the clinicians . Infertility can damage s elf-image and impair sens e of health and integrity. S ome individuals feel that they are being made to suffer for past wrongs ; others blame the medical profess ion for being inadequate or inattentive. A sense of panic, helples sness , and loss of control may compromis e s elf-es teem. W omen and men alike are generally overwhelmed by the complexity, invas iveness , and uncertainty ass ociated with medical intervention or adoption. Almost all patients who infertility treatment (T able 28.1-1) experience a los s of privacy as they cope with phys icians, nurs es, carriers , psychologists, hospitals, and laboratory T he sens e of intimacy that reinforces marriage and mutuality may be challenged when s ex and procreation are separated by technology (T able 28.1-2). Ultimately, infertility presents the specter of a ps ychological death. T hus, it is not s urprising that patients with infertility as much anguis h and distress as patients newly with acquired immunodeficiency s yndrome (AIDS ).

Table 28.1-2 As s is ted Tec hniques 3036 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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Method

C omments

Ovulation induction or augmentation (multiple agents , particularly recombinant or highly purified gonadotropins )

S timulates multifollicular development and may produce multiple births ; us ed in anovulation, luteal phase deficiency, unexplained infertility, and as sisted reproduction

Induction of spermatogenesis

Used in men with hypothalamic hypogonadis m of or organic nature

Artificial insemination

Donor sperm is injected the uterine cavity or the fallopian tubes; the sperm the hus band may be used healthy

G amete intrafallopian transfer

T ransfer of collected and s perm into the tubes ; zygote may als o be transferred; used for infertility from endometriosis and 3037

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unexplained infertility In vitro fertilization and embryo

T ransfer of developing embryos into the uterus after extracorporeal incubation of collected sperm with oocytes retrieved by laparoscopic surgery or by ultrasoundguided transvaginal as piration; us ed with occlusion of the fallopian tubes or s ignificant sperm dysfunction; permits preimplantation genetic diagnosis

Intracytoplas mic sperm injection

Injection in vitro of sperm head or sperm DNA to fertilization and production of embryos for transfer to receptive endometrium; may be used even if are barely viable; genetic caus es of male infertility may be transmitted to offspring

G amete donors

Donation of sperm or oocytes to another couple;

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can include oocytes only, oocyte cytoplasm only to res tore reproductive competence to aged donor s perm alone, or any combination; cytoplasmic transfer considered unethical and is illegal in some s tates S urrogate mother

S urrogate mother receives donated embryo and the baby to term; a highly controvers ial technique unclear legal ramifications

Data in part from S usman V . P regnancy in S ciences for Me dical S tudents . B altimore: Wilkins ; 1993. Ideally, psychological s upport s ervices should be for all individuals and couples undergoing active evaluation and intervention for infertility. Unlike the traditional medical model, in which diagnostic testing precedes and directs the course of treatment, in empirical therapy may precede more invas ive tes ting. C ause and effect can be difficult to identify, and magical or s uperstitious thought process es are patients and practitioners alike. Infertility can threaten 3039 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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marital adjus tment, particularly if the partners react differently to the challenges . Although fertility is an attribute of a couple, blame may be prematurely or incorrectly as signed to one pers on in the dyad. In to individual or couples counseling, groups , such as R es olve, can offer support and information. W hen sperm, oocytes, or embryos or s urrogate motherhood being considered, a thorough psychological evaluation recommended in advance of treatment to ensure that parties agree to the treatment plan and understand the potential implications and ramifications . R eproductive technologies have made it poss ible to separate biological and social parenthood. A s ingle woman may choos e parenthood. T he us e of donor insemination or other fertility therapies in single women controvers ial. Most women who seek s uch s ervices cons idered the cons equences of s ingle parenthood feel that they will be able to rise to the challenges . Nonetheles s, psychological evaluation should be made available to ensure that important topics and cons equences have been cons idered. No long-term up on the mental health and development of children born to single mothers has been done. P.2301 Dys functional attitudes and dis harmony cons tantly threaten the infertile pers on. P rophylactic evaluation is preferred in all treatment s ettings , but specialized may not always be immediately available. S tress can compromise gametogenesis and libido, and infertility treatment alone can be s tres sful enough to activate the central mechanisms that compromis e reproductive 3040 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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function. P sychological s upport is intended to less en likelihood of this effect and revers e it if it is already occurring. P harmacological agents used to treat disorders of ovulation or to hyperstimulate the ovaries may alter and cognition. T he agents include clomiphene citrate (C lomid) and other anties trogens , G nR H analogs, gonadotropins , hC G , proges terone, and bromocriptine (P arlodel). Danazol (Danocrine), a s ynthetic androgen, be us ed to arrest the growth of endometriosis as a or medical adjunct to later infertility therapy. T reatment infertility itself is anxiety provoking becaus e of the uncertainty and s ens e of expectation. However, most the agents do alter es tradiol and proges terone levels , the res ultant hormonal fluctuations may trigger mood lability in sensitive individuals . Agents such as danazol, and bromocriptine may als o have direct on the brain. If the use of thes e agents is indicated, ps ychological support should be offered ins tead of anxiolytics and antidepres sants . A further concern of infertile couples is whether ass is ted reproductive techniques increas e the ris k of neurodevelopmental or other abnormalities, including childhood cancers. T he uncertainty as to whether there is a link between treatments and poor health outcomes in the mother or child only s erves to exacerbate anxiety and guilt. is a far more devastating disorder than mos t lay and phys icians realize.

Pregnanc y L os s Unlike infertility, which can continue indefinitely, pregnancy loss is a defined event with an end. Acute 3041 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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reactions to an isolated miscarriage or perinatal los s, as blame, guilt, anger, and denial, gradually lead to acceptance and resolution. A single miscarriage does predict poor future reproductive performance. pre gnancy los s , defined as three or more loss es before weeks of gestation, carries an unfavorable prognosis res embles infertility in its chronicity and sense of lost potential. Although it might be as sumed that grief and emotional turmoil would be related to ges tational age, as sumption is not supported by observations . W omen miscarry have more than twice the relative risk of a depres sion compared with community women. More half of women with a history of major depress ion experienced a recurrence after miscarriage. B ecause significant ris k of depress ion, acute intervention is recommended for all women and couples who a mis carriage or perinatal loss ; services s hould be extended beyond the acute event when indicated.

Ps eudoc yes is P s e udocye s is is the development of the clas sic of pregnancyamenorrhea, naus ea, breas t enlargement pigmentation, abdominal distention, and labor painsin a nonpregnant woman. P s eudocyes is demons trates the ability of the ps yche to dominate the soma, probably central input at the level of the hypothalamus . P redisposing ps ychological proces ses are thought to include a pathological wish for and fear of pregnancy; ambivalence or conflict regarding gender, s exuality, or childbearing; and a grief reaction to los t potential after miscarriage, tubal ligation, or hys terectomy. T he may have a true s omatic delus ion that is not s ubject to reality testing, but, often, a negative pregnancy tes t 3042 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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or pelvic ultrasound s can leads to res olution. P sychotherapy is recommended during or after a presentation of ps eudocyes is to evaluate and treat the underlying ps ychological dysfunction. A related event, couvade, in which the father of the child undergoes a simulated labor as if he were giving birth, occurs in cultures.

Fertility C ontrol E lec tive A bortion E lective abortion is dis tinct from spontaneous abortion (i.e., mis carriage) (T able 28.1-3). E lective abortion is planned termination of a pregnancy. C enters for C ontrol (C DC ) s tatistics indicate that approximately 1.2 million abortions were performed in the United S tates 1997 (the mos t recent year with data available from all states )306 abortions for every 1,000 live births . In nations, mos t women who obtain abortions are young, unmarried, and primiparous ; in underdeveloped abortion is most common among married women with two or more children.

Table 28.1-3 Types of Abortion S pontaneous S pontaneous expulsion of the products of conception before viability (500 g or approximately wks from last mens es ) 3043 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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R ecurrent

T hree or more s pontaneous abortions

Miss ed

Abnormal development of an intrauterine pregnancy; us ually caus ed by the presence of a blighted ovum and lack of fetal development

T hreatened

Uterine bleeding or cramping and positive pregnancy test; mus t be distinguished from an ectopic (us ually tubal) pregnancy

Incomplete

S pontaneous pass age of a portion the products of conception and retention of placental fragments that res ult in ongoing bleeding

E lective

Induced by medical or s urgical techniques before fetal viability; techniques include dilation, evacuation, and curettage; suction curettage; injection into the amniotic sac of s aline or prostaglandins; hys terotomy; prostaglandins with antiproges tins (R U-486) or methotrexate; indications include the detection fetal abnormalities by ultrasound 3044

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amniocentes is

C DC statis tics from 1999 es timate that 22 percent of abortions were performed at or under 6 weeks of gestation, 36 percent between 7 and 8 weeks , 20 between 9 and 10 weeks, and 10 percent between 11 12 weeks. T he remainder occurred after 13 weeks, P.2302 with 1.5 percent occurring after 21 weeks . T able 28.1-4 summarizes the most common abortion techniques. In contrast to what was previously thought, recent studies show no s ignificant untoward psychological effects of elective abortion on the mental health of women. In in one study comparing the outcomes of women who sought treatment in a clinic because they thought they were pregnant, women who were pregnant and chose abort were reported later to be doing better emotionally and in purs uing personal, educational, and work endeavors than were either thos e who were not or thos e who chose to continue the pregnancy. Another study suggested untoward consequences on the health and well-being of women who were denied the option to abort and, thus, were required to unwillingly 3045 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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carry the pregnancy to term and then raise an child. T his study sugges ted untoward cons equences the mental health and well-being of the child as well. However, termination of a wanted pregnancy becaus e an abnormal karyotype or fetal anomalies can be traumatic, and supportive intervention is

Table 28.1-4 Abortion Type

B enefits

R is ks

C ervical dilation and evacuation of uterine contents by curettage or vacuum as piration

Most commonly performed procedure for termination of pregnancy; be done 24 wks ' gestation

Uterine perforation, adhes ions, hemorrhage, infection, incomplete removal of fetus and placenta (all rare)

Mens trual as piration (miniabortion)

C an be done within 13 wks of mis sed period

Implanted zygote not removed, uterine perforation

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(rare), failure recognize ectopic pregnancy Medical induction (cervical dilation with laminaria followed by high dose of oxytocin)

C an be used secondtrimes ter abortion

Water intoxication, uterine rupture, infection

Intraamniotic hyperosmotic solutions (s alting out)

C an be used secondtrimes ter abortions

Hyperos molar crisis, heart failure, peritonitis, hemorrhage, water intoxication, myometrial necros is

P ros taglandin (oral, intravaginal, cervical, or intraamniotic)

Noninvasive procedure; be us ed in conjunction with antiproges tins

E xpuls ion of live fetus, miss ed ectopic, hemorrhage, incomplete

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(R U-486) or methotrexate

abortion

Antiprogestins (R U-486)

Nons urgical; first trimester only

Incomplete abortion, hemorrhage

Methotrexate

Nons urgical; first trimester only

Leukopenia, hemorrhage, incomplete res ults

T echniques for inducing abortion (T able 28.1-4) have known for at least 5,000 years. In view of the ris ks of childbearing and the requirements of child rearing, induced abortion was viewed historically as a means of modulating the maternal and societal risks of childbearing. Induced abortion affords women a of autonomy over a unique and ps ychologically bodily function, but it arous es personal and public ambivalence and inspires controvers y. His torically, the concept of therapeutic abortion before quickening, which is generally defined as the time at the mother perceives fetal movements , was well In the United S tates, legis lative regulations regarding induced abortion were introduced in the early 1800s , their intent was to protect women from sepsis and complications as sociated with the procedures. Induced abortion, whether by surgical or chemical means, now 3048 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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entails minimal medical ris k and is clearly safer than carrying the pregnancy to term. C urrent legis lative attention has shifted from maternal health to the ethics of abortion and the right of women to exercise control over their bodily functions . T raditionally, ethical deliberations regarding abortion res erved for religions . B ecaus e of the divers ity of perspectives on the role of women and on procreation, cons ens us is neither likely nor necess arily desirable. Nonetheles s, the current legis lative debate centers on has the authority to regulate induced abortion and to degree. T he 1992 S upreme C ourt ruling in P lanne d P are nthood of S outheas te rn P enns ylvania v. C as e y the bas ic right of women to elect pregnancy termination before fetal viability, but also upheld the right of the to regulate and res trict abortion and to define viability. F urther, in s ome states (e.g., P enns ylvania), pregnant women los t the right to select whether they wis h to receive advanced life support in life-threatening T he F reedom of C hoice Act put before the U.S . recognized the right of states to regulate the strictly medical as pects of abortion to s afeguard maternal It restricts the freedom of a woman to terminate a pregnancy after, but not before, fetal viability. T his legis lative effort repres ented a compromis e between those who argue agains t any medical mediation of the proces s and thos e who would grant women complete autonomy. Application of this law would hinge on the interpretation of the phrase fe tal viability, a concept that not eas ily defined. Making the option of induced contingent on fetal viability reveals continuing ambivalence about allowing women the autonomy to 3049 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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make decis ions about phys iological proces ses that shape their lives. It is difficult to appreciate how a legis lative body can entrust the life of a child to the and s imultaneously limit the mother's autonomy in making reproductive decis ions. C urrent legis lative have focused on res tricting the techniques us ed to perform late-term abortions by criminalizing phys icians. T his debate regarding abortion is far from res olution P.2303 and is likely to continue as medical advances s uch as mifepristone (R U-486), the antiproges tin that can chemically induce abortion in the early firs t trimes ter, increase therapeutic options. T he medical ris ks of either surgical or medical abortion few, but both procedures require physician input. abortion, however, requires less phys ician input, it does require careful monitoring to ens ure that the abortion occurs in a timely fas hion. R arely, hemorrhage occurs that requires s urgical intervention or a Medical abortion can potentially increase a woman's autonomy of her reproductive capacity.

C ontrac eption Methods of contraception fall into four main categories barrier methods , hormonal agents, devices , and natural family-planning methods that abstinence around the time of ovulation (T able 28.1-5). T he perfect contraceptive would be completely free of adverse effects , and completely efficacious . no perfect contraceptive is now available, people must select a method that bes t meets their needs. 3050 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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the res ponsibility for choosing and us ing a falls primarily on the woman. T his can lead to lack of compliance, and marital disharmony. F or thos e stable relations hip, contraceptive counseling can both partners.

Table 28.1-5 C urrent Methods o Type

E ffic acy a

Advantages

Dis advan

B arrier (chemical or mechanical)    S permicidal agents

Moderate

R eadily available easy to use

Mess y; lo spontane requires forethoug

   Diaphragm, cervical cap

Moderate

Inexpens ive; does not interfere with mens trual cycle

User fam required; prescripti fitting req may inter with spontane requires forethoug

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   Male

Moderate

R eadily available easy to use; protects agains t sexually transmitted diseases (S T Ds )

May inter with spontane requires forethoug

   F emale condom

Moderate

R eadily available easy to use; protects agains t

May inter with spontane requires forethoug

Hormonal (s uppress es ovulation and/or impairs endome    Oral contraceptives, contraceptive patches and rings

High

P rotect agains t uterine and ovarian cancer, S T Ds

P harmaco side effec require da weekly us regardles frequency sex; mus t prescribe monitored health ca profes sio

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   P ostcoital steroids

High

C an be used after intercours e; inexpens ive

Must be initiated w 72 hrs ; re some me supervis io

   C ontraceptive implants (rods)

High

Implantable device that provides contraception for up to 1 once in no forethought required

Irregular bleeding spotting d endometr effects an suppress ovarian function; be surgic placed an removed

   Injectable steroids

High

Injectable proges tin or combination of estrogen and

S low retu ovarian a after last not remov

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that prevents ovulation suppress es ovarian activity; IM at an interval that depends on the product    Antiproges tins High (R U-486)

E as y to us e; does not disrupt mens trual cycle when adminis tered in luteal phase; can us ed postcoitally

C urrently available United S t must hav predictab cycles

F ailure very rare; 20-min office procedure

Morbidity 12% of pa includes infections

S terilization    Male sterilization (vasectomy)

High

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   F emale sterilization

High

Almos t protection; no impairment of sexual function or pleas ure

More com procedure vasectom revers al i complicat and diffic

Other

 

 

 

   Intrauterine device

High

Once in no forethought required; impairs endometrial receptivity

May caus nonbacte endometr heavy me requires profes sio insertion

   R hythm

Low

No cos t

Impos ed timing

   Natural planning

Moderate

R eadily available

User mus monitor mucus an body temperatu clos ely;

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coital timi    W ithdrawal, coitus interruptus

Low

R eadily available

Difficult to implemen

aE stimates

of efficacy are thos e as sociated with use rath High, <5% chance of contraceptive failure during the firs chance; low, >20% chance. bOther

than failure (pregnancy).

T he as sess ment of the risks and benefits of a given contraceptive s trategy should not be limited to a cons ideration of the biological ris ks alone but must take into account the mind-set of each party, particularly regard to gender iss ues and cultural pers pectives. If significant dis cord exis ts within a couple, couns eling be indicated. C ounseling can also be cons idered for person or couple who feels guilty about the idea of interfering with natural bodily functions for this purpose. C linicians mus t be mindful of the difference between actual and perceived ris k. C oncerns of current and bodily harm from use of contraception are common, the ris ks of childbearing and child rearing frequently underes timated. T he mortality as sociated with childbearing is es timated to be 10 per 100,000 live between the ages of 20 and 24, 44 per 100,000 the ages of 35 and 39, and 71 per 100,000 after age 3056 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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However, comparable mortality in nonsmoking women oral contraceptives is 1.2 per 100,000 live birth, 3.9 per 100,000 live births, and 6.6 per 100,000 live births , res pectively. T he potential ris ks of child rearing are to quantify, but they include role strain and s tres s, interrupted education or career advancement, loss of independence, and compromis e of the ps ychos exual relationship with the partner. T his misperception of ris k is particularly prevalent among adoles cents , who may be uninformed and have ideas about the rewards of pregnancy and the ris ks of sexually transmitted diseas es. In addition, a teenager's aptitude for listening and making decisions may be by ambivalence and confusion. In short, des pite the availability and relative affordability of contraceptive means , their use is cons trained by the dis crepancy between actual and imagined risk. B ecaus e coitus is always anticipated, there is a need for postcoital or socalled emergency contraceptives . Available methods include ins ertion of an intrauterine device (IUD), high doses of levonorges trel, high doses of combinations, and antiprogestins. T he us e of levonorgestrel0.75 mg taken twice 12 hours apartwithin hours of intercours e was more effective (>99% ) and as sociated with les s s evere adverse effects than the combined oral contraceptives . In the United S tates, combined oral contraceptives (P reven) are explicitly marketed for us e as postcoital contraception. T he mental and phys ical health ris ks of contraceptive are s ignificantly lower than are thos e ass ociated with pregnancy, parturition, and parenthood. However, contraception often gives an unwarranted illusion of 3057 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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control over a bodily proces s. No method is perfect, unintended pregnancy can occur despite respons ible Als o, if a couple or person intends to have children, childbearing should not be pos tponed indefinitely in the hope that the perfect time will arrive. It can be difficult conceive on demand.

S terilization S terilization can be accomplished by s everal methods tubal ligationby hys terectomy with or without oophorectomy in women and by vasectomy in men. Hys terectomy for s terilization alone is as sociated with more morbidity and mortality than any method of tubal ligation; vas ectomy is s afer than are any of the pres ent methods of tubal ligation. Mos t studies do not s upport contention that tubal ligation carries an increased incidence of gynecological s equelae, but failure rates high in the first year after tubal ligation. In general, it is safes t to perform a tubal ligation by laparos copy at several weeks after delivery. T ubal ligations after delivery are done becaus e of convenience or of a woman's unwillingness or inability to return for a tubal ligation. It is difficult to determine how often reversal of a tubal ligation or vas ectomy is s ought or performed, and it is even more difficult to es timate the frequency of regret the sterilization was performed. No formula can predict who will seek revers al, but factors such as remarriage, young age at time of s terilization, death of a child, and performing the sterilization during the postpartum seem to play roles. R egret is high when s terilization is undertaken as a way to stabilize a marriage. T he 3058 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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revers al depends on a variety of factors, including the method of sterilization, the ages of the partners, and elaps ed time since the sterilization procedure. need to make couples and individuals aware of these cons iderations but s hould not us e them as reas ons to the planned procedure. Again, when a couple is the mutuality of the decision s hould be discus sed to later res entment. V oluntary sterilization, es pecially vasectomy, has become the mos t popular form of birth control in couples married for more than 10 years .

S E X UA L L Y TR A NS MITTE D A s e xually trans mitte d dis e as e (S T D) is a contagious acquired as a res ult of a physical sexual interaction. have always been a reality, but from the 1950s through 1970s the infections were cons idered treatable and not threatening. AIDS , which is caused by infection with human immunodeficiency virus (HIV ), is currently incurable, life threatening, and transmis sible from to fetus. T he s pecter of AIDS has captured the popular imagination. Although it was initially found in male homos exuals and intravenous drug abusers , HIV boundaries . S exual monogamy or abs tinence has been advocated to ens ure emotional health and a s table arrangement for the potential outcome of s exual intercours e, children, but mutual sexual monogamy or abstinence als o prevents S T Ds , particularly AIDS . Another s equela of S T Ds, s uch as gonorrhea and chlamydia, is pelvic inflammatory disease (P ID). P ID can develop in bilateral tuboovarian absces ses neces sitate hysterectomy and bilateral salpingooophorectomy. E arly antibiotic treatment is advocated 3059 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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prevent development of the absces ses and to reduce likelihood of infertility, chronic pelvic pain, and ectopic pregnancy from tubal damage. T hese infections can lead to obstruction of the vas deferens and chronic prostatitis in men and s ubs equent male infertility. Another S T D that can have s erious consequences is venereal warts, or human papilloma virus (HP V ). infections with certain P.2304 subtypes of HP V can lead to premalignant changes of penis , vulva, vagina, and cervix and are thought to cervical cancer. V enereal warts can be removed or s urgically but are difficult to eradicate completely. Women who contract HP V are encouraged to have gynecological examinations and P apanicolaou's detect premalignant les ions. S exual monogamy and abstinence will prevent mos t and are advocated as public health meas ures . libidinal P.2305 impulses can be difficult to control and res trict. meas ures such as condom us e are recommended as alternative public health meas ure. T he ideal can be defined, but clinicians and policy makers need to remember that it cannot always be attained. in particular, need to know the potential cons equences sexual activity with regard to S T Ds and pregnancy. Admonishing teens to remain chaste is unlikely to be completely effective and may be counterproductive. T o 3060 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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make res pons ible decisions, people need to the ris ks . C linicians need to remember that the risks of s exual intercours e may be forgotten or seem minimal in comparis on to the need for affection, contact, release, es cape. P ersons who have low s elf-es teem or are may view sex as a means of bols tering their s elf-image es caping their s tres ses . T he reinforcing properties of ensure that the problem of S T Ds will endure.

P E L VIC P A IN P elvic pain can have many caus es, including endometriosis, pelvic adhes ions, ovarian or adnexal mass es , hernias , and bowel or rectal dis eas e. P elvic can also be secondary to psychogenic causes , s uch as fertility or infertility fears, and the emotional as sociated with ongoing or pas t incest or sexual abus e. P elvic pain s hould not be attributed to ps ychogenic unles s thorough evaluation has excluded organic In most ins tances , the evaluation s hould include a diagnostic laparoscopy. Likewise, dyspareunia, or pain with intercourse, s hould not be as sumed to have a ps ychogenic origin unles s all anatomical causes have excluded.

R E P R ODUC TION P regnancy, parturition (childbirth or delivery), and the postpartum period involve a series of tightly hormonal events that create the potential for unique ps ychological states . As pregnancy advances , and proges terone concentrations ris e and a hos t of placentally elaborated polypeptide hormones induce 3061 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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metabolic adaptations. T he effect of those hormonal excursions on C NS activity and rhythms remains to be inves tigated; however, in the absence of predisposing ps ychological conditions or complications of most women adjus t to the changing hormonal milieu without overt phys ical or ps ychological difficulty. P arturition is an intens e biological event that is by most, but it eventuates in the abrupt withdrawal of es trogens , proges terone, and other placental P arturition also triggers the neuroendocrine cascade permits lactation. T he metabolic demands of lactation, need to deliver infant care acros s the usual circadian res tactivity cycle, and the hypoestrogenis m that accompanies lactational amenorrhea present unique phys iological challenges. Menses (and ovulation) res ume in 6 to 12 weeks if the mother declines to nurse when lactational frequency declines (usually after 4 to months) if she does nurse.

Pregnanc y P s yc hologic al A daptation T he stages of ps ychological adaptation to an intended pregnancy are not well unders tood. B oth men and who des ire a pregnancy initially tend to feel when it is achieved. However, as the pregnancy and the realities of how life will be altered emerge, ambivalence develops . T his is a normal ps ychological res ponse to a major life trans ition. In general, mos t adjus t to the multiple bodily and psychological changes and develop effective coping s trategies or attitudes. instance, a hus band may compliment his wife on her changing physique as a means of reas suring both of 3062 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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that the child and parenthood are welcome, that the dyadic relations hip is intact, and that he is s haring in proces s. A woman may rejoice in her increasing girth wear clothing that displays it, or she may wish to deemphas ize the changes until they are advanced. Medical advice and role models are helpful, but each woman mus t develop her own strategies to cope with hormonal, metabolic, and ps ychological demands of pregnancy. During the early stages of pregnancy, concerns tend to focus on bodily adjustmenthow to cope with morning sicknes s, breast tendernes s, changes in phys ique, diet, and exercis e. Depending on body habitus, abdominal s ize, breast size, or both may be apparent early as 1 or 2 weeks after a miss ed mens es or may apparent until 10 to 12 weeks later. T hroughout pregnancy, the pregnant woman mus t adapt to both phys ical and ps ychological boundaries . As the pregnancy advances , concerns s hift to finances , the room and material needs, employment iss ues , and capacity for parenthood. T he extent to which the urge prepare for the baby is biologically driven is not known, but, in animals, the preparatory efforts (nesting) appear be hormonally initiated. In humans , this preparatory proces s does not seem to depend exclusively on hormones, as men also participate. E ach partner may on a s pecial concern, particularly if the marriage is on discrete, stereotypical gender roles. However, throughout the pregnancy, each must share concerns acknowledge ambivalence to facilitate adjus tment and mutuality. If this does not occur, the psychological and phys ical demands of pregnancy can lead to isolation 3063 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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negative attitudes. Although parenting can be satis fying and deeply rewarding, it is a big respons ibility; anxiety is normal and focuses energies on important ps ychological tas ks . T he potential parents who have fantas ies about the unlimited joys of parenting may not adjus t well to the mundane, tedious realities as sociated with caring for babies and children. If the parents have other children, they mus t also develop s trategies for coping with sibling adjustment. Unfortunately, violence toward the pregnant woman by men may at this time. S ome authors speculate that this reaction may, in part, be precipitated by jealous y of the time and attention the potential infant receives or secondary to uncertainty regarding paternity. T he firs t pregnancy heralds a new life stage for both parents , but attention generally has focused on the developmental iss ues of the expectant mother. is seen as a maturational event that allows gender identity and provides an opportunity to nurture the next generation. T he ps ychological energy required deal with is sues of identification and differentiation in conjunction with profound metabolic and hormonal changes may lead to emotional lability, intros pection, anxiety, or a des ire for increased contact with one's parents . T he age, life stage, and circumstances of the pregnant woman undoubtedly affect adjustment, but pregnancy is universally as sociated with concerns adequacy during ges tation and delivery and as a In consolidating her identity, the woman must negotiate is sues of autonomy, dependence, and sexuality. P as t adjus tment and current s upport play critical roles in determining the outcome of this pivotal developmental 3064 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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event. Although men do not have to confront the demands of pregnancy in thems elves , the adjus tments required of men involve the s ame is sues cons olidation of gender identity, attachment, autonomy, sexuality, and generativity). B eing able to anticipate facilitates adjus tment. B y definition, the first-time parent does not know fully what required. T he s ituation is made wors e if the expectant mother or father has no guarantee of P.2306 maternity or paternity leave. Allowing employers to this decision on an individual basis is inappropriate and leaves too much room for employer self-interes t. S tandardized guidelines that guarantee a reasonable amount of financial and job security mus t be developed and applied uniformly. T he needs of normal infants are predictable and do not vary by race, parental age, or socioeconomic s tatus . B oth parents need time and to initiate the ps ychological proces s of becoming a Obvious ly, the s ucces s of any economy depends on its human potential; strategies are needed that balance short-term needs of bus iness with the s hort- and longterm needs of children and parents . W orking fathers always been a reality; working mothers are now a and are likely to remain so. It is hypocritical and counterproductive to extol the virtues of parenthood but not develop reas onable provis ions that allow working mothers and fathers to balance their commitments . As pregnancy can arous e primitive jealousies, working women who are pregnant may find that they are in subtle ways for neglecting their job or other external 3065 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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res ponsibilities. E mployment policies that protect pregnant women from undue press ure can help ameliorate that s ituation.

P s yc hologic al Tas ks A s s oc iated Teenage P regnanc y A certain level of ambivalence regarding pregnancy the anticipated life changes ass ociated with normal and adaptive, but ambivalence can become extreme when the expectant mother is a teenage girl. R ates of pregnancy among teenagers in the United are among the highest of all indus trialized countries. T eenage pregnancy carries with it a unique set of ps ychological challenges for the expectant mother and family. Intended pregnancies among teenage girls may an attempt to consolidate a romantic relationship, to es cape an unhappy s ituation or environment, to ass ert one's s tatus as a mature adult, to alleviate lonelines s, ensure that one is needed and loved by another human being. More often than not, the long-term phys ical, emotional, and financial s trains of motherhood are not well cons idered. Unintended teen pregnancy includes own set of challenges regarding decis ions as to continue the pregnancy and, if the pregnancy is continued, decis ions regarding adoption or negotiations regarding the father's ins trumental and financial role in child rearing. W hen available, nonjudgmental and instrumental support from family members can aid this process . G iven the high rates of underpayment or nonpayment of child s upport, many young, single will face chronic financial strain and ps ychological 3066 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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involved with obtaining consis tent financial support unwilling fathers. T een pregnancy is also accompanied by elevated stress felt by a young girl who is not yet equipped or to cope with the los s of s ocial approval; the loss of that pregnancy engenders ; the los s of future career, or s ocial options ; or the demands of caring for a child. W hen the challenges of pregnancy are superimposed on the developmental challenges of adoles cence, risk for psychopathology increas es . F or example, depres sion prevalence rates are particularly elevated among pregnant adolescents , with depres sive symptoms often worsening during the second and third trimes ters . Moreover, although pregnancy and motherhood are generally as sociated with lower rates suicide, teenage mothers tend to display an increased suicide ris k. P regnancy has not always been as sociated with low of suicide, however. B efore the availability of contraception and legal abortion, pregnancy was often caus e of suicide, particularly if the pregnant woman unwed and lacked social supports. In the past, punitive attitudes and advers e s ocietal s anctions not only did prevent unintended pregnancies, but als o were with increased maternal mortality from s uicide and the complications of illegal abortions performed by unsafe techniques in unsterile s ettings .

P s yc hologic al Tas ks A s s oc iated A s s is ted R eproduc tion Options and outcomes related to advanced technologies have introduced novel psychological 3067 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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addition to the more universal themes, that mus t be negotiated during and after pregnancy. T he following situations are likely to be as sociated with enhanced anxiety and novel concerns: multiple ges tation (W ill the babies s urvive? How can we parent s o many at surrogacy (C an I [or s he] give up this baby? ); donor or s perm (W ho is the real mother or father? ); s elective reduction (Did the best child s urvive? ); s ingle with donor s perm (C an I truly provide all that is Who is the father? ); in vitro fertilization or gamete intrafallopian transfer (Will the child be normal? How should I parent this s pecial child? W ho s hould know this child was conceived? ). T hese is sues also arise in adoption and in s ingle parenthood unrelated to reproduction, but the elective decis ion to use technologies may make parents feel an enhanced res ponsibility or predis pos e them to unrealis tic about the child. T he expectant parents in these may warrant prophylactic ps ychological intervention or, the very leas t, especially attentive obs tetricians and pediatricians .

Depres s ion during P regnanc y P revalence rates for depres sion peak between the 25 and 44. Hence, depress ion during pregnancy is common, particularly in women with a previous his tory depres sion. Y et, depres sion during pregnancy remains unrecognized and undertreated problem. T he of depress ion during pregnancy can be confounded by overlap in somatic complaints common to both conditions, such as s leep disturbances , eating disturbances , weight gain, irritability, and fatigue. common somatic complaints of pregnancy may be 3068 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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miscons trued as s ymptoms of depres sion when using traditional depres sion as sess ment s cales (such as the Depress ion Inventory, the Hamilton R ating S cale for Depress ion, or the C enter for E pidemiological S tudies Depress ion S cale), symptoms of depres sion reported pregnant women may be misidentified as normal pregnancy-related complaints by treating obs tetricians. P rovider bias about pregnancy being a gift or an unconditionally happy time for women may als o s erve blunt recognition of depress ive symptoms in this population. Us e of the ten-item E dinburgh P ostnatal Depress ion S cale (E P DS ) (T able 28.1-6) has been accurately identify depres sion in pregnant and women. T his brief s creening instrument has been validated in pregnant and postpartum populations and may be easily incorporated for s tandard practice us e in obstetrical treatment settings.

Table 28.1-6 E dinburgh Pos tnatal Depres s ion S c ale (E PDS ) As you have recently had a baby, we would like know how you are feeling. P lease UNDE R LINE answer which comes closes t to how you have felt T HE P AS T 7 DAY S , not just how you feel today. Here is an example, completed.

*5. I have felt or panicky for no very good reason 3069

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   I have felt happy:

   Y es, quite a lot

   Y es, all the time

   Y es, sometimes

   Y es, mos t of the time

   No, not much

   No, not very often

   No, not at all

   No, not at all

*6. T hings have been getting on of me

T his would mean: I have happy most of the time during the pas t week. complete the other in the s ame way.

   Y es, mos t of the time I haven't been able to cope at all

   Y es, sometimes I haven't been coping as well as  

   No, most of the time I have coped quite well

In the pas t 7 days :

   No, I have been coping as well as ever

1. I have been able to laugh

*7. I have been so

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and s ee the funny side of things

unhappy that I had difficulty sleeping

   As much as I always

   Y es, mos t of the time

   Not quite s o much now

   Y es, sometimes

   Definitely not s o much

   Not very often

   Not at all

   No, not at all

2. I have looked forward enjoyment to things

*8. I have felt s ad miserable

   As much as I always did

   Y es, mos t of the time

   R ather les s than I us ed to

   Y es, quite often

   Definitely less than I used

   Not very often

   Hardly at all

   No, not at all

*3. I have blamed mys elf unnecess arily when things went wrong

*9. I have been so unhappy that I been crying

   Y es, mos t of the time

   Y es, mos t of the 3071

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time    Y es, some of the time

   Y es, quite often

   Not very often

   Only

   No, never

   No, never

4. I have been anxious or worried for no good reason

*10. T he thought harming mys elf occurred to me

   No, not at all

   Y es, quite often

   Hardly ever

   S ometimes

   Y es, sometimes

   Hardly ever

   Y es, very often

   Never

R es pons e categories are s cored 0, 1, 2, and 3 according to increas ed severity of the symptom. Items marked with an as terisk are reverse scored 3, 2, 1, and 0). T he total s core is calculated by together the scores for each of the ten items . may reproduce the scale without further providing they respect the copyright (which with the B ritis h J ournal of P s ychiatry) by quoting name of the authors, the title, and the source of 3072 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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paper in all reproduced copies. Ins tructions for users : 

 





T he mother is asked to underline the that comes clos es t to how s he has been in the previous 7 days. All ten items must be completed. C are should be taken to avoid the pos sibility the mother discus sing her ans wers with T he mother should complete the scale unles s s he has limited E nglish or has difficulty with reading. T he E P DS may be us ed at 68 wks to screen postnatal women. T he child health clinic, postnatal check-up or a home vis it may suitable opportunities for its completion.

F rom C ox J L, Holden J M, S agovs ky R : Detection postnatal depress ion. B r J P s ychiatry. 1987;150:782786, with permiss ion. R es earch indicates that 9 percent of pregnant women meet criteria for major depress ive illnes s. Y et, ris ks involved with treating women during pregnancy res ult in the provision of inadequate depres sion treatments for pregnant women. Indeed, the American P sychiatric Ass ociation's C ommittee on R es earch on P sychiatric T reatments recently identified treatment of depres sion during pregnancy as a priority area for improvement in clinical management. 3073 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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Parturition F ears regarding pain and bodily harm during delivery universal and, to some extent, warranted. P reparation childbirth affords a s ens e of familiarity and can eas e anxieties , which facilitates delivery. C ontinuous support during P.2307 labor reduces the rate of cesarean section and forceps deliveries, the need for anes thes ia, the us e of oxytocin, the duration of labor. A technically difficult delivery, however, does not appear to influence the decis ion to additional children. Male respons es to pregnancy and labor have not been studied, but the recent trend toward inclusion of fathers the birth process es eas es their anxieties and elicits a sens e of participation. If fathers are to be full partners parenting, they must be given opportunities to and expres s themselves during pregnancy and F athers do not parent the s ame way as mothers , and mothers often need to be encouraged to res pect these differences and view them pos itively.

Pos tpartum T he postpartum period entails multiple physiological ps ychological adjus tments . E strogen and proges terone concentrations decline precipitously, adrenal secretion cortis ol is altered, los s of placental hormones changes metabolism profoundly, and many new ps ychological challenges exis t. Delivery its elf als o entails a metabolic challenge, especially if a cesarean section was 3074 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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Interes tingly, longitudinal data indicate that recovery a vaginal delivery takes longer than recovery from a cesarean s ection. T he additional recovery time be related to perineal trauma and its s equelae. sleep deprivation is a common, if not universal, cons equence of the infant's lack of circadian cycle. T he average time for an infant to develop a recognizable nocturnal sleep pattern is 12 weeks . At time, infants dis play a clear nyctohemeral pattern of melatonin s ecretion, indicating maturation of the clock, the s uprachias matic nucleus .

L ac tation Lactation occurs because of a complex ps ychoneuroendocrine cas cade that is triggered by the abrupt decline in es trogen and proges terone concentrations at parturition. Lactation P.2308 becomes es tablis hed in respons e to the neurological stimulation trans mitted by suckling. T he compos ition amount of breas t milk changes as the infant grows . In general, babies s hould be fed as needed rather than by schedule. B reast-feeding has many benefits. T he composition of breas t milk s upports timely neuronal development, confers pass ive immunity, and reduces allergies . P sychological benefits accrue to both mother and infant. E very effort should be made by health profes sionals to convey these benefits. T he workplace should include a place where women s o interested can expres s breas t milk. If for s ome reason, however, the mother is not able to breas t-feed, reass urance that the 3075 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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child can be well cared for and adequately fed with formulas should be provided to minimize the attendant guilt that may occur. C ertain organizations that insist breast-feeding for 2 years so as not to deprive the child his or her natural rights may deter maternal and child being.

P erinatal Mood Dis orders R is k of depres sion is particularly high for women during the perinatal period, with 10 to 15 percent of women experiencing a major depres sive episode this time. B ecaus e there is no formal s creening for pos tpartum psychiatric dis orders, recognition falls to obstetricians , who may only see the patient once at the week postpartum checkup, or to pediatricians. F or and other reasons, detection of postpartum ps ychiatric disorders remains a major problem in this country. It is critical for the obstetrician to ask patients about postpartum adjus tment in a nonjudgmental manner and to indicate that the patient s hould call or return for help she becomes overwhelmed. Optimally, the obstetrician should have an es tablis hed screening and referral for new mothers to enhance the detection and of pos tpartum psychiatric dis orders (T able 28.1-6). In Wes tern E uropean countries, there are nationwide surveillance programs established to permit better detection of postpartum mood dis orders. P ostpartum ps ychiatric disorders may include transient depress ive symptoms (i.e., the pos tpartum blues), pos tpartum depres sion, postpartum psychosis, and common disorders .

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POS TPAR TUM B LUE S T he most common cons tellation of mood symptoms experienced by women in the immediate postpartum period is typically referred to as the pos tpartum blues baby blue s . A relatively common phenomenon in 50 to 80 percent of women), postpartum blues transient symptoms and rapid mood shifts , including tearfulnes s, irritability, anxiety, ins omnia, lack of loss of appetite, and the general experience of feeling overwhelmedparticularly with regard to newborn caregiving tasks. B y definition, the pos tpartum blue s transient in nature. Onset typically occurs after the third postpartum day, after the mother has left the hospital delivery. S ymptoms typically peak by day 5 and spontaneously resolve by day 10 pos tpartum. It has es timated that 75 percent of women who experience symptoms of postpartum blues will display such a timelimited course; however, 20 to 25 percent may go on to experience full-blown postpartum depres sion. T hus , treatment of the postpartum blues s hould include ps ychoeducation, validation of the mother's and careful monitoring for a wors ening or prolongation symptoms that may indicate the development of a fullblown mood or anxiety disorder.

POS TPAR TUM DE PR E S S ION P os tpartum depress ion occurs in 10 to 15 percent of postpartum women. Apart from the pos tpartum timespecifier, the diagnostic criteria for postpartum are indis tinguis hable from thos e of major depress ive disorder. A number of studies, however, sugges t a incidence of anxiety s ymptom comorbidities with 3077 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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postpartum versus nonpostpartum depres sion. R isk for the development of pos tpartum depres sion include personal or family his tory of depress ion in general, as as a pers onal his tory of previous depres sions related to reproductive events (such as premens trual dysphoric disorder or previous postpartum depress ions ). T hes e other findings s uggest that a s ubgroup of women, particularly thos e with a his tory of recurrent depres sion, may dis play a heightened sensitivity to changes in reproductive hormone levels , such as thos e occurring premenstrually, as well as to changes that occur during postpartum and perimenopaus al reproductive T his is not to underes timate the potential role of ps ychos ocial variables as ris k factors for depres sion during the pos tpartum period. As with nonpos tpartum depres sions , women facing multiple or severe ps ychos ocial problems or chronic interpersonal are at increas ed risk of experiencing a major episode during the postpartum period. R esearch that ps ychosocial stress ors may s ens itize the brain to subs equent metabolic or hormonal changes and vice versa.

POS TPAR TUM PS YC HOS IS T he most severe of the perinatal mood disorders , postpartum ps ychosis is rare, affecting approximately to 0.2 percent (1 in 1,000 to 1 in 500) of pos tpartum women. C urrent evidence indicates that pos tpartum ps ychos is is most commonly as sociated with the of bipolar dis order. E pisodes of postpartum psychosis typified by auditory or vis ual hallucinations , paranoid or grandiose delusions , elements of delirium or disorientation, and extreme deficits in judgment 3078 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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accompanied by high levels of impulsivity that may contribute to increas ed risks of s uicide or infanticide. It often has a mercurial course, changing rapidly the day and throughout the postpartum period. T his disorder tends to show ons et within 2 weeks however, it may present later in the cours e of the a depres sion (i.e., 3 to 5 months pos tpartum). ps ychos is carries a relatively good prognos is with early detection and aggress ive treatment.

POS TPAR TUM B IPOLAR DIS OR DE R Women with a history of bipolar disorder are at exceptionally high risk for epis ode recurrence during postpartum period. Although the cause of this recurrence ris k during pos tpartum is unknown, it may as sociated with abrupt changes in estrogen and proges terone, perturbation of the hypothalamicthyroid axis , decreased or erratic s leep patterns, ps ychos ocial stress as sociated with motherhood and young infant care, or any combination of these factors . Indeed, res earch indicates that dis ruptions in social rhythms and, mos t notably, sleep dis ruption may s erve mediate the link between life stress and increased ris k relaps e among bipolar patients, as s leep deprivation precipitate mania. Hence, close clinical monitoring and efforts to enlist the aid of s ocial s upports to prevent disruption and s tabilize s ocial rhythms in the new with a history of bipolar disorder may be particularly important. It is advisable to maintain the woman on stabilizers within 24 hours of delivery in severe cas es prevent the high risk of relaps e that occurs during the postpartum period. 3079 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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OTHE R PS YC HIATR IC DIS OR DE R S MAY PR E S E NT IN PR E G NANC Y OR POS TPAR TUM As with unipolar depress ion, women tend to s how an increased lifetime prevalence of a number of anxiety disorders , as compared with men. T hese syndromes include anxiety disorders , such as panic dis order, of agoraphobia, s ocial phobia, specific phobias, and generalized anxiety disorder. T hus, it is important for gynecologis ts and primary care practitioners to have a basic familiarity with the anxiety dis orders to promote early detection and treatment.

Ps yc hiatric Treatment Dec is ion during Pregnanc y and Pos tpartum C linical decision making is particularly complicated for pregnant and breas t-feeding women becaus e definitive answers regarding the relative s afety of available ps ychotropic medications , which often represent firstdepres sion treatments , are unlikely to become the near future. Although ethical considerations limit performing randomized, prospective medication studies with pregnant women, additional obs ervational data should be collected in regis tries . T he U.S . F ood and P.2309 Drug Adminis tration (F DA) rates drugs in five safety for use in pregnancy, with categories of risk A, B , C , D, and X (T able 28.1-7). T he usefulness of this categorization in treating depres sed women has come question, however, as most antidepres sants fall into C ategory C , which includes medications for which 3080 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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studies are lacking.

Table 28.1-7 U.S . Food and Drug Adminis tration R ating of Drug S afety in Pregnanc y C ategory

Definition

Drug E xamples

A

No fetal ris ks in controlled human studies

Iron

B

No fetal ris k in animal s tudies but no controlled human studies or fetal risk in but no ris k in wellcontrolled human studies

Acetaminophen

C

Advers e fetal effects in animals and no human data available

Aspirin, haloperidol, chlorpromazine

D

Human fetal ris k

Lithium,

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X

seen (may be in life-threatening situation)

tetracycline, ethanol

P roved fetal ris k humans (no indication for us e, even in lifethreatening situations)

V alproic acid, thalidomide

When a woman becomes pregnant, current us e of medications should be identified immediately and ris kbenefit analys es of medication continuation s hould re-evaluated in light of altered ris ks as sociated with treatment continuation and ris k of illness recurrence during pregnancy. T he hormonal effects of pregnancy, moreover, may change the cours e of the patient's is not neces sary to induce unwarranted guilt or to have woman cons ider aborting if she does become pregnant while on ps ychotropic medications . W hen exposure to teratogen is s us pected, one should consider that during weeks 2 to 8 of ges tation represents the highest for organ malformation. C linical decision making in the treatment of pregnant women s hould be structured to include patient regarding depres sion, identifying and reviewing likely and benefits ass ociated both with depres sion and available depres sion treatments, and frank dis cuss ion 3082 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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available treatment options. T his decision-making must be tailored to addres s the s everity of the patient's current illnes s and psychiatric his tory, as well as the experiences , values, and concerns of the patient. Open communication, provis ion of ris kbenefit information to patients in a comprehens ible format, and the ability to listen to, reflect, and res pect the patient's concerns and value s tructure are critical to optimizing treatment decis ions and obtaining fully informed consent for treatment. R is kbenefit analyses of depres sion treatment options should cons ider the potential risks that may accrue if depres sive epis odes go unmonitored or untreated in pregnant patient. R is ks of clinical deterioration include severe ps ychological distress , suicidal ideation, social occupational dysfunction, financial hardship, and an inability to plan for and s ucces sfully cope with the impending life trans itions . In addition, the biological dysregulation of major depres sion, including potential neuroendocrine dysfunction of the HP A s tres s axis, represent a toxic environment for the developing fetus . T he behavioral ramifications of major depress ion must be cons idered. T hes e may include poor prenatal care seeking, social withdrawal, s leep disturbance, poor nutrition, and weight loss , as well as increas ed ris k of cigarette, alcohol, and drug use. E ach of thes e outcomes can compromise the health of both the and the developing fetus . Moreover, s ubs tantial indicates that untreated depress ion in mothers can the neurocognitive development of the child. G iven the neuroendocrine aberrations that can accompany depres sion, s uch as hypercortisolemia and 3083 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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hypothyroxinemia (low thyroxine), fetal compromis e is surpris ing. High cortis ol levels as sociated with distress have been linked to congenital fetal anomalies . Als o, the mother is the only source of thyroxine for the fetus in early gestation, and thyroxine is critical for fetal brain development. Antidepress ant us e may reverse or ameliorate the untoward neuroendocrine patterns as sociated with maternal depress ion. Nonpharmacological depress ion treatments, such as outpatient ps ychotherapy, can present advantages for pregnant patients with mild to moderate depress ion by eliminating psychotropic expos ure, while providing the new mother with emotional s upport and instrumental development needed to facilitate coping with transitions to the motherhood role. W hen available, patients to avoid pharmacological treatments may als o cons ider other alternative depres sion treatments, such as bright light therapy or wake therapy (s leep deprivation). planned pregnancy in a psychiatrically stable patient, withdrawal of psychotropic medications should be cons idered and, when appropriate, attempted under supervis ion. T he importance of close rapport between treating phys ician and the pregnant or breast-feeding patient cannot be overs tated and will obviate or reliance on psychotropic medication in many cases . Des pite the potential advantages of depres sion treatments , pharmacotherapy may more effective treatment option for patients with s evere depres sion or for thos e whos e s ymptoms do not to ps ychotherapy alone. P harmacotherapy may also represent a more practical approach for patients for the competing and oftentimes overwhelming demands 3084 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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work, child care, s ingle parenthood, and financial s train may prohibit participation in weekly psychotherapy. In these cas es , clinical decision making must balance the known and unknown risks of medication treatment with the known and unknown ris ks of untreated depres sion. Women with previous epis odes of depress ion or occurring during pregnancy or the puerperium may develop s ignificant anticipatory anxiety about experiencing the potentially devastating effects of illness es again, which can be dramatically mitigated by ongoing care and effective management by the health care provider. In the United K ingdom, Aus tralia, and certain E uropean countries , for example, the existence motherbaby units and home health care providers has major impact on improving the recognition and management and reducing the advers e cons equences these dis orders. W hether treatment interventions are ps ychos ocial or pharmacological, early intervention clos e follow-up and maintenance throughout the puerperium have the best prognosis and prevent the untoward consequences and refractory course that otherwis e may develop.

Pharmac ologic al Treatments during Pregnanc y Major Depres s ion F or women with a diagnos is of major depress ion, treatment with antidepres sants is appropriate. little information exis ts on the us e of tricyclic and other antidepres sants in pregnancy, especially cons idering frequency of major depres sion in women of 3085 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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age. Depress ion in the first trimester, if not moderate to severe, s hould be treated, if pos sible, by s upportive meas ures , as pregnancy its elf may improve minor depres sive s ymptoms. C ases of suicidality, vegetative P.2310 signs , or ps ychos is warrant hospitalization. Us e of antidepres sants, including S S R Is, is indicated for signs accompanying a major depress ive epis ode that not res olve with supportive intervention. T he available data s how no evidence for a s tatistically significant as sociation between fetal expos ure and high rates of congenital malformations in fetus es exposed to tricyclic other antidepres sant drugs , although isolated cases of abnormalities have been reported in clinical and animal studies. T he clinician also needs to inform women the potential for neonatal toxicity and long-term behavioral teratogenicity. T here has been concern the effects of the use of antidepress ant drugs in the second and third trimesters on the neurological development of the fetus , particularly with res pect to neurotransmitter s ys tems. In s tudies of rodents, affects neurotrans mitter s ys tems in the brain, although difficult to know how these findings may apply to If antidepress ants are us ed in the third trimester, the pediatrician should be warned to anticipate the of withdrawal s ymptoms in the infant, and any marked change in maternal blood press ure is an indication for obstetrical s urveillance of uteroplacental s ufficiency. F or new onset of depress ion, an S S R I may be tried because s uch agents are ass ociated with a low ris k of 3086 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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effects in patients taking an overdose, as well as with of administration. However, if the patient has previous ly had a pos itive respons e to a s pecific drug from any antidepres sants, that agent s hould be s trongly Women may be more likely to have a response to serotonergic agents, such as the S S R Is and than to nonserotonergic tricyclic antidepress ants . S low increases in the dos e are helpful in managing side Dos ages of certain drugs (i.e., tricyclic antidepres sants, lithium) may need to be increas ed in the third trimes ter.

TR IC YC L IC ANTIDE PR E S S ANTS Amitriptyline (E lavil) and trimipramine (S urmontil) have been as sociated with adverse pregnancy outcomes in and rabbits . T razodone (Des yrel) and amoxapine have als o been ass ociated with poor fetal outcome in lower mammals . T hus , in general, although has not been proved, it is advis able to avoid using drugs in the first trimester. In addition, thes e agents interfere with normal labor. Is olated case reports have documented a withdrawal syndrome in neonates , including cyanosis, difficulty breathing, and feeding difficulties after desipramine (Norpramin), urinary retention after nortriptyline (P amelor), and dystonic movements and s eizures after imipramine (T ofranil). findings have led s ome authors to recommend a withdrawal period for patients on tricyclic drugs. no evidence indicates that intrauterine withdrawal is than extrauterine withdrawal. B ecause fetal and s eizures are pos sible, extrauterine withdrawal may safer. Like phenothiazines , tricyclic drugs can caus e hypotens ion. 3087 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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S E LE C TIVE S E R OTONIN R E UPTAK E INHIB ITOR S (S S R IS ) One s tudy comparing pregnancy outcome after first trimes ter expos ure to fluoxetine, tricyclic antidepres sants, and nonteratogens found that infants born to women treated with either fluoxetine or tricyclic antidepres sants had more neonatal complications than the group exposed to nonteratogens but no increas ed teratogenic ris k. Another s tudy found that women fluoxetine during pregnancy do not have an increas ed of spontaneous pregnancy loss or major fetal but infants expos ed to fluoxetine in the third trimester at increas ed risk for more perinatal complications (premature delivery, admiss ion to s pecial-care poor neonatal adaptation, including respiratory cyanosis on feeding, jitteriness , lower birth weight, and shorter birth length). T hese inves tigators recommend fluoxetine be dis continued, if pos sible, before the last trimes ter. One s tudy found that the neurodevelopment preschool children exposed in utero to tricyclic drugs or fluoxetine during pregnancy and followed from birth 86 months did not differ from that of the control group. T here were no significant differences in temperament, mood, arousability, activity level, dis tractibility, global intelligence quotient (IQ), or language development in children exposed to S S R Is in fetal life. Another study reported pregnancy outcomes after maternal us e of the S S R Is fluvoxamine, paroxetine, and sertraline and that outcome among women who took an S S R I throughout pregnancy did not differ from those who the drug only during the first trimester or from women who were exposed to nonteratogens . 3088 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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MONOAMINE OXIDAS E INHIB ITOR S (MAOIS ) T he us e of monoamine oxidase inhibitors (MAOIs ) is contraindicated in pregnancy for several reas ons. F irst, studies found growth retardation in animals receiving doses in exces s of the maximum human recommended dose. S econd, pregnancy-induced hypertension is a common complication of pregnancy that often has an insidious onset; further exacerbation of that condition us e of MAOIs may lead to placental hypoperfusion and have serious fetal cons equences . T hird, if premature occurs, tocolysis with β-mimetics may be obs tetrically indicated but not pos sible becaus e of potential with the MAOI. F ourth, anesthetic management in labor may be complicated by the relative contraindication of opioids in patients taking MAOIs . If pregnancy occurs the patient is taking MAOIs , the drug s hould be discontinued. G uidelines have been s ugges ted for appropriate obs tetrical anesthes ia and analges ia for women treated with MAOIs.

P s yc hos is P sychos is is a medical emergency because of the ris k for infanticide or s uicide. Imminent referral to a ps ychiatris t, hospitalization, or initiation of antips ychotic medication is indicated. P sychotic illnes s its elf confers greates t increase in risk of poor fetal outcome.

ANTIPS YC HOTIC S No conclus ive evidence indicates that antipsychotics teratogenic. Unless the patient presents a danger to herself, her unborn child, or others or hos pitalization 3089 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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not adequately control her ps ychos is , phenothiazines should be avoided in the first trimester because they slightly increase the risk of congenital anomalies (0.4 percent). Us e of thes e agents in the second and third trimes ter is unlikely to caus e fetal malformation, and, in contrast to data in animals , there is no evidence of term effects on behavioral functioning or IQ up to age 5 humans. T he pediatrician should be alert to the of trans ient perinatal syndromes (motor restles sness , tremor, hypertonicity, abnormal movements , difficulty with feeding, and pos sible neonatal jaundice and functional bowel obstruction) that generally res olve days , but may last up to 10 months after birth. In view of the potential for hypotension with aliphatic phenothiazines and thioridazine (Mellaril) and the increase ris k of fetal malformations with (T horazine), us e of high-potency agents appears preferable as first-line management; low-potency should be us ed only if unacceptable adverse effects with the use of other agents . Monitoring of sufficiency is indicated if severe hypotension occurs. newer atypical antips ychotic medications, s uch as ris peridone (R is perdal) or clozapine (C lozaril)perhaps because they are not specific for dopamine type 2 receptors linked with puerperal ps ychos is do not appear be as effective as the high-potency dopamine blockers , such as haloperidol (Haldol), in reducing psychotic symptoms during the puerperium. Medications to treat the extrapyramidal s ide effects of neuroleptics are generally not needed during pregnancy because of the effect of estrogen on dopamine receptors. T heir routine us e is not advised given the ass ociation between the 3090 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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of thes e drugs , s uch as benztropine (C ogentin), trihexyphenidyl (Artane), and amantadine (S ymmetrel), and malformations. Maintenance on antipsychotic medication for at least 6 weeks is warranted, with close monitoring, at least, at weekly intervals . If recognized in its early stages and treated aggress ively, postpartum ps ychos is has a good prognos is . However, nonpsychotic depres sive may pres ent later in the cours e P.2311 of the illnes s. If recognition or treatment of ps ychos is is delayed, it often develops into a chronic illnes s more refractory to intervention.

Mania In women with preexisting illness , there is a high recurrence of mania during pregnancy that may ps ychos is , thus, maintenance on lithium is important to deter the development of adverse sequelae to the and infant. T he ris k of the development of E ps tein's anomaly in the first trimester with us e of lithium is lower than was previously thought. Lithium cros ses the freely, and maternal and fetal plasma concentrations similar. R eversible goiter from trans placental lithium poisoning can occur. Neonates exposed to lithium in have exhibited a variety of neurological side effects, including muscle flaccidity, inhibition of normal reflexes, lethargy, and cyanos is, and cardiovas cular including atrial flutter, tricuspid regurgitation, and congestive heart failure. C areful monitoring of lithium concentration is required because of the dramatic s hifts 3091 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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fluid volume during pregnancy. A higher glomerular filtration rate, coupled with the increas ed plas ma often leads to a requirement for higher dos ages in the gravid woman to achieve comparable serum lithium concentrations. Dehydration may occur during labor, there may be a rapid loss of fluid volume after delivery. T hus, when lithium is us ed in the s econd and third trimes ters , the clinician s hould monitor lithium every 2 weeks and taper lithium slowly to 25 to 50 percent of us ual dos age 2 weeks before the es timated date of confinement, if clinically indicated. T he anticonvulsants carbamazepine (T egretol) and valproic acid (Depakote) have not proved s afer than lithium. Although they are effective mood s tabilizers , their use has been with a 1 to 5 percent incidence of spina bifida or other neural tube defects. T he risk is thought to be higher valproic acid. If mania cannot be controlled with antips ychotics or mood s tabilizers , clonazepam is a reasonable alternative. B enzodiazepines, such as diazepam (V alium), cross the placenta throughout gestation, and us e of diazepam has been ass ociated cleft lip and palate. It is advisable to us e a low-dose neuroleptic for treating the s ymptoms of mania and attendant anxiety.

Pharmac ologic al Treatments during Pos tpartum Depres s ion E ducation and reas surance can manage maternity F or major depres sion, antidepress ant medication is indicated. However, only one placebo-controlled trial three open trials that s pecifically addres s postpartum 3092 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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depres sion have been published. T he S S R I fluoxetine compared with ps ychotherapy, and both treatments similarly effective. F luoxetine was s ignificantly more effective than placebo. In open trials, sertraline, venlafaxine, and drugs grouped according to clas s and tricyclic antidepres sants ) were effective. Women who have given birth recently often are to the side effects of medications . T reatment should be initiated at half the recommended s tarting dose (e.g., mg of sertraline per day or 10 mg of paroxetine per for 4 days , and doses s hould be increased by small increments (e.g., 25 mg of s ertraline per week or 10 paroxetine per week) as tolerated until full remis sion is achieved. If the patient has a res ponse to an initial trial medication las ting 6 to 8 weeks , the same dos e s hould continued for a minimum of 6 months after a full has been achieved to prevent a relapse. If there is no improvement after 6 weeks of drug therapy or if the patient has a res ponse but then has a relapse, referral ps ychiatris t s hould be cons idered. Long-term treatment for the prevention of recurrence should be cons idered women who have had three or more epis odes of depres sion. As depress ive s ymptoms often present anxious, agitated features early in the postpartum antidepres sant treatment for these symptoms is to use of the benzodiazepines, given their high in breast milk and propensity to induce res piratory depres sion. All antidepres sants are excreted in breas t milk. the lowest effective dos e of antidepress ants s hould be us ed in a lactating mother. Obs ervation of the infant's behavior before the mother is treated permits clinicians 3093 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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avoid misinterpreting typical behavior as potentially related.

TR IC YC L IC ANTIDE PR E S S ANTS AND B R E AS T-FE E DING T ricyclic antidepress ants (T C As ) are not typically found meas urable amounts in nurs ing infants . Of the tricyclic antidepres sants, nortriptyline and des ipramine have side effects . R es piratory depress ion and s edation, the advers e outcomes reported with any T C A, occurred in infant whose mother was taking doxepin. Of the drugs this class , nortriptyline has been s tudied the most as a treatment for breast-feeding women. C hildren who expos ed to T C As through breast milk have been through pres chool and compared with children who not expos ed to these drugs, and no developmental problems were found. T C As, however, are not first-line drugs for the treatment of depress ion.

S S R IS AND B R E AS T-FE E DING An E xpert C ons ens us G uideline S eries has that the S S R I s ertraline be used as a firs t-line breast-feeding mothers because of its low risk, sporadic high levels have been observed in some One report obs erved minimal change in infants who expos ed to s mall amounts of s ertraline through breast by as sess ing platelet serotonin level, reflective of neuronal s erotonin transporters . Other inves tigators not obs erved adverse effects in breast-fed infants mothers were treated with sertraline, paroxetine, or fluvoxamine. In one report, the S S R I citalopram, with a relatively s hort half-life, was ass ociated with uneasy 3094 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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in an infant with a measurable serum level. W ith fluoxetine, breas t-fed infants of fluoxetine-treated gained less weight after birth, although unusual was not obs erved in these infants . C olic has been in three infants who were breas t-fed by mothers taking fluoxetine. T he infants had s erum levels of fluoxetine the active metabolite norfluoxetine that were in the therapeutic range for adults . As both fluoxetine and norfluoxetine have long half-lives (84 and 146 hours, res pectively), continuous expos ure to fluoxetine breast milk is more likely than exposure to other S S R Is lead to meas urable s erum levels. T here are no publis hed long-term evaluations of infants expos ed to S S R Is through breas t milk. As most of the published s tudies on antidepress ant levels in infants expos ed through breas t milk are in full-term infants, clinical monitoring and meas urement of s erum levels warranted for premature or sick newborns. T he fullneonatal cytochrome P 450 activity is approximately half that found in adults. T he collective data on s erum levels s uggest that infants more than 10 weeks of age at low risk for adverse effects from at leas t tricyclic antidepres sants. T he higher lipid content of hind milk makes it likely that the s econd half will have a higher concentration of maternal medication than the fore T aking medication immediately after breas t-feeding minimizes the amount pres ent in milk and maximizes clearance before the next feeding.

P s yc hos is G iven the high risk to the mother and infant during a ps ychos is and the minimal side effects of antipsychotic 3095 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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medication during breas t-feeding, imminent us e of lowdose, high-potency neuroleptics is warranted for this condition. T he patient s hould be left on the medication at least 6 weeks after the res olution of the psychos is, recurrences are common, particularly in the early postpartum period. Only minimal dos ages may be required to control s ymptoms. T he milk to plas ma ratio chlorpromazine (T horazine) is 0.3 to 1.0, and the ratio perphenazine (T rilafon) is 1 to 1. T he P.2312 us e of phenothiazines in lactating women has not been as sociated with s erious consequences, although developmental delays were obs erved at 12 to 18 in three infants exposed to a combination of haloperidol and chlorpromazine in one s tudy in which only one of infants had detectable s erum levels of neuroleptic. feeding by mothers taking thes e medications is not contraindicated, but monotherapy is advis ed whenever poss ible. G iven the risks of inducing hypotension with phenothiazines, the clinician is wise to use higherneuroleptics (such as haloperidol) in s mall dosages (1 mg) instead. As clozapine may induce fatal in adults and given the lack of data on infants with atypical antipsychotics, which may not exert specific efficacy on dopamine receptors , it is imprudent to use these medications as a first-line treatment or for treated with thes e agents to breast-feed. As es trogen modulate dopamine receptors , antiparkinsonian medication is generally not needed. F urthermore, as described above, antiparkinsonian medications have been adequately tested and may be ass ociated with 3096 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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significant side effects. T hus , they should not be us ed and should be administered only to treat advers e effects ass ociated with the use of medication.

Mania B ecaus e there is a high incidence of mania in the postpartum period, antips ychotic medication or mood stabilizers may be needed to control it. Although lithium carbonate is a first-line prophylactic treatment for women who are not bearing a child, its excretion the breast milk in mothers and the kidneys in infants makes its use problematic during lactation. T he mean concentration of lithium in breast milk is approximately half the maternal serum concentration, with a range 25 to 77 percent. Lithium concentrations in the s erum breast-feeding infants are es timated to be one-tenth to one-half of those in maternal serum. During the firs t several months of life, the infant's kidney function is not fully developed and the lithium excretion is s lower than that of an older child. S everal reports of lithium toxicity breast-feeding infants exis t, including cyanos is , T -wave abnormalities , and decreased mus cle tone. T oxicity is es pecially likely during dehydration, such as during infection. T hus, becaus e of this potential for toxicity, lithium is contraindicated in breast-feeding women. V alproic acid (Depakote) and carbamazepine also used as mood stabilizers in the treatment of B ecaus e of rapid metabolism, their use in lactating is s afer than lithium in the pos tpartum patient who be adequately controlled on neuroleptics but who on breast-feeding, provided that the infant is carefully monitored for pediatric clinical s tatus , liver enzymes , 3097 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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platelets . B ecause benzodiazepines , such as (V alium) and chlordiazepoxide (Librium), are excreted breast milk and may contribute to respiratory nursing mothers s hould avoid the use of these compounds. If necess ary, occas ional low doses of acting compounds are s afer.

Hormonal Interventions during Pos tpartum E strogen and proges terone have been us ed to treat postpartum depres sion. One study compared 17βes tradiol (200 mg per day) with placebo. T he es tradioltreated group had a s ignificant reduction in depress ion scores during the first month. Half of the women, were on antidepress ant treatment. T ransdermal may be used with antidepress ants for women with postpartum depres sion without interfering significantly with lactation. G iven the lack of randomized controlled trials , us e of proges terone as a treatment or the management of pos tpartum mood dis orders is not advis ed. P rophylactic adminis tration of a progestogen after delivery increased the ris k of pos tpartum as compared with placebo. T o inves tigate the hormonal basis of postpartum depres sion, one study s imulated decline in reproductive hormones after delivery in nonpregnant women with the us e of leuprolide to a hypogonadal state. T he women were then treated supraphys iological doses of es tradiol and proges terone and then both s teroids were withdrawn under doubleblind conditions . F ive of eight women with a his tory of postpartum depres sion, but none of eight women previous depress ion, had mood changes . T hus, with pos tpartum depress ion appear differentially 3098 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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to the effects of the withdrawal of gonadal steroids on mood.

Ps yc hotherapy Outc omes during Pregnanc y and Pos tpartum P regnanc y One report found that a 16-week pilot trial of ps ychotherapy was effective in significantly reducing depres sive ratings in 13 women with antepartum major depres sion. In another study of 35 economically disadvantaged women, inves tigators adminis tered a group intervention bas ed on interpersonal during pregnancy, which prevented pos tpartum depres sion.

P os tpartum One s tudy examined outcomes in 120 postpartum who were either given a 12-sess ion treatment with interpersonal psychotherapy that focus ed on changing roles and important relations hips or put on a waiting lis t for therapy (control condition). T he active therapy was effective in relieving depress ive s ymptoms and ps ychos ocial functioning. In another study, in addition to fluoxetine did not improve outcomes more than fluoxetine alone in women with postpartum depres sion.

E lec troc onvuls ive Therapy (E C T) Pregnanc y and Pos tpartum E lectroconvulsive therapy (E C T ) is an effective for pregnancy and postpartum depres sion and although it requires referral to a psychiatris t with 3099 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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certification in this proces s to implement.

Prophylac tic Treatment during Pregnanc y and Pos tpartum P regnanc y If a woman has brittle bipolar illness , s he should her ps ychotropic medication, as the advers e effects of recurrence of her illness outweigh the ris ks from medication.

P os tpartum P reventive therapy after delivery should be considered women with any previous his tory of depress ion. T he to which the patient previous ly responded or an S S R I reasonable choices . T he T C A nortriptyline did not protection compared with placebo in a follow-up study. One s tudy found that lithium carbonate served as an effective prophylactic agent. An international trial is way to investigate this work further by tes ting the of a neuroleptic (haloperidol) medication versus lithium carbonate in the prevention of recurrent pos tpartum ps ychos is .

C hronobiologic al Treatments during Pregnanc y and Pos tpartum One theory for depress ion includes desynchronization circadian rhythms. T reatment implications are to res ynchronize the biological rhythms of s leep and with those of other underlying circadian rhythms , s uch melatonin, cortis ol, thyroid-stimulating hormone (T S H), prolactin. T his end may be achieved by P.2313 3100 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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adminis tration of bright light (>2,500 lux) or wake (s leep deprivation) at critical times of the day. Although in its experimental stages , the us e of bright light or therapy in women with pregnancy or pos tpartum depres sion has had promising results in pilot s tudies . F urther s tudies in this area would be worthwhile given relatively s hort ons et of action of thes e treatments and avoidance of ris ks as sociated with pharmacological interventions .

C onc lus ions It is critical to recognize the symptoms of depress ion ps ychos is during pregnancy and pos tpartum. T he the symptoms are recognized, the earlier they can be treated, which dramatically improves their prognosis prevents the otherwise potentially devas tating effects of these illness es on the child, mother, family, and society.

Parenthood P arenthood is a major role that requires marked ps ychological adaptation. B y neces sity, a highly human being becomes the focus of one's time and E stablishing an effective balance between the equally important roles of autonomy and dependence within of the parents and between the spous es requires major shifts and reorganization. In many cultures , additional family members live with or nearby the new family and provide s upport and s hare time-cons uming and energy-demanding burdens of the infant. S uch extended families may contribute to role s train in the parents, but, on balance, they typically 3101 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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help to stabilize the family unit. Increas ingly in this country, parents are being required to live up to the multiple roles of parents , s pous e, friend, lover, and colleague in is olation. It often proves to be too much. Multiple competing res ponsibilities can precipitate child abuse, marital disruption, or mental illnes s. T he old that it takes a village to raise a child s eems well by experiences with parenthood. W ith all the stress ors parenthood, the situation of single parenthood (whether by choice or not) further accentuates these role Often, single parents must seek s ubstitute care in the of babysitters , live-in help (if affordable), and day care schools or religious institutions . B ecaus e s uch are only minimally available and often very expensive, role s train of parenthood without nearby family s upport systems may precipitate a s tate of cris is . E ven in modern society, women s till have the primary res ponsibility for child rearing, so parenthood places particularly intense demands on the mother. W orking career-oriented mothers may be financially able to other s upport s ys tems to ease the demands of parenthood, but further role s train can be precipitated demands and roles at work. Often, women have authoritarian demands at work but not enough power to carry out ass ignments. P s ychological demand is further increased by the many respons ibilities at home. men experience conflicts between family and work, but often their ability to us e power in the workplace is balanced by their ability to receive nurturance at home, with relatively fewer demands and respons ibilities and, ultimately, more control than women have. T he ps ychological strain on both men and women, 3102 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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if it involves change and is not in keeping with their biological predisposition, exacerbates the cus tomary demands of parenthood.

R E P R ODUC TIVE S E NE S C E NC E Menopaus e Menopaus e, the ces sation of ovulation, is due to the depletion of res ponsive ovarian oocytes and generally occurs between the ages of 47 and 53. T he marker amenorrhea. T he accepted definition is the ces sation mens es for a year (not due to other causes), but this narrow definition belies the complexity of the reproductive and psychological trans ition that the term me nopaus e connotes . T he hypoestrogenism that can lead to hot flashes, sleep dis turbances, vaginal and irritation, s exual dys function, joint pain, and and affective disturbances . E umetabolic predis pos es to osteoporosis, dementia, and disease. Menopaus e is generally heralded by 5 to 10 of erratic ovarian function revealed by irregular uterine bleeding. B efore the 1900s , menopaus e tended to just before death. P revious negative as sociations partly reflect the nearly coincident timing of menopaus e and death. T his relationship no longer holds, and it is commonplace for women to live 30 or more years after menopaus e. T he challenge now is to avoid the acute chronic disabilities that are related, in full or in part, to uniquely female los s of gonadal function. G iven that may be as many as 30 to 50 years of profound hypoestrogenism, this is no s mall challenge. F urther, today's and tomorrow's women mus t adjus t to the challenge of life after the loss of endogenous 3103 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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capacity. G iven women's longevity and s hort window, it makes little sense to define them solely by individual or collective reproductive competencies or events. S urgical menopaus e occurs when the ovaries are T his removal is often done in women older than age 35 who require a hysterectomy in an effort to reduce the probability of ovarian carcinoma. P rophylactic oophorectomy is a controversial procedure, however, the symptoms that follow s urgical castration before the age of natural menopause generally are more than are those that follow natural menopaus e. In menopaus e, the ovaries remain intact and continue to secrete androgens , including testosterone and andros tenedione, which can be converted in many to es trone, a weak es trogen. S urgical menopause an abrupt and complete loss of the ovarian secretion of androgens , es trogens, and proges terone, often well the age of menopause. E strogen replacement therapy generally indicated when bilateral oophorectomy is performed before natural menopause, but compliance may be compromised by ambivalence or a s ens e of premature loss if the decision to undergo was made without full cons ideration of all the risks and benefits. Androgen therapy is more controvers ial, in because a tested, s afe, physiological replacement is not yet commercially available. T he adrenal hormone dehydroepiandros terone (DHE A) is an androgen being promoted as a dietary s upplement to restore a of well-being, but few data are available on its longsafety and effects. T he s ame holds for the androgen andros tenedione, which is often promoted to enhance 3104 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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athletic performance or s upport libido. T here are no commercially available testosterone products , but one hormone product combines estrogen and methyltestosterone. Its use is recommended to libido. It remains to be demonstrated that methyltestosterone trans gres ses the bloodbrain barrier and gains access to the key brain centers that drive

Hormone R eplac ement Therapy T he pros and cons of hormone replacement therapy not been fully clarified. T he question of whether to or continue this therapy poses a medical, financial, and philosophical challenge. Until recently, mos t s tudies supported the conclusion that estrogen replacement increased longevity because of its cardioprotective properties. T he res ults of the W omen's Health Initiative have rais ed ques tions about the cardiovas cular us ing a s tandard combined oral estrogen plus (conjugated equine es trogens plus or a standard dose of combined equine estrogen preparation in all P.2314 women, regardles s of weight, age, or baseline health. However, becaus e not all es trogens have the s ame molecular properties , the res ults of the W omen's Initiative are not generalizable to other hormone In particular, evidence s ugges ts that more preparations, s uch as transdermal estradiol patches, minimize risks while retaining benefits. A negative of synthetic progestins as compared to progesterone also been advanced as an explanation for some of the 3105 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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findings of the W omen's Health Inititative and related epidemiological s tudies . Although concern exis ts that combined oral hormone use after menopause the ris k of breast cancer and affords minimal, if any, cardioprotection, there is also evidence of benefits. Hormone use retards bone loss and reduces the risk of os teoporos is and fracture, maintains urogenital stabilizes mood and other critical brain outputs , motor abilities, and maintains body composition. hormone therapy protects against dementia also controvers ial. S ome experts have s uggested that the increased ris k of venous thromboembolis m and stroke with orally delivered es trogens may have counteracted trophic effects of es trogens on neurons and glia. It is thought that normal routes of delivery of estradiol may prove neuroprotective, as there is increas ed ris k of thromboembolism with nonoral formulations . Although women at midlife tend to gain weight, s tudies have demonstrated that women who use hormone therapy gain less weight and that the weight gained is preferentially deposited in a gynecoid (hips and thighs ) rather than android (abdominal) pattern. Of note, recent, prospectively collected population data showed that rates of dementia increased in both men women after age 75 but that the increase was much greater in women than in men (relative risk, 2.1). rates of dementia in women were reduced in proportion years of hormone use after menopause. Ongoing us e for longer than 10 years, especially when begun contemporaneous ly with the onset of menopause, reduced the ris k of dementia in women to that of men. not widely appreciated that the brain converts 3106 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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tes tos terone to es tradiol and that men typically have, at times in their lives, more es tradiol bathing their neurons and glia than women do. B ecause men do not gonadal ces sation at midlife, as women do, their brains continue to be protected by estradiol indefinitely. T he and benefits of the us e of s elective estrogen receptor modulators (S E R Ms ) by postmenopausal women are being defined. E ach S E R M will have its own riskbenefit profile. However, becaus e the brain centers mediating cognition, attention, and mood are heavily inves ted the es trogen receptor s ubtype alpha (E R α) and most current S E R Ms are E R α antagonis ts, there is that the long-term us e of S E R Ms will increase the risk dementia. S E R Ms als o increase the ris k of venous thromboembolism, which may increase the ris k of C urrent evidence does not reveal a strong ass ociation between es trogen use and breast cancer. In particular, contraceptive us e, even in older women, is not with an increas ed risk of breast cancer. In terms of of life, hypoestrogenism can impair s exual enjoyment libido and can caus e hot flas hes , night sweats, and profound fatigue. T hese sequelae can generally be ameliorated or reversed with es trogen us e. T he trend present is to us e the smalles t dose that relieves thes e symptoms. P rogestin use is generally recommended for women uterus to guard against the development of endometrial hyperplas ia and carcinoma; whether or to what degree proges tin use compromises the beneficial effects of es trogen us e needs clarification. T he availability of a proges tin-containing intrauterine device (IUD) may minimize or obviate altogether the risks of s ys temic 3107 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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proges tin exposure. T he advers e effects that mos t limit proges tin use are depress ion and bloating. However, concern has been raised that the us e of progestins than proges terone will revers e cardioprotection by promoting vas ocons triction. P roges tins may als o the ris k of breast cancer, particularly when used continuously. W omen who previously experienced depres sion or premens trual s yndrome are most prone mood dis turbances with proges tin us e. T o avoid or minimize the effects of proges tin expos ure, it is prudent prescribe the s malles t amount of proges tin necess ary protect the endometrium from hyperplas ia or use a proges tin-containing IUD. R ecent data s upport the that antidepres sant and antidementia agents are more efficacious in women when they are estrogen replete. achieve the bes t ris kbenefit profile, it is worth titrating individualizing route, dos e, type, and regimen with the goal of maximizing benefits and minimizing advers e effects. T he recent introduction of a wide range of es trogen proges tin products , including so-called designer or S E R Ms, has expanded options . T here is even less information about the long-term risks and benefits of partial es trogen agonists or S E R Ms than about more conventional es trogen preparations. T he s ame holds phytoestrogens derived from soy and flaxs eed. Directcons umer marketing of hormone preparations means patients have more ques tions, concerns, and Although women want more information and guidance, phys icians are poorly reimburs ed for this type of couns eling and often lack s ufficient information. B oth men and women age and experience an age3108 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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decline in reproductive capacity, but only women experience P.2315 complete gonadal cess ation. Los s of reproductive may pres ent a ps ychological challenge to thos e who not reconciled to the loss of fertility. However, even gonadal failure, the availability of donor oocytes and sperm means that pregnancy can be initiated in a menopaus al woman with an intact uterus who elects to pursue that option. S ome women find these multiple options overwhelming. Menopaus e is not only a marker life s tage, it als o presents biological and psychological challenges unique to women.

P s yc hophys iologic al A daptation Depress ion at menopause was previous ly attributable the empty-nest s yndrome. Indeed, many women report enhanced sense of well-being and enjoy the to purs ue pos tponed goals. R ecent acknowledgment women's roles may encompas s more than child rearing has helped facilitate this attitude. T hus , ps ychological factors may enhance well-being in older women. T here is, in fact, little evidence to support the popular belief that menopaus e is directly as sociated with rates of major depress ion on a population level. some studies indicate increased levels of mood among perimenopaus al women, these ass ociations to be driven by common vasomotor symptoms of perimenopaus e, which may disrupt s leep and thereby to increas es in mild mood symptoms and irritability. strongest predictors of major depres sion among 3109 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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perimenopaus al women include a prior history of depres sion, high levels of vasomotor symptoms, and levels of ps ychosocial stress . Hence, women with a history of unipolar depres sion or bipolar disorder, particularly thos e women with a his tory of episode recurrence during previous reproductive events (s uch postpartum episodes or premens trual s ymptom fluctuations ), may be at particular risk for recurrence during the menopaus al trans ition.

A ging F urther investigations are required to dis tinguis h the ps ychological and biological effects of aging from those menopaus e. Aging is as sociated with diminished and circadian rhythmicity in both men and women. Des ynchronized or reduced biological rhythms may compromise sleep, cognition, and mood. T he brain is a target organ for gonadal steroids . Only women complete gonadal cess ation. T he los s of ovarian and proges terone exposure can precipitate hot flas hes , reduced libido, s leep disturbances , affective and decreased memory. However, both men and experience a gradual decline in adrenal and gonadal androgen production. Androgens help maintain libido, muscle mas s, strength, and energy. Androgen therapy been advocated as a way to retard the aging proces s, tes ted, s afe androgen replacement preparation is not commercially available for women. Many other chemotherapeutic agents have been advocated to the burdens of aging. T hese include antioxidants , s uch vitamin E , phytoestrogens, vitamin C , as pirin, alcohol, folate, vitamin D, and calcium; herbal s upplementals , as gingko biloba; and hormones , s uch as DHE A, 3110 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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andros tenedione, growth hormone or analogs, and melatonin. Menopaus al women often expect that phys icians who offer hormonal products at menopaus e increase long-term health will also know whether other chemotherapeutic strategies have merit. P sychological factors play a role in age-related Dis eas e and disability pres ent ps ychological and engender the need for changes in lifes tyle and employment. F urther, s tres s may accelerate certain proces ses. In a longitudinal population s tudy of the elderly, women whos e cortis ol levels remained acros s the observation interval of 2.5 years displayed progres sive cognitive impairment, whereas cognition improved in thos e whose cortisol levels returned to the normal range. T he mos t common stress was s ocial is olation. Depress ion in the elderly remains underrecognized and, therefore, undertreated, in part, because the pres enting s igns and symptoms may be confused for dementia or other concomitants of aging. S uccess ful aging demands adaptation to unique biological, and psychos ocial challenges .

S UG G E S TE D C R OS S Many of the reproductive trans itions that may occur a woman's life cycle are discuss ed els ewhere, S ection 26.4 on other conditions not attributable to a mental disorder, S ection 12.16e on pos tpartum disorders , S ection 28.2 on premenstrual dys phoric disorder, and S ection 24.6 on endocrine and metabolic disorders . C hapter 18 on normal human sexuality and sexual disorders discus ses important concepts gender and sexuality, including the s exual dys functions 3111 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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(S ection 18.1a). C hapter 19 discus ses eating conditions in which ovarian cyclicity is often dis rupted. Interactions between ps yche and soma are discus sed C hapter 8 on clinical manifestations of ps ychiatric disorders , S ection 24.9 on stress and ps ychiatry, and S ection 1.11 on ps ychoneuroendocrinology. between self and s ociety and the influences of culture discuss ed in S ection 4.1 on anthropology and and S ection 4.2 on sociology and psychiatry.

R E F E R E NC E S Adler NE , David HP , Major B N, R oth S H, R uss o NP , G E : P sychological respons es after abortion. 1990;248:41. Appleby L: S uicide during pregnancy and in the first postnatal year. B MJ . 1991;302:137. B erga S L. Disorders of gonadotropin secretion. In: S halet S , Was s J , eds. O xford T e xtbook of Oxford: Oxford Univers ity P res s; 2002:11191129. B erga S L, Marcus MD, Loucks T L, Hlas tala S , K rohn MA: R ecover of ovarian activity in women functional hypothalamic amenorrhea who were with cognitive behavior therapy. F e rtil S te ril. 2003;80:976981. C hambers C D, J ohnson K A, Dick LM, F elix R I, Lyon K : B irth outcomes in pregnant women taking N E ngl J Me d. 1996;335:10101015. 3112 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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C ohen LS , F riedman J M, J efferson S W , J ohns on M, Weiner ML: A reevaluation of risk of in utero to lithium. J AMA. 1994;271:146. C yranows ki J M, F rank E , Y oung E , S hear MK : onset of the gender difference in lifetime rates of depres sion: A theoretical model. Arch G e n 2000;57:2127. Dubal DB , Zhu H, Y u J , R au S W , S hughrue P J , Merchenthaler I, K indy MS , W is e P M: E strogen α, not β, is a critical link in estradiol-mediated agains t brain injury. P roc Acad Natl S ci U S A . 2001;98:19521957. F inkelstein J W , S usman E J , C hinchilli V M, D'Arcangelo MR , S chwab Demers LM, Liben LS , Lookingbill G , K uhn HE : E strogen or tes tos terone increases s elf-reported aggress ive behaviors in hypogonadal adolescents . J C lin E ndocrinol Metab. 1997;82:2433. G regoire AJ P , K umar R , E veritt B , Henders on AF , J W W : T rans dermal oes trogen for treatment of postnatal depress ion. L ance t. 1996;347:930. Hollander LE , F reeman E W , S ammel MD, B erlin J A, G ris so J A, B attistini M: S leep quality, estradiol behavioral factors in late reproductive age women. O bs te t G yne col. 2001;98:391397. K endell R E , C halmers J C , P latz C : E pidemiology of 3113 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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puerperal psychoses . B r J P s ychiatry. *K oren G . P as tus zak A, Ito S : Drugs in pregnancy. J Me d. 1998;338:1128. LeB lanc E S , J anowsky J , C han B K S , Nelson HD: replacement therapy and cognition. J AMA. 2001;285:14891499. Marchbanks P A, McDonald J A, W ils on HG , F olger Mandel MG , Daling J R , B erns tein L, Malone K E , S rom B L, Norman S A, W ingo P A, B urkman R T , S imon MS , S pirtas R , W eis s LK : Oral contraceptives the ris k of breast cancer. N E ngl J Me d. 2002;346:20252032. McE wen B S : T he molecular and neuroanatomical for es trogen effects in the central nervous system. J E ndocrinol Me tab. 1999;84:17901797. Moses E L, Drevets WC , S mith G , Mathis C A, K alro B utters MA, Leondires MP , G reer P J , Lopres ti B , T L, B erga S L: E ffects of es tradiol and proges terone adminis tration on human serotonin 2A receptor binding: A P E T study. B iol P s ychiatry. Moses -K olko E L, F eintuch MG : P erinatal psychiatric disorders : A clinical review. C urr P robl O bs te t F e rtil. 2002;25:66. Neugebauer R , K line J , S hrout P , S kodol A, G eller P , S tein Z. S us ser M: Major depress ive 3114 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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the 6 months after mis carriage. J AMA. Nulman I, R ovet J , S tewart DE , W olpin J , G ardner T heis J G W, K ulin N, K oren G : Neurodevelopment of children exposed in utero to antidepres sant drugs . N E ngl J Me d. 1997;336:258262. P ers on E S . Dreams of L ove and F ate ful E ncounte rs : P owe r of R omantic P as s ion. New Y ork: Norton; *S chmidt P J , Nieman LK , Danaceau MA, Adams LF , R ubinow DR : Differential behavioral effects of steroids in women with and thos e without premenstrual s yndrome. N E ngl J Me d. S colnik D, Nulman I, R ovet J , G lads tone D, C zuchta G ardner HA, G ladstone R , Ashby P , W eksberg R , E inarson T , K oren G : Neurodevelopment of children expos ed in utero to phenytoin and carbamazepine monotherapy. J AMA. 1994;271:767770. S eeman T E , McE wen B S , S inger B H, Albert MS , Increase in urinary cortisol excretion and memory declines : MacArthur s tudies of s ucces sful aging. J E ndocrinol Me tab. 1997;82:24582465. S tadberg E , Matts son LA, Milsom I: T he prevalence severity of climacteric s ymptoms and the us e of different treatment regimens in a S wedis h Acta O bs te t G ynecol S cand. 1997;76:442448. *T aylor S E , K lein LC , Lewis B P , G ruenwald T L, 3115 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/28.1.htm

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R AR , Updegraff J A: B iobehavioral responses to females: T end-and-befriend, not fight-or-flight. R ev. 2000;107:411. Weiss man MM, W arner V , W ickramarate P , Moreau Olfs on M: Offs pring of depress ed parents . Arch G e n P s ychiatry. 1997;54:932940. *Wis ner K L, P arry B L, P iontek C M: P ostpartum depres sion. N E ngl J Me d. 2002;347:194. Wisner K L, P erel J M, F indling R L: Antidepress ant treatment during breast-feeding. Am J P s ychiatry. 1996;153:1132. *Zandi P P , C arls on MC , P lass man B L, W els hMayer LS , S teffens DC , B reitner J C S : Hormone replacement therapy and incidence of Alzheimer's disease in older women. J AMA.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 29 - P s ychiatric E mergencies > 29.1: S uicid

29.1: S uic ide Howard S . S udak M.D. P art of "29 - P sychiatric E mergencies" S uicide is the primary emergency for the mental health profes sional, with homicide and failure to diagnos e an underlying potentially fatal medical illness representing other, but less common, emergencies. S uicide is also a major public health problem: T here were almos t 30,000 deaths in 2000 in the United S tates (>80 per day) and least 10 to 20 times that number of attempts . Although suicide is impos sible to predict precisely, there are numerous clues , as enumerated in the following discuss ion, that can help the practitioner reduce the for his or her patients. T here are als o s ome generally accepted standards of care that facilitate risk reduction, well as less en the likelihood of s uccess ful litigation, a patient death occur and a laws uit be filed. One can consider s uicide from many vantage pointsfor example, historical, sociological, cultural, biological, genetic, ps ychological, diagnos tic, philosophical, theological, economical, occupational, exis tentialand thes e disparate but complementary viewpoints are all, at leas t minimally, touched on in this chapter. One may also focus on s uicide ideation, attempts, or completed s uicides (avoid the adjectives uns ucce s s ful and s ucces s ful because of their connotations ) and on parasuicides (high ris k-taking 3117 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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behaviors ). It is als o well to es chew the term ge s ture , because it is pejorative and judgmental, may also lead underes timation of s ubs equent risk, and often (thereby poss ibly dismis sing) the s elf-injurious frequently seen in borderline patients. S uicide efforts may be focus ed on primary, s econdary, or levels or on prevention, intervention, or pos tevent efforts as is explained later in this chapter. S uicide also to be discuss ed in the context of s o-called as sisted s uicide. Las tly, s uicide needs to be terms of the devastating legacy that it leaves for those who have s urvived a loved one's suicide, as well as the ramifications for the clinicians who cared for the decedents . P erhaps the most important mess age to reiterate regarding s uicide is that s uicide is almos t the res ult of a mental illness , us ually depress ion, and is amenable to psychological and pharmacological treatment.

HIS TOR Y S uicide's history goes back at leas t to the earlies t written records (e.g., S ocrates , S eneca) or, poss ibly, to pictorial ones, if they have been deciphered correctly. of the earlies t scientific class ifications was by E mile Durkheim, who divided s uicides into egois tic, anomic, altruis tic types . T he egois ts were lonely, withdrawn individuals who were insufficiently integrated into their environments , whereas the anomic types were out of owing to life-circums tance changes (e.g., loss of job, love) or because they were chronically s o. T he altruis ts died for a cause (e.g., the soldier in the foxhole who hims elf on a grenade to s ave his comrades). Despite forbidden by almost all W es tern religions, s uicide has 3118 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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managed to flouris h over time. E ven religious s anctions (e.g., no burial in hallowed ground), aside from the and Middle Ages, were generally circumvented by the presumption of mental illness rather than evil.

INC IDE NC E A ND E P IDE MIOL OG Y In the las t half of the 20th century, the overall U.S . rate reached its highest level in the 5-year period 1990. B y 2000, the rate had fallen to around the 1980 (F igs. 29.1-1 and 29.1-2). W hy the rate per 100,000 fell between 1990 and 2000 is unclearhopefully, it relates improved detection and treatment (particularly pharmacological) for mental illnes ses. Although overall rates fell approximately 10 percent, rates fell more for adoles cents . It is helpful, when comparing rates, to us e 100,000 as the s tandard denominator for population or s ubpopulation being s tudied (the numerator being deaths , attempts, etc.). It is critical, comparing data, to ensure that the numerators and denominators refer to the exact s ame populations (e.g., both s exes or just men, age-adjus ted or crude rates , all other races or blacks ). R ank orderings , such as leading caus es of death, may be confusingfor ins tance, for age s tudents , suicide ranks as the s econd or third caus e of death compared to ranking between the to 12th leading caus e of death for all ages combined. C ollege-age s tudents are not more likely to die by than are older adults; however, becaus e their general health is better than older people, there are fewer deaths (s uch as heart disease and strokes ) in this population. T hus, even a lower rate of s uicide could in a higher ranking in a lis t of causes of death. F urthermore, such rankings are sensitive not only to 3119 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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changes in mortality for nonsuicidal deaths , but als o to modifications in the Inte rnational S tatis tical Dis e as es and R e late d He alth (IC D).

FIGUR E 29.1-1 S uicide rates , 1979 to 1999, all ages combined, for white and black men, white and black women, and for all races combined. (Data from the C enter for Health S tatis tics, C enters for Dis eas e

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FIGUR E 29.1-2 S uicide rates at s elected ages, all races genders combined, for 1979, 1989, and 1999. (Data the National C enter for Health S tatistics , C enters for C ontrol.) T here are approximately 30,000 deaths attributed to suicide each year in the United S tates . T his is in approximately 20,000 deaths annually from homicide. It es timated that s uicide attempts are at least ten times frequent than completed s uicides. Although there were significant s hifts in the suicide death rates for certain subpopulations during the last century (e.g., increas ed adoles cent and decreas ed elderly rates ), the overall approximately 20 s uicidal deaths per 100,000 pers ons, remained remarkably cons tant. T he exceptions to this number were the years of the G reat Depress ion (when 3121 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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rates rose markedly) and the two W orld W ars (when decreased dramatically).

Gender Differenc es In the United S tates, men have completion rates that roughly three times higher than those for women, regardless of racedes pite the fact that women attempt suicide approximately three times as often as men (F ig. 29.1-3). T his is P.2443 P.2444 not clearly understood but is us ually explained as due methodologythat is, women are more inclined to methods of lower lethality and less dis figurement and are les s painful, s uch as pills ; cons equently, there is a greater margin of s afety postattempt for women than men (who are more apt to choose methods of higher lethality, s uch as guns). It s hould be noted, however, there is increasing use of guns among women. F urthermore, the argument that women die les s often suicide attempt because they elect less lethal methods begs the ques tion of why they choose s uch methods . they wish to die less than men? Is it merely to avoid and disfigurement that they gravitate toward pills ? Is it reflection of a culture in which women are allowed latitude of emotional expres sion (particularly sadnes s) more lability than men? Is it that women tend to be impulsive when feeling suicidal and avail themselves of whatever they have readily available (such as pills), regardless of how lethal it is ? S imilar arguments posit 3122 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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men are s upposed to be s trong, macho, and deliberate Wes tern culture, keeping their sad feelings to so that a depress ed man has pres umably brooded a time about suicide before he acts and has had ample to arrange for a highly lethal means to carry out his plan. Another theory is that the lower female rate is due to the lower rate of alcohol abus e in women; thus, when s tudies control for this difference, the completed s uicide rates appear more comparable.

FIGUR E 29.1-3 S uicide rates by age and race, 1998. for black women 45 years of age and older are (Data from the National C enter for Health S tatistics , for Disease C ontrol.) Another explanation for the dis parity in rates is that women are more likely to seek medical help when they depres sed or to have another mental problem than are 3123 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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men. T he s ick role is les s uncomfortable to them than it for many men who feel obliged to tough it out. A complementary hypothesis is that women are more affiliative than menthey have a better network of via friends and family and are more likely than men to discuss their feelings within thes e networks, thereby poss ibly diminis hing their s uicidal feelings . T hey als o would be more likely to have others available to to get help, and so forth. T he fact that female completion rates are low male rates is all the more remarkable when one the prevalence of depress ion in women and men. Although male and female lifetime prevalence rates are comparable for bipolar disorder (manic-depres sive the incidence and prevalence of all depres sions together (which include dysthymic disorder, adjustment disorders with depress ed mood, depres sion not specified, etc.) are much higher for women. It is of that this male-female s uicide completion rate disparity may not be true all over the world. In C hina, for male and female completion rates are reported as comparable, and, in mos t countries other than the S tates, female rates increase as women get older, as case for U.S . white men.

Age Differenc es F or all groups, suicide is rare before puberty. F or white men, rates then increase in nearly direct proportion to (there is a diphas ic increase, with men 20 to 30 years having s lightly higher rates than men 30 to 40 years of age). African American male rates are nearly white male rates up to 25 to 30 years of age but then 3124 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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decrease, rather than increase, with increased age. striking divergence from the white male pattern has postulated, rather s peculatively, to relate to vulnerabilitythat is , African American men are less than P.2445 white men in the United S tates , and this s maller, vulnerable pool of s uicidal individuals has mos tly died by s uicide by approximately 30 years of age. A hypothes is is that it is s o difficult to be an African male in a still-prejudiced U.S . s ociety that African men age prematurely vis --vis s uicide potential (thus, a year-old African American man would have s uicide comparable to a 40- or 50-year-old white man). white rates continue to increas e after 50 years of age, explanation still fails to account for the African decreases after 30 to 35 years of age. White female are somewhat convex, with highes t rates in the middle years . African American female rates are low the life cycle. C ertain s pecific age populations , s uch as adoles cents the elderly, warrant special attention. B etween 1950 1980, completion rates for 15- to 24-year-old white and African American men and women increased threefold (300 percent). F or white women 15 to 24 age, rates doubled. T he rates continued to ris e in the 1980s , but the slope of the curve was les s s teep and, 1990 to 2000, had begun to drop (F ig. 29.1-4).

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FIGUR E 29.1-4 S uicide rates , from 1993 to 1997, for 19-year-old white and black men, white and black and all combined. (Data from the National C enter for Health S tatis tics, C enters for Disease C ontrol.) Much media attention focus ed on this dramatic T he expected attendant theorizing led to facile post hoc theories in which any other increase or decrease could post hoc, correlated directly or indirectly with the increased ratefor example, drug and alcohol abuse, availability, nuclear angs t, decreased role of religion, family breakdown. Daniel Offer and P aul C . Holinger offered a population hypothes is namely, that the ris ing proportion of adolescents vis--vis the remainder of the population that followed as the postW orld W ar II babyboom children entered adoles cence in 1955 or s o disadvantaged this group (fewer good jobs , only s o 3126 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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Ivy League acceptances available, etc.), so their s tres s levels and, consequently, their s uicide rates increased. How is it that the overall rate of suicide barely changed from 1950 (19 out of 100,000) to 1980 (20 out of during which period adoles cent rates tripled? S ome groups ' rates must have decreased over this same T hat is exactly what happened. E lderly (55 years of older) rates fell enough to balance out the adolescent increase. B ecaus e the period from 55 years of age to end of the life cycle encompass es many more years the period encompas sed by adoles cence and young adulthood, from 15 to 24 years of age, the elderly appeared less dramatic. T he explanations pos ited for elderly decrease relate to the quality of life improving in general for s eniors during this period owing to s ocial security, better medical care in general, and improved treatment of depres sion.

R ac ial Differenc es White male and female rates are approximately two to three times as high as African American male and rates across the life cycle. W hy s hould this be s o? protective about being African American? Here, again, theories are unsatisfying. A formerly popular, but overs implified hypothes is related to the viciss itudes of aggres sion. According to this theory, African more apt to externalize their aggress ion (hence the homicide rates), whereas whites tend to internalize aggres sion (hence the high s uicide rates). Herbert in B lack S uicide , challenged this by pointing out both suicide rates and high homicide rates in young African American males in Harlem. T he means -versus 3127 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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hypothes is holds that African P.2446 Americans realize that the playing field is not level and adjus t their aspirations in accord with the realities of discrimination. B ecaus e they therefore do not get their hopes too high, they are less apt to be disappointed depres sed). Another theory posits that strong family church affiliations within the African American are protective. A third holds that, like J ews in W orld concentration camps , the oppres sed cling to life with a special determination. It is of interes t that the gap to be narrowing from its traditional threefold difference being consistently twofold recently. Is this an by-product of as similation, or is it reflective of the of a larger African American middle class , or both? the role of socioeconomic differences between African Americans and white Americans is frequently ignored when African American and white data are compared. C ontrolling for s ocioeconomic s tatus (S E S ) differences markedly reduces many apparently racially bas ed differences.

Mis c ellaneous G roup Differenc es Native Americans have the highes t U.S . rates of suicidepartially or fully related to their high rates of subs tance abus e and likely compounded by high and gun availability rates. P rotestants and J ews in the United S tates have higher rates than C atholics but not much higher. Mus lims have much lower rates. R ates first-generation Americans mirror those of the countries from which their parents emigrated. Although urban 3128 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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res idents appeared to have rates significantly higher rural ones, recent data indicate that the R ocky and P lains states have higher rates than more areas, although there is some dis pute about this for time periods. Homosexual men and women appear to have higher rates of s uicide than matched and, again, reasons for this are not clear, as stress ed R ichard C . F riedman.

E TIOL OG Y OF S UIC IDE Although many of the vantage points mentioned in the introduction could s erve as subheadings for this (e.g., s ociocultural, philos ophical, and economic etiology), for practical reasons , this s ection focus es on biological, psychological, and biopsychosocial aspects .

Ps yc hologic al As pec ts Depress ed identical twins are far more likely to be concordant for s uicide than nontwin pairsbut not 100 percent concordant. W hy one twin and not another? R oughly 85 percent of individuals with bipolar illness kill thems elves . W hy is that? Is there als o a gene for suicide? What is there (or is n't there) in the mental of thos e who snuff out their lives ? W hat childhood colored their psyches in these fatal ways? William S hakes peare wrote of adoles cents whose love was frus trated, but is this a s ufficient explanation (F riar Lawrence's maladroit advice notwithstanding)? E ven Hamlet's exis tential questioning hardly provides a satis factory ans wer. E dwin S . S chneidman writes of victim's unbearable mental pain, ps ychache , and how, terminally, his perceptions are narrow (tunne l vis ion), 3129 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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he can see only one solutionhis death. S igmund F reud, Mourning and Me lancholia, wrote of aggress ion turned inward when one internalizes a los t object and then this rage on ones elf. K arl A. Menninger added to this he wrote of the s uicidal triada wish to die, a wis h to kill, and a wish to be killedas components of all s uicides . R edfield J amison, in An U nquie t Mind, writes her own s uicidal despair, as did W illiam S tyron in V is ible . E ach des cription is eloquent yet incomplete as answer. T hes e memoirs are generally about the mental accompaniments to depres sed states a s tate that can envis aged as looking at the world through blackglass es , s o that past, pres ent, and future all look dark bleak. T his all-pervas ive lens allows only and, ultimately, for s ome, s uicide appears to be the answer. P res umably, there is no s ingle psychological to suicide, but there are multiple ps ychodynamics that may lead to s uch a tragic final outcome.

B iologic al As pec ts C ontemporary biological theories about s uicide are inextricably linked to studies of depres sion, becaus e the mental condition most often underlying s uicide. Axelrod's pioneering studies of biogenic amine metabolism and Marie As berg's later work on serotonin HT ) and norepinephrine levels in the brains of individuals laid the groundwork for a cas cade of later studies. T he ess ence of these is that there is a relative deficiency of s uch neurotransmis sion at critical sites in brain, which res ults in depres sion. T his deficiency may due to ins ufficient production, exces sive reuptake of transmitter at the s ynaps e, or some failure of the system. Alternatively, some antagonist neurochemical 3130 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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agent may be lowering the effective levels. Although 5and norepinephrine are the mos t s tudied, other transmitters (e.g., γ-aminobutyric acid [G AB A]) or other agents (e.g., G proteins, kinas es, or brain-derived neurotrophic factor, as described by F . L. Loweand N. J . Nutt) may also play a role. Numerous s tudies found a decreas ed level of 5-HT in the brains of decedents and of 5-hydroxyindoleacetic acid (5-HIAA), HT 's major metabolite, in the cerebrospinal fluid (C S F ) living depres sed patients. In addition, depres sed individuals who have made suicide attempts or suicide have lower levels of 5-HT than depress ed who were not s uicidal. F urthermore, those who have more violent suicide attempts and completions (e.g., stabbing, and jumping) have lower levels than thos e less violent means (e.g., pills). Other s tudies have also found s uch neurochemical decreas es for gamblers , fire setters , and impuls ive individuals , in general, as to control populations , and this nons pecificity has led some inves tigators to view these lowered neurotransmitter levels as indications of general dyscontrol rather than more s pecific impulse

B iops yc hos oc ial As pec ts In addition to studying biogenic amines, an alternative, poss ibly complementary, hypothesis relates to the hypothalamic-pituitary-adrenal (HP A) axis . T his system regulates adrenal cortical hormone (s teroid) levels and mediates reactions to s tres s. C harles B . Nemeroff has reported elevated corticotropin-releas ing factor (C R F ) concentrations in the C S F and decreased C R F binding in the frontal cortex of suicide victims . He has also that s eparating infant rats from their mothers 3131 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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them to reacting more profoundly to later stress es (as meas ured by elevated cortisol levels) than control Independently, Nemeroff, at E mory, and J ohn J . Mann, C olumbia, have each pos ited stress -diathesis models suicide. T hese hold that individuals who have genetic, prenatal, or early life tendencies toward impulsivity (the diathesis ), when s tres sed later in lifeparticularly if they become depress edare more likely to harm themselves than are those not so predis pos ed. C hildhood trauma, es pecially physical or sexual abuse, can predis pos e individuals who later become depres sed to impuls ively on their s uicidal impulses. S uch events therefore may apparently constitute the impulsive-aggres sive-suicide diathesis if they are early and severe enough or may as the stress ors if they occur later or are s omewhat traumatic. D. J . P.2447 Newport, Z. N. S towe, and Nemeroff describe this well their paper on animal models of los s. T here are many hypotheses, but the previous ly two models have represented the leading theories regarding depress ion and s uicide since the or earlier. B ecause alcohol abus e is known to greatly increase the risk of suicide in depres sed patients, it is interes t that Mann found that alcohol itself lowers 5-HT some of the s ame s ites in the brain as s een in patientsa sort of chemical compounding of the problem (which also shows how alcohol can serve as an antagonis t to 5-HT enhancing antidepres sants ). Alcohol also a well-known disinhibitor, thus augmenting any tendencies toward impuls ivity, as well. 3132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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B ecaus e mos t persons with depres sive illnes ses even with apparently comparable degrees of attempt nor complete suicide, what are the differences between thos e who do and thos e who do not? A study Mann revealed that attempters experienced more subjective (and not necess arily objective) depress ion hopeless nes s and had more suicide ideation. T hey perceived fewer reas ons for living, despite comparable numbers of advers e life events. W ere they predis pos ed react more strongly to illnes ses or other s tres sors ? T he suicidal patients als o demonstrated lifelong patterns of greater aggres sivenes s and aggres sion. A pas t history family history of attempts may be clues to such an underlying diathesis.

DIA G NOS IS S uic ide Inquiry A careful and thorough inquiry regarding suicide is part every ps ychiatric evaluation. T he tone of this inquiry is crucial; there are ways of as king ques tions that may to the patient that the clinician really desires a negative res ponsefor example, you're not s uicidal, are you? T he clinician s hould time the inquiry to appropriately fit the context of taking the patient's history. F or patients who overtly depres sed, careful and detailed ques tions about suicide are abs olutely es sential; for covert depress ions, positive res ponses to ques tions regarding vegetative symptoms of depres sion (e.g., weight and sleep cons tipation) should alert the clinician to a poss ible underlying depres sion and, therefore, the need to this area (depres sion and s uicide) more thoroughly. S uicide ques tioning bes t proceeds s tepwise. On 3133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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as certaining that the patient is depress ed or might be suicidal, the clinician begins with the mos t general questions , s uch as Do you feel so terrible that you sometimes wish you hadn't been born? or that you that you were dead? If the patient denies such feelings, and one believes him or her, one might then drop this of ques tioning. If the patient agrees that he or she has such feelings, one proceeds further with the inquiryfor example, Have you ever had thoughts of hurting If s o, ask what the thoughts were, whether they were acted on, and whether the patient pres ently has them. there an actual plan for hurting himself or herself and, if so, what is it? Does he or s he actually have the means available to carry out his or her plans ? Is he or frightened that he or she might actually hurt himself or herself? If there is a history of prior attempts , try to obtain an unders tanding of how lethal these were (how likely was the patient to die from what he or s he did) and how on death was the patient (how likely it was that the would be discovered in time to be s aved). T he combination of past attempts of high lethality and high intent is particularly worrisome; pas t attempts of low lethality and low intent are somewhat less worrisome; ones of mixed high lethality and low intent or of low lethality and high intent are s omewhere in the middle less predictable for the clinician). F urthermore, despite these clues , one cannot as sume that subsequent will always be of comparable lethality and intent to prior onesyes terday's aspirin taker may be tomorrow's selfinflicted gunshot wound, for instance. Aaron T . B eck recently indicated that asking about the mos t serious 3134 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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intent may be the bes t predictor of lethality of future attempts. T he American P s ychiatric Ass ociation (AP A) publis hed P ractice G uidelines for the As sess ment and T reatment P atients with S uicidal B ehaviors in November 2003. an excellent and comprehensive review of this topic.

DS M-IV-TR DIA G NOS E S Most estimates of the incidence of revis ed fourth the Diagnos tic and S tatis tical Manual of Me ntal (DS M-IV -T R ) diagnoses in those who kill thems elves from 70 to 90 percent. Axis I category diagnos es be most repres ented, but other Axes can not be

Axis I Mood Dis orders T he mood dis orders are the ones mos t clos ely linked to suicide. F igures in the range of 60 to 70 percent are cited as the percentage of s uicide victims who were experiencing a s ignificant depres sion at the time of deaths . It is estimated that the lifetime risk for death by suicide is approximately 15 to 20 percent for individuals with bipolar dis order (generally in their depres sed, than their manic, periods ) and approximately 10 for other mood dis orders . S ome B ritis h investigators, however, feel these prevalence rates are less than

S c hizophrenia P atients with schizophrenia also have high rates of with a lifetime prevalence of death by s uicide es timated 10 percent. P atients with s chizophrenia appear to be 3135 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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particularly vulnerable when they firs t become aware of having a severe mental illnes s and als o appear more vulnerable if they become depres sed after recovery an exacerbation of their illness . S imilarly, patients with schizoaffective s chizophrenia dis order (with its component) may be at increased ris k. C ommand hallucinations , in schizophrenia and ps ychotic in which one hears voices telling one to kill ones elf, traditionally been believed to carry imminent this has been questioned by David Hellers tein.

Other A xis I Dis orders Other Axis I dis orders , particularly substance abuse disorders and panic disorder, appear to be more as cofactors , rather than being primary in thems elves . is , coexis tent panic or subs tance-related dis orders accompanying a major depress ive disorder (or schizophrenia), considerably increase the ris k of

Axis II B orderline personality dis order (which has suicidal behavior as one of its diagnostic criteria) is the Axis II diagnosis mos t clos ely as sociated with suicide. T he injurious behavior (e.g., superficial wris t cuttings ) so frequently seen in these patients is generally not reflecting a wis h to die as much as a wis h to relieve anxiety. However, this does not mean that these do not kill themselves . T hey do kill thems elves and careful monitoring, cons equently. Although patients antis ocial pers onality disorder are believed to have too little guilt (and, therefore, a low likelihood of hurting thems elves ), they, in fact, have elevated rates of 3136 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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(perhaps attes ting to an inconsistency, rather than an insufficiency, of their cons ciences). A tendency toward impulsivity appears to be the common denominator relating s uicidal tendencies to Axis II disorders .

Axis III C oexis tent medical conditions also increas e the risk for suicide. T his is particularly s o for chronic, painful conditions and is especially s o for central nervous (C NS ) pathology, such as epileps y, Huntington's cerebral vascular accidents (C V As ), multiple sclerosis P.2448 dementias , acquired immune deficiency s yndrome and head injuries . S ome have sugges ted that C NS disorders , in and of thems elves, may lead to and depres sionthereby compounding the ris ks . conditions als o increase the risk.

R IS K FA C TOR S General R is k Fac tors In addition to being aware of the increas ed ris k posed certain diagnoses, as des cribed previous ly, the should also look for the presence of additional risk T hese can be divided into acute and chronic although the boundaries between these domains are blurred. Acute factors, indicating a current elevation of include the presence of a s pecific plan, the means to out such a plan (particularly, the availability of prior s uicide attempts, coexis ting s ubs tance abus e or panic dis order with depres sion, and recent loss es (relations hips , occupational, health, economic, and 3137 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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A high intention to die is als o an important clue. traditionally, an actual attempt is viewed as an acute factor, work by J an F awcett indicates that, for women more than men, attempts predict high risk for death by suicide within 6 months of the previous attempts. F or sexes, attempts (and the communication of s uicide do predict a s ignificantly increas ed risk for the ens uing 10 years. T his , of cours e, does not mean that attempts should be disregarded. T hey remain the mos t potent predictor of subs equent death by suicide of all. F awcett also believes that s evere anxiety accompanying a depres sion is a critically important ris k factorone that warrants prompt treatment with benzodiazepine-type atypical antipsychotic) medication and one that may to an unexpected completed s uicide in a depres sed who has neither made prior attempts nor threats and may be s ubtly delusional. B uilding on F awcett's work, role of temperament in the prediction of ris k has been elaborated on by J . D. Mas er's group. Other such as Douglas G . J acobs, divide risk factors into that are predis pos ing (e.g., Axis I diagnoses ) versus that are potentiating (e.g., family history, Axis II and phys ical illness ). Asking patients if they are frightened that they might actually kill or hurt themselves may als o be helpful, because an affirmative ans wer virtually mandates that such patients be protected from suicide. A negative res ponse, however, does not automatically indicate an absence of risk, because a patient may be s o resigned the idea of death that the prospect does not caus e Longer-term or chronic ris k factors include a pas t suicide attempts (an acute and a chronic ris k), a history 3138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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impulsive behavior, a family his tory of depress ion or suicide attempts or completed suicide, living alone, widowed or divorced, and being white, male, or elderly. Acces s to lethal agents is an acute and chronic ris k that, if the patient is already s uicidal, such access increases the ris kbut, even if the patient is currently not suicidal, s uch access increas es the ris k for such subpopulations (e.g., high completion rates in dentis ts , pharmacists , nurses, police, and people who in homes where there are guns). All depres sed patients should be as ked about gun availability, and steps be taken, as appropriate, to res trict access . Increased attention is being paid to advers e life experiences particularly childhood phys ical or sexual or neglectthat appear to be directly proportional to later suicidal behaviors , according to S . R . Dube and others . Note that the interplay of childhood advers e and later experiences may be quite complex. F or a child with attention-deficit/hyperactivity dis order (ADHD) may be more likely to elicit aggres sive from his or her environment than would a more placid child (es pecially s o if the child's parent is also so T his aggress ion to the child provokes even more aggres sion by the child, and a cycle of violence ensues (T able 29.1-1).

Table 29.1-1 R is k Fac tors

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Primary Diagnos is

Demographic and Mis cellaneous Pers onality Fac tors Fac tors C omorb

B ipolar

Male

S chizophrenia Older age

B orderline

S ubstan abuse

Narciss is tic

P anic

Major depres sive episode

White race

Antisocial

Anxiety

Dys thymia

Homosexuality

C onduct disorder

Axis III diagnos

Adjustment disorder with depres sion

His tory of attempt

Impulsive

 

C onduct disorder

F amily history

 

 

P sychos is

S uicidal ideas

 

 

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Hopeles s

 

 

 

Helples s

 

 

Genetic R is k Fac tors Are there genetic predis pos itions to s uicide that are distinct from those predis pos ing to depress ive S tudies reviewed by A. J . Zametkin's group included a review of J anice E geland's and J . N. S uss ex's report Order Amis h in which they identified clusters of families with mood disorders and s uicides, as well as clusters mood dis orders but without suicide, indicating independent inheritance of mood dis orders and s uicidal behavior. Other studies include the class ic Danish F ini R . S huls inger, S eymour K ety, David R osenthal, Wender revealing that 12 of 269 biological relatives of adoptees who had died by s uicide had also died by as compared to only 2 of 269 biological relatives of adoptees who had not killed thems elves . F urthermore, Alec R oy has s hown a concordance for s uicide of 13.2 percent for monozygotic twins but only 0.7 percent for dizygotic twins.

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S uicide completions and s uicide attempts can be s een representing two somewhat distinct, but als o populations. Older white men with Axis I diagnoses of depres sive dis orders, especially if there is coexis tent subs tance abus e, repres ent the profile of the typical suicide completer. Y ounger adult white women with disorders , such as borderline personality, narcis sistic, histrionic personality dis order, compris e the typical attempter profile. T hos e who have made an attempt of low lethality are often treated dis miss ively in rooms (We're here to treat really s ick people, victims, people seeking attention and doing things to T he fact that, at the least, such individuals are the P.2449 of inadequate coping styles often is ignored. all attempters grouped together, between 8 and 10 percent of those making an attempt ultimately kill thems elves (however, two-thirds of those who suicide have never attempted previous ly). B ecaus e completers are not around to inform of their ps ychological s tate of mind when they their acts , what may be inferred by s tudying one views the suicidal spectrum as being on a with suicidal ideas and fantasies at one extreme, with suicidal wis hes next, then acts, and then completions the other extreme, one certainly can learn some just psychologically, but also biologically. F or instance, C S F , blood, and urine are available from attempters are without the problems related to pos sible degradation. Detailed interviews and ps ychological can be carried out with attempters, and results can be 3142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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extrapolated to completers, even knowing that there be significant differences. S ome inves tigators have focus ed on only those attempters who ought to have but were miraculous ly and unexpectedly s aved (failed suicides)feeling that here is a group most closely res embling the population of completers. Another approach is to s tudy only thos e completers who were active long-term ps ychotherapy at the time of their suicides and whose therapists are willing to s hare data about them. Hendin's group, ass ociated with the F oundation for S uicide P revention, has studied 26 such cases in detail and has discerned s ome common in their treatments (e.g., therapists mis sing changes of affect, new los ses , and annivers ary is sues) and also that 21 of the 26 therapists would have changed medications or hospitalized their patients or would cons ulted with their patients' prior therapists, in retrospect.

IS P R E DIC TION P OS S IB L E ? B ecaus e s uicide is relatively uncommon, correct predictions of s uicide are rare. (B ear in mind that as sess ment of suicide risk, by a careful review of factors , is poss ible and expected of the clinician, in contrast to the well-known difficulties in accurately predicting actual s uicide.) T his suicide-prediction is true even for s ubgroups with high rates (e.g., young adult, male, Native Americans ). A negative prediction suicide is almos t always statis tically correct when groups , as Alex D. P okorny s howed in his clas sic s tudy veterans. T his does not mean that the mos t careful as sess ment of risk for a given individual that can be should be made. It is known that certain diagnos es and 3143 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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factors , as described previous ly, significantly increase and that, once a threshold of concern has been intervention is needed. Defining that thres hold and determining the components of which that intervention should cons is t are matters of clinical judgment. there are no ps ychological tes ts and s cales that ensure prediction (B eck's hopeles sness s cale coming the to date), tes ts are cons tantly being refined. S imilarly, although the biochemical predictors that are currently available are too invas ive to be practical (e.g., C S F 5levels), there may be more practical tools , s uch as the res urgence in interes t in the dexamethasonetes t (DS T ) as a predictor. W illiam C oryell and Michael S chles sor found that 32 of 78 total patients with major affective disorder or schizophrenia had positive DS T s comprised 26 percent of total s uicides, whereas only percent of the patients who had negative DS T s killed thems elves . B ecaus e more chronically depress ed may be more likely to have pos itive DS T s, this may skew the results s omewhat.

IS P R E VE NTION P OS S IB L E ? It is not poss ible to prevent all s uicides or to totally and absolutely protect a given patient from suicide. W hat is poss ible is to reduce the likelihood of s uicide for populations and subpopulations and to reduce the risk suicide for a given individual. F or example, ps ychiatric hospitalization, even with cons tant observation, is not a guarantee of no s uicidebut it certainly changes the Hos pitalization not only may protect the patient, but buys time for treatment to begin, risks to decrease, supports to be mobilized, and arrangements to be for safe aftercare of the patient. Hos pitalization als o 3144 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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capitalizes on the ambivalence felt by most s uicidal patients as s taff attempt to shift the patient's balance toward a more life-affirming one. F rom a public health standpoint, primary prevention is targeted at the elimination of diseas es before they example, via genetic counseling, gene manipulation, improved quality of life for all, and gun and pois on S econdary prevention attempts to minimize the effects the diseasefor example, better therapy for depres sion prevention of suicide attempts in depress ion. T ertiary prevention is aimed at minimizing morbidity and once a suicidal attempt has occurred. C ategorizing reducing efforts as unive rs al (i.e., general populations targeted), s e le cte d (i.e., populations at specific risk targeted) or indicate d (i.e., populations with the are targeted) is a s imilar schema to des cribe B ecaus e an es timated 50 percent or more of s uicide completers have seen a primary care phys ician (P C P ) month before their deaths, according to a C enters for Dis eas e C ontrol (C DC ) s urvey, a natural prevention strategy is to target P C P s for education programs to improve their recognition and treatment of depres sion and s uicide. S uch a study was carried out in G otland, a S wedish Island, in 1984. Although the res ults were impres sive, it was clear that these educational efforts would have to be repeated or reinforced at least every years . T his preventive s trategy is pres ently being and replicated in Hungary by the American F oundation S uicide P revention. Another way to categorize prevention efforts is by population-based s trategies as oppos ed to ris k-based strategies , as described by P aul Duberstein and 3145 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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C onwell in their review of prevention s trategies for adults . T he former are s imilar to primary prevention approaches, and the latter target P C P practices or depres sed persons in general.

ME THODS OF S UIC IDE Methods of s uicide change over time and are als o dependent on what is available (e.g., rural suicides few deaths by jumping, at least partly owing to the absence of tall buildings). Although the method sometimes appears to have a special, symbolic for the decedent, more often, it reflects expediency and the des ire to avoid pain or disfigurement or death or G uns are currently the most common method (approximately 60 percent of all s uicides), and, cannot be said with absolute certainty that better gun controls would decreas e deaths by s uicide, it certainly be said that homicide rates would be dramatically lowered. However, it is strongly s us pected that, were availability reduced, fewer s uicide fatalities would occureven if the total number of attempts by all were not to decrease. It is well to keep in mind that, as pointed out by Mark R osenberg, there were 32,436 by firearms in 1997, of which 54 percent (17,566) were suicides, and 41 percent (13,252) were homicides a reminder of what an enormous public health problem remains. (In fact, the S urgeon G eneral's report, S trate gy for S uicide P re ve ntion: G oals and O bjectives Action, marked the first real acknowledgment of the gravity of suicide as a public health is sue.) W hen one means of suicide becomes precluded (e.g., after the from coal gas to a nonlethal stove gas in E ngland), rates by s uicide tend to drop initially 3146 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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P.2450 but then ris e again as s ubs titute methods become T he percentage of s uicidal deaths via guns is women, the elderly, and for African American men.

THE R A P Y Management of the S uic idal Patient Although there are s ome data indicating that there may a genetic predis pos ition to s uicide, distinct from any genetic predispositions to depres sion, suicide and behaviors are generally viewed as s ymptoms, not diagnoses. J us t as fever is a sign, and what needs to treated is the underlying infection, with s uicidal the underlying illness esfor example, major affective disorder, s chizophrenia, and borderline pers onality disorderare what are primarily targeted for treatment. B ecaus e treatment of these underlying conditions a living patient, however, steps mus t be taken to the patient's s afety. T he clinician's judgment regarding acutenes s of the situation determines the next s teps , it has been concluded that there is a ris k of s uicidal behavior. If the ris ks are felt to be minimal, the may elect to simply treat the underlying conditions on outpatient bas is and to continue to evaluate the risk of suicide (to determine if continued outpatient treatment safe). E ven though a patient may be believed to be at the clinician may elect to try outpatient therapy if the patient has a reliable s upport network that can be informed and enlisted by the therapist to help monitor patient and to ens ure that the therapis t is notified the patient's clinical s tate worsen. T his als o ass umes 3147 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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the patient is deemed reliable and cooperative and that the therapist believes that a pos itive relations hip exis ts between him or her and the patient. F or those patients believed to be too much at risk for outpatient therapy or partial hospital programs, inpatient treatment is S uch hospitalization is preferably on a voluntary bas is , if the patient refus es , involuntary admiss ion is required. G etting this arranged may be logis tically difficult. If office is in a ps ychiatric hospital, it may entail only an emergency buzzer to summon s taff and to s tart the proces s. F or mos t practitioners , however, the patient's family or friends may need to be enlis ted to maintain surveillance over the patient (and remove dangerous articles) before and during the period when emergency admis sion papers are prepared and filed. C ontact with family and friends of s uicidal patients is ess ential, and maintaining patient confidentiality is not mandatory if divulged material is believed to be necess ary to protect the patient's life. T here are some patients who appear imminently and acutely s uicidal that the clinician is to let them out of the office. T he patient s hould be told that the therapist is s o concerned about him or her that or s he is to remain in the office or waiting room (with a res ponsible pers on) until s omeone (family, friend, etc.) comes for him or her or until s omeone can escort or her to a s uitable holding area. S ome patients refus e cooperate with this , however, and may bolt, regardless the therapist's ins tructions . T he therapis t then s hould immediately inform the family and friends (if they have accompanied the patient to the s es sion). T he family friends (or the therapis t, hims elf or herself, if there are contacts or if the contacts refuse to comply) may then need to contact the police or other appropriate health 3148 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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officials . T he advent of managed care, s tringent admis sion requirements, and leas t-res trictive environment barriers admis sion make dealing with acutely s uicidal patients more complicated than ever. B ecaus e a managed care company appears to be a third party to the proceedings (along with the therapis t and patient), and becaus e control reimbursements to the hospital, the therapis t as sume that they call the tune. S uch an as sumption is incorrect, however. R egardless of whether an ins urer agrees , it is still the psychiatrist's res ponsibility to do whatever appears clinically neces sary for the patient's welfare. T his , at times , may mean hospitalizing a when the ps ychiatrist deems it is warranted, even if the insurer does not. T his likely results in the attendant with administration and going through appeals procedures . S imilarly, the burden is on the phys ician to whatever appears medically necess ary if and when an insurer denies additional days , and yet the phys ician believes that the patient is not safe to dis charge. maintain that they do not make medical decisions it is to the physician to make thes e regardless of reimbursement is sues. T his conundrum may be further compounded by ins tances in which the clinician that an admis sion is warranted (or believes that a not ready for discharge), but the family believes T he burden remains on the physician to at leas t do whatever he or she believes is medically proper. do so can res ult in a tragic outcome for the patient (and also in s ucces sful litigation against the physician, suicide or s erious injury occur). It cannot be s tated too often, vis --vis potential litigation, 3149 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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that the wis e clinician should carefully document his or decis ion-making process and his or her awarenes s of attendant risks, should he or she end up not admitting patient who might be s uicidal or dis charging one who has s ome depres sive symptoms and could potentially at risk, for example. S imilarly, in dealing with a insurer, the clinician s eeking hospitalization may not be able to effect this with an administrator who is afraid the hos pital will not be reimbursed, but he or s he at needs to document his or her efforts to get or keep the patient in, document his or her appeals , and spell out he or s he had to s ettle for a s uboptimal dis pos ition in documentation. A third parallel with these situations occurs when the clinician becomes convinced that the legal system will not approve an involuntary admiss ion a more extended commitment for a patient that the clinician believes is s uicidal, becaus e they do not meet criteria of the legal s ys tem. F or the patient's s ake and the physician's own s ake (legally), one makes the effort nonetheless . Although the courts appear to incur no liability when they refuse admis sion or commitment and an untoward result obtains, at leas t the clinician can demonstrate that he or she has made the attempt to hospitalize the patient (or to retain him or her in the hospital). J ust as the bes t theories regarding s uicide encompass ps ychological and biological aspects, the best therapy suicidal patients als o encompass es both domains . P harmacotherapeutic interventions for depress ion are effective in approximately 60 percent of patients, and similar figures are reported for ps ychotherapy. the approaches leads to improvement in the 70 percent 3150 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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range. Although combined treatment is preferable, it is simpler to discuss each approach separately.

Ps yc hotherapy Many types of psychotherapy are used with suicidal patients. T he choice should be made based on the patient's underlying illness and on empirical documentation of a treatment's effectivenes s, not on a given therapist's particular expertise (which is why the Accreditation C ouncil on G raduate Medical E ducation [AC G ME ] ins ists on demonstrated competencies in a divers e group of ps ychotherapies before psychiatric res idents can graduate). F or example, a patient with a borderline pers onality disorder is probably better by being treated with medication and behavior therapy (preferably dialectical behavior therapy [DB T ]) than by seeing a gifted analytically oriented ps ychotherapis t happens not to be knowledgeable about other approaches. W ith acutely suicidal patients who are hospitalized, the hospital milieu may be one of the critical parts of early therapy in terms of monitoring for safety P.2451 and providing hope for recovery. G roup experiences on the unit may als o be helpful. Individual inpatient therapy is initially directed at trying unders tand why nowinthat is , what is different now that made the patient become s uicidal or precipitated the event that neces sitated hos pitalization? Later, the on the why nowout? that is , what has changed in the patient's life to make the therapist believe it is now s afe 3151 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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discharge the patient from the hospital? B es ides the primary focus of keeping the patient safe, early efforts directed at formulating diagnoses and beginning to how to have the patient leave the hos pital safely and follow up reliably in therapy. T he phys ician, along with nursing s taff, needs to decide what level of s urveillance neces sary to protect the patient initially and throughout his or her stay. Nursing s taff and hos pital are often fond of no-s uicide or s afety contracts , which patients are asked to sign promising that they will seek staff out if they feel s uicidal. T hes e are particularly should the patient refuse to s ign, because this is a signal that the patient is s aying he or she cannot be so relied on (or that he or s he may be manipulating). T hey otherwis e far from reliable and may lead s taff to a false sens e of security, as noted by R obert S imon and T he suicidal outpatient in psychotherapy generally to be s een at least weekly until he or s he is no longer acutely suicidal. S hort-term ps ychotherapy, group ps ychotherapy, behavior therapy, cognitive-behavioral therapy (C B T ), DB T , interpers onal therapy, ps ychoanalytically oriented psychotherapy, and other psychotherapeutic approaches have all been with reported success .

Pharmac otherapy As with psychotherapy, the primary determinant of the pharmacotherapy is the underlying dis order. P atients depres sions get antidepres sants and, perhaps , mood stabilizers ; manic patients receive mood s tabilizers perhaps , antipsychotics; psychotic patients are treated with antipsychotics; s ubstance-abusing patients may 3152 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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receive drugs , s uch as methadone (Dolophine), (R eV ia), or dis ulfiram (Antabus e). W hat is different for suicidal patient, however, is the sens e of urgency felt the clinician to do something quicklybefore the patient harms himself or hers elf. In some cas es , particularly in patients with a pas t history of being refractory to medication, electroconvuls ive therapy (E C T ) may be elected for the depres sed and suicidal patient. A disorder patient may be more effectively treated with a monoamine oxidase inhibitor (MAOI) than a selective serotonin reuptake inhibitor (S S R I) (as may a patient an atypical depress ion), and combinations of antidepres sant medications are becoming increasingly commonparticularly for s uicidal patients . B ecaus e the time before the ons et of s ymptom relief is so prolonged for antidepress ants, F awcett has propos ed the liberal of benzodiazepines (or atypical antips ychotics ) in the stage of treatment for those depres sed suicidal who are s ignificantly agitated. S uch individuals are at special ris k, and the s hort-term us e of s uch agents can provide enormous relief (and needed s leep) during this waiting period. B rief use of such agents appears to relatively low potential for addiction and abus e. In an S S R I or one of the newer pos t-S S R I suicidally depres sed individuals , most psychiatrists are inclined to use thos e agents or combinations of agents that s eem more potent and rapidly acting to them (perhaps paying s omewhat les s attention to their side effect profiles than they would otherwise). As indicated previously, the current dip in suicide rates made investigators s us pect that better identification pharmacological treatment of depress ion are 3153 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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B ecaus e controlled s tudies of s uicidally depres sed treated with and without antidepres sants have not been done, this cannot be s aid for certain. T here have been studies of the us e of lithium in bipolar patients, by F red G oodwin and K ay J amison, and Mark B auer and Mitchener, however, that show that lithium does suicide and that discontinuation of lithium, particularly if abrupt, gives ris e to an increas e of s uicide. A by J ohn G eddes ' group has also confirmed this . Meltzer has data on s chizophrenic patients treated with clozapine (C lozaril), demonstrating a significantly suicide rate. Marsha M. Linehan has s hown that DB T significantly decreas e attempts in borderline disorder.

S P E C IA L P OP UL A TIONS Adoles c ents T he signs and s ymptoms of depres sion in adolescents not be the s ame as those in adults. David S haffer the quiet, perfectionistic, s o-called good boy who never gets into trouble but who cannot sustain the level of perfection that he (or others ) expects of hims elf; he warns of boys with conduct dis turbances who get depres sed and act out impulsively (or boys who appear to develop conduct disturbances , perhaps as way of express ing depress ion). C hanges in school performance or friends may betoken a covert as may beginning to abuse substances. Although the bereaved parents of adoles cent s uicide victims insis t that their child was totally free of any s ymptoms before the s uicide, this rarely appears to be true on scrutiny (and may reflect the parents ' denial or their 3154 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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inability to recognize the s igns of depress ion). E fforts being made to develop s creening materials for high schools and colleges to help identify at-ris k students to get them evaluated (e.g., C olumbia T een S creen), date, the s pecificity-versus-sens itivity is sue has been a major impediment to finding a practical mass -screening method. J unior and s enior high s chool education programs have often been touted but have yet to be adequately evaluated. Adoles cents appear to be more vulnerable to contagion or imitative effects than older populations. S uch copy-cat s uicides are not only seen more frequently in adolescents , but also appear to be proportionate to those media accounts that romanticize overdramatize their reports of suicides , overs implify the deaths by citing precipitating events as caus al, and provide gory details . C ombined efforts by foundations journalis m s chools are now making efforts to teach writers how to report more res ponsibly.

E lderly T he elderly have the highes t rates of suicide of any age group. C onwell and Dubers tein have shown that, they compris e approximately 12 percent of the total population, they repres ent almos t 19 percent of the U.S . completed s uicides. As is the cas e for elderly individuals may express their depress ion than the nonelderly. R ather than becoming tearful, sad, or anhedonic, they may just appear to be more withdrawn or to have s ome appetite and s leep S omatic express ions of depress ion are quite common, as tute geriatric phys icians know to cons ider depres sion quickly when no cause can be found for an elderly vague s omatic symptoms. T he elderly pers on who 3155 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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expres ses s ome s adness is too eas ily dismis sed as what els e can you expect? S imilarly, s ome therapists unenthusias tic about the us e of antidepres sants in the elderly, becaus e you can't give them back their youth. F ortunately, this bias is fading as it becomes clear that the elderly can profit from psychotherapy and res pond quite well to pharmacotherapy (or E C T , if indicated). Dos es generally need to be diminis hed in elderly, however, and caution is warranted regarding drugdrug interactions , because the elderly are often on multiple P.2452 agents . Als o, caution regarding combining s edating medications in the elderly is neces sary. E ven in the demented elderly patient, antidepress ants may be in ameliorating a res ulting or coexis tent depress ion. It also well to remember that untreated depres sion may increase the risk for cardiovas cular diseas e, poss ibly cortical HP A axis (and the ris k of death, for depress ed at least), and that, reciprocally, cardiovascular dis eas e also increas e the risk for depres sion. B ecaus e the elderly have the lowest ratio of attempts completion of any age groupthat is, when they make an attempt, it is more likely to be fatalthere is less of a for safety in the elderly (caretakers do not get many warnings ). E lderly persons more than 70 years of age firearms in 70 percent of their fatal suicides. Also, suicide rates fell s ignificantly between 1990 and 2004 acros s the life cycle, this is not true for the very old, rates continue to increas e. Is this due to compres sion morbidity (i.e., improved health care, quality of life, and 3156 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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treatment of depres sion are all helpful for the elderly, one can only fool Mother Nature for so long and then medical morbidity finally catches up and one's life plummets and depres sion ensues )?

P HYS IC IA N-A S S IS TE D S UIC IDE Much political and theological heat has been generated recent years by the debate on phys ician-as sisted Oregon has pass ed enabling laws, and the federal government has tried to circumvent them. T he AP A, American Medical As sociation (AMA), and many other medical groups have gone on record opposing it. T he policy in the Netherlands has been prais ed by and damned by opponents . W ithout question, there are some incurably ill patients in great phys ical pain who not clinically depres sed but who desire (and actually require) as sis tance in ending their lives . T he problem is that their numbers are probably extremely small and legalizing ass is ted s uicide would be so prone to abuse the negative effects appear to outweigh the pos itive the early results of the Dutch experienceas leas t as through the eyes of an opponent). P eople on both this iss ue, however, generally agree that the treatment pain in the chronically ill is a major factor in many reques t for ass is tance in dying. Not only does the system fail to adequately teach young doctors how to alleviate pain and s uffering in the chronically ill, but the medical system also has prohibitive laws and pertaining to narcotics, which too often result in phys icians s hunning such patients or treating them inadequately. An additional important is sue in this is that many of the patients reques ting death are depres sed and would be likely to respond to 3157 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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ps ychotherapy or pharmacotherapy, or both. they have been inadequately diagnosed or treated, or both. R equiring the P C P to obtain a second opinion another P C P colleague before ass isting in such a hardly an adequate safeguard agains t miss ing a s ubtle depres sion, becaus e s killful ps ychiatric expertise may required to elucidate its presence. Als o, the mild dementia or a metas tatic cancer means, by neither that the depress ion is realis tic nor that it would unrespons ive to appropriate treatment.

S UIC IDE S INVOL VING OTHE R Vic tim-Prec ipitated Homic ide T he phenomenon of us ing others, usually police, to kill oneself is well known to law enforcement personnel. Des cribed by Marvin W olfgang, the clas sic s ituation is exemplified by a person holding up a gas station or allnight store and brandis hing a gun, which he threatens us e on the police when they arrive. T hey then shoot thinking that it is in s elf-defens e. T he ps ychology of victims is not clear, except that they apparently believe that this is the only way that they can die. A 25-year-old, white, divorced father of twin 3-year-old boys had been threatening to his wife, and, she had an order of res traint placed on him. one evening, he went to her home, carrying a realis ticlooking toy pis tol in his pocket to give her a s care. S he refused to admit him, and, when he began to create a scene, s he called the police. When three police officers arrived, he refused to leave, pointed the toy pis tol at and taunted them to shoot him. T hey drew their 3158 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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ordered him to drop his weapon (which he did), and res trained him. T hey took him to a local emergency department, where the nurs e's admiss ion note read: divorced and angry man threatened others with a toy pistol. T he on-call psychiatrist saw him briefly, the denied suicidal or homicidal intent, and he concluded it was s afe to dis charge him (as a s ituational problemmarital iss ues ). T he following day, he killed by us ing carbon monoxide. Although this was not a completed victim-precipitated homicide, hos pital s taff failed to perceive that this repres ented attempted precipitated homicide and was an act of high risk. that he threatened others with a toy pis tol, trivialized gravity of pointing what appears to be a genuine gun at armed police and telling them to shoot. In effect, he given up control over this life-threatening situation to police, and only their s elf-res traint protected him from being killed that evening.

Murder-S uic ides Murder-suicides receive a disproportionate amount of attention, because they are dramatic and tragic. Unles s a pact between two truly cons enting adults, they testify the enormous amount of aggres sion inherent in many suicidesin addition to the depress ion. F urthermore, appears to be a pact is often, in fact, more of a flat-out murder) than a true pact among equals . P acts to be made more often by females or elderly couples .

Group S uic ides S uicides by groups or martyr suicides have a long F rom the biblical J ews at Masada to J immy J ones and 3159 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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followers in G uyana, killing ones elf for a cause and in a group is familiar to everyone. E ven when done by those belonging to a common group (e.g., selfimmolating B uddhist monks ), these suicides als o poss ess group and martyrdom characteristics . Are be class ified as altruistic s uicides , us ing Durkheim's cons tructs? If one (and one's family) profits from the is it s till altruis tic? B ecause the sense of altruism is in mind of the decedent, it is hard to know how much preselection, conscious or otherwis e, may have gone the decis ion to martyr ones elf (i.e., these pres umably not simply random martyrs).

S UR VIVING S UIC IDE T o be a s uicide s urvivor refers to those who have lost a loved one to suicide, not to someone who has suicide but lived. T he toll on s uicide survivors appears greater than that by other deaths , mainly becaus e the opportunities for guilt are so great. It feels to the that the loved one intentionally and willfully took his or her life and that if only the s urvivor had done differently, the decedent would s till be here. B ecaus e decedent cannot tell them otherwis e, survivors are at mercy of their often merciless consciences . W hat is generally more accurate is that the decedents were not entirely willful but were themselves victims of their own genetic P.2453 or lifetime experience predispositions to depres sion suicide. F or children, in particular, the los s of a parent suicide feels like a shameful abandonment for which 3160 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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child may blame hims elf or hers elf. F or parents of who have killed themselves, their grief is compounded only by having los t a part of thems elves , but also by having failed in what they perceive as their for the total feelings of their child. T o provide mutual support, S urvivors of S uicide groups have appeared throughout the United S tates, generally led by nonprofess ional s urvivors themselves . T herapists who have los t patients to s uicide comprise another survivor groupone too often ignored and uns upported, des pite their own cons iderable s uffering and sense of guilt, and compounded by the s pecter of litigation potentially brought to bear.

S UG G E S TE D C R OS S S ociocultural is sues are discus sed in C hapter 4; epidemiology is discus sed in S ection 5.1; s ubs tancerelated dis orders are discus sed in C hapter 11; schizophrenia and mood disorders are covered in 12 and 13, respectively; anxiety disorders are covered C hapter 14; personality dis orders are covered in 23; other psychiatric emergencies are covered in 29.2; psychotherapies and biological therapies are presented in C hapters 30 and 31, res pectively; mood disorders and suicide in children and adoles cents are covered in C hapter 45; and geriatric psychiatry is presented in C hapter 51. Many other chapters also material relevant to this topic.

R E F E R E NC E S AP A practice guidelines for the ass es sment and treatment of suicidal behaviors . Am J P s ychiatry. 3161 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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2003;160:3. Asberg M, T raskman L, T horen P : 5-HIAA in the cerebrospinal fluid: A biochemical suicide predictor? Arch G en P s ychiatry. 1976;33:1193. B auer MS , Mitchener L: W hat is a mood s tabilizer? evidence-based res pons e. Am J P s ychiatry. B eck AT , B rown G K , S teer R A, Dahls gard K K , S uicide ideation at its worst point: A predictor of eventual suicide in ps ychiatric outpatients. S uicide T hre at B e hav. 1999;29:1. C oryell W , S chless er M: T he dexamethasone suppress ion test and s uicide prediction. Am J 2001;158:748. Dube S R , Anda R F , F elliti V J , C hapman DP , DF , G iles W H: C hildhood abus e, hous ehold and the ris k of attempted s uicide throughout the life span. J AMA. 2001;286:3089. *Duberstein P , C onwell Y : P reventing suicide in adults . Dir P s ychiatry. 2000;20:351. E geland J , S us sex J N: S uicide and family loading affective dis orders. J AMA. 1985;254:9915. *F awcett J : P redictors of early suicide: Identification appropriate intervention. J C lin P s ychiatry. 1998;49 [S uppl]:7. 3162 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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F riedman R C : Homos exuality, ps ychopathology and suicide. Arch G e n P s ychiatry. 1999;56:887. G eddes J R , B urges s S , Hawton K , J amis on K , G M: Long-term lithium therapy for bipolar disorder: S ys tematic review and meta-analysis of randomized controlled trials . Am J P s ychiatry. 2004;161:217. G oodwin F , F ireman B , S imon G E , Honkeler E M, R evicki D: S uicide ris k in bipolar disorder during treatment with lithium and divalproex. J AMA. 2003;290:1467. G oodwin F , J amis on K R . Manic-Depre s s ive Illne s s . Y ork: Oxford Univers ity P res s; 1990. Hellers tein D, F rosch W, K oenigsberg HW : T he significance of command hallucinations. Am J P s ychiatry. 1987;144:219. Hendin H. S educe d by Death: Doctors , P atients , As s is ted S uicide . New Y ork: W W Norton; 1998. Hendin H, Lipschitz A, Maltsberger J T , Haas AP , Wynecoop S : T herapists ' reactions to patients ' Am J P s ychiatry. 2000;157:2022. *Holinger P C , Offer D: T oward the prediction of deaths among the young. In: S udak HS , F ord AB , R us hforth NB , eds. S uicide in the Y oung. B os ton: Wright; 1984. 3163 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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Ins kip HM, Harris E C , B arraclough B : Lifetime ris k of suicide for affective disorders , alcoholism, and schizophrenia. B r J P s ychiatry. 1998;171:35. J acobs DG , J amis on K R , B aldess arini R J , F awcett Hendin H: S uicide: clinical/ris k management is sues ps ychiatris ts. C NS S pe ctrum. 2000;5:3. Linehan MM, T utek DA, Heard HL: Interpers onal outcomes of C B T for chronically s uicidal borderline patients. Am J P s ychiatry. 1994;151:1771. Lowe-P onsford F L, Nutt NJ : P athophys iology of depres sion. P rimary P s ychiatry. 2001;8:43. *Mann J J , W aternaux C , Haas G L, Malone, K M: clinical model of suicidal behavior in ps ychiatric patients. Am J P s ychiatry. 1999;156:181. Maser J D, Akis kal HS , S chettler P , S cheftner W, E ndicott J , S olomon D, C layton P : C an identify affectively ill patients who engage in lethal or near-lethal suicidal behavior? A 14-year prospective study. S uicide L ife T hreat B e hav. 2002;32:10. Meltzer HY , Okayli G : R eduction of s uicidality during clozapine treatment of neuroleptically res is tant schizophrenic patients : Impact on ris k-benefit as sess ment. Am J P s ychiatry. 1995;152:183. Menninger K A: P s ychoanalytic as pects of s uicide. 3164 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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P s ychoanal. 1933;4:376. Miller C M, J acobs DG , G utheil T G : T alisman or T he controvers y of the suicide prevention contract. Harvard R ev P s ychiatry. 1998;6:78. Muss elman DL, E vans DL, Nemeroff C B : T he of depress ion to cardiovascular disease: biology and treatment risk for depress ion. Arch G e n P s ychiatry. 1998;55:580. National S trate gy for S uicide P re ve ntion: G oals and O bje ctive s for Action. R ockville, MD: U.S . P ublic S ervice; 2001. *Nemeroff C B , Owens MJ , B is sett G : R educed corticotropin releasing factor binding s ites in the cortex of suicide victims. Arch G e n P s ychiatry. 1988;45:577. Newport DJ , S towe ZN, Nemeroff C B : P arental depres sion: Animal models of an advers e life event. J P s ychiatry. 2002;159:1265. P okorny AD: S uicide prediction revis ited. S uicide T hre at B e hav. 1993;23:1. R os enberg M, Mercy J , P otter L: F irearms and E ngl J Me d. 1999;341:1609. R oy A, R ylander C , S archiapone M: G enetics of family s tudies and molecular genetics . Ann N Y 3165 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/29.1.htm

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1997;836:135. R us s MJ , S hearin E N, C larkin J F , Harrison K , Hull S ubtypes of s elf-injurious patients with borderline personality dis order. Am J P s ychiatry. R utz W, W alinder J , V an K norring L, R ihmer Z, H: P revention of depress ion and suicide by and medication: Impact on male suicidality, an from the G otland study. Int J P s ychiatry C lin P ract. 1997;1:391. S chneidman E S : S uicide as psychache. J Ne rv 1993;181:147. S haffer D, G ould MS , F isher P : P s ychiatric child and adoles cent s uicide. Arch G e n P s ychiatry. 1996;53:339. S hulsinger R , K ety S , R os enthal D, Wender P . A study of s uicide. In: S hou M, S tromgren E , eds. P revention and T re atme nt of Affe ctive Dis orders . Y ork: Academic P res s; 1979. Zametkin AJ , Alter MR , Y amini T Y : S uicide in J AMA. 2001;286:3120.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 30 - P s ychotherapies > 30.1: P s ychoana lys is and P s ychoana l P s ychotherapy

30.1: Ps yc hoanalys is and Ps yc hoanalytic Ps yc hotherapy T. B yram K aras u M.D. P art of "30 - P sychotherapies " T he term ps ychoanalys is literally means the breaking of the psyche into its constituent elements and their dynamic process es. As unders tood today, it has three interrelated meanings : (1) a comprehensive, carefully wrought, and revised the ory of pers onality and mental disorder (i.e., neuroses ); (2) a proce dure or method of inquiry into the mental contents of the mind; and, of primary focus here, (3) a highly s tructured the rape utic modality. T he current practice of ps ychoanalysis and ps ychotherapy repres ents a century of revolution and evolutionradical revis ion and gradual refinement by its creator S igmund F reud and his followers and A wealth and diversity of psychoanalytic thinking, both theoretical and technical, have produced a variety of clinical modifications that are increasingly applicable to broad s pectrum of patients and problems . T echnical parameters now range from the vestiges of orthodox term ps ychoanalys is to an array of shorter-term neoF reudian and non-F reudian ps ychodynamic 3167 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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some with a fixed time limit. T he problems currently treated extend from class ic neuros es to character es pecially borderline and narciss is tic disorders of the T his, in turn, means address ing very early deficits , as well as s ubs equent intrapsychic conflicts stem from childhood. S imilarly, s ince the 1980s , the predominant model of (one-person) ego ps ychology been s upplanted and, at times, replaced by object relations and self ps ychology, primarily developed by K ernberg and Heinz K ohut, respectively. T hese and new directions in (two-person) relational and inters ubjective perspectives have major implications for both theory and practice. T oday, as a cons equence of many changes s ince F reud, there has been greater divers ity, increased integration of multiple perspectives and techniquesexpress ive and s upportive, brief and term, intrapsychic and intersubjectiveand incorporation old and new therapeutic elements from the varied fields linguistics , hermeneutics , philosophy, and religion.

HIS TOR Y Pre-Freud: 18th and E arly 19th C enturies E ighteenth-century mes merism, originated by F ranz Mesmer (1733 to 1815), sowed the earlies t s eed of ps ychoanalytic practice, even though neither Mesmer's theoretical premises nor his actual practices are by ps ychoanalys ts today. Us ing a procedure referred to the magne tic pas s , Mes mer (in the role of magnetis t) his patient would s it face to face with knees touching, the charis matic Mesmer would cas t a s pell through sweeping movements across the patient's body. In 3168 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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succes sful cases, a magnetic crisis , or hysterical ensued, after which the patient's s ymptoms would disappear. Nineteenth-century followers of Mesmer remained the same basic framework, retaining both the general theory of magnetic fluid and the patient's acting as a pass ive recipient of the therapist's active maneuvers . C hanges in theory were minor until J ames B raid the term hypnotis m to des cribe the earlier proces s, attributing its effectivenes s not to phys iological factors (i.e., fluid), but to psychological ones (i.e., what the therapist expected the patient to experience). B raid laid the foundation for the modern concept of on which S igmund F reud based his initial practices but ultimately rejected.

Freud: L ate 19th and E arly 20th C entury Us e of Hypnos is T he emergence of psychoanalysis as created by F reud the late 1800s was a direct outgrowth of the treatment neurotic patients at that time by phys icians in general practicethe use of hypnosis for hysteria. F reud's friend older colleague, the V iennese internist J os ef B reuer, stage in 1881 with his s erendipitous dis covery that a patient's s ymptoms dis appeared as a consequence of verbal expres sion under a hypnotic trance. (T his was famous cas e of F raulein Anna O., who resides in the of psychoanalysis for having given it its impetus, as its lasting name, the talking cure .) W hen F reud heard succes s of the technique in 1882, he was jus t 3169 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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his medical training with an as signment at V ienna's Allgemeine K rankenhaus. S truck by B reuer's account, he s pent the year 1885 to 1886 s tudying at the S alpetrire in P aris with the F rench neurologis t Martin C harcot. T he latter's direct demonstration that could both elicit and abolish hys terical s ymptoms with hypnosis s o captured F reud's imagination that it major turning point in his thinking. In his own practice in the late 1880s , F reud used hypnosis only to enable patients to s uppress or deny their s ymptoms while its influence. More important to F reud, however, was us e of hypnosis in retracing the history of s ymptoms.

C athartic Method When F reud returned to V ienna and subsequently es tablis hed his general medical practice, he had no succes s in treating hysterical patients with the more methods of the day, s uch as hydrotherapy, and res t cures . He then decided to draw on the influences of B reuer and C harcot. At that time, the hypnotic method was used s trictly for psychic catharsis that is , attempting to gain access to patients ' reminiscences that they could not remember under any other conditions. T he particular method that F reud borrowed was a form of cathartic therapy, originally B reuer's invention, that F reud revived 10 years later in 1887 at B reuer's personal sugges tion. P.2473 In their collaborative work on hys teria in the mid-1890s (S tudie s in Hys teria), B reuer and F reud dis cuss ed their theory that the symptoms repres ented repress ed ideas 3170 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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that had not reached cons cious nes s and were a transformation or convers ion. T hey s uggested that hypnotic treatment was effective becaus e of the of affect previous ly attached to the repres sed mental called abre action. A major requis ite for the cathartic method, which was contingent on that theoretical position, was that the patient could be hypnotized and, thus, be enabled to revert to the ps ychic s tate in which or her morbid symptoms had appeared for the first T heir clinical experience and observations s uggested them that the patient's memories, thoughts , and that were no longer cons cious could enter the mind hypnosis and that, when recounted to the phys ician, es pecially under circums tances of intens e emotion, the symptoms would dis appear. T he main characteris tic that differentiated the cathartic method from other methods us ed in psychotherapy that its potency did not lie in the s uggestive command the physician, but, rather, the symptoms were thought disappear automatically as s oon as the original source the symptoms had been appropriately dis charged. It in concordance with the theory that hysteria was the of traumatic experiences , usually sexual in nature, large quantities of affect that had been barred from cons ciousnes s appeared in disguis ed form as In 1889, following B reuer's precedent with Anna O., us ed the cathartic method (in conjunction with to locate the traumatic origin of the hys terical symptomatology of F rau E mmy von N. In describing case, F reud anticipated his later thes is, which that inhibited sexuality may have played a role in the etiology of her illness . F reud, also frus trated by the 3171 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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transitory effects of hypnos is (which s eemed to last long as the patient's contact with the phys ician), began suspect that the therapeutic effects depended more on the relationship between patient and doctor than on the technique per se. His sus picions were prompted by a striking incident in which one of his female patients her arms around him on waking from a hypnotic trance. (B reuer had earlier reported a s imilar incident.) S uch events both increased F reud's dis satisfaction with hypnosis and turned his thinking in the direction of the phys icianpatient relations hip, the origins of his of transference.

C onc entration Method It was not until his us e of hypnosis failed in the cas e of F raulein von R . in 1892 that F reud felt obliged to experiment with modifications of the original hypnoticcathartic method. T he physician Hippolyte B ernheim of the Nancy S chool, an advers ary of influenced the technical direction that F reud took. decis ion to give up the hypnoticcathartic method was largely based on B ernheim's observation that the recalled during hypnosis (in a hypnoid s tate) could be revoked by patients in states of cons cious nes s when prompted by leading ques tions and urgings of the phys ician. B asing his concentration method on this premis e, F reud developed a s trategy in which he reques ted that the patient lie on a couch with eyes and then concentrate on a particular s ymptom and attempt to recall pas t memories . F reud would place his hands on the patient's forehead as a physical way of facilitating the memory process . 3172 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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F ree A s s oc iation T hrough his work with the same recalcitrant patient, F raulein von R ., F reud dis covered the method that is identified with the true creation of ps ychoanalys is , free as sociation. F reud s oon realized that his interruptions the patient and his cons tant prodding for additional details hindered the s pontaneous flow of the patient's thought. A s imple remark by F raulein von R . that s he not know what to s ay becaus e s he was not s ure what F reud wanted to hear s parked his realization of the undes irable effects of cens ors hip and direction by the analyst. T hus , he began to instruct his patients to even the mos t irrelevant, unpleasant, or trivial material. T he method of free as sociation is , thus , the gradual cons equence of experimentation with techniquefrom hypnosis and the cathartic method to a concentration method to an approach almos t antithetical to the suggestive methods . As a new technique, free was (1) unlike hypnos is, which required patient suggestibility; (2) unlike cathars is , which focused on releas e of affects only; and (3) unlike the concentration method, which prodded, directed, and interrupted the patient.

Trans ferenc e and R es is tanc e In altering his therapeutic technique, F reud realized different though not contradictory conception of the therapeutic proces s was warranted. With the new emphasis on the removal of amnes ia and the recovery repress ed memories, he obs erved that the s ame forces that brought about repress ion to obliterate pathogenic material from consciousness continued to 3173 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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exert force (res is tance) against full dis clos ure through as sociation. Moreover, unexpected feelings toward the analyst (trans ference) provided additional resis tance to treatment. T he pers istence of repress ion with free as sociation brought to the fore these two concepts, remain the critical cons tructs of modern F reud's first reference to trans ference came early in on Hys teria. He noted that s ome patients cons is tently tended to bring their intens e personal feelings toward analyst into treatment, transferring to the phys ician disturbing ideas that aros e from their pas t and that recapitulated earlier ties with significant persons from childhood, thereby making a false connection to the analyst. In 1905, in the s ubs equent cas e of Dora, feelings resulted in her breaking with F reud (acting something s he had not dared to do with her lover. Dis turbed by her premature termination, F reud the need to analyze resistance and transference manifestations. J ust as F raulein von R . had been the pivotal failure hypnosis that led to F reud's major shift away from its the case of Dora became the turning point in ps ychoanalytic technique by highlighting for F reud the neces sity to interpret feelings transferred onto the Again, it was a therapeutic failure that instigated the change in approach. F reud's later papers were preoccupied with the dynamics of trans ference and res is tance, their positive and negative aspects, as well with warnings to analys ts about how to behave s o as to manage their inherent difficulties. T hos e papers , which spanned the years 1912 to 1917, addres sed the of psychoanalytic technique as practiced to the pres ent 3174 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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time.

Pos t-Freud: E arly 20th C entury to Pres ent T he history and growth of the ps ychoanalytic from clas sic ps ychoanalys is to current practices , have marked by repeated revis ions by F reud himself, as well by reappraisals and rebellions by neo-F reudian and F reudian contemporaries and des cendants, as manifest in internecine conflicts over divers e and points of theory and practice (T able 30.1-1). F rom the beginning, s ome analys ts have argued agains t nearly F reud's basic conceptual premis es , from the s trictly etiology of the neuros es to his views on female ps ychology. Others have reacted more directly to their clinical concerns that too few patients are amenable to rigorous requirements ass ociated with orthodox ps ychoanalys is and have attempted to make the more widely applicable, affordable, and terminable.

Table 30.1-1 His toric al Development of Ps yc hoanalytic Ps yc hotherapy Theoris t

Major C ontributions to Ps yc hoanalytic Ps ychotherapy

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1920s 1940s

 

   Otto R ank, S andor F erenczi

Active technique; nurturant approach with emphasis on affective as pect of analytical experience; end-setting time limit

   W ilhelm S tekel

Ins titute of Active Analys is : first attempt at ps ychoanalytically brief psychotherapy

   W ilhelm R eich, Otto F enichel

E xpanded analys is of res is tances pathological character traits and defens es , e.g., analysis of armor (R eich)

   F ranz Alexander and T homas F rench

E stablished innovative school: of analys t to provide corrective emotional experience by being different from parents and alternative to early developmental experiences ; technical modifications of s hort-term duration, emphasis on face-tointerviews

   K aren Horney

R ejection of F reud's theory of neuros is with interpersonal approach led to extension of transference to current context, 3176

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clos ed distinction between and therapy, free as sociation and couch not es sential, active role, s hort-term goals 1950s 1960s

 

   Harry S ullivan

P ioneering work with schizophrenics : developed faceface psychiatric interview with therapist as participant observer; interpersonal extens ion of transference beyond parents to teachers and peers based on of parataxic dis tortion

   K urt Wilfred B ibring, Leo S tone, Merton G ill

E xpanded definition, indications, and s cope (parameters ) of ps ychoanalys is (E iss ler, B ibring, S tone), including broadened analysis of transference to hereand-now (G ill)

   Melanie K lein, Winnicott, E dward Michael B alint

Influence of B ritis h object school on ps ychoanalytic theory and technique (M. K lein): of holding e nvironment, goodenough mothe ring (W innicott), the rapis t as containe r (B ion), and he aling the bas ic fault (B alint) 3177

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addres sed patients without adequate mothering in early months of life    E lizabeth Zetzel, G reenson, Medard

E xtens ion of therapeutic relations hip to nontransferential as pects : concepts of the rape utic alliance (Zetzel) and working alliance (G reenson) advanced that analysis incorporates reality or real relationship into treatment, using both obs erving and experiencing ego of patient; exis tential emphas is on the human encounter between and patient (B os s)

   Heinz Hartmann, E rns t K ris

Advanced ego psychology in adaptation: postulated conflicts phe re of ego and defined of self as s eparate s tructure (Hartmann); concept of the s e rvice of the e go the ego's participation in the analytical process (K ris )

   Anna

Application of ego ps ychology to ps ychoanalytic treatment and analysis, with emphasis on the adaptive function of defens e

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mechanisms    E dith J acobson

Developmental model as bas is of comprehensive ps ychoanalytic theory, integrating ego object relations , and drive

   Margaret Mahler

Direct observation and res earch infants and mothers; delineated separationindividuation of child development, with impact on adult personality and and implications for analytical treatment process

1970s 1980s

 

   P eter S ifneos , Habib Davanloo, David J ames Mann

Development of different types of brief ps ychoanalytically oriented ps ychotherapy: use of active, confrontative, and supportive techniques; reduced or s et time limits

   Heinz K ohut

Development of self theory in analytical treatment of narciss istic disorders ; delineation of self(mirroring and idealizing) transferences ; emphasis on empathic atmos phere to facilitate 3179

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insight and trans muting internalization to crys tallize s elf    Otto K ernberg

E xtens ion of object relations to ps ychoanalytic psychotherapy techniques in treatment of borderline disorders ; delineation expres sive techniques alone for analyzing primitive transferences and defens es

   Hans S trupp and J effery B inder, Lubors ky

Operational manuals for the application of dynamic ps ychotherapy (S trupp and and ps ychoanalytic supportiveexpres sive treatment (Lubors ky)

C urrent trends

 

 

R eformulation and integration of ps ychoanalytic theories and unifying conceptual s chemas for treating patients acros s a broad diagnostic (neuroses , borderline, narcis sistic disorders ) and developmental (oedipal, preoedipal) spectrum

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   R oy R ichard C hes sick, Irvin Y alom, T . B yram K arasu

Application and blend of philosophy, religion, and the humanities, such as (Y alom), hermeneutics language (S chafer), and (K arasu) to a new unders tanding patients in psychoanalys is and ps ychotherapy

   R obert S tolorow, S tephen Mitchell, T homas Ogden, G eorge J oseph S andler

F ocus on intersubjective perspective (S tolorow) and relationality (Mitchell) in the interaction between analys and analyst; both ps ychopathology treatment viewed as a two-person event; greater attention to countertransferential phenomena (Ogden, G . K lein, S andler)

   F red P ine, K arasu, Daniel S tern

Developmental movement away from a single theory of the mind toward multiple pers pectives of clinical phenomena, including drive, ego, object relations, and experience (P ine); generic conceptualization of practice on dyadic and triadic deficits and conflicts (K arasu); and developmental ps ychology combined in res earch s tudies of

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earliest inner life of the infant and its impact on the motherchild relations hip (S tern)

P.2474 In the 1920s and 1930s, s uch analysts as S andor Otto R ank, and W ilhelm S tekel tried to broaden the applicability of ps ychoanalys is to a larger clinical by shortening treatment time (R ank was the firs t to propos e an end-setting time limit) and emphas izing a more active, affective, care-taking approach, with the use of the therapis t as a s ubs titute primary in the treatment of young children. S tekel's Institut fr Aktive Analyse (Institute of Active Analysis) was the organized attempt at ps ychoanalytically P.2475 based brief ps ychotherapy. In the late 1940s , these technical innovations culminated in the es tablis hment the school of F ranz Alexander and T homas F rench, the group to experiment directly with influencing the transference by varying the frequency of sess ions and emphasize face-to-face interviews . Alexander and defined the major role of the analys t as one who a corrective emotional experience to compens ate for 3182 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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developmental experiences by being different from the patient's parents. However, thes e therapies s oon major controversy over whether the therapis ts could be considered ps ychoanalys ts. T hreatened by the widening s cope of ps ychoanalytic technique, orthodox therapists claimed that any departure from a s trictly neutral interpretive stance would drastically treatment.

S ec es s ion from F reud With the widespread dis semination of ps ychodynamic concepts and applications after W orld W ar II, a major turning point in ps ychoanalytic development occurred the 1950s . As the practice of psychoanalysis include a great variety of clinical conditions, es pecially with the extens ion of class ic analysis to ps ychos es and character dis orders, analys ts were obliged to alter both their s trategies and the theories they us ed to explain changes in perspective. Initially, es pecially in the of pos twar ps ychiatry, ps ychoanalys is was applied indis criminately to a wide range of mental disorders reflecting every degree of severity of illness ; during this experimental period, analys is began more actively to recognize the limitations of standard methods. T hose critical years s aw the expans ion in cultural, and phenomenological directions of the ps ychoanalytic movement. E uropean and American analytical theoristsincluding Alfred Adler, Otto R ank, J ung, E rich F romm, K aren Horney, Harry S tack Medard B os ss eparately s eceded from F reud (some to their own schools ) and sought sufficient theoretical changes to challenge and extend the early boundaries 3183 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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ps ychoanalys is. Horney's rejection of F reud's libido theory of neurosis favor of a more social orientation led to an approach in the analysis of neurotic patients that drew distinction between analysis and psychotherapy, gave analyst a more active role, and dis pensed with free as sociation and the couch. S ullivan's pioneering work a population of s chizophrenic patients drew attention to their distorted parataxic thinking (illogical causal connections between concurrent events) in adult interpersonal relationships, and he influenced techniques by defining the face-to-face psychiatric interview that fostered the role of the analyst as participant observer. W ithin the framework of analysis (for example, B oss ' Das e inanalys is ), the role analyst was further altered by emphasizing the real, and-now encounter. Others who were engaged in the treatment of patients with character problems began to acknowledge the increasing need to enlarge the s cope treatment by introducing parame ters (K urt E is sler's that would help such patients in analys is.

C ONTE MP OR A R Y TR E NDS : E G O P S Y C HOL OG Y A ND B E Y OND S everal competing, and often overlapping, theoretical domains characterize ps ychoanalytic theory today, with important implications for revis ions in analytical techniques and applications to patient populations than neuros es . E xtending beyond ego psychology, include the major contributions of object relations self-ps ychology, and the newest arrivals, the inters ubjective and relational schools of thought. 3184 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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In the 1950s and 1960s, the growing effects of ego ps ychology on the unders tanding of ego defects and as sociated problems influenced new technical Wilhelm R eich's analysis of character armor, as well as F enichel's inves tigations of problems of psychoanalytic technique, expanded the analysis of res is tances in determining pathological character traits as s uch as Merton G ill, Leo S tone, E is sler, and W ilfred B ibring attempted to define and expand the horizons of ps ychoanalys is. T his s et the s tage for Heinz Hartmann his colleague's exploration of the technical implications ego ps ychology that postulated the exis tence of a free sphere of the ego and further defined the concept the self as a separate s tructure within the ego. B ased Hartmann's theory of adaptation, Anna F reud's of ego mechanisms placed new emphasis on their adaptive, rather than s trictly defens ive, function. E dith J acobson's developmental model as a foundation of comprehensive psychoanalytic theory, which integrated drive theory with ego ps ychology and object relations theory, was supported by Margaret Mahler's res earch infants and their mothers during the separationindividuation stages of child development. C oncurrently, object relations theory came to the fore G reat B ritain, whereby internalized relations hips and interactions between the infant and his or her replaced biological instincts as having a primary motivating power in the life of the child and, later, adult. T he influence of the B ritish object relations school and theories of Melanie K lein, E dward B ion, Donald and Michael B alint led to modifications in technique s o to accommodate patients who did not experience 3185 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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adequate mothering in the early months of life, in the concepts of therapy as a holding environment, therapist as container, and healing the bas ic. E lizabeth Zetzel and R alph G reenson followed Anna F reud's in the real relationship between analys t and patient by developing the now-accepted notion of the therapeutic working alliance, which recognized the need to incorporate nontransferential elements into analys is . Advances were als o being made on a more theoretical front. T he evolution in psychoanalytic techniques paralleled change in analytical focus from inhibitory traits to impulsive and acting-out behavior and character pathology and, then, to a direct interest in the of defective egos . T he analys is of character armor in ps ychoanalytic practice, an early effort of R eich's, has become the basis for a major thrust in ps ychoanalytic ps ychotherapyits application to characterological disorders . S ince the 1970s, the changing analytical direction has been greatly influenced by the direct clinical s tudy of narcis sistic and borderline personality dis orders, which provides the pivotal foundation for both the theory and practice of ps ychoanalytic psychotherapy today. T he attention on turbulent transferences , disturbances in image and object relations, and such primitive projective identification and s plitting has ins pired a therapeutic concern with developing theories so as to unders tand the etiology of s uch disorders and for managing them. Otto K ernberg's application of ps ychoanalytic object relations theory to the of psychoanalytic techniques in the treatment of 3186 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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borderline pers onality disorder patients and K ohut's ps ychology of the s elf in the understanding of remain at the center of current analytical practice, the latter s parking a virtual revolution in clinical thinking. K ernberg and K ohut's observations have profoundly influenced notions of the nature of transference manifestations that appear in treatment (for example, K ohut's mirror and idealizing transferences , which are pathognomonic for narcis sistic personality dis orders) the major mutative change agents of ps ychoanalytic ps ychotherapy (for example, les s emphas is on insight se and more on the empathic atmos phere for internalizations ). In addition, their techniques have been contrasted, s upporting their respective theoretical tenets and P.2476 having implications for the therapist. T hus, K ernberg's predominant technique of confronting as a defense of patient's grandiose self (as it presumably protects hatred and envy of the therapist) means that the may be the recipient of the very oral aggres sion that is conceptually viewed as the core of severe pers onality disorder. In comparis on, K ohut's major strategy of the transference to unfold and to, himself, become the empathic self-object that was pres umably mis sing in patient's past (so that he can gradually explore the meaning of the patient's disappointment in the parent/therapis t), s upports his more benign theoretical contention that aggres sion is, at most, secondary to narcis sistic ps ychopathology.

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Inters ubjec tivity and R elational Ps yc hoanalys is P os t-K ohutian s elf-ps ychology has been marked by the ris e of inters ubjectivity, as pos ited by R obert S tolorow his ass ociates , which s uggests that ps ychoanalys is is science of the inters ubjective focus ed on the interplay two differently organized s ubjective worlds of patient analyst in which pathology its elf is understood as a person event. How the patient's s elf-object needs are within an empathicintrospective inters ubjective field of treatment is thus believed to influence both the s everity pathology and the therapeutic cours e and outcome. Whatever goes on in analysis is always viewed as a cons truction, based on the critical thesis that the fundamental operation of the psyche is bas ed on its striving not for gratification of instinctual drives , but for relational connections and communication. R elational psychoanalysis (and its major originator, S tephen Mitchell) takes this pos ition to its limit by suggesting that the clinical process in psychoanalysis always been, first and foremos t, relational, or, in words , our relational embeddedness with others. Incorporating as pects of attachment theory, Mitchell further s ugges ts that the analys t's interpretations of the patient's verbalizations are themselves a form of interpersonal attachment experience. Ultimately, he relational ps ychoanalys is as a broad, multidimens ional vision of human inters ubjectivity.

C onflic tDefic it Duality C ompeting cros scurrents of ps ychodynamic thought 3188 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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given ris e to two predominant paradigms of theory and therapy today. An unres olved debate over conflict and deficit models represents the culmination of nearly a century of internecine conceptual controvers y over the etiology and evolution of individual development. In the original conflict model of ego ps ychology primarily pivots on intraps ychic drives and ego defenses based repress ed memories and dis tortions of the pas t, the de ficit mode l places its crucial focus on the creation destruction of the self-structure based on real and traumas in primary relations hips. T he former intraps ychic clas hes among unconscious forces of the mind, es pecially repress ed s exual drives and the and adaptive mechanis ms that guard against them F reud's formation of the neuros es ), or, in more recent theoretical expansion to earlier, archaic beginnings , propos es a primitive s plitting between object love and hate s o as to deal with uncons cious aggres sion, oral and rage (i.e., K ernberg's formation of borderline personality dis order). T he extens ion to severe character pathology embodies broadened view that uncons cious intrapsychic conflicts are not simply s truggles between impulses and but denote two oppos ing units or s ets of internalized object relations . S uch ps ychopathology is thus of a defens ive cons tellation of s elf and object representations directed agains t an opposite (and often dreaded) repress ed self and object repres entation. conflict-based conceptualizations have been a deficit model, which postulates early environmental events of interpersonal insufficiency, es pecially lack of affective attunement between the original caregiver 3189 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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the infant, in the defective development of the s elf. the arrival of the latter thesis , the new onus is no longer placed on frus trated libidinal oedipal origin within a triangular s truggle, as the patient desires (or rivals ) the paternal parent; rather, it attributed to traumatic failures of empathic res ponsiveness within the preoedipal motherchild ambiance, as the de prived patient yearns for unmet maternal mirroring and merger. T hese pivotal positions, which encompas s a complexity significant developmental influences on the ps yche, also been viewed as a chronology of s eparate ps ychologies for depicting basic human motivation and the res ultant ills that befall man. T wo predominant have been pos ed, each of which evolve out of a historical period within the temper of the res pective According to K ohut, an earlier prototype termed guilty man embodies the s earch for gratification of hidden forbidden s exual longings, whereas a later prototype termed tragic man express es the basic s triving for cohes ion of a fragmented or mis sing s elf. E rikson put it more pragmatically in clinical terms when he obs erved that the patient of today s uffers mos t under the of what he or s he may be or become, whereas the of earlier days s uffered most under inhibitions that prevented him or her from being who he or she thought him- or hers elf to be. In addition, this dichotomous theme has been applied an overriding diagnostic duality: ne uros e s (pertaining to less dis turbed patients ) versus pe rs onality and characte rological dis orders (pertaining to more patients). T hus, the traditional understanding of the 3190 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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etiology of psychological ailments in terms of the unfulfillment of yes terday's yearnings (i.e., the cons equences of intraps ychic drives along with their protective ego defens es ) is being compounded or replaced by the repercus sions of today's traumas (i.e., interpersonal/environmental failures and flaws of object relations and s elf-structure). At the same time, the historical s ource of ps ychopathology long attributed to oedipal events (i.e., rivalrous wishes and cas tration that have their height at 2 to 5 years of age) has been similarly s upplanted by the s alience of preoedipal ones (i.e., longing for infantile bliss through union with the mother, but bes et by deficits in the primary object bond beginning at birth). T he conflictdeficit dichotomy has also been framed in other terms , representing a pervas ive shift from an intraps ychic to an inters ubje ctive perspective in theory treatment. T he former is defined and bounded by the limits of the individual psyche as class ically examined the objective ps ychotherapis t. In comparis on, the latter orientation focus es on the interplay between the inner worlds of the two participants of the endeavor. It takes a position within, rather than outside the dyadic unit of s tudy. T his ostens ible dualis m has also meant a marked the relative significance of class ic oedipal fathermotherchild impact (i.e., three-person, triadic) core preoedipal motherchild (i.e., two-person, dyadic) influence. T hese developmental distinctions have als o direct implications for ps ychotherapy practices, as well the populations treated. T hey broadly coincide with the movement from express ive to s upportive s trategies, 3191 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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a modus operandi that entails a dis pas sionate interpretation and confrontation of a primarily advanced (i.e., erotic) transference to a respons ive therapist's replacement of s ustaining s elf-objects within a largely primitive (i.e., narciss is tic) trans ference, and from belief the curative power of insight to that of empathy.

S hort-Term (B rief) Therapy T he emergence of a variety of short-term (brief) ps ychodynamic ps ychotherapies was also a hallmark the 1970s and 1980s: T hes e ps ychotherapies are now primary, preferred modalities in their own right. Like forms of psychoanalytic psychotherapy, they meet contemporary needs socioeconomic P.2477 cons traints that make protracted and costlier treatment less viable, the wis h to serve larger numbers of and the current pres sures for accountability (which for systematic studies of ps ychotherapy outcomes on specific formats and circums cribed time frames ). As further attraction, the earlier fears of symptom as an inevitable cons equence of short-term treatment have ess entially been quelled, allowing the enduring strengths of the F reudian legacy to be retained as the foundation for newer, more expedient techniques . P eter S ifneos 's anxiety-provoking ps ychotherapy, Malan's intensive brief psychotherapy, Habib broad-focus short-term dynamic ps ychotherapy, J ames Mann's time-limited psychotherapy, and Lewis eclectic s hort-term ps ychotherapy are examples of the range of brief treatments that derive from the 3192 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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ps ychoanalytic approach. T heir combined interpretive noninterpretive techniques, active approaches , and abbreviated time requirements are all accepted current ps ychoanalytic ps ychotherapy. Operational for psychoanalytic practice have been developed. Hans S trupp and J effrey B inder's time-limited dynamic ps ychotherapy and Lester Lubors ky's principles of ps ychoanalytic psychotherapy, a manual for s upportive expres sive treatment, are two examples of the approach to ps ychodynamic treatment.

INTE G R A TION OF MODE L S A major theme of current ps ychoanalytic the integration of multiple theories or perspectives into the unders tanding of clinical phenomena and the treatment of a broadened spectrum of patients , those considered unamenable to traditional ps ychoanalys is.

Toward an Integrative Model Although s ome theoretical work has s erved to sharpen schism between conflict and deficit (defect or models, others have addres sed their coexis tence and potential integration. F or example, in cons idering structural versus object relations conflict, T heo Dorpat delineated two models of the minda higher tripartite model of id, ego, and superego and a lower object relations model that occurs before it. He regarded them two s ucces sive stages of individual development that, together, compris e the ps yche's internal architecture. 3193 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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Others have sugges ted that looking at symptomatology alone may not reveal whether intrapsychic conflict (neuros is ) or developmental arres t (s elf-object disorder) is responsible. S tolorow and Lachmann, who began with conflictdeficit as a dual line of thinking, elaborated on a complex confluence of s ubtle and masked manifes tations . T heir clinical examination of developmental arrests has elucidated a crucial between two types of mental activitydefenses that primarily function to ward off conflicts (within a welles tablis hed ps ychic structure) and thos e that predate them (at a prestage of defensive development), which are vestiges of structural voids defects. F or example, detachment can be a res ult of an early developmental failure of attachment or a later instance of defens ive avoidance of interpersonal T heir natural overlap or interface is demonstrated by simultaneous occurrence in actual psychic life. T rauma to empathic failure by a parental figure does not the child from conflict-based ambivalence toward that significant other. G illian E agle s uggests that the two sources of ps ychopathology are intertwined ins ofar as developmental deficiencies may influence the capacity deal with conflict, whereas unres olved conflicts may be precurs ors that trigger developmental regress ions or arrests . More s pecific to the developmental perspective that undergirds ps ychoanalytic thinking is the recent work of Daniel S tern, who examines the inner life of the infant and his or her relations hip with the world. T hus , extends the clinician's orientation to the earliest of infancy, broadening it to include the reciprocal 3194 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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interpersonal interface between s ubtle emerging perceptions and the s ubjective s tate of the infant vis -the mother (that is , affect attunement), which s erves as forecast for lifelong patterns of behavior. On a broader level, F red P ine has attempted a clinical phenomena derived from four major s ources: theory, ego ps ychology, object relations theory, and experience. P ine offers a multimodal perspective studies of child development and its impact on adult ps ychopathology that focus es less on theory than on clinical developmental phenomena with which the practitioner works. S imilarly address ing the need to the theoretical and the clinical, recent efforts of the to locate generic factors in all ps ychotherapy have culminated in a developmentalis t metatheory. Its experience-near framework integrates various cons tructs of past and present analytical thinking, es pecially the schis m between deficit and conflict viewpoints . P atients are viewed not in terms of clas sifications or standard diagnos tic nomenclature, rather, according to major maturational configurations. B oth deficits and conflicts having origins in different phases of development are repres ented, including the combined impact of the very early motherchild relations hip and the subsequent fathermotherchild relations hip. In brief, the author's fourfold matrixdyadic deficit, dyadic conflict, triadic deficit, triadic conflictestablishes a generic base of developmental patterns for the practitioner. T he flexible contemporary theory and practice of psychodynamic psychotherapy extends across a broad range of ps ychopathologyfrom neuros es to borderline and narcis sistic personality 3195 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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disorders . It also serves to reconcile divergent by advancing the combination and complementarity of divers e orientations and therapeutic techniques whose variations can be applied to an extens ive patient In other attempts to find a unifying conceptual schema, some theorists have used a human s cience framework extends beyond metaps ychology to philos ophy, hermeneutics , language, and religion. R oy S chafer, for example, has reconceptualized psychoanalysis in an action language. He continues to search for the best terms in which to render the findings of ps ychoanalytic practice and to s ys tematize them. In his pos t-F reudian conceptualization, S chafer has developed a clinically us eful alternative to traditional descriptions of the apparatus of the mind and its intraps ychic proces ses. In a different vein, R ichard C hes sick als o goes beyond ps ychology per se in questioning the implicit upon which the understanding of a patient res ts . B y delving into the phenomenological and philosophical thinking of J ean-P aul S artre, J acques Lacan, J eanLen F oucault, Martin Heidegger, E rich F romm, and numerous others, he emphasizes multideterminants in formation of ps ychic s tructure. In another exploration of what is common to all patients, Irvin Y alom examines relevance of an exis tential dilemma for both patients ps ychotherapis ts. He stress es that all human beings for meaning and certainty in a univers e that has He also emphasizes the participant role of the therapist the lives of his or her patientsthat is, both clinician and patient are affected and changed by the mutual encounter. T he author's view of the psychotherapist as healer shares the existential domain but goes further to 3196 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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the realm of the human spirit. T he author has six tenets of trans cendence within ps ychoanalytic treatment P.2478 that have, at their core, the needs for belief and others , love of work, love of belonging, believing in the sacred, believing in unity, and believing in T hey are based on the thesis that the way of love is and the way of s pirit is believing. T he application of spiritual ps ychotherapy in clinical practice thus vehicle, both in matters of life and of death, for the art of s erenity.

MA J OR THE OR E TIC A L IN P S YC HOA NA L YTIC P R A C TIC E : E A R L Y ME TA P S YC HOL OG IC A L C ONC E P TS A variety of postulates have been posed that are not objectively demonstrable but form the early foundation for the psychoanalytic theory of mental phenomena. metapsychological concepts describe the mental apparatus with regard to both s tructure and process . B roadly, within the analytical framework, the individual regarded as the recipient of turbulent intrapsychic impulses s truggling to be set free. T hese impuls es are inner and unknown desires and urges , largely libidinal aggres sive, to which the individual is inherently (biologically) s ubject, but which he or she continually defends against, creating a reservoir of infantile and wis hes that are inacces sible to the cons cious self. Herein, five early constructs are incorporated that are 3197 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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integral to the psychoanalytic conception of the minddynamic, topographical, s tructural, economic, and genetic. Although the theoretical premises are a longstanding legacy left by ps ychoanalys is proper and primarily apply to it, they als o form a major foundation subs equent ps ychoanalytic psychotherapy theory and practice.

Dynamic T he dynamic pers pective reflects the notion that mental phenomena are the res ult of a continual interaction of forces that oppos e one another. It implies that human behavior and motivation are active, energy laden, and changing at all times. It is the basis for such concepts as conflict and re s is tance , which relate, res pectively, to the foundations of mental illnes s as the cons equence of competing demands and wis hes and largely unwitting ways in which the patient fights getting well. It als o has pos itive connotations for a person's capacity to overcome pathology, to evolve, to adapt, to mature as the balance of mental forces perpetually

Topographic al T he topographical pe rs pe ctive refers to the premise mental phenomena reveal thems elves at different manifestation, from the deepest recess es of the mind (unconscious), to the border of awarenes s and, finally, to the s urface (conscious). T his model laid groundwork for the etiological phenomenon of which describes the process es by which forbidden and impulses (initially believed to be largely sexual in narrower and wider s ens es of the word) are denied 3198 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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to the conscious mind and whos e revers al removes the original s ource of illnes s. Its general orientation the human being's pervasive avoidance of painful or experiences by keeping unpleas ant thoughts, and affect from awarenes s. It also recognizes the persis tence, res ilience, and inaccess ibility of underlying conflicts that remain alive and active but may appear in divers e and dis guis ed forms that are often by their recipient.

S truc tural T he s tructural pe rs pe ctive refers to the idea that the apparatus is organized into functional units of a natureid, ego, and superegoand that bas ic personality organization forms the theoretical structure of conflict among three hars h masters: ins tincts (id), reality demands (ego), and one's moral precepts or standards (superego). T he ego s erves the pivotal and executive function in mediating between the primitive instinctual drives and his or her internalized parental and s ocial prohibitions, and that concept is pertinent to the overall ps ychoanalytic goal of replacing with ego in the proces ses of maturation, development, and achievement of health.

E c onomic T he economic perspective relates to how ps ychic distributed, discharged, and transformed. It has implications for how ideas and affect are expres sed (for example, verbally, somatically) and for how the person fends off psychic threats through a variety of defense mechanisms (s uch as s ublimation, whereby 3199 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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drives are diverted into s ocially acceptable forms ; formation, which turns an impuls e into its opposite; and displacement, in which feelings belonging to one object are transferred to another). Dis placement has direct treatment implications for the phenomenon of transference, in which affect meant for early s ignificant figures in the patient's life is placed onto the analyst.

Genetic T he genetic perspective concerns the his torical personality and its subsequent development. It relates analytical beliefs that the intrinsic core of illness res ides a particular period of infancy (for example, the oedipal stage, the source of the tabooed erotic bond between child and his or her opposite-sex parent) that early experiences are repeated (repetition compuls ion) until they can be neutralized through cons cious nes s and regress ion to infantile modes of behavior is both a manifestation of illnes s and a technical proces s that facilitates the recreation within analys is of the patient's original conflict (i.e., trans ference neuros is ), of which res olution is the es sence of clas sic analytical cure. T he genetic perspective has broader implications for the of psychic determinism, which illuminates the crucial notion that pres ent behavior is meaningfully related to one's past and for developmental stages through which the person evolves from infancy to adult maturity (for example, oral to genital phas es).

FUNDA ME NTA L TR E A TME NT C ONC E P TS P sychoanalytic practice is dis tinguis hed by the 3200 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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of two integrally related events of treatment: and res is tance. T ransference (earlier called love ) is the unconscious affective bond that forms the for analytical work and underlies the patient's desire to remain in treatment. R es is tance is the defens ive that continually counteracts analytical progress and agains t it. C onsidered opposite s ides of the same coin, they are inextricable insofar as transference can at any time be transformed into resistance and interrupt its positive powers. C omposing the es sential dynamics of analytical s ituation, the dual forces of s hifting valence operating at all times as the patient continually to be cured of his or her illness . F actors contributing to the goal of health include the rational and cons cious component of the patient's that wis hes to be free of symptoms through realis tic cooperation with the analyst, the part of the patient that would like to please the analys t s o as to receive his or approval (love), and those as pects of the patient that do what is considered correct or appropriate behavior. Interfaced with thes e is an opposing force that res is ts therapeutic progres s that may be generated by the unhealthy part of the patient that s till needs his or her pathology and neurotic defenses those des tructive designed to displease the analys t by s abotaging efforts and the need for other benefits that may accrue from being ill, s uch as getting s pecial attention, being nurtured, or not having to meet the demands of reality. F reud initially believed that the primary purpos e of ps ychoanalys is was to analyze transference and to circumvent resistance, but he P.2479 3201 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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later advocated the uncovering and repeated analysis res is tances in a s ys tematic way. R ather than to actual content of the patient's verbalizations, the objective became to confront and understand the defens ive maneuvers by which the patient delayed well. Only then could the deeper levels of neurotic be expos ed and ultimately resolved.

Trans ferenc e T rans fe rence is broadly defined as the experience of feelings toward a person that, in fact, belong to another person from the past. In analys is, it refers to intense toward the analyst that is a repetition of affect toward earlier significant figures, particularly as a revival of the infantparent bond. As a manifes tation of reawakened erotic wishes derived from the oedipal period, the paradigmatic neurotic form of transference occurs the patient falls in love with the analys t. T ransference is unequivocally the heart of and the analysis of transference distinguis hes ps ychoanalys is from all other forms of ps ychotherapy. S ince F reud's original s erendipitous discovery of the strange phenomenon of transference in the ps ychoanalytic treatment of every neurotic patient, transference has been conceptualized in various ways: (1) as a distinct type of therapeutic relations hip has s ince been dis tinguis hed from nontransferential therapistpatient bonds (that is, therapeutic alliance, real relations hip), (2) as s ubs titute pathology express ed in formation and res olution of a s o-called transference neuros is , and (3) as a general phenomenon that 3202 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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transcends the boundaries of analysis into all human relations hips .

Trans ferenc e A s a Therapeutic R elations hip T he typical trans ference relationship is one in which patient directs toward the analys t an unusual degree of attachment and affection that is not a realistic respons e the relationship between them but can only be traced wis hful unconscious fantas ies . T hos e fantas ies are repeated in analysis as unres olved childhood attitudes affects that are anachronistic and inappropriate, in part, because repress ed material neces sarily contains strivings and, in part, because the analys t promotes appearance through special methods and analytical that intens ify reactivation. Although there is genuine care and rapport that allows analytical work to ensue, transference as a unique unreal interpersonal bond is a function both of the inherent nature of neuros es and of the des ign of the analytical s ituation (which facilitates a subs titute neuros is ). T he peculiarity of the transference relations hip with the analyst lies in its exces s, in both character and degree, what is rational and justifiable. Its major manifes tation an overendowment of the analys t as an idealized often including overestimation of the analys t's qualities , adoption of s imilar interests, and jealous y of other individuals in the analyst's life. As a largely libidinized figure who becomes the predominant object of the patient's unres olved s exual (and aggres sive) desires , analyst arous es intense erotic feelings that, in the of cure, must remain unrequited. B ecaus e the 3203 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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relations hip is bas ed on projection and fantas y on the of the patient and becaus e the analyst neither cravings of the patient nor reveals him- or hers elf in a reciprocal or pers onal fashion, it is characterized (and criticized) as being an artificial and as ymmetrical bond. T hese qualities have been amended in later nontransferential types of therapeutic relationships (for example, working alliance, real relations hip) that fos ter mutual partners hip and genuine encounter between therapist and patient. Often what dis tinguis hes a trans ference from a nontransference reaction is not its content per s e, but a group of qualities that tend to characterize transference res ponses and that may be used as signals to the denote their occurrence. T hes e qualities include inappropriateness (the largely irrational character of the transference response), intens ity (the unus ual strength reaction elicited in the patient), ambivalence (the shift split in affect toward the analyst that occurs simultaneously or alternately), tenacity (the res ilience which s uch feelings tend to pers is t des pite the analyst's actual behavior), and capriciousness (the erratic and sometimes trivial or frivolous events that evoke the feelings). As trans ference distortions develop, their can be either pos itive or negative, paralleling the ambivalence that underlies all feelings that are, in part, unconscious. P os itive trans fe rence refers to the of good feelings toward the analyst, of love and its variationsas manifest in (albeit excess ive) interest, admiration, res pect, sympathy, and so onthat can predominate as the motive force behind the wish to 3204 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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change and to receive the analyst's approval. In the of pos itive trans ference, the patient overvalues and endows the analys t with some of the s ame magical attributed during infancy to the patient's parents. S uch feelings may be the bas is for the benign dependency by the analyst to gain the patient's trust and es tablish rapport insofar as the patient is well motivated and receptive to the analys t's influence. At the other end of affective spectrum, ne gative trans fe re nce refers to intens e bad feelings toward the analystanger, hostility, mistrust, rebellious nes s, and so on. In negative transference, the patient undervalues the analys t in that also repeat comparable feelings toward parents or parent-subs titutes of the past. B oth types of are inevitable as pects of psychoanalys is and must be interpreted. S ome analysts cons ider pos itive to be libidinal, bas ed on sexual drives, and negative transference as predominantly a function of unres olved aggres sive s trivings. Negative transference usually becomes most and requires analysis if treatment is to proceed. T his happens becaus e it becomes manifes t in ways that interrupt treatment progress , either through direct on the analyst or by the acting out of negative feelings instead of exploring them. Nevertheles s, very intense positive transference, often expres sed in exces sive pass ionate demands on the analys t, can be mis leading because it may als o be a manifes tation of res is tance patient defends against further probing into unres olved conflicts. Another obs tacle to analytical progres s may the analyst's own s trong reactions to the patient, or counte rtrans fe re nce , which can inappropriately enter 3205 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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treatment if the analyst is not s ufficiently aware of personal feelings . As traditionally understood, trans fe rence refers unrealistic dis tortions from the pas t, whether pos itive or negative; it does not pertain to reactions to pres ent as when the patient becomes legitimately angry. transference responses are increasingly recognized as having both objective and subjective components , relating both to significant figures of the past and to res ponses to the analyst; new editions of old conflicts exact replicas that are total projections, whereas editions attach themselves to actual therapist characteristics .

Trans ferenc e A s S ubs titute TR ANS FE R E NC E NE UR OS IS T he most vivid expres sion of transference is the of a transference neurosis , a substitute pathology that reiterates the fundamental pathology in which the ps ychologically regress es to the earliest stages of development and returns to the source of the problem the pas t s o as to transcend it. W hen the original displaced onto the relations hip with the analyst, a new, artificially acquired neuros is replaces the earlier one. the patient's s ymptoms los e their original P.2480 significance and adapt thems elves to a new meaning, the res olution of the trans ference neurosis coincides the cure of illnes s. R epetitions of childhood are the patient becomes continually frus trated in the search 3206 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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for gratification from the analys t, an approach bas ed on the as sumption that a full-blown transference neurosis should eventually take place in which inappropriate infantile feelings are revived and reexperienced in their original intensity. Manifestations of the transference neurosis do not immediately but emerge in the s o-called middle phas e analysis, when the patient is most subject to the forces induced by the analytical s ituation and to the emergence of infantile needs for gratification. Its appearance may be epis odic or it may never truly although much of the effort of the middle phas e is to remove res istances so as to allow the transference neuros is to s urface. T he trans ference neuros is was originally regarded as a serious obs tacle to analytical even though it also allows the analyst to observe the recapitulation of the patient's childhood res ponses. T he depth of the transference neuros is has s everal determinants. T he nature of the neuros is contributes to the repetition compulsion and to the amount of the patient has already undergone in the process of symptom formation. S uperimpos ed on the illness , the treatment s ituation also influences the nature of transference dependency, including the degree of frus tration (intentional withholding of wis h fulfillment of any information about the analyst so as to increase tension), the absence of reality information (the paucity cues and feedback to validate the patient's and the analyst's stance and activity (the greater the neutrality and silence, the deeper is the trans ference regress ion; the more extensive the use of analytical techniques, the more the trans ference is encouraged). 3207 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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E ach interpretation has been conceptualized as a form frus tration or deprivation that induces transference formation. Apart from individual variations in the timing and extent the transference neurosis , there is s ome controversy its content. F or s ome, it cons is ts only of the new old conflicts that F reud proposed, whereas , for others, pertains not only to the original oedipal transference as displaced onto the analys t, but also to the defens es res is tances that are built up against it. Mos t agree that the only way to resolve the transference neuros is is to analyze it. B ecaus e the unearthing of memories and the formation of a substitute neuros is gradual proces ses not easily attained that may not be feasible for s ome patients, achieving a complete transference neuros is and working through to its res olution may bes t be regarded as a final theoretical that cons titutes an ideal that is s ought but rarely fully accomplis hed.

NAR C IS S IS TIC TR ANS FE R E NC E T he term trans fe rence ne uros is is generally us ed to the intens e cons tellation of events that gradually places the analyst in a pos ition of unsurpass ed dominance in patient's life. F reud als o us ed the term diagnos tically to separate patients who could from those who could not develop s uch an irrational attachment without decompensating further. He characterized the former having a trans ference neuros is and the latter as having narcis sistic neurosis . T his divis ion contains the seeds later work by K ohut, K ernberg, and others who new analytical theories and techniques to 3208 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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such differences among patients. T he increasing appearance in treatment of severe character pathology, especially narcis sistic and personality dis orders, has confirmed that the structural organization of these patients is very different from that of their ps ychoneurotic counterparts . Instead simply excluding s uch patients from ps ychoanalysis, analysts have adopted both theoretical and technical modifications to deal with the particular ego of self-image, faulty self-es teem, and s plit object that dominate their clinical picture. T he F reudian premises , which primarily focus on and aggres sive impuls es , are considered inadequate unders tanding self disorders and place s erious on their us e as a model. Not only is the actual content the transference neuros is (that is , incestuous sexual strivings ) less pronounced, but the ideal of oedipal (which pres umes that uncons cious conflicts derive from developmental s tage after s table differentiation self and others has occurred) als o needs modification. ps ychoanalys is, the patient is as sumed to already cohes ive s ens e of self and to have achieved a stage of developmental maturity beyond that attained by with s erious ego dis orders. Much of the concern about altering analysis relates to the need to manage the particular archaic preoedipal transference partial object relations, and primitive defens e of s plitting and diss ociation that are exhibited in with self pathology toward the primary goal of of the damaged or deficient s elf. K ohut observed that patients with narciss istic disorders reactivate the specific mirroring and 3209 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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needs to which s ignificant figures (self-objects) of early infancy failed to res pond and, thus , do not develop transference neuros es . Instead of inces tuously parental figures, the central manifes tations involve which the patient deals with unfulfilled narciss istic K ohut defines two types of narciss istic (or s elf-object) transferences that are considered pathognomonic for disorders and are direct repetitions in treatment of preoedipal interaction: (1) mirror trans ference, in which unfulfilled need for acceptingconfirming mirroring is revived; and (2) idealizing trans ference, which the patient's need to merge with a source of idealized strength. In a s imilar vein, K ernberg has observed a personality constellation in borderline pers onality patients that als o produces atypical transference manifestations (i.e., chaotic, contradictory, turbulent, impulsive).

Trans ferenc e A s a G eneral B eyond the boundaries of the analytical situation, in transference feelings are particularly intense, may als o refer to the ubiquitous (and us ually less exaggerated) tendency to dis place onto all as pects of living the emotions and forgotten memories of one's particularly from the earlies t, most affect-laden years of life. Manifes tations of the trans ference-res is tance can appear not only in ps ychoanalysis, but als o in other treatment s ituations , such as a hos pital environment (called ins titutional trans fe rence) or between the and s ymbolic repres entations of the desired object, authority or es tablis hment figures (for example, phys icians ). In this global s ens e, trans fe rence may als o to rational and adaptive as pects , as well as to irrational 3210 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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distortions that derive from uncons cious desires.

R es is tanc e R es is tance refers to any opposition to exposing the unconscious. It embraces all the forces or defens ive operations of the mental apparatus that work agains t recovery of unconscious repres sed memories and that obstruct the progres s of analysis by opposing the analytical procedure, the analys t, and the patient's reasonable ego. C omparable to transference as a pivot of psychoanalys is , analyzing or managing is at the heart of analytical work, functioning in counterpoint to transference in two ways : (1) as to the trans ference, which means that the patient fights agains t the development of a transference neuros is P.2481 thus, prevents the analyst from tapping the s ource of intraps ychic conflict; and (2) as trans ference which means that the transference itself is used as a res is tance by s tubbornly adhering to irrational transference manifes tations ins tead of as a path to experiences and memories . F reud introduced the term re s is tance in 1892 in the treatment of E lizabeth von R . He believed that the patient fended off certain ideas with a repelling force that the amount of energy us ed was equal to the of the resistance. It was recognized at this point that res is tances were s tubborn and had to be removed. B y 1900, F reud had made several references to relation to dreams . B y 1905, the Dora case had first published example of the trans ference relations hip 3211 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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a form of resis tance in itself, an idea that was elaborated. T he notion of transference as the mos t powerful and frequent form of res is tance is still R es istance can be cons cious or unconscious and can produced by the ego, the id, or the s uperego. res is tance is the deliberate withholding of information from the analyst or the like. S uch res is tance is transient us ually eas ily rectified by pointing it out to the patient. Uncons cious res istance, however, is a more significant res ilient phenomenon; it aris es as a defense agains t uncovering repres sed material that the ego wis hes to avoid at all cos t. Instead of appearing early in very intermittently, uncons cious resistance occurs throughout analys is as a cons tant oppos itional force whenever significant data begin to s urface. E very as sociation and every act of the pers on undergoing treatment mus t confront the res is tance, which a compromis e between the forces that are s triving recovery and the opposing ones that need to keep the neuros is intact. T he clinical s igns and manifes tations of resis tance are manifold. Any persistent, s tereotyped, or inappropriate interruption of the treatment process may be a clue to res is tance. C ommon examples include the silence of a patient who impedes progres s through failure to and, at the other end of the spectrum, the compulsive talking of the patient who is ostensibly obeying the fundamental requirement to say whatever comes to but whos e verbal productions are unconscious barriers insight. S pecific variations of res is tant behavior include undue focus on the past that diverts attention away the present and inces sant inclus ion of trivia or external 3212 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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events s o as to avoid painful or emotion-laden topics . T ypical forms of res is tance also include lateness , hours, or delaying (forgetting) to pay one's bill. Managing res istances in psychoanalys is , which is the tas k of the analyst, involves addres sing defensive maneuvers of the patient before the avoided material be approached. B ecaus e ps ychoanalys is is by a s ys tematic and thorough analysis of res is tances , analyst mus t discover how the patient res is ts, what is being resisted, and why. T he immediate cause of res is tance (for example, anxiety, guilt, or shame) may superficial or s urface indication of what is going on in patient. R epeated uncovering and confronting of res is tances should reveal the affects underlying these behaviors . An important clinical distinction is made between those res is tances that are ego-syntonic (viewed by the acceptable or consistent with his or her total and those that are ego-alien (unacceptable or inconsistent). Only when the patient feels that a is ego-alien will he or s he be willing to give it up. T he patient will generally deny the exis tence of, belittle, or rationalize ego-syntonic res is tances . Although the term re s is tance is generally s ynonymous defens e mechanismsthat is, process es that guard danger and pain (for example, Anna F reud's denial, displacement, projection, rationalization, formation, conversion)the concept as unders tood today has been extended to refer to broader sources of information about pos itive adaptation of the ego to the world around it. In addition, analysis of basic armor against external threats to ins tinctual impulses 3213 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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added character traits to the arena of analysis, as well sens itized the analys t to the physical pos tures and nonverbal cues that reveal res is tance.

C ountertrans ferenc e C ountertrans fe rence is transference in the revers e directionfrom analys t to patient. It generally refers to analyst's uncons cious emotional needs , wis hes , and conflicts that are evoked by the patient, brought into analytical s ituation, and influence (usually negatively) analyst's objective judgment and reas on. T he term counte rtrans fe re nce was coined by F reud in Although he wrote little about the phenomenon, his reflects a related is suethe need for pros pective undergo a careful analysis as a training requis ite so as be cognizant, through their own res ponses, of the meaning in material pres ented by their patients . C ountertransference becomes manifes t in many ways . commonly acute, temporary, superficial, and eas ily recognized and managed, but it can also be chronic, permanent, deeply rooted, largely uncons cious , and the analyst's control. Acute countertrans ference may in res pons e to very s pecific content that aris es or in identification with s ome concrete aspect of the patient's personality. C hronic countertransference involves more general and ingrained patterns of behavior, often pathological, that pervade the analysis in a way that is untherapeutic and to which the analys t remains blind without external intervention. T he former type of countertrans ference is more typical occurs in every analys is . Like the patient, the analys t 3214 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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into the analysis as pects that do not belong there. countertransferences may become manifes t in special cons ideration of an attractive patient, as in eagerly an unavailable hour available or in failing to remember changed appointment hour of an uninteresting patient. C ommon warning s igns of countertransference in include experiencing uneasy feelings during or after sess ions with certain patients ; pers is tently feeling or actually falling asleep during s ess ions; altering or s howing careles sness about s cheduling (for extending hours or forgetting appointments); making special financial arrangements (for example, being strict with some patients and under-as siduous with others ); wis hing to help the patient outside the s ess ion; dreaming about one's patients or being preoccupied them in one's leis ure time; us ing the patient as an to impres s a colleague or having the urge to lecture or write about a particular patient; reacting strongly to the patient thinks of him or her (that is, needing a particular patient's approval); wanting, or not wanting, patient to terminate; finding ones elf unable to explore certain material or to understand what is going on with patient; and evincing s udden or exces sive feelings, anxiety, depress ion, or boredom during sess ions. C ountertransference is pres umed to relate primarily to unresolved and irrational res pons es , yet it may also reasonable reactions to a patient's behavior, as when feeling arous ed by a seductive patient, paternal toward deprived patient, frightened by an aggres sive patient, burdened by a demanding patient, or jealous of a succes sful patient. C ountertrans ference feelings are an inevitable part of any treatment. However, when such 3215 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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feelings are not situation-specific and evoke s trong reactions that belong to former events or pers ons in the analyst's life, there is a chance that the analyst will them into the analys is in the form of unneces sary, if not untherapeutic, behaviors . C ountertrans ference us ually signifies that the analyst has failed to obey the fundamental rules of abs tinence or neutrality. F orms of countertransference reflecting chronic left unsettled in the analys t's own analysis are more serious. E xamples include the analyst with an masochism who accepts abus e from patients without adequately analyzing its reas ons ; the grandiose P.2482 analyst who takes on the mos t difficult patients with promis es of cure without recognizing when he or she needs help if the treatment is not going well; the s omacho male analys t who allows the s eductive patient act out, reciprocating her sexual advances instead of examining the wis h to arouse him and acknowledging own need for sexual conques t; or the lonely analys t encourages the patient's dependency and will not terminate treatment for fear of abandonment. W hen the analysis becomes a s ource of narcis sistic gratification the analyst, who encourages the love or idolatry of the patient without introducing a more realistic appraisal or prematurely terminates patients who do not improve sufficiently, the analyst's own return to analys is may become necess ary. R ecent changes in theoretical and technical emphases relationality and intersubjectivity have res ulted in awarenes s of the complexity, multiplicity, and subtlety 3216 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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forms of countertransference. T hes e encompass such contemporary pos t-F reudian phenomena as projective identification (as defined by G eorge K lein, Otto T homas Ogden, and Heinrich R acker), role (as originated by J os eph S andler), and enactment (as developed by T heodore J acobs, J ames McLaughlin, J udith C hus ed, and others ). G eorge K lein originated the term projective refer to a dual concept, having both an intraps ychic interpersonal aspect. T he former aspect reflects a of forceful evacuation of an idea and is compos ed, firs t, penetration into the object and, s econd, of reinternalization of the injured or hos tile object. At the same time, it reflects a means of communication or interactional proces s very primitive in nature that goes beyond the countertransference as commonly unders tood. K ernberg viewed this phenomenon as an incomplete projection, in which the pers on repres ses is intolerable, then projects it onto an object and, ultimately, attempts to separate or dis tance him- or herselfand control the objects o as to additionally fend the intolerable. In effect, the individual unconsciously interacts with the object, experiencing what has been projected onto him- or hers elf. T hese projections can include preoedipal fantasies (as well as oedipal ones ), representing s ome of the earlies t internalized object relations of the infant. Ogden, a major thinker on this concept in its contemporary use, described a series of three steps or as pects (an interpers onal dialectic rather than linear proces s) in which (1) a dis avowed part of the patient's is unconsciously placed into the analys t; (2) the analys t 3217 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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in effect, coerced by the patient to uncons cious ly with the particular projection; and (3) the analyst reprocess es the projection such that a modified form is reintrojected by the patient. T his triple relationship proces s simultaneous ly s erves to go beyond two subjectivities of analys t and patient, creating what he refers to as an analytical third (i.e., the analys t as a creation of the two s ubjectivities). Ogden goes further suggest that understanding thes e very early proces ses helps to clarify the patient's relations hip to analyst in the present. T he complexity of this triad of inters ubjective experiences is further compounded by preexisting feelings of the analys t and those projected or evoked by, the patient. T he s ubtlety of thes e manifestations is als o defined by R acker's distinction between complementary and concordant countertransference reactions ; in the former, the identifies with a s elf-representation of the patient, whereas , in the latter, he identifies with a projected internal object repres entation. (T he presumption here that the infant's early ego is able to perceive and such self and object repres entations, which infant S tern believes , however, is unlikely.) S andler's term role re s pons ive ne s s is another variation this theme emphasizing the reflexive acceptance of the role which the patient is forcing on him. It is reminis cent B ion's explicit emphasis on the coercion the analys t to play a role in the patient's fantas y. Although the may totally attribute an irrational res ponse on his or her part as a personal blind s pot, in fact, it may be a compromise formation between his or her own tendencies and the coerced acceptance of an 3218 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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role. On the other hand, the analyst s hould not too absolve him- or hers elf of responsibility for intense emotional reactions to a patient's words or deeds by attributing them to affects s olely induced by the patient. T heodore J acobs originated the term enactme nt to refer to s ubtle interlocking transferencecountertransference phenomena, s uch as change in body posture as an unconscious enactment the part of either party, ins ofar as both are continually reacting to one another. C hus ed defined it as the actualization of transference fantas y that evokes a countertransference reaction. As a special phenomenon, it, too, can provide significant information about the patient's internal world. In fact, one of work in this area is the belief that insight into one's countertransference may only occur after s ome countertransference enactment has been recognized unders tood. Other members of the relational s chool of thought (e.g., S tephen Mitchell, Lewis Aron) also insist in the final analysis, analys ts always uncons cious ly as signed roles in an interactive proces s, no matter how cons ciously they try to do otherwis e. S ome analysts regard countertrans ference and its variations as invariably irrational and inappropriate, but may als o be viewed in a broader, more pos itive light. Within the larger context of countertransference, the analyst uses his or her perceptions and responses to insight into and empathy with the patient's productions . that capacity, countertransference may be cons idered an inevitable and therapeutically necess ary that allows the analyst to identify, at leas t temporarily, the patient. S imilarly, it has been s ugges ted that, 3219 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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projective identification may be experienced by the analyst as an alien force taking control of him or her, which, in turn, may interrupt his or her s ense of identity, it can also become a vehicle to as sis t the in the externalization of the patient's internal world of object relations hips . T his es pecially occurs when there good fit between the internal conflicts and of both parties.

C onc epts of Nontrans ferenc e Although F reud acknowledged that transference was a piece of real experience, he noted that it was of a provis ional nature inas much as what appears to be is only a reflection of a forgotten past. C arl J ung was the firs t analysts to depict transference, despite its irrationality, as ps ychological rapport, emphas izing the analyst's function and s uggesting that if the patient is to fulfill the demands of adaptation adequately, he or must find a relations hip to an object in the living B efore the 1950s , whatever was not trans ference in analytical practice was regarded as subversive (Anna F reud's term). E ven today, there are schools (for followers of Melanie K lein) whose adherents contend everything emanating from the patient is an expres sion transference and others that s tres s the need to and even to nurture, nontrans ferential respons es in the here-and-now. It was not until the 1950s, however, that analys ts explore directly the varieties of object relatednes s that occur in the therapeutic s ituation. Zetzel made the firs t broad differentiation in analytical treatment between its transferential and its realis tic as pects by introducing 3220 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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term the rape utic alliance ; G reenson later revised the to working alliance and further delineated the nontransferential aspect of the analytical relationship both transference and another form of the real relations hip.

Therapeutic A llianc e T he therapeutic (or working) alliance is the tas kcollaboration between therapis t and patient in which therapist's aims are to form an alliance with the adult ego of the patient and to encourage the patient to be a s cientific P.2483 partner in the exploration of his or her problems . Nonneurotic rapport is the basis for mutual, purpos eful, and realis tic interaction, des pite transference (and countertransference) impulses that are s imultaneously play. No analysis can proceed without the formation of a rational, trusting therapeutic alliance; its establishment the firs t task of treatment before a deeper transference neuros is can be facilitated. T he patient's s ens e of and the prospects of help from the analyst impel the patient to want to form a cooperative relationship. In addition to the therapist's consistent concern, care, and res pect, which contribute to the formation of a rational working alliance, the therapis t helps the patient distinguish between what is realis tic, healthy, and appropriate and what is dis torted, neurotic, and inappropriateto separate the fantas y figure from the one. T o the extent that a nontrans ferential, 3221 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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interaction is s ustained, the therapist will be able to monitor the patient's regres sion and irrationality and enable the patient to receive and comprehend the therapist's communications rationally, to review and interpretations reas onably, to participate cooperatively and res ponsibly, and, ultimately, to integrate the that are gathered in treatment. T he therapeutic alliance does not arise or s us tain its elf automatically. A trial period may be neces sary to extent to which a patient can form and maintain an ongoing collaboration. F or some fragile patients, the connection to another human being mus t be continually cons olidated before therapeutic work can be done. F or others , the empathic regard and profes sional concern the therapist are more eas ily transmitted and s erve as foundation for an already developed s ens e of s ecurity. During treatment, the inevitable intrusion of elements requires the therapist to repeatedly res tore therapeutic alliance so that irrationality and regres sion not disorganize the patient and threaten treatment. Major requisites for maintenance of the optimal working alliance are the capacity of the patient for controlled splitting (ability to os cillate between subjective affects the experiencing ego and objective judgment of the observing ego), which means that while one part of the patient's mind uncons cious ly repeats ps ychic conflicts , another part must be capable of being conflict-free and rational, of distancing itself s o as to recognize the nature of his or her respons es ; a s table s ens e of of self and object, which developmentally allows the patient to accept benign dependency on the analyst without its fus ing into an exces sive bond; achievement 3222 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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object cons tancy so as to relate consistently to another person over time irres pective of need; and a bas ic trus t, without which an emotional tie cannot be es tablis hed. Only after a rational therapeutic alliance been founded can a transference neurosis be

R eal R elations hip T he real relations hip is the realistic (reality-oriented undis torted) and genuine (authentic and true) as pect of the therapeutic relations hip. It is contrasted with the transference, which is genuine but unrealis tic, and the working alliance, which is realis tic but not genuine (that an artifact of the analytical situation). Most current psychoanalys is recognizes the distinction between transference (which is relived as if it were and that part of the therapistpatient interaction that is cons tituting an authentic human relations hip; the latter the medium through which trans ference reactions transpire, but it also has an independent exis tence. ps ychoanalytic work with patients with s evere mental disorders has placed greater emphas is on the real reparative object relationship (without which patients unable to develop an analyzable transference). In to the treatment of neurotic patients, the treatment of ps ychotic patients has traditionally centered on the real relations hip (as repres ented by s uch analysts as F rieda F romm-R eichmann, P aul F edern, and Harold S earles , well as S ullivan and W innicott). E specially in his or her initial contact, the therapis t presents to the patient as a real pers on who sets up structure of reality through mutual negotiations such is sues as s cheduling, fees, and vacations . 3223 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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P sychoanalytic ps ychotherapy not only introduces reality into treatment, but also accepts more readily the patient's perception of the therapis t may be the of objective, or real, respons es , not jus t distorted projections from the past. E xclus ive attention to transference may produce biased or erroneous interpretations , and, in s ome therapis ts , it reflects a defens ive flight to avoid their dis comfort with direct interpersonal engagement. E xistential analys is , the ardent express ion of that pos ition, is bas ed on the that transference is always a genuine relationship, s ui ge neris , between the analyst and analys and and entire emphas is on the real immediate encounter the two partners. In psychotherapy, the major technical is sue remains titrating gratification of real object need while s ustaining viable transference. R eal object need is fundamental to human functioning and transcends diagnos is ins ofar as every form of therapy begins with a patient who the therapist and the treatment situation as real. T hus , tas k of every treatment is in s etting each other as ide as objects (to a greater or less er degree) and forming a therapeutic barrier agains t the patient's natural to prefer to be gratified by the therapis t. T he difficulty in analysis relates to the extent to which it attempts to sustain a frus trating as-if s ituation, which is the fact that the patient inevitably learns real facts the analyst, both in and outs ide of the office, and the analyst behaves in a genuine way so as to be attuned to the patient's needs . Ultimately, if both the object and the transference aspects of the therapeutic relations hip are properly managed, they are inevitable 3224 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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complements to each other in providing optimal reality and nurturance without compromising the technical of trans ferential fantas y and frus tration.

Interpretive P roc es s P sychoanalysis is generally characterized by the role interpretation as its fundamental strategyin effect, to analyze means to interpret. As a process , it is by the analytical techniques of confrontation and clarification, each of which plays an integral part in the therapeutic path to self-unders tanding. refers to pointing out or highlighting the particular event that the patient mus t face. C larification places a vague or confusing event in clearer focus by s eparating important aspects from unimportant ones and on them. Inte rpre tation goes beyond the material that been discerned and elucidated by making the patient aware of psychic content and conflict that has been warded off and by attributing an underlying meaning or caus e to the event in question (i.e., is the pinnacle of ps ychoanalytic technique). W orking through, mos t referred to as an ongoing process or s tage of analys is rather than as a technique, is the culminating that combines all three techniques . It entails the progres sive, and elaborated exploration of made until the material has become fully integrated into the patient's ego. Interpretation involves the s pecial s kill (or art) by which analyst deciphers the latent meanings of the patient's verbalizations and translates them in a way that can be comprehended and accepted. It includes hidden connections between pres ent and previous behaviors, 3225 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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between feelings toward the analys t and thos e meant significant others, between instinctual impulses and defens es built P.2484 agains t them, and, ultimately, between cons cious thoughts and uncons cious wishes traced to their roots. T he interpretive process should form an sequence that links the neurotic adult with the child who lurks beneath the s urface. T hrough extrapolations from the manifes t material of free as sociation, dreams, and parapraxes (s lips of the mislaying of objects , and so on), interpretation decodes the disguised s ymbolic language of the uncons cious meaningful terms that are pers onally relevant to the patient. Interpretations have both direct and indirect functions. T he major purpos e is to provide the patient with an unders tanding of him- or hers elf and the s ource of the problem. T hey als o s erve the technical purpos e of frus tration rather than gratification, becaus e each introduced interpretation takes the patient away from analyst as the fulfiller of wishes. As the primary communication link between analyst and patient, the of interpreting may also s erve to trans mit empathy, concern, and care along with the painful content of the interpretation. P sychoanalysis is often dis tinguis hed by the us e of interpretations that are dynamic and genetic in nature. dynamic interpretation demonstrates how ps ychic operate to produce a particular effect on ps ychic life example, the superego's role in feelings of guilt). T he 3226 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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genetic interpretation traces patient behaviors and feelings back to their early origins in infancy and childhood. T hese recons tructions maintain an caus eeffect framework, s eeking the meaning of events old, disguis ed conflicts or traumas (for example, tracing patient affect to early sexual or rivalrous feelings as expres sions of unres olved oedipal wis hes ). B y historically incomplete (or here-and-now) may be used in psychoanalytic ps ychotherapy. S uch interpretations are les s penetrating, attributing patient res ponses to the present s ituation or to relatively events, and they are usually more concerned with the preconscious or conscious experience of the patient with long-standing uncons cious dis tortion. T hey may us ed as a prelude to, or s ubs titute for, more in-depth interpretation when deep genetic interpretations are too threatening or premature. (S imilarly, dis tinctions are represented by transference interpretations, which expres sly focus on the analyst as a s ubs titute or figure from the pas t, versus nontrans ference interpretations , which ess entially view the patient's res ponses as undis guised reactions to current events persons.)

G uidelines Ideally, interpretation is an individualized, patientcentered s trategy, with both content and timing based the unique ps ychic activity and receptivity of the analysand rather than on analys t preconceptions or preferences . T he further the analys t departs from the spontaneous data provided, the greater the chance of erroneous or premature interpretations . Other general guidelines pertain to the us e of a topographical 3227 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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in which the analyst s tarts from manifes t content or the patient's defens e before attempting to deal with the latent content that underlies it, and the viewing of conflicts in an increasingly historical perspective by providing interpretive links to early emotion-laden pas t events only when more recent material has been integrated. T itrating the timing and dos age of interpretation is a clinical skill whereby the analyst may gauge the areas of strongest or most inappropriate or those often-repeated themes that indicate focal conflicts and, at the same time, as sess the patient's capacity to accept the particular interpretation at that moment. Interpretation in psychoanalys is is traditionally characterized by a centripetal orientation toward the analystpatient axis , in which analys is of transference is regarded as a relatively closed or circumscribed intras ess ion activity, as oppos ed to a more centrifugal orientation of psychotherapy away from that axis, in greater attention is paid to extratherapeutic events.

Dream Interpretation F reud's class ic work, T he Inte rpre tation of Dre ams , and subs equent papers on the mental phenomena of sleeping and waking demons trate that dreams , parapraxes , jokes, puns , and metaphors are not sens eles s events but are meaningful acts s ubject to basic laws governing unconscious process es. F reud believed early on that the analysis of dreams s uch as had conducted on himself was s ufficient for a full s elfanalysis. As the fas tes t and s ures t route to the origins ps ychic conflicts (the royal road to the uncons cious ), dreams remain for many analys ts the perfect paradigm the interpretive proces s and often supply a source of 3228 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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information that cannot be derived in any other way. Dreamwork is a distorting proces s by which latent thoughts are condensed, displaced, and converted through symbolic s ubs titution into manifes t dream material, of which the recollection, upon wakening, is an unintelligible facade or disguis e. T he dream is looked on as a microcosm of the major concerns of the patient, es pecially as a commentary on the events of preceding day (day residue). F or the dreamer it serves largely wis h-fulfilling function, behind which res ides the original unsatis fied instinctual impulse. C urrent views suggest a prospective function of dreams, as a direct attempt to adapt to pres ent stress es or to solve future problems . Despite its salient role in analysis, however, dream interpretation s hould not be pursued for its own sake but be s ubject to the s ame rules that govern all analysis. E xcess ive attention to dreams can become a of res is tance by drawing the patient away from more spontaneous concerns .

MUTA TIVE C HA NG E A G E NTS Ins ight Although F reud did not use the term ins ight, he the curative process in ps ychoanalysis as riddles to be solved whose solution mus t be accepted by the Ins ight has s ince been defined as the proces s by which meaning, significance, pattern, or use of an experience becomes clear, or as the unders tanding that res ults the proces s. T heoretically, it has been portrayed as occurring in four s ucces sive stages : (1) preparation, characterized by frustration, anxiety, feelings of 3229 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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and despair, often accompanied by trial-and-error and falling into habitual patterns (repetition (2) renunciation, in which one des ires to escape from problem or is unmotivated to make ins ightful efforts (res is tance, negative transference); (3) inspiration or illumination, in which the problem is gras ped and solutions s uggest themselves (beginning of discovery based on interpretive process ); and (4) elaboration and evaluation, in which the validity of the insight is and confirmed agains t external reality (working Ins ight is not fully unders tood, and it is frequently misidentified as a dramatic eureka phenomenon. S uch sudden enlightenment rarely occurs in analysis, and, if does, it is usually s hort-lived, but may mis lead the or the patient into wishfully believing that profound unders tanding has transpired. It is much more common the patient to achieve insight in a slow and s ubtle in small ripples rather than in s udden tidal waves. also tend to be circums cribed and specific to certain problem areas rather than whole-truth revelations that as sociated with mys tical experiences or religious conversions . Des pite its presumed potency as a therapeutic agent, neither the role nor the function of insight in ps ychoanalys is is definitive. As yet, P.2485 there is no proof of a necess ary relation between the (or fals eness ) of ins ight and therapeutic res ults, that finding may be clinically obviated by the role of mutual belief as a nons pecific healing agent. W hat is clinically known, however, is that intellectual insight 3230 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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is of minimal value; ins ight must be emotionally (even though the distinction may be difficult to make). Moreover, not all change in ps ychoanalys is is to ins ight, and not all insight leads to behavioral P erhaps the major controversy that characterizes contemporary thinking on the subject is the mutative of ins ight versus the role of the therapeutic atmos phere the empathic relationship within which the occurs.

Identific ation and E mpathy Ins ight is s till regarded as the s ine qua non of analytical cure, and trans ference remains the primary vehicle through which mutative change occurs, but greater attention in recent years has been paid to the role of therapeutic atmos phere in facilitating ins ight and to the therapeutic relations hip as a corrective emotional experience in itself. Although the traditional concern been more with recreating the original infantile neurosis than with the ameliorating qualities of the analyst as an ideal or real person who is different from desired past objects, F reud recognized early that there are two which a pers on aims to recreate the s tate of blis sful symbiotic fus ion with the mother: identification (repair from the inside) and object relations hip (repair from the outside). G reater emphas is is now being placed on reparative phenomena, es pecially in the application of ps ychoanalys is to more dis turbed patients. Identification occurs when the s elf takes on the a s ubs titute object or model. T his phenomenon, an expres sion of an emotional tie with another pers on, is cons idered a consequence of the desire to believe in 3231 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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benevolent power of another, the tendency both cons ciously and uncons cious ly to want to be like the or admired object. B ecaus e the therapist's values are presumably more realis tic and constructive than those the patient, repeated identification with the image of the analyst serves not only to less en the harsh quality of patient's s uperego, as the analys t grants permis sion through acceptance of the patient, but also to modify patient's ego with the analyst as role model, increasing self-es teem through identification with the analyst's qualities . T he therapist's role as an identification model facilitated, at leas t in part, by his or her elevated transferential image as an idealized authority. E mphas is on the role of the therapeutic atmos phere in recent years is also expres sed in the concept of which, in clas sic psychoanalysis , comes closes t to a principle of freely s us pended attention, in which the analyst's nonjudgmental stance is a way of listening to the patient. More recently, K ohut's attention the importance of empathy in the cons truction of the and to the need to find an empathic object in the figure the analyst has expanded that concept in analytical practice. K ohut believes that the infant's ps ychological survival requires a s pecific psychological environmentthe of respons ive empathic s elf-objects and a s pecific of psychological structure formation within that environment, called trans muting internalizationthrough which the nuclear s elf becomes crystallized. Ultimately, autonomous s elf replaces thos e s elf-objects and within the context of s ecure caretaking, which forms nucleus of s elf-confidence and inner security. E mpathic 3232 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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unders tanding on the part of the analyst helps the to gain access to archaic narcis sis tic needs while also functioning as a partial gratification of thos e needs . T he patient, in expres sing, becoming aware of, and preoedipal needs , can convert them into normal selfes teem and the formation of ideals. No longer simply a tool of objective observation (for the analyst's scientific benefit), empathy is thus viewed as having mutative for the patient. As the analyst communicates an unders tanding of the patient's problems and ps ychic empathic res onance not only enters the inner world of patient, but may als o facilitate insight. C urrent res earch now sugges ts that even the most accurate and wellinterpretation will not be effective if s uch an accepting therapeutic atmos phere is absent. T he reality of a benevolent object in the here-and-now als o provides insight by differentiating the fantas ied trans ferential from the real one. In short, technique and relations hip factors may be inextricable. T he complex question of mutative change agents in ps ychotherapy is as yet unres olved. R ecent by J erome F rank, S trupp, the author, and others that the critical ingredients of psychotherapeutic effectivenes s may transcend specific strategies or treatment and, to a large extent, reside in nons pecific ingredients that all therapies s hare.

S C OP E OF P S YC HOA NA L YTIC P R A C TIC E Definition and B oundaries P sychoanalysisclas sic (orthodox) psychoanalysis as 3233 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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distinguished from the more recent variations referred as ps ychoanalytic ps ychothe rapyis virtually with the renowned name of its founding father, F reud (1856 to 1939). F reud's grand plan was to conceptualize psychology as a natural science by the principles of the nervous s ys tem to the realm of the mind and by trans lating ps ychological proces ses into phys iological language. T hat initial intent, in answer to perennial mindbody problem, was to provide psychiatry with its mis sing ps ychological foundation, and, thus, hoped to discover the common ground on which and mental disorders would ultimately meet. F reud's experimental laboratory for this ambitious task not only his keen, intricate clinical observations of as a neurologically trained phys ician in V ienna, but years (1897 to 1901) of undaunted and pains taking analysis. His belief that ps ychoanalys is could bes t be scientifically demonstrated by courageous ly applying it hims elf prefaced a lifetime of unceas ing introspection scholarly s tudy. Largely through the deciphering of dreams , F reud traversed the forbidden territory of his unrevealed (and therefore unresolved) s exual and aggres sive s trivings. P sychoanalysis has s ince become the predominant procedure by which analysts follow that uncharted for their patients and for thems elves . B as ed on the of sexual repress ion, ps ychoanalys is traces unfulfilled infantile libidinal wishes in the individual's unconscious memories . It remains unsurpas sed as a s crupulous beneath the surface of lives to dis cover the meaning motivation of behavior. T he ps ychoanalytic movement repres ents nearly a 3234 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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of enduring, as well as changing, theoretical constructs and clinical techniques. T his complex and often controvers ial cours e reflects an ongoing s earch, which F reud hims elf anticipated, for methods that would be applicable to a more general population than could be succes sfully treated with clas sic, long-term At the s ame time, he feared that the large-scale applications of our therapy will compel us to alloy the gold of ps ychoanalys is with the copper of direct suggestion. F or him, that purity resided in the analytical (interpretive) method alone. P sychoanalytic ps ychotherapy may be regarded as the analytical amalgam foreseen by F reud. Y et, although ps ychoanalytic psychotherapy goes beyond the boundaries of class ic practice by permitting analytical techniques to be modified and combined with nonanalytical techniques , it is no longer necess arily cons idered uncontrolled or contaminated treatment. R ather, modifications offer acceptable and appropriate applications of the analytical armamentarium, in with the sociocultural climate and temper of the times . early 20th-century V ictorian W e ltens chauung an age of s exual P.2486 repress ion that made hys terical neuros es the disorder of its day has been supers eded by the late century's culture of narciss ism, with its more modern manifestations of mental illness , s uch as the and borderline pers onality disorders and other ego disturbances . At the s ame time, current economic cons traints and the impact of public policy on the 3235 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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of psychiatric treatment have enforced practical cons iderations in the design of revis ed analytical techniques to meet a broader s pectrum of patients and problems . T he res ult has been an array of shorter-term ps ychodynamic s trategies, in addition to long-term ps ychoanalys is. As derivatives of clas sic ps ychoanalys is, the ps ychoanalytic psychotherapy represent modifications that both resemble and depart from it. As broadly practiced today, psychoanalytic treatment wide range of uncovering s trategies us ed in varied degrees and blends. Despite the inevitable blurring of boundaries in actual application, the original modality clas sic ps ychoanalys is and major modes of ps ychotherapy (express ive and s upportive) are separately here (T able 30.1-2). Analytical practice in all complexity res ides on a continuum. Individual always a matter of emphas is , as the therapist titrates treatment according to the needs and capacities of the patient at every moment.

Table 30.1-2 S c ope of Ps yc hoanaly C linic al C ontinuuma  

 

Feature

Ps yc hoanalys is

Ps yc hoanalyti E xpres s ive Mode

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F requency

R egular 45 times /wk; 50minute hour

R egular 13 times /wk; to full hr

Duration

Long-term; us ually 35+ yrs

S hort- or longterm; s everal sess ions to months or years

S etting

P atient primarily on couch with analyst out of view

P atient and therapist faceface; occas ional us e of couch

Modus

S ys tematic analysis of all positive and negative transference res is tance; primary focus analyst and intras ess ion events; transference neuros is facilitated;

P artial analys is dynamics and defens es ; focus on current interpersonal events and transference to others outs ide of sess ions; of negative transference; positive transference left

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regress ion encouraged

unexplored unles s impedes progres s; limited regress ion encouraged

Analys t/therapist Abs olute role neutrality; frus tration of patient; reflector/mirror role

Modified neutrality; implicit gratification of patient and greater activity

Mutative agents

Ins ight predominates within relatively deprived environment

Ins ight within more empathic environment; identification with benevolent object

P atient population

Neuroses; mild character ps ychopathology

Neuroses; mild moderate character ps ychopathology, es pecially narcis sistic and borderline disorders

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P atient requis ites

High motivation, ps ychologicalmindedness ; good previous object relations hips ; ability to maintain transference neuros is ; good frus tration tolerance

High to motivation and ps ychologicalmindedness ; ability to form therapeutic alliance; some frus tration tolerance

B as ic goals

S tructural reorganization personality; res olution of unconscious conflicts; ins ight into intrapsychic events; relief an indirect res ult

P artial reorganization of personality and defens es ; res olution of preconscious cons cious derivatives of conflicts; insight into current interpersonal events; object relations ; symptom relief a goal or prelude further exploration

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Major techniques

F ree method predominates ; full dynamic interpretation (including confrontation, clarification, and working through), with emphasis on genetic recons truction

Limited free as sociation; confrontation, clarification, and partial interpretation predominate, with emphas is here-and-now interpretation and limited genetic interpretation

Adjunct treatment

P rimarily avoided; if applied, all negative and positive meanings and implications are thoroughly analyzed

May be neces sarye.g., ps ychotropic drugs as temporary meas ure; if applied, its negative implications explored and

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diffus ed

aT his

division is not categorical; all practice resides on a

P S YC HOA NA L YS IS Ps yc hoanalytic Proc es s T he ps ychoanalytic process involves bringing to the surface repres sed memories and feelings by means of scrupulous unraveling of hidden meanings of material and of the unwitting ways in which the patient wards off P.2487 underlying conflicts through defens ive forgetting and repetition of the past. T he overall process of analys is is one in which neurotic conflicts are recovered from memory and expres sed, reexperienced in the trans ference, recons tructed by the analys t, and, ultimately, res olved through understanding. F reud referred to these as re collection, repe tition, and working through, which up the totality of remembering, reliving, and gaining insight. R ecollection entails the extension of memory to early childhood events, a time in the distant pas t 3241 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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the core of neurosis was formed. T he actual of thes e events comes through reminiscence, and autobiographical linking of developmental events. R epetition involves more than mere mental recall; it is emotional replay of former interactions with significant individuals in the patient's life. T he replay occurs within the special context of the analys t as projected parent, a fantas ied object from the patient's past with whom the latter unwittingly reproduces forgotten, unres olved feelings and experiences from childhood. F inally, through is both an affective and cognitive integration of previous ly repres sed memories that have been brought into cons cious nes s and through which the patient is gradually set free (cured of neuros is ). T he analytical may be s ubdivided into three major s tages: S tage one : During the initial phase, or beginning of treatment, the patient becomes familiar with the methods, routines, and requirements of analys is , realis tic therapeutic alliance is formed between and analyst. B asic rules are es tablis hed, the patient describes his or her problems, there is some review history, and the patient gains initial relief through catharsis and a sense of s ecurity before delving deeply into the s ource of the illnes s. T he patient is primarily motivated by the wish to get well. S tage two: During the long middle phas e, a transference neuros is emerges that s ubs titutes for actual neuros is of the patient and in which the wish health comes into direct conflict with the simultaneous wis h to receive emotional gratification from the analyst. T here is a gradual s urfacing of 3242 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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unconscious conflicts; an increased irrational attachment to the analys t, with regres sive and dependent concomitants of that bond; a developmental return to earlier forms of relating (s ometimes compared to that of mother and infant); and a repetition of childhood patterns and recall of traumatic memories through trans fer to the analyst unresolved libidinal wis hes. In ess ence, the middle stage is characterized by a continual battle within the ps yche of the patient and between patient and analys t, wherein infantile problems of childhood are played out with the as the object of the patient's repress ed strivings. It also the mos t protracted and pains taking phase, in which recall, repetition, and s ynthes is of early interpersonal patterns are relived and over and over until the patient develops new modes reacting and interacting that are more mature and realis tic. T hrough the proces s of working through, patient's ego is confronted with the same material, variations of it, many times over until the warded-off material can be s ufficiently neutralized and permanently integrated into the ps yche. T he length the middle phase (sometimes interminable) is a function of the res ilience of infantile behavior and a manifes tation of the fact that it takes repeated confrontations, clarifications , and interpretations to alter the psychic s tructure so as effect permanent change; neither a single experience, however intens e, nor a single interpretation, however incisive, is s ufficient for the ego to achieve mas tery over deep and long3243 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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feelings. S tage thre e : T he termination phas e is marked by diss olution of the analytical bond as the patient prepares for leave-taking. T he irrational attachment the analyst in the transference neuros is has because it has been worked through, and more rational as pects of the psyche pres ide, providing greater mas tery and more mature adaptation to the patient's problems . However, it is not an experience because it often revives s eparation and old is sues of dependence on versus from s ignificant pers ons of the pas t (as well as transient recurrences of original symptoms ). It has been likened to a mourning proces s in which the patient grieves over the impending los s of the and the loss of his or her former s elf. However, by incorporating the insights received, the patient can better use his or her s elf-knowledge to s eparate the reality of the analys t from the fantas y and the pas t from the present. T ermination is not a hard-and-fas t event, and the patient invariably has to continue to work through any problems outs ide of the therapy situation without the analys t or may need as sistance after analysis has technically F reud compared ps ychoanalysis to a chess game, in the initial and end s tages are s ubject to uniform rules that are virtually identical for all players but whose long middle phas e repres ents a spontaneous unfolding which each protagonis t's part is played out differentlyit thus, often thought to be the most creative stage. T he analogy s till broadly holds insofar as each analys is is 3244 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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individual, its course can never be precisely predicted, the participants mus t carefully receive their cues from other at each particular moment. In other ways, extending that paradigm may be mis leading. It is for example, to view psychoanalys is as a purely exercise in which, if each partner makes the perfect (the correct and well-timed interpretation on the part of the analyst and immediate insight on the part of the patient), ps ychoanalys is can proceed according to a preconceived s chedule.

Indic ations and C ontraindic ations In general, chronic cases of ps ychoneuroses (and mild ps ychopathology), including all forms of anxiety, obs es sional, and hysterical neurotic manifestations, are considered the mos t amenable to ps ychoanalys is. More recently, its application to with neurotic depres sion has met with success . P sychoanalysis is precluded when dangerous phys ical s ymptoms require more immediate attention for virtually the entire realm of the psychos es, in which severe ego deficits and tenuous reality are apparent. However, psychoanalys is has been applied to a wide of patients well beyond thos e with s ymptomatic in part, because the kinds of patients who appear for treatment today differ diagnos tically from thos e in the past. P atients with hys teria and other neuros es have largely been replaced by those with character diagnostic group that nonetheles s shares s ome with symptomatic neuros es. S ome groups probably require modifications of ps ychoanalys is and are broadly contraindicated. 3245 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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Narciss is tic character dis orders can be treated with ps ychoanalytic methods , but res ults tend to be to the extent that neurotic traits are evident, along with narcis sistic ones . T he s ame appears to be true of disorders : S ome patients with deviant behaviors seem be intractable to ps ychoanalysis, but, when thos e behaviors are accompanied by neurotic difficulties, are considered as amenable to psychoanalytic work, heteros exuals who have s exual problems. A small percentage of patients with ps ychos omatic illness may also need special modifications of ps ychoanalys is , in of a clus ter of characteristics often observed in such patientscalled ale xithymic (unable to verbalize feelings , poverty of fantas y life, and denial of psychic conflict) make them poor candidates for traditional methods . P ers ons with schizoid or paranoid personality dis orders also uns uitable, as are P.2488 those with more serious ps ychosocial disorders , the substance us e dis orders (narcotic addictions and alcoholism) and antisocial personality dis order. Infantile demands, poor impulse control, an inability to tolerate frus tration, impaired s ocial judgment, and the phys ical concomitants of substance abus e severely limit ps ychoanalys is. E ven less amenable are patients with ps ychos es , es pecially of the paranoid type, who are to form anything but the most archaic transferences . T hese diagnos tic categories raise the related iss ue of concomitant or adjunct treatment. P s ychoanalys is es sentially discourages any other concurrent therapies, because they may introduce artifacts into the 3246 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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ps ychoanalytic process . F or thos e disorders or when other therapies (for example, pharmacologic are als o used, is sues relating to their use are inevitably brought into analysis for exploration.

Patient R equis ites T he most important patient requis ites for are the following: 1. High motivation. T he patient needs a strong motivation to persevere, in light of the rigors of intens e and lengthy treatment. T he desire for and s elf-unders tanding must s urpass the neurotic need for unhappiness . T he patient must be willing face iss ues of time and money and to endure the and frustration as sociated with s acrificing rapid in favor of future cure and with foregoing the secondary gains of illnes s. 2. Ability to form a relations hip. T he capacity to form maintain, as well as to detach from, a trusting relations hip is es sential. P s ychoanalys is can begin, be sus tained, nor terminate properly without such a basis. T he patient also has to withs tand a frus trating and regres sive trans ference without decompensating or becoming excess ively P atients with a his tory of impaired or trans ient interpersonal relations who cannot establish a connection to another human make poor for psychoanalysis. 3. P sychological-mindedness and capacity for ins ight. an intros pective process , ps ychoanalys is requires curios ity about ones elf and the capacity for self3247 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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scrutiny. T hose who are unable to articulate and comprehend their inner thoughts and feelings negotiate with the fundamental analytical coinand their meanings. T he inability to examine one's own motivations and behaviors precludes benefits from the analytical method. 4. E go strength. E go strength is the integrative to os cillate appropriately between two antithetical types of ego functioning: On the one hand, the must be able to reflect temporarily, to relinquis h for fantasy, and to be dependent and pass ive. On other hand, the patient has to be able to accept analytical rules , to integrate interpretations , to defer important decisions , to shift pers pectives so as to become an observer of his or her intrapsychic proces ses, and to function in a s ustained relations hip as a res ponsible adult.

Goals T he aim of ps ychoanalysis, in its mos t parsimonious is express ed in the now-famous F reudian dictum, was , so shall ego be. When forbidden ins tinctual are no longer repres sed and creating debilitating neuros es, the rational and healthy aspects of the will have replaced them. As an extension of that intraps ychic reorganization, a reduction in the patient's punitive superego is also expected, express ed in les s paralyzing guilt and a greater capacity for pleasure. patient is better able to accomplish F reud's two life of arbe ite n und liebe nto work and to loveas thes e basic activities of living are releas ed for fuller gratification 3248 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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because the underlying inhibitions have been removed. S tated in developmental terms , psychoanalys is aims at gradual removal of amnesias rooted in early childhood based on the ass umption that when all gaps in memory have been filled, the morbid condition will cease the patient no longer needs to repeat or remain fixated the pas t. G iving up infantile wishes and not having to recapitulate early inappropriate behaviors is an of the patient's success ful negotiation of success ive of ps ychosexual development, culminating in the phase of mature s exuality and intimacy. T he patient be better able to relinquis h former regress ive patterns to develop new, more adaptive ones, particularly as he she learns the reasons for his or her behavior. A goal of ps ychoanalys is is for the patient to achieve meas ure of self-unders tanding or insight. P sychoanalytic goals are often considered formidable example, a total personality change), involving the reorganization of old developmental patterns bas ed on earlier affects and the entrenched defens es built up agains t them. G oals may als o be elusive, framed as are in theoretical intrapsychic terms (s uch as greater strength) or conceptually ambiguous ones (res olution the transference neuros is ). C riteria for s ucces sful ps ychoanalys is may be largely intangible and and are bes t regarded as conceptual end points of treatment that mus t be translated into more realis tic practical terms. In practice, the goals of psychoanalysis for any patient naturally vary, as do the many manifes tations of T he form that the neuros is takes uns atisfactory s exual object relations hips , inability to enjoy life, 3249 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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underachievement, and fear of work or academic or exces sive anxiety, guilt, or depress ive ideationdetermines the focus of attention and the direction of treatment, as well as the specific goals. goals may change at any time during the course of analysis, especially as many years of treatment may be involved.

Major Approac h and Tec hniques S tructurally, ps ychoanalys is us ually refers to individual (dyadic) treatment that is frequent (four or five times week) and long-term (s everal years). All three features their precedent from F reud himself. T he dyadic arrangement is a direct function of the F reudian theory of neurosis as an intrapsychic phenomenon, which takes place within the person as instinctual impuls es continually seek dis charge. dynamic conflicts must be internally resolved if personality reorganization is to take place, the memory and perceptions of the repres sed past are F reud initially s aw patients 6 days a week for 1 hour day, a routine now reduced to four or five s ess ions of clas sic 50-minute hour, which leaves time for the take notes and organize relevant thoughts before the patient. Long intervals between sess ions are avoided that the momentum gained in uncovering conflictual material is not lost and confronted defens es do not time to res trengthen. F reud's belief that s ucces sful psychoanalys is always long time becaus e profound changes in the mind occur slowly still holds . T he proces s can be likened to the 3250 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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sens e of time that is characteristic of our unconscious proces ses. Moreover, because psychoanalysis detailed recapitulation of pres ent and pas t events, any compromise in time presents the risk of losing pace the patient's mental life.

P s yc hoanalytic S etting Like other forms of ps ychotherapy, psychoanalysis place in a profes sional setting, apart from the P.2489 realities of everyday life, in which the patient is offered temporary sanctuary in which to ease ps ychic pain and reveal intimate thoughts to an accepting expert. T he ps ychoanalytic environment is designed to promote relaxation and regress ion. T he s etting is usually and s ens orially neutral, and external s timuli are

US E OF THE C OUC H T he traditional setting is a formalized part of the ps ychoanalytic heritage, s till modeled on the phys ical arrangement of F reud's medical office at B ergas se 19 V ienna. T he analys t's couch is the mos t enduring requirement. T he couch allows the patient to lie down within view of the analyst, who remains seated in a outside the patient's field of vision. T he couch is a convention that preceded carryover from the days when F reud us ed hypnos is . It persis ted as a primary feature of ps ychoanalys is , to facilitate patient communication by way of free as sociation. Its original rationale was neither comfort convenience but involved both nostalgic and private 3251 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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motives for F reudit was the las t ves tige of the hypnotic method out of which ps ychoanalys is evolved, and, on a more personal level, F reud could not bear being looked for 8 hours a day and believed that other analys ts that distaste. Nevertheles s, the couch has several clinical that are both real and s ymbolic: (1) the reclining relaxing becaus e it is as sociated with sleep and s o the patient's cons cious control of thoughts ; (2) it minimizes the intrusive influence of the analyst, thus curbing unneces sary cues ; (3) it permits the analys t to make obs ervations of the patient without interruption; (4) it holds s ymbolic value for both parties, a tangible reminder of the F reudian legacy that gives credibility to the analyst's profes sional identity, allegiance, and expertise. However, the reclining position of the patient with analys t nearby can als o generate threat and discomfort, as it recalls anxieties derived from the parentchild configuration that it physically resembles . It may als o have pers onal meanings for some, a portent dangerous impuls es or of s ubmiss ion to an authority figure; for others , a relief from confrontation by the (for example, fear of use of the couch and to lie down, or couch-diving, may reflect res istance thus, need to be analyzed). Although the us e of the is requis ite to analytical technique, it is not applied automatically, is introduced gradually, and may be suspended whenever additional regres sion is or countertherapeutic.

FUNDAME NTAL R ULE T he fundamental rule of free as sociation requires 3252 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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to tell the analyst everything that comes into their heads however disagreeable, unimportant, or nonsensicaland to let themselves go as they would in a conversation that leads you from cabbages to kings . It differs decidedly from ordinary convers ationinstead of connecting one's remarks with a rational thread, the patient is as ked to reveal thos e very thoughts and that are objectionable precisely becaus e the patient is avers e to doing s o. T his directive repres ents an ideal becaus e free does not arise freely but is guided and inhibited by a variety of conscious and unconscious forces. On the overt level, to renounce the natural tendency toward deliberate censorship, especially with a relative requires a firm basis in trust. On a more covert level, is an interplay of motives that direct the ambivalent of free ass ociations , alternately fostering and the progres s of analysis . T he analyst must not only encourage free as sociation through the physical setting and a nonjudgmental attitude toward the patient's verbalizations, but als o examine those very instances the flow of ass ociations is diminished or comes to a they are as important analytically as the content of the as sociations. T he analys t s hould also be alert to how individual patients us e or misus e the fundamental rule. S ome obsess ive-compuls ive patients, for example, apply the rule so literally that they appear to be fas tidiously complying with it while actually s abotaging treatment by using it to avoid s elf-observation. In other patients, the inability to stop primary process because of a breakdown of ego functioning may s ignal latent psychos is. 3253 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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Aside from its primary purpos e of eliciting recall of hidden early memories , the fundamental rule reflects analytical priority placed on verbalization, which the patient's thoughts into words so that they are not channeled phys ically or behaviorally. As a direct concomitant of the fundamental rule, which prohibits action in favor of verbal expres sion, patients are to pos tpone making major alterations in their lives, marrying or changing careers , until they dis cuss and analyze them within the context of treatment.

PR INC IPL E OF E VE NLY S US PE NDE D ATTE NTION As a reciprocal corollary to the rule that patients communicate everything that occurs to them without criticis m or selection, the principle of evenly sus pended attention requires the analys t to sus pend judgment and give impartial attention to every detail equally. T he method cons ists s imply of making no effort to on anything s pecific, while maintaining a neutral, quiet attentivenes s to all that is s aid. F reud described the analyst's attitude as the s urrender to unconscious activity so as to avoid as much as poss ible any cons cious expectations to catch the drift of the patient's unconscious with his own unconscious . T his special attitude, or way of listening, was originally out of F reud's major concern that the analyst needs to keep in mind innumerable dates , names, detailed reminiscences , and as sociations without us ing any expedient, s uch as note taking, as an as sis t to Often misunders tood as an intellectual or objective orientation that distances the analys t from the patient, fre e -floating attention means forming a connection to 3254 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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patient while giving free play to ideas arous ed in T he notion of equidis tance (Anna F reud) als o similar principle by suggesting that the analys t attempt, effect, to keep equidistant from all of the ps ychic (id, ego, s uperego), not allying too clos ely with any of them. T he analys t thus allows each area of mental functioning to be fully expres sed without influencing its strength by excess ive attention or collusion.

ANALYS T AS MIR R OR A s econd principle is the recommendation that the be impenetrable to the patient and, like a mirror, reflect only what is s hown. Analysts are advis ed to be neutral blank screens and not to bring their own personalities treatment. T his means that they are not to bring their values or attitudes into the dis cuss ion or to share reactions or mutual conflicts with their patients , even though they may sometimes be tempted to do s o. T he major rationale for neutrality is in the interest of science, as well as in the facilitation of a regres sive T he bringing in of reality and external influences can interrupt or bias the patient's unconscious projections. Neutrality als o allows the analys t to accept without cens ure all forbidden or objectionable responses. However, the mirroring role is never entirely neutral or pass ive, as it is sometimes characterized. T he idea of analyst as totally value-free is a fallacy, as it is not to impart one's s ocial, cultural, or personal through uncons cious cues or behaviors . In practice, the mirroring role can misrepresent the human part the analyst implicitly plays. T he analys t's restraint from suggestion and affective interaction s hould not 3255 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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transmitting respect, concern, and nonjudgmental

R UL E OF AB S TINE NC E F reud advised that the analyst carry through the treatment in a state of renunciation. T he analys t P.2490 must deny the patient who is longing for love the satis faction he or s he craves . It not merely means or s exual abstinence, but als o encompass es the of emotional needs and wishes. T he fundamental rule abstinence allows the patient's longings to pers is t and serve as driving forces for analytical work and to change. Although the analyst is advised to as sume a pos ture of privation and not s atis fy the patient's wishes , the expected to continue to s eek substitute gratifications during analys is to alleviate his or her s uffering. T he rationale for this analytical s tance is that the patient be prepared to deny instinctual satis faction for the s ake talking about feelings instead of acting on them and having them relieved. T he analyst must curb the temptation to take on the role of a nurturing figure (parent, lover, or friend) who satis fies the patient's libidinal wis hes or to interact behaviorally instead of analyzing the patient's ass ociations . Like any other instrument, the rule of abs tinence mus t be applied with profes sional judgment to achieve the optimal balance frus tration and gratification (in light of the patient's tolerance for being denied what he or she craves). It is misunderstanding of analytical intent, not to mention practice, to ass ume that the analyst mus t be totally 3256 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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and withholding or that the patient s hould be expected endure such treatment without getting wors e or

L imitations Limitations of psychoanalys is as a body of theory (for example, biological orientation, determinis tic viewpoint) and as a s cientific instrument (for example, idiographic approach) have implications for its credibility as a form therapy. T hese limitations involve the complex is sues the universality and validity of major psychoanalytic cons tructs (from the Oedipus complex to the tripartite mental s tructure of id, ego, and s uperego) and the reliability of the case study method, which is the most subjective form of res earch observation in es tablis hing effectivenes s. More specific is the the validation of interpretations , on which res ts the integrity of ps ychoanalys is as a clinical method. R elating to psychoanalysis as a science, S chafer has advanced the adaptive concepts of Hartmann by propos ing an action language for psychoanalysis as a systematic alternative to F reudian metaps ychology. B y making explicit and codifying the inner reality of the patient in nonmechanis tic terms, S chafer's language addres ses unconscious communication through words and behavior by transforming each ps ychological event, or experience into a kind of activity. C harles B renner, in confirming that psychoanalysis is a devis ed principles by which interpretations can be validated, including types of intrinsic patient of analys t conjectures and, rarely, heuristic from s ources outs ide of analys is . At present, the predominant treatment cons traints are 3257 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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often economic, relating to the high cos t in time and money, both for patients and in the training of future practitioners. In addition, because clinical requirements emphasize s uch requis ites as psychologicalverbal and cognitive ability, and stable life s ituation, ps ychoanalys is may be unduly res tricted to a diagnostically, s ocioeconomically, or intellectually advantaged patient population. Other intrins ic is sues pertain to the use and mis us e of its s tringent rules, whereby overemphas is on technique may interfere with an authentic human encounter between analyst and patient, and to the major long-term risk of in which protracted treatment may become a s ubs titute for life. R eification of the class ic analytical tradition may interfere with a more open and flexible application of its tenets to meet changing needs . It may als o obstruct a comprehensive view of patient care that includes a appreciation of other treatment modalities in with or as an alternative to psychoanalysis. Ms. A., a 25-year-old articulate and intros pective student, began analys is complaining of mild, chronic anxiety, dys phoria, and a s ens e of inadequacy, des pite above-average intelligence and performance. S he also expres sed difficulty in long-term relations hips with her male peers . Ms. A. began the initial phas e of analysis with self-disclos ure, frequent reports of dreams and and overidealization of the analys t; s he tried to please by being a compliant, good patient, jus t as s he had good daughter to her father (a profess or of medicine) going to medical school. 3258 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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Over the next several months, Ms . A. gradually a s trong attachment to the analys t and s ettled into a of exces sive preoccupation with him. S imultaneous ly, however, she began dating an older psychiatrist and proceeded to complain about the analys t's coldnes s unrespons ivenes s, even cons idering dropping out of analysis because he did not meet her demands. In the course of analysis, through dreams and Ms. A. recalled early memories of her ongoing with her mother for her father's attention and realized failing to obtain his exclusive love, s he had tried to become like him. S he was also able to see how her increasing interest in becoming a psychiatrist (rather following her original plan to be a pediatrician), as well her recent choice of a man to date, were the pas t vis --vis the analys t. As this repeated pattern recognized, the patient began to relinquish her intense erotic and dependent tie to the analys t, viewing him realis tically and beginning to appreciate the ways in his quiet pres ence reminded her of her mother. S he became less disturbed by the s imilarities she shared her mother and was able to disengage from her father more comfortably. B y the fifth year of analys is , s he was happily married to a class mate, was pregnant, and was pediatric chief res ident. Her anxiety was now and s ituation-specific (that is, s he was concerned motherhood and the termination of analysis).

P S YC HOA NA L YTIC P sychoanalytic ps ychotherapy is based on dynamic formulations and techniques that derive from ps ychoanalys is and is des igned to broaden its s cope. 3259 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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P sychoanalytic ps ychotherapy in its narrowes t s ens e is us e of ins ight-oriented methods only. However, as generically applied today to an ever-larger clinical spectrum, it incorporates a blend of uncovering and suppress ive meas ures . T he strategies of psychoanalytic ps ychotherapy range from express ive (ins ight-oriented, uncovering, evocative, or interpretive) techniques to supportive (relations hip-oriented, s uggestive, s uppress ive, or repress ive) techniques. Although those two types of methods are s ometimes regarded as antithetical, their precis e definitions and the dis tinctions between them by no means absolute. In an early attempt to dis tinguis h psychoanalys is from other forms of psychotherapy, the primary distinction that of analyzed vers us unanalyzed trans ference. in therapy can be influenced by either type. T he latter regarded simply as the placebo or s ugges tion effect by virtually all therapies ; the former is the s ys tematic analysis of transference. It follows that the pivotal is sue for ps ychoanalytic ps ychotherapy is how the transference is used or managed, to what extent it is interpreted or uninterpreted, and to what extent it is fos tered or suppres sed by the therapist. T hirty years after delineating four intrins ic criteria of ps ychoanalys is (centrality of trans ference, neutral regress ion to P.2491 transference neuros is , interpretation as s ole G ill revised them in 1984 to provide the backbone of 3260 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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modern ps ychoanalytic psychotherapy: (1) T he of trans ference is broadened to encompass nontransference manifes tations ; (2) the guiding of neutrality is loosened to acknowledge the real personality and attitudes of the analyst; (3) the transference neuros is is supplanted or replaced by less frus tration, fantas y, and focus on the past (and greater gratification, reality, and focus on the present); and (4) interpretation is extended to include more methods (with genetic interpretations expanded by and-now interpretations). T hes e intrinsic changes accompany three major extrinsic changes : reduced frequency, reduced or more flexible treatment duration, and abandonment of the couch. With the widened spectrum of more s everely ill the major rationale for decreasing the frequency of sess ions is to influence the nature of the transference is formed by diluting the transference bond so as to control excess ive regress ion and dependency. As a full transference, neurosis is less appropriate and a and more flexible frequency standard is maintained. T he duration of psychoanalytic ps ychotherapy is shorter and more variable than in ps ychoanalys is. T reatment may be brief, even with an initially agreedfixed time limit (for example, Mann's time-limited ps ychotherapy), or may extend to a les s definite months or years. B rief treatment is chiefly us ed for problems or highly focused conflict, whereas longer treatment may be applied in more chronic conditions or for intermittent episodes that require ongoing attention deal with pervasive conflict or recurrent In either event, when a time frame is es tablis hed at the 3261 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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beginning, it can often be altered in the course of as patient needs and goals change. Unlike ps ychoanalytic ps ychotherapy rarely us es the couch; instead, patient and therapis t sit face to face. T his helps to prevent regres sion becaus e it encourages the patient to look on the therapist as a real person from whom to receive direct cues, even though transference and fantas y will continue. T he couch is cons idered unnecess ary because the free-as sociation method is us ed, except when the therapist wishes to gain acces s fantas y material or dreams to enlighten a particular In current practice, the us e of the couch may not even advis able in many ins tances (es pecially in the type), becaus e extensive uncons cious data are not or becaus e the primitive thinking or behavior that may accompany severe illnes s makes further regres sion undes irable. Another iss ue is the use of adjunct treatment during ps ychoanalytic ps ychotherapy, which differs from ps ychoanalys is in two ways . F irst, becaus e of the more severe pathology of patients in ps ychoanalytic ps ychotherapy, there is often a greater need for treatment, especially for ps ychotropic drugs , to relieve acute symptoms of anxiety or depress ion s o that exploration can ens ue; other treatments may also be neces sary, such as hospitalization, rehabilitative or family therapy. S econd, the need to analyze the viciss itudes of adjunctive therapy is als o s us pended so the prescription of medication or s ome other therapy is more acceptable and can be directly dis cuss ed (that is, their negative implications diffus ed and their positive emphasized). 3262 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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E xpres s ive Ps yc hotherapy Indic ations and C ontraindic ations E xpres sive psychotherapy has become a des irable and widely applicable form of treatment under the following circums tances : (1) P s ychoanalysis is diagnos tically or clinically contraindicated becaus e the patient lacks sufficient ego s trength to tolerate the extent of frus tration, or s us pens ion of reality that is required; the patient is deficient in the cognitive res ources neces sary the achievement of deep ins ight; the patient is not sufficiently motivated because of competing family, or cultural influences ; or the problem is so pres sing that lengthy treatment is unsuitable. (2) P ractical or cons iderations prevail whereby patients otherwis e for a more lengthy psychoanalysis are unavailable for term treatment for reasons of time, money, or F or this group, the techniques used are closer to thos e ps ychoanalys is proper, because extrins ic rather than intrins ic factors are largely res ponsible for the change approach. Nonetheless , the category of healthier cons titutes a s izable population of recipients of current ps ychoanalytic psychotherapy. (T he inclus ion of both categories here in part accounts for the blurred and confusion in the application of express ive ps ychotherapy.) Diagnos tically, psychoanalytic ps ychotherapy in its expres sive mode is s uited to a range of with mild to moderate ego weakening, including conflicts, s ymptom complexes , reactive conditions, and the whole realm of nonpsychotic character dis orders, including those dis orders of the s elf that are among the 3263 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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more trans ient and les s profound on the s everity-ofspectrum, such as narcis sis tic behavior dis orders and narcis sistic pers onality disorders. It is also the controvers ially recommended for patients with personality dis orders, although special variations may required to deal with the ass ociated turbulent characteristics , primitive defens e mechanisms, toward regress ive epis odes , and irrational attachments the analyst. P sychoanalysis is generally limited to those patients can develop a transference neurosis (that is , their cathexes can be displaced). T his neces sarily precludes patients with narciss is tic neuroses, whose libidinal cathexes are rigidly focus ed on the s elf. P sychoanalytic ps ychotherapy, through its modifications , can be us ed effectively to treat thes e patients. No longer seen as unanalyzable, they can develop a les s erotic, more aggres sive trans ference to the therapist that can also interpreted, albeit in a more limited way. T he individuals bes t s uited for the expres sive ps ychotherapy approach have fairly well integrated and the capacity both to sustain and to detach from a bond of dependency and trust. T hey are, to some ps ychologically minded and self-motivated, and they generally able, at least temporarily, to tolerate doses of frus tration without decompensating. T hey mus t also the ability to manage the rearous al of painful feelings outside the therapy hour without additional contact. P atients must have s ome capacity for intros pection and impulse control, and they s hould be able to recognize cognitive distinction between fantasy and reality. 3264 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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G oals T he overall goals of expres sive psychotherapy are to increase the patient's s elf-awarenes s and to improve object relations through exploration of current interpersonal events and perceptions. In contrast to ps ychoanalys is, major structural changes in ego and defens es are modified in light of patient limitations . Ins tead of systematically res olving the unconscious nuclear conflict, the therapist may opt to resolve some conflict areas and undo specific res is tances , overlooking or reinforcing others . T he aim is a more limited and, thus , s elect and focused unders tanding of one's problems . R ather than uncovering deeply hidden and past motives and tracing them back to their origins infancy, the major thrust is to deal with precons cious or cons cious derivatives of conflicts as they became in pres ent interactions. Although insight is sought, it is extensive; ins tead of delving to a genetic level, there is greater emphas is on clarifying recent dynamic patterns and maladaptive P.2492 behaviors in the pres ent. S ymptom relief may be an acceptable aim, rather than s imply a concomitant of the better res olution of conflicts . In more integrated who have the capacity for greater ins ight, it may be a prelude to further analytical work.

Major A pproac h and Tec hniques F acilitating a full-blown, regres sive trans ference neither neces sary nor appropriate. R ather, the major modus operandi involves es tablis hment of a 3265 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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alliance and early recognition and interpretation of negative trans ference. Only limited or controlled regress ion is encouraged, and positive transference manifestations are generally left unexplored, unless are impeding therapeutic progress ; even here, the emphasis is on shedding light on current dynamic and defens es . Although technical neutrality is largely maintained, the therapist is less strictly anonymous and s ilent and is active and responsive in his or her overall stance and nature of s pecific interventions . T he free-as sociation method is no longer used as the major patient tool, and primary process material is elicited only as a selective of acces sing s pecific conflictual data. C larification and interpretation are s till us ed, but they are altered both qualitatively and quantitatively. Interpretation is us ed relatively less , with more of the therapis t's time spent clarification, es pecially on how the patient understands the content of interpretation. P artial interpretations addres s s ome conflict areas, as others are left the depth of interpretation is les s penetrating, with emphasis on the present.

L imitations A general limitation of expres sive psychotherapy, as of ps ychoanalys is, is the problem of emotional integration cognitive awarenes s. T he major danger for patients are at the more dis organized end of the diagnostic spectrum, however, may have les s to do with the overintellectualization that is s ometimes seen in patients than with the threat of decompensation from or acting out of deep or frequent interpretations that the 3266 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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patient is unable to integrate properly. S ome therapists fail to accept the limitations of a insight-oriented approach and so apply it to modulate the techniques and goals of Overemphas is on dreams and fantasies, zealous us e the couch, indiscriminate deep interpretations, and continual focus on the analys is of trans ference may less to do with the patient's needs than with those of a therapist who is unwilling or unable to be flexible. Ms. B ., an intelligent and verbal 34-year-old divorced woman, presented with complaints of being unappreciated at work. Always angry and irritable, she cons idered quitting her job and even leaving the city. social life was also being negatively affected; her had threatened to leave her because of her extremely hostile, clinging behavior (the same reas on her exhusband had given when he left her 9 years earlier only 16 months of marriage). Her past included promiscuity and experimentation with various drugs , and, currently, she indulged in heavy drinking on weekends and occasionally smoked S he had held many jobs and had lived in various cities. eldes t of three children of a middle-clas s family, she from an unhappy and uns table home: her brother had been in and out of psychiatric hospitals; her s is ter had home at the age of 16 after becoming pregnant and forced to marry; and her overly controlling parents had subjected their children to psychological (and phys ical) abus e, alternating between heated and pass ionate reconciliations. Initially, Ms. B . attempted to contain her rage in 3267 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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but it frequently surfaced and alternated with child-like helpless nes s; she interrogated the ps ychiatris t his credentials , ridiculed ps ychodynamic concepts , cons tantly challenged statements, and would demand practical advice but then denigrate or fail to follow the guidance given. T he psychiatrist remained unprovoked her aggress ion and explored with her the need to him negatively. Her response was to ques tion and tes t continued concern. When her boyfriend finally left her, s he attempted (s he cut her wris ts s uperficially), was briefly and, on discharge, was placed on s elective s erotonin reuptake inhibitors (S S R Is ) for 6 months for her minor protracted depress ion. T he ps ychiatris t maintained regular frequency of ses sions despite her greater demands. Although she was puzzled by the s teadiness his interest, she gradually felt safe enough to expres s vulnerabilities . As they explored her lack of full commitment to work, friends, and therapy, s he began unders tand the meaning of her anger in terms of the abusive relationship with her parents and her tendency bring it into contemporary relationships . W ith the ps ychiatris t's encouragement, s he als o began to s eek and make small strides in relations hip-oriented efforts . the end of her s econd year of treatment, s he had to remain in the city, to stay at her place of employment and to continue therapy. S he needed to experience practice her s omewhat fragile new s elf, which included greater intimacy in relations hips , additional mas tery of work skills, and a more cohesive s ens e of self.

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S upportive psychotherapy aims at the creation of a therapeutic relations hip as a temporary buttress or for the deficient patient. It has roots in virtually every therapy that recognizes the ameliorative effects of emotional support and a s table, caring atmosphere in management of patients. As a nons pecific attitude mental illness , it predates scientific ps ychiatry, with foundations in 18th-century moral treatment, whereby the first time patients were treated with understanding and kindnes s in a humane interpersonal environment from mechanical res traints . T his pers pective underlies such divers e developments milieu therapy for rehabilitating chronic hospitalized patients; crisis intervention to as sist otherwise individuals through sudden periods of great turmoil or stress ; and guidance or counseling practices for ex-patients, and nonpatients who need interim help in social, academic, or vocational areas but do not long-term or in-depth exploration. S upportive ps ychotherapy has been the chief form used in the practice of medicine and rehabilitation, frequently to augment extratherapeutic measures, such as of medication to s uppress s ymptoms, res t to remove patient from excess ive s timulation, or hos pitalization to provide a structured therapeutic environment, and control of the patient. It may be applied as primary ancillary treatment. T he global pers pective of ps ychotherapy (often part of a combined treatment approach) places major etiological emphasis on rather than intrapsychic events , particularly on s tres sful environmental and interpersonal influences on a damaged s elf. 3269 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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As a viable modality within the psychoanalytic supportive ps ychotherapy has been described as the ill-defined and nebulous of all ps ychotherapies . It is the treatment to which very difficult, characterologically or intellectually limited patients are referred when no other modality, particularly ins ight-oriented ps ychotherapy, seems s uitable. In the late 1940s , Alexander and noted the persistent tendency to differentiate between two main categories of treatmentprimarily supportive methods and primarily uncovering methods . T he oppos itional pos ture in direct relation to ps ychoanalys is may be ascribed to its long-standing secondary place P.2493 within the analytical framework, in which any deviation from the original pure form constituted a compromis ed inferior approach.

R ole in A nalys is With the widening s cope of ps ychoanalysis, supportive ps ychotherapy has emerged as a specific body of techniques. T he contributions of modern ego and object relations theory, which have broadened the focus and goals of ps ychoanalytic ps ychotherapy clas sic ps ychoanalys is , have generated renewed defining the role of s upportive ps ychotherapy in work. T oday, such psychotherapy is the preferred when primarily s upportive (s uppress ive) s trategies, suggestion, pers uas ion, encouragement, reass urance, advice, reality tes ting, and environmental manipulation, are us ed (instead of, or in addition to ins ight-oriented strategies ) and when caretaking in the form of a 3270 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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relations hip provides the basic context or milieu for listening to and understanding patients (no matter what specific s trategies are us ed). Not only the actual but the entire atmosphere and nature of are characterized by support and s afety. T his modus operandi has been considered a substitute form of treatment that temporarily gives the patient what he or she lacks or has been deprived of and can be therapeutically supplied or, at leas t, s trengthened. T he therapist as auxiliary or substitute ego thus offers the patient a s ecure and nurturing interpersonal as well as specific control, direction, and counsel. In the psychoanalytic spectrum, supportive represents not s o much a s eparate entity as an emphasis within its express ivesupportive boundaries . Ins tead of being negatively viewed as a compromised approach for patients uns uitable for analys is, it is viewed as effective treatment for a broad clinical range patients. C oncern and empathy are integral to all therapeutic endeavors , but the focus here is on a interpersonal bond that is affectively respons ive (rather than neutral) and oriented to pres ent reality (rather projections from the past), in which interpretive work in the broades t s ens e can more readily occur. Most recent examinations of the s ubject explicitly recognize the complementarity of expres sive and supportive modes of treatment, which can be modified, and individualized according to the needs of patient. B y placing the therapeutic focus more directly the pos itive or caring doctorpatient relationship (without analyzing it as a past transference manifes tation) and modifying the analytical technique and verbal 3271 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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communication (les s silent and neutral), a s upportive philosophy that emphas izes nurturance, real object gratification, and pres ent reality can be us ed to an analytical s tructure founded in psychodynamic concepts and expres sive techniques.

Indic ations and C ontraindic ations S upportive psychotherapy is generally indicated for patients for whom clas sic ps ychoanalys is or insightoriented ps ychoanalytic psychotherapy is typically contraindicatedthos e who have poor ego s trength and whos e potential for decompensation is high. Amenable patients fall into the following major areas : (1) in acute cris is or a temporary s tate of dis organization inability to cope (including thos e who might otherwise well functioning) whose intolerable life circums tances have produced extreme anxiety or s udden turmoil (for example, individuals going through grief reactions, divorce, job los s, or who were victims of crime, abuse, natural dis as ter, or accident); (2) patients with chronic severe pathology with fragile or deficient ego (for example, thos e with latent psychos is, impuls e disorder, or s evere character dis turbance); (3) patients whos e cognitive deficits and phys ical s ymptoms make them particularly vulnerable and, thus, uns uitable for insight-oriented approach (for example, certain ps ychos omatic or medically ill persons); (4) individuals who are psychologically unmotivated, although not neces sarily characterologically res is tant to a depth approach (for example, patients who come to treatment res ponse to family or agency press ure and are only in immediate relief or thos e who need ass istance very s pecific problem areas of social adjus tment as a 3272 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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poss ible prelude to more exploratory work). S upportive psychotherapy is us ually used when other complications enter the clinical picture, such as when primary diagnosis is physical illness but the patient help in dealing with disability, or for long-term mental illness , in which intermittent s upport and guidance in everyday living augment the control of s ymptoms pharmacotherapy and provide out-of-hospital management. R egardles s of the diagnosis , a approach is also us ed in the early phas es of virtually all treatments as preparation for the es tablis hment of a therapeutic alliance (even when express ive treatment the predominant mode), or intermittently whenever the patient is in danger of excess ive regress ion. B ecaus e s upport forms a tacit part of every therapeutic modality, it is rarely contraindicated as such. T he attitude regards better-functioning patients as not because they will be harmed by a s upportive approach, but becaus e they will not be s ufficiently benefited by it. In aiming to maximize the patient's potential for further growth and change, s upportive therapy tends to be regarded as relatively res tricted superficial and, thus , is not recommended as the of choice if the patient is available for and capable of a more in-depth approach. K ernberg's finding that patients with borderline personality disorders do not do well with either class ic ps ychoanalys is, supportive ps ychotherapy, or a supportive and express ive methods is of particular He ass erts that supportive ps ychotherapy is contraindicated for such patients with severe character pathology, because (1) leaving certain defens es to 3273 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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ego integration runs counter to the severe egoeffects of their primitive defens ive s tructure; (2) cons cious impuls e express ions of thos e patients only increases their fear of their own impulses and acting out; (3) failing to analyze their s evere negative transferences and paranoid dispositions has dis ruptive effects on the therapeutic relations hip and preempts efforts to provide a stable, reliable, and empathic atmos phere; and (4) gratifying their transference needs significantly dis torts these patients ' perceptions of the therapeutic s ituationins tead of identifying with the as pects of the analyst, they identify with an overly idealized version that they feel incapable of living up to (which, in turn, has a deleterious effect on their autonomous growth). S omewhat ironically, then, better-integrated patients can benefit from a mixture of expres sive and supportive modes of treatment, those more s evere pathology require expres sive methods T his approach is controvers ial, however, and many supportive s trategies are often used for s uch patients.

G oals S upportive psychotherapy has more limited objectives than does insight-oriented ps ychotherapy, becaus e the patient's ps ychopathology and diminis hed ps ychic res ources res trict the potential for major intraps ychic change or growth. B ecaus e the patient is us ually in a decompensated s tate, all efforts (at leas t initially) aim recons tituting and s tabilizing the patient's function. Although the individual aims of supportive treatment the general thrust is toward the amelioration or relief of symptoms through behavioral or environmental res tructuring within the existing psychic framework. 3274 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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often means helping the patient to adapt better to problems and to live more comfortably with his or her ps ychopathology. T o res tore the dis organized, fragile, decompensated patient to a s tate of relative the major goal is to s uppress or control and to P.2494 stabilize the patient in a protective and reass uring atmos phere that militates against overwhelming and internal press ures. T he ultimate goal is to the integrative or adaptive capacities so that the patient increases the ability to cope, while decreasing by reinforcing as sets and s trengthening defens es .

Major A pproac h and Tec hniques T he techniques of supportive ps ychotherapy are to restore or enhance the patient's ego s trength by helping the patient to control impulses through direct limit setting, to gain a more accurate picture of reality through the clarification and testing of perceptions, to sustain the adaptive s tructure by accepting (not or confronting) defensive maneuvers , and to develop better coping skills through direct leaching and advice and through the us e of the therapis t as a role and as a constantly reass uring figure on whom the can rely. T he active therapist s erves as a s ubs titute or auxiliary ego until the patient is able to incorporate as sets in which he or she is largely deficient, either or characterologically. T he safety and s ecurity of a controlled and cons istent therapeutic atmosphere als o as a holding environment to contain the patient's 3275 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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aggres sion and dangerous impulses as he or s he better to repress or sublimate the tendencies to act out feelings rather than to verbalize them. Although s till within an analytical framework, the nonanalytical techniques of s uggestion and advice may predominate, as the therapist directly as sists the cope in a practical way with reality. T he traditional analytical techniques of clarification and interpretation also used to the extent that they focus on the here-andnow of the patient's problems , but genetic are contraindicated and may cause decompensation in already fragile patient. T ransference management als o differs from that of ps ychoanalys is and express ive psychoanalytic ps ychotherapy. S upportive ps ychotherapy focuses on fos tering and maintenance of a positive transference at times and on vitiating the effects of negative should it aris e. Ins tead of facilitating a regres sive transference neuros is , complete or partially controlled transference regres sion is contraindicated, as intense transferences that are allowed to develop in egopatients can produce s udden, turbulent reactions that have dis ruptive effects on both the patient and Although all attempts are made to ens ure a positive transference, it is rarely analyzed as such. E xceptions those ins tances when positive transference may lead acting out, which can be fores talled by drawing to the patient's dis torted perceptions and projections . development of negative transference is minimized by us e of highly s tructured interventions , with the as suming a much more direct and active approach expres sive psychotherapy. T his includes dis couraging 3276 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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as sociations, fantasies, or primary process magical and continually bringing the patient back to reality and the immediate s ituation. T echniques are, thus , des igned to focus on conscious external events and on the therapist as a largely nontransferential figure. T o accomplish s uch aims , therapeutic neutrality is judiciously s uspended, with greater direction, disclos ure, and gratification offered would be appropriate in more uncovering approaches . therapist as a real object s erves to validate the reality testing, diminishes the breakthrough of negative trans ference, and provides a reliable to sus tain the patient until he or she can function independently.

L imitations T o the extent that much s upportive therapy is s pent on practical, everyday realities and on dealing with the external environment of the patient, it may be viewed more mundane and superficial than depth approaches . B ecaus e those patients are s een intermittently and les s frequently, the interpersonal commitment may not be compelling on either the patient's or the therapis t's part. G reater severity of illness (and poss ible ps ychos es ) makes s uch treatment potentially more erratic, demanding, and frustrating. T he need for the therapist deal with other family members, caretakers, or (auxiliary treatment, hos pitalization) can become an additional complication, as the therapist comes to an ombuds man to negotiate with the outside world of patient and with other profes sional peers. F inally, the supportive therapist needs to be able to accept 3277 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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limitations and the patient's limited ps ychological res ources and to tolerate the often unrewarded efforts until small gains are made. Mr. C ., a 50-year-old married man with two sons and owner of a s mall cons truction company, was referred his internis t after recovery from bypass surgery frequent, unfounded physical complaints. He was minor tranquilizers in increasing dos es, not complying with his daily regimen, avoiding sexual contact with his wife, and had dropped out of group therapy for posts urgical patients after one ses sion. He came to his firs t appointment 20 minutes late, after having forgotten two previous appointments. He was extremely anxious , often lost in his train of thought, and was semidelusional about his wife and s ons, that they might want to have him locked up. He briefly told his life his tory, which included his coming from a and hard-working but caring middle-clas s family and death of his mother when he was only 11 years old. He joined his father's busines s (taking over after his death 2 years earlier), with both of his s ons as Des cribing hims elf as s ucces sful in work and marriage, claimed that the only test I ever failed was the stress Mr. C . explained his lack of compliance with diet res trictions as a lack of will and his constant contact the internist as his having real phys ical problems not diagnosed; he rejected the idea of addiction to tranquilizers , insis ting that he could quit any time. He no fantasy life, remembered no dreams , made it clear he had entered treatment on his internist's instruction only, and started each s ess ion by stating that he had 3278 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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nothing to talk about. After sugges ting that Mr. C . was coming to s ess ions pass the s anity test and that there was no reas on to him locked up, the ps ychiatris t encouraged the patient join him in figuring out the real reas ons for his anxiety. Initial s ess ions were devoted to discuss ing the patient's medical condition and providing factual information heart and bypass s urgery. T he therapis t likened the patient's condition to that of an older hous e getting new plumbing, trying to allay his unrealis tic fears of death. As Mr. C .'s anxiety declined, he became les s defens ive and more psychologically access ible. As the therapist began to explore his difficulty in accepting Mr. C . was able to talk about his inability to admit problems (i.e., weakness es). T he therapis t's explicit recognition of the patient's strength in admitting his weaknes ses encouraged the patient to reveal more hims elfhow he had welcomed his father's death and his belief that perhaps his illness was punis hment. T he ps ychiatris t also encouraged him to speak about his unrealistic guilt and, at the s ame time, helped him recognize his s us picion of his sons as the reflection of own wishes concerning his father and his lack of commitment to his medical regimen as a wis h to die so to expiate guilt. After s teady urging by the therapist, Mr. returned to work. He agreed to meet monthly with the ps ychiatris t and to taper off his us e of tranquilizers. He even agreed that he might s ee the psychiatrist for deep analysis in the future because his wife now jokingly complained of his obs ess ive dieting, his exercise regimens, and his regularly scheduled sexual activities. 3279 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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P.2495

E THIC A L IS S UE S T he values and ethical problems of ps ychoanalytic ps ychotherapy are express ed in the overall nature of its goals and methods, including how value-free the is or ought to be, unproven validity and pos sible effects of treatment, and the financialethical interface between aims and costs.

Values and the Value-Free Fallac y A neutral and accepting s tance is often believed to be backbone of the psychoanalytic endeavor, whereby the clinician s us pends judgment by attentively lis tening and being objective toward the patient's problems. T heoretically at least, this means exercising res traint and not imposing personal views or values . In reality, however, the notion of the analyst as value-free cons idered a fallacy. R ather, the current unders tanding that all therapists embody particular s ocial standards, orientations, or pers onal preferencesunconsciously, if cons ciously. It is thought that even diagnos is can be a of value judgmentfor example, is homosexuality a pervers ion (F reud), a gender identity disorder and S tatis tical Manual of Me ntal Dis orde rs [DS M]), or a lifes tyle preference? Other social, cultural, and religious values are directly or indirectly, every time a clinician encourages a married man to cease having affairs, an unmarried to have an abortion, a troubled couple to divorce (or to together), a failing student to remain in s chool, a 3280 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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traumatized child to leave home, or a s exually abus ed daughter to take legal action against her father. Is it unethical in analys is to take one or another position, tacitly? C an the moral therapist be expected to good advice or renounce social standards in the name neutrality? T he greater fear, however, is that prejudiced ps ychoanalys ts may hide their beliefs and bias es profes sional claims of neutrality. Long-term ps ychotherapy also holds the ethical danger of keeping patients beyond necess ity, although it has been that any aspect of therapy that makes the patient an addict to treatment is undes irable (and even immoral). some ardent analys ts may deceive thems elves , and patients, by failing to permit timely termination or by not mentioning alternative approaches (e.g., drug or brief therapies) that might be us eful.

B oundary Problems and S exual Trans gres s ions Another iss ue that the psychotherapy endeavor is susceptible to is that of blurred or broken profess ional boundaries between analys t and analysand, from of extra time or phone availability, friendly interchanges exchange of gifts , to the cardinal s in of psychoanalys is , sexual trans gres sion. Here society's value system has influenced the way in which s exual activities are and, in turn, how one should deal with such violations treatment. In the 1960s and 1970s, there was acceptance of forms of s exual conduct, including endors ement of touching and pres umably nonerotic phys ical behaviors , especially by members of the potential movement. T he 1990s and beginning of the century have seen a reversal of this trend, with less 3281 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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emphasis on sexuality as the major motivating force more s tres s on actual s exual trauma, abus e, and misconduct. B ecaus e the pivot of psychoanalytic ps ychotherapy is the therapeutic relations hip, which differs from all other profes sional or fiduciary transference repres ents its greatest ethical weaknes s that it implicitly places the therapis t in an idealized position of power and persuasion. It s ets the stage for potential boundary violations becaus e of the expected es tablis hment of transference love and the reciprocal countertransferential respons es it may arouse in the therapist. T he intensity of this bond can eas ily activate sexual feelings and fantas ies while potentially objectivity needed to retain ethical boundaries. G raphic sexual content, which is traditionally explored in ps ychotherapy, als o reinforces s uch thoughts and emotions . At the s ame time, the patient may be modelling his or her behavior on that of the therapis t by identification or by receiving covert permis sion to eas e superego s tandards as part of the therapeutic proces s. T herapists ' libidinal or promiscuous behaviors , in fact, been explored as a form of loves ickness . (A national revealed that nearly three-fourths of thos e therapists had been s exually involved with their patients ins is ted they were in love at the time.)

E thic al and L egal Options in S exual Trans gres s ion C urrently, therapists who violate s exual boundaries face cens ure, pos sible dis miss al from profess ional organizations through the action of their ethics committees , the ris k of malpractice litigation, and, in U.S . s tates, criminal prosecution. T he recommendation 3282 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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some experts , s uch as W illiam Masters and V irginia J ohns on, that the perpetrator be charged with criminal statutory rape has yet to be accepted. T here are unans wered ques tions about the criminalization of therapistpatient s ex that need to be explored if this is going to be a form of therapist censure. T he over criminal s anction may be viewed from several standpoints, including philosophical, clinical, legal, and empirical: (1) P hilosophically, the definition of consent (versus coercion) res ides at the center of the criminal charge. It s hould be determined what cons titutes cons ent within the therapeutic relations hiphow much is genuine, rational, and autonomous , as oppos ed to pathological, irrational, and coercive. In the light of the fiduciary relations hip and uncons cious forces at play, is patient always a noncons enting party and the therapis t always the perpetrator? (2) C linically, what is the the therapeutic alliance; in particular, when is it over? S ome s uggest that the therapeutic relationship is never over, that trans ference distortions remain long after the treatment has terminated. (3) Legally, the right to interfaces with the nature of consent, as mutual has been used as a defense in thes e cases; it has suggested that it was the therapist who had not cons ented. (4) F rom an empirical pers pective, there is question of the effects of criminal actionsare they really deterrent? If the therapist is deemed a criminal, s hould patient victims be compens ated?

S ugges tion in S exual Abus e S exual abuse has become a subject of increasing and alarm both in the clinical literature and in the press . E arly memories of s exual molestation are often 3283 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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reported during psychoanalytic ps ychotherapy, as they have been since the dawn of psychoanalys is . (T hey the bas is for F reud's original seduction theory; he that his patients [us ually female] had been seduced by their fathers in early childhood.) T his thes is was later repudiated and replaced by the notion of erotic desires; the recollection of such experiences were repress ed fantasies, not facts. T he earlier theory has recently emerged with new with greater belief in and evidence for actual sexual violations in childhood. Major victims include not only young children, but als o adoles cents and adults who to therapy as rape victims, inces t s urvivors, or battered wives. Others s eek treatment for less obvious s exsymptoms, including sexual dysfunction, chronic anorexia, depress ion, low self-es teem, or borderline personality problems, which are eventually traced to inces tuous relations . F rom an ethical perspective, this clinical and potentially criminal s cenario places the ps ychotherapis t in a position with respect to the truth or falsehood of s uch allegations. It poses a dilemma in P.2496 terms of the extent to which the clinician validates the reported experiences and pres ents a legal quandary regarding prospective litigation agains t presumed perpetrators . T his has direct implications for the of the sexual victim, pas t or pres ent, and for alleged abusive parents or other s ignificant figures , s uch as members, friends, s choolteachers , or clergy. T he is particularly pres sing due to the extens ion of the 3284 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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of limitations in damage s uits. In fact, the concept of repress ed memory made criminal history in the United S tates in 1991, when a father was convicted of murder based on his daughter's post facto recollections 22 after the event. It is now pos sible for an individual to for sexual misconduct anytime within 3 years not of the event per s e, but from the first time it is recovered from memory. It has resulted in claims even 40 years after abuse, as long-lost memories are retrieved within the therapeutic s ituation.

R epres s ed Memory C ontrovers y B ecaus e the remembrance of early traumas is with unprecedented frequency in recent years , the ps ychotherapis t has been placed at the center of an unexpected conflict, the s o-called repres sed memory controvers y. Are all repres sed memories real, and, if what extent could the ps ychoanalytic psychotherapis t have aided or abetted in their recovery? As the buried memories cannot be s cientifically proven, the es sence of a contemporary ethical argument is that ps ychotherapis ts may not simply be neutral recipients their patients ' unearthed reports of s exual abus ethey even be unwitting partners or provocateurs who have elicited fals e and exaggerated information through suggestion. In defense of the accused, an upsurge of evidence has emerged that s upports the elus ive, inaccurate, and malleable nature of repres sed memories memories can altered. T his finding has turned (perhaps dis placed) the ethical onus onto the therapist. S uch studies claim that therapist can, and often does , evoke the very sexual 3285 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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material that he or she expects, es pecially in patients who thems elves cannot separate fantas y from reality. More problematic from a therapeutic point of such claims are currently confirmed by clinicians ' own accounts of how they proceed with abus e cas esnot probing, but persis tent confrontation in delving into recalcitrant memories . P erhaps more troubling is the degree to which clinicians may be doing s o for countertransferential reas ons (e.g., identification with victims of abuse), with covert collus ion in their as a therapeutic act.

C ONF IDE NTIA L ITY C onfidentiality and Privilege: Protec tion of Privac y T he is sue of privacy in ps ychotherapy is s pecial the scope of its contents are not circums cribed to medical matters and may go beyond the s ens itivity and stigma ass ociated with many phys ical ailments. ps ychological problems pertain to s ome of the mos t and troubling thoughts and feelings about one's private life, its revelations are frequently fraught with fear, and guilt about s ocially unacceptable events and behaviors . In fact, many countries grant the privacy between psychiatrist and patient the s ame abs olute protection accorded to husband and wife or lawyer and client. W hereas confidentiality is concerned with the protection of a patient's disclos ures in a therapeutic setting (and has a long ethical his tory), privilege that protection to decisions about s pecific material to potentially released, us ually for judicial or quas ijudicial 3286 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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purpos es (and is of relatively recent legal origin). B ecaus e confidentiality requires utmos t care and impeccable therapist judgment regarding all formal and informal verbal exchanges , as well as written reports case records , potential ethical dilemmas for the ps ychotherapis t can arise regarding treatment, training, adminis trative res ponsibilities (i.e., in contact with members, in consultation with other profes sionals or agencies , in bureaucratic access ibility to clinical notes hospital records , in training us e of patient pres entations and teaching aids). It may also carry over to more transgress ions, such as the us e of case material for own writings, or the more insidious instance of gos sip among colleagues and friends. T here are two major circums tances under which the patient's right to confidentiality is waived: when the patient choos es to so (i.e., patie ntlitigant e xce ption to tes timonial privile ge ) when the therapis t mus t do so (i.e., protection of public private pe ril).

P atientL itigant E xc eption to P rivilege Des pite patients' general expectations and right to confidentiality, exception is often made in ins tances of legal action, as when the patient wants information releas ed becaus e he or s he is a plaintiff in an damages laws uit. An ethical dilemma often aris es here, between clinician and court, prosecuted party, or a party (e.g., workmen's compens ation board), but therapist and patient. T his is due to the therapist's erroneous belief that he or she should have the las t on the nature of privilege. R ather, patient consent is 3287 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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always needed (alone or, only if the patient desires, profes sional as sis tance). T he therapis t has no choice; she mus t releas e case records or provide profess ional tes timony. Nonetheles s, at leas t three s ituations the patient's right: (1) the ps ychotherapis t has that the patient is in need of hos pitalization; (2) the orders an examination of the patient's physical, mental, emotional state; and (3) a communication of the condition is es sential to a legal claim or defense.

P rotec tion of P ublic P eril: Taras off Dec is ion T he groundbreaking T arasoff case involved the confidential disclos ure by a young male outpatient of plan to kill his former girlfriend. F aced with an ethical dilemma, the therapis t made a profes sional decis ion to waive patient confidentiality in two ways: he sought by cons ulting two colleagues , and he notified the T he patient, who had been legally detained in this information, was released from custody shortly thereafter on denial of violent intent. In addition, he retaliated the therapist's breach of confidence by off treatment. T wo months later, when the patient committed the planned murder, both therapis t and supervis or were sued by the victim's parents for failure inform their daughter of the impending peril. T he legal cons equence was the order that clinicians have a duty warn the endangered person(s). T he primary exception to the therapis t's protection of patient confidentiality, which occurs irres pective of the patient's wis hes , arises in the context of prospective danger to others . T he famous T aras off decision 3288 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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R ege nts of the Unive rs ity of C alifornia, 1974) maxim that P rotective privilege ends where public peril begins . It refers to the requirement that therapis ts warn authorities and potential victims of poss ible endangerment express ed to them by their patients . case highlights the complex ethical dilemma of the right of confidentiality of individuals vers us of society from danger. It can be a delicate balance on both conceptual and practical levels it presumes that ps ychotherapis t is an expert in predicting violent (and can perhaps even prevent it). It also compromises patient confidentiality, as well as treatment, by lowering the threshold of privacy. T he therapist is held in an extremely difficult pos itionhe or she is liable not only for failing to warn the prospective parties , but also for invas ion P.2497 of privacy (and even defamation of character) if the potential threat fails to materialize; at the same time, fidelity of the treatment process is at risk, and the may los e the betrayed patient at a time when therapy is most needed.

P rotec tion of P rivate P eril: Danger to S elf A complicated conceptual conflict pertains to one's philosophical or religious s entiments regarding the of one's life. It is considered a diagnostic iss ue (Is its elf an illnes s; is it always a concomitant of it always irrational? ), a functional problem that may immediate or chronic care, or an existential iss ue of the 3289 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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very value of human life. In any event, the ques tion is if and when to therapeutically intervene. More must the moral clinician actively dis courage such behaviors regardless of specific circums tances (i.e., called rational s uicide in cases of terminal illness or disability)? B eyond this , how res ponsible is the ps ychotherapis t in predicting and preventing danger to self? At what point mus t confidentiality be by informing others (i.e., hos pital s taff, family)? As an extension of thes e ethical dilemmas , is there a line between s uicidal threats and actual attempts where confidentiality may be breached?

C onfidentiality and the Future T he protection of confidentiality of the traditional therapistpatient relations hip has been under unprecedented pres sure in recent times , as third-party insurance and peer-review organizations require information about treatment. T hree forces have been identified in the escalating conflict between the right to secrecy and the right to information: (1) increasing involvement of the government in areas that were previous ly cons idered as private, such as busines s regulation and health care; (2) the technological in data collection, storage, and retrieval (i.e., records , videotapes, wiretapping); and, in respons e to greater threat to privacy, (3) increas ed awareness of cons umer rights and actions. In light of the above, ethical ques tions aris e: W hos e agent is the ps ychotherapis tthe patient, the family, s ociety, or the What are the goals and motives for sharing a confidencebetter evaluation and treatment, support and validation, countertrans ferential need (e.g., 3290 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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self-aggrandizement, peer approval)? W hat are the and ramifications of divulging informationjeopardy of patient trus t, termination of treatment, a poss ible

R E S E A R C H A ND E VA L UA TION A cardinal principle in contemporary ethics s tates that a health profes sional should practice a method of healing founded on a s cientific bas is . Y et there are a host of unresolved research problems in ps ychoanalytic ps ychotherapy, including the anecdotal nature of individual cas e reports , the elus ivenes s of many bas ic concepts (e.g., repres sion, trans ference, ins ight), and complexity of therapis t, patient, and relations hip that are involved. Des pite s pecific claims and counterclaims in behalf of one or another modality, res earch s ugges ts that all psychotherapeutic may be equally efficacious. T his may be largely due to nonspecific factors or common elements that all therapeutic methods are presumed to share: a healing setting; a mutual belief system between therapis t and patient, offering hope for help; an emotionally-charged, trus ting relations hip; and enhancement of a sense of mastery. F or example, in one study that examined four reputedly different therapeutic approaches (three of ps ychoanalytic)F reudian, K leinian, J ungian, and G estaltwith the s ame patient, descriptive ratings by objective observers failed to differentiate the respective schools of thought. T his finding came as a s urprise not only to the investigators, but also to the therapists thems elves . A review of literature bas ed on s everal res earch investigations of this subject s ubsequently concluded that effective therapists , irrespective of theoretical orientation, behave s imilarlythey appear 3291 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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confident, express concern, communicate clearly, and empathic. S ignificant differences had more to do with general level of experience than with specific avowed theoretical allegiances . A multitude of efficacy s tudies of psychoanalysis and ps ychodynamic ps ychotherapy have been conducted. host of res earch investigations at major ps ychoanalytic institutions , such as the Menninger F oundation, New P sychoanalytic Ins titute, C olumbia Univers ity, and P sychoanalytic Institute, have unanimously concluded patients who have been deemed s uitable for ps ychoanalys is derive s ubstantial benefit from it. T heir improvement rates are highly s ignificant, ranging from to 90 percent. S ome found a positive correlation length of treatment and pos itive therapeutic outcome. However, thes e s tudies often have a major flawtreatment and control groups are not randomized. T hus, the pas sage of time alone, often 3 to 7 years, have produced good results unrelated to the treatment that was provided. Due to innumerable methodological problems , including finding a suitable control group, dropout rates, and the multiplicity of uncontrolled life events that may or may not be accounted for, s tudies often focus on a s pecific process meas ure, or minioutcomes within a small time frame or s ess ion, as a microcos m of the total process . F or example, s everal studies of the effects of accurate interpretations of the patient's core conflicts predicted positive treatment outcome in both s hort- and long-term follow-up inves tigations . Diagnos is has always been a significant differentiating factor in therapeutic results with psychodynamic 3292 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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treatment (i.e., favoring less severe pathology). F or example, one study that compared outcomes of outpatients with brief to moderate length of treatment (i.e., 9 to 53 s ess ions) found that, for patients with personality dis orders, the number of sess ions received directly correlated with the degree of ins ight that was attained after 2 years of treatment, as well as with the degree of positive change at 4-year follow-up after termination. In another study of patients with disorders , those who received ps ychodynamic ps ychotherapy for more than 2 years and were more than 5 years after termination showed significant gains : Nearly three-fourths of them no longer met the criteria for pers onality disorder diagnosis at both time periods. A wealth of evidence now sugges ts that psychotherapy indeed efficacious , with the average treated patient significantly improved more than 80 percent of patients. One of the major implications of this finding is that it is believed to be unethical (even if it is ideally scientific) to withhold s uch beneficial treatment for who need it. T he effects of ps ychodynamic therapies , however, are not significantly different from other therapeutic modalities. T he early research conclusion (borrowed from Alice in W onde rland) that everyone has won and all must have prizes s till holds . T hat is , ps ychodynamic psychotherapy is not significantly different in efficacy from cognitive-behavioral therapy, interpersonal therapy, or other relatively s tandardized modalities. On a totally different plane has been the recent provocative thes is that psychotherapy be cons idered a 3293 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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biological treatment. T hus, not only medication, but dream interpretation, and even empathy, acting biochemical mechanisms, may be viewed as diverse of altering different neurotrans mitters . C ontemporary res earch on bonding, attachment, and object relations , example, has implications for how a mother's actions toward her infant alter brain P.2498 structure. Dependency can thus be translated into phys iological terms. More recent research on bridging ps ychology and neuros cience presented a biological perspective on empathy, s uggesting that it may be a phylogenetically and ontologically determined phenomenon in all primates . R eferring to empathy as a biological concept par excellence, a confluence of data from a variety of dis ciplines sugges t that empathy (a subjective experience between people), socioeconomic communication (in animals ), and social s ignal (in neurons ) can all be unders tood as as pects of a phenomenon. A major shift in res earch concern has been the factor cost, es pecially in relation to outcome. Long-term ps ychotherapy is therefore being s tudied in terms of only its effects , but also the price paid. A study in has s uggested that long-term ps ychoanalytic ps ychotherapy for patients with borderline pers onality disorder was not only effective, but cos t-effective. visits, hos pital admiss ions, inpatient s tays, and self-harm were significantly reduced during and 1 year after termination of treatment, amounting to significant reductions in overall mental health expenses . S imilarly, 3294 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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examination of a managed care organization to treat families of the U.S . military with outpatient confirmed that for every dollar s pent on psychotherapy, were saved through marked reductions in psychiatric hospitalization over a period of 3 years . T he increased emphasis on economics, of course, may have a noneconomic price, as there is press ure to reduce of time in treatment for financial reas ons, often at the expense of quality. One author has even as ked empathy is cos t-effective; a related is sue is the countertransferential view of very needy, expensive patients as bad objects who financially overload the mental health s ys tem.

S UG G E S TE D C R OS S T he basic hypothes es of ps ychoanalys is and its techniques are also dis cus sed in the chapter on ps ychoanalys is as a theory of personality and ps ychopathology (S ection 6.1). As a s ubspecialty of ps ychiatry, individual ps ychodynamic psychotherapy is detailed as one of s everal modalities in the ps ychiatric treatment of children (S ection 48.1). G reater time-limited dynamic ps ychotherapy and short-term ps ychoanalytic approaches appears in the chapter on ps ychotherapy (C hapter 30.9), as well as in the chapter the us e of combined treatments individual and group (S ection 30.4) and the chapter on ps ychotherapy with pharmacotherapy (S ection 30.12). S ection 51.4h individual ps ychotherapy for geriatric patients . beyond the field of ps ychoanalytic psychotherapy per varied text on evaluation of ps ychotherapy (S ection hospital and community psychiatry (C hapter 52), ethics and forens ic psychiatry (C hapter 54), and, finally, the 3295 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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of psychiatry (S ection 55.3), all have major implications the nature of individual psychodynamic ps ychotherapy the decades to come.

R E F E R E NC E S Alexander F , F rench T M. P s ychoanalytic T he rapy. Y ork: R onald P ress ; 1956. B renner C . P s ychoanalytic T e chnique and P s ychic New Y ork: International Universities P res s; 1976. B uckley P : R evolution and evolution: A brief history of American psychoanalys is during the past decades. Am J P s ychother. 2003;57:117. C hes sick R D. T he T e chnique and P ractice of Inte ns ive P s ychothe rapy. Northvale, NJ : J as on 1989. C hes sick R D. A Dictionary for P s ychothe rapis ts : C oncepts in P s ychothe rapy. New Y ork: J as on 1993. F enichel O. P roblems in P s ychoanalytic T e chnique . Albany, New Y ork: T he P s ychoanalytic Quarterly; F reud A. T he E go and Me chanis ms of De fens e . International Universities P res s; 1966. *F reud S . S tandard E dition of the C omple te W orks of S igmund F re ud. London: Hogarth P res s; 3296 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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19531964. *G abbard G O. P s ychodynamic P s ychiatry in C linical P ractice . 3rd ed. Was hington, DC : American P res s, Inc.; 2000. G ill MM: P s ychoanalysis and psychotherapy: A Int R e v P s ychoanal. 1984;11:161179. G reenson R . T he T e chnique and P ractice of P s ychoanalys is . V ol 1. New Y ork: International Univers ities P ress ; 1967. Hartmann H. E go P s ychology and the P roble m of Adaptation. New Y ork: International Univers ities 1959. Havens L. Approaches to the Mind. C ambridge, MA: Harvard University P ress ; 1987. J ones E . T he L ife and W ork of S igmund F re ud. New B as ic B ooks; 19531957. K arasu T B : P sychotherapies : An overview. Am J P s ychiatry. 1977;134:851863. K arasu T B . W is dom in the P ractice of Northvale, NJ : J ason Aronson; 2001. K arasu T B : A developmental metatheory of ps ychopathology. Am J P s ychother. 1994;48:581.

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K arasu, T B . T he P s ychothe rapis t as He ale r. J ason Aronson; 2001. *K aras u, T B . T he Art of S ere nity. New Y ork: S imon S chus ter; 2003. K ernberg OF . O bje ct R e lations T he ory and C linical P s ychoanalys is . New Y ork: J as on Arons on; 1976. K ernberg OF . Aggre s s ion in P e rs onality Dis orde rs P ervers ions . New Haven: Y ale Univers ity P res s; K lein M. C ontributions to P s ychoanalys is , 191145. London: Hogarth P ress ; 1948. *K ohut H. Analys is of the S e lf. New Y ork: Univers ities P ress ; 1984. Lubors ky L. P rinciple s of P s ychoanalytic New Y ork: B asic B ooks ; 1984. *Mitchell S A. R elationality: F rom Attachment to Inte rs ubje ctivity. Hills dale, NJ : T he Analytic P ress ; P ine F . Drive , E go, O bje ct R e lations , S e lf. New B ooks ; 1990. S chafer R . A New L anguage for P s ychoanalys is . Haven: Y ale University P ress ; 1976. S tern D. Diary of a B aby. New Y ork: B asic B ooks ; 3298 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/30.1.htm

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S trupp H, B inder J L. P s ychothe rapy in a Ne w K e y. Y ork: B as ic B ooks; 1984.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 31 - B iologica l T herapies > 31.1: G enera l P rinciples P s ychopharmacology

31.1: General Princ iples of Ps yc hopharmac ology Norman S us s man M.D. P art of "31 - B iological T herapies " Of the nearly 1,700 pages in the firs t edition of K aplan S adock's C ompre hens ive T e xtbook of P s ychiatry, in 1967, a mere 25 pages were devoted to drugs as treatments for mental disorders . C hlorpromazine (T horazine), approved by the U.S . F ood and Drug Administration (F DA) 15 years earlier, was alone the drugs acknowledged to be a s ignificant therapeutic breakthrough. Other ps ychotropic agents , including the benzodiazepines (introduced in 1959), were as playing a minor therapeutic role, serving as adjuncts ps ychotherapy or as a last res ort for patients failing to res pond to therapy. T here was no intimation that benzodiazepines would become the mos t widely prescribed drugs of any type within a few years . (E skalith), which had been des cribed as an effective treatment for mania in 1949, was mentioned in a brief paragraph. Indeed, in reading the first edition of K aplan and S adock's C ompre he ns ive T e xtbook of P s ychiatry other textbooks of that time, it would have been difficult to predict how psychotropic drugs would s oon the treatment of mental disorders. In a reversal of positions , psychoanalytic theory, which once served to 3300 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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define the practice of ps ychiatry, has been s upplanted ps ychopharmacology as the mos t widely used form of treatment for ps ychiatric disorders . R eflecting the expanded role of ps ychopharmacology, well as the variety and s heer number of psychotropic drugs available, the chapters on ps ychotropic drugs follow repres ent a virtual textbook within a textbook. T hese chapters are also complemented by dis cuss ions other s ections that focus on the treatment of specific disorders and special patient populations . T his s ection intended as a review of important principles underlying the selection and us e of ps ychotropic medications . It provides a review of common is sues that arise in the clinical s etting, as well as cons iderations for more us e of available agents . E very effort has been made to provide a comprehens ive discus sion of the properties the drugs, as well as guidance on their mos t us e. Nevertheless , it needs to be emphasized that ps ychopharmacology is a rapidly evolving field and that many patients experience idiosyncratic or paradoxical res ponses to treatment. Detailed discuss ions about the proces s of drug development and approval, as well as the use of drugs, can also be found in the chapters that follow. the approach used in other textbooks , drugs in the following chapters are dis cuss ed by their mechanism of action or structure instead of by their primary indications . T his permits thes e agents to be dis cus sed terms of their pharmacology and their us e in what increasingly extends to a wide range of dis orders and symptoms. 3301 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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HIS TOR Y F or centuries, people have us ed plant extracts and naturally occurring substances to influence mood and anxiety, to modulate sleep and arous al, to produce euphoria, and to alter cons cious nes s. Notable include alcohol, opium preparations, bromides , and hallucinogens. Us e of cocaine-containing s oothing and elixirs was common. In the 19th and early 20th centuries , s everal types of s e dative s were developed. of thes e compounds , chloral hydrate (Aquachloral S upprettes) and the barbiturates, are s till in us e. F rom 1930s to the 1950s , the mos t effective biological for a mental disorder was electroconvuls ive therapy but the image of s o-called s hock therapy was to many patients. In 1931, two psychiatrists in India, G anpath S en and K artik C handra B os e, des cribed the ability of R auwolfia s e rpentina to reduce s ymptoms of ps ychos is , but this report was overlooked by W es tern medicine for many decades. W hen rediscovered, (S erpalan) became one of the first agents to offer to patients with schizophrenia. Unders tanding of res erpine's effects on monoamine neurotransmitters spurred further research into the involvement of norepinephrine, serotonin, and dopamine in the of ps ychiatric disorders and the synthesis of drugs that targeted these agents. S imilarly, published findings on antimanic properties of lithium salts appeared in 1949 were neglected by mos t ps ychiatris ts. It was more than two decades before lithium became accepted as the standard treatment for bipolar disorder. Modern ps ychopharmacology began and evolved during the s econd half of the 20th century. Nearly 3302 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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simultaneous discoveries in the early 1950s began the transformation of psychiatric treatment from a ps ychoanalytic to a biological orientation. T he first breakthrough occurred between 1950 and 1952 with observation that chlorpromazine, a pres urgical antihistamine, brought about dramatic control of ps ychotic symptoms as sociated with mania and schizophrenia. T he effect of the drug was des cribed as miraculous and as tonis hing. C hlorpromazine was for clinical us e in 1954 and, within 8 months, was adminis tered to more than two million patients. P atients with long histories of hos pitalization owing to disorganized thinking and bizarre behavior sufficient improvement to be discharged from their overcrowded institutions . F or a time, there were expectations that chlorpromazine and its analogs, then referred to as tranquilizers , could eradicate or cure s chizophrenia. Although this turned out to be a hope, newer vers ions of these drugs improve the life of many patients, enabling them to be productive to live in the community. In 1952, iproniazid (Mars ilid), a hydrazine derivative tes ted as a treatment for tuberculos is, was obs erved to caus e a dramatic P.2677 elevation in mood. Over the next few years, came to recognize this antidepres sant action of and s imilar hydrazine analogs . Is olated cases of unexpected hypertens ive epis odes as sociated with monoamine oxidase inhibitors (MAOIs ) were reported soon after the introduction of these drugs, but an 3303 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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explanation for this so-called cheese reaction did not emerge until 1963 in an article by B arry B lackwell. S hortly after the dis covery of MAOI antidepres sant imipramine (T ofranil), a derivative of chlorpromazine, observed to alleviate depres sive symptoms . the firs t tricyclic antidepress ant (T C A), and iproniazid, first MAOI, became available for clinical us e in 1957. 1 year of its releas e, more than 400,000 patients imipramine for depres sion. Des pite the progress that has been made in more than half century, no other antidepress ants have surpas sed T C As and MAOIs in efficacy. Nevertheles s, these have never lived up to their full potential becaus e of troublesome s ide effects and concerns about safety. dietary res trictions reduced the acceptability of MAOI treatment. T he anticholinergic s ide effects of T C As and their toxicity in overdose als o had a res training effect their us e. T he availability of meprobamate (E quanil) in 1955 the firs t time that a treatment for anxiety had a wide margin of s afety. C ompared to the barbiturates , meprobamate caus ed les s dos e es calation and a less severe withdrawal syndrome. B y the end of that an even better tolerated and s afer alternative emerged. 1957, the benzodiazepine chlordiazepoxide (Librium) found to produce s edative, mus cle relaxant, and anticonvuls ant properties , but without s ignificant ris k of serious toxicity in overdose or during withdrawal. B y chlordiazepoxide was marketed, soon followed by diazepam (V alium). It is worth noting that chlordiazepoxide was introduced into clinical practice 3304 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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2.5 years after its pharmacological studies were In 1958, P aul J ans sen synthesized another important chemical family of compounds us ed to treat psychoses, the butyrophenones . T he prototype of this clas s, haloperidol (Haldol) remains one of the most popular drugs used for the management of ps ychosis . T he first atypical antips ychotic was s ynthes ized in the late but it was another of P aul J anss en's compounds, ris peridone (R is perdal), that became the first widely prescribed atypical neuroleptic or serotonin-dopamine antagonis t. Attitudes toward psychotropics were trans formed in the early 1980s after reports were publis hed that (X anax) could s uppres s panic attacks . Until that time, T C As and MAOIs had been s hown to control panic symptoms, and benzodiazepines were not thought to effective in treating this s evere form of anxiety. B as ed on the newly gained understanding that T C As not only norepinephrine reuptake, but also serotonin, Arvid C arlss on and his colleagues s et out to develop a selective inhibitor of s erotonin reuptake. Zimelidine, the first of these selective s erotonin reuptake inhibitors was developed in the early 1970s and was found to be potent antidepress ant. It was marketed in E urope but quickly withdrawn from clinical use because of a rare neurological side effect. It was not until the introduction fluoxetine (P rozac) late in 1987 that an S S R I became available in the United S tates . E arly clinical experience fluoxetine was followed by the surpris ing realization by patients and physicians that the drug sometimes produced dramatic res ponses without the same type of tolerability problems ass ociated with the T C As. T his led 3305 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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public s crutiny marked by articles in magazines , news papers , and best-selling books such as L is te ning P rozac and P rozac B acklas h. T his publicity on balance positive effect by increas ing awarenes s of depres sion the availability of medication. Quickly, first-line of depress ion quickly shifted from the T C As to and other S S R Is . E ven at the turn of the century, the majority of new pres criptions for antidepress ant treatments were for S S R Is . T he full impact of the early advances in ps ychopharmacology was not immediately appreciated ps ychiatry as a whole and by s ociety at large. Indeed, concept that thos e medications could be effective as choice treatments met with cons iderable res istance. ps ychoanalytic theory dominant, it was widely held that most, if not all, mental dis orders could be explained treated using psychodynamic constructs and treated ps ychoanalys is. Ironically, in 1930, S igmund F reud that the hope of the future here lies in organic access to it through endocrinology. He added that this future is s till far dis tant, but one s hould s tudy every case of ps ychos is because this knowledge one will guide the chemical therapy. Acceptance of ps ychotropic drugs has , indeed, as they have become s afer and better tolerated and as evidence of their effectivenes s is reinforced. T he status these agents has evolved from that of a treatment curios ity, mainly used in the most dis turbed or res is tant patients, to one that has largely supplanted various forms of psychotherapy as a defining treatment modality of psychiatry. T here has been a reciprocal dynamic between the growing number and variety of 3306 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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ps ychotropic drugs , diagnostic precision, and insight the underlying pathophys iology of mental dis orders. It needs to be recalled that at the time of the s o-called ps ychopharmacology revolution during the 1950s , only acetylcholine, norepinephrine, and serotonin were to be present in the brain. T he neurotrans mitter of thes e biogenic amines had not yet been elucidated. T he firs t psychotropic drugs were thus discovered observations of behavioral effects in animals or As the mechanis ms underlying the actions of thes e have been determined, it has facilitated rational drug development of new compounds, s uch as the S S R Is , more s elective action. It also has led to the disorders that are preferentially res ponsive to s pecific agents . P atients now have many more treatment and the drugs used are better unders tood.

C L A S S IF IC A TION T here has never been and s till is not a consensus how to clas sify psychotropic drugs . T he terminology describing it is continually evolving. As a rule, agents organized according to s tructure (e.g., tricyclic), mechanism (e.g., MAOI), his tory (e.g., first generation, traditional), or uniqueness (e.g., atypical). W hatever approach, a foremost cons ideration in drug is its major clinical application. P s ychotropic drugs are referred to as antide pres s ants , antips ychotics , and anxiolytics . T he firs t drugs to treat schizophrenia were termed tranquilizers . W hen newer drugs emerged as therapies anxiety, a distinction was drawn between major and tranquilizers . At firs t, antidepres sants were T C As or 3307 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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However, in the 1970s and 1980s , as newer drugs emerged, they were labeled as s e cond- or thirdge neration antide pre s s ants . More recently, older us ed as treatments for ps ychos is became known as conve ntional, or traditional neuroleptics . Newer ones became atypical ne urole ptics . T his lack of cons is tency clas sification of psychotropics caus es confus ion, but a more fundamental limitation is that drugs continue to defined by their major indications . F or example, the standard categories of drugs are (1) antips ychotic neuroleptics us ed to treat ps ychos is , (2) antidepress ant drugs used to treat depres sion, (3) antimanic drugs or mood stabilizers used to P.2678 treat bipolar disorder, (4) antianxiety or anxiolytic drugs us ed to treat anxious states or used at higher doses, (5) hypnotic agents to promote sleep. Des cribing ps ychotropic drugs as diagnos is specific ignores the fact that, over time, mos t agents multiple therapeutic applications . F or example, aspirin, which first appeared as an antipyretic, eventually us ed as an antiinflammatory agent and more recently us ed for prevention of s troke. It is more important for a prescribing phys ician to be familiar with the pharmacological profile of the aspirin (B ayer) than the indication granted by the F DA. T his is evident in the treatment of anxiety dis orders, for which patients are less likely to be treated with benzodiazepines than originally indicated for depress ion. It is widely that antidepres sant drugs , in fact, have a wide action. Agents such as the S S R Is and venlafaxine 3308 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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although s till mainly used to treat depres sion, have gained F DA approval as treatments for disorders as as panic dis order, generalized anxiety disorder, s ocial anxiety dis order, obs es sive-compuls ive disorder posttraumatic stress disorder (P T S D), and dysphoric disorder. S imilarly, some neuroleptic drugs become commonly us ed as mood s tabilizers and as augmentation agents to treat depress ion and OC D. drugs as clonidine (C atapres ), propranolol (Inderal), verapamil (Is optin), and gabapentin (Neurontin), all not officially recognized as psychotropic agents , are widely us ed to manage a variety of psychiatric dis orders. Although the familiar terminology based on indication continues to be widely used and repres ents a form of shorthand, particularly in clinical discus sions , in view of the editors , a s ys tem based on indications is helpful as one that organizes the drugs mechanis tically structurally. Accordingly, the drugs in the chapters that follow have been presented according to s hared mechanism of action or by similarity of structure. T his provides consistency, ease of reference, and comprehensiveness . Authors have nevertheles s been encouraged to express their opinions about the bes t to characterize the drugs that are covered in their chapters. Iss ues that arise about the use of drugs for patients with s pecific disorders are covered in the that discuss those dis orders.

S OUR C E S A ND DA TA T he content of this and the s ubs equent chapters in the ps ychopharmacology s ection of this book is bas ed on 3309 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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many sources of information. T hese are the same that are us ed by clinicians and that influence treatment decis ions. Information about and perceptions of ps ychotropic drugs come from randomized, controlled trials , open-label studies, cas e reports , the opinions of experts as reflected in review articles and clinical guidelines, discus sions with colleagues , and direct experience in the clinical s etting. Depending on the of information or clinical experience to which a clinician expos ed, the picture that is formed of a drug can vary cons iderably. E ven among experts, the relative given to certain evidence can result in widely differing opinions about drug profiles . Although randomized clinical trials are cons idered to provide the most accurate evidence, exclus ive reliance the findings of published clinical trials can result in a distorted picture of a drug's properties. All forms of evidence need to be weighed and s ynthes ized. based medicine is not res tricted to randomized trials metaanalyses but involves integrating all relevant evidence and applying that knowledge to the individual patients. S o-called thought leaders who rely on clinical data as the basis for their opinions can mis s the mark widely when characterizing a drug. Y et, clinicians are dependent on and influenced by so-called experts, because few clinicians have been trained in the of research methods, statis tics, and critical apprais al. Accordingly, they cannot judge if the evidence is s ound enough to be used as the bas is of treatment decis ions. unders tanding of res earch methods , including research design and the s tatistical techniques used to draw conclus ions, is thus the bes t protection agains t being 3310 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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misled by poor evidence or mis leading promotional activities. T he purpos e of research is to confirm or to refute that a drug may have therapeutic effects. T o efficacy, a study mus t prove that the new agent is more effective than a placebo or as effective as a proven intervention. R isks of a treatment should not outweigh benefits. Although it s eems paradoxical, s tudies begin the null hypothes is , that is , that the treatment is not effective than no treatment at all. T he burden on res earchers is to des ign a protocol that proves that the hypothes is is incorrect and that a difference, indeed,

R andomized, Double-B lind, Plac eboC ontrolled Trials R andomized trials should be dis tinguished from open trials . In open trials , there is no control, s o the patient the physician know which active treatment is being Observed rates of res ponse are typically higher than reported when an active or placebo control is used. label trials have the advantage of attracting s ubjects might not want to participate in a placebo-controlled study but should be recognized as being sugges tive not definitive. C linicians should be mindful of the fact most drugs that appear to be promising in open trials to demons trate efficacy when studied in randomized controlled trials . R andomization is a key component of clinical trials. P atients s hould be well matched in terms of diagnos is , age, treatment his tory, and s ymptom s everity. Inclusion criteria require subjects to pas s a cut-off score on a standard rating ins trument. E s tablishing a thres hold for 3311 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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symptom severity s erves to s creen out patients with temporary changes related to factors such as s tres s, rejection. It has als o been argued that, if baseline are too low, the ability to measure change may be diminis hed. C onvers ely, higher baseline scores offer greater power in discriminating active drug from Nevertheles s, higher entry scores have not been serve as a more s ens itive bas is for discriminating drugplacebo and drugdrug differences. T here is that raising the bar for study inclus ion may actually limit the availability of eligible patients and may result in questionable enrollment of s ubjects for the purpose of meeting s tudy requirements . It is ess ential that any or informal attempt to compare res ults from s eparate studies point out the differences in s ymptom s everity at entry, as well as other patient characteristics . Inclusion placebo group enhances the value of a study. F or if two drugs are s tudied in a head-to-head trial, the might s how no difference in efficacy between the two an advantage for one over the other. W ithout a placebo arm to the study, it cannot be determined if the res ults the study represent a type I error. In many studies with placebo group, there is no difference between active and placebo. T he impact of randomized, double-blind, placebocontrolled clinical trials is often watered down by the that these studies are typically done in highly s elected patients, with restrictions on us e of nons tudy T he us e of the medications in real-world patients who taking multiple medications for comorbid dis orders thus often results in clinical effects that differ from thos e in even well-done s tudies . T hus, over time, 3312 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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studies, cas e reports, chart reviews , and clinical modify the unders tanding of the true nature of a agent. Another us eful technique to try to make sense of multiple, sometimes inconsistent, clinical trials is to conduct a metaanalysis. P.2679

Metaanalys es B etween-drug comparis ons are complicated by inconsistencies in s tudy design and data analys is. criteria, dosing, sample size, duration of treatment, and definitions of outcome vary cons iderably in different studies of the s ame drug. F or example, in a study comparing two drugs , nonequivalent dosing can give drug an unfair advantage over another. S tatis tically significant findings may not be clinically meaningful if data s et is s mall. A metaanalys is overcomes the limitations of a large number of s tudies with s mall numbers of subjects, thus detecting meaningful differences between treatment groups . W hen done well, metaanalyses provide a more accurate picture of differences between interventions. integrity of a metaanalysis is dependent on the s pecific quality meas ures of the individual s tudies included in analysis. T able 31.1-1 describes definitions of quality meas ures that should be applied to randomized, controlled trials and that can lead to underestimation or exaggeration of the observed treatment effect. It is als o important to know if all relevant s tudies are available inclusion. Metaanalys es that rely on published s tudies overs tate the effectivenes s of a treatment, because 3313 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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negative studies are less likely than positive s tudies to published. S uch publication bias is the result of not publis hing negative studies and journals rejecting negative or failed s tudies.

Table 31.1-1 Quality Meas ure Definitions Quality Meas ure

Des c ription

S tudy ques tion well defined in introduction and methods

S tudy needed to define clearly the intervention s tudied, the population s tudied, the condition of interest, and the outcome of interest in introduction or methods of main body of text or

S tudy ques tion well defined anywhere in article

As des cribed for the previous quality meas ure, but criteria could be met from any s ection article.

P lacebo

R equired term place bo or description of placebo (e.g., saline). 3314

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Appropriate outcome studied

Were study outcomes appropriate bas ed on s tudy design, condition, and intervention s tudied?

Multicenter study

Did study include more than site?

S tudy country

S tudy is cons idered to be from United S tates or other res earch country if any of the were bas ed in that country. Analyzed in two ways .

Adequate selection

Were inclusion and exclus ion criteria clearly and completely reported?

R andomization methods described

Was any description given of how randomization (allocation among treatment arms ) was achieved, or did the article s ay only randomized?

C entral randomization site

Was randomization performed by res earchers at a s ite from the patients and (central) or at a site where caregivers could be involved in patient allocation (local)? 3315

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center and multicenter s tudies could have central or local randomization. R andomization by pharmacy or laboratory staff was as sumed to be central there was indication that thes e staff may have been directly involved in patient care. R andomization methods such the us e of envelopes , cards , or registration numbers were as sumed to be local unles s explicitly stated. Allocation concealment

Was allocation fully randomization s ite was central, or randomization method was performed using computers, blinded code or blinded medicine vials , or opaque envelopes, allocation was adequately concealed. T ables, cards , etc. were not adequately concealed. R andomization by birth year or registration was not adequately concealed regardless of where randomization was performed.

P atients

Were patients reported to have

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been blinded? If not s tated explicitly, infants and patients receiving identical-appearing treatments (active or placebo) were considered to have been blinded. C aregivers blinded

C aregivers included nurses , and other health care practitioners in direct patient care or parents (or equivalent) outpatient infants .

Outcome as sess ors blinded

Outcome as ses sors included phys icians or other health care practitioners or res earchers evaluated patients, their or their laboratory or radiology tes ts to determine s tudy outcomes .

Data analys ts blinded

Data analys ts were cons idered be blinded in s tudies that explicitly reported that the analysis of data was performed by individuals who were unaware of the treatment as signment.

Double blinded

Were patients and the 3317

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or outcome as sess or blinded? V alid s tatistical methods

Were the statis tical methods us ed considered valid and appropriate, bas ed on s tudy design and outcomes of

S tatistician author or acknowledged

T he degrees and department affiliations of the s tudy authors were examined. If any author an M.P .H. or P h.D. or or if any author was a member a department of s tatistics , epidemiology, or equivalent, person was considered to be a statis tician (or to have knowledge). In addition, the acknowledgment s ection was reviewed for mention of a statis tician.

Intention-totreat analysis

Are all analyzed patients analyzed in the group to which they were originally allocated? Dropouts were allowable, s o as the reas ons for withdrawal were not related to the group to which they were ass igned

P ower

Was a power calculation 3318

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calculation reported

reported for any outcome evaluated in the study?

S topping rules described

Did the article report and describe rules for s topping the study, s uch as exces s (T his does not include the rules for dropping patients from the study.)

B as eline characteristics reported

Were any baseline reported that compared the treatment and control groups?

G roups s imilar at bas eline

Were the treatment and control groups similar in the characteristics reported?

C onfounders accounted for

If there were baseline in the groups that could be confounders, were these examined?

Dropouts recorded

Were the number of dropouts recorded (explicitly or by reporting the number enrolled and the number evaluated)?

P ercentage dropouts

What percentage of subjects dropped out? 3319

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R eas on for dropouts given

If there were dropouts, were reasons for dropouts reported?

F indings support conclus ions

Were the conclus ions valid on the findings, s tudy design, and power?

F rom B alk E M, B onis P A, Moskowitz H, et al.: C orrelation of quality meas ures with es timates of treatment effect in meta-analyses of randomized controlled trials . J AMA. 2002;287:29732982, with permis sion.

C as e R eports C linical experience represents the mos t direct source insight into the true nature of a drug's profile. As tute observation and intuition have led to most of the major advances in ps ychopharmacology. P ublished act as alerts that create awareness of advers e events therapeutic benefits that were overlooked in clinical T he limitations of anecdotal reports from a s cientific perspective is that this type of evidence repres ents the least rigorous type of data. A report of an adverse for example, does not reflect the frequency of its occurrence. S imilarly, a patient with a dramatic, unexpected respons e to a medication should not be inferred as being a repres entative example. T he multiple reports does not neces sarily indicate that a 3320 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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effect is not wides pread. T ypically, once something has been noted in several publications , potential authors no longer feel the need to s ubmit additional reports. T he example of this was the early recognition that S S R Is significant rates of sexual dysfunction. After an initial of letters to the editor, accounts of patients with diminis hed libido or orgas mic dysfunction were no news worthy. S ometimes , cas e reports become overvalued, having exaggerated impact on prescribing decisions . marketing and sales activities can create false alarm the frequency or s eriousness of a reported event or the importance of a beneficial effect. It is not for isolated case reports to become incorporated into tables of side effects or as antidotes for side effects, as suming the s tatus of es tablished clinical wis dom.

IMP OR TA NT C ONC E P TS IN DE S IG N A ND A NA L YS IS B ecaus e research is regarded as the mos t important of empirical and objective evidence, it repres ents an important influence on clinicians ' perceptions of an intervention. A dis cuss ion of the elements of res earch design decisions and key as pects of s tatistical analysis beyond the s cope of this chapter. However, there are several crucial concepts with which all prescribers have familiarity.

Handling of Dropouts R eaders need to recognize which groups are used for analysis of change from bas eline. T he primary analysis in most psychotropic drugs cons is ts of 3321 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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examination of respons e rates in two groups of One cons is ts of all randomly as signed subjects who received at leas t one dose of s tudy medication and had least one valid pos tbas eline rating. T his group is the intent-to-treat (IT T ) group, and the analysis is last observation carried forward (LOC F ), because the rating continues to be imputed to all rating periods in study. In the second approach, only patients who continue in the s tudy have their scores recorded at point in time. T hese two approaches, although to determine the degree of clinical change of a from baseline, yield different percentages. If the LOC F approach is cons idered to be overly cons ervative, representing an underes timate of a drug's true efficacy, res ults based on an obs erved cases model probably overs tate the treatment benefit. T hose in a modified IT T group are analyzed using the method. T his attempts to address the problem of data that result from patients who prematurely drop out a s tudy. Owing to the fact that ps ychotropic trials study drug effects over a period of weeks to years , patients may withdraw from the trial before reaching primary end point. R esearchers have s truggled to find way to account for mis sing data in a way that most accurately reflects the effectiveness of a drug. Alternatively, those who discontinue participation can simply be dropped from the rating periods after they out. Depending on which method is used, the s tudy findings can differ dramatically. One method is to the miss ing res ponses by us ing the las t observed value and carrying it forward to each time point until the end of the study. P atients are typically included in the 3322 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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analysis if they have been randomized, have taken at one dose of the double-blind study medication, and least one pos tbaseline as ses sment. T hey are included the final analys is regardless of why they drop out (e.g., effects, lack of res ponse, moved away, changed mind). approach, the LOC F method, typically yields the mos t cons ervative percentages, becaus e the s core of who drop out early in treatment tends to reflect less change than the s core of thos e who continue in the T heir fixed s cores are s ometimes des cribed as de ad An LOC F analys is tends to reduce the mean observed change at each time point, leading to the criticis m that LOC F model underestimates the intrinsic effectiveness drugs. W hen miss ing data are imputed, the results es sentially represent an inference about the treatment effect. Whether the LOC F method is the mos t accurate to determine the probable efficacy of a drug, its main importance is that it has s erved as the de facto frame of reference for es tablis hing res ponse and rates for several decades . T he mixed-model approach is an alternative to us ing LOC F or observed cases methods. T his involves miss ing data by es timating how patients in an arm of a study would have done by extrapolating from those patients who did complete the trial. T hus , subjects who drop out early do not have their last value carried as a fixed number but can have their s cores adjusted provide an es timate of additional improvement, had remained in treatment. B ecaus e miss ing data are miss ing completely at random, ps ychiatric res earchers biostatis ticians increas ingly are becoming concerned bias in outcome as ses sment that can res ult through its 3323 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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T he mixed-model analysis takes into account why drop out of a s tudy and addres ses s ome of the of an LOC F analys is . F or example, if noncompliance is res ult of treatment-emergent s ide effects , s hould this cons idered as a treatment failure comparable to a who fails to res pond after completing the full study? If a patient exhibits significant improvement halfway a s tudy but then drops out because of an intolerable effect, the final rating would s how the patient to have been a res ponder. T his model potentially reflects drug placebo differences more accurately than other but, because it has not been extens ively us ed, need to unders tand that res ults P.2680 based on this method us ually represent percentages are higher than thos e derived from an LOC F analys is . Without realizing it, most clinicians' unders tanding of res ponse and remiss ion percentages is bas ed on danger when a mixed-model approach is used is that it may not be recognized by unwitting clinicians as percentages that are not comparable to those bas ed LOC F .

B as ic S tatis tic s Is s ues T here is no single s tandard for analyzing the data from randomized, controlled trials . V arious statis tical approaches are us ed to determine the s ignificance of observed changes in s ymptoms. T he results of thes e analyses are express ed as a percentage of patients T ypical psychotropic drug trials are designed to detect differences between a drug and placebo. However, 3324 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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trials of psychotropic agents have insufficient statis tical power to show differences in intrins ic effectiveness between two active drugs . B ecaus e of this low as say sens itivity, s tudies may find equivalence to proven treatments or s uperiority to placebo but do not s how one drug is better than the other. T hese are thus as equivalence s tudies . P.2681 T o ans wer the question about whether a treatment the larger the number of subjects in a study, the more likely the results are valid. In the case of mos t drug trials , they are designed to show drugplacebo differences, but not drugdrug differences. T he mos t important statistical concepts and cons iderations in ps ychotropic drug s tudies are s ummarized in T able

Table 31.1-2 G los s ary of Terms and C onc epts Us ed in Ps yc hopharmac ology R es earc h Ass ay sens itivity    An active group (e.g., a commonly us ed ps ychotropic agent) in an clinical trial serves as index of quality control or as s ay s ens itivity. As say sens itivity is the ability of the study to dis criminate between a proven medication and placebo 3325 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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condition. F or example, if both medications fail to beat placebo, it is considered as a failed, rather negative study. P harmaceutical companies us e underpowered comparator arms , that is, fewer subjects than in the group receiving their drug, because it provides ins urance agains t their drug losing (i.e., a negative outcome). C onfidence interval    Along with reporting P values, the confidence interval is a way of express ing statis tical S pecifically, a confidence interval address es the of an observed effect. It provides an es timated of values where true value is most likely to be. C onfidence intervals are us ually calculated s o the percentage is 95 percent. A wide interval indicates that a finding is les s definite and that is less precis ion. T he narrower the interval, the precis e is the es timate. T he width of the interval gives s ome idea about how uncertain the res earcher is about the unknown parameter (s ee precis ion). A wide interval may indicate that more data s hould be collected before anything definite can be said about the parameter. T he confidence interval can als o be characterized as the margin error. A margin of error at the 95 percent interval is equal to two standard deviations in the polling s ample. A 99 percent confidence interval corres ponds to three s tandard deviations . T hus, a

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larger margin of error equates with greater confidence that a finding accurately reflects effectivenes s of a drug.    T he intervals for the various s amples are displayed by horizontal lines . T he values at each of the interval are called the confidence limits . All the values between the confidence limits make the confidence interval. If the confidence interval does not overlap zero, the effect is s aid to be statis tically significant. C onfidence limits are expres sed in terms of a confidence coefficient. Although the choice of confidence coefficient is somewhat arbitrary, in practice, 90 percent, 95 percent, and 99 percent intervals are often us ed, with 95 percent being the most commonly us ed. tes t for s tatistical significance does not confirm whether the effect is meaningful. It merely that the therapeutic effect is greater than zero. A statis tically significant effect may be clinically insignificant. T o determine whether the effect is meaningful, confidence intervals should be used. E ffect s ize    E ffect size is measure of the difference in between treatment groups . It repres ents the difference standard deviation of the differences . B ecaus e efficacy of mos t psychotropics for a is similar, mos t ps ychotropic drug s tudies find

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effect sizes . T hey can be clas sified as follows : 0.2; moderate, 0.4; and large, 0.6.    A study that yields a P value of precis ely .05 95 percent confidence interval that begins (or precis ely at zero. A s tudy that yields a P value of precis ely .01 yields a 99 percent confidence that begins (or ends) precisely at zero. In this reporting an effect size with corresponding confidence intervals can serve as a s urrogate for tes ts of s ignificance (if the confidence interval not include the nil effect, the s tudy is s tatistically significant), with the effect size approach focus ing attention on the relevant is sue.    E ffect size, when combined with confidence intervals , provides information about how large effect is , as well as the likely boundaries for the and upper limits of the true effect size.    T he results of a significance tes t are not an indication of effect size. F or example, a P value of .001 is as sumed to reflect a large effect, P value of .05 is ass umed to reflect a moderate T his is inappropriate, becaus e the P value is a function of s ample s ize, as well as effect size. An insignificant P value does not indicate that a drug has been proven ineffective. T he insignificant P value, although poss ibly reflecting lack of effectivenes s, could als o reflect the fact that the

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study was underpowered. Null hypothes is    R andomized controlled trials begin with the null hypothes is . In a s tudy of drug efficacy, the null hypothes is states that there is no difference the study drug and placebo or a comparator drug. fact, the hypothes is that the res earcher is hoping is that the null hypothes is is wrong, and a real difference exists. W ith the null hypothesis, there as sumption that there is no effect until proved otherwis e. In reality, investigators rarely initiate studies if they believe that there is no reason to that an effect will be found. S o, when a s tudent res earcher gets P >.05 and therefore accepts the hypothes is, he or she usually concludes that there is no effect. If he or s he gets P <.05 therefore rejects the null hypothesis, he or she has little idea of how big or how s mall the effect could be in the population. Odds ratios    Many s tudies , particularly s ys tematic reviews , report their results as odds ratios , or as a odds ratios. O dds repres ents the ratio of the probability that an effect is pres ent to the that it is not present. In graphs , odds ratios are plotted us ing a logarithmic scale. T he odds ratio 3329 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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when there is no relations hip. An odds ratio is calculated by dividing the odds. T he odds ratios statis tically significant if their 95 percent intervals do not include 1. T his means there is than a 1 in 20 chance that the reported effect is solely due to chance. T his would als o repres ent a probability of <.05, or, in terms of gambling, odds better than 19 to 1. C linical trials typically look for treatments that reduce the pres ence of a or disorder more than a control group and that odds ratios of less than one. T he odds as sociated with the outcomes of a heads-tails coin tos s are 1 1. It can be written as 1:1, indicating that both probabilities are identical. P value    S tudy res ults are commonly s ummarized by a statis tical tes t, and a decis ion about the of the result is based on a P value. P is s hort for probability. A P value displays that a res ult is likely to occur by chance (<1 or 5 percent of the time). It is a way of express ing statis tical and that a drug has an effect. W hen it is that a significant difference between treatments exis ts (e.g., the null hypothes is is rejected), it is expres sed as P <.05. If no difference is found the null hypothes is is accepted), it is express ed >.05. W hen P = .05, there is no more than a 5 probability that a statis tically s ignificant res ult will

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occur s imply by chance (i.e., a false-positive type I error). T ype I error    A type I error is a fals e-positive res ult. It may by chance. Mos t s tudies are designed to avoid type of error. With a type I error, 95 percent is s tandard. T ype II error    A fals e-negative result is more common in ps ychotropic drug s tudies , mainly because the number of s ubjects s tudied is too s mall, that is , studies are underpowered. With a type II error, 80 percent certainty is standard failure to find a difference between two drugs. It may reflect that study has low statis tical power.

P HA R MA C E UTIC A L INDUS TR Y INF L UE NC E T he pervas ive influence of pharmaceutical companies the perception of an individual drug is predictable, the reality that almost all trials of drug treatments are conducted by indus try. Information obtained by is thus filtered through advertis ing, sales calls , advisory boards , and pharmaceutical industrys ponsored 3331 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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promotional and educational activities. Most recognize that pharmaceutical companies engage in conflicting activities : One is to inform clinicians about empirical evidence of their drug's pharmacological T he other is to exaggerate the pos itive evidence about their compound. T his us ually involves playing down potential liabilities or explaining away unfavorable res ults. It is also ess ential that clinicians unders tand not all trial results are published or presented at Inconclusive or negative findings are often withheld by their s ponsors or rejected by journal editors . W ithout knowing if a published or pres ented s tudy represents entire body of res earch findings , it is imposs ible to determine the true relevance of the data. T o avoid mis leading promotional efforts by pharmaceutical companies, pres cribers s hould expect presentations of s tudy findings include relevant information about the des ign, conduct, and analys is of study. S lides or vis ual aids that do not include a full description of the numbers of patients studied, the duration of treatment, comparative dos ing, drop-out for each treatment arm, and outcomes showing LOC F observed cases results should be rejected as Most industry-spons ored studies are conducted to regulatory requirements and thus do not address clinical questions. T ypical patients in pivotal trials are pristine in terms of comorbid disorders and the us e of concomitant medications that they rarely res emble patients who s eek or need treatment. Attempts to discount clinical experience that contradicts findings of randomized, controlled trials s hould be countered with mention of the fact that these trials are not necess arily 3332 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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reflection of a drug's true pharmacological profile.

R E G UL A TOR Y IS S UE S T he F DA has the authority to approve a drug for clinical us e if it is found to be safe for us e and effective in us e. F DA is also charged with ensuring that product labeling truthful and contains all information pertinent to the and effective us e of that drug. T he F DA is res ponsible monitoring the pos tmarketing experience with a drug, propos ing changes in the product information, and overs eeing the way in which drugs are manufactured. ability of the F DA to perform its tas k is hampered by limited administrative res ources . An additional level of government regulation is directed by the Drug E nforcement Agency (DE A), which has class ified drugs according to their abuse potential, and clinicians are advis ed to exercis e increased caution when prescribing controlled subs tances (control level II through IV ).

Pres c ribing Information F DA-approved product information for marketed drugs appears as a package ins ert. It is also referred to as product labe ling. T he P hys ician's De s k R e fere nce merely an annual collection of product information for prescription drugs . T he product information for most drugs, not jus t ps ychotropic agents, contains an list of potential side effects, drug interactions, the need special monitoring, and res trictions for us e. T his information reflects the res ults of critical evaluations submitted to the F DA about the s afety and efficacy of drug for the approved indications . P os tmarketing experience is added to the product information over 3333 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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T he limitations of the prescribing information are in the many adverse events that are underreported clinical trials and the frequent us e of dos es of in clinical practice that exceed the recommended limits.

B lac k B ox Warning T he prescribing information for a drug sometimes a black box warning to alert phys icians about important safety information. T he term describes a box at the beginning of the package ins ert that the warning. It is cons idered the s tronges t warning, more s erious than jus t bolded text. A black box warning may be included in the product information when a is approved by the F DA, or it can be added later. T he presence of a black box warning deters s ome clinicians from us ing a drug as a firs t-choice agent. In some manufacturers have decided agains t bringing a drug to market because of the competitive disadvantage that a warning label confers. A notable recent example of a that was withheld from the market is the serotonindopamine antagonist s ertindole (S erlect), which was shown to produce delays in cardiac conduction. Unless new agents have a unique benefit, it is unlikely that will be marketed if a black box warning is required by F DA. T he longer that a drug has been in clinical use, the the unders tanding of its side effect profile. E ven though new agents undergo extensive s crutiny for safety and tolerability, clinical trials do not typically capture the full range and s everity of all side effects . Most clinical trials of too short duration and lack sufficient power to detect 3334 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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the full extent of s ide effect risk. Approximately 10 of all drugs approved in the United S tates in recent have acquired a black box warning after marketing or been withdrawn. In terms of timing, one-half of black additions have occurred within the firs t 7 years after a was marketed. P s ychotropic drugs with added black warnings (T able 31.1-3) include nefazodone (S erzone), pemoline (C ylert), droperidol (Inapsine), lamotrigine, clozapine (C lozaril), divalproex (Depakote), and thioridazine (Mellaril). In the latter cas e, the warning added after the drug had been in us e for many the context of safer alternatives , the benefits of thioridazine no longer outweighed the risk of cardiac conduction abnormalities. A warning about the ris k of stroke in elderly patients has been added to the prescribing information for ris peridone.

Table 31.1-3 Ps yc hotropic Drugs with Pos tmarketing B lac k B ox Warnings Drug

Ps yc hiatric Applic ation

B as is for Warning

C lozapine (C lozaril)

R efractory schizophrenia

Myocarditis

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Droperidol (Inaps ine)

S edation of agitated patients

T ors ades de pointes or and QT c prolongation, or both, and other cardiovascular events

T hioridazine (Mellaril)

P sychos is

T ors ades de pointes or and QT c prolongation, or both, and other cardiovascular events

Divalproex (Depakote)

Acute mania

Hemorrhagic pancreatitis and hepatic failure

Nefazodone (S erzone)

Depress ion

Acute failure

P emoline (C ylert)

Attentiondeficit/hyperactivity disorder

Acute liver failure

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Approximately one-half of drug withdrawals due to is sues occur within the first 2 years after a drug is marketed. B etween 1993 and 2002, there were seven recalls that followed reports of death or severe health complications . It is worth noting that none of these involved ps ychotropic drugs . T his is a remarkable tes timonial to an often overlooked fact: P s ychotropic drugs are among the s afes t drugs available. S ince nomifens ine (Merital) was withdrawn in 1986, within 1 of its marketing, no other ps ychotropic agent has been withdrawn becaus e of serious s ide effects.

NONA P P R OVE D DOS A G E S A ND UNDE R THE F E DE R A L FOOD, A ND C OS ME TIC (F DC ) A C T It is now common practice to treat ps ychiatric dis orders with drugs that are approved for nonps ychiatric conditions. C arbamazepine (T egretol), an is a mainstay of treatment for bipolar P.2682 P.2683 disorder. Amphetamines are routinely added to antidepres sants to counteract the emotional blunting as sociated with chronic S S R I use. Opiates have helpful when us ed in patients with treatment-res is tant depres sion. S ome individuals who are leading normal productive lives because of s uch judicious off-label us e drugs would be experiencing lives of disability and were their phys icians unwilling to take advantage of the full range of potential therapeutic interventions . 3337 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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Off-label use of a drug is not a violation of law or a departure from good medical practice. T he F ood, Drug, and C os metic (F DC ) Act does not limit the manner in which a physician may us e an approved drug. may be prescribed for any reas on shown to be indicated for the welfare of the patient. Once a drug is approved for commercial us e, a physician may, as part the practice of medicine, lawfully pres cribe a different dosage for a patient or may otherwis e vary the of use from what is approved in the package labeling without notifying the F DA or obtaining its approval. F ailure to follow the information on the drug label does not in itself impose liability and should not preclude a phys ician from using good clinical judgment in the of the patient. P hys icians are permitted to use a drug indications not included on the drug's official labeling without violating the F DC Act. However, this fact does absolve the physician of res ponsibility if there is an untoward result from treatment. P atients can s till s ue poss ible medical malpractice with the reasoning that failure to follow the F DA-approved label can be interpreted as deviating from the prevailing s tandard of care. When using a drug for an unapproved indication or in a dose outs ide the us ual range, it is thus good clinical practice to explain to the patient and to document in chart why a drug is being used instead of an approved agent. If there is doubt about a plan to use a drug offa consultation with a colleague s hould be obtained. Drugs without an F DA indication for a ps ychiatric are us ed routinely. P hysicians should not feel choos e one drug over another based solely on F DA3338 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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approved labeling if the publis hed literature s upports effectivenes s of the entire class in treating a disorder, an alternative agent offers an advantage in safety or tolerability for a patient. S ome of thes e agents and include propranolol for s ocial anxiety and treatment of lithium-induced tremor; verapamil for mania and treatment of MAOI-induced hypertens ive crisis; levothyroxine (Levoxyl) for antidepres sant clonidine and guanfacine (T enex) for attentiondeficit/hyperactivity dis order (ADHD) and P T S D; dextroamphetamine (Dexedrine) for antidepress ant augmentation; and carbamazepine for bipolar disorder. In some cas es, a drug has obtained a limited approval an indication. Divalproex, quetiapine (S eroquel), and ris peridone, for example, are approved by the F DA for acute, but not long-term, treatment of mania. Nevertheles s, thes e drugs are routinely used for longprevention of recurrences of mania and bipolar the case of lamotrigine, it was accepted as a firstagent for the treatment of bipolar disorder long before F DA granted approval for that indication. S ome off-label drugs fail to produce s ucces sful in the majority of patients but res ult in s tartling improvement of isolated cases. Y et, because these cannot be proven to be as effective as standard treatments , they are not likely to win regulatory

P HA R MA C OL OG IC A L A C TIONS Heterogeneity of res pons e characterizes all drugs. Among other considerations, genetic and environmental factors influence individual respons e to tolerability of ps ychotropic agents. T hus , a drug that 3339 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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not prove effective in large numbers of patients with a disorder can dramatically improve symptoms in some. these cas es , identification of characteristics that might predict potential candidates for that drug becomes important but often remains elus ive. At the moment, attention is focused on gaining a better unders tanding the thousands of genes that regulate express ion of metabolizing enzymes and of the complex functions of brain. Drugs , even within the s ame class , are distinguished one another by often s ubtle differences in molecular structure, types of interactions with neurotransmitter systems , differences in pharmacokinetics , the absence of active metabolites , and protein binding. differences, combined with the biochemistry of the patient, account for the profile of efficacy, tolerability, safety and the ris kbenefit ratio for the individual. T hese multiple variables , some poorly understood, make it difficult to predict a drug's effect with certainty. Nevertheles s, knowledge of the nature of each increases the likelihood of s ucces sful treatment. T he clinical effects of drugs are best understood in terms of pharmacokinetics, which des cribes what the body does drug, and pharmacodynamics , which des cribes what drug doe s to the body. P harmacokinetics and pharmacodynamics need to be in the context of the underlying variability among with res pect to how drug effects are express ed P atients differ in their therapeutic res pons e to a drug the experience of side effects. It is increasingly clear these differences have a strong genetic basis . P harmacogenetics res earch is attempting to identify 3340 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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role of genetics in drug respons e.

DR UG S E L E C TION S election of a psychotropic agent is dependent on multiple factors . Although all F DA-approved are similar in overall effectiveness for their indicated disorder, they differ cons iderably in their pharmacology and in their efficacy and adverse effects on individual patients. T he ability of a drug to prove effective is thus partially predictable and is dependent on poorly unders tood patient variables . It P.2684 is nevertheless pos sible that some drugs have a niche which they can be uniquely helpful for a subgroup of patients, without demons trating any overall s uperiority efficacy. No drug is universally effective, and there is evidence of the unambiguous s uperiority of any s ingle agent as a treatment for any major ps ychiatric T he only exception, clozapine, has been approved by F DA as a treatment for cas es of treatment-refractory schizophrenia. Decisions about drug selection and us e are made on a case-by-case basis, relying on the individual judgment the physician. T here are three factors in drug s election: the drug, (2) the patient, and (3) the prescribing F ailure to consider each of thes e components reduces probability of a s ucces sful outcome.

DR UG F A C TOR S Pharmac odynamic s 3341 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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T he time course and intensity of a drug's effects are referred to as its pharmacodynamics . Major pharmacodynamic cons iderations include receptor mechanisms, the dose-res ponse curve, the therapeutic index, and the development of tolerance, dependence, and withdrawal phenomena. Drug mechanis m of action subs umed under pharmacodynamics. T he clinical res ponse to a drug, including advers e reactions, results from an interaction between that drug and a patient's susceptibility to thos e actions . P harmacogenetic are beginning to identify genetic polymorphis ms linked individual differences in treatment res ponse and sens itivity to side effects.

Mec hanis ms T he mechanis ms through which mos t ps ychotropic produce their therapeutic effects remain poorly unders tood. S tandard explanations focus on ways that drugs alter synaptic concentrations of dopamine, serotonin, norepinephrine, histamine, γ-aminobutyric (G AB A), or acetylcholine. T hese changes are said to from receptor antagonis ts or agonists , interference with neurotransmitter reuptake, enhancement of neurotransmitter releas e, or inhibition of enzymes . drugs are ass ociated with permutations or these actions. T hus , a drug can be an agonist for a receptor, thus stimulating the s pecific biological activity the receptor, or an antagonis t, thus inhibiting the biological activity. S ome drugs are partial agonists , because they are not capable of fully activating a receptor. S ome psychotropic drugs also produce effects through mechanisms other than receptor interactions. F or example, lithium may act by directly 3342 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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inhibiting the enzyme inositol-1-phosphatase. S ome effects are clos ely linked to a s pecific s ynaptic effect. example, most medications that treat psychosis s hare ability to block the dopamine type 2 (D 2 ) receptor. S imilarly, benzodiazepine agonis ts bind a receptor complex that contains benzodiazepine and G AB A receptors. Accounts of s o-called mechanisms of action s hould nevertheless be kept in perspective. E xplanations of ps ychotropic drugs actually work that focus on synaptic elements represent an oversimplification of a complex series of events . If merely rais ing or lowering levels of neurotransmitter activity is as sociated with the clinical effects of a drug, then all drugs that cause thes e should produce equivalent benefits . T his is not the Multiple obscure actions , s everal steps removed from events at neuronal receptor s ites , are probably for the therapeutic effects of psychotropic drugs . T hese downs tre am elements are pos tulated to repres ent the actual reasons that thes e drugs produce clinical improvement. One way to dis cover how drugs work is to examine pathways and s ys tems known to be implicated in the pathophys iology of psychiatric dis orders. New agents can then be developed that target thes e or s ys tems with compounds. G oing directly to so-called downstream actions promises to lead to novel that increase res pons e rates , eliminate delays in onset effects, and improve tolerability.

S IDE E F F E C TS S ide effects are an unavoidable risk of medication 3343 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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treatment. Although it is impos sible to have an encyclopedic knowledge of all pos sible adverse drug effects, prescribing clinicians should be familiar with more common advers e effects, as well as thos e with serious medical cons equences. No s ingle text or document, including the product information, contains a complete list of poss ible treatment-emergent events. A major advantage of being treated by a knowledgeable experienced psychopharmacologist is the greater likelihood that treatment decis ions are based on a and deeper awareness of potential treatment-emergent events.

Probability S ide effect considerations include the probability of its occurrence, its impact on a patient's quality of life, its cours e, and its caus e. In cons idering the likelihood of a effect, the concept of numbe r ne e de d to harm may be helpful. F or example, a s ide effect that is found to 0.5 percent of patients means that 200 patients would need to be treated to see that adverse event. In a study involving fewer than that number, the s ide effect might not occur. C linicians s hould differentiate between probable or reas onably foreseeable adverse effects those that are rare or unexpected. J us t as no one drug certain to produce clinical improvement in all patients, side effect, no matter how common, occurs in every patient. W hen concurrent medical disorders or a pas t history of a similar adverse reaction puts a patient at increased ris k for a side effect, it is logical to cons ider prescribing a compound not typically as sociated with advers e reaction. 3344 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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Impac t on Quality of L ife P sychotropic side effects can have a major impact on a patient's quality of life. Impact of a potential s ide effect quality of life also needs to be considered. T remor, although not life-threatening, can be s ocially disabling. T he inability to hold a cup of coffee without shaking leads to s ocial withdrawal, as does s weating through a shirt in an air-conditioned office and keeping extra K eep in mind that the mos t common reas on for early discontinuation of treatment is unwanted side effects. E ven the most effective drug is useless if it is not R are side effects that may have s erious medical cons equences include heart block, agranulocytosis, neuroleptic malignant s yndrome, hepatic dys function, exfoliative dermatitis . S ome patients find certain s ide effects acceptable, whereas others do not. E fforts be made to determine if patients have an aversion to a side effect or have a pas t history of s ens itivity to a s ide effect.

C aus e S ide effects may res ult from the same pharmacological action that is res ponsible for a drug's therapeutic or from an unrelated property. In examples of the latter, some of the mos t common adverse effects of the T C As caus ed by blockade of muscarinic acetylcholine or his tamine 2 receptors . If a patient is sensitive to effects, alternative agents without thes e properties be pres cribed. When s ide effects are manifes tations of drug's presumed mechanis m of action, s ide effects unavoidable. T hus, blockade of serotonin reuptake by S S R Is may caus e nausea and s exual dys function. T he 3345 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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blockade of drugs us ed to treat psychosis may cause extrapyramidal s ide effects . Agonis t action of benzodiazepine receptors can caus e ataxia and sleepiness . P.2685 In thes e cas es, additional medications are frequently to make the primary agent better tolerated.

Time C ours e Advers e effects differ in terms of their onset and S ome s ide effects appear at the outset of treatment then rapidly diminish. Naus ea occurring with S S R Is or venlafaxine and sedation occurring with mirtazapine (R emeron) are good examples of early, time-limited effects. E arly-onset, but persistent, s ide effects include mouth that is as sociated with noradrenergic reuptake inhibition or antimus carinic activity. S ome side effects appear later in treatment (late -appearing s ide e ffects ) sometimes, may be just the oppos ite of adverse events early in treatment. F or example, patients may typically weight during early treatment with S S R Is , only to find, time, that there has been a revers al, s o that they gain weight. S imilarly, early activation or agitation may be followed by cons tant fatigue or apathy. B ecause mos t about new drugs come from s hort-term s tudies , 8 weeks in duration, early-onset side effects are overrepres ented in product information and of newly marketed information. It is es sential that clinicians follow the letters to the editor s ections of journals and other sources of information to revise cons tantly their unders tanding of the true s ide effect 3346 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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profile of a drug. Advers e effects differ in their impact on compliance potential to cause harm. Depending on a patient's threshold of tolerance for a side effect and the impact quality of life, s ide effects may lead to drug discontinuation. E xamples of s erious side effects agranulocytosis (clozapine), S tevens -J ohns on (carbamazepine), hepatic failure (nefazodone), stroke (phenelzine [Nardil]), and heart block (thioridazine). Overall, the ris k of life-threatening side effects with ps ychotropics is low. Drugs that carry such a ris k monitored more clos ely, and the prescribing physician should take into account whether the potential clinical benefits jus tify the additional ris k. Any drug with a ris k, as reflected in a black box warning, is generally less extens ively than would otherwise be the case. E vidence of the underlying anxiety about psychotropic drugs comes in the form of the ques tion How much is known about the long-term effects of these F or some medications, the ans wer is that much is F or example, with benzodiazepines , tricyclics , and there are decades of experience, and, bas ed on during that time, it can be s aid that few unexpected advers e effects can be anticipated. In the cas e of haloperidol and other dopamine receptor antagonis ts, long-term complications , s uch as tardive dyskinesia, have been well documented. E merging evidence also sugges ts that the use of dopamine antagonis ts is as sociated with a s mall increase in the breast cancer and that this is related to larger doses . In cases in which s erious risk is as sociated with drug, clos er medical monitoring of medication 3347 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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is warranted. B ecause the mos t widely us ed such as the S S R Is and s erotonin-dopamine have only been in us e s ince the 1980s or 1990s, there less certainty about long-term effects, but there has no evidence that there are s ide effects that are not extensions of those already evident during initial It s hould als o be kept in mind that most drugs us ed in treatment of chronic medical disorders have not been us e long enough to provide as surances about long-term adverse effects . T able 31.1-4 lists s ome of the more common s ide that occur with commonly us ed psychotropic agents .

Table 31.1-4 C ommon S ide As s oc iated with Newer Ps yc hotropic Drugs Movement disorders    F irs t-generation antips ychotics the dopamine receptor antagonis tsare the most common caus e medication-induced movement dis orders. T he introduction of s erotonin-dopamine antagonists greatly reduced the incidence of these side but varying degrees of dose-related akathisia, and dys tonia s till occur. R is peridone (R is perdal) mos t clos ely res embles the older in terms of these side effects. Olanzapine 3348 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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also causes more extrapyramidal effects than trials sugges ted. T here have been rare reports of S S R I-induced movement dis orders, ranging from akathisia to tardive dyskinesia. S exual dysfunction    T he use of psychiatric drugs can be as sociated sexual dys functiondecreased libido, impaired ejaculation and erection, and inhibition of female orgasm. In clinical trials with the S S R Is, the sexual s ide effects was gross ly underes timated, because data were based on spontaneous patients. T he rate of s exual dys function in the original fluoxetine (P rozac) product information, example, was <5 percent. In subs equent s tudies which information about s exual s ide effects was elicited by specific questions , the rate of S S R Ias sociated sexual dysfunction was found to be between 35 and 75 percent. In clinical practice, patients are not likely to report s exual dys function spontaneously to the phys ician, so it is important as k about this s ide effect. Als o, s ome s exual dysfunctions may be related to the primary ps ychiatric disorder. Nevertheles s, if s exual dysfunction emerges after pharmacotherapy has begun, and the primary res ponse to treatment been positive, it may be worthwhile to attempt to treat the symptoms. Long lists of poss ible to thes e s ide effects have evolved, but few

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interventions are consistently effective, and few have more than anecdotal evidence to support us e. T he clinician and patient s hould cons ider the poss ibility of sexual s ide effects with a patient selecting a drug and switching treatment to drug less or not at all as sociated with s exual dysfunction if this adverse effect is not acceptable the patient. Weight gain    W eight gain accompanies the us e of many ps ychotropic drugs as a res ult of retained fluid, increased caloric intake, decreas ed exercise, or altered metabolis m. W eight gain may also occur symptom of dis order, as in bulimia or atypical depres sion, or as a s ign of recovery from an of illness . T reatment-emergent increas e in body weight is a common reason for noncompliance a drug regimen. No s pecific mechanisms have identified as causing weight gain, and it appears the histamine and s erotonin systems mediate changes in weight as sociated with many drugs to treat depress ion and ps ychos is . Metformin (G lucophage) has been reported to facilitate loss among patients whos e weight gain is to use of s erotonin-dopamine reuptake inhibitors and valproic acid (Depakene). V alproate, as well olanzapine, has been linked to the development insulin resistance, which could induce appetite

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increase, with s ubs equent weight increase.    W eight gain is a noteworthy s ide effect of clozapine (C lozaril) and olanzapine. G enetic that regulate body weight, as well as the related problem of diabetes mellitus , s eem to involve the HT 2C receptor. T here is a genetic polymorphism the promoter region of this receptor, with significantly les s weight gain in patients with the variant allele than in those without this allele. with a s trong 5-HT 2C affinity would be expected to have a greater impact on body weight of patients with a polymorphis m of the 5-HT 2C receptor promoter region. Weight los s    Initial weight loss is as sociated with S S R I but is us ually trans ient, with most weight being regained within the firs t few months. B upropion (W ellbutrin) has been s hown to cause modest weight loss that is s us tained. W hen combined diet and life style changes , bupropion can more s ignificant weight loss . T opiramate and zonis amide (Zonegran), marketed as for epileps y, produce sometimes s ubs tantial, sustained loss of weight. G lucos e changes

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   Increas ed risk of glucos e abnormalities, diabetes mellitus, is ass ociated with weight during psychotropic drug therapy. Data are not conclus ive, but olanzapine is ass ociated with frequent reports than other serotonin-dopamine antagonis ts of abnormalities in fasting glucos e levels, as well as in reported cases of diabetes and ketoacidosis . Hyponatremia    Hyponatremia is as sociated with oxcarbazepine (T rileptal) and S S R I treatment, es pecially in patients. C onfusion, agitation, and lethargy are common s ymptoms. C ognitive    C ognitive impairment means a disturbance in capacity to think. S ome agents , such as the benzodiazepine agonis ts, are recognized as of cognitive impairment. However, other widely us ed psychotropics , s uch as the S S R Is , (Lamictal), gabapentin (Neurontin), lithium T C As, and bupropion, are also as sociated with varying degrees of memory impairment and finding difficulties . In contrast to the benzodiazepine-induced anterograde amnesia, these agents caus e a more subtle type of absentmindedness . Drugs with anticholinergic 3352 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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are likely to worsen memory performance. S weating    S evere perspiration unrelated to ambient temperature is as sociated with T C As , S S R Is, and venlafaxine (E ffexor). T his s ide effect is often disabling. Attempts can be made to treat this side effect with alpha agents , s uch as terazosin and oxybutynin (Ditropan). C ardiovascular    Newer agents are les s prone to have direct effects. Many older agents, such as T C As and phenothiazines, affected blood pres sure and conduction. T he drug thioridazine (Mellaril), which has been in use for decades , has been s hown to prolong the QT c interval in a dose-related and may increas e the risk of s udden death by delaying ventricular repolarization and caus ing tors ades de pointes. Newer drugs are now scrutinized for evidence of cardiac effects. A promis ing treatment for ps ychosis , s ertindole (S erlect), was not marketed because the F ood Drug Adminis tration would have required a black box warning. S light QT c effects noted with zipras idone (G eodon) delayed the marketing of drug. High-normal and high-dose olanzapine may caus e prolongation of the P R interval and 3353 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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atrioventricular conduction delay.    T he management of s pecific s ide effects for individual drugs is covered in their respective chapters. R as h    Any medication is a potential s ource of a drug S ome psychotropics , s uch as carbamazepine (T egretol) and lamotrigine, have been linked to increased ris k of s erious exfoliative dermatitis, s o patients s hould be informed about the of wides pread lesions that occur above the neck involve the mucous membranes. If such manifest, a patient s hould be instructed at the that the medication is pres cribed to go to an emergency department and not to firs t attempt to contact the prescribing psychiatris t.

5-HT 2C , s erotonin type 2C ; S S R I, s elective reuptake inhibitor; T C A, tricyclic antidepres sant.

Idios ync ratic and Paradoxic al Drug R es pons es Most between-patient differences in drug res ponse can conceptualized as reflecting variability in drug and receptor s ens itivity. Idios yncratic reactions may 3354 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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occur when a patient experiences a particularly rare effect from a drug. F or example, some patients become quite agitated when given a benzodiazepine, as diazepam, or the anticonvuls ant gabapentin. An example of a paradoxical respons e is the occurrence of spontaneous orgasms instead of anorgasmia during therapy. Another example is behavioral dis inhibition instead of sedation in a patient being treated with a benzodiazepine. It is wise to cons ider any undes ired treatment emergent event as poss ibly being related to medication. T he abs ence of a mention of that s ide the product information does not exclude the poss ibility that it is a rare event that was not detected during trials or that it is idiosyncratic to the patient.

S A F E TY Life-threatening side effects are rare among drugs but do occur. S ide effects may be dose related. agents have a high therapeutic index.

Therapeutic Index T he rape utic inde x is a relative meas ure of the toxicity safety of a drug and is defined as the ratio of the toxic dose to the median effective dose. T he median dose is the dos e at which 50 percent of patients experience a specific toxic effect, and the median dose is the dos e at which 50 percent of patients have a specified therapeutic effect. W hen the therapeutic high, as it is for haloperidol, it is reflected by the wide range of dosages in which that drug is prescribed. C onvers ely, the therapeutic index for lithium is quite thus requiring careful monitoring of s erum lithium levels 3355 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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patients for whom the drug is prescribed.

Overdos e S afety in overdos e is always a cons ideration in drug selection. F ortunately, almost all of the newer agents a wide margin of safety when taken in overdos e. B y contrast, a 1-month supply of T C As could be fatal. T he depres sed patients they treated were the group mos t at ris k to attempt s uicide. B ecause even the safes t drugs sometimes produce severe medical complications , es pecially when combined with other agents, clinicians must recognize that the prescribed medication can be us ed in an attempt to commit s uicide. Although it is prudent to write nonrefillable prescriptions for small quantities , this practice pass es along increas ed copay to the patient. In fact, many pharmacy benefit management programs encourage the prescribing of a month supply of medication. In cas es in which s uicide is a major concern, an should be made to verify that the medication is not hoarded for a later overdose attempt. R andom pill or asking a family member to dispens e daily doses also be helpful. S ome patients attempt s uicide just as are beginning to recover. Large quantities of with a low therapeutic index should be prescribed judiciously. Another reas on to limit the number of pills prescribed is the poss ibility of accidental inges tion of medications by children in the hous ehold. P sychotherapeutic medications s hould thus be kept in safe place. P hysicians who work in emergency rooms should know which drugs can be hemodialyzed. T he iss ues involved 3356 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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complex and are not bas ed on any s ingle chemical property of the drug. F or example, it is generally that drugs with low protein are good candidates for dialysis. However, venlafaxine, which is only 27 protein bound, is too large as a molecule dialyzed. Hemodialysis has long been presumed to be ineffective valproic acid (Depakene), becaus e it is 90 to 95 protein bound. However, at high levels that are with overdos e, binding sites on serum albumin are saturated, decreas ing the percentage of bound valproic acid, thus facilitating the benefits of hemodialys is . P.2686 P.2687

Pharmac okinetic s P harmacokinetic drug interactions are the effects of on the plas ma concentrations of each other, and pharmacodynamic drug interactions are the effects of drugs on the biological activities of each other. P harmacokinetic concepts are us ed to describe and to predict the time course of drug concentrations in parts of the body, such as plas ma, adipos e tiss ue, and central nervous s ys tem (C NS ). F rom a clinical pharmacokinetic methods help explain or predict the onset and duration of drug activity and interactions between drugs that alter their metabolis m or excretion. P harmacogenetic research focus es on finding variant alleles that alter drug pharmacokinetics and pharmacodynamics . R es earchers are attempting to identify genetic differences in how enzymes metabolize 3357 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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ps ychotropics, as well as C NS proteins directly drug action. It is likely that identification of patient genotypes will facilitate prediction of clinical res pons e different types of drugs. Drugs differ in their propens ity to interact with other drugs. Awarenes s of potential drugdrug interactions grown dramatically over the past two decades. Most clinicians need to consult charts or computer programs determine when potential interactions may occur and, if so, how clinically relevant they may be. W henever it is preferable to us e a medication that produces ris k of drug interactions . Als o, it is recommended that prescribers know the interaction profiles of the drugs they mos t commonly prescribe. E xamples of pharmacokinetic interactions include one drug increasing or decreasing the concentrations of a coadministered compound. T hes e types of interactions can also lead to altered concentrations of metabolites. some cases , there may als o be interference with the conversion of a drug to its active metabolite. T here is enormous variability among patients with respect to pharmacokinetic parameters , s uch as drug abs orption metabolism. Another type of interaction is represented interactions involving the kidney. C ommonly us ed medications , s uch as angiotens in-converting enzyme (AC E ) inhibitors , nons teroidal antiinflammatory drugs (NS AIDs), and thiazides , decrease renal clearance of lithium, increas ing the likelihood of severe elevations of lithium. Drug interactions may be pharmacokinetic or pharmacodynamic. P harmacogenetics is being used to study why patients differ in the way that they metabolize drugs. In patients 3358 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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who are ultrarapid or extensive metabolizers , the concentrations of a drug may be lower than expected.

P A TIE NT-R E L A TE D F A C TOR S R es pons e to medication, as well sensitivity to s ide is influenced by factors related to the patient. T his is there is no one-size-fits -all approach to treatment. T his is reflected in the finding that, although drugs used to treat a s pecific disorder demons trate comparable efficacy in head-to-head s tudies , these are not equally effective in all patients. P atient-related variables include diagnos is , genetic factors, lifestyle, overall medical status , concurrent disorders , and pas t history of drug res ponse. A patient's attitude toward medication in general, avers ion to certain types of s ide effects, and preference for a s pecific agent also need cons idered.

Diagnos is Accurate diagnosis is an integral component of the treatment process . F ailure to correctly diagnose a diminis hes the likelihood of optimal drug selection. Misdiagnos is not only can result in a mis sed but also can, at times, produce worsening of Inadvertently diagnosing a patient in the depres sed of bipolar dis order as having unipolar depress ion can induce mania or rapid cycling. T reatment failure or exacerbation of s ymptoms should prompt a of the working diagnosis.

Pas t Treatment R es pons e A s pecific drug s hould be s elected according to the 3359 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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patient's history of drug res ponse (compliance, res ponse, advers e effects), the patient's family his tory drug res ponse, the profile of adverse effects for that with regard to the particular patient, and the pres cribing clinician's usual practice. If a drug has previous ly been effective in treating a patient or a family member, the same drug should be used again. However, for that are not understood, some patients fail to res pond previous ly effective agent when challenged again. A history of severe advers e effects from a specific drug is strong indicator that the patient would not be compliant with that particular drug. It is helpful if patients can recall the details of pas t ps ychotropic drug treatment: the drugs prescribed, in what dos ages, for how long, and in what combinations. Unfortunately, because of their mental disorders , many patients are poor historians. If poss ible, patients ' records s hould be obtained to confirm their reports. members are a good s ource of collateral information.

R es pons e in Family Members It is widely held that drug res pons es cluster in families . T hus, res ponse to a drug in a relative is an indicator of whether a patient might als o benefit from that Although there is no conclus ive evidence s upporting as a cons ideration in drug s election, existing s tudies do confirm that a his tory of pos itive respons e to treatment with a drug s hould be cons idered in making treatment decis ions.

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Initial as sess ment s hould elicit information about coexisting medical disorders. In s ome cases, there a medical disorder that is res ponsible for the P atients with thyroid disease who are not adequately treated may appear depress ed. S leep apnea produces depres sion and cognitive impairment. R are conditions , such as K leine-Levin syndrome, can mimic bipolar A drug s hould be s elected that minimally exacerbates preexisting medical problems that a particular patient have. R ecreational drug us e, exces sive cons umption of and frequent inges tion of caffeine-containing can complicate and even undermine ps ychotropic drug treatment. T hes e compounds pos sess significant ps ychoactive properties and, in s ome cases, may the source of the patient's s ymptoms . It is reas onable as k patients to abs tain from us e of these substances at least until the benefits of psychotropic drug treatment have been unequivocally es tablis hed. G radual reintroduction of moderate amounts of alcohol, tea, and coffee can then take place. P atients can then observe thems elves whether there are any untoward effects on their clinical s tatus.

C L INIC IA N A TTITUDE S A ND C ONF IDE NC E C linicians s hould understand the basis for their choices . As in all types of psychotherapy, conscious unconscious feelings toward the patient, as well as about s pecific treatment modalities, need to be acknowledged. T here s hould also be recognition of degree of comfort with knowledge of the medications 3361 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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prescribed. E ven among ps ychopharmacologis ts, there different areas of clinical interest and expertise. Dis agreement about choice of treatment is common, because different weight can be given to any one of the variables involved in drug selection.

Drug Preferenc e S ome prescribers have obvious favorites among the available ps ychotropic agents. T his bias or allegiance regarding a treatment can s tem from a combination of factors . P.2688 A dramatically s ucces sful patient res ponse during early experience with a new drug can produce a conve rs ion expe rience , in which the pres cribing physician forms a highly positive opinion of that drug. P atients being by that phys ician are more likely to receive that medication than alternatives. Other factors that may to a clinician s eeing a drug as firs t-line include a journal article, the influence of dis tinguished thought leaders, and persuas ive marketing and sales activity.

Therapis t Attitudes P sychiatrists trained primarily as ps ychotherapists may prescribe medication more reluctantly than thos e who more oriented to biological ps ychiatry. C onvers ely, who view medication as the preferred intervention for most psychiatric dis orders may be reluctant to refer for therapy. T herapists who are pes simis tic about the ps ychotherapy or who mis judge the patient's motivation may pres cribe medications out of their own nihilis tic 3362 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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beliefs; others may withhold medication if they ps ychotherapy or undervalue pharmacological When a patient is in psychotherapy with s omeone than the clinician pres cribing medication, it is important recognize treatment bias and to avoid contentious turf battles that put the patient in the middle.

Therapis t C onfidenc e T herapists may differ in their level of comfort with prescribing medication. S ome of this discomfort comes from the feeling, perhaps correct, that he or s he insufficient knowledge about dos ing or potential s ide effects. C onsequently, there may be overreliance on a limited range of agents and poss ible us e for too long in the face of inadequate respons e. Any therapist who prescribes medication should become as as poss ible about the drugs that he or s he uses. If he sees himself or hers elf as primarily an expert in doing ps ychotherapy, he or she should recognize the

INF OR ME D C ONS E NT A ND E DUC A TION E stablishing trus t and providing motivation to comply with the medication regimen are ess ential components succes sful treatment. P atients s hould be informed treatment options and the probable side effects and unique benefits of each treatment. P atient preference should be res pected, unles s there is a compelling advantage involving efficacy, tolerability, or s afety with alternative agent. If a particular medication is being recommended, the reas ons for this recommendation should be explained. P atients are more likely to 3363 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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taking their medication if they fully understand the reasons why it is being pres cribed. P hysicians no longer have a monopoly over the knowledge regarding ps ychotropic drugs . Many now routinely s earch the Internet for information about available treatments . W hat phys icians do have is an unders tanding of the clinical circumstances that would lead to the choice of one drug among the many that available. Medication treatment benefits from a strong therapeutic alliance between a clinician and a patient. G iven the unpredictability of medication res ponse, the frequent occurrence of side effects, and underlying ambivalence about or fear of taking medication, a pos itive, trus ting relations hip serves to improve patient compliance. R epeated failed trials may be needed before a seen. A patient's confidence in the phys ician's and judgment enables medication trials and more complex regimens, such as the use of multiple medications . Dis cus sions about drug selection should be in notes, but a signed informed cons ent is not needed. S urprisingly, patients who are informed of potential advers e effects report a higher incidence of side effects do not have higher rates of premature dis continuation. How the patient and family are engaged in the plan can determine the success of treatment. T he ps ychodynamic meaning to the patient and family and environmental influences, psychos ocial s tres sors, and support s hould be explored. S ome patients may view treatment as a panacea, and others may view it as the 3364 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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enemy. W ith the patient's consent, relatives and other clinicians s hould be instructed on the reas ons for the treatment, as well as the expected benefits and ris ks . In addition, the clinician may also find it us eful to explain the theoretical bas is for pharmacotherapy to patient and other s ignificant parties .

DOS ING , DUR A TION, A ND MONITOR ING Dos ing T he clinically effective dos e for treatment depends on characteristics of the drug and patient factors, such as inherited s ensitivity to and ability to metabolize a drug, concurrent medical dis orders, use of concurrent medications treatments , and history of expos ure to previous medications . Dos es used in clinical practice often differ from thos e in pivotal studies , which, in turn, form the bas is for recommendations that eventually appear in the product information. T he reason for this divergence is that in pivotal trials are highly selected and are not representative of people who are ultimately treated. a drug achieves wides pread use in real world patients , discovered that the dos es needed for optimal efficacy need to be higher than sugges ted by clinical trial S imilarly, the doses needed for tolerability may be than thought. E ven when a dis parity on dos ing actual practice and clinical trial is es tablis hed, the insert is rarely, if ever, changed. T his would involve the conduct of costly and time-cons uming s tudies and submiss ion of an application for change. At times , it 3365 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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be clinically beneficial to exceed the upper dose limit drug, s o-called high-dose therapy. However, it is bes t to exceed the recommended upper dos e threshold without a clear understanding of the potential benefits and risks involved. T his caution is particularly important when a drug is ass ociated with a s evere concentrationdependent side effect. P lasma concentrations of many ps ychotropics can vary to tenfold. T hus, to s ome extent, the optimal dos e for individual is ultimately determined by trial and error, guided by the empirical evidence of the usual dose for that drug. S ome drugs demons trate a clear between increases in dose and clinical res pons e. T his res ponse curve plots the drug concentration against effects of the drug. T he potency of a drug refers to the relative dos e to achieve certain effects, not to its efficacy. for example, is more potent than chlorpromazine, approximately 5 mg of haloperidol is required to the same therapeutic effect as 100 mg of However, thes e drugs are equal in their clinical is , the maximum clinical response achievable by adminis tration of a drug. Drugs must be used in effective dos ages for sufficient periods. Although drug tolerability and safety are cons ideration, s ubtherapeutic doses and incomplete therapeutic trials should be avoided. T he use of inadequate doses merely exposes the patient to the side effects , without providing the probability of therapeutic benefit. In view of the wide margin of safety as sociated with mos t currently pres cribed medications, there is more risk in underdosing than in overshooting 3366 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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recommended dos e range. T ime of dosing is usually based on the plas ma half-life drug and its s ide effect profile. S edating drugs are at night or P.2689 with dis proportionate daily doses at night. T he oppos ite true with activating drugs. T he frequency of dosing is clear cut. Most dos ing regimens of ps ychotropic drugs , such as once-a-day vers us divided dos es , are bas ed meas urements of plasma concentrations rather than receptor occupancy in the brain. E vidence sugges ts there is a significant diss ociation between brain and plasma kinetics. R eliance on plasma kinetics as the for dos ing regimens leads to misunderstanding of neces sary s chedules. As a rule, psychotropic drugs s hould be us ed E xceptions are the us e of drugs for insomnia, acute agitation, and severe s ituational anxiety. A common mistake is the use of high-potency benzodiazepines, as alprazolam and clonazepam (K lonopin), only after attack has begun. T hese drugs s hould be used as part regular s chedule. S ome patients who experience sexual dysfunction being treated with S S R Is take a drug holiday, that is, skipping a daily dose from time to time to facilitate performance. Intermittent dosing regimens of S S R Is have been be effective as a treatment for premens trual dysphoric disorder. T he drugs are taken daily during the 2-week luteal phase of the mens trual cycle. 3367 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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Duration of Treatment A common question that a patient typically asks is How long do I need to take the medication? T he answer, of cours e, depends on multiple variables, including the nature of the disorder, the duration of s ymptoms, the family history, and the extent to which the patient tolerates and benefits from the medication. P atients be given a reasonable explanation of the probabilities should be told that it is firs t best to s ee if the works for him or her and whether the side effects are acceptable. Any more definitive discus sion of duration treatment can be held once the degree of s ucces s is E ven patients with a philos ophical aversion to the use ps ychotropic drugs may elect to stay on medication indefinitely if the magnitude of improvement is great. Most psychiatric dis orders have high rates of chronicity and relaps e. B ecause of this , long-term treatment is needed to prevent recurrence. Nevertheles s, the fact remains that psychiatric treatments are not said to cure disorders they treat, but rather to help control the symptoms. T reatment is conceptually broken down into three the initial therapeutic trial, the continuation, and the maintenance phase. T he initial period of treatment last at least several weeks becaus e of the delay in therapeutic effects that characterizes mos t clas ses of ps ychotropic drugs . T he required duration of a trial of a drug should be dis cus sed at the outs et of treatment, so that the patient does not have unrealis tic expectations of an immediate improvement in P atients are more likely to experience side effects early the cours e of pharmacotherapy than any relief from 3368 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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disorder. In some cases , medication may even some symptoms. P atients should be counseled that a initial reaction to medication is not an indicator of the ultimate outcome of treatment. F or instance, many patients with panic disorder develop jitterines s or an increase in panic attacks after starting on tricyclic or treatment. B enzodiazepine agonis ts are an exception the rule that there is a delay in clinical onset. In most their hypnotic and antianxiety effects are evident immediately. Ongoing use of medication does not, however, provide absolute protection agains t relaps e. C ontinuation provides clinically and s tatistically significant protective effects against relapse. T he optimal duration of continuation or maintenance therapy is variable and dependent on the clinical history of the patient. E arlyonset chronic major depress ion, for example, has a severe cours e and greater comorbidity than late-onset chronic major depres sion. In addition to early ons et, a history of multiple pas t epis odes , s everity of the current episodes , and length of current epis ode would make longer, even indefinite, treatment appropriate.

Frequenc y of Vis its Until an unequivocal res pons e to treatment occurs, patients s hould be seen as frequently as warrant. T he frequency of follow-up or monitoring visits determined by clinical judgment. In s everely ill patients , this might mean several times a week. F or patients are not suicidal or otherwis e a ris k to thems elves or follow-up visits can be every 2 to 3 weeks . With improvement, the visits can be s paced out. Mos t 3369 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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ps ychiatric disorders are chronic or recurrent and long-term treatment. P atients on maintenance therapy, even when s table, need monitoring, but there is no cons ens us for the frequency of follow-up therapy. T his decided on a case-by-case bas is , depending on the patient's clinical s tatus and the nature of the drug T hree months is a reasonable interval between visits, months may be adequate after long-standing T he rationale for regular follow-up, even when patients doing well, includes monitoring for movement subtle s ide effects that might be mis attributed to other conditions, renal and thyroid function (lithium), and hematological and hepatic status (valproate). T he influence of managed care has s everely reduced the frequency of visits during the initial and maintenance phases of pharmacotherapy.

L A B OR A TOR Y TE S TS A ND THE R A P E UTIC B L OOD Laboratory tes ting and therapeutic blood monitoring should be bas ed on clinical circums tances and the being used. F or most commonly us ed ps ychotropic routine tes ting is not required. T here is no currently available laboratory tes t that confirms the diagnosis of mental disorder. P retreatment tes ts are routine as part of a workup to es tablis h baseline values and to rule out underlying medical problems that may be causing the ps ychiatric symptoms or that might complicate treatment with R es ults of recently performed tes ts s hould be obtained. With agents known to caus e cardiac conduction a pretreatment electrocardiogram (E C G ) should be 3370 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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obtained before initiating treatment. W ith lithium and clozapine, the poss ibility of serious changes in thyroid, renal, hepatic, or hematological functions requires pretreatment and ongoing monitoring with appropriate laboratory tes ts. As a result of both anecdotal and findings of s ometimes severe glucos e dys regulation during treatment with olanzapine, the F DA has that patients being treated with any atypical be monitored for the emergence of diabetes. T here are certain circums tances in which us ing plasma concentrations to monitor patients is necess ary or T hese include the monitoring of drugs with narrow therapeutic indexes , such as lithium; drugs with a the rape utic window, the optimal dos e range for a therapeutic res ponse; drug combinations that may lead interactions that rais e drug concentrations of or their metabolites, which can caus e toxicity; toxicity at normal therapeutic dos es; and failure to res pond in a patient who may be noncompliant. T he clinician with a patient who abus es s ubstances s hould have no reservations about requesting random urine toxicological tes ts.

TR E A TME NT OUTC OME S T he goal of ps ychotropic treatment is to eliminate all manifestations of disorder, thus enabling the patient to regain the ability to function P.2690 as well and to enjoy life as fully as before he or she ill. T his degree of improvement to below the s yndromal threshold is defined as re mis s ion. 3371 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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R es pons e and R emis s ion R emiss ion is the preferred outcome of treatment not because of the immediate impact on functioning and of mind, but also because emerging evidence s uggests that remitted patients are les s likely to experience and recurrence of their dis order. P atients who improve but do not experience a full res olution are cons idered to be res ponders . T hey may exhibit s ignificant improvement, but continue to experience s ymptoms . In depress ion studies, re s pons e us ually defined as a 50 percent or greater decrease baseline on a standard rating scale, s uch as the Depress ion (HAMD) S cale or the Montgomery-Asberg Depress ion R ating S cale (MADR S ). R emis s ion is an abs olute s core of s even or les s on the HAMD or ten less on the MADR S . E xpectations about the likely improvement should be bas ed on what is known about the res ponsivenes s of specific disorders to medication therapy. OC D and s chizophrenia, for example, are likely to be as sociated with residual manifes tations of illness than major depress ion or panic disorder. T he probability of full remis sion from OC D with S S R I alone over a 2-year period is les s than 12 percent, and probability of partial remiss ion is approximately 47 percent. E vidence sugges ts that early identification and may arrest the progress ion of psychiatric disorders perhaps , the emergence of a disorder. T here has been speculation that treatment of anxiety disorders may prevent progres sion to major depress ion dis order. studies, for example, s how that antidepress ants may 3372 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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structural alterations in dendrites and axons and in the number of neuronal cells. Other s tudies sugges t lithium in bipolar disorder and dopamine receptor antagonis ts in s chizophrenia produce normalizing structural changes in brain morphology. E arly placebocontrolled trials of dopamine receptor antagonis ts in schizophrenic patients found that those receiving active treatment had a les s severe s ubs equent course of T his has led to the concept that there is a poss ible inoculation effect. T o tes t this hypothesis , s tudies are way in which children at high risk for the development schizophrenia are s tarted on medication even before symptoms emerge. An alternative conclusion, als o unproven, sugges ts that drugs may wors en the course of illness once they are discontinued. T hese are bas ed on the clinical that s ome patients experience an increas e in the and intens ity of symptoms and greater resistance to treatment once their medicine is s topped. T here have been concerns that the discontinuation of medication res ult in treatment res is tance after recurrence of the disorder. T wenty-eight of the patients in a study of us e in bipolar disorder patients were free of lithium and experiencing an episode of mania or s chizoaffective diagnosed according to R esearch Diagnos tic C riteria they entered the s tudy, recovered while taking lithium, later experienced a recurrence while not taking lithium, and then resumed lithium treatment. T hes e findings provide no evidence that lithium discontinuation res ults treatment res is tance when lithium is res umed.

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T he initial treatment plan should anticipate the that the medication may be ineffective. A next-step strategy s hould be in place at the initiation of treatment. R epeated drug failures s hould prompt reass es sment of patient. F irst, was the original diagnosis correct? In answering this ques tion, the clinician s hould include poss ibility of an undiagnosed medical condition or recreational drug use as the cause of the ps ychiatric symptoms. S econd, are the obs erved s ymptoms the original disorder, or are they actually advers e the drug treatment? S ome antips ychotic drugs , for example, can produce akinesia, which res embles withdrawal, or akathis ia and neuroleptic malignant syndrome, which resemble increased ps ychotic Long-term us e of S S R Is can produce emotional which can mimic depress ion. Intolerance of side effects may be the mos t common reason for treatment failure. T hird, was the drug adminis tered at an appropriate dos age for a sufficient length of time? B ecause patients can vary greatly in absorption and metabolis m of drugs , the clinician may need to meas ure plas ma levels of a drug to ensure a sufficient dose of the drug. F ourth, did a or pharmacodynamic interaction with another drug that the patient was taking reduce the efficacy of the newly prescribed drug? F ifth, did the patient take the drug as directed? Drug noncompliance is a common clinical problem that arises as a res ult of complicated drug regimens (more than one drug in more than one daily dosage), adverse effects (es pecially if unnoticed by the clinician), and poor patient education about the drug treatment plan. P atients may dis continue medication 3374 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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when they recover, thinking that they are cured and no longer benefiting from the medication.

Treatment R es is tanc e S ome patients fail to respond to repeated trials of medication. No s ingle factor can explain the ineffectiveness of the various interventions in these S trategies in thes e cases include the use of drug combinations, high-dose therapy, and us e of unconventional drugs . T here is limited evidence on the comparative success rates ass ociated with any given strategy.

Toleranc e T he development of tolerance is marked by a need, time, to use increased doses of a drug to maintain a effect. T his decreas ed res ponsivenes s to a drug occurs after repeated doses. T olerance also des cribes sens itivity to advers e effects of the drug, such as T his phenomenon is used as the bas is for starting drugs at s ubtherapeutic doses, with the plan to adjus t schedule once the patient can tolerate higher doses. C linical tolerance appears to represent changes in the such as altered receptor configuration or dens ity. with similar pharmacological actions often exhibit tolerance.

S ens itization C linically manifes ted as the reverse of tolerance, sens itization is s aid to occur when there is increased sens itivity to a drug effect over time. In these cases , same dos e typically produces more pronounced effects 3375 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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treatment progress es. C onvers ely, if the therapeutic index is low, as it is for lithium, careful monitoring of serum levels is es sential. most psychotropic drugs, the therapeutic index is high.

Withdrawal T he development of phys iological adaptation to a drug, with a s ubs equent risk of withdrawal s ymptoms , has reported for many clas ses of ps ychotropic drugs . T echnically, withdrawal s hould be cons idered a side T he probability and s everity of thes e reactions are with most drugs and more common with others. As a general rule, the more abruptly a drug is s topped and shorter its elimination half-life, the more likely it is that clinically s ignificant withdrawal symptoms will occur. When using s ome short-acting drugs, withdrawal can result from mis sed P.2691 doses and during daily intervals between doses. tapering of medications after prolonged use is recommended when poss ible. Although this reduces ris k of withdrawal reactions , it does not ensure that will not occur. S o-called s edative hypnotics and opiates the agents most often as sociated with mentally and phys ically distress ing discontinuation reactions . In cases, s uch as the barbiturates , withdrawal can be T here are marked differences among agents, even given clas s, with respect to the probability and s everity discontinuation effects . F or example, among the benzodiazepines, alprazolam and triazolam (Halcion) commonly produce more immediate and intens e 3376 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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withdrawal symptoms than other compounds. Among S S R Is, there is a well-described withdrawal syndrome appears to be more frequent and severe with (P axil). It can, however, occur with any S S R I. E ven fluoxetine may be ass ociated with dis continuation symptoms, but the s ymptoms may be delayed and attenuated due to its long elimination half-life of its metabolite. T hes e manifestations are s ubtle and are delayed for weeks after the las t dose. V enlafaxine also produces a s evere S S R I-like withdrawal s yndrome. In addition to half-life, many variables can influence the likelihood and degree of dis continuation symptoms . C hanges in the rate of drug metabolism, as an can play a role. P aroxetine is primarily metabolized by cytochrome P 450 (C Y P ) 2D6 is oenzyme. However, paroxetine is also a potent inhibitor of C Y P 2D6. T his res ults in autoinhibition, a dos e-dependent inhibition of own metabolis m, with a subsequent increase in plas ma concentrations of paroxetine. If the dos e of paroxetine decreased or the drug is s topped, the decline in its concentrations can be s teep, caus ing withdrawal to Withdrawal can occur in rare cases in which the a drug is not decreas ed, but a second agent, which been inhibiting its metabolism, was stopped. F or alprazolam is metabolized via the C Y P 3A3/4 enzyme system. Nefazodone inhibits that enzyme. If a patient taking both agents for several weeks dis continues the nefazodone, it could res ult in a rapid increase in the alprazolam metabolism and a consequent drop in concentrations. T he development of s us tained-releas e versions of such as alprazolam, paroxetine, and venlafaxine has 3377 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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reduced the s everity of their withdrawal reactions . T he prolonged half-life of those agents results from delayed absorption rather than prolongation of the elimination phase. T he frequency of drug dos ing is reduced but not the rate of fall off in plas ma concentrations. P oor bioavailability with a generic agent may account unexpected loss of clinical effect in emergence of withdrawal symptoms. T he occurrence of these events soon after refilling a pres cription s hould prompt examination of the new medication. It should be confirmed whether the dispens ed medication and dos e are both correct. It is difficult to as certain whether medications are truly equivalent, so the pos sibility that differences in potency may underlie adverse in clinical status . Withdrawal s ymptoms invariably occur hours or days dose reduction or discontinuation. S ymptoms res olve within a few weeks , s o the persistence of s ymptoms agains t withdrawal. Although depletion s tudies have shown to provoke rapid return of symptoms , in clinical practice, ps ychotic and mood s ymptoms do not usually reappear abruptly after long-term treatment.

C OMB INA TION OF DR UG S According to the American P sychiatric As sociation G uidelines for the T reatment of P s ychiatric Dis orders , us e of multiple agents s hould be avoided if poss ible in treatment of ps ychiatric dis orders. Although represents the ideal, polypharmacy, the s imultaneous of psychotropic medications , has been commonplace since chlorpromazine was combined with res erpine in early 1950s. T he practice of combining drugs is 3378 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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commonplace, and the merits of various augme ntation combination s trategies are routinely dis cuss ed in the literature and at s cientific meetings. T he mean number simultaneously prescribed medications has increas ed recent decades. Among ps ychiatric inpatients, the number of psychotropics prescribed is approximately three. F ixed combinationsdrugs that contain more than one active ingredienthave been s ucces sfully marketed the pas t, and research on new combinations is fluoxetine-olanzapine fixed combination has been approved as a treatment for bipolar disorder. T he use such drugs may increas e the patients ' compliance by simplifying the drug regimen. A problem with combination drugs, however, is that the clinician has flexibility in adjusting the dosage of one of the components; that is , the us e of combination drugs may caus e two drugs to be adminis tered when only one continues to be necess ary for therapeutic efficacy. S ometimes distinctions are made between and combination therapy. W hen two ps ychotropics with the same approved indications are us ed concurrently, is termed combination the rapy. Adding a drug with another indication is termed augme ntation. often entails us e of a drug that is not primarily a psychotropic. F or example, in treating depres sion, it common to add thyroid hormone to an approved antidepres sant. S ome s trategies are more popular or preferred but are not necess arily more effective than other. F or example, a s earch on the ME DLINE Web (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) of published s tudies involving combinations of antidepres sants over a 15-year period up to J une, 3379 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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coupled with a review of bibliographies of studies with sample s ize of four or more s ubjects, found that only studies met inclus ion criteria. T he total number of was only 667. In 14 studies, patients had at least two unsuccess ful trials of antidepres sant monotherapy or trial plus augmentation, or both; the res t included with only one failed trial. T he authors concluded that combining antidepress ants cannot be recommended first-line treatment for treatment-res is tant depress ion. T hey als o commented that the s carcity of data combination treatment with other medication s trategies, such as switching and augmentation, makes it to address when or which combination treatment be applied in the sequencing of treatments for the management of treatment-res is tant depress ion. T he widespread reliance on multiple drug therapy, in face of official dis couragement and the absence of objective evidence s upporting this practice, is eas y to explain: Many patients do not become well with monotherapy with exis ting drugs. In a typical s cenario, patient has little or no response to a medication, so the phys ician adds a s econd agent to induce a better res ponse. In s ome cases, the use of multiple the rule. Almos t all patients with bipolar dis order are taking more than one psychotropic agent. C ombination treatment with drugs that treat depres sion and receptor antagonis t or serotonin-dopamine antagonist long been held as preferable in patients with psychotic depres sion. S imilarly, S S R Is typically produce partial improvement in patients with OC D, s o that the addition a s erotonin-dopamine antagonis t may be helpful. Medications may be also be combined to counteract 3380 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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effects, to treat s pecific s ymptoms , and as a temporary meas ure to transition from one drug to another. It is common practice to add a new medication without the discontinuation of a prior drug, particularly when the drug has provided partial benefit. T his can be done as of a plan to transition from an agent that is not a s atisfactory respons e or as an attempt to maintain patient on combined therapy. P.2692 Advantages of combining drugs include building on exis ting res ponse, which may be les s demoralizing, the pos sibility that combinations produce new mechanisms that no s ingle agent can provide. One limitation is that there is increased noncompliance and advers e effects and that the clinician may not be to determine whether it was the s econd drug alone or combination of drugs that res ulted in a therapeutic succes s or a particular advers e effect. C ombining can create a broad s pectrum effect and als o changes ratio of metabolites. T he merits of going to a s ingle drug with a different pharmacological profile include lower risk of drugdrug interactions, simplicity, and lower cost. It is les s burdens ome to be taking one medication than two or three and is less likely to meet resistance by the Many patients are ambivalent about taking even one medication, let alone two. T his practice is less newly treated patients than in thos e who have failed repeated trials .

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C OMB INE D P S YC HOTHE R A P Y P HA R MA C OTHE R A P Y It is a matter of faith among many ps ychiatris ts that patients are best treated with a combination of and ps ychotherapy. W hen pharmacotherapy and ps ychotherapy are us ed together, the approach s hould coordinated, integrated, and s ynergis tic. In many has been demonstrated that the results of combined therapy are superior to thos e of either type of therapy alone. When the ps ychotherapy and the are directed by two separate clinicians , the clinicians communicate clearly with each other.

Depres s ive Dis orders P sychoanalysts long objected to the use of medication treat depres sion, becaus e it might mas k the thus impeding ps ychotherapy. T hat has never been demonstrated. Quite the opposite, depres sion often interferes with the intros pection and focus that are for therapy. A large s tudy has s hown that combination therapy is more effective than medication or counseling alone. T he antidepress ant nefazodone combined with form of ps ychotherapy specifically designed for chronic depres sion offers the bes t treatment for people experiencing chronic depres sion. T he psychotherapy in the s tudy, cognitive behavioral analys is system of ps ychotherapy (C B AS P ), teaches patients to focus on their thinking and behavior affect their interpersonal interactions and to apply a specific problem-solving technique to improve their functioning in interpersonal situations. After 12 weeks, s ignificantly more patients received the nefazodone and C B AS P improved, 3382 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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to patients receiving either single treatment. Among patients who completed 12 weeks of combination 85 percent demons trated a res pons e, compared to approximately 50 percent of drug-only and therapy-only patients. T he combination of medication with ps ychotherapy was also as sociated with an earlier res ponse than ps ychotherapy alone.

Obs es s ive-C ompuls ive Dis order C ombined behavioral and cognitive therapy is the mos t effective regimen for the treatment of OC D.

S uic idal B ehavior T he poss ibility of suicide mus t be considered in treating patients with schizophrenia, bipolar I dis order, disorders , severe personality disorders , and anxiety disorders (es pecially thos e who have panic attacks ). If clinician decides that the patient is at imminent risk for suicidal behavior, hos pitalization is always indicated. If patient can be managed outside a hospital, the medication s upply should be given to a res ponsible member who can monitor the dos age and frequency of the prescribed medication. As a further precaution, the clinician may pres cribe the patient a drug that is known have little or no lethal potential when taken in however, even thes e drugs can become lethal when a patient takes multiple different medications in an overdose. Many drugs are effective in managing the s igns and symptoms as sociated with the wide range of anxiety disorders . As symptoms are controlled by medication, patients are reass ured and develop confidence that 3383 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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will not be incapacitated by the disorder. T his effect is particularly relevant to panic disorder, which is often as sociated with s ignificant anticipatory anxiety about attack. Depress ion may als o complicate the symptom picture in patients with anxiety dis orders and has to be addres sed pharmacologically and

S c hizophrenia and Other Ps yc hotic Dis orders Drug therapy is almos t always us ed in the treatment of these disorders . In attempting individual ps ychotherapy with these patients , the therapist mus t work es pecially hard to establish an effective treatment relations hip therapeutic alliance with the patient. B ecaus e this population often lacks ins ight into the fact that they disorder, rates of nonadherence to treatment are high. R ates of noncompliance with drugs us ed to treat have been found in s tudies to be between 20 and 89 percent. P atients who are engaged in ongoing therapy more likely to continue taking medication, although it also be argued that those who do engage in therapy also thos e who are more predis pos ed to compliance medication.

S ubs tanc e Abus e P atients who abuse alcohol or other substances special challenges to therapis ts who wis h to combine ps ychotherapy with pharmacotherapy. S ome clinicians rarely use medications in this patient group, although treatment of underlying anxiety or depres sion might with the abuse in particular patients.

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S P E C IA L P OP UL A TIONS Although every patient brings a unique combination of demographic and clinical variables to the clinical certain patient populations require special When treating the young, the elderly, thos e with disorders , and women who want to conceive, are pregnant, or are nurs ing, awarenes s of risks with medication ass umes increas ed importance. Data derived from clinical trials are of limited value in guiding many decis ions, because populations in these studies cons isted of healthy young adults and, until recently, excluded many women of child-bearing age. S tudies of children and adolescents have become more common, that unders tanding of treatment effects in this has grown.

C hildren Understanding of the safety and efficacy of mos t ps ychotropic drugs when us ed to treat children is more on clinical experience than on evidence from clinical trial data. Other than ADHD and OC D, us ed ps ychotropic drugs have no labeling for pediatric us e, s o results from adult s tudies are extrapolated to children. T his is not neces sarily appropriate because of developmental differences in pharmacokinetics and pharmacodynamics . Dos ing is another special cons ideration in drug us e with children. Although the small volume of distribution sugges ts the use of lower doses than those us ed in adults, a child's higher rate of metabolism sugges ts that a higher ratio of milligrams of drug to kilograms of body weight s hould be used. In practice, it is best to begin with a s mall dose and to 3385 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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increase it until clinical effects are observed. However, clinician P.2693 should not hesitate to us e adult dos ages in children if these dos ages are effective, and the advers e effects acceptable. T he paucity of res earch data is a legacy of many years which manufacturers avoided conducting trials in because of liability concerns , s mall market s hare, and, hence, limited profit potential repres ented by this population. T o correct this problem, the F DA Modernization Act (F DAMA) of 1997 provided for encouragement and incentives to s tudy drugs for us e. S ome drugs us ed to treat ps ychiatric disorders carry a higher ris k of serious s ide effects . Lamotrigine, for example, is as sociated with a s ubs tantially higher incidence of serious rash among children than among adults .

Pregnant and Nurs ing Women T here are large gaps in knowledge of the effects of ps ychotropic agents on the developing fetus and on the neonate. T his precludes any definitive as surances that drug is completely without risk. No psychotropic medication is absolutely contraindicated during pregnancy, although drugs with known risks of birth defects, premature birth, or neonatal complications be avoided if acceptable alternatives are available. P sychotropic drugs are not intentionally s tudied in 3386 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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who are pregnant or lactating. It is only recently that women of child-bearing age were able to participate in clinical trials . Most of what is known is the result of anecdotal reports or regis tries that have been for many drugs . T he basic rule is to avoid administering any drug to a woman who is pregnant (particularly the firs t trimester) or who is breast-feeding a child, the mother's ps ychiatric dis order is severe, and it is determined that the therapeutic value of the drug outweighs the theoretical adverse effects on the fetus newborn. A woman may elect to continue on because she does not want to chance a pos sible recurrence of painful s ymptoms . P hysicians considering the us e of ps ychotropic drugs during pregnancy s hould weigh known ris ks or the lack available information against the ris ks of nontreatment. ps ychotropic medications are administered during pregnancy, clos e fetal monitoring by obs tetricians who specialize in high-ris k pregnancies should follow the pregnancy. T he agents with the mos t well-documented risk of birth defects are lithium and two of the drugs used to seizure, carbamazepine and valproate. Lithium adminis tration during pregnancy is as sociated with E bs tein's anomaly, a s erious abnormality in cardiac development. R ecent evidence s uggests that the ris k is as great as previous ly believed. C arbamazepine and valproic acid are as sociated with neural tube defects , which can be prevented by us e of folate during S ome experts advise that all women of child-bearing who are treated with ps ychotropics take supplemental folate. 3387 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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Other psychoactive drugs (antidepres sants, and anxiolytics) are less clearly ass ociated with birth defects but s hould als o be avoided during pregnancy, if all poss ible. T he mos t common clinical situation occurs when a pregnant woman becomes psychotic. If a is made not to terminate the pregnancy, treatment with antips ychotic drugs or E C T is preferable to lithium. T he administration of ps ychotherapeutic drugs at or delivery may cause the baby to be overly sedated at delivery, thus requiring a res pirator, or to be physically dependent on the drug, requiring detoxification and the treatment of a withdrawal s yndrome. T here have been reports of a neonatal withdrawal s yndrome ass ociated with third trimes ter use of S S R Is in pregnant women. V irtually all psychiatric drugs are secreted in the milk of nursing mother; therefore, mothers on those agents should be advis ed not to breas t-feed their infants.

E lderly Patients T he two major concerns when treating geriatric with ps ychotherapeutic drugs are that elderly persons be more s usceptible to adverse effects (particularly effects) and may metabolize and excrete drugs more slowly, thus requiring lower dos ages of medication. In practice, clinicians s hould begin treating geriatric with a s mall dose, us ually approximately one-half of the us ual starting dose. T he dos age should be rais ed in increments, more slowly than for middle-aged adults, a clinical benefit is achieved or unacceptable adverse effects appear. Although many geriatric patients small dosage of medication, many others require a full 3388 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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therapeutic dosage. E lderly patients account for approximately one-third of prescription drug use and a s ubs tantial percentage of over-the-counter preparations, as well. E ven more significant is the incidence of polypharmacy. R ecent surveys have found that elderly patients in the are taking between three and five medications and that hospitalized elderly patients are treated with an ten drugs. Nearly one-half of all patients in long-term facilities are prescribed one or more ps ychotropic In view of these statis tics, clinicians need to cons ider potential types and likelihood of drug interactions when selecting medications . P sychotropic drugs have, in the pas t, been shown to caus ally related to falls in the elderly. Discontinuation ps ychotropic drugs results in an estimated 40 percent reduction for falls . T his ass ociation between and falls and hip fractures may weaken as newer become widely us ed. As a rule, new-generation compounds produce les s unwanted s edation, parkinsonis m, and pos tural hypotension. R es pons e to treatment is les s predictable among older adults than younger adults. Age-related changes in clearance and hepatic metabolism make it more to be cons ervative with the s tarting doses of as well as the rate of dose titration. T he frequent of medical disorders and the us e of medications to them make it neces sary to recognize how psychotropic drugs interact with the nonpsychiatric disorders and medications . W ithin any clas s of agents , those with drug interactions or s ide effects with potentially s erious cons equences, such as hypotens ion, cardiac 3389 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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abnormalities , anticholinergic activity, and res piratory depres sion, are not suitable choices. Drugs that cause cognitive impairment, such as benzodiazepines and anticholinergics, may mimic or exacerbate symptoms dementia. S imilarly, dopamine receptor antagonists wors en or induce P arkinson's disease, another agedisorder. S ome side effects, such as S S R I-as sociated syndrome of inappropriate secretion of antidiuretic hormone (S IADH) and oxcarbazepine-as sociated hyponatremia, occur more commonly in older patients. A common ethical dilemma with the medically ill elderly those with dementia is the ques tion of their capacity to give informed cons ent before treatment with drugs or E C T .

Medic ally Ill Patients T here are s pecial considerations, diagnos tic and therapeutic, when adminis tering psychiatric drugs to medically ill patients. T he medical disorder s hould be out as a caus e of the ps ychiatric symptoms. F or patients with neurological or endocrine disorders or human immunodeficiency virus (HIV )infected patients experience disturbances of mood and cognition. medications , s uch as corticosteroids and L-dopa, are as sociated with induction of mania. A patient with diabetes mellitus is better treated with an agent without the risk of weight gain or glucose dysregulation. Depending on the diagnosis, drugs that might treat the primary ps ychiatric dis order and also weight loss , drugs such as bupropion, topiramate P.2694 3390 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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(T opamax), and zonis amide (Zonegran), s hould be prescribed for thes e patients . P atients with obs tructive pulmonary disease should not be given s edating drugs, which rais e the arousal threshold and s uppress P atients with medical dis orders are also taking other medications , which can res ult in pharmacodynamic and pharmacokinetic interactions . C ombined treatment with an inducer of multiple C Y P enzymes and a drug that is subs trate for thos e enzymes could res ult in levels, leading to inadequate s ymptom control. Us e of tuberculos is treatment rifampicin (R ifadin) with carbamazepine is an example of this . Use of drugs that inhibit C Y P 2D6, agents such as paroxetine and can prevent the convers ion of hydrocodone (R obidone) and other opiates into an active analgesic form. NS AIDs are also a rare caus e of perceptual and ps ychotic symptoms . Other is sues include a potentially increas ed s ens itivity to adverse effects , including increased or decreas ed metabolism and excretion of the drug, and interactions with other medications . Drug interactions are an obvious concern when drugs with a narrow therapeutic range are being us ed. Any change in the rate of metabolis m or with the formation and elimination of metabolites can profoundly influence the activity of that drug. S imilarly, interactions that interfere with drug metabolis m can produce an increase in side effects and toxicity. As with children and geriatric patients , the most reasonable clinical practice is to begin with a s mall to increas e it slowly, and to watch for clinical benefit advers e effects. Determining the plas ma drug concentrations may be helpful for s uch patients, but 3391 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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therapeutic blood concentrations for most ps ychotropic drugs are neither necess ary nor routinely available. caution is needed with potential drugdis eas e P atients with diabetes mellitus s hould not be treated drugs such as valproic acid, mirtazapine, or which risk increasing body weight, or with drugs such olanzapine or valproic acid, which cause ins ulin P atients with seizure disorder should not receive bupropion, maprotiline (Ludiomil), or clomipramine (Anafranil), which lower the seizure threshold.

S ubs tanc e Abus e Many patients who seek or need treatment for a ps ychiatric disorder engage in chronic use of illicit subs tances or drink exces sive amounts of alcohol. Marijuana is the most commonly us ed illicit drug in the United S tates . Dis continuation of chronic drug or alcohol use can not only in craving, but als o in clinically significant ps ychiatric and physiological withdrawal s ymptoms. many patients, s ucces sful treatment of their underlying ps ychiatric disorder may not be poss ible in the ongoing marijuana, cocaine, and alcohol use. If s everal trials of medications fail, hos pitalization for may be necess ary. T here is little res earch and no about how to use ps ychotropic agents in patients who regular users of cocaine, marijuana, or other drugs. If these agents are used as a method of coping, called avoidance coping, it appears to not be effective.

WHY P S Y C HOTR OP IC DR UG S C ONTR OVE R S IA L 3392 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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Interes t in ps ychotropic drugs among the general cons istently high. T elevision reports and magazine frequently focus on the ris ks and, less frequently, the benefits of these agents . T hus, this attention is often accompanied by heated debate about the value, appropriatenes s, and even neces sity of these agents . T here are many explanations for the mis trus t that surrounds the use of ps ychotropic drugs. S ome apprehens ion stems from the legacy of abuse and dependence ass ociated with earlier agents. Many treatments were potentially toxic when taken in Although there are s ide effects that accompany the use newer drugs as well, thes e tend to be more benign and less lethal. However, widely publicized laws uits against manufacturers of s ome of the newer drugs alleging a list of actionable negative effects have played on fears about these agents. T his has been most evident those occas ions in which criminal attorneys have used ps ychotropics as an excuse for the violent actions of clients. Antipathy toward psychotropic drugs also reflects a held negative view of people with emotional problems having character flaws . T hus, drug treatments are as coddling the morally weak with chemical crutches . Drugs are als o portrayed as not dealing with the underlying caus es of the disorder, which is presumed res ult from environmental factors . It may be necess ary wait for the elucidation of specific genes that are res ponsible for the expres sion of ps ychiatric disorders before conventional wisdom accepts the fact that disorders are true medical disorders that can benefit drug therapy in the same way that diabetes , asthma, 3393 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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hypothyroidism, and other chronic disorders are res ponsive to medication. Other interventions may to improve the s everity of the disorder, as in the cas e exercise and dietary control of diabetes , but, ultimately, is the medication that is the determining intervention in terms of optimal control of the disorder. T he fact that psychotropic drugs modulate mood, cognition, and behaviordomains s een as fundamental an individual's identity and personalityprovokes anxiety. T he poss ibility of changing who a person is or the subjective experience of reality does not arise with types of medical treatment. Unlike psychotropics , antibiotics and AC E inhibitors do not produce changes in perception, relatedness , cognition, or C oncerns about thes e effects should be respected and addres sed as part of counseling and education when ps ychotropic drugs are pres cribed. It s hould be emphasized that ps ychotherapeutic drugs are us ed to treat patients with mental dis orders , in individuals in whom key functions are disordered, which, by must be disabling or dis tres sing. T hey are not used to modulate normal variations in mood reactions to routine stress ors . Orchestrated opposition has also come from groups organizations that offer help for people who are having situational problems or who are looking for meaning in life. In s ome ins tances , thes e are groups that attempt attract members by publicizing unsubstantiated of serious ris ks as sociated with psychotropic drugs. T here are also concerns that thes e drugs are coercive. general public is not aware of the mental hygiene laws that are in place to protect the rights of patients and 3394 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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monitor the us e of medication. A small number of are forced to take medications if they are an immediate danger to themselves or others . T his usually takes the inpatient setting, although there is a growing trend outpatient commitment, whereby the court can order patients who have demonstrated repeated with medication to be monitored by mental health workers. E ven the term compliance implies a degree of external press ure or influence to act on s omeone else's to pleas e family members. F ew patients feel that taking antibiotic or AC E inhibitor is coercive, becaus e they unders tand and believe that there is a legitimate health need to treating an infection or hypertens ion. T he is sue with patients with many types of psychiatric dis orders is that they lack awareness or insight about their T hey do not appreciate P.2695 the ris ks as sociated with their, at times, destructive or threatening behavior. T o a delusional or paranoid certain defens ive actions seem perfectly rational. W hen told to take medication, these patients thus perceive phys icians are doing things to them not for them.

C ONC L US IONS Many considerations go into the us e of medications to treat ps ychiatric disorders . T reatment occurs in the of a cons tantly changing s ocioeconomic and s cientific environment. Managed care has unques tionably affected the way in which patients receive treatment. In recent years , for 3395 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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example, there has been a s hift to the us e of health organizations , s o-called carve-out programs that are aimed at containing costs of psychiatric treatment. 2000, nearly 70 percent of people with health had their psychiatric care covered through carve-out programs. T his has led to distortions in clinical care. the demonstrated advers e cons equences of this shift been a los s of continuity of care for many patients. also may not have acces s to a clinician in their who is expert in the us e of ps ychotropic drugs. T he scientific bas is of drug research has als o changed. S tudies of brain metabolis m have identified changes in neuronal activity patterns in the brains of patients with several psychiatric disorders . T his research is being extended to the identification of brain regions that show variations in res ponse to medication. In the near future, may be poss ible to identify patients who are more likely show preferential res ponse to different agents. In view the rapidly growing body of knowledge about ps ychotropic drugs , it is imperative that clinicians current with the clinical literature. It is als o important prescribers be thoughtful about the drug choices that make. C urrent ps ychotropic drug research is focused on the development of mechanistic approaches that are more effective and better tolerated than exis ting treatments . C ons iderable interest is currently focus ed on the complex relationships between psychiatric dis orders the inflammatory res ponse, activity in the immune and the hypothalamic-pituitary axis. R adically new therapeutic compounds may target elements of these systems . T he advent of genomic medicine may lead to 3396 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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identification of genes ass ociated with drug res ponse susceptibility to specific side effects. T his knowledge be us ed in drug development and to improve drug selection for individual patients. It may even be predict which individuals will develop a mental disorder and to develop primary prevention agents that act on gene express ion and thus block the emergence of symptoms. B ureaucratic obstacles remain to obtaining F DA for common s ymptoms or behaviors that do not fit into exis ting diagnostic categories. E xamples include common problems, s uch as behavioral dys control, aggres sion in demenita, impulsivity, and bipolar s elfmutilation. Although clinical experience has shown that drugs may be us eful in helping patients with these symptoms, any drug us ed is used off-label.

G UIDE TO US E An alphabetical list of generic drug names is pres ented T able 31.1-5, with cross -references to the s ections in they or their clas s is dis cus sed. T able 34.1-6 lists combination drugs used in psychiatry.

Table 31.1-5 C ros s -R eferenc es by G Drug Generic Name

B rand Name

S ec tion Title

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Acebutolol

S ectral

β-Adrenergic R ece Antagonists

Acetophenazine

T indal

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

Alprazolam

Xanax

B enzodiazepine Agonis ts and

Amantadine

S ymmetrel

Anticholinergics an Amantadine

Amobarbital

Amytal

B arbiturates and Acting S ubs tances

Amoxapine

Asendin

T ricyclics and

Aprobarbital

Alurate

B arbiturates and Acting S ubs tances

Aripiprazole

Abilify

S erotonin-Dopami Antagonists (Atypic S econd-G eneratio Antips ychotics )

Atenolol

T enormin

β-Adrenergic R ece Antagonists

Atomoxetine

S trattera

S ympathomimetics

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Dopamine R ecepto Agonis ts B enztropine

C ogentin

Anticholinergics an Amantadine

B iperiden

Akineton

Anticholinergics an Amantadine

B rofaromine

C ons onar

Monoamine Oxida Inhibitors

B romocriptine

P arlodel

Other P harmacolo and B iological

B uprenorphine

B uprenex

Opioid R eceptor Agonis ts: Methado Levomethadyl, and B uprenorphine

B upropion

Wellbutrin

B upropion

B us pirone

B uS par

B us pirone

B utabarbital

B utisol

B arbiturates and Acting S ubs tances

B utaperazine

R epois e

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

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C arbamazepine

T egretol, C arbatrol

C arbamazepine

C aris prodol

S oma

B arbiturates and Acting S ubs tances

C arphenazine

P roketazine

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

C hloral hydrate

Noctec

B arbiturates and Acting S ubs tances

C hlorpromazine

T horazine

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

C hlorprothixene

T aractan

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

C italopram

C elexa

S elective S erotoni R euptake Inhibitor

C lomipramine

Anafranil

T ricyclics and

C lonazepam

K lonopin

B enzodiazepine Agonis ts and

C lonidine

C atapres

α2 -Adrenergic R ec

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Agonis ts: C lonidine G uanfacine C lorgyline

Monoamine Oxida Inhibitors

C lozapine

C lozaril

S erotonin-Dopami Antagonists (Atypic S econd-G eneratio Antips ychotics )

C ycrimine

P agitane

Anticholinergics an Amantadine

C yproheptadine

P eriactin

Antihis tamines

Dantrolene

Dantrium

Other P harmacolo and B iological

Des ipramine

Norpramin, P ertofrane

T ricyclics and

Dexfenfluramine

Other P harmacolo and B iological

Dextroamphetamine

Dexedrine

S ympathomimetics Dopamine R ecepto Agonis ts

Diazepam

V alium

B enzodiazepine

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Agonis ts and Diltiazem

C ardizem

C alcium C hannel Inhibitors

Diphenhydramine

B enadryl

Antihis tamines

Dis ulfiram

Antabus e

Other P harmacolo and B iological

Donepezil

Aricept

C holinesterase and S imilarly Actin C ompounds

Doxepin

Adapin, S inequan

T ricyclics and

Droperidol

Inaps ine

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

Duloxetine

C ymbalta

S elective S erotoninNorepine R euptake Inhibitor

E scitalopram

Lexapro

S elective S erotoni R euptake Inhibitor

E stazolam

P roS om

B enzodiazepine Agonis ts and

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E thchlorvynol

P lacidyl

B arbiturates and Acting S ubs tances

E thinamate

V almid

B arbiturates and Acting S ubs tances

E thopropazine

P ars idol

Anticholinergics an Amantadine

F enfluramine

P ondimin

Other P harmacolo and B iological

F lumazenil

R omazicon

B enzodiazepine Agonis ts and

F luoxetine

P rozac

S elective S erotoni R euptake Inhibitor

F luphenazine

P rolixin, P ermitil

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

F lurazepam

Dalmane

B enzodiazepine Agonis ts and

F luvoxamine

Luvox

S elective S erotoni R euptake Inhibitor

G abapentin

Neurontin

G abapentin

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G lutethimide

Doriden

B arbiturates and Acting S ubs tances

Halazepam

P axipam

B enzodiazepine Agonis ts and

Haloperidol

Haldol

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

Hydroxyzine

Atarax, V is taril

Antihis tamines

Imipramine

T ofranil

T ricyclics and

Is ocarboxazid

Marplan

Monoamine Oxida Inhibitors

Labetalol

Normodyne, T randate

β-Adrenergic R ece Antagonists

Lamotrigine

Lamictal

Lamotrigine

Levetiracetam

K eppra

Lamotrigine

Levodopa

Larodopa

Levodopa

Levomethadyl acetate

OR LAAM

Opioid R eceptor Agonis ts: Methado Levomethadyl, and

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B uprenorphine Levothyroxine

Levoxine, Levothroid, S ynthroid

T hyroid Hormones

Liothyronine

C ytomel

T hyroid Hormones

Lithium

E skalith, Lithobid

Lithium

Lorazepam

Ativan

B enzodiazepine Agonis ts and

Loxapine

Loxitane

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

Memantine

Namenda

C holinesterase and S imilarly Actin C ompounds

Mephobarbital

Mebaral

B arbiturates and Acting S ubs tances

Meprobamate

Miltown

B arbiturates and Acting S ubs tances

Mesoridazine

S erentil

Dopamine R ecepto Antagonists (T ypic

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Antips ychotics ) Methadone

Dolophine, Methados e

Opioid R eceptor Agonis ts: Methado Levomethadyl, and B uprenorphine

Metharbital

G emonil

B arbiturates and Acting S ubs tances

Methohexital

B revital

B arbiturates and Acting S ubs tances

Methylphenidate

R italin

S ympathomimetics Dopamine R ecepto Agonis ts

Methyprylon

Noludar

B arbiturates and Acting S ubs tances

Metoprolol

Lopres sor, T oprol

β-Adrenergic R ece Antagonists

Midazolam

V ers ed

B enzodiazepine Agonis ts and

Mirtazapine

R emeron

Mirtazapine

Moclobemide

Manerix

Monoamine Oxida Inhibitors

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Modafinil

P rovigil

S ympathomimetics Dopamine R ecepto Agonis ts

Molindone

Moban

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

Nadolol

C orgard

β-Adrenergic R ece Antagonists

Naltrexone

R eV ia

Opioid R eceptor Antagonists: Naltre and Nalmefene

Nefazodone

S erzone

Nefazodone

Nifedipine

Adalat, P rocardia

C alcium C hannel Inhibitors

Nimodipine

Nimotop

C alcium C hannel Inhibitors

Nortriptyline

P amelor, Aventyl

T ricyclics and

Olanzapine

Zyprexa

S erotonin-Dopami Antagonists (Atypic S econd-G eneratio Antips ychotics )

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Orphenadrine

Norflex, Dis pal

Anticholinergics an Amantadine

Oxazepam

S erax

B enzodiazepine Agonis ts and

Oxcarbazepine

T rileptal

Other Anticonvulsa T iagabine, Zonis am Oxcarbazepine, an Levetiracetam

P araldehyde

G enerics

B arbiturates and Acting S ubs tances

P aroxetine

P axil

S elective S erotoni R euptake Inhibitor

P emoline

C ylert

S ympathomimetics Dopamine R ecepto Agonis ts

P entobarbital

Nembutal

B arbiturates and Acting S ubs tances

P erphenazine

T rilafon

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

P henelzine

Nardil

Monoamine Oxida Inhibitors

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P henobarbital

S olfoton

B arbiturates and Acting S ubs tances

P imozide

Orap

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

P indolol

V is ken

β-Adrenergic R ece Antagonists

P iperacetazine

Quide

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

P razepam

C entrax

B enzodiazepine Agonis ts and

P regabalin

Other P harmacolo and B iological

P rochlorperazine

C ompazine

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

P rocyclidine

K emadrin

Anticholinergics an Amantadine

P romazine

S parine

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

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P romethazine

P henergan

Antihis tamines

P ropranolol

Inderal

β-Adrenergic R ece Antagonists

P rotriptyline

V ivactil

B enzodiazepine Agonis ts and

Quazepam

Doral

B enzodiazepine Agonis ts and

Quetiapine

S eroquel

S erotonin-Dopami Antagonists (Atypic S econd-G eneratio Antips ychotics )

R eboxetine

E dronax, Norebox

Other P harmacolo and B iological

R es erpine

Diupres

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

R is peridone

R is perdal

S erotonin-Dopami Antagonists (Atypic S econd-G eneratio Antips ychotics )

S ecobarbital

S econal

B arbiturates and Acting S ubs tances

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S elegiline

E ldepryl

Monoamine Oxida Inhibitors

S ertindole

S erlect, S erdolect

S erotonin-Dopami Antagonists (Atypic S econd-G eneratio Antips ychotics )

S ertraline

Zoloft

S elective S erotoni R euptake Inhibitor

S ulpiride

Dogmatil, S es if

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

T acrine

C ognex

C holinesterase and S imilarly Actin C ompounds

T emazepam

R es toril

B enzodiazepine Agonis ts and

T hiopental

P entothal

B arbiturates and Acting S ubs tances

T hioridazine

Mellaril

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

T hiothixene

Navane

Dopamine R ecepto

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Antagonists (T ypic Antips ychotics ) T iagabine

G abitril

Other Anticonvulsa T iagabine, Zonis am Oxcarbazepine, an Levetiracetam

T opiramate

T opamax

T opiramate

T ranylcypromine

P arnate

Monoamine Oxida Inhibitors

T razodone

Des yrel

T razodone

T riazolam

Halcion

B enzodiazepine Agonis ts and

T rifluoperazine

S telazine

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

T riflupromazine

V es prin

Dopamine R ecepto Antagonists (T ypic Antips ychotics )

T rihexyphenidyl

Artane

Anticholinergics an Amantadine

T rimipramine

S urmontil

T ricyclics and

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L-T ryptophan

Other P harmacolo and B iological

V alproic acid

Depakene, Depakote

V alproate

V enlafaxine

E ffexor

S elective S erotoninNorepine R euptake Inhibitor

V erapamil

C alan, Is optin

C alcium C hannel Inhibitors

V igabatrin

S abril

Other Anticonvulsa T iagabine, Zonis am Oxcarbazepine, an Levetiracetam

Y ohimbine

Y ocon

Other P harmacolo and B iological

Zaleplon

S onata

B enzodiazepine Agonis ts and

Zipras idone

G eodon

S erotonin-Dopami Antagonists (Atypic S econd-G eneratio Antips ychotics )

Zolpidem

Ambien

B enzodiazepine

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Agonis ts and Zonis amide

Zonegran

Other Anticonvulsa T iagabine, Zonis am Oxcarbazepine, an Levetiracetam

Table 31.1-6 C ombinatio

Ingredients

Preparation

P erphenazine and amitriptyline

Manufac turer

A E

Mylan

Ta 4: 2:

 

 

 

 

Dextroamphetamine

Adderal

S hire

Ta

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and amphetamine

 

10 15 30 Adderal XR

S hire

C 15 m

C hlordiazepoxide and clidinium bromide

Watson

C

C hlordiazepoxide and amitriptyline

Mylan

Ta 10

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Olanzapine and fluoxetine

S ymbyax

Lilly

6: 12

DE A, Drug E nforcement Administration. P.2696 P.2697 P.2698 P.2699

S UG G E S TE D C R OS S T he proces s by which new drugs are approved in the United S tates is explained in S ection 31.3; pharmacokinetics and drug interactions are des cribed S ection 31.2; and the combination of psychotherapy pharmacotherapy is explained in S ection 30.12. Medication-induced movement dis orders are discus sed S ection 31.4.

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R E F E R E NC E S B alk E M, B onis P A, Moskowitz H, S chmid C H, J P , Wang C , Lau J : C orrelation of quality meas ures es timates of treatment effect in meta-analyses of randomized controlled trials . J AMA. *B an T A: P harmacotherapy of depress ion: A analysis. J Ne ural T rans m. 2001;108:707716. B elanoff J K , R oths child AJ , C ass ody F , DeB attis ta B aulieu E -E , S chold C , S chatzberg AF : An open of C -1073 (mifepris tone) for psychotic major depres sion. B iol P s ychiatry. 2002;52:386392. B ogetto F , B ellino S , R evello R B , P atria L: Dis continuation s yndrome in dysthymic patients treated with s elective serotonin reuptake inhibitors. C NS Drugs . 2002;16:273283. B ull S A, Hunkeler E M, Lee J Y , R owland C R , T E , S chwab J R , Hurt S W: Discontinuing or selective s erotonin-reuptake inhibitors. Ann P harmacothe r. 2002;36:578584. C arls son A. Neuropharmacology. In: B an T A, Healy S horter E , eds . T he R is e of P s ychopharmacology S tory of C INP . B udapest: Animula; 1998:124128. C oryell W , S olomon D, Leon AC , Akiskal HS , K eller S cheftner W A, Mueller T : Lithium dis continuation subs equent effectiveness . Am J P s ychiatry. 3417 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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1998;155:895898. E is en J L, G oodman W K , K eller MB , W arshaw MG , DeMarco LM, Luce DD, R as muss en S A: P atterns of remis sion and relapse in obsess ive-compuls ive A 2-year prospective study. C lin P s ychiatry. 1999;60:346351; quiz, 352. *G oodwin F K , G haemi S N: T he impact of the of lithium on ps ychiatric thought and practice in the US A and E urope. A us t N Z J P s ychiatry. 1999;33 [S uppl]:S 54S 64. G rippo AJ , F rancis J , Weiss R M, F elder R B , C ytokine mediation of experimental heart failureinduced anhedonia. Am J P hys iol R e gul Inte gr P hys iol. 2003;284:R 666R 673. Heis ler LK , C owley MA, T ecott LH, F an W , Low MJ , J L, R ubins tein M, T atro J B , Marcus J N, Hols tege H, C E , C one R D, E lmquist J K : Activation of central melanocortin pathways by fenfluramine. S cience. 2002;297:609611. K eller MB , McC ullough J P , K lein DN, Arnow B , DL, G elenberg AJ , Markowitz J C , Nemeroff C B , J M, T has e ME , T rivedi MH, Zajecka J : A nefazodone, the cognitive behavioral-analysis ps ychotherapy, and their combination for the treatment of chronic depress ion. N E ngl J Me d. 2000;342:14621470.

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K han A, K han S R , Leventhal R M, K ris hnan R R , J M: An application of the revised C ONS OR T F DA s ummary reports of recently approved antidepres sants and antips ychotics . B iol P s ychiatry. 2002;52:6267. *K ing C , V oruganti LN: W hat's in a name? T he of nomenclature of antips ychotic drugs . J P s ychiatry Neuros ci. 2002;27:168175. K os ky N: A poss ible ass ociation between high and high dose olanzapine and prolongation of the interval. J P s ychopharmacol. 2002;16:181182. K ramer P D. L is te ning to P rozac. New Y ork: 1993. *Lam R W, W an DDC , C ohen NL, K ennedy S H: antidepres sants for treatment-res is tant depress ion: review. J C lin P s ychiatry. 2002;63:685693. Nickola T J , Ignatowski T A, R eynolds J L, S pengler Antidepress ant drug-induced alternations in neuronlocalized tumor necros is factor-α mR NA and α2 adrenergic receptor sensitivity. J P harmacol E xp 2001;297:680687. *Quitkin F M, R abkin J G , G erald J , Davis J M, K lein V alidity of clinical trials of antidepress ants. Am J P s ychiatry. 2000;157:327337. R ay W A, Daugherty J R , Meador K G : E ffect of a 3419 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/31.1.htm

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health carve-out program on the continuity of antips ychotic therapy. N E ngl J Me d. R eynolds G P : As sociation of antips ychotic drugweight gain with a 5-HT 2C receptor gene polymorphis m. L ance t. 2002;359:20862087. R os enbloom M: C hlorpromazine and the ps ychopharmacologic revolution. J AMA. 2002;287:18601861. S en G , B ss e K C : R auwolfia s erpentina: A new for ins anity and high blood pres sure. Indian Me d 1931;11:194201. T auscher J , J ones C , R emmington G , Zipursky R B , S : S ignificant dis sociation of brain and plasma with antips ychotics . Mol P s ychiatry. 2002;7:317321. V itello B , J ens en P : Medication development and tes ting in children and adoles cents: C urrent future directions. Arch G e n P s ychiatry. Wang P S , W alker AM, T s uang MT , Orav E J , G lynn Levin R , Avorn J : Dopamine antagonists and the development of breas t cancer. Arch G e n P s ychiatry. 2002;59:11471154.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 32 - C hild P s ychiatry > 32.1: Introduction a nd Overview

32.1: Introduc tion and Overview C aroly S . Pataki M.D. P art of "32 - C hild P s ychiatry"

HIS TOR Y T he field of child and adolescent psychiatry has demonstrated cons iderable expansion s ince the 1990s , reflecting an increas ing scientific knowledge bas e and more wides pread us e of empirical methods to new challenges . F or example, ongoing brain imaging studies of children and adolescents have already that s tructural data will likely help provide the s cientific basis of many cognitive behaviors, emotional reactions, and brain development in children and adolescents . A growing number of scientifically designed of the safety and efficacy of ps ychopharmacological agents for a wide range of child ps ychiatric dis orders now guide clinicians in choos ing reliable modalities as components of treatment for children and adoles cents . T he field of child and adolescent has expanded into a truly multimodal academic C hild psychiatry began its evolution with the child guidance s ervice delivery s ys tem, which consisted of a multidis ciplinary team of ps ychiatris ts , social workers , ps ychologists that performed evaluations and provided 3421 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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recommendations to families. T his s ys tem originated the historic C ommonwealth C hild G uidance C linics of 1920s , whos e mis sion, des pite the absence of formally trained in child ps ychiatry, was to provide to emotionally dis turbed children and their families . services most often included clinical interviews , some of psychological testing adminis tered by a and treatment characterized by a ps ychodynamically based play therapy. In this system, psychodynamic was the basis of treatment, and empirical s tudies of childhood ps ychiatric disorders were not yet pres ent. In 1946, the American As sociation of P sychiatric C hildren was established, using the C ommonwealth G uidance C linics as a base for training. In 1953, an organization of medical practitioners was formed, the American Academy of C hild P sychiatry. In 1959, the academy was legitimized as a medical s ubs pecialty with the establishment of board certification under the American B oard of P s ychiatry and Neurology.

E MP IR IC A L A P P R OA C H TO A DOL E S C E NT Phenomenology and C las s ific ation T he empirical approach to the study of child and adoles cent ps ychopathology is based on the and clas sification of clinical phenomenology of child adoles cent psychiatric disorders . T he clinical phenomenology of a psychiatric dis order comprises the es sential core features , as sociated and relevant s ubtypes of the disorder. Once the features of a psychiatric disorder are identified, its 3422 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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history can be followed over time. T he W orld Health Organization (W HO) published the 6th edition of the International S tatis tical C las sification of Diseas es (IC Dwhich was the first edition of this document to contain a section for mental illness . T he first formal draft of a variant of this document, the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M), was developed thereafter, in 1952, by the American P sychiatric Ass ociation C ommittee on Nomenclature and Dennis C antwell, along with many colleagues, was instrumental in the field of child and adolescent because he promoted revisions to the DS M system that would facilitate empirical inves tigation of and adolescent psychopathology. T hese efforts were realized in the development of the DS M-III, publis hed 1980. T he DS M-III included a number of important methodological innovations, such as a requirement for explicit diagnostic criteria for each dis order, us e of the multiaxial system, and a diagnostic focus on phenomenology. B oth categorical and dimens ional approaches are describing psychiatric s yndromes in childhood and adoles cence. T he DS M uses categorical criteria to the clus ters of s ymptoms that pres ent together in cases. T his bas is of identifying the clinical of ps ychiatric s yndromes and class ifying them into disorders facilitates meaningful investigation of many areas of child and adolescent psychiatry. G iven the overlap of behavioral and mood symptoms in variety of different childhood and adolescent dis orders, defining the boundary between one disorder and can be challenging. Additionally, within the more 3423 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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ps ychiatrically impaired child and adoles cent comorbidity is the rule rather than the exception. T he most current vers ion of the DS M, DS M-IV -T R , is a categorical clas sification that reflects the consensus of current formulations of ps ychiatric disorders , with no as sumption that each category of disorder is a discrete entity with clear-cut boundaries . C hildren and adoles cents who meet criteria for the same psychiatric diagnoses may pres ent with heterogeneous clinical pictures. DS M-IV -T R defines a ps ychiatric dis orde r as clinically significant set of s ymptoms that is ass ociated with current dis tres s or impairment in one or more functioning.

DE VE L OP ME NTA L P E R S P E C TIVE Ons et O ns e t of a psychiatric disorder is a challenging concept child and adoles cent psychiatry, as it is difficult to reliable landmarks for many of the dis orders. Defining onset of a disorder by a P.3016 single s ymptom might lead to inclusion of a heterogeneous group of dis orders, whereas inclusion only a rigid s et of s ymptoms may exclude important subtypes . Age at ons et of a disorder is an important scientific variable because it can give important clues . T hus, age of onset can differentiate genetically determined disorders from those occurring sporadically and can s eparate cas es of the s ame disorder that from different genes . E arlier age of onset of some 3424 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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(e.g., depres sive disorders ) has been ass ociated with increased probability of depres sive disorders in

Delayed Ons et T he inves tigation of age at onset of a disorder leads studies of models of delayed onset of illnes ses . B oth developmental and genetic mechanisms of delayed of dis eas e process es within the human body are to psychiatric dis eas es. T he following examples of onset of disease shed light on potential future studies the ps ychiatric dis orders. Degeneration is a model of delayed ons et of dis eas e that characterizes dis eas es as Alzheimer's dis ease and P arkinson's dis eas ethat is , gradual loss of target neurons over time results in a predictable behavioral and neurological deficit. Developmental failure (i.e., a lack of phys iological development within the nervous s ys tem at the appropriate time) is another model of dis eas e process . Although most of the pervasive developmental of childhood do not appear to have a delayed ons et, a deficit of brain function and aberrant brain function to characterize thes e disorders.

Vulnerability Another theory of delayed onset of a disorder, the twomodel, was firs t propos ed in relation to the genetics of retinoblas toma. E s sentially, the emergence of a related to a genetic vulnerability triggered by exposure a s econd event that might be environmental. F or the rate of bipolar disorders increases markedly during adoles cence, is maximal in young adulthood, and then gradually diminishes. One model to explain the 3425 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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emergence of a dis order with this distribution is a predis pos ition (first hit) for the disorder and a second expos ure, such as an adverse life event (second hit), res ults in the emergence of the dis order. G e ne tic anticipation is defined as the emergence of severe forms of a genetic disorder in s ucces sive generations. T his mechanis m has been shown to contribute to the s everity of pathology in a number of genetic disorders that are caused by mutations of deoxyribonucleic acid (DNA) triplet repeat nucleotide sequences. Increas es in repeat patterns of three nucleotides , (e.g., G AC G AC G AC ) increas e the length DNA sequences and res ult in pathological genes. repeat expans ion has been s hown to be the a number of genetic disorders , including Huntington's disease and fragile X s yndrome. Anticipation has been suggested as a pos sible explanation for increasingly ps ychopathology in s ucces sive generations in disorders . F uture investigation of poss ible molecular of anticipation in ps ychiatric disorders , such as the increased density of genetic triplet repeat expansions shown in Huntington's dis eas e and fragile X mental retardation, is on the horizon.

NE UR OB IOL OG Y T he development of the brain is currently being inves tigated, with increasing s ophis tication at the level, as well as through a variety of neuroimaging technologies .

C ell B iology S tudies C ell biologis ts have identified a critical period for the 3426 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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acquisition of various cognitive and motor s kills . E nvironmental factors , including exposure to alcohol, drugs, or infections, appear to alter brain development during critical periods of nervous s ys tem growth and development, impacting future skills potentials. F or example, differentiation of neurons and their migration their proper places are critical for making necess ary synaptic connections . R ecent research on the of language has s hown that early neuronal activity can influence the organization of the brain.

Neuroimaging S tudies C hild and adolescent brains can be considered works progres s, with a s eries of predictable patterns of development that extend into the teenage years . res onance imaging (MR I) s tudies at the National of Mental Health, under the direction of Dr. J udith R apoport and colleagues , found that, in children whos e brains were s canned every 2 years , an additional wave high production of gray matter occurred just before puberty. B efore thes e s tudies, it was believed that the majority of gray matter was produced in the first 18 months of life. In adoles cents , gray matter increases significantly in the frontal lobes , known to be the site of variety of brain functions related to planning, impuls e control, and reasoning. T hese data provide poss ible between adoles cent development of brain structure function. F unctional MR I scans have determined the s patial relations hip of language centers in children who have and s econd languages. C hildren who learn firs t and languages early in life have evidence of changes in 3427 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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language centers in the s ame cortical region, whereas, when a s econd language is acquired in adult life, the language center is not repres ented in the same cortical region as the firs t language. S tudies such as this are for ultimate understanding of both cognitive and behavioral function and dysfunction. Another s eries of MR I studies provides s ome evidence adoles cents proces s emotional s timuli differently than adults . Us ing functional MR I, presenting pictures of depicting various emotions, Dr. Y urgelun-T odd and colleagues have s hown that, in young teens , who have difficulties with the tas k, the amygdala (a brain for fear reactions) is activated during the tas k of the emotions pres ented, whereas, in older teens, who perform better on the tas k, the frontal lobes are more active in the proces s of identifying emotions in the T here were als o additional findings indicating that language tasks correlated with activation of temporal lobes in young teens and of frontal lobes in older teens . T hese changes in brain activation are also correlated structural changes known to occur in the temporal lobe white matter. Advances in neuroscience, genetic res earch, and neuroimaging techniques have opened up doors within child and adoles cent psychiatry to the unders tanding of developmental changes as children grow and develop, well as in single-gene disorders , s uch as fragile X and more complex neuropsychiatric phenotypes. Dis ruptions of brain development may account for of the more common dis orders s een by child and adoles cent psychiatrists , s uch as dyslexia. Overall, the broader the understanding of neurobiology and 3428 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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neuros cience of the brain, the greater the chance of comprehending the complex behavior of children and adoles cents .

R IS K A ND P R OTE C TIVE R is k factors include all variables that increase the probability that a given child or adoles cent will develop ps ychopathology. P rotective factors decrease the ris k developing psychopathology. Demographics, factors , biological factors , genetics , family environment, and external environment interact to produce ris k and protection from ps ychiatric disorders . R arely can a ris k factor account for the entire variance between the emergence and inhibition of a ps ychiatric disorder. the study of ps ychiatric ris k is complicated and multifactorial. R isk factors often s tudied for influence on the emergence of psychiatric disorders among children and adolescents include family his tory of psychiatric disorders , social clas s, P.3017 intellectual function, adverse life events, factors , and the quality of family and peer relationships. Developmental delays, child maltreatment, and high of family conflict increase the ris k of ps ychiatric P rotective factors that have been identified and s tudied include individual temperamental predis pos ition, family relations hip, and other attributes of the external environment.

TYP E S OF INTE R VE NTIONS Interventions that can be inves tigated for efficacy 3429 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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clinical interventions , targeted interventions , and interventions . Intervention s tudies are an important outcome component of an empirical model of s tudy within child and adolescent ps ychiatry. C linical inte rve ntions are those in which a family with a child or adolescent who has been identified as having a ps ychiatric problem s eeks treatment. P sychosocial, ps ychopharmacological, and other environmental interventions can be compared with a placebo and with each other. S uch efficacy studies are subs tantiate the benefit of the treatments. B ecaus e to one-half of families who begin ps ychiatric treatment terminate prematurely, the nature and delivery of the treatments als o merit inves tigation. T argete d interve ntions are those des igned for children have been identified as having an increas ed risk of a ps ychiatric disorder but whos e families are not seeking treatment. C hildren can be identified either by an factor, such as a family characteristic (e.g., drugparent, family receiving state ass is tance), or through a behavior (e.g., defiance or aggress ion in the T hus, a child can be monitored or receive some ps ychos ocial intervention on the bas is of the risk some cases , correlated with an already existing disorder and, in other cas es, preempting the a psychiatric disorder. T he difficulty with these interventions is that, s ometimes , the families may not the intervention or the thres hold for identification is not correlated with a clinically relevant behavior. Univers al inte rve ntions are received by all children and families within a particular geographical distribution. may occur throughout a targeted s chool or community 3430 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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on a citywide, statewide, or national basis . T his strategy, als o termed primary pre ve ntion, obvious ly more children than any other method of intervention, questions arise about the benefit and need of the intervention for the population at large, as well as the costbenefit ratio. Much study of the risk factors and etiology of ps ychopathology is needed to develop the most combination of prevention s trategies for children and adoles cents . Interventions in child and adoles cent ps ychiatric disorders will continue to be influenced by genetics , family environment, adverse life events , biological factors, and behavioral genetic s tudies . T he goals within child and adolescent psychiatry are to diminis h ris k factors and enhance protective factors to prevent the emergence of psychiatric disorders in this population.

S UG G E S TE D C R OS S In-depth reviews of the following areas of child and adoles cent ps ychiatry can be found in C hapters 32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48 C hapter 32 details normal child and adolescent development; C hapter 33 discus ses the ps ychiatric examination of the infant, child, and adolescent. 34 covers mental retardation; C hapters 35,36, and 37 learning disorders , motor skills disorders , and communication dis orders. C hapter 38 reviews the pervas ive developmental dis orders; C hapter 39, the attention-deficit disorders ; and C hapter 40, the behavior disorders . C hapter 41 covers feeding and disorders of infancy and early childhood. C hapter 42 3431 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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covers tic disorders ; C hapter 43, elimination disorders ; C hapter 44 details stereotypic movement disorders and other disorders of infancy, childhood, and adolescence reactive attachment disorder of infancy or early C hapter 45 discus ses mood dis orders; C hapter 46 anxiety disorders of childhood, including separation anxiety dis order, obsess ive-compuls ive disorder, and selective mutism. C hapter 47 discus ses s chizophrenia childhood onset. C hapter 48 details psychiatric including individual psychotherapy, s hort-term ps ychotherapy, cognitive and behavioral therapies, ps ychotherapy, pharmacotherapy, residential and inpatient treatment, community-based treatments , hospital and ambulatory services , and ps ychiatric treatment of adoles cents . C hapter 49 includes s pecial areas of interest within child and adoles cent ps ychiatry, including ps ychiatric as pects of day care; adoption; care; physical abus e, sexual abus e, and neglect of children's reaction to illnes s, hos pitalization, and ps ychiatric sequelae of human immunodeficiency virus (HIV ) and acquired immune deficiency syndrome childhood or antisocial behavior; borderline intellectual function and academic problems; dis sociative posttraumatic stress disorder; gender identity and is sues; identity problem and borderline disorders ; adoles cent s ubs tance abuse; forensic child ps ychiatry; ethical iss ues in child psychiatry; s chool consultation; ps ychiatric prevention in children.

R E F E R E NC E S B arr C L: G enetics of childhood dis orders: XXII. P art 6: the dopamine D4 receptor gene. J Am Acad 3432 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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Adoles c P s ychiatry. 2001;40:118. *E rns t M, R ums ey J M, eds. F unctional C hild P s ychiatry. C ambridge, E ngland and New C ambridge Univers ity P res s; 2000. G iedd J N, B lumenthal J , J effried NO, C astellanos H, Zijdenbos A, P aus T , E vans AC , R apoport J L: development during childhood and adolescence: A longitudinal MR I s tudy. Nat N euros ci. 1999;2:861. G liner J A, Morgan G A, Harmon R J : B as ic designs: Analys is and interpretation. J Am Acad Adoles c P ychiatry. 2002;41:1256. *Harmon R J , Morgan G A: C linicians ' guide to methods and statistics : S eries preface. J Am Acad Adoles c P s ychiatry. 1999;38:99. Hockfield S , Lombroso P : Development of the cortex, IX. C ortical development and experience, I. J Acad C hild Adole s c P s ychiatry. 1998;37:992. Hus ain A, C antwell DP : F undamentals of C hild and Adoles ce nt P s ychopathology. American P sychiatric Was hington, DC ; 1991. *McMahon F I, DeP aulo J R . G enetics and age of S hulman K I, T ohen M, K utcher S P , eds . Mood Acros s the L ife S pan. W iley, New Y ork; 1996. Morgan G A, G liner J A, J armon R J : G eneral des ign 3433 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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clas sifications. J Am Acad C hild Adole s c P s ychiatry. 2002;41:226. *Mrazek DA: Leadership in child ps ychiatry: A perspective from a department chair. C hild Adole s c P s ychiatr C lin N Am. 2002;1:103. Offord DR , K raemer HC , K azdin A, J ensen P S , R : Lowering the burden of s uffering from child ps ychiatric disorder: trade-offs among clinical, and universal interventions . J Am Acad C hild P s ychiatry. 1998;37:686. R ey J M, W alter G : C hild and adoles cent psychiatry res earch comes of age. A us t N Z J P s ychiatry. 2001;35:261. S chultz R T , G relotti DJ , P ober B : G enetics of disorders : XXV I. W illiams s yndrome and brainJ Am Acad C hild Adole s c P s ychiatry. 2001;40:606. S owell E R , T hompson P M, Holmes C J , J ernigan T L, AW: In vivo evidence for pos t-adoles cent brain maturation in frontal and s triatal regions. Nat 1999;2:859. *T homps on P M, G iedd J N, W oods R P , MacDonald E vans AC , T oga AW : G rowth patterns in the brain detected by us ing continuum mechanical maps . Nature . 2000;404:191. V accarino F , Lombroso P : Development of the 3434 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/32.1.htm

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cortex, V II. G rowth factors, II. J Am Acad C hild P s ychiatry. 1998;37:789.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent P s ychiatric E xamination of the Infant, C hild, and Adolescent

33 Ps yc hiatric E xamination of the Infant, C hild, and Adoles c ent R obert A. K ing M.D. Mary E . S c hwab-S tone M.D. B radley S . Peters on M.D. Armin Paul Thies Ph.D. P sychiatric ass es sment of the child or adolescent is undertaken for a variety of purposes , including office or clinic evaluation to determine the need for treatment; emergency department ass es sment of is sues and need for hos pitalization; consultation with pediatric, school, or legal services ; as a component of family or other mode of treatment; and for res earch purpos es. Although the structure and s tyle of the as sess ment vary to s ome extent depending on the purpos e and s etting, certain elements are common to C ore features of the clinical diagnos tic as ses sment of child are identification of the reas ons for referral, evaluation of the nature and extent of the child's emotional or behavioral difficulties, and determination factors in the child, family, and environment that cause, exacerbate, or potentially ameliorate thos e difficulties . 3436 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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Although information gathering and differential are the primary aims of s uch as sess ment, the proces s should als o facilitate the development of an alliance with the clinician around understanding the difficulties and purs uing the treatment that emerge from the evaluation. B ecaus e decisions about intervention follow from evaluation, clinical ass ess ment may rightly be regarded a cornerstone of child and adolescent psychiatry. evaluation of the child or adolescent is challenging and complex in that the clinician must draw on multiple sources and a range of techniques for eliciting on various as pects of the child's functioning. T his information must then be integrated from multiple theoretical perspectives, using the clinician's development and ps ychopathology to arrive at a diagnostic formulation that can guide treatment effectively. T he initial portion of this chapter focus es on the comprehensive clinical ass ess ment of the child and adoles cent; subsequent sections discuss more types of ass es sment, such as the ass ess ment of adoles cents , ps ychological tes ting, laboratory and clinical res earch as sess ment instruments .

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S T ANDAR DIZE D AS S E S S ME NT INS T R UME NT S C HILDR E N AND ADOLE S C E NT S P S Y C HOLOG IC AL AND AS S E S S ME NT LAB OR AT OR Y ME AS UR E S DIAG NOS T IC F OR MULAT ION AND R E C OMME NDAT IONS S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent C LINIC AL INT E R V IE W O F T HE C HILD

C L INIC AL INTE R VIE W OF C HIL D P art of "33 - P sychiatric E xamination of the Infant, and Adoles cent" T he ps ychiatric as ses sment of the child requires a comprehensive approach that evaluates the child's developmental progress in various domains and adaptive capacities, as well as the presence of the pathognomonic s ymptoms of s pecific disorders . A developmental approach to the ass ess ment of the child es sential, because children differ from adults in certain res pects .

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F irst, psychiatric dis turbances in children often cons ist lack of developmental progres s in one or more rather than the presence of s pecific s ymptoms that are pathognomonic of adult dis orders . F or example, a school child's failure to develop useful s ocial language interactions or a s chool-aged child's inability to meet developmental expectation of s eparating from parents and s ettling into the school day may prompt the parent school, or both, to reques t an as ses sment. S econd, the child's developmental s tatus may affect clinical presentation of various syndromes . F or children, depress ion often presents with irritability and somatic complaints, whereas excess ive guilt or delus ions are rare. T hird, development brings expectable periods in which distress ing emotions or impairing behavior may occur part of a normal transition, for example, the separation anxiety of a child starting pres chool or the of the adoles cent. In many cas es, clinical conditions repres ent severe symptoms found in milder form in nonreferred children. F ears, tantrums , moodines s, or restless nes s are common in childhood and occur transiently at different stages. As sess ment may be s ought by concerned needing guidance on how to unders tand and manage these developmental manifes tations . T hus, the clinician must judge whether the behavior is likely to res olve time and without s ubs tantial deleterious impact on the child or family or whether, ins tead, the level of distress , compromised functioning, or s ymptom persistence indicates the need for clinical intervention. 3439 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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T o dis tinguis h trans ient or normative difficulties from those that are more clinically worrisome, the evaluator must pos sess a s olid knowledge of normal and child development. T his developmental frame of includes an understanding of what behaviors can be expected normally in children of different ages, the time frame within which various behaviors normally wax and wane, and the natural his tory of psychiatric different s tages in development, including knowledge the ages at which particular s yndromes are more or likely to present. Another difference in the adult and child psychiatric as sess ment is that many children coming to clinical attention have difficulties that cannot be neatly under the rubric of a single diagnostic label. T hus , comorbidity is us ually not the exception but the rule in childhood disorders . E ven in epidemiological s tudies of children and adoles cents, as many as one-half of those who meet diagnostic criteria for one disorder als o meet criteria for at leas t another dis order. T his high rate of comorbidity, found even in nonreferred populations , have several sources. Many traditional nosological draw their definition from clinical experience with although childhood analogs clearly exis t, the descriptive boundaries may not be the s ame. impairing symptoms P.3045 in childhood tend to have a ramifying effect by with the ongoing acquisition of key developmental s kills multiple areas. F inally, regardless of whether the a given form of childhood psychopathology lie in 3440 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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biological factors, family or s ocial environment, or an interaction between thes e realms, thes e pathogenic often produce s ymptomatic difficulties that cut across many diagnostic lines .

Dis tinc tive A s pec ts of C hild A s s es s ment S ave for patients brought involuntarily for evaluation, most adults coming for ps ychiatric as sess ment acknowledge, at leas t implicitly, some degree of selfperceived distress and wish for help, no matter how ambivalent the wish may be. In contrast, for mos t the res ponsibility for initiating and following through a psychiatric evaluation lies with the parents . In many cases, children's behavior is a greater source of others —parents , teachers , and peers —than to the children themselves. Other children, even while acknowledging distress , view the locus of the troubles purely external, and hence see little need for even if they comprehend the proces s. In any event, the lack of any stated wish for help or active role in s eeking evaluation colors the child as sess ment process from start. As a result, explicit attention mus t be paid to as sess ing the child's view of the problem and to the child's engagement in the proces s. A related as pect of the child psychiatric ass es sment involves the need for the clinician to as sess and to accommodate to limitations in the child's ability to to conceptualize, and to report experiences and states . T hese capacities emerge only gradually with maturation and are influenced by normal and factors . T hus , the clinician's communication must be 3441 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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attuned to the child's developmental level and may require play, stories, drawing, and other alternative of interaction in addition to direct dis course.

C ontext and the Need for Multiple Informants E ven more so than for an adult, the child's functioning ps ychological well-being are s trongly related to the context—the family, s chool, and community s ettings — which the child lives and develops. T hus , to evaluate nature and severity of the child's ps ychiatric status , information is needed about the child's relationship to, and functioning in, thes e diverse s ettings . T he fit of the child and social environment can be apprais ed from parents s ay about their relations hips with the child and from the child's direct report, as well as from play and drawings ; however, direct obs ervation of the content tone of parent–child interactions in the office s etting provides much useful additional data. In some cas es, a home vis it may provide invaluable information. It is als o important to gather information on the child's functioning in s chool, a task that often requires with the child's teacher or guidance counselor, in to reviewing school reports and educational Here too, direct class room obs ervation can provide invaluable in vivo information. F or children involved child welfare, juvenile justice, or other ins titutional systems , information from cas eworkers , probation and institutional caretakers is es sential.

S pec ial Types of A s s es s ment T he main emphas is of this chapter is on the 3442 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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children and adolescents , especially those capable of participating verbally in the as sess ment process . developmental cons iderations shape the evaluation proces s, infants and toddlers, on one hand, and adoles cents , on the other, require specific the general approach outlined in this chapter. or language-impaired children, s uch as those with pervas ive developmental dis orders or mental also require s pecialized as sess ment techniques. Although the prototype for clinical as sess ment of the is the office cons ultation or clinic visit, evaluations a variety of s ettings , including s chools , pediatric wards , res idential treatment centers , detention centers, and hospital emergency departments . P rocedures vary with the s etting and reasons for carrying out the as sess ment. T he following general model for the outpatient evaluation can be adapted to fit more clinical s ituations. More specialized types of evaluation discuss ed in a separate s ection later in this chapter.

P reliminary C ontac t In the initial phone call to the clinician or clinic intake office, it is helpful to gather s ome bas ic information the nature of the chief complaint; to s et the time, date, place of the first appointment; and, if relevant, to is sues of fee or ins urance coverage. During the evaluation, the clinician wants to see the parents alone, the child alone, and the parents and together. T he order in which these should be done and corollary is sue of who attends the first meeting s hould discuss ed at the initial contact. T his decision is usually made with reference to the child's age. W hen 3443 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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young child, the parents are often seen first, without child. T his allows the clinician to obtain a history and to discuss how to prepare the child for the evaluation. On other hand, the adoles cent should us ually be included the initial interview, so that the youngster does not identify the clinician as an agent of the parents, which interfere with the adoles cent's willingness to talk with clinician and impair the formation of a treatment If children or adolescents are to attend the initial appointment, the clinician should discuss in the initial how they are to be prepared for the appointment. In the initial phone contact, the is sue of which adults attend s hould also be dis cuss ed. W hen the family is the presence of both parents is optimal. W hen this is the case, the clinician and parent should discus s noncustodial parent, stepparent, or other adult should present.

P arent Interview In the initial parent interview, the clinician seeks to unders tand the parents ' view of the problems that have led to the referral, including the nature of the child's current difficulties, the explicit and implicit reas ons for timing of the referral, and the impact of the child's difficulties on the parents , individually and as a couple, the well-being and functioning of the family as a whole. detailed his tory of the child's development and a review family medical and ps ychiatric disorders are obtained. F inally, the clinician seeks to understand how the functioning in their community and cultural setting. T his includes a careful apprais al of the strengths of the child and the family, in addition to the history of the 3444 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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symptoms and areas of impairment.

C hild's C urrent Diffic ulties and for R eferral In child psychiatry, referrals are us ually initiated by the parent or parents rather than the child. S imilarly, are key in determining whether a recommendation for treatment is followed. Over and above the need to information about the child's symptoms and the parent interview provides an opportunity to develop an alliance with the parents around the goals of and helping the child's difficulties. S uccess of this P.3046 requires unders tanding the parents ' expectations and concerns regarding the evaluation and its outcome. these is sues are address ed depends on the nature of child's problems and the parents' knowledge of and previous experience with ps ychiatric evaluations and treatment. Attention to the parents ' view of the proces s allows the clinician to addres s unrealis tic fears excess ive expectations about what can be a given time and to reduce family stress when parental anxiety is too high. In taking a history of the current problem, the clinician obtains a detailed picture of the parents' current emotional and behavioral concerns about the child. P arents should be asked to describe specific instances the child's problematic behavior, frequency, intensity, duration, circums tances in which the behavior occurs , res ponses , and the child's responses to it. T he extent which the s ymptoms cause functional impairment is 3445 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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as certained by asking about the level of the child's interference with social and academic activities , impact ongoing development, and the effect of the child's behavior on others . T he clinician s hould als o inquire directly about behaviors or symptoms not reported by parents but known to be commonly as sociated with the presenting problem or with dis orders that the problem may s uggest. T hus, one goal of the initial interview is to develop a detailed picture of the problems , their cours e, their effect on functioning and the family, and what has been tried to help alleviate T he clinician is also interes ted in the implicit and reasons why the child has been brought for help at this particular moment. Often, the reason lies in an of troubles ome behavior or in the deleterious impact of deficit emerging into sharper relief (e.g., a learning disability or attention deficit becoming more apparent the child faces the increased demands of a new other cas es, the child's behavior may not have but some change within the family or loss of compens atory s upport may have made it imposs ible for the parents to tolerate or to ignore previous ly bearable behavior. T hes e iatropic factors (factors propelling to seek clinical attention) are often complex. In surveys the general child population, rates of diagnosable ps ychiatric disorder (defined as meeting diagnos tic and impairment criteria) approach 20 percent, yet the of children actively s eeking or receiving clinical far lower. P erceived barriers to s ervices alone do not account for this low rate of seeking help. T hroughout the his tory taking, the clinician s trives to unders tand the meaning and function of the symptoms 3446 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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relation to the factors in the child and environment that influence them. A given symptom (e.g., a period of theft, or hallucinations) may have quite different meanings , functions , and clinical implications in children. T hus , detailed information on precipitating circums tances , behavioral concomitants, and cons equences and alleviating factors is needed, much the case in taking a medical his tory. However, this information must be interpreted within the broader developmental and family contexts in which the symptoms occur; thus , while gathering his tory, the clinician s imultaneously takes in information about contextual elements . His tory taking and diagnostic formulation are not dis tinct process es ; during the interview process , clinicians continually formulate and tentative hypotheses that guide further ques tions and diagnostic poss ibilities under cons ideration. T o understand the child's pres enting problems , developmental s tatus, and family and social context, clinician mus t learn about the child's s trengths , talents, and areas of adequate or s uperior adjus tment. S uch information is ess ential for a full diagnostic unders tanding of the child and helps the clinician the child's overall adjus tment and functioning. in planning for treatment, factors that may help counterbalance or remediate the child's vulnerabilities must be identified. F inally, the clinician's appreciation discuss ion of the child's strengths and areas of good functioning provides s upport and reass urance at a time when the child's problems and limitations have been parents ' major focus of attention. T he parent interview should als o cover the practical 3447 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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adminis trative aspects of the diagnos tic as sess ment, including discus sion of fees, scheduling, confidentiality, and permis sion to obtain information from s chool personnel and other clinicians . If the child was not included in the initial interview, the clinician s hould discuss appropriate preparation of the child for a

Developmental His tory T he developmental history is a detailed accounting of child's development across phys ical, cognitive, social, and emotional domains . One task of this part of parent interview is to ascertain the timing and developmental events from pregnancy to the present. P arents vary in their ability to provide precise on the timing of s pecific milestones ; however, an sens e of the course of development can often be by having the parents compare the patient's progress particular domain with that of s iblings. Asking parents about the timing of changes in the family, such as or other memorable life events, may help provide a chronological framework for remembering features of child's development. B es ides gathering des criptive information about the child's development, this part of interview often allows one to tap the emotional as pects the parent–child relationship by querying the parents ' hopes , worries, expectations , and life circums tances in relation to different developmental events . It is useful to conceptualize the child's pas t and current development in the following domains: cognitive and academic development; family relations hips; peer relations hips ; phys ical development and medical emotional development and temperament; 3448 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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of conscience and values ; interests , hobbies, talents , avocations; and unusual circums tances .

C OG NITIVE A ND A C A DE MIC DE VE L OP ME NT T he child's pattern of cognitive s trengths and weakness should be traced from early childhood, including verbal and attentional s kills . Although academic performance important (including areas of particular strength and weaknes s), important information about as pects of emotional and social development als o flows naturally from the discuss ion of how the child progres sed from school year to the next. T hus , in tracking cognitive development and academic s ucces s, as k about the ability to s eparate from parents and to attend school regularly, interpers onal relations hips with peers and teachers, motivation to learn, ability to function independently, tolerance for frustration and delay of gratification, attitudes toward authority, and ability to accept criticis m, among others. A grade-by-grade of the schools attended can be obtained during this the interview, as well as the reasons for any changes . R etentions, the reas ons for them, and the child's at the time and later in development should be noted. When the child's behavior or progres s at s chool is the reasons for the ps ychiatric evaluation, one should obtain permis sion to communicate with the child's teachers, couns elors , or other school personnel and to review the s chool records, including results of standardized tes ts.

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T he parent interview should include ass ess ment of the child relates to each family member and how the fits into the overall family s ys tem. T he child's reactions major family changes should be noted (e.g., deaths ; of siblings; marital separation, divorce, or remarriage; changes in caretaking arrangements , custody, or visitation), as well as parental res ponses to those Ask about compliance with family rules and s tandards , well as consequences when the child does not comply P.3047 us ual mode of discipline or limit s etting) and the child's res ponse to s uch interventions .

P E E R R E L A TIONS HIP S T he clinician s hould gather information about how the child relates to peers, including the number of friends , preferences regarding age and gender of friends , and major changes in peer group; the child's satisfaction these relationships ; their relative stability; activities and interes ts shared with peers; and parents ' feelings about child's clos e peers or lack thereof. T he parents ' on the child's social s kills and deficits should be including their s ens e about any difficulties the child has this domain. F or adolescents , this part of the history includes is sues such as the capacity for intimate relations hips , romantic interes ts, sexual activity, and concerns over s exual orientation.

P HY S IC A L DE VE L OP ME NT A ND HIS TOR Y Ass es sment of phys ical development includes fine and 3450 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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gross motor development, toilet training and its laps es, eating behavior and attitudes , and s leep patterns. P recocious development or delays in physical growth pubertal maturation should be noted. In this context, parents s hould be as ked s ys tematically about illness es, hos pitalizations , operations , epis odes of los s cons ciousnes s, s eizures, head injury, or other serious injuries, as well as the child's reactions to these and impact on s ubs equent health and activities . Inquiry tics, difficulties with hearing or vis ion, lead exposure, other s pecific conditions may be suggested by the presentation. W hen neces sary, medical reports should obtained and reviewed.

E MOTIONA L DE VE L OP ME NT A ND TE MP E R A ME NT Although s ome of thes e topics regarding emotional development and temperament will have been covered taking the history of the pres enting problems , the should fill in gaps with a s ys tematic review. T his as sess ment includes the child's present and past mood and capacity for affect regulation, anxieties , and ability adapt to changes and situations that are new, or frustrating. P revailing mood as perceived by the should be as ses sed; the clinician should as k about s uicidal ideation, ges tures, or attempts, the child has s hown depress ive s ymptoms, including irritability. W orries, fears , and other manifes tations of anxiety should be covered, and the level of any and impairment s hould be explored. T he generalized or specific nature of s ymptoms, situational evokers , precipitants, and impact on the child are relevant. fears, exces sive s hynes s or withdrawal, and obses sive 3451 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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compuls ive s ymptoms are also important. T he child's capacity to regulate aggress ion falls within domain and s hould be reviewed. As k about in which the child becomes angry or aggres sive, the of expres sing anger (i.e., verbal or phys ical, or both), impact on others , and the child's reaction to and proces sing of s uch feelings and behavior. In this the clinician s eeks to evaluate how the child manages aggres sion and whether the child is too aggres sive or fearful of his or her own anger or that of others. aggres sive s ymptoms , (e.g., bullying, fire s etting, vandalis m, or cruelty to animals ) should also be

DE VE L OP ME NT OF C ONS C IE NC E VA L UE S T he clinician s hould ass es s the development of to gauge whether it is too harsh, lax, or overly focus ed particular is sues. T he effectivenes s of cons cience in helping the child conform to family and s ocietal expectations is important. R eligious or ethical concerns and their concordance with those of the family can be addres sed in this phas e of his tory taking. T he family's expectations with regard to the child's values and life choices s hould be as certained from the parents' perspective, and areas of potential discord should be noted.

INTE R E S TS , HOB B IE S , TA L E NTS , A VOC A TIONS Although this line of inquiry is als o pursued with the it is us eful to obtain the parents' perspectives on the interes ts and activities and to ass ess the parents ' 3452 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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involvement, and s upport for them. Indications of child conflict should be probed and may provide us eful information about the relationship. T he presenting difficulties may have affected the child's ability to focus or to engage in previously enjoyable areas of interest activity, s uch as sports or mus ic. T he quantity and type of televis ion programs, movies , videos that a child is permitted to watch provide information on the child's interes ts and the quality of parental limit setting.

UNUS UA L C IR C UMS TA NC E S T he clinician s hould ass es s the child's exposure to or traumatic circums tances , such as sexual or physical abuse, family or community violence, natural disaster, armed conflict. If a his tory of s uch expos ure exis ts, the child's immediate and s ubs equent reactions and the nature of the res ponse from parents or other adults be as ses sed.

Family and C ommunity B ac kground C hildren develop in the contexts of the family and community, and these provide opportunities and challenges that influence and shape the cours e of that development. T he clinician s hould gain a picture of the child's functioning in thes e contexts and their on the child. Although the clinician learns a great deal about thes e areas from taking the his tory of the problem and the developmental his tory, direct questioning may also be needed.

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T he clinician s hould ass es s the parents as individuals as a couple, including strengths, weakness es , and conflict or difficulty. If the child res ides with s omeone other than the parents (e.g., a relative or foster parent), obtain information on the his tory and circums tances of that relations hip, including how the child came to be in that adult's care. Determine what the child's previous experiences were with the parents and the nature of bond with them. T he clinician should s imilarly ass es s current caregivers and their parenting relationship with the child. If the child is adopted, obtain information on the circums tances , the parents ' feelings and expectations about the adoption, the age at adoption, the child's adjus tment at the time and later on, and how the child family members currently view the fact of the adoption. R eview how the adoption has been dis cus sed with the child and any concerns or ques tions about the parents . When taking the developmental his tory, it is often to inquire about the parents' feelings and involvement with the child at different s tages. P arents' pas t attitudes and behavior are likely to reflect on their res ponses in current situation; hence, one wants to know how they about past difficulties and what they have done to help and to support the child. T he parents' individual views the causes of the child's difficulties , and the extent to which they agree or dis agree on this and other aspects the child's care and management affect how they to the clinician's recommendations . Information on the parents ' own backgrounds and histories with their of origin helps the clinician unders tand and work with 3454 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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their responses to their child. Ask about the parents' ethnic and religious T hey may be a s ource of s hared identification and to be imparted to the child or a s ource of conflict the parents or between the adoles cent and the parents. clinician s hould be s ufficiently familiar with the culture language of the family to unders tand the child's and family's s ituation in that context. T he parents ' education and occupation may bear on they unders tand and res pond to the evaluation. How knowledgeable and worried they are may depend on past experiences and familiarity with psychiatric iss ues . F inancial res ources and insurance coverage should be as certained, becaus e P.3048 this may be a s ource of stress or worry and may pos e practical constraints on the treatment options available the family. T he clinician s hould gain an understanding of how the family s ys tem functions , with whom the child lives , and nature of relations hips between hous ehold members the child. E xplore boundaries and alliances within the family and the child's affinities and conflictual with parents , s iblings, and other hous ehold members. Ass es s family communication and problem s olving, including how is sues of separation or disagreement are handled. T he emotional tone of the family (e.g., tens e, anxious, critical, warm, or s upportive) can be by observing interactions and by direct inquiry. the family as a whole or individual members (e.g., 3455 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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migration, illness , accidents, job los s, or legal should also be addres sed.

C OMMUNITY T he clinician s hould understand the community or neighborhood in which the family lives and their and identification with it. Information on the family's involvement with civic, community, and religious (and the extent to which the child participates) s hould as certained. T he clinician also wants to know about of safety and adversity (e.g., poverty, poor housing, high rates of crime or urban violence) in the neighborhood. In s ome communities , mental health res ources are viewed pos itively; in others, their use is stigmatized, which may advers ely affect the child. is sues should be ass es sed and understood, because may affect how and where the child receives any treatment.

Family Medic al and Ps yc hiatric A careful family medical and psychiatric history is to identify any medical or ps ychiatric disorders with potential genetic or environmental implications for the child. Among thos e to be routinely cons idered are ps ychotic dis orders, mood disorders, anxiety disorders , and obsess ive-compuls ive s pectrum dis orders, alcohol subs tance use dis orders, attention-deficit disorders , learning disorders , and antis ocial pers onality disorder, well as metabolic and neurological dis orders. T he of any family members ' symptoms, hospitalizations , or incarcerations s hould be probed, with particular to the child. 3456 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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S pec ial Is s ues in the Parent INF OR MA NT DIF F E R E NC E S Although parents ' concerns usually play a major role in initiating the evaluation, parents may perceive the problems differently and may disagree about their and the need for treatment. P arents ' accounts of the difficulties and of various as pects of the developmental history may not agree completely with each other or those of the child, teachers , or records of pas t events. note these discrepancies is not to denigrate the of parents as informants, but rather to emphas ize the neces sity of multiple informants . Informants provide differing accounts of children's problems for a number of reas ons . T hus, dis crepancies should be noted and regarded as potentially useful regarding what they reflect about the clinical s ituation. Informants may interact with the child in different that vary in the extent to which the child expres ses disturbing feelings and problematic behavior. T his is commonly true for behaviors expres sed most in settings that challenge the child in vulnerable areas (e.g., the s chool's demand that a child with attentiondeficit/hyperactivity dis order [ADHD] s it s till and pay attention). Information about s uch situation-specific symptoms is bes t provided by thos e who spend the time with the child in that s etting. T hes e different perspectives on the child's behavior may als o have led tension between informants who see the child discrepantly. (T his is often true with divorced or parents whos e child may show quite different behavior the context of each parent's home.) T he clinician 3457 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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aware of these different perspectives and the feelings they generate, so that the focus is maintained on evaluating and providing s ervices for the child, with working together rather than at cross -purpos es. Another reas on for discrepant reporting involves differences in how the informants evaluate the child's behavior. Observers may judge the same behavior by differing s tandards or expectations for many reasons. clinician's appreciation of the informant's psychology or cultural background is us eful for unders tanding and working with such differences. F or example, when one parent is overly worried about the child having a disorder, and the other is too ready to chalk up as something the child will “just grow out of,” the must navigate carefully to allow both parents to move reasonable middle ground that best s erves the child's needs . In such instances, understanding each parent's defens ive s tyle helps the clinician avoid appearing to collude with one parent and alienating the other. Dis crepant reporting als o results from differences informants in their willingnes s or ability to report their views to the clinician. F or example, parents may be to report a behavior that they find disturbing or whereas a child may be unable to des cribe the problematic behavior verbally, may not appreciate the level of dis turbance that it creates for others, or may report it because of feelings of s hame or fear of being blamed or punished. G enerally s peaking, methodological studies and clinical experience s uggest that parents are more likely than children to report disruptive or externalizing behaviors, such as res tles sness , impulsivenes s, opposition, or 3458 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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aggres sion. C onversely, children may be more likely to report anxious or depres sive feelings and s ymptoms (including s uicidal thoughts and acts) of which the may be unaware. B ecaus e children may be immature their capacity to report information, s uch as frequency duration of symptoms, parents are us ually more informants about chronological details . T he child, however, may be the only source of information on such as sexual abuse, exposure to violence, or that occurred in peer contexts . G enerally, children more reliable reporters of s pecific s ymptoms with age, with prepubertal children tending to be les s reliable reporters of symptoms than their parents. Mothers and fathers also differ in their experiences with their children, depending on the child's age and shared interes ts, parental availability, and the temperaments and pers onalities of the parents and Although mothers have been reported to be more informants than fathers, in practice it is wises t, for gathering the fullest information poss ible and for an alliance with the parents, to involve both parents the outset. When appropriate, other informants, s uch siblings , grandparents, or child caregivers , may be on to contribute information, but only after the implications for the family s ys tem and the child's relations hips with household members are carefully thought out. P arents and teachers may view the nature and s everity the child's difficulties differently because of the specific nature of s ome presentations . When present at home and at s chool, symptoms, s uch as hyperactivity inattention, may carry a different clinical significance 3459 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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prognos is than those noted in only one (but not both) setting. P arents and teachers may also differ in their appraisals of the child's behaviors . F or example, a and preoccupied mother may be oblivious to her child's behavior, whereas an observant teacher with years of experience with s imilar-aged children may readily the child as dis tres sed or disruptive. F or the clinician conducting the ass ess ment, the iss ue not which informant is right but how to unders tand the differences in P.3049 viewpoint mos t effectively for the patient's benefit. eliciting and s ynthes izing information from multiple informants is a critical as pect of the clinical evaluation children and adolescents .

INTE R VIE W TE C HNIQUE S WITH T he clinician s hould use a variety of interview to elicit information from parents. T he type and quality information obtained is , in part, determined by the methods used and the clinician's skill and comfort in them. A series of empirical studies confirm that factual information and details about onset and timing symptoms are generally most eas ily elicited by specific direct questions , whereas an understanding of feelings and relations hips in the family is us ually gained most effectively by means of more open-ended, indirect questioning strategies. In the initial interview, parents s hould have the opportunity to tell their story in their own way. F or to develop, they mus t feel that they have been able to 3460 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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expres s their concerns in their own words and were and empathically understood. An open-ended also avoids narrowing down too quickly on a s ingle of the child's situation and conveys the clinician's in many different as pects of the child's s ituation. S ubsequent probing can clarify details and can help the clinician's unders tanding of diagnos tic and potential treatment iss ues . P arents are mos t likely to be nondefens ive and comfortable about s haring personal information when they feel that the clinician is trus tworthy, interested, unders tanding, and nonjudgmental. C linicians mus t convey res pect and empathy and avoid seeming aloof excess ively familiar. T hey should discus s the child's family's s ituation in a natural way, using words and concepts that the parents can unders tand. T he range questions and the tone of the inquiry convey the interes t in the whole child (including s trengths , and talents) and an appreciation that the child is not merely the repository of a set of symptoms .

E X P E C TA TIONS A ND A NX IE TIE S P arents may hold strong preconceived ideas about the nature of their child's problem and the kind of help needed. B ecaus e of the extens ive coverage of iss ues relating to ps ychotropic medications in the popular many parents have drawn their own conclus ions about appropriatenes s of medications in general and in to their child's needs . F or example, parents may arrive convinced that their child needs fluoxetine (P rozac) or methylphenidate (R italin) is an addicting and inherently harmful drug. 3461 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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P reconceptions or parental anxiety or conflict may also played out around the iss ue of blame for the child's problems . In s uch s ituations, a parent may maneuver have the clinician arbitrate or to agree that the teacher, school, or other parent is res pons ible for the child's behavior and distress . T he clinician s hould be alert to situations and s hould handle them without making parent feel defens ive or discounted. If ignored, s uch hidden or overt agendas can have a deleterious effect the as ses sment proces s and the likelihood that recommendations will be accepted. P arents may bring other entrenched, preconceived agendas to the clinical evaluation process . A parent insis t that the evaluation confirm that the child has abused (e.g., by an ex-spous e) or does not have a ps ychiatric problem but a medical one. Alternatively, parent may demand that the clinician agree that there nothing wrong with the child. In s uch instances, must explain carefully and clearly that they will conduct thorough as sess ment and provide thoughtful advice, adding that the as sess ment must be done without preordained conclusions . T his may not s atis fy some parents , and some situations may simply not be workable. B ringing a child for ps ychiatric evaluation is a charged emotionally difficult step for nearly all parents, and it is only taken after much worry and dis appointment that home remedies or school-based adjus tments have not sufficed. C hildren are the repos itories of parents' hopes (and often darkest fears ) for thems elves. parent may rationally conclude that s eeking is reasonable and neces sary, admitting that one's child 3462 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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oneself) needs help is always painful. S ubmitting one's child and one's parenting to profes sional s crutiny stirs many anxieties , as well as positive expectations of even in the mos t enlightened parents. P arents often bring uns poken anxieties about the poss ible diagnosis or prognos is to the evaluation. anxieties may be based in the parent's own pers onal or family experience with psychiatric disturbance or may derive from accounts in the popular media. F or the child's uneven development a s ign of autism or retardation? Do the facial grimaces mean that the child developing a dis abling tic disorder? Is the child's moodines s a harbinger of a serious depres sion or Other parental anxieties may be guilty ones . Is failed parental rearing or trans mitted heredity somehow to blame for the child's difficulties ? Is the child fated to the parent's (or other relative's ) own painful s truggle depres sion, anxiety, or psychosis? Does the parent's relations hip to the child s eem to recapitulate some distress ing as pect of the parent's own early family experience? T he clinician mus t be aware of s uch parental anxieties must remain alert for hints of them as the evaluation progres ses ; s ome parents are too anxious or as hamed be forthcoming about them. B y and large, it is best to these concerns aired, even if they cannot be s ettled at initial s tage of the evaluation and perhaps cannot be settled for some time. When s uch anxieties are suggested indirectly, the clinician must express an in them with s ens itivity. R es pect and concern for thes e anxieties can be conveyed without dis miss ing them or providing premature or unfounded reass urance. T he 3463 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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clinician may need to acknowledge the limits of knowledge about caus e or prognos is in individual P arents often s eek ps ychiatric as sess ment after years worry, having been given well-meaning (but inappropriate) reass urances that the child would grow of it. F rank discus sion of these iss ues may provide relief to the parents , albeit perhaps not definitive to their questions .

P R E P A R A TION OF THE C HIL D At s ome point in the initial interview, the clinician and parents s hould discus s the preparation of the child for or her first appointment. C hildren have many reactions a first visit to the psychiatric clinician, and parents must anticipate their child's pos sible reaction and prepare own res ponse. C hildren may feel anxious because they cannot envis ion what will transpire or because the evaluation may feel like a punis hment. S ome children that the as sess ment will reveal some profound or irremediable problem (this may be projected on to the clinician or parent with the reproach “Y ou think I'm Many younger children fear s hots or having to get undres sed for a phys ical examination. In most cas es , child is probably aware of many of the parental or concerns that have led to the evaluation and may feel a sens e of relief (which can nevertheless coexist with anxiety) about the poss ibility of getting s ome help. T he child's anxiety or defens iveness may be reduced if the purpos e of the vis it is put in s upportive (rather than pejorative or accus atory) terms . T he parents might be encouraged to tell the child something like, “We know you've been having a hard time at school (or feeling and s ad or having trouble with friends ), s o we are 3464 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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see Dr. —, who is used to helping kids with that s ort of problem and can maybe figure out what would help.” younger children, explanatory terms , s uch as a fe e lings doctor P.3050 or a talking doctor who helps children with problems worries, may be us eful. T he parents must give and encourage children to tell the clinician about their concerns , even thos e that might s eem to involve family matters not otherwis e s poken about to others.

C hild Interview In the child interview, the clinician directly ass es ses the child's ps ychological functioning, developmental status acros s different domains , and perceptions and of the pres enting problems . Like the parent interview, child interview also provides an important opportunity es tablis h rapport. S uch rapport reduces the level of experienced by the child during the ass es sment enhances the child's engagement and willingness to information, and facilitates the child's cooperation with subs equent recommendations for intervention. T hus , the outset, the clinician should convey empathy and interes t in unders tanding and helping the child. T here has been debate regarding the reliability, and clinical usefulness of various approaches to the interview, but it is generally agreed that the direct child interview is an es sential component of a clinical child as sess ment. It provides observational and diagnostic and his torical information that are not access ible from other s ources . In particular, 3465 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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about feelings and moods, level of distress , and the view of significant events is ess ential for a full unders tanding of the child's problems . F or their own reasons, parents may not unders tand or fully the importance of thes e iss ues , or the child or may not have divulged them. T he child may be important information, s uch as s ecrets about abuse, or antisocial activities, s uicide attempts, pathological patterns of eating, or collusive family dynamics. C ertain symptoms, such as compulsions, premonitory urges, obses sive or s uicidal thoughts, or hallucinations , may apparent only to the child. Other symptoms may mislead the untrained eye; detection of tics or a disorder may require direct clinical observation. T here are many varieties of child interviews , depending the nature of the presenting problem, the clinical and the purpos e of the as sess ment. T hus , the scope, duration, s etting, and predominant techniques used depending on whether the as ses sment is an department evaluation of a s uicidal threat, a pediatric ward consultation of a regres sed or uncooperative forens ic cus tody evaluation, an investigation of alleged child abuse, or the evaluation of a child who is academically underachieving, anxious , or manifes ting T he clinician approaches the child interview with a developmentally based unders tanding of child and adoles cent functioning and ps ychopathology. W ithin framework, the clinician expects to obtain information relevant to the diagnostic ques tions rais ed by the presenting problems and so systematically reviews the major domains of symptomatology. T he order and of conducting the child interview vary with the child's 3466 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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and developmental s tatus, the nature of the presenting problems , the setting and context, and the clinician's T he cons tant elements in the interview process are the orienting framework chos en and the clinician's clinical in engaging and eliciting relevant data from children of varying ages and capacities, with diverse problems and concerns . S ome data may emerge spontaneously; require ques tioning or other deliberate means of information.

C omponents of the C hild Interview T he components of the child interview are often conceptualized under two broad headings : history and the mental status examination. His tory taking inquiry into the s ignificant areas of the child's life and functioning, pas t and present, including the presenting problem. T he me ntal s tatus e xamination cons is ts of an as sess ment and description of the child's appearance functioning as manifes ted in the interview. Although as pects of the child interview can be conceptually distinguished, they us ually proceed concurrently. F or example, the interviewer may as k a specific question, as who lives at home with the child or how the child along with a sibling or a teacher. F rom a his tory-taking point of view, the child's respons e provides some information about thes e facts , as well as how the child feels about them. Although the child's response is thus interes t for the his torical information it reveals, the child also providing the clinician with data relevant to the mental s tatus examination (e.g., how the child conceptualizes the res ponse, how fluent the child is , readily the child engages, how confiding or sus picious child is toward the interviewer). S imilarly, while 3467 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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young child in play with figures or puppets, the clinician can s imultaneously gather information for the mental status examination (e.g., s peech, relatedness , and conceptual s kills ) and inferential data about the child's feelings, fantas ies , and conflicts. S everal dis tinctive characteris tics of clinical work with children bear on the manner of conducting the child interview and mental s tatus examination and on interpreting the data that they yield. T he focus of taking and the mental s tatus examination of the child is developmental, that is, it seeks to des cribe the child's current pres entation in various domains and to the child's functioning in these areas with that expected for the child's age and phas e of development. Another distinctive as pect of the child interview involves the potential lability and propensity to react in more ways when tired, sick, anxious, or s tres sed by an situation. Although one can s ometimes gather s ufficient information for an as sess ment from a single interview, us ually more than one interview is needed to as sess child's optimal or characteristic level of functioning.

Mental S tatus E xamination F or the mental status examination, the child observes and as sess es the following areas: P hys ical appearance —including phys ical presence of minor congenital anomalies, style of and dress , cleanlines s, and other indicators of the quality of self-care or parental attentivenes s (or its lack) to the child's physical appearance and Manne r of re lating to e xamine r and parents — 3468 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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ease of s eparation, how confiding or guarded the seems toward the clinician, eagerness to pleas e or impres s, flirtatious behavior, readiness to make excuses or to minimize, pas sive withholding, or defiance. T he child's behavior toward the examiner compared to that observed or reported toward the parents or other adults . R eactions to the clinician's phys ical appearance, gender, or ethnicity different from that of the child) should be noted. Affe ct—the child's predominant mood and range of emotion during the interview and appropriatenes s mood. C oping me chanis ms —as manifested toward the clinician, express ed in play, or des cribed by the relation to important others; age-appropriatenes s of the child's dependent longings, s exual interests and impulses, and aggress ive feelings, with respect to intens ity, object, and mode of express ion; child's control or modulation of s uch urges (e.g., finding alternative or socially permis sible means of them); strategies used for coping when anxious or frus trated. O rie ntation to time, place, and pe rs on—whether children are accurately aware of the date, where are, and who they are. T his can be evaluated by the child “What is the year? season? date? day? month? ” or “Where are we? ” (name of building, state, country). P.3051 Motor behavior including activity le ve l— 3469 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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presence of unus ual pos tures or motor patterns tics, compuls ions , or stereotypies, such as hand flapping or twirling). Q uality of thinking and pe rce ption—including of hallucinations, delusions , thought disorder, and flight of ideas and adequacy of hearing and vision. S pe e ch and language —including reading and articulation, inflection, pitch, rhythm, and fluency of the child's s peech; richnes s, limitation, or as pects of vocabulary and s yntax; pres ence of echolalia or pers is tent neologisms; mis us e of and gender; delayed or deviant s ocial use of and lack of accompanying nonverbal behavior (e.g., lack of facial express ion or eye with interlocutor). W hen evidence of delays or problems in these realms exis ts, formal s peech and language evaluation by a qualified s pecialis t may warranted. O ve rall inte lligence and fund of knowle dge — for class ification, abs traction, and inference appropriate to age; counting, alphabet, days of the week, months of the year, reading, writing, computational abilities; geographical and historical facts . Atte ntion, concentration, and impuls ivity—level of attention to an activity or topic of dis cus sion, to which child jumps from activity to activity, need phys ical limits, dis tractibility (e.g., by outs ide Me mory—immediate s hort-term and long-term memory (e.g., repeat three items and recall at 5 3470 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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minutes and 30 minutes ). Neurological functioning—fluctuating alertness , tremor, nys tagmus , choreiform movements , gait, neurological soft s igns, and cerebral (preferred hand, foot, eye, or ear); testing for neurological soft signs can be incorporated in a like fashion (e.g., ball throwing, walking on a line, to-toe walking, evidence of hand overflow when walking on outside of feet, and timing 20 repetitions finger tapping, success ive finger tapping, and alternating pronation-supination of the hand are reliable components of the revised Neurological E xamination for S ubtle S igns [NE S S ]). J udgment and ins ight—es pecially concerning the presenting problem; this is most usefully judged the child has had the opportunity to develop s ome rapport with the clinician, as the child's initial may be to deny or to minimize the parents' concerns . P refe rred mode s of communication—Is the child to talking directly about the presenting problems the s ignificant as pects of his or her life, or is the more comfortable with indirect modes of such as play or drawing? R eliable detailed ass es sment of a child's speech and language capacities , intelligence, academic attainment, attentional and executive functioning, and memory requires s tandardized ps ychometric testing. S ome tas ks , s uch as those used in the Mini-Mental S tate E xamination (as adapted for children by R . A. Ouvrier colleagues), can be incorporated in a game-like fashion 3471 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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into the interview of the child to provide a rough s creen higher mental functions, s uch as orientation, attention, memory, language, and cons tructional ability (T able

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Although the clinician s hould usually evaluate all areas the mental s tatus ass ess ment, the emphas is and detail given to the different elements vary with the presenting problem and the type of as sess ment. F or example, in agitated, potentially delirious child on a pediatric ward, particular attention is paid to the child's orientation, alertness , memory, verbal coherence, neurological functioning, and the pos sible pres ence of

C hild Interview Tec hniques A range of techniques is used in the psychiatric of the child or adoles cent. T he choice and timing of techniques depend on the child's developmental, cognitive, and linguis tic level; the emotional difficulty of the is sue being addres sed; and the degree of rapport between child and clinician. B eing able to gauge the potential usefulnes s of a technique at a particular and feeling comfortable with s hifting from one to another as the occasion demands are important for thos e conducting child and adolescent clinical as sess ments.

P L A Y TE C HNIQUE S C hildren younger than 7 years of age have limited capacities to verbally recount their feelings or interpersonal interactions. F or these younger children, well as a number of older ones , play is a us eful adjunct direct ques tioning and dis cuss ion and is often a les s challenging mode for the child. S ome children P.3052

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find it eas ier to communicate in displacement; thus , imaginative play with puppets, small figures , or the interviewer can provide us eful inferential material about the child's concerns , perceptions, and characteris tic of regulating affects and impuls es . T he skilled interviewer can facilitate the child's engagement in play, without prematurely introducing speculations or reactions that might distort or cut short the presentation of certain types of material. During the cours e of play, the clinician follows the sequences of content, noting themes that emerge, points at which a child backs away from the s tory line or s hifts to a new sequence or activity, and situations in which the child stuck or falls into a repetitive loop. T o facilitate the play component of an interview, the interview room should have a supply of human and animal figures or dolls and appropriate props. T hes e s hould be relatively s imple, because elaborate toys can become dis tractions rather than s erve as vehicles for the express ion of the child's fantas ies . S tock characters (such as B arbie or Dis ney characters ) may impose their own specific story lines thus may limit acces s to the child's own concerns. Not only is the content of the child's play a rich s ource information, but careful observation of the form of play also provides important information for the mental examination. During imaginative play, the clinician can observe the child's coordination and motor capacities , speech and language development, attention span, readiness to engage the interviewer, capacity for thought, and affective state. Absence of imaginative or limited, concrete, noninteractive play may indicate a pervas ive developmental disorder. 3475 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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G ames, such as cards or board games , are als o useful putting the child at eas e and developing rapport. T hese provide opportunities to obs erve the degree of the engagement in and enjoyment of the shared activity; the child manages competition, including reactions to winning or losing; or whether the child is prone to cheating. S ome play activities (e.g., throwing a ball and forth or eas y card games, such as war) are simple enough to permit ongoing convers ation, while helping discharge tension and diminis h the press ures of the interview s ituation. As with toys, elaborate games (e.g., ches s) s hould be avoided; games that demand much cognitive energy and concentration us ually preclude discuss ion of iss ues relevant to the as sess ment and become a means of avoiding iss ues involved with the child's difficulties .

P R OJ E C TIVE TE C HNIQUE S In addition to imaginative play, projective techniques often help provide an indirect picture of concerns that child may be reluctant or unable to report directly. techniques can help the child feel more comfortable the clinician, are often experienced as fun, and may provide access to concerns that are important to the diagnostic formulation. One commonly us ed technique is picture drawing. T he child can be as ked to draw a picture, leaving the choice subject up to the child or, alternatively can be given a specific reques t (e.g., draw a person or the child's doing something). When the picture is finis hed or so, it is helpful to compliment the child's effort and to expres s interest in what is happening in the drawing. 3476 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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child's elaboration provides information that may not be readily apparent from the drawing its elf. T he content form of the drawing offer a window on the child's emotional concerns and as pects of intellectual and visuomotor development. F or example, the relative s ize and placement or omiss ion of family members in a drawing may be important nonverbal indicators of the child's perceptions or feelings about the family. or s exual themes may be reflected more readily in drawings than in words. S elf-image may be indicated through depictions of the child as nonhuman, inconsequential, or of the oppos ite gender. T he should become familiar with the developmental progres sion and norms for human figure details, such limbs , joints, facial features , and clothing, which can provide a useful rough es timate of intellectual maturity. V arious systems have been developed for as sess ing the cognitive and emotional aspects of drawings . Als o, the child's behavior and s peech while drawing may yield us eful information (e.g., throwing the picture away unfinished and s aying that it is no good). F requently us ed verbal projective techniques are what animal the child would most or leas t like to be or whom the child would pick to take along to a des erted is land. It is us eful to ask what the child would do with magic wis hes ; if elaboration is needed, the clinician explain that the wis hes could be to have anything, to the world be any way, or to change ones elf in any way. C hildren's res ponses are often revealing. S ome may needily or impuls ively wis h for material poss es sions, as a video game or a million dollars. Other res ponses reveal longings to change dis tress ing circums tances , 3477 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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as “for my mom and dad to get back together again,” to have tics anymore or to get teas ed about them,” or have a dad who does n't yell at me all the time.” S till children appear uncomfortable wis hing for s omething thems elves , preferring instead s eemingly altruis tic res ponses , s uch as “no more poverty or wars.” res ponses can be us ed as the s tarting point for further exploration. F or example, the child who wis hes for “a house and lots of money,” may be asked who els e live there and what they would do. C hildren who wis h “no more fighting in the world” can be as ked if there are some particular fights that they would es pecially like to stop. S ome interactive imaginative techniques us eful to interviewers comfortable with them provide elements of playing a game, which may appeal to the child. T he squiggle drawing game developed by Donald W innicott cons ists of the clinician drawing a curvy line and as king child to turn it into a picture of something; the child then draws a curvy line that the therapist elaborates , and s o taking turns. T he Despert fables are a s eries of affectively evocative s tories that the child is as ked to complete. Asking the child to tell about a dream or a book, movie, television program can provide information about the child's interes ts and preoccupations. (If the clinician is familiar with the plot, the dis tortions the child may introduce can be informative regarding the child's cognitive and emotional s tyle.) Inquiring about what the child would like to do for a living when grown up can provide insight into the child's as pirations, values , and concerns , as well as those of the family. 3478 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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DIR E C T QUE S TIONING Direct ques tioning about the current problems and as pects of the child's life requires tact, attention to the child's level of cognitive and linguis tic development, regard for the impact of the questions on the child's es teem. T he goal of s uch discuss ion is to determine children s ee their world and functioning in it, including attachments and antipathies , pleas ures and anxieties, strengths and weaknes s, which may include difficulties that led to the evaluation. It is important to phrase ques tions in language that is appropriate to the child's developmental level and capacities. C hildren may become confused or made anxious by technical words or abstract or complicated questions . C losed questions often yield little F or example, “Do you get along OK with your brother? ” may bring forth a s imple “yes ” or “no,” whereas openended or descriptive questions are more likely to elicit richer picture of how a child thinks and feels (e.g., sort of guy is your brother? ” or “T ell me about your last play-date with Danny.”) S ome usefully evocative include “What s orts of things make you P.3053 mad (or make you feel afraid)? ” “What is your s addes t happiest) memory? ” “What do you like to daydream about? ” If it is important to establish the order or of events , school-aged children do better if the are anchored to markers in their own lives (e.g., “Did happen before or after your birthday? ” or “Have you trouble with that s ince s chool got out? ”). S everal 3479 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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studies by Michael R utter and colleagues have the effects of various interview s tyles on the elicited from children and parents. Although direct questions are often needed to initiate or to focus discus sion, s ettling into a direct ques tion may constrict the interview process and give children impres sion that the clinician just wants to hear the facts and is not so interes ted in their own feelings and experiences . Y oung children frequently respond in a manner that they believe to be s ocially desirable, older children are often reluctant to acknowledge, even thems elves , feelings of s adness or vulnerability. should convey, by demeanor and tone of voice, their interes t in the child's real feelings . When discus sion of feelings s eems difficult for the may be us eful for the clinician to acknowledge the link between a s ituation and the child's affective res ponse (“S ome kids might have felt mad if that happened to how about you? ”). However, the clinician mus t avoid leading a child who is not yet well known by ass uming experiences or feelings . P robing a bland, equivocal res ponse may prove useful; for example, in res ponse “Okay, I gues s,” the clinician may say, “S ounds like not quite s ure.” T he as sess ment should convey respect for the child should protect the child's s elf-es teem. Many children as hamed or guilty about the difficulties that have them to the evaluation. W hen the clinician conveys a nonjudgmental unders tanding, us ing language that suggests that the difficulties are problems to be helped rather than trans gres sions , the child is more likely to be forthcoming. T he child has come to the evaluation 3480 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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because of problems , but one should also talk with the child about s trengths . F or example, in inquiring about school, it may be useful to s ay, “T ell me about the parts school you like best” before asking “Are there subjects (clas smates , teachers ) that give you trouble? ” or “What the rough s pots at school? ” It may be better to as k the socially isolated child “Do you sometimes have trouble making or keeping friends as much as you'd like? ” and then “What do you think the trouble is ? ” rather than “Do you have any friends ? ” (es pecially if the truthful answer this ques tion is “no”).

S truc ture and S equenc e of the C hild Interview When interviewing the child, the clinician has in mind overall map of the functional and historical areas to be covered; however, the format and s equence of any interview are res ponsive to the individual child, the presenting problems, the unfolding pattern of the interview, and the clinician's personal style. F or every as ses sment, the clinician s hould ask about the cardinal symptoms of depress ion, anxiety, and behavior dis orders, but when, how, and in what order is done vary from one interview to another.

B E G INNING THE INTE R VIE W T here are various ways to s tart the interview. T he one chos en s hould be comfortable for clinician and child should s et the s tage for a productive interchange. clinicians prefer not to address the pres enting the outset. S ome clinicians , for example, remain quiet let the child look about the room and begin playing or 3481 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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talking without prompting or guidance. T his approach impos es a minimum amount of structure; the clinician see how the child reacts to the materials present in the playroom and to the clinician. It also provides about how the child handles the s ituational anxiety that often evoked by the firs t meeting with the clinician. However, this uns tructured approach may leave many children disoriented and uncomfortably uncertain as to the clinician's goals and intentions. Other clinicians are more direct in attempting to place the child at ease and begin by inviting the child to explore the available play materials (“What looks interesting? ”). Others open the interview by inquiring about neutral or pleasurable (“T ell me about what you like to do for fun.”). T he must read the child's cues regarding level of comfort urgency in deciding when to addres s the problems that led to the evaluation. S ome children prefer to firs t talk about nonthreatening topics, whereas others expect to down to bus ines s and talk about their problems right away. Although it may be us eful to establish some initial around neutral or interesting topics , most children unders tand that they have not come for a conventional social encounter. Hence, relatively early in the is us eful to ask what the child's ideas are about the purpos e of the meeting. It is usually best to do this in a matter-of-fact manner by as king, “What did your mom dad tell you (or what do you know) about why they wanted you to come and see me today? ” If the child already met with the clinician together with the parents part of an earlier contact, the clinician will have asked something s imilar at that time and may have heard 3482 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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the child's view of the presenting problem and its If s o, the clinician can follow up by s aying, “Last time, mostly your mom and dad s aid what they thought things . T oday, we have a chance to talk more about things look to you. Are there any things we talked then that we should talk about today? ” Asking what the child knows or thinks about the purpose of the shows the clinician's interest in the child's view of the situation and allows the clinician to hear how the child describes or ass umes res pons ibility for the problem (or repudiates it as someone els e's concern). Asking for child's view up front, before the child has become engaged or focused on some aspect of the interview proces s, allows the clinician to address It als o provides an opportunity for the clinician to in terms that can be understood and potentially acknowledged by the child, the iss ues (at least as the clinician unders tands them) that have prompted the as sess ment.

A S S E S S ME NT OF MA J OR R E A L MS F UNC TIONING T hroughout the ass es sment, the clinician elicits and as similates information to develop a picture of the functioning in the realms of family, school, peers , and recreation. Discus sion of the pres enting problem information, particularly with respect to impairments, in these domains; however, additional discuss ion of the child's experiences in thes e areas enhances the picture the child's life and level of adaptation. It is often us eful begin exploration of each of thes e realms by asking for objective facts (e.g., “Who lives at home with you? ” do you like to play with [or hang out with]? ” “What 3483 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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do you go to? W hat grade are you in? ” or “What do you to do for fun? ”). T his can be followed up with probes for more s ubjective views: “How do people in your family along? Are there any problems at home? (things fight about? things you get in trouble for? things people home do that you don't like? ).” T his approach is to open up discus sion of the major realms of not to simply elicit rote res ponses. It is often helpful to begin by inquiring about the child's recreational activities (“What do you like to do for T his allows the clinician to learn about the child's preoccupations, and talents and may provide a less threatening or problematic starting point than the areas peer and academic functioning. F amily functioning can approached by as king who lives at home, how the child gets P.3054 along with each person, and how family members get along with each other. One can also inquire more specifically “What do you like to do with your dad (or relative)? ” or “What is your brother like? ” In the cas e of nontraditional family s tructures or families of divorce or separation, the clinician may inquire about the history the current arrangement and what sort of relationship is maintained with the noncustodial parent.

INQUIR Y A B OUT P S Y C HOP A THOL OG IC A L J ust as a medical evaluation includes a review of key symptoms in the major systems , the child ps ychiatric evaluation s hould include a s et of ques tions that 3484 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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symptoms of common or major dis orders. T he family or child may not s ee a link between one behavior or area distress and another and may not volunteer s ymptoms that s eem unrelated to the pres enting problem. C omorbidity is relatively common in children with ps ychiatric disorders; thus , the child ps ychiatric must routinely ques tion acros s the major areas of ps ychopathology. Us ing developmentally appropriate language, this inquiry s hould cover depres sive (e.g., low self-es teem, anhedonia, and s uicidal ideation behavior), exces sive anxiety or fears , obses sions and compuls ions, hallucinations and delus ions, and behaviors . F or example, one should as k “Do you feel grumpy a lot of the time? Do you often feel like crying? ” the ans wer is positive, one can follow up concerning persis tence (“Does that last for more than a few frequency (“Does that us ually happen every week [or days ]? ”), and context (“What s orts of things make you that way? ”). T o inquire about s uicidal ideation, one can begin by asking, “Do you ever feel that, life is so hard, wis h you weren't alive (or would be better off dead)? ” following up with the more explicit “Have you ever tried hurt yours elf (or done anything to try to make yourself dead)? ” E xpos ure to potentially traumatic experiences should be routinely covered, and developmentally appropriate language s hould be us ed (e.g., “Have any really s cary things ever happened to you? ”).

ME NTA L S TA TUS E X A MINA TION T hroughout the clinical interview, the clinician observes and notes information relevant to the domains of the mental s tatus examination. S ome abnormalities or may be evident through this proces s; however, other 3485 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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require direct examination, which can us ually be incorporated in a playful way into the clinical interview. Although intens ive developmental, ps ychometric, language, and neurological ass es sment usually cannot subs umed within the clinical interview, a brief semistructured evaluation requires only approximately to 10 minutes and provides useful information. T his generally involves drawing, copying a design, and tes ts of orientation, recall, general knowledge, and language (e.g., naming three objects ; repeating a such as “No ifs, ands , or buts ”; a three-stage such as “T ake a piece of paper in your right hand, fold paper in half, put the paper on the floor”; a writing [s uch as as king the child to write a sentence of their choice]; and a brief screen of neurological s oft signs).

C L OS ING THE INTE R VIE W In winding up the interview, the clinician can check for concerns that have not been covered and that als o that the interview is coming to a close by asking, talked about a lot of things; are there any other things would be important for me to know about you? ” one may as k, “I've as ked you a lot of questions; do you have any questions you want to as k me? ” T he clinician should also give the child a general idea of what will be done with all the information the child has s hared and some sense of what happens next. F or example, one explain “I'm going to think over what I've heard from and your folks and meet again with them (and you) to about what might help with. … Are there any particular things I s hould be s ure to mention? ” If the clinician has a sense of what interventions might be helpful, this may be tentatively broached with the child, keeping in 3486 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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mind the parents' right to hear and decide on thos e recommendations . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent S P E C IAL IS S UE S IN T HE AS S E S S ME NT OF ADOL E S C

S PE C IAL IS S UE S IN THE AS S E S S ME NT OF ADOLE S C E NTS P art of "33 - P s ychiatric E xamination of the Infant, and Adoles cent" T he clinical as sess ment of adoles cents requires with the distinctive dynamics of adoles cents and their characteristic patterns of managing conflicts , anxiety, interactions with adults. T he adoles cent's attitude toward the evaluation has important implications for how the ass es sment proces s unfolds. In contrast to the adult patient (who us ually the res ponsibility and initiative for s eeking help) and child patient (who is s imply brought by parents ), many adoles cents are cautious ly ambiguous as to whether is a problem with which they want help or whether they are merely pas sively complying with their parents' initiative. One important initial decision concerns who is to be in the initial interview: the parents , the adoles cent, or together. S eeing adolescents alone firs t has the of emphas izing their active participation in the process 3487 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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and underlines the clinician's interest in their on the other hand, it may mean that crucial elements of the history are not available to the ass es sor. some embattled youngs ters may protes t that they are being identified as the patient or bearer of a problem they feel resides in their parents or in the family as a T he clinician may to need to explain explicitly that the evaluation is not a judicial proceeding to ass es s blame, rather an attempt to understand what the problems are. In some cas es, when the adoles cent balks at being all, the clinician may need to meet with the parents to facilitate the youngs ter's participation in the R egardless of when the adolescent is seen, the should, at some point, be s een alone to explain their concerns about the child, to obtain a full developmental and family history, and to hear about as pects of their spous al and parenting relations hip that may be significant but that may not be appropriate to discuss initially in the adolescent's pres ence. Meeting with the adolescent and parents together is us ually helpful. T his provides an opportunity to explore how family members interact, their convergences or divergences of perspective, and their capacity to work together therapeutically. S uch conjoint interviews require active s tructuring by the clinician, so that the purpos e is framed as an occas ion to talk together. such active intervention, the family sess ion can eas ily deteriorate into an adversarial proceeding in which the parents complain about the adolescent, who, in turn, retreats into hostile or guarded silence.

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T he as sess ment of adoles cents often rais es complex of confidentiality. Although the parents and the adoles cent mus t know that the adolescent's communications are kept confidential, they must all unders tand from the onset that this does not extend to situations that pose a clear danger to the patient or F or example, if the adolescent reveals significant ideation or a recent s uicide attempt of which the are unaware, parents must be informed for the safety. Having made clear that the parents need to the tas k is then to negotiate whether the adolescent prefers to tell the parents directly or to have the inform them. It is us ually bes t to have the adolescent undertake this res ponsibility, but, s ometimes , after discuss ion with the youngs ter, the clinician must be the one to s peak with the parents , preferably in the adoles cent's pres ence. Less clear-cut s ituations P.3055 in which the adolescent reveals problematic, but not imminently dangerous, antisocial or sexual behavior or subs tance use mus t be decided on an individual basis. T reatment may not be poss ible without some confidentiality; on the other hand, confidentiality must become collus ion.

Developmental Is s ues Adoles cents' usual s trong pus h toward autonomy is linked to a warines s of feeling vulnerable, dependent, controlled. T olerating feelings of ambivalence, guilt, or other painful affects or internal conflicts does not come easily to adolescents . In addition, adolescents are 3489 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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externalize their concern or embarrass ment over s elfperceived shortcomings or difficulties. As a res ult, even adoles cents who conscious ly desire help often clinical as sess ment with the fear that revealing what perceive as shameful weakness es leaves them to criticism, control, or regress ive dependency. F ear of acknowledging vulnerability or dependency may result bland denials of any problems or insistence that “I can handle it by myself” or “I don't need a shrink; I can talk about my problems with my friends.” E xternalizing their conflicted feelings about autonomy vers us adoles cents may fluctuate between grievances about parental overprotectiveness and complaints about perceived lack of care. R eversal of affect and counterphobic defens es may mas k anxiety, shame, or other painful affects. T he s killed clinician learns to look beyond s urface behavior and to notice when an adoles cent “doth protes t too much.” Although many adoles cents seem intolerant of selfreflection, an unrealis tic belief in the omnipotence of thought often helps s upport denial and avoidance. when confronted with a pattern of long-standing maladaptive behaviors , the adolescent may insist “I stop any time I really want to” or “I don't do that any more” (i.e., not s ince S aturday). T he lability of adolescents' moods and their truncated perspective often make it useful to extend the over time to distinguish the transient iss ues from those that are more enduring.

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Interviewing adoles cents requires tact, flexibility, a of humor, and clinicians who have come to terms with their own adoles cent iss ues . C ondes cension, s arcas m, competitivenes s, or excess ive pas sivity on the part of interviewer is likely to result in failure. On the other although conveying a genuine interest in the youngster es sential, s eductivenes s, overfamiliarity, or the failure maintain an adult role are likely to frighten the T he interviewer s hould resist the temptation to be too “with it” or too “cool”—nothing is more dated than last year's s lang. B ecause adoles cents can s o easily feel defens ive, criticized, or embarras sed, the interviewer learn to talk frankly, yet tactfully, about areas of difficulty. Many embattled adoles cents see adults as for them or agains t them; hence, the clinician needs to convey a genuine empathic interes t in the adoles cent's view of a s ituation without implying collus ive, uncritical acceptance of it or entering into an adversarial dis pute. T he general obs ervation that it is important to learn youngsters' strengths and interes ts, as well as their problems and vulnerabilities , is es pecially true of adoles cents . W ithout appearing squeamis h or avoidant the problem areas, the clinician s hould inquire about adoles cent's interests, hobbies , recreations, and friends hips. K nowledge about the areas of accomplis hment, talent, and gratification is required for full picture that includes the youngster's adaptive and compens atory s trengths and as sets. F urthermore, s uch inquiry helps facilitate rapport and conveys an interest the adoles cent as a whole person, rather than s imply a bearer of problems . A too-exclusive focus on pathology puts many youngsters on the defens ive, and an 3491 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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opportunity to talk about more neutral areas or those of greater mas tery or confidence helps the adoles cent less on the s pot. Instead of the interviewer s training to demonstrate familiarity with the lates t band or winning team, letting adoles cents teach the interviewer about details of their interests lets the youngsters enjoy a of mas tery, control, and a degree of parity with the interviewer that helps put them at eas e. Indeed, what been called the cons tructive us e of ignorance is often a us eful technical element of the adolescent interview. cons ists of being able to ask about s ome mis sing piece the s tory or about some puzzling impass e with an ingenuous curios ity that invites the adolescent's selfreflection. Although interviewing and taking the history of the adoles cent cover the same general areas outlined previous ly, certain domains are of particular salience the adoles cent. T hes e relate to the core developmental tas ks of adoles cence: developing increased autonomy individuation from parents; taking over the tasks of phys ical s elf-care; developing a s atisfying, realis tic image in the face of pubertal changes; mas tering burgeoning s exual and aggress ive impulses; an identity, including ethical values and vocational developing a network of satis fying peer relations; and, later adolescence, developing a capacity for romantic intimacy with an appropriate partner (T ables 33-2 and 3).

Table 33-2 Developmental Tas ks of Adoles c ene 3492 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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G radual development as an independent Mental evolvement of a satis fying, realistic body image Appropriate control and express ion of sexual E xpans ion of relationships outs ide the home Implementation of a realistic plan to achieve and economic s tability T ransition from concrete to abstract conceptualization Integration of a value system applicable to life events

F rom G ros s R T , Duke P M. Adolescence. In: MD, C arey W B , C rocker AC , et al., eds. B ehavioral P e diatrics . P hiladelphia: WB 1983, with permiss ion.

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In the realm of values , ideals, and aspirations , the should explore the adolescent's values and the models whom the adoles cent wishes to emulate or to reject. T o what extent do thes e values complement or conflict those of the parents? W hat expectations and (realis tic or not) does the adoles cent have concerning future? T he world of peers and friends s hould also be explored with adolescents . W ith whom do they “hang out”? What crowd do they s ee themselves part of? How do they along with peers , and what do they do for fun? Asking teenagers to describe a clos e friend provides a chance learn how they think about people and relationships to ass es s their capacity for empathy. T he topic of friends leads naturally to the topic of and s exual interests and relations hips. E xploration of area requires tact, and the clinician cannot always be of receiving a candid response. Nonetheles s, as with questions concerning depress ion or s ubs tance use, the clinician's tone can convey the sense that the inquiry these sensitive areas is motivated by a genuine and 3494 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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legitimate wis h to unders tand the adoles cent. One can begin by as king whether the teenager dates and there is anyone of either s ex with whom the youngster clos e? If so, who are they, and what attracted the adoles cent to them? Are the adolescent's interes ts reciprocated? P.3056 How has the relations hip gone? Does the teenager any recurrent patterns in terms of the type of pers on to whom he or she is attracted or how s uch relations hips have unfolded in the pas t? Have any of the teenager's relations hips developed into s exual ones? Has the adoles cent had other sexual experiences ? (Here one be open to hearing about poss ible epis odes of sexual abuse or concerns about sexual orientation.) B ecaus e of the high prevalence of depres sion, s uicidal ideation, and even suicide attempts in the general population, s pecific inquiry about these areas as previous ly is particularly important. T he clinician s hould also inquire matter-of-factly about whether the smokes , drinks, or us es drugs illicitly, and, if so, with frequency, in what amounts , in what contexts, and with what cons equences. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent AS S E S S ME NT OF INF ANT S AND T ODDLE R

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P art of "33 - P sychiatric E xamination of the Infant, and Adoles cent" T he as sess ment of infants and toddlers poses s pecial challenges for the clinician. F irs t, the evaluation of children requires specific and detailed familiarity with cognitive, linguis tic, motor, and adaptive developmental landmarks of 1 month to 6 years of age, as well as the specialized techniques needed to as sess these competencies. S econd, although direct observation of child is an important s ource of data, the preverbal or limited verbal capacities of the child s everely restrict historical material that can be obtained from the direct interview of the child. T hird (and perhaps most infants and young children cannot be ass ess ed, or treated apart from their caregiving environment, includes not only the parents, but also other members the extended family and day care and other care T he developmental tasks of infancy include achieving phys iological homeostasis; developing stability of state and learning to negotiate trans itions between states ; organizing basic phys iological rhythms of wakefulnes s feeding; coping with novel s timuli; perceiving coherent patterns of experience; mastering s imple s ensorimotor schema; es tablishing a s pecific and s ecure relations hip with a caretaker; maintaining a positive affective tone; developing express ive and receptive channels of communication (including vocalizations and facial and gestural cues ); and forming s chemas of caus ality, intentionality, object permanence, and affect. T he older infant or toddler must grapple with the regulation and socialization of bodily functions (e.g., eating, toileting, 3496 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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sleep), learning to concentrate and regulate s hared attention, acquiring the capacity for imaginative play more complex forms of imitation, the challenge of socialization (including development of more complex forms of s ocial perception, communication, and and negotiating conflicts of will with caregivers and control of negative mood and aggres sion, and of core gender identity. Development can proceed at a different pace in each area and may go awry in any or them. T he goal of the developmental as sess ment of infants toddlers is to depict functional capacities in each of areas, the relationship between the various domains of development, their ability to adapt, and the range of coping s trategies they use in doing s o, as well as the caregiving environment as it impinges on them, the quality of caregiving interactions , and the impact of developmental s tatus on the caregiver. As with older children, the purpose of the ass es sment is to define if any, interventions are neces sary, while at the same helping form an alliance with the parents that facilitates implementation of any recommendations that may out of the ass ess ment. T he most common referral problems for infants and toddlers involve 1. Developmental delays (e.g., s pecific delays , s uch delayed, absent, or deviant motor or s peech development, or general delays in multiple areas of development) 2. P sychophys iological dysregulation (fus sy behavior, disturbances of sleep or feeding, rumination, 3497 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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self-stimulatory behaviors [head-banging, rocking], and failure to thrive) 3. B ehavioral dis turbances (exces sive tantrums , negativis m, aggres sion, and hyperactivity) 4. Dis turbed s ocial development (lack of apparent awarenes s of or interest in others , res ponse to neglect, or multiple placements or repeated or prolonged separations ) 5. Medical or genetic problems (e.g., prematurity and genetic s yndromes) 6. E xpos ure to environmental stress ors (such as depres sion, change of caretaker, domestic sequelae of trauma) B ecaus e s o many as pects of early development are interdependent, the s ignificance of difficulties in one functional domain cannot be unders tood without reference to the child's developmental s tatus in other areas. F or example, s peech, language, and hearing difficulties profoundly affect pers onal and s ocial development. Ass es sment of motor or adaptive competency that involves interaction with the caregiver as sess or is affected by disturbances in relatednes s hence yield findings that appear erratic or uneven. P.3057 Infants and toddlers are particularly s ens itive to environmental s tres ses , which may delay the of phas e-appropriate skills or may lead to trans ient regress ions. 3498 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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Tec hnic al Is s ues in the of the Infant and Young C hild T he as sess ment of the young child us ually requires sess ions. In addition to s ess ions spent with the parents alone to gather his tory and to pres ent the res ults of the as sess ment, familiar adults mus t be present during the as sess ment of the child; this is neces sary to place the at eas e in the as ses sor's presence and to permit direct observation of child and caregiver interaction. F urthermore, the behavior of infants and young highly s tate dependent (and s ensitive to fatigue or and one us ually needs to see the child on more than occasion to have a sufficient sample of characteristic behavior. T he general principles of his tory taking from the and as sess ment of the caregiving environment follow those outlined previous ly. However, particular given to the parental perception of the pregnancy— whether the conception was planned or came at a time in the life of the family and what the impact of the child's arrival was on the parents individually and on family as a whole. T he history s hould explore parental grandparental) expectations for the child, the meaning that the child has for them, whom the infant reminds of, and what they perceive as the child's best and worst traits. T he developmental history for the young child includes prenatal, perinatal, and pos tnatal complications, maternal illness , medication and s ubs tance use, and neonatal s tatus. In addition to the areas outlined previous ly, ass es sment of the child's behavioral 3499 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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organization should include the regulation of phys iological state, alertnes s, and activity patterns. C hildren's ability to cons ole thems elves and to adapt to new situations and their res ponse to separations are key areas of evaluation. T he history s hould also history of childcare arrangements (nannies , relatives , of-home day care) and the child's reaction to any in these arrangements . T he child's mastery of various gros s motor, fine motor, language, adaptive, and personal-social milestones be systematically as sess ed, by history and in the direct evaluation of the child. In taking s uch a his tory, the as sess or may be aided by a variety of s creening instruments, such as V ineland Adaptive B ehavior is us eful to inquire about the timing of the child's of thes e milestones relative to any s iblings. Within the firs t few months of life, children begin to manifest distinctive and often enduring behavioral or temperament. T able 33-4 s hows the nine temperamental categories and three distinctive cons tellations of temperament as defined by S tella and Alexander T homas . T he goodness of fit, or degree cons onance between the child's temperament and the parents ' expectations or demands of the child, is an important predictor of future development.

Table 33-4 Temperament C ategories

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Activity level: T he motor component pres ent in a given child's functioning and the diurnal of active and inactive periods. R hythmicity (re gularity): T he predictability or unpredictability in time of any function; it can be analyzed in relation to the sleep–wake cycle, feeding pattern, or elimination schedule. Approach or withdrawal: T he nature of the initial res ponse to a new s timulus, be it a new food, a toy, or a new person. Approach responses are positive, whether displayed by mood expres sion (e.g., s miling, verbalizations ) or motor activity swallowing a new food, reaching for a new toy, active play). W ithdrawal reactions are negative, whether displayed by mood express ion (e.g., fus sing, grimacing, verbalizations) or motor (e.g., moving away, spitting new food out, new toy away). Adaptability: R es ponses to new or altered One is not concerned with the nature of the initial res ponses , but with the eas e with which they are modified in a desired direction. T hre s hold of re s pons ive nes s : T he intens ity level stimulation needed to evoke a dis cernible irrespective of the s pecific form of the res ponse the sensory modality affected. T he behaviors 3501 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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concern reactions to sensory s timuli, objects, and social contacts . Inte ns ity of re action: T he energy level of irrespective of its quality or direction. Q uality of mood: T he amount of pleasant, joyful, friendly behavior (as contras ted with unpleas ant, crying, and unfriendly behavior). Dis tractibility: T he effectivenes s of extraneous environmental s timuli in interfering with or altering the direction of the ongoing behavior. Atte ntion s pan and pers is tence: Attention s pan concerns the length of time a particular activity is pursued by the child. P ers is tence refers to the continuation of an activity in the face of obs tacles the maintenance of the activity direction. Qualitative analysis , s upplemented by factor analyses , led to the formulation of, in addition, cons tellations of temperament made up of combinations of the individual categories , which appeared to have functional s ignificance. T hes e    E as y te mpe rament: T he combination of regularity, approach tendencies to the new, quick adaptability to change, and a predominantly mood of mild or moderate intensity. T his group 3502 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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comprised approximately 40 percent of the study population.    Difficult te mpe rame nt: T he oppos ite of easy temperament, namely, biological irregularity, withdrawal tendencies to the new, slow to change, and frequent negative emotional expres sions of high intens ity. T his group approximately 10 percent of the study population.    S low-to-warm-up tempe rame nt: W ithdrawal tendencies to the new, slow adaptability to and frequent negative emotional reactions of low intens ity. S uch individuals are often labeled shy. group compris ed approximately 15 percent of the study population.

Adapted from C hes s S , T homas A. T emperament its clinical applications. In: Lewis M, ed. C hild and Adoles ce nt P s ychiatry. 3rd ed. B altimore: Williams & W ilkins ; 2002:221. P articularly s alient aspects of the parental interview include a detailed his tory of the parents' own and history of care, out-of-home placement, and experience in their families of origin. T he impact of child on each parent and their marital relations hip be as ses sed, as well as the appropriatenes s and congruity in their res pective expectations of the child. 3503 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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Adequate caregiving for the young child requires a delicate balance between gratification, comfort, and frustration that is appropriate to the child's developmental phas e. It is important to hear (and to observe) which as pects of parenting and which the child's behavior the parent feels most comfortable with or mos t challenged by. T he clinician should parents ' overall level of psychological functioning; the parental difficulties that adversely affect a young child's development do not always involve such gross failures serious neglect or abus e but may involve problems difficult to identify, s uch as pers is tent maternal T o help obtain a concrete picture of the parent, child, their interaction, it is useful to as k for a detailed of a day in the life of the child. In addition to providing data regarding the child's capacities , responses, and temporal organization, such a description provides to the parents' attunement and affective res ponses to various elements of the child's behavior. Although much of the clinical obs ervation is focus ed on the child's behavior and capacities, direct observation the parent–child relationship is es sential. Inviting the family to interact in the play room as they us ually would home allows observation of their P.3058 interaction in uns tructured parent–child or family play; as signing various structured tasks may also be useful. Observing the child in interaction with each parent separately helps reveal relations hip-specific patterns of behavior. Among the dimensions of parental behavior be as ses sed are the ability to engage the child 3504 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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and nonverbally); the quality and affective tone of this engagement; the parent's attunement to the child's parental vigilance, protectivenes s, and limit s etting; the parent's facilitation or res triction of autonomous play by the child; thematic content; and the degree of mutual pleas ure during play. Although instruments for formally as sess ing parental res pons ivity and parent–young interaction, s uch as the Home Observation for Meas urement of the E nvironment (HOME ) and the C hild E arly R elational As ses sment (P C E R A), are used primarily for research purpos es, familiarity with the facets of such instruments is clinically useful.

Obs ervation and E xamination of Infant and Toddler T he direct examination of the young child draws on levels of observation: the child's res pons e to structured as sess ment items during formal testing, the child's res ponse to other interactions with the as ses sor and as sess ment environment, and the spontaneous interactions of the child and parent in a naturalis tic

S truc tured As s es s ment Ins truments A variety of instruments exists for the structured as sess ment of infants and young children, and each somewhat different goals, theoretical orientation, and ps ychometric properties (T able 33-5). T hese do not yield diagnos es ; they detail the child's in various areas relative to a normative population. F or example, the Denver Developmental S creening T est II (Denver II) (F ig. 33-1) is s uitable for s creening use by pediatricians or trained paraprofes sionals to help 3505 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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children with s ignificant motor, social, or language who need fuller evaluation. P opulation-specific norms also available for ass ess ing children from families of various ethnic or educational backgrounds . T he B ayley S cale of Infant Development II, which is adminis tered trained as ses sor, can be us ed to as sess children 1 to months of age; it includes a mental s cale (as sess ing information process ing, habituation, memory, social s kills , and cognitive s trategies), a motor s cale as sess ing gros s and fine motor s kills , and a B ehavior S cale for as sess ing qualitative aspects of the child's behavior during the as sess ment. T his wellinstrument yields s tandard s cores for a mental development index and P sychomotor Development

Table 33-5 S elec ted Formal Te Developme Tes t (R eferenc e)

Age

Domains

Norm

Neonatal tes ts

 

 

 

M, T A, V , A, MT

Not

   G raham/R osenblith — B ehavioral T es t for Neonates 3506

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(R os enblith, 1979)    B razelton B ehavioral Ass es sment S cale(B razelton, 1984)

37–44 wks G A

NI, B , P S

Not

Infant and toddler development tes ts

 

 

 

   B ayley S cale of Infant II (B ayley, 1993b)

1–42

Mental, M,

Large repre

   Mullen S cales of E arly Learning (Mullen, 1995)

0–68

G M, F M, RC, EC

Large repre

   B attelle Developmental

0–95

P S , Ad, F M, E C ,

S ma repre

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Inventory (Newborg et al., 1984)

C g (and subdomains )

   G riffiths Abilities B abies (G riffiths , 1954)

0–24

Lm, P S , E H, P

S ma Lond

   Infant P sychological Development (Uzgiris and Hunt, 1975)

Not applicable

S ee text

Not

S creening tests

 

 

 

   B attelle Developmental Inventory S creening T es t (Newborg et 1984)

6–95

P S , Ad, F M, E C , Cg

S ma repre

3–24    B ayley Infant Neurodevelopmental S creen (Aylward, 1995)

N, R C , Cg

Large repre

   B irth to T hree Developmental (B angs and

E C /R C , C g, PS, M

S ma ques repre

0–36

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1979)

   Denver Developmental S creening T est II (F rankenburg et al., 1990)

0–72

G M, P S , E C /R C

Large Denv

   Developmental Activities S creening Inventory–II (F ewell and Langley, 1984)

0–60

15 sensory and problemsolving

>200 child

   Developmental Indicators for the Ass es sment of Learning-R evised (Mardelland G oldenberg, 1990)

24–72 mos

M, AS , E C /R C , B

Large repre

   Diagnostic Inventory for S creening C hildren(Amdur et al., 1996)

0–60

F M, G M, E C , AM, Ad, P S

S ma south Onta

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   Developmental Observation C hecklis t S ystem (Hres cko et al.,

0–72

C g, E C /R C , PS, Adj, P S &S

Adeq repre

   Developmental P rofile–II (Alpern et al., 1986)

0–114 mos

M, Ad, P S , AS , E C /R C

Large

   E arly S creening P rofile (Harris on, 1990)

24–72 mos

C g, E C /R C , M, Ad/P S ,

Adeq repre

   K ent Infant Development (R euter and B ickett, 1985)

0–12

C g, M, E C /R C , Ad, PS

All fro north Ohio

   C hild Inventory (Ireton, 1992)

15–72 mos

G M, F M, R C , Ad, P S , N

S ma P aul,

Note: A virgule (/) indicates that multiple domains are as A, auditory respons iveness ; Ad, adaptive, s elf-help, or d attention and memory; Ar, articulation; AS , academic or or problem-solving; E C , expres sive communication/lang 3510 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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motor; G M, gros s motor; HS , hearing and s peech; L, let muscle tone; N, numbers; NI, neurologic intactnes s; P , p stress and s upport; R C , receptive communication and la res ponsiveness ; V M, visual attention and memory; V R , F rom G illiam W S , Mayes LC . C linical as sess ment of infa Adoles ce nt P s ychiatry: A C ompre he ns ive T extbook. 3rd 2002:519, with permiss ion.

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FIGUR E 33-1 Denver II—Denver Developmental T es t II. (C opyright W .K . F rankenbeurg and J . B . Dodds, with permis sion.) Although tests such as the B ayley S cale of Infant Development may s how good reliability and concurrent validity, their ability to predict later performance on intelligence quotient (IQ) as sess ments or later adaptive functioning is highly variable. Among the reas ons for weaknes s of prediction are the intervening effects of and family environment and the heavy emphasis infant tes ts place on perceptual and motor skills that may relatively little to do with information-proces sing capacities. T he mental status examination of the infant and young child may be organized us ing a s chema such as that in T able 33-6.

Table 33-6 Infant and Toddler Mental S tatus E xamination by Anne L . B enham, M.D. I. Appearance S ize, level of nouris hment, dres s and hygiene, apparent maturity compared to age, dysmorphic features (e.g., facies, eye and ear shape and 3513 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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placement, epicanthal folds, digits), abnormal size, cutaneous lesions . II. Apparent reaction to s ituation Note where and with whom the evaluation takes place.    A. Initial reaction to setting and to strangers: explores ; freezes ; cries ; hides face; acts curious, excited, apathetic, or anxious (des cribe).    B . Adaptation       1. E xploration: when and how child begins exploring faces , toys, stranger.       2. R eaction to transitions: from uns tructured structured activity; when examiner begins to play with infant; cleaning up; leaving. III. S elf-regulation    A. S tate regulation: An infant's s tate of cons ciousnes s ranges from deep sleep through stages to intens e crying. P redominant s tate and range of states observed during sess ion, patterns transition (e.g., s mooth vers us abrupt), capacity being soothed and self-soothing, capacity for alert s tate. (S ome of these categories als o apply 3514 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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toddlers.)    B . S ens ory regulation: reaction to s ounds, smells, light and firm touch; hyperres ponsiveness hyporespons ivenes s (if observed) and type of res ponse, including apathy, withdrawal, fearfulnes s, excitability, aggres sion, or marked behavioral change; excess ive s eeking of sens ory input.    C . Unus ual behaviors; mouthing after 1 yr of head banging; smelling objects; s pinning; twirling; hand-flapping; finger flicking; rocking; toe staring at lights or s pinning objects; repetitive, perseverative, or bizarre verbalizations or with objects or people; hair pulling; ruminating; or breath holding.    D. Activity level: overall level and variability that toddlers are often incorrectly called hyperactive). Describe behavior, for example, squirming cons tantly in parent's arms , s itting on floor or in infant seat, cons tantly on the go, climbing on des k and cabinets, exploring the pausing to play with each of six to eight toys .    E . Attention span: capacity to maintain attentivenes s to an activity or interaction, longest and average length of sustained attention to a toy or activity, distractibility. Infants : vis ual fixing 3515 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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following at 1 mo of age, tracking at 2–3 mos of attention to own hands or feet and faces , duration exploration of object with hands or mouth.    F . F rus tration tolerance: ability to pers is t in a difficult tas k, des pite failure; capacity to delay reaction if easily frustrated, for example, crying, tantrums, withdrawal, avoidance.    G . Aggres sion: modes of express ion, degree of control of or preoccupation with aggres sion, appropriate as sertiveness . IV . Motor Muscle tone and strength, mobility in different positions , unus ual motor pattern (e.g., tics , activity), intactnes s of cranial nerves (e.g., of face, mouth, tongue, and eyes , including swallowing, and gaze [note exces sive drooling]).    A. G ross motor coordination. Infants: pushing head control, rolling, sitting, s tanding. T oddlers: walking, running, jumping, climbing, hopping, kicking, throwing and catching a ball. (It is useful have something for the child to climb on, such as chair.)    B . F ine motor coordination. Infants: grasping releas ing, transferring from hand to hand, us ing 3516 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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pincer gras p, banging, throwing. T oddlers: using pincer gras p, s tacking, s cribbling, cutting. F ine and visual-motor coordination can be screened observing how the child handles puzzles , s hape boxes , a ball and hammer toy, s mall cars , and with connecting parts. V . S peech and language    A. V ocalization and speech production: quality, rate, rhythm, intonation, articulation, volume.    B . R eceptive language: comprehension of speech as s een in verbal or behavioral res ponse follows commands), points in response to “where questions , unders tands prepositions and (include estimate of hearing, es pecially in child language delay, for example, res ponse to loud sounds and voice; ability to localize sound).    C . E xpress ive language: level of complexity vocalization, jargon, number of single words , phrases, full sentences ); overgeneralization (e.g., us es kitty to refer to all animals); pronoun use, including revers al; echolalia, immediate or unusual or bizarre verbalizations . P reverbal communicative intent (e.g., vocalizations , imitation, and gestures, such as head s haking pointing), caregiver's ability to understand infant's communication, child's effectivenes s in 3517 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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communication. V I. T hought T he us ual categories for thought dis order almos t never apply to young children. P rimary process thinking, as evidenced in verbalizations or play, is expected in this age group. T he line between and reality is often blurred. B izarre ideation, perseveration; apparent loose as sociations, and persis tence of pronoun revers als , jargon, and echolalia in an older toddler or pres chooler may noted in a variety of psychiatric disorders , pervas ive developmental dis orders.    A. S pecific fears : feared object, worry about lost or separated from parent.    B . Dreams and nightmares: C ontent is obtainable in children 2–3 yrs of age. C hild does always perceive it as a dream; for example, “A mons ter came in the front door.”    C . Diss ociative state: s udden epis odes of withdrawal and inattention, eyes glazed, “tuned out,” failure to track ongoing s ocial interaction. Dis sociative s tate may be difficult to differentiate from an abs ence seizure, depres sion, autis m, or deafness . T he context may be helpful (e.g., child a history of neglect freezes in a dis sociative s tate 3518 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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mother leaves room). Neurological or audiological evaluation may be warranted.    D. Hallucinations : extremely rare, except in the context of a toxic or medical dis order, then visual or tactile. V II. Affect and mood T he as sess ment of mood and affect may be more difficult in young children because of limited language, lack of vocabulary for emotions , and of withdrawal in response to a variety of from s hynes s and boredom to anxiety and depres sion.    A. Modes of express ion: facial, verbal, body and positioning.    B . R ange of express ed emotions: affect, in parent–child relationship.    C . R espons ivenes s: to s ituation, content of discuss ion, play, and interpersonal engagement.    D. Duration of emotional state: need his tory or multiple obs ervations.    E . Intensity of express ed emotions: affect, es pecially in parent–child relationship. 3519 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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V III. P lay P lay is a primary mode of information gathering all s ections of the Infant and T oddler Mental E xamination. In young children, play is especially us eful in the evaluation of the child's cognitive symbolic functioning, relatednes s, and affect. T hemes of play are helpful in as sess ing toddlers. T he management and expres sion of aggres sion are as sess ed in play as in other areas behavior. P lay may be with toys or with child's or another's body (e.g., peek-a-boo, verbal (e.g., s ound imitation games between and infant), or interactional or s olitary. It is to note how the child's play varies with different familiar caregivers and with parents versus the examiner.    A. S tructure of play (ages are approximate).       1. S ens orimotor play          a. 0–12 mos of age: mouthing, banging, dropping and throwing toys or other objects .          b. 6–12 mos of age: exploring objects (e.g., moving parts, poking, pulling).       2. F unctional play

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         a. 12–18 mos of age: C hild's use of objects shows understanding and exploration of their use function (e.g., pus hes car, touches comb to hair, telephone to ear).       3. E arly symbolic play          a. 18 mos of age and older: C hild pretends increasing complexity; pretends with own body to eat or to sleep; child pretends with objects or people (e.g., “feeds ” mother); child us es one to represent another, for example, a block a car; child pretends a sequence of activities cooking and eating).       4. C omplex s ymbolic play          a. 30 mos of age and older: C hild plans and out dramatic play s equences, us es imaginary objects. Later, child incorporates others into play with as signed roles.       5. Imitation, turn taking, and problem solving part of play.    B . C ontent of play. T he toddler's choice and toys often reflect emotional themes . It is desirable have on hand toys that tap different and emotional domains . An overfull playroom be overwhelming or overs timulating and may 3521 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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reduce meaningful observations . Y oung toddlers both s exes often gravitate to dolls , dishes, and moving toys , s uch as cars. T he examiner's of specific materials may facilitate the express ion pertinent emotional themes. F or example, a child traumatized by a dog bite may more likely the trauma if a dog and doll figures are available. child's reaction to s cary toys, such as s harks , dinos aurs , or guns , should be noted, especially if they are avoided or dominate the s ess ion. Does aggres sive pretend play become real and hurtful? B y 2.5–3 yrs of age, a child's animal or play can reveal important themes about family including reactions to s eparation, parent–child sibling relationships, experiences at day care, of nurturance and discipline, and phys ical or abuse. T he examiner mus t use caution in interpreting play, viewing it as a poss ible combination of reenactment, fears, and fantas y. IX. C ognition Using information from all previously mentioned areas, es pecially play, verbal and s ymbolic functioning, and problem s olving, roughly as sess child's cognitive level in terms of developmental intactnes s, delays , or precocity. X. R elatednes s

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   A. T o parents: How in tune do the child and seem? Does the child make and maintain eye, or physical contact? Is there active avoidance by child? Note infant's level of comfort and relaxation being held, fed, molding into caregiver's body. toddler move away from caregiver and check bring toys to show, to put into his or her lap, to with together or near caregiver? C omment on phys ical or verbal affection, hostility, reaction to separation and reunion, and us e of transitional objects (blanket, toy, caregiver's poss es sion). Des cribe differences in relating if more than one caregiver is present.    B . T o examiner: Y oung children normally show some hes itancy to engage with a stranger, after 6–8 mos of age. Appropriate warines s in children may res ult in a period of watching the examiner, staying phys ically clos e to a familiar caregiver before engaging, or s howing s ome cons triction of affect, vocalization, or play. After initial warines s, does the child relate? Does the engage too soon or not at all? How does with a s tranger compare to that with a parent? Is child friendly vers us indiscriminately attention seeking or guarded versus overanxious ? C an the examiner engage the child in play or structured activities to a degree not s een with caregiver? the child show pleas ure in s ucces ses if the shows approval?

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   C . Attachment behaviors: Observe for showing affection, comfort seeking, as king for and help, cooperating, exploring, controlling behavior, and reunion res ponses. Describe age-related disturbances in thes e normative behaviors . Dis turbances often are seen in abused and neglected children; for example, fearfulnes s, clinginess , overcompliance, hypervigilance, impulsive overactivity, and defiance; restricted or hyperactive and dis tractible exploratory behavior; and res tricted or indis criminate affection and comfort s eeking.

F rom American Academy of C hild and P sychiatry: P ractice parameter on ps ychiatric as sess ment of infants and toddlers (0-36 Am Acad C hild Adole s c P s ychiatry. 1997;36 with permiss ion.

Diagnos tic F ormulation of the A s s es s ment of Infants and Young C hildren Although mental retardation, autism, and other developmental disorders can be at least tentatively diagnosed in infants and toddlers, the mos t widely official diagnos tic s ys tem—the fourth edition of and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV ) tenth edition of the Inte rnational S tatis tical 3524 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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Dis e as es and R e late d He alth P roble ms (IC D-10)— lack a developmental pers pective and diagnos tic categories s uitable for infants and young children. T he Zero to T hree/National C enter for C linical Infant Diagnos tic C las s ification of Me ntal H ealth and Dis orde r of Infancy and E arly C hildhood provides a diagnostic s chema for this age group that is intended to complement DS M-IV . T his new schema is s till under development, and the nosological approach to this developmental epoch remains an area of ongoing and debate. T he appropriate outcome of a thorough clinical as sess ment of the young child thus extends far beyond attempt at a s pecific categorical diagnosis. T he formulation s hould provide a detailed picture of the strengths and weaknes ses in the child's social, cognitive, linguis tic, motor, and perceptual the quality of the child's temperament, attachment, and regulatory capacities; hypotheses regarding the the child's difficulties ; and potential exacerbating or ris k factors and protective or ameliorative factors in the and family. T his formulation, which should be shared the family in a comprehens ible and us able form, ought provide the basis for recommendations regarding intervention or further ass ess ment. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent S P E C IAL T Y P E S OF AS S E S S ME N

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P art of "33 - P s ychiatric E xamination of the Infant, and Adoles cent" T his chapter des cribes the comprehens ive clinical as sess ment of the child. Although the clinician mus t be aware of the many facets of his tory taking, interview, observation described herein, certain clinical s ettings tas ks may call for a narrower focus of inquiry or emphasis for the evaluation. F or example, an urgent situation may require therapeutic intervention before a comprehensive ass es sment can be completed; in such cases, the immediate evaluation focuses on defining crisis and s electing the mos t s uitable immediate intervention. T hus , the emergency room or crisis center evaluation focus es on precipitants and extent of the current decompens ation, predis pos ing vulnerabilities , exacerbating factors impinging on the child and family and the ameliorative res ources available to the family such s ituations, the risk of danger to self or others, and other iss ues germane to making an immediate (including as sess ing the potential need for E valuation of suicidal ideation, threats , or attempts or aggres sive outbursts are perhaps the most common clinical context for s uch urgent evaluations (T able 33C hildren expos ed to acute trauma (e.g., natural catas trophe or violence) are often screened outs ide the traditional clinic s etting, in a combination of emergency as sess ment and crisis intervention. T he noncompliant, acutely agitated, or delirious child in the pediatric raises yet a different set of ass es sment iss ues (T able

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Table 33-7 Ques tions to As k in E valuation of S uic idal R is k in C hildren S uicidal fantasies or actions

   Do they go to a better place?

   Have you ever thought hurting yours elf?

   Do they go to a pleas ant place?

   Have you ever threatened or attempted to hurt yourself?

   Do you often think about people dying?

   Have you ever wis hed tried to kill yourself?

   Do you often think about your own death?

   Have you ever wanted or threatened to commit suicide?

   Do you often about people or yours elf dying?

C oncepts of what would happen

   Do you know who has died?

   W hat did you think would happen if you tried to hurt or kill yourself?

   W hat was the of this person's

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   W hat did you want to have happen?

   W hen did this person die?

   Did you think you die?

   W hen do you think you will die?

   Did you think you have severe injuries ?

   W hat will happen when you die?

C ircumstances at the of the child's suicidal behavior

Depress ion and affects

   W hat was happening at the time you thought about killing yours elf or tried to kill yourself?

   Do you ever feel upset, angry, or bad?

 

   Do you ever feel no one cares about you?

   W hat was happening before you thought about killing yourself?

   Do you ever feel you are not a worthwhile pers on?

   W as anyone els e with you or near you when thought about s uicide or tried to kill yourself?

   Do you cry a lot?

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   Do you get angry often?

P revious experiences suicidal behavior

   Do you often fight with other people?

   Have you ever thought about killing yours elf or tried to kill yourself before?

   Do you have difficulty s leeping, eating, or concentrating on school work?    Do you have getting along with friends ?

 

   Do you know of anyone who thought about, attempted, or committed suicide?

   Do you prefer to by yours elf?

 

   Do you often feel tired?

   How did this person out his or her s uicidal or action?

   Do you blame yours elf for things happen?

   W hen did this occur?

   Do you often feel guilty? 3529

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   W hy do you think that this pers on wanted to kill hims elf or herself?

F amily and environmental situations

   W hat was happening at the time at which this person thought about suicide or tried to kill hims elf or herself?

   Do you have difficulty in s chool?

   Do you worry doing well in s chool?

  Motivations for s uicidal behaviors

   Do you worry that your parents will punis h you for doing poorly in school?

   W hy do you want to kill yours elf?

 

   W hy did you try to kill yours elf?

   Do you get teased other children?

   Did you want to someone?

   Have you started a new s chool?

   Did you want to get with s omeone?

   Did you move to a new home?

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   Did you wish s omeone would rescue you before you tried to hurt yours elf?

   Did anyone leave home?

 

   Did anyone die?

   Did you feel rejected by someone?

   W as anyone sick in your family?

   W ere you feeling hopeless ?

   Have you been separated from your parents ?

   Did you hear voices telling you to kill

   Are your parents separated or divorced?

   Did you have thoughts?

   Do you think that your parents treat harshly?

   W hat els e was a for your wis h to kill yours elf?

   Do your parents fight a lot?

E xperiences and of death

   Does anyone get hurt?

   W hat happens when people die?

   Is anyone in your family s ad, 3531

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or ups et? W ho?    C an they come back again?

   Did anyone in your family talk about suicide or try to kill hims elf?

F rom P feffer C R . T he S uicidal C hild. New Y ork: G uilford P ress ; 1986, with permiss ion.

Table 33-8 Differential Ps yc hos oc ial Diagnos is of the Unc ooperative Patient Inadequate understanding of the nature of illness injury, treatment details , or s taff expectations and intentions Anxiety and regres sion    S eparation anxiety    C oncerns over bodily integrity

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   R esponse to immobilization    Denial    Idiosyncratic sources of anxiety    Inadequate pain control Depress ion E xacerbation of preexisting psychopathology, es pecially oppositional or conduct difficulties F amily iss ues    P arental anxiety or hostility toward s taff    P arental psychopathology: depres sion, or factitious dis order by proxy    P rior family experiences with illness    C ultural iss ues Developmental is sues (especially adolescence)    E mphasis on autonomy, ambivalence regarding dependency    E mphasis on activity, peer involvement 3533 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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   S elf-cons ciousnes s about body    T he body as a means of expres sing is sues Mature decis ion to refus e treatment

F rom K ing R A, Lewis M: Differential psychosocial diagnosis of the uncooperative patient. C hild P s ychiatr C lin N orth Am. 1994;3:531, with V arious specialized cons ultative purpos es als o require distinctive techniques or procedures or s pecific areas inquiry. F or example, forensic evaluations raise s pecial is sues of role definition, confidentiality, and privilege require familiarity with the legal iss ues involved. must be clear about whether they are serving as impartial advocates for the best interests of the child at behes t of the court or as cons ultants to one party or another. Although the clinician treating or as ses sing child for clinical purpos es may have information to a forens ic evaluation, it is us ually in the bes t the therapy and the legal proceedings for the evaluator be someone other than the therapis t. T he forensic evaluation of children or adolescents who may have been physically or sexually abus ed is a form of forensic evaluation. In addition to ass ess ing the child's competency and credibility, the examiner may be as ked for recommendations regarding whether the 3534 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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child should testify in court (and if s o, how) and P.3059 P.3060 P.3061 P.3062 whether removal of the child or alleged perpetrator the home is needed, as well as any therapeutic interventions that may be required. A forensic requires careful documentation of parent and child interviews . T he sugges tibility of younger children raises the danger of fals e accusations and fals e denials and requires meticulous safeguards against repetitive, suggestive ques tioning. C hild cus tody evaluations als o require careful definition the as sess or's role with all concerned; s pecific must be given to the bes t interests of the child in terms continuity and s tability of care, the quality of parent– attachment and attunement, the child's s tated preferences , the mental health of each parent, and the level of parental conflict and its impact on the child. C ons ultations for the juvenile court regarding youthful offenders or children in need of services and probate or commitment hearings repres ent other forms of forensic evaluation. Other specialized forms of evaluations medication consultations and consultation to day care centers, s chools, or pediatric s pecialty clinics (e.g., oncology clinics ). 3535 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent S T ANDAR DIZE D AS S E S S ME NT INS T R UME NT S F O R C HIL DR E N AND ADOLE

S TANDAR DIZE D INS TR UME NTS FOR AND ADOL E S C E NTS P art of "33 - P sychiatric E xamination of the Infant, and Adoles cent" P.3063 T he decades since the 1970s have seen the of a number of standardized interviews and rating that provide s ys tematic methods for eliciting about child and adolescent ps ychiatric symptoms and combining that information to yield categorical or dimens ional s cores on statis tically derived scales. wave of interes t in developing and testing was stimulated in substantial part by the rapid of res earch activity in child and adolescent psychiatric disorders over this period. Another likely factor for this increase in standardized methodologies is attributable to changes in the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M) nos ological system (beginning with the third edition of the DS M [DS M-III] in 1980), such that diagnoses are based on specific, ope rationalized criteria with a certain number of clearly described symptoms required, occurring with sufficient and s pecified frequency, intensity, or duration, or a 3536 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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combination of thes e. Hence, concurrent developments diagnostic clas sification and in res earch methodology have confronted the field with the need for an array of youth psychiatric ass es sment techniques . T here are a number of reasons why the development meas ures to as sess ps ychopathology in children is challenging than the comparable task with adults . challenges include (1) the need to incorporate an unders tanding of various as pects of development into framing and wording of ques tions about symptoms and into the process of discriminating normative from pathological behavior; P.3064 (2) the necess ity of conducting the as sess ment with and parent (and at times with the teacher), because kinds of information may be uniquely acces sible to one another informant; (3) the importance and difficulty of integrating concepts of social context and adaptive functioning into a s ymptom-based as ses sment; and (4) lack of a readily available gold standard with which to compare the results from as sess ment methods to and to improve them. Despite—or perhaps becaus e these challenges, extensive res earch efforts have been directed toward refining diagnos tic as ses sment in child and adolescent psychiatry. T his effort has yielded a number of measures for us e in res earch contexts; some of the methods des cribed in the following have als o found appropriate adjunctive roles in clinical settings .

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Interviewer-B as ed Interviews Diagnos tic interviews differ from each other in several res pects . One fundamental distinction can be conceptualized as the re s pondent-bas e d versus bas e d approach. T he respondent-based interview been described by S haffer and coworkers as a “precis e script” to obtain clinical information from the informant. T he R B I is a highly structured interview with precisely worded and ordered questions and equally s tructured res ponse options . T here is a branching sequence of questions that s pecify s ymptom frequency, intens ity, duration, as well as degree of ass ociated impairment. T hese questions help determine the significance of the reported behavioral-emotional state and aim to whether it reaches a certain clinical thres hold. Alternatively, an initial negative respons e allows “skip of thes e s pecific and not relevant questions . T he relative advantages of the R B I include the methodological development and als o is sues of and public health applicability. B ecaus e this type of interview is given in the same way each time, it is to study its performance and then to modify it with a relative degree of confidence in the rationale for Another advantage is the potential for relatively data gathering. B ecaus e interview s tructure drives adminis tration, nons pecialis ts can be administrators , subs tantially reducing costs . F urthermore, the us e of a computerized version virtually eliminates administrator error, and diagnostic results can be made available and efficiently, becaus e the computer as sembles the information according to preprogrammed diagnos tic algorithms. E ven more cost effective is s elf3538 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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us ing visual or auditory prompts, or both, which the need for and expense of interviewers . T he potential us e as a screening tool in community and other which clinicians are not available is another highly attractive feature of this method. Interviewer-based interviews (IB Is), on the other hand, the s kills of the clinically trained interviewer to make judgments about the presence and clinical significance reported phenomena. T hese interviews contain s ome degree of s tructure in that definitions are provided what cons titutes a s ymptom, but, although questions provided to prompt the clinician-adminis trator, it is expected that he or s he will pursue inquiry until clinical judgment is satisfied about whether a symptom is T his implies a degree of flexibility and respons iveness the body of clinical data that are ordinarily us ed to determine the significance of reported emotions , and behavior, for example, observation of affectual res ponse to a query or to obs ervational data, s uch as contact, pos ture, and voice inflection. T he choice of interview type and then of the s pecific interview depend on the intended us e, and, before selecting a measure, it is worthwhile to examine some the extens ive literature that has developed on thes e methodologies. B riefly, R B Is probably do not do well in diagnosing extreme and atypical phenomena (e.g., ps ychos is ), as they ass ume that res pondents (youth or parents ) interpret the question as intended by the interview developer and also that the res pondent has capacity to reflect and to s elf-observe about the or abs ence of the symptom. IB Is are more flexible and res ponsive to the s tate of the respondent and hence 3539 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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be shorter to adminis ter. F or example, an as tute can usually addres s manic s ymptomatology fairly and efficiently in a previously high functioning youth. the careful clinician s hould catch mos t ins tances of the res pondent misunders tanding the intent of the whereas the R B Is have little capacity to s elf-correct for inevitable s ource of error. IB Is , although relatively more costly than R B Is to adminis ter, are particularly for clinically bas ed research in which s ubtle diagnostic distinctions may be critical for defining s amples and in which s ample sizes are small enough to justify the of hiring interviewers trained to make thes e judgments. R B Is, however, as noted previous ly, have many flexible innovative applications in research and public health contexts . T hey have also found recent application in an increasing number of clinical contexts , for example, as efficient aids in collecting comprehens ive s ymptom and diagnostic information at clinic or even inpatient intake. B ecaus e they systematically review symptoms acros s domains , it sometimes occurs that this type of screen uncovers significant s ymptomatology, such as s uicidal tendency, that was not queried or not revealed on initial clinical interview. F urthermore, although the R B Is are, some extent, mechanical and lack the personal a s killed clinical interview, it is also likely that many adoles cents , in particular, appreciate the privacy of the computer-based methods (a familiar modality for many youth today). R B Is provide highly s pecified protocols that are us eful for epidemiological studies in which large sizes (i.e., in the thous ands) require us ing many nonclinician interviewers. T hes e s tudies investigate 3540 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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of prevalence of dis orders, developmental patterns of ps ychopathology, psychosocial correlates , and risk and protective factors , topics that often require large to provide enough statis tical power to examine study hypothes es. T he ultimate choice of a measure requires careful weighing of the goals that it is intended to the res ources available, and the pragmatics of the situation. P.3065 R B Is and IB Is have been developed with the goal of reducing error in the collection of information relevant making diagnos es. E rror in the counting and of symptom data to determine a diagnos is can be minimized with R B Is or IB Is by the use of s pecified algorithms, usually computer applied, to establis h sufficient s ymptoms are pres ent for the diagnosis and whether they meet DS M criteria for intensity, and duration. Ultimately, the method that best serves ends of error reduction, logistics , economy (relative to intended goal), and general appropriatenes s is an informed judgment call. As opposed to the early 1980s , however, there now exists cons iderable theoretical and empirical information on which to base such decisions. E arlier in the history of diagnostic methodological development, the ps ychometric properties of reliability and validity were touted as the bases for determining meas ure was best. It is important for users to these concepts and to be familiar with a proposed instrument's performance in these res pects. B riefly, the re liability of an as sess ment method is often as the extent to which the results of an as ses sment 3541 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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repeated. T here are various types of reliability. Inte rrate r involves the s tability of an as sess ment when it is adminis tered by different raters (in this cas e, T e s t-re te s t re liability reflects the s tability of res ults over time (i.e., when an ins trument test is administered on occasions separated by a period of time in which the degree of real change in the condition being measured expected to be trivial). T o as sess the test-retest child ps ychiatric diagnostic instruments , the measure is often adminis tered twice, approximately 2 weeks apart. T his interval is chos en to minimize memory effects child or parent is not likely to remember, and thus precis e respons es to a great number of the ques tions previous ly asked). T he relatively long duration of many child ps ychiatric conditions makes it likely that changes between the firs t and second adminis tration reflect unstable aspects of the measure rather than real in the dis order. V alidity is the extent to which an instrument meas ures what it purports to meas ure. T here are various ways to conceptualize and to as sess validity. T o ass es s what is termed cons truct validity, the child ps ychiatric generated by a particular ins trument are usually to thos e generated by an expert, or criterion, S tatistical methods are then applied to quantify the of agreement on whether diagnos es are present or In the methodological evaluation of the validity of an instrument, agreement is determined diagnosis by diagnosis, s o that it can be revis ed in areas of poor agreement with the criterion. T he es sential challenge in determining the cons truct validity of a meas ure is to 3542 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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compare it to some s tandard that is known to be diagnostically correct. T he problem in the field of ps ychiatric as ses sment is to determine that s tandard, because there is no laboratory test to provide objective evidence for the pres ence of a disorder. P ure clinical as sess ments of child ps ychiatric diagnoses are for varying from clinician to another; thus, the so-called standard is a moving target and hence lacks utility. situation has led to an approach that cons iders an instrument's performance within the nomological net of theory and findings about the condition being S tated briefly, this means that, to the degree that an instrument's findings converge with accumulated and knowledge in the field, one may have relative confidence that, at leas t at this point, the ins trument validly measures what it claims to ass ess . B ecause the major diagnos tic as sess ments have s hown convergence in their evidence for reliability and validity, the pure examination of s tatistical coefficients is provide a sound bas is for choosing what measure to However, in the complex proces s of instrument development, it is important to be aware when a new meas ure is falling below existing standards in these res pects .

R es pondent-B as ed Interviews : The Diagnos tic Interview S c hedule for C hildren T he National Ins titute of Mental Health (NIMH) Interview S chedule for C hildren (DIS C ) is the most extensively developed and s tudied of the R B Is . Initial on it began in 1980, and, over subsequent years , it has gone through numerous methodological revisions and 3543 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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tes ting in clinical and community settings. T he DIS C developed to ass es s the major and relatively common child and adoles cent psychiatric disorders . (It was not intended to identify certain dis orders that clearly clinical interaction, for example, autis tic dis order, for specific s tandardized as ses sments have been T he DIS C was initially des igned for adminis tration by trained nonclinicians who read ques tions and respons e options to res pondents. (R ecent computerized versions can be self-adminis tered.) T wo parallel versions exist, for the youth (DIS C -Y ) and the other for the parent or caretaker (DIS C -P ). T he current version is compatible DS M-IV and IC D-10 (als o the revis ed third edition of DS M [DS M-III-R ]) and covers three time frames (past 4 weeks, pas t year, and lifetime, although the accuracy recall for the lifetime frame is questionable). A uniform question structure has been applied in which an initial s te m ques tion is as ked and is then followed by questions that elicit increas ingly more specific types of information about characteris tics of the potential symptom. T his s tructure builds a great deal of into the interview, but, given the complexity of information required for DS M-IV diagnos es, the early protocols are no longer practical. C omputer-as sisted versions ens ure fidelity to the intended s tructure of the questioning, as well as reduce time los t by the interviewer's need to consider what the next ques tion should be. In addition to s ymptom questions, the DIS C includes questions in each diagnos tic section that about ass ociated impairment and perceived s everity of impairment. T hese questions are as ked if a res pondent meets a certain bas e level of s ymptomatology for a 3544 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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diagnosis. An extensive literature is now available on the DIS C as sociated technologies (acces sible through the W eb http://www.c-disc.com/). Diagnos es are derived by application of a set of extensively developed computer algorithms. T he DIS C -IV has been constructed in s uch way that it is als o poss ible to generate symptom scale scores, further increasing its flexibility and general us efulnes s. Importantly, res pondent acceptability has demonstrated to be quite good, des pite s ome (but not overwhelming) perception that it is a bit lengthy. A S panis h version has been developed and extensively tes ted. T he DIS C -IV has been translated into languages and has found various innovative around the world. P articularly exciting are those in can ass ist in clinical contexts in places where trained mental health clinicians are in s hort supply. It should go without saying that, of cours e, no R B I can s ubstitute for thoughtful clinical practice, and the developers of this method have been clear that its use is adjunctive and facilitative, not diagnostically definitive, when applied in clinical s ettings .

Interviewer-B as ed Interviews V arious IB Is have been developed to meet different res earch needs. In choos ing an IB I for a particular or clinical application, it is necess ary to cons ider their different s trong points and limitations . S ome frequently us ed interviews include the S chedule for Affective Dis orders and S chizophrenia for C hildren (K -S ADS ), C hild and Adoles cent P s ychiatric As ses sment (C AP A), Diagnos tic Interview for C hildren and Adolescents 3545 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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the C hild As ses sment S chedule (C AS ), and the Dis orders Interview S chedule for C hildren (ADIS -C ). these measures, an extensive literature is available defies s ummary in a s ingle chapter. F ollowing are brief comments about the most commonly us ed IB Is. T here are a variety of different vers ions of the K -S ADS , reflecting the modification of this meas ure by at different sites and with differing specific interests and as sess ment philosophies. One important feature of the S ADS method is that, unlike that des cribed for the previous ly, the parent is interviewed first; the same interviewer then interviews the child and us es of the parent's report to res olve differences and to a conclus ion about s ymptom presence. P.3066 T he C AP A is a comprehens ive measure that, in ps ychiatric symptomatology and impairment, covers family, environmental, and ps ychosocial problems; life events; impact of the child's problems on the family; mental health service use. It has been des igned for adminis tration by nonclinicians who have been extensively trained. T his is accomplished by providing detailed definitions and rules that govern the of reported phenomena and determination of whether they s hould be rated as s ymptoms . T he DIC A has IB I and R B I versions (the latter being computer based). A modification of it called the Ass es sment of G enetics Interview for C hildren provides specifications on eliciting and coding B oth forms have versions specifically des igned for 3546 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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adminis tration to children in the range from 6 to 12 of age. T he C AS is distinctive in being organized around such that its s tructure is more like the usual clinical interview of the child than most s tandardized which are generally organized by diagnos is . S imilarly, C AS has the interviewer rate a number of aspects of child's behavior during the interview. T here are child, adoles cent, and parent forms of the C AS , and it has us ed by trained lay interviewers, as well as by T he ADIS -C provides extens ive coverage of anxiety disorders and less extens ive coverage of other types of symptomatology. T he ADIS -C is designed for clinician adminis tration and was developed from the adult of the s ame name.

R ating S c ales A large variety of checklis t rating scales have been developed s ince the 1980s to ass es s s ymptomatology various aspects of behavior and adaptive functioning. Different measures have been des igned for completion parents , teachers , or children. T hese focus on a broad range of symptoms or a s pecific area (e.g., depress ion anxiety). T he development of each s cale involves its reliability and validity and administering it to large divers e s amples to determine norms and clinically cutoffs. P robably the most widely used comprehensive rating scale is the C hild B ehavior C hecklist (C B C L). It been refined and developed into a s ys tem of measures that includes a young child vers ion (C B C L/2–3), the 3547 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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T eacher R eport F orm (T R F ), a Y outh S elf R eport adoles cents (ages 11 to 18 years ), and the Direct Observation F orm (DOF ) (which is completed after observing clas sroom behavior), in addition to the C B C L (now the C B C L/4–18). Important features of this system of meas ures include its empirical development the large population s ample on which it was normed, well as testing on large s amples of clinically referred children. T he availability of age-based and gendernorms provide a convenient way to s creen for overall of symptomatology, and, when scored, the C B C L profile of problem areas and competencies . T he C B C L stable over relatively brief intervals (i.e., good tes treliability) but also reflects changes res ulting from treatment. T he C B C L, T R F , and Y S R have been widely in epidemiological and clinical research and in many clinical s ettings and countries. T hese measures can be us eful clinical s creening tool, as well as an efficient clinics to gather uniform information for characterizing populations served and changes in thos e groups over time. T he B ehavior As ses sment S ys tem for C hildren (B AS C ) another as sess ment s ys tem for evaluating aspects of behavior and pers onality in children and adolescents 4 to 18 years. It cons is ts of parent, teacher, and child youth self-rating scales and a S tructured His tory form and a S tudent Observation S ys tem (for clas sroom behavior). T he parent and teacher have forms appropriate for ages 4 to 5 years, 6 to 11 and 12 to 18 years . A distinctive feature of the B AS C is emphasis on positive as pects of the child's adjustment, addition to rating symptoms and problem behaviors. An 3548 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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additional feature of this system is its coverage of problems related to s chool functioning, s uch as in social or study s kills . Norms have been es tablis hed children by age, gender, and clinical s tatus. T his been designed for application in clinical, educational, res earch, and program evaluation contexts. T he R evised C onners ' P arent R ating S cale (C P R S -R ) revis ion of the commonly used C onners ' P arent R ating S cale (C P R S ) that collects systematic information from parents on child oppositionality, cognitive difficulties , hyperactivity-impulsivity, anxiety and shyness , perfectionism, s ocial problems, and ps ychosomatic complaints . It was developed and tested on a s ample children and youth 3 to 17 years of age. T he R evis ed C onners ' T eacher R ating S cale (C T R S -R ) is a instrument completed by the child's teacher that can be convenient means of collecting information on behavior. Its factor structure maps onto the first s ix of seven parent factors, as ps ychosomatic s ymptoms are as sess ed in the teacher version. It is often a us eful in evaluating and particularly in monitoring children treated with medication for ADHD. T he R evised B ehavior P roblem C hecklis t (R B P C ) symptoms of conduct disorder, socialized aggress ion, attention problems and immaturity, and anxiety and withdrawal, with auxiliary scales for ps ychotic behavior and motor tens ion-excess . It is designed for us e by and teachers of children and youth 5 to 17 years of Although generated using factor analytical s tudies of clinical s amples , it has also been normed on children and youth. T he Louis ville B ehavior C hecklist is a comprehensive 3549 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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parent rating s cale to be completed by parents of 4 to 17 years of age. It consists of 19 scales that cover wide range of behavior and s ymptomatology. T he P ers onality Inventory for C hildren (P IC ) is an inventory developed for parents to complete on children and 3 to 16 years of age. It is an extens ive meas ure, on the model of the Minnesota Multiphasic P ers onality Inventory (MMP I), with a variety of component s cales . T he C B C L, B AS C , C onners ' families of rating scales, R B P C are examples of as ses sment tools des igned to information acros s a range of symptoms and competencies. More narrowly focused s ymptom rating scales have been developed to permit the quantitative as sess ment of specific symptom realms . T hese latter may be useful in quantifying the presenting s everity of certain s ymptoms to es tablis h a bas eline against which res ponse to a therapeutic intervention can be number of thes e s cales are self-report meas ures . have the advantages of providing an opportunity for the child to report on s ymptoms that might be difficult to conceptualize or verbalize. S ometimes parents or (es pecially adoles cents ) are initially more willing to an area of difficulty in the s eemingly more anonymous context of a ques tionnaire than they are in a face-tointerview. On the other hand, s elf-reports als o carry the of the child mis understanding some ques tions or compelled to provide s ocially desirable res ponses than acknowledging behaviors and feelings that the believes might be met with disapproval. With these potential limitations in mind, child self-report meas ures can provide useful adjunctive information in clinical settings or res earch studies . 3550 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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Among the rating scales useful in research and clinical practice are those for ass ess ing the severity of symptoms. One of the mos t widely us ed, the C hildren's Depress ion Inventory (C DI), is a s elf-report meas ure as sess ing symptoms of depress ion in children 7 to 17 of age. It was adapted from the well-known adult scale, B eck Depres sion Inventory, and has s een considerable in clinical and res earch s ettings . T he R eynolds Depress ion S cale (R ADS ) was designed specifically to as sess depress ive s ymptoms in adoles cents and has us ed in various populations. In addition to res earch applications , it may be particularly appropriate to for depress ion in s chools or other such s ettings . T he C hildren's Depress ion R ating S cale–R evised, modeled the adult Hamilton R ating P.3067 S cale for Depress ion, as sess es 17 depres sive areas, bas ed on a 20- to 30-minute, focus ed, semistructured interview. It is well s tandardized and us eful sens itive and reliable s creening instrument and meas ure of depres sion for children 6 years of age and older. V arious rating s cales for different types of anxiety symptoms, traits , and disorders are als o available. F or example, the R evised C hildren's Manifes t Anxiety C MAS ) is a child self-report meas ure that ass es ses symptoms of anxiety (including physiological anxiety), worry, overs ens itivity, s ocial concerns, and C hildren at a third-grade reading level or greater can fill out individually or by group adminis tration, and it has been us ed with younger children by reading the items 3551 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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aloud. T he Multidimens ional Anxiety S cale for C hildren (MAS C ) is a self-report meas ure for children and adoles cents 8 through 18 years of age that ass ess es symptoms of anxiety in the areas of phys ical symptomatology, s ocial anxiety, harm avoidance, and separation anxiety, as well as seven more refined subdomains . It has been us ed in a number of treatment studies to monitor response. T he S tate-T rait Anxiety Inventory for C hildren (S T AIC ) cons is ts of two scales to meas ure thes e aspects of anxiety through self-report. T he S creen for C hild Anxiety-R elated Dis orders (S C AR E D) is a s elf-report instrument for and parents that ass ess es symptoms of several types DS M-based anxiety disorders (generalized anxiety disorder, s eparation anxiety dis order, panic disorder, social anxiety disorder). Its component items s ort into factors , corres ponding to the dis orders noted plus a s chool phobia factor. Ins truments are also available for ass es sing many types of child and adoles cent s ymptomatology, symptoms of obsess ive-compuls ive disorder (OC D) child version of the Leyton Obsess ive Inventory and C hild Y ale-B rown Obses sive C ompuls ive S cale), tic (Y ale G lobal T ic S everity S cale), and eating dis orders related attitudes (E ating Disorder Inventory and E ating Attitudes T est). F or ass es sment of autis m and related disorders , there is the Autism Diagnos tic Observation S chedule (ADOS ), a play-based interview with standardized probes and ratings for various facets of relatednes s, communication, and repetitive behaviors; Autism Diagnos tic Interview-R evised (ADI-R ) is a semistructured interview adminis tered to parents 3552 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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regarding developmental miles tones and aspects of interaction, communication, and repetitive behaviors . Ins truments also exis t for ass es sing level of adaptive functioning and impairment, globally or with respect to specific domains . T he C hildren's G lobal Ass ess ment (C G AS ) provides a quantitative s cale for the clinician's rating of overall impairment. T he C olumbia Impairment S cale is a rating scale of impairment that taps four areas of functioning: interpers onal relations , broad ps ychopathological domains , functioning in s chool or at job, and use of leis ure time. T he V ineland Adaptive B ehavior S cales provide a comprehensive age-normed framework for systematically recording and ass es sing development of children with res pect to various realms adaptive functioning. T he S ocial Adjus tment Inventory C hildren and Adoles cents (S AIC A) is a s emistructured interview for as ses sing social functioning. V arious structured and semi-structured formats for performing or recording portions of the child mental status examination have been developed. S ome, such the child version of the Mini-Mental S tate E xamination contain s pecific s tandardized items for screening functions . Other instruments , such as the Mental Ass es sment F orm, provide a format for organizing status data derived from a s emistructured clinical interview.

L imitations of S truc tured C linic al A s s es s ment Interviews and scales , s uch as those des cribed can, at times , be us eful adjuncts in clinical as ses sment thoughtfully chosen and adminis tered with sensitivity to 3553 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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their meaning in the overall proces s of the evaluation. example, they can help ens ure a comprehensive symptoms or provide a s tandardized baseline measure severity for later determination of intervention efficacy. T hey cannot, however, replace an individualized child ps ychiatric interview or be relied on as the sole basis es tablis hing diagnoses or planning treatment. Most standardized interview schedules are designed as symptom inventories and not as the comprehensive as sess ment of feelings , personality s tyle, coping mechanisms, s ituational context, and adaptive that the clinical interview affords . S uch factors may be crucial to the clinical as sess ment and treatment as the pres ence or absence of a given pathognomonic symptom or categorical diagnosis. T he res earcher interested in s electing meas ures for a protocol mus t review carefully the exis ting meas ures in area of interes t and cons ider the ps ychometric characteristics of potential meas ures and the appropriatenes s of the measures for the s tudy s ample the goals of the s tudy. It is useful to begin by some up-to-date critical reviews of thes e instruments . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent P S Y C HO LOG IC AL AND NE UR OP S Y C HOLO G IC AL AS S E S S M

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P art of "33 - P sychiatric E xamination of the Infant, and Adoles cent" P sychological ass es sment using tests of pers onality mental functioning can be a valuable part of the child ps ychiatric evaluation. P s ychological evaluations unique perspective on the child's condition by information complementary to that obtained from observation, and interview. With history and such ps ychological data may clarify relations hips various etiological factors or may help direct the of an appropriate intervention. Although partly the clinical information derived from projective tes ts of personality is les s influenced by certain reporting (e.g., s ocial desirability) than s elf-report. P s ychological tes ting also provides data that are more quantitative the qualitative information provided by the child's presenting complaints, and clinical pres entation. T he quantitative character of tes t findings is more important in the as sess ment of cognitive abilities than personality ass es sment, becaus e the child's relative strengths and weaknes ses in mental proces sing can es timated only gros sly from history taking and clinical observation. S uch clinical estimates are also less accurate. T he ability to discriminate meaningful differences among various domains of functioning clarify the particular pattern or s yndrome evidenced by child. T he as sess ment of cognitive functioning also cognitive impairments that may underlie or influence ps ychological condition under investigation (e.g., poor s ocial judgment in a child with conduct dis order res ults from a nonverbal learning dis ability). 3555 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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the manner in which any cognitive impairments or strengths interact with the child's psychological can be delineated. F indings from tests of pers onality identify important dynamics that affect the child's condition.

R eferral for P s yc hometric A referral for a ps ychometric as sess ment of the child is reques t for a profes sional cons ultation from which an opinion regarding the referral ques tions can be T he referral for ps ychological examination is analogous that made to a neurologis t or radiologist, who uses his her as sess ment methods and particular expertis e to contribute potentially valuable information that can then be considered, evaluated, and integrated into the ps ychiatric evaluation. R eferrals are, therefore, best worded in terms of the information that is needed, the is sue to be resolved, or the decis ions that mus t be rather than requesting that s pecific tests be P.3068 R eferral ques tions can be broad in scope, such as reques ting a s econd opinion regarding the child's condition from the unique perspective of ps ychological tes t findings . R eques ts for as sistance in delineating differential diagnoses or in identifying idios yncratic attributes of the child that may affect treatment are narrower referral questions that, nonetheless , s till relatively broader ps ychological examinations . In more narrowly focus ed ques tions, such as the the child's reality testing, may permit more focused examinations. However, the extent to which 3556 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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evaluations can be res tricted to a narrowly defined question has a lower limit. Usually a critical mas s of required to interpret tes t findings properly. R eferrals for psychological examination s hould be profes sionals who us e the appropriate ins truments and can interpret the findings . J ust as psychiatrists may specialize in the treatment of adult, child, or geriatric patients or may develop a s pecial expertise with certain disorders , s o ps ychologists also develop s pecialized in as ses sing certain groups of children or s yndromes. as in medicine, board certification in clinical ps ychology clinical neuropsychology is one method for identifying ps ychologists practicing s pecialties . T he American P sychological Ass ociation directory or various of certifying boards are useful references in the s earch an appropriate examiner. Although it is still bes t to state a referral ques tion, are frequently made for a particular type of evaluation (e.g., psychological vs. neuropsychological). A request ps ychological evaluation is commonly unders tood by ps ychologist to mean ass es sment of personality and intelligence, with only a screening of achievement or cognitive functioning unless specifically requested. In contrast, a reques t for a neuropsychological evaluation a neuropsychologis t is as sumed to mean as sess ment of cognitive functioning, including intelligence, complex mental proces sing, attention, memory, language, perception, and motor functioning, with only a screening of personality. T he primary purpos e of neurops ychological evaluations not to detect brain damage. R ather, comprehensive as sess ment of cognitive functioning, attention, 3557 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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language, perception, and motor functioning permits identification of deficits that cause academic, s ocial, or developmental disabilities or that impede ps ychiatric treatment. S uch as ses sments also identify the child's of strengths and weakness es and help provide the for pres cribing rehabilitative interventions that may be delivered as s pecial education, occupational therapy, phys ical therapy, or vocational or cognitive B y pars ing the ps ychological and cognitive that contribute to the child's functional dis ability, s uch as sess ments als o help delineate the interaction the child's ps ychological disorder and cognitive impairments . Although neurops ychologists are familiar with the cognitive s equelae of various neurological conditions and can be particularly helpful in the as sess ment of children with neurological dis orders, any child requiring a detailed ass ess ment of cognitive functioning is appropriate for referral.

P s yc hologic al Tes t B atteries T able 33-9 contains a lis t of commonly us ed meas ures for various domains of functioning. A comprehensive examination samples all of the whereas a more focused evaluation s elects a s ubs et of domains . In the mos t general sens e, a battery of tests cons ists merely of a collection of tests to meas ure a of mental functions . T here are loos ely defined batteries that are routinely administered in ps ychological examinations. F or example, the ps ychological battery child often includes the W echs ler Intelligence S cale for C hildren–IV (W IS C -IV ) or the K aufman As sess ment for C hildren–II (K -AB C -II) as the meas ure of addition, there may be a measure of achievement in 3558 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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linguistic skills and math, such as the T ests of from the W oodcock-J ohns on P sychoeducational III (W J P B -III) or the W echs ler Individual Achievement (W IAT ). A tes t of visuomotor integration or visual cons truction, such as the B eery-B uktenica T es t of motor integration (V MI) or the B ender V is ual-Motor T es t, is als o us ually administered. F inally, a variety of personality tests and behavior rating s cales are used.

Table 33-9 C ommonly Us ed C hild Adoles c ent Ps yc hologic al Ins truments Tes t

Age C omments (Yrs )/G rades

Intellectual ability

 

 

   W echsler Intelligence S cale for C hildren–IV (W IS C -IV )

6–16

Index scores : IQ, performance F ull-S cale IQ, freedom from distractibility, and proces sing s peed.

   W echsler Adult Intelligence

16 to adult

Index scores : IQ, performance

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III (W AIS -III)

F ull-S cale IQ, working memory, and proces sing speed.

   W echsler P res chool and P rimary S cale of Intelligence–III (W P P S I-III)

3–7

T his test is old, and the third edition has jus t been developed.

   K aufman Ass es sment for C hildren–II (K AB C -II)

3–18

S cores : mental proces sing composite (F ullS cale IQ equivalent); sequential and simultaneous proces sing indices and achievement.

   K aufman Adoles cent and Adult Intelligence T es t (K AIT )

11–85+

S cores : composite intelligence scale, crys tallized intelligence, and fluid intelligence.

   S tanford-B inet, fourth edition (S B :IV )

2–23

S cores : IQ, verbal, abstract or visual, and quantitative

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reasoning shortterm memory. Language

 

 

   C omprehensive Ass es sment of S peech and Language (C AS L)

3–21

Ass es ses of language at four levels: lexical or semantic, supralinguis tic, pragmatic.

   Oral Written Language S cales (OW LS )

3–21

Ass es ses listening comprehension, oral expres sion, written express ion.

   P eabody P icture V ocabulary T es t– (P P V T -III)

4 to adult

Meas ures semantic vocabulary.

Achievement

 

 

   W oodcockJ ohns on P sychoeducational B attery–III (W J P B III): T es ts of Achievement

2–90+

S cores : reading mathematics (mechanics and comprehension), written language, and other achievement;

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and age s cores, standard s cores, percentiles, and other s tatistical scores.    W echsler Individual Achievement II (W IAT -II)

G rades K –

S tandard scores : basic reading, mathematics reasoning, spelling (cons tituting S creener); reading comprehension, numerical operations , listening comprehension, oral expres sion, written express ion. C onormed with WIS C -III.

Adaptive behavior

 

 

   V ineland B ehavior S cales

Normal: 0– 19

S tandard scores : adaptive behavior composite and communication, daily living s kills , socialization and

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motor domains ; percentiles, age equivalents , developmental scores. S eparate standardization groups for normal, visually handicapped, hearing impaired, emotionally disturbed, and retarded.  

R etarded: ages

 

   S cales of Independent B ehavior–R evised

Newborn to adult

S tandard scores : four adaptive (motor, social interaction, communication, personal living, community living) and three maladaptive (internalized, as ocial, and externalized) G eneral

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Maladaptive Index and B road Independence clus ter. E xecutive proces sing and attentional

 

 

   C onner's C ontinuous P erformance T est (C P T -II)

6 to adult

C omputerized meas ure of attention, and impulsivity.

   C onner's C ontinuous P erformance T est: K iddie V ersion (K CPT)

4–5

C omputerized meas ure of attention, and impulsivity for younger children.

   T rail Making

8 to adult

S tandard scores , standard deviations, ranges; corrections for age and education.

   W is consin C ard S orting T es t

6.6 to adult

S tandard scores , standard deviations, T percentiles,

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developmental norms for number of categories achieved, perseverative errors, and failures to maintain s et; computer meas ures .    B ehavior Ass es sment for C hildren

4–18

T eacher and rating scales and child s elf-report of personality permitting multireporter as sess ment variety of domains in home, school, and community. P rovides validity, clinical, and adaptive scales. ADHD component avails.

   Home S ituations Ques tionnaire– R evised (HS Q-R )

6–12

P ermits parents to rate child's s pecific problems with attention or

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concentration. S cores for number of problem mean severity, factor scores for compliance and leisure s ituations.    ADHD R ating S cale

6–12

S core for number symptoms keyed Diagnos tic and S tatis tical Manual Me ntal Dis orde rs cutoff for diagnos is of ADHD; s tandard scores permit derivation of significance for total s core and two factors hyperactive and impulsivehyperactive).

   S chool Ques tionnaire– R evised (S S Q-R )

6–12

P ermits teachers rate a child's specific problems with attention or concentration. S cores for number

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of problem and mean    C hild Attention P rofile (C AP )

6–12

B rief meas ure allowing teachers ' weekly ratings of presence and degree of child's inattention and overactivity. Normative s cores for inattention, overactivity, and total s core.

V is ual–spatial perception and visual cons truction

 

 

   B enton V is ual R etention T est

6 to adult

Ass es ses of deficits in figure memory. Mean scores by

   B ender V is ual Motor G es talt T es t

5 to adult

Ass es ses vis ualmotor deficits and visual-figural retention. Age equivalents .

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   R ey-Osterrieth C omplex F igure

10 to adult

Ass es ses vis ual cons truction, organization, and visual s patial perception.

P rojective personality tests

 

 

   R orschach test

3 to adult

S pecial s coring systems . Mos t recently developed and increasingly universally accepted is J ohn E xner's C omprehens ive S ys tem (1974). Ass es ses accuracy, integration of affective and intellectual functioning, reality tes ting, and other ps ychological proces ses.

   T hematic apperception test

6 to adult

G enerates stories that are analyzed

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(T AT )

qualitatively. Ass umed to es pecially rich regarding interpersonal functioning.

   Machover DrawA-P ers on (DAP )

3 to adult

Qualitative and hypothes is generation, es pecially subject's feelings about s elf and significant others .

   K inetic F amily Drawing (K F D)

3 to adult

Qualitative and hypothes is generation regarding an individual's perception of structure and sentient environment. objective s coring systems in exis tence.

   R otter S entences B lank

C hild, adoles cent,

P rimarily analysis, although

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and adult forms

some objective scoring s ys tems have been developed.

Objective personality tests

 

 

   Minnes ota Multiphasic P ers onality InventoryAdoles cent A)

14–18

1992 vers ion of widely us ed personality meas ure, developed specifically for us e with adoles cents . S tandard scores : three validity 14 clinical scales, additional content and scales.

   Millon P ers onality Inventory (MAP I)

13–18

T s cores for 20 scales grouped three categories: personality s tyles , expres sed and behavioral correlates . on adoles cent

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population. on broad spectrum, not jus t problem areas . Meas ures 14 primary traits, including emotional stability, self-concept level, excitability, and self-as surance.    Millon C linical Inventory (MAC I)

13–19

T s cores for 30 scales grouped four categories : validity scales, personality patterns, concerns , and clinical

   P ersonality Inventory for C hildren–2 (P IC -

5–19

T s cores for 33 scales grouped ten categories : validity scales, cognitive, ADHD, delinquency, reality testing, somatizing, discomfort,

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withdrawal, and social s kills .    C hildren's P ers onality Ques tionnaire

8–12

G enerates combined broad trait patterns, including extravers ion and anxiety.

Neurops ychological   tes t batteries

 

   R eitan-Indiana 5–8 Neurops ychological B attery for

C ognitive and perceptual-motor tes ts for children with suspected brain damage.

9–14    Halstead-R eitan Neurops ychological B attery for Older C hildren

S ame as R eitanIndiana Neurops ychologica T es t B attery for C hildren.

   NE P S Y : A 3–12 Developmental Neurops ychological Ass es sment

Domains: attention/executive language, sens orimotor, visuospatial, and

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memory.

ADHD, attention-deficit/hyperactivity disorder. Adapted from Moss NE , R acusin G R . P s ychological as sess ment of children and adolescents . In: Lewis M, C hild and Adole s ce nt P s ychiatry. 3rd ed. B altimore: Lippincott W illiams & W ilkins ; 2002. S ome published test batteries cons is t of measures of various mental functions that have been developed together and can usually be combined into compos ite factor scores . F or infants and pres chool children, ps ychometric instruments primarily focus on development, including motor, sensory, perceptual, language development, and the development of conceptual reasoning. C omprehens ive developmental quotients are derived from many of these instruments . revis ion of the B ayley S cale of Infant Development and Mullen S cales of Development are two notable T he Woodcock-J ohns on P s ychoeducational B attery the NE P S Y are appropriate for school-aged children examine a variety of s maller domains of functioning.

P ers onality Meas ures P ers onality tests for the young s chool-aged child primarily of projective tes ts of personality. P rojective contrast with objective tests of pers onality in that projective tests us e limited structure and ambiguous 3573 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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stimuli to which the child can res pond in a virtually unlimited variety of ways. P erhaps the best-known example of a projective technique is the R ors chach Other projective tes ts commonly us ed for the young, school-aged child include the R obert's T hematic Apperception T est (R T AT ) and the C hildren's T es t (C AT ), which require that the child compose a res ponse to a picture depicting a s cene that is s uitable children. A variety of tes ts administered to this age require the child to draw, such as the Draw-A-P ers on tes t, the House-T ree-P ers on (HT P ) tes t, and the F amily Drawing (K F D). (Methods exis t for scoring drawings to ass es s cognitive and vis ual motor development, as well as affective content.) F or the part, the interpretation of res ponses to projective tes ts personality is inferential; that is, the meaning is not evident in the res ponse. T he inferences are based on accumulated clinical experience reported in the symbolic interpretation or analogous reasoning based theory (e.g., psychoanalytic theory), and, to a much extent, empirically es tablis hed norms . T he notable exceptions are the s cores derived from the E xner S ys tem for the R orschach test and the R T AT , which norms and have been extens ively studied in empirical res earch. Objective pers onality tes ts are usually more structured than are projective tests , in that the s timuli have limited ambiguity, and only a s elect number of respons es are permitted. In mos t objective meas ures , individuals are as ked whether various statements are true or fals e for them. P erhaps the best-known example of an objective tes t of pers onality is the MMP I, which is now in its 3574 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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revis ion (MMP I-2) and is appropriate only for adults. Objective meas ures of pers onality for younger children us ually limited to behavior rating scales or structured reports by parents or caregivers. T he P IC and the good examples of these measures . T here are objective tes ts of personality available for adolescents in the of the MMP I-2. T he Minnes ota Multiphasic P ers onality Inventory–Adoles cent (MMP I-A), the Millon Adolescent P ers onality Inventory P.3069 P.3070 (MAP I), and the Millon Adoles cent C linical Inventory (MAC I) are three well-known examples. T hes e tests personality profiles bas ed on the relative deviations of scales that measure various ps ychological attributes .

Validity and R eliability Although the validity and reliability of individual tests, meas ures of s pecific mental functions, are established group data, the reliability and validity of findings for the individual child are also a concern for the examining ps ychologist. T es t batteries provide some advantages determining the reliability and validity of individual tes t findings. An integrated battery contains s ome overlap the tes ting of mental functions , permitting comparative as sess ment of the consis tency of the child's acros s meas ures . In addition, if there is a theoretical or empirical basis for knowing that s ome mental abilities as sociated with each other, then cons is tent findings meas ures of thos e abilities s trengthens the confidence 3575 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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the findings for the individual child. E xaminations that focus on a few mental functions by adminis tering a number of tests do not permit detection of trans ient performance factors that may cause spurious s cores . addition, no test is a pure meas ure of the target therefore, performance P.3071 on a s ingle test may be impeded by impairment of a mental function necess ary for performing the task but the function that the tes t purports to measure. If ps ychometric evaluations have been performed, the reliability of findings for the particular child can be es timated from the cons istency of findings across examinations. F inally, the ass es sment of children with motor, hearing, or vis ual impairments pres ents a special challenge. E very psychological measure requires a modality of perception, mental proces sing, and of express ion. T o ass es s children with impairments in of thes e functions, tests are selected with forms of and expres sion that avoid the obvious ly impaired functions . C hildren with pervas ive disorders of mental proces sing require as ses sment methods appropriate their level of functioning. In such cases, it is frequently more helpful to characterize the impairments in terms criterion-referenced measures, which list abilities mastered, or in terms of the child's s tanding among children of the s ame diagnostic group.

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T he interpretation of ps ychometric findings is on s tandardized administration of the tes ts. In addition, the proper interpretation of ps ychometric findings generally requires knowledge of parametric and nonparametric statis tics, mas tery of the literature on performance and test cons truction, familiarity with the cons truction and ps ychometric properties of the tes ts us ed, and knowledge of the literature on thos e instruments. T he res ults of ps ychological examination are often bes t integrated in a concluding discuss ion of the findings as they pertain to the referral ques tion. T he res ults of a neurops ychological examination are organized around discuss ion of various functions with a concluding integration. T he interpretation of test results includes cons ideration of the immediate context in which the were administered (e.g., performance factors , s uch as fatigue, anxiety, rapport, level of cooperation, and motivation of the child). T here are generally three analysis for the tes t s cores themselves : (1) s ymptoms, levels of performance, and (3) syndromes or patterns . S yndrome analysis interprets scores within the context the res ults of other meas ures and is the most powerful form of analys is in terms of the ability to extrapolate beyond the immediate test data. T his capacity to extrapolate is based on the known characteris tics of children evidencing the syndrome. F inally, in testing children, one must bring a developmental pers pective the findings, so that future difficulties can be with the changes that occur as the child grows older. P sychometric findings are communicated more easily if the clinician receiving them understands some bas ic 3577 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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principles of ps ychometrics . Most people clus ter some average score for mos t meas ures of mental and fewer persons s core high or low. T he dis tribution approximates a binomial distribution in the form of an inverted U, known as the normal curve . R aw s cores frequently the number of correct res ponses during a and are not usually reported. P ercentile s cores indicate percentage of pers ons obtaining raw scores equal to or less than the raw s core obtained by the individual. In normal distribution, small changes in raw scores clos e the average (where many people are grouped) res ult in relatively large shifts in the percentile rank, whereas shifts in raw s cores at the high or low ends of the distribution may change the person's percentile rank T o compensate for the variations in the rate of change percentile scores, and to make performance levels comparable acros s tests, raw s cores are converted to standard, or deviation, s cores that indicate the extent which an individual deviates from the mean or average. convention, the average s tandard score for most ps ychological tes ts is 100, and the standard deviation at 15 IQ points or standard s core points with thes e ps ychometric properties . B y the us e of standard performance levels on meas ures of specific mental can be compared with IQ or with other tes t res ults. S tandard scores also give the best indication of differences among s cores, becaus e the intervals scores of the same magnitude are equal anywhere the distribution of scores. S tatis tical s ignificance occurs when the probability is low that a difference between scores could have occurred by chance, as the result of inherent error variance in the test. B y convention, a 3578 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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of .05 probability is set as the standard for s tatistical significance. Although two scores may differ, that does mean that the difference is meaningful or has clinical significance. Many s tatistically significant differences frequently in the normal population. F or example, a difference of 15 points between the verbal and performance IQ s cores of the WIS C -IV is s tatistically significant; however, a difference of this magnitude or greater occurs in approximately one-fourth of the subjects us ed to s tandardize the test. Of cours e, a difference of this magnitude could have clinical significance in a particular cas e, if the advers e effect of difference was exacerbated by other factors. S ome tests for children allow calculating s tandard from age norms or grade norms, for example, the Woodcock-J ohns on P sychoeducational B attery and the K aufman T es ts of E ducational Achievement. T he between these two methods of calculation illustrates importance of understanding test s cores in relation to normative reference group. A standard s core bas ed on norms compares the performance of the child to that of other children of the s ame age. A s tandard s core grade norms compares the child's performance with of other children in the s ame grade. If the child has retained in grade to compens ate for learning problems , the standard s core based on grade norms is artificially inflated, mas king the extent of the child's impairment. the other hand, an achievement s core based on grade norms indicates how well the child has mastered the curriculum at that grade level. In general, grade scores age s cores, as opposed to s tandard scores , s hould be interpreted cautiously, becaus e their psychometric 3579 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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properties are poor, and the implications of the s cores acros s levels . C linical decisions should not be based on thes e types of scores. T here has traditionally been a concern about reporting scores, because people do not understand that the are not abs olute and immutable. R eporting the error of measurement or confidence intervals helps realize that s cores have inherent error and vary to extent over s ucces sive adminis trations of the test, even when the tes t is valid and reliable by present C onfidence intervals are the range of s cores believed contain the true s core at a specified level of probability. T he WIS C -IV and W J P B -III scoring programs, for will calculate confidence intervals for s tandard s cores, 90 percent and 95 percent probability. Higher levels of confidence necess itate larger ranges of scores .

R eport of the P s yc hometric Ordinarily, the child's parents are informed of the a ps ychological or neurops ychological evaluation. tes t s cores are easily mis interpreted, reports of ps ychological tes t findings should not to be given to the child or parents unless a qualified profes sional is explain the findings and to ans wer questions . It is the referring clinician indicates how such feedback is to given. In many s ituations , es pecially if the findings create dis tres s for the child or family, the referring may wish to provide the feedback. If a written report is desired, then a report can be written for the family that does not include confus ing technical information and is P.3072 3580 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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designed to minimize advers e effects of s ens itive In other cases , the referring clinician may choos e to the ps ychologist provide feedback. Alternatively, the referring clinician may decide to meet with the ps ychologist and the family, so that the ps ychologis t explain any technical as pects of the evaluation and its findings, whereas the referring clinician can place the findings within the context and perspective of the as sess ment and treatment recommendations. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent LAB O R AT OR Y ME AS UR E S

LAB OR ATOR Y ME AS UR E S P art of "33 - P sychiatric E xamination of the Infant, and Adoles cent" A burgeoning number of research studies applying new techniques of molecular genetics , neurobiology, and s tructural imaging, and neuroendocrinology are rapidly expanding unders tanding of the pathogenes is various childhood psychiatric disorders . T his section, however, focus es on the practical us e of various studies in the clinical ass ess ment of the child for psychiatric evaluation.

P ediatric and Other A djunc tive E valuations Pediatric E valuation C los e collaboration with the child's pediatrician is an important component of any evaluation. T he 3581 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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pediatrician is a valuable source of information about child's developmental and medical history and can contribute a unique long-term perspective on the child and family. A general pediatric examination is a us eful adjunct to ps ychiatric evaluation of a child. In addition to a review of s ys tems, the pediatrician should as ses s the child's current and pas t phys ical growth (head circumference, height, weight, and pubertal s tatus ). S creening of hearing and vis ion, with more detailed tes ting as indicated, is important, because deficits in areas can manifest themselves in learning, language, social delays or s eeming inattention or opposition. F or children with developmental difficulties, a careful of perinatal ris k factors is taken; the pediatric includes careful evaluation for major or minor anomalies, dys morphic features, dermatological abnormalities (hyperpigmentations , tubers, and or ophthalmological findings (lens abnormalities and retinal pigmentation) (T able 33-10). His tory taking abnormal movements or abs ence s pells sugges ting seizures , abnormal pos tures , and tics . T he phys ical examination notes difficulties in muscle tone and as ymmetrical, abnormal, or primitive reflexes ; tremor; gait or pos tural disturbances .

Table 33-10 C lues to Developmen Dis ability from the Phys ic al

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Area

Findings

Implication

G rowth

Head circumference

Microcephaly highly with cognitive deficits .

 

 

Macrocephaly may indicate central system abnormalities (e.g., hydrocephalus) storage disorder.

 

Linear growth

S mall size may indica genetic disorder or embryopathy (e.g., alcohol s yndrome) or endocrine abnormalit (e.g., thyroid).

 

 

Large s ize may genetic disorder (e.g. cerebral gigantis m or S otos' s yndrome).

C ongenital anomalies

Organ defects

S torage dis orders (e. mucopolys accharidos may have enlarged organs .

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Major anomalies

Major anomalies , s uc heart defects, may be as sociated with developmental delays

 

Minor anomalies

Minor anomalies , s uc wide-set eyes , low hairline, or extra digit may s ugges t a genet syndrome.

S kin

Hyperpigmentation

—

 

T umors or

S kin lesions may be in neurocutaneous syndromes, s uch as neurofibromatosis or tuberous s cleros is .

E ye findings

Lens dis location

Abnormalities ins ide eye may sugges t metabolic disorders o congenital infections .

 

C orneal clouding

 

 

C ataracts

 

 

R etinal pigmentation

 

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Adapted from Levy S E , Hyman S H: P ediatric as sess me child with developmental delay. P ediatr C lin N orth Am. 1993;40:465.

T he pediatric his tory and examination, in turn, help decis ions about what further medical consultations neurological, orthopedic, audiometric, or genetic) and which diagnos tic tes ts (e.g., neuroimaging, laboratory tes ts , or electroencephalogram [E E G ]) are likely to be informative.

Diagnos tic L aboratory Tes ts T he clinical us efulnes s and cos t effectiveness of laboratory tes ts for children who present with problems have not been thoroughly s tudied. Most guidelines for performing thes e tests for children have historically been developed using data from studies of adults . Adult s tudies generally s ugges t that routine laboratory tes ts are not clinically us eful in typical ps ychiatric settings, such as outpatient clinics and most inpatient units. Laboratory s creening tests are of s ome in ps ychiatric s ettings in which patients are at high risk medical illnes s, such as the emergency room, abuse treatment centers, acquired immune deficiency syndrome (AIDS ) clinics , and geriatric clinics, as well patients who have new-onset psychos is, depress ion, or 3585 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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dementia. S imilarly, routine screening laboratory are more likely to yield clinically significant information when clinical symptoms of phys ical illness are pres ent. T he few s tudies of the use of routine laboratory tes ts in child ps ychiatry patient populations have yielded conclus ions. One review of routine laboratory (thyroid function tes ts, E E G , chest X-ray, chemis try urinalys is, complete blood count, electrocardiogram and rapid plas ma reagin) in 100 consecutive inpatient admis sions reported variable rates of values, depending on the specific test, but in only 1 of these 100 patients did the tests produce a change in diagnosis from functional P.3073 to organic—and even then the diagnos tic information proved to have little clinical relevance. Most laboratory abnormalities in this s tudy were regarded as minor and not indicate a need for clinical follow-up. More s pecialized diagnos tic laboratory evaluations computed tomography [C T ], magnetic res onance [MR I], or chromosomal analys es ) als o provide a low yield of clinically us eful information. In a s tudy of cons ecutive child ps ychiatric inpatients , these were done only when clinically indicated; despite their judicious use, the tes ts provided clinically relevant information in only seven patients (3.5 percent of the patient sample) or in 7 of 136 tes ts (5.1 percent of all performed). C hromos omal analys es proved to be the informative of all these tes ts, yielding new medical diagnoses in 5 of 32 (15.6 percent) s elected children whom they were performed. A study of 111 putatively 3586 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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high-ris k inpatients with new-onset adoles cent produced s imilar conclus ions. In this population, endocrine and neuroimaging s creening evaluations to provide any information of diagnostic usefulness in patient (although incons equential laboratory abnormalities were pres ent in 15.4 percent of the neuroendocrine s creens and 11 percent of the neuroimaging screening tes ts). More specialized neuroimaging technologies , such as pos itron emis sion tomography (P E T ), single photon emis sion tomography (S P E C T ), functional MR I (fMR I), and brain electrical activity mapping (B E AM), currently have no routine clinical or diagnostic usefulnes s in child and adoles cent psychiatric populations .

Tes ting in S pec ific C hildhood C ertain child psychiatric patient populations may specific diagnostic tes ts. G enerally, the pediatric and phys ical examination guide the appropriate use of laboratory tes ts.

ME NTA L R E TA R DA TION A ND DE VE L OP ME NTA L DIS OR DE R S In general, the more severe the child's disability, the greater the likelihood of an identifiable (albeit not neces sarily treatable) caus e. F or example, one s tudy that a medical caus e could be identified in 60 to 70 percent of children with severe mental retardation, only 35 to 55 percent of children with mild mental retardation. C hromos omal abnormalities, especially, trisomy 21 (Down syndrome) or fragile X s yndrome, account for more than one-half of cases of mental 3587 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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retardation. T he pediatric his tory and examination provide clues . Loss of previously acquired developmental miles tones or the presence of congenital anomalies, dysmorphic features , microcephaly or macrocephaly other growth problems , abnormal skin pigmentation or lesions , and symptoms s uggesting seizure activity or neurological abnormality warrant more detailed metabolic, or neurological evaluation (T able 33-10). Autistic children have relatively high rates of mental retardation, s eizure dis order (20 to 40 percent), and tuberous s cleros is (1 to 5 percent). Most experts would therefore still advocate a W ood's lamp examination to search for tubers, an E E G to exclude s eizures, and chromosome analys is to exclude fragile X in children display features of autism, retardation, or pervasive developmental disorder. Lead tes ting is also indicated cases of mental retardation, because chronic lead inges tion due to pica can caus e s ubstantial retardation; conversely, many children with retardation or pervas ive developmental disabilities from other causes indulge in pica and may accumulate a substantial lead burden.

MOOD DIS OR DE R S C ommon medical causes of mood disorders in child adoles cent ps ychiatric populations include s ubs tance abuse and infectious diseases (e.g., mononucleosis , disease, human immunodeficiency virus [HIV ], and abnormalities ). R apid ons et, s evere fatigue, and a in cognition sugges t an organic basis for the mood disturbance. R outine thyroid function, infectious and toxicology tes ting is probably indicated in this 3588 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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population.

P S Y C HOTIC DIS OR DE R S T he patient's history and phys ical examination s hould guide the use of diagnostic tests beyond a general screening battery. C ognitive decline, an altered level of cons ciousnes s, headache, an abnormal neurological examination, altered vital signs, leukocytosis, or newseizure dis order are all indications for further clinical laboratory workup that may include examination of the cerebrospinal fluid (C S F ).

A TTE NTIONDIS OR DE R T hyroid function abnormalities (particularly hypothyroidism) in ADHD were first reported in 5.4 percent of a group of 277 children with this disorder compared to reported rates in the general population below 1 percent. Matched control children were not included in this s tudy, however, so the res ults were cons idered preliminary. In a subsequent s tudy of 196 inpatient adolescents with ADHD who were routinely tes ted for thyroid function abnormalities, mos t of the observed abnormalities had normalized by the time of repeat testing 1 week later, and none of the actually required treatment for the abnormalities. T herefore, routine thyroid testing is not currently in children newly diagnos ed with this disorder who do have other signs or s ymptoms of thyroid dys function.

TIC A ND OB S E S S IVE -C OMP UL S IVE DIS OR DE R S 3589 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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His tory and physical examination differentiate tics and compuls ive behaviors from other stereotypies and movement disorders , such as choreoathetos is , ballismus, akathisia, and tremor. Once the diagnos is of disorder or OC D is made, further laboratory tes ting is generally not indicated. However, with an acute ons et acute exacerbation of s ymptoms or with chronic or recurrent pharyngitis, a throat culture and serological studies for group A β-hemolytic s treptococcus infection, which include antideoxyribonucleas e B and antis treptolysin O antibody titers , are probably R ecently, G AB HS has been pos tulated to initiate and sustain in s ome children an autoimmune dis order, due to cros s-reactivity of G AB HS and neuronal similar to the presumed cause of another movement disorder, S ydenham's chorea. T he evidence for the G AB HS in the caus e of tic disorders and OC D, much les s clear than it is in S ydenham's chorea. An elevated antistreptococcal titer by itself is not a indicator of an autoimmune origin for tics or OC D but merely s hows that the child has had a recent strep infection.

S UB S TA NC E US E DIS OR DE R S S ubstance abuse and dependence can caus e a wide of neuropsychiatric s ymptoms . T he high prevalence of subs tance abus e in adoles cent populations has recommendations that toxicology screens be obtained (1) all adoles cents who have psychiatric symptoms or exhibit acute behavioral changes ; (2) high-ris k such as delinquents and runaways; and (3) who have recurrent accidents or unexplained somatic 3590 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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symptoms.

S E X UA L L Y TR A NS MITTE D C hildren and adoles cents with a history of sexual or s exual abus e who are being evaluated for a change in cognitive function should be evaluated for sexually transmitted dis eas es, including HIV infection syphilis. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent DIAG NO S T IC F OR MULAT ION AND R E C OMME NDAT IO

DIAGNOS TIC AND R E C OMME NDATIONS P art of "33 - P sychiatric E xamination of the Infant, and Adoles cent" In the diagnos tic formulation, the clinician attempts to integrate the data gathered through the as sess ment proces s into a coherent account of the child's the factors that appear to have predis pos ed the child to develop the problem, the concomitants and of the problem, and the factors that maintain the or that might ameliorate it. It is not always poss ible to provide a P.3074 complete formulation at the conclusion of the initial as sess ment; under such conditions , the bes t that the clinician may be able to provide is a differential 3591 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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that can point toward the appropriate treatment options and the subs equent s teps needed to establish a One product of the as ses sment may be the as signment a diagnos is of one or more categorical ps ychiatric disorders using the multiaxial diagnostic s chema of IV or IC D-10. Although these nos ological systems have done much to s tandardize diagnos tic practices and to improve the quality of research, one must be aware of their clinical limitations as applied to children. Many children experience sufficient symptoms, dis tres s, or impairment to be regarded as ps ychiatrically dis turbed and to warrant therapeutic intervention without meeting the full criteria of a categorical ps ychiatric dis order. F urthermore, as currently conceptualized, the DS M-IV clas sification is descriptive and atheoretical; it s pecifies neither pres umed etiology nor treatment for the various diagnostic categories. If the as sess ment process is to provide a picture of the child that suffices to guide intervention, the resulting diagnostic formulation mus t beyond s imply as signing a categorical ps ychiatric diagnosis (if one is warranted). As noted in the introduction, comorbidity is often the rule rather than exception in childhood, and many children have patterns of developmental and behavioral difficulties are not adequately captured by a list of multiple categorical diagnos es . C hildren who s hare a given categorical diagnos is may differ in crucial res pects that influence current s everity, natural history, and res ponse. E xamples of potential ris k (or exacerbating) factors and protective (or ameliorative factors) include intelligence, compens atory s kills , family resources and supports, and vulnerabilities , s uch as comorbid 3592 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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pathological pers onality traits or neurological impairments . When the DS M-IV or IC D-10 is being the full multiaxial diagnostic s ys tem must be us ed. In addition to Axis I dis orders (categorical psychiatric disorders ), this includes s pecifying comorbid disorders and mental retardation (Axis II), general conditions (Axis III), level of psychosocial and environmental problems (Axis IV ), and a global of current functioning (Axis V ). T he clinician's diagnos tic formulation s hould thus supplement the as signment of any formal categorical diagnoses by attempting to identify, as far as poss ible, potential causes , predisposing factors, and current determinants of the child's difficulties . On the basis of information and the clinician's expertise regarding the various interventions available for the diverse forms of childhood ps ychopathology and developmental difficulties , the clinician formulates appropriate recommendations for treatment of the child's problems .

C ommunic ating Findings and R ec ommendations C ommunicating the findings and recommendations that res ult from the as sess ment to the parents and child is es sential part of the evaluation process and may one or more sess ions . Depending on the problem and child's age and level of comprehens ion, presenting the findings usually involves meeting with the child and parents , s eparately or together. S everal principles mus t be obs erved to maximize the likelihood that the parents and child hear, unders tand, experience the clinician's findings and 3593 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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as helpful. F irst, the clinician must communicate a the child as a whole pers on, with s trengths and well as problems and vulnerabilities . T his pers pective conveys a s ense of the clinician's appreciation and empathic unders tanding of the child, reduces defens iveness , and helps mitigate the fear that there is only bad news . T he findings and recommendations are mos t us eful to family and likely to be implemented if the interpretive sess ion is a dialogue rather than a lecture. T he must use language comprehens ible to the parents and child, must avoid jargon, and mus t keep technical a minimum. W hen technical terms are neces sary, they should be explained clearly, so the parents and child unders tand them; terms that are merely descriptive to clinician may hold frightening or negative connotations the child or family. T he clinician should allow ample opportunity for the parents and child to discus s the recommendations ; this provides a chance to judge whether the clinician's formulation made sense to the family, to addres s any differences of opinion, and to explore the feasibility and acceptability of the recommendations offered. R emaining areas of or ambiguity about the as sess ment or should be clearly noted and dis cuss ed. If the ass ess ment is a consultation requested by an a s chool, or another clinician, the findings and recommendations s hould be communicated to the referring party in appropriate terms, after being with the parents and child and with their consent. If evaluation or treatment is indicated but is best done by someone els e, the clinician should offer to as sis t in 3594 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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appropriate referral. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent S UG G E S T E D C R O S S -R E F E R E NC

S UGGE S TE D C R OS S R E FE R E NC E S P art of "33 - P sychiatric E xamination of the Infant, and Adoles cent" G eneral principles of the ps ychiatric interview, his tory, mental s tatus examination are pres ented in S ection T he ps ychiatric report is discuss ed in S ection 7.3, ps ychiatric rating s cales are dis cuss ed in S ection 7.9, medical as ses sment and laboratory testing are in S ection 7.8. T heories of personality and ps ychopathology are discus sed in C hapter 6. T he development of children is discus sed in S ection 32.2, the normal development of adoles cents is dis cuss ed in S ection 32.3. Details regarding the personality of children are found in S ection 7.6. T reatment in child ps ychiatry is dis cus sed in C hapter 48, and s pecial interes t in child ps ychiatry are discuss ed in C hapter 49. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 33 - P s ychiatric E xamination of the Infant, C hild, and Adolescent R E F E R E NC E S

R E FE R E NC E S *American Academy of C hild and Adolescent P sychiatry: P ractice parameters for the psychiatric as sess ment of children and adolescents . J Am Acad 3595 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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Adoles c P s ychiatry. 1995;34:1386. American Academy of C hild and Adolescent P ractice parameters for the forensic evaluation of children and adoles cents who may have been phys ically or sexually abus ed. J Am Acad C hild P s ychiatry. 1997;36[S uppl]:37S . American Academy of C hild and Adolescent P ractice parameters for the ps ychiatric as sess ment infants and toddlers. J Am Acad C hild Adole s c 1997;36[S uppl]:21S . American Academy of C hild and Adolescent P ractice parameters for child custody evaluation. J Acad C hild Adole s c P s ychiatry. 1997;36[S uppl]:57S . American P s ychiatric Ass ociation. Handbook of P s ychiatric Me as ure s . Arlington, V A: American P sychiatric P ublishing Inc; 2000. *Angold A. Diagnos tic interviews with parents and children. In: R utter M, T aylor E , Hers ov L, eds . C hild Adoles ce nt P s ychiatry. 4th ed. Oxford, UK : S cientific; 2002:32–51. Angold A, Mess er S C , S tangl D, F armer E M, B urns B J : P erceived parental burden and service child and adoles cent psychiatric disorders . Am J Health. 1998;88:75. B es son P S , E lise E : Us e of the Modified Mini-Mental 3596 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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S tate E xamination with children. J C hild Neurol. 1997;12:455–460. B ird HR , K es tenbaum C J . A s emistructured clinical as sess ment. In: K es tenbaum C J , Williams eds. Handbook of C linical As s e s s me nt of C hildre n Adoles ce nts . V ol 1. New Y ork: New Y ork Univers ity 1988. C arter AS , B riggs-G owan MJ , Davis NO: young children's s ocial-emotional development and ps ychopathology: recent advances and recommendations for practice. J C hild P s ychol P s ychiatry. 2004;45:109–134. C hes s S , T homas A. T emperament and its clinical applications . In: Lewis M, ed. C hild and Adole s ce nt P s ychiatry. 3rd ed. B altimore: Lippincott W illiams & Wilkins ; 2002. C houdhury MS , P imentel S S , K endall P C : anxiety dis orders: parent-child (dis)agreement using structured interview for the DS M-IV . J Am Acad Adoles c P s ychiatry. 2003;42:957–964. C ollett B R , Ohan J L, Myers K M: T en-year review of scales. V : S cales ass ess ing attentiondeficit/hyperactivity dis order. J Am Acad C hild P sychiatry. 2003;42:1015–1037. P.3075

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C ollett B R , Ohan J L, Myers K M: T en-year review of scales. V I: S cales ass ess ing externalizing Acad C hild Adole s c P s ychiatry. 2003;42:1143–1170. C os tello E J , Angold A, K eeler G P : Adoles cent of childhood disorders : T he cons equences of and impairment. J Am Acad C hild Adole s c 1999;38:121. F reud A. Normality and P athology in C hildren. New International Universities P res s; 1965. *G illiam WS , Mayes LC . C linical ass ess ment of and toddlers. In: Lewis M, ed. C hild and Adole s ce nt P s ychiatry: A C ompre he ns ive T e xtbook. 3rd ed. Lippincott W illiams & W ilkins ; 2002:507–525. G old A, C os tello E J , F armer MZ, B urns B J , E rlanki Impaired but undiagnosed. J Am Acad C hild P s ychiatry. 1999;38:129. G reenspan S I, G reens pan NT . T he C linical C hild. 2nd ed. W ashington, DC : American P res s; 1991. Herjanic B , R eich W : Development of a structured ps ychiatric interview for children: An agreement between child and parent on individual s ymptoms . J Abnorm C hild P s ychol. 1982;10:307. J ens en P S , W atanabe H: S herlock Holmes and ps ychopathology ass ess ment approaches: T he cas e 3598 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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the false pos itive. J Am Acad C hild Adole s c 1999;38:138. K es tenbaum C J . T he clinical interview of the child. Weiner J M, ed. T e xtbook of C hild and Adole s cent P s ychiatry. 2nd ed. W ashington, DC : American P sychiatric P ress ; 1997. K aufman AS , K aufman NL. K AB C -II: K aufman B atte ry for C hildre n, S e cond E dition. C ircle P ines, American G uidance S ervice; 2004. K ing R A, Nos hpitz J D. P athways of G rowth: C hild P s ychiatry. V ol 2. P s ychopathology. New Wiley; 1991. Levy S E : P ediatric evaluation of the child with developmental delay. C hild Adole s c P s ychiatr C lin Am. 1996;5:809. Lewis M, K ing R A. P s ychiatric as sess ment of children, and adoles cents. In: Lewis M, ed. C hild Adoles ce nt P s ychiatry: A C ompre he ns ive T e xtbook. B altimore: Lippincott W illiams & Wilkins; 2002:525– *Moss NE , R acus in G R : P s ychological as ses sment children and adoles cents. In: Lewis M, ed. C hild and Adoles ce nt P s ychiatry: A C ompre he ns ive T e xtbook. B altimore: Lippincott W illiams & Wilkins; 2002:555– Naglieri J A, McNeish T J , B ardos AN. DAP : S P E D, P ers on: S cre e ning P rocedure for E motional 3599 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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E xaminer's Manual. Aus tin, T X: P ro-ed; 1988. Nos hpitz J D, ed. Handbook of C hild and Adole s ce nt P s ychiatry, V olume 5: C linical As s e s s me nt and P lanning. New Y ork: W iley; 1998. Ouvrier R A, G olds mith R F , Ouvrier S , Williams IC : value of the Mini-Mental S tate E xamination in childhood: A preliminary study. J C hild Neurol. 1993;8:145. P aul R . L anguage Dis orders from Infancy through Adoles ce nce : As s e s s ment and Inte rve ntion. 2nd ed. Louis : Mosby; 2001. P uura K , Almqvis t F , T amminen T , P iha J , K , R as anen E , Moilanen I, K oivisto AM: C hildren symptoms of depres sion: W hat do the adults s ee? J C hild P s ychol P s ychiatry. 1998;39:577. R abin AI, Haworth MR , eds . P roje ctive T e chnique s C hildre n. New Y ork: G rune & S tratton; 1960. R andazzo K V , Landsverk J , G anger W : T hree reports of child behavior: parents , teachers, and parents . J Am Acad C hild Adole s c P s ychiatry. 2003;42:1343–1350. R utter M: R outes from research to clinical practice in child ps ychiatry: R etros pect and pros pect. J C hild P s ychology P s ychiatry. 1998;39:805.

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R utter M, Y ule W . Applied scientific thinking in as sess ment. In: R utter M, T aylor E , eds . C hild and Adoles ce nt P s ychiatry. 4th ed. Oxford, UK : S cientific; 2002:103–116. *S haffer D, Lucas C , R ichters J . Diagnos tic C hild and Adole s ce nt P s ychopathology. New Y ork: G uilford P ress ; 1999. S hiner R , C aspi A: P ersonality differences in and adolescence: meas urement, development, and cons equences. J C hild P s ychol P s ychiatry. S immons J E . P s ychiatric E xamination of C hildren. P hiladelphia: Lea & F ebiger; 1987. S olnit AJ , C ohen DJ , Neubauer P B . T he Many of P lay: A P s ychoanalytic P e rs pe ctive. New Haven, Y ale Univers ity P res s; 1993. S parrow S S , B alla DA, C icchetti DV . T he V ine land Adaptive B e havior S cale s : Intervie w E ditions , C ircle P ines , MN: American G uidance S ervice; S parrow S S , C arter AS , R acus in G , Morris R . C omprehens ive ps ychological as ses sment the lifes pan: A developmental approach. In: C ohen DJ , eds. Manual of De ve lopme ntal P s ychopathology. V ol 1. New Y ork: W iley; 1995. T homas G V , S ilk AM. An Introduction to the C hildre n's Drawings . New Y ork: New Y ork 3601 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/33.htm

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P res s; 1990. V erhuls t F C , V an der E nde J . R ating scales. In: T aylor E , eds. C hild and Adole s ce nt P s ychiatry. 4th Oxford, UK : B lackwell S cience; 2002:70–86. Wechs ler D. W e chs le r Inte lligence S cale for F ourth E dition. S an Antonio, T X: P s ychological C orporation; 2003. Wools ton J L, R iddle MA: T he role of advanced technology in inpatient child ps ychiatry: Leading or useful aid? J Am Acad C hild Adole s c P s ychiatry. 1990;29:905. Zametkin AJ , E rnst M, S ilver R : Laboratory and diagnostic testing in child and adolescent psychiatry: review of the past 10 years . J Am Acad C hild P s ychiatry. 1998;37:464.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > 34 - Mental R etardation

34 Mental R etardation B ryan H. K ing M.D. R obert M. Hodapp Ph.D. E lis abeth M. Dykens Ph.D. 

HIS T OR Y OF ME NT AL R E T AR DAT ION

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DE F INIT ION OF ME NT AL R E T AR DAT ION

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P R E V ALE NC E

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E T IOLOG IC AL C ONS IDE R AT IONS

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G E NE T IC ME NT AL R E T AR DAT ION B E HAV IOR AL P HE NOT Y P E S DE V E LOP ME NT AL C ONS IDE R AT IONS IN WIT H ME NT AL R E T AR DAT ION

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P S Y C HOP AT HOLOG Y IN ME NT AL

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T R E AT ME NT

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T R E AT ME NT OF ME NT AL DIS OR DE R S

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S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > HIS T OR Y OF ME NT AL

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R E TAR DATION P art of "34 - Mental R etardation" T here can be no doubt that intellectual gifts have been distributed on a continuum for as long as mankind has walked the earth. Y et, through the ages , unders tanding and treatment of persons with mental retardation has moved like a pendulum between extremes. At one extreme, pers ons with mental retardation have been exalted, considered le s e nfants du B on Die u (children G ood G od). T o this day, movies s uch as “B eing T here” “F orrest G ump” convey the mes sage that persons with mental retardation are somehow bless ed with s impler, more s traightforward unders tandings of basic human truths. Y et, at the s ame time, s uch persons have also vilified. T he word cre tin (congenital hypothyroidism), its origin from C hris tian or C hris t-like , even as its definition includes descriptors such as s tupid, vulgar, ins e ns itive . T o this day, society wrestles with the exact nature of s uch pers ons; witnes s the recent S upreme ruling, by a 6-to-3 vote, that individuals with mental retardation can be tried and jailed but not executed v. V irginia). E vidence for the recognition and treatment of mental retardation dates to the earliest of medical writings . Hippocrates , for example, des cribed microcephaly and craniostenos is , and G alen actively explored causes of cognitive disability. In the Middle Ages , Avicenna propos ed treatments for meningitis and hydrocephalus and even defined levels of intellectual function. 3604 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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T he modern his tory for the field of mental retardation begins in the late 18th and early 19th centuries . At that time, J ean-Marc Itard attempted a natural experiment educate V ictor, a “wild child” discovered in the forests Aveyron, F rance. Although Itard hims elf judged his with V ictor to be a failure, this renowned experiment marked the first time that anyone had cons idered the poss ibility that persons with disabilities could be Itard's efforts s parked interest in educational and other interventions for persons with disabilities. An overview the history of this complex field s hould include mention three interrelated topics: service delivery, res earch, organizations .

S ervic e Delivery S purred by Itard's work, the F rench educator E douard S eguin developed his physiological view of education the mid-1800s . S eguin's education focus ed on development in three areas: activity, intelligence, and Activity involved muscular or phys ical education, exercises and movement to “awaken” the child's body. Inte llige nce emphasized educating the senses. with mental retardation were taught to handle objects , discriminate musical and environmental s ounds, to and to perform tongue movements for s peaking, and to discriminate visually forms , colors, and s izes . S uch discriminations eventually led to drawing and writing. final component of S eguin's educational program educating the will, a “moral education” akin to what be called s ocialization. T hroughout, S eguin des ired children with mental retardation take their rightful place the societies of their day. His views that children with mental retardation could be trained s ucces sfully fit well 3605 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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with the progress ive, reform-minded s pirit of the times. S uch optimis m helped create the early training schools, the res idential component of s ervice delivery in mental retardation. F irs t begun in 1848 in Mas sachus etts by S amuel G ridley Howe (the firs t public facility) and Wilbur (the firs t private facility), the late 1800s saw the creation of many such training schools . T hese schools originally s mall and home-like, often hous ing only eight ten res idents . R es idential s chools had as their original the return of children to their families after a period of intervention. B y 1890, 20 s uch res idential s chools had sprung up in 15 s tates. G radually, however, these res idential s chools became larger, les s focus ed on education and more on care. T o many superintendents, it was becoming clear many res idents could not return home. In addition, the is olated placement of mos t training s chools allowed for the segregation, overcrowding, and abus es seen in years . S uch is olated placements als o fostered a goals : F rom an original focus on a warm, home-like res idence that might help children return to their communities, residential s chools began to be seen as custodial institutions designed to keep pers ons with mental retardation away from society. During their peak us age, from 1950 until the late 1960s , institutions were home to approximately 1 per 1,000 Americans . S ince the mid-1960s , many fewer pers ons with mental retardation have been institutionalized in the United S tates. T his move toward de ins titutionalization has from many sources. F irs t, the overcrowding and common in many large ins titutions came to light in expos es during the late 1960s. B urton B latt and F red 3606 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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K aplan's photo s tory, C hris tmas in P urgatory L ook magazine), G eraldo R ivera's televis ion reports, R obert F . K ennedy's attacks on the R ome and institutions in New Y ork all s hocked the nation.

Normalization Other forces als o led to deinstitutionalization. P robably most important of thes e forces was the philos ophy of normalization, the idea that individuals with mental retardation were entitled to a more normal lifestyle, including a culturally normal rhythm to one's day or work, leis ure time, and s leep), week (weekdays and weekends), and year (vacations and holidays). In 1972, Wolf W olfensberger extended the idea of normalization the service delivery s ys tem itself, calling on all schools , and other s ervices for persons with retardation be as normative as pos sible. P arent and profess ional advocacy groups also fought hard for legis lative and victories to decreas e the s ize of large institutions . C ompared to the 1970s, changes in U.S . res idential institutions have been dramatic. S everal states have their institutions , and remaining institutions have much smaller. T ypically, those remaining in large or medium-sized institutions are the mos t s everely and profoundly impaired; many of thes e residents also have severe behavior problems or motor or sensory in addition to their s evere to profound mental P.3077 Overall, from 1967 to 1994, the total ins titutional population—defined as s tate-operated institutions with or more res idents—has decreased by almost two3607 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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from 194,650 to 65,818. S chooling is the other major s ervice for pers ons with mental retardation. F ollowing the move to school all American children that began in the mid-1800s , and adminis trators s oon dis covered that a subset of children was having difficulties in performing school less ons . As a res ult, clas ses for so-called problem began in many cities and towns in the late 1800s. In the firs t clas ses s pecifically for children with mental retardation were formed in P rovidence, R I. In rapid succes sion, s pecial education clas ses were begun in S pringfield, MA (1894), C hicago (1898), B oston (1899), Y ork (1901), P hiladelphia (1901), and Los Angeles Local school districts have his torically held an attitude toward s pecial education class es . Often within the leas t desirable buildings and rooms , these clas ses were frequently furnished with s carce and materials and had few s pecially trained teachers. 1968, Lloyd Dunn declared that mos t children with retardation could be mains tre ame d in clas ses with nonretarded age mates; he ques tioned the need for segregated special education class es for most children with mental retardation. Dunn's article took note of the S upreme C ourt's ruling that “separate could not be in educational s ettings , that research had not s hown children with mild mental retardation learn better in special education clas ses versus regular education and that educational techniques had advanced to allow for the effective s chooling of most children with retardation alongs ide other, nonretarded children. In education and living settings, then, the pos t-1970 has witnes sed the strong influence of mains treaming, 3608 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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community living, and normalization. On the whole, movements have proven beneficial, as persons with mental retardation increas ingly take their rightful place within modern s ociety. Many profess ionals do, question whether normalization has s ometimes gone far. Not every child with retardation may be able to be schooled optimally with typically developing age mates , nor might every adult be able to live independently in community. T hese iss ues continue to be hotly debated among profess ionals , families, and organizations as sociated with persons with mental retardation.

R es earc h Like service delivery, the modern his tory of res earch begins in the mid-19th century. In 1838, J ean E s quirol differentiated mental retardation from mental illness propos ed s everal levels of mental retardation. Later in century, various workers proposed different systems . P robably the mos t well-known was a system ethnic clas s ifications propos ed by J . Langdon Down in 1866, hence the term mongolis m for pers ons with syndrome, the type of retardation that he first identified. In addition to class ifying pers ons with mental genetics plays an important historic role in retardation res earch. E arly in this century, that role was mainly negative. S purred by the rediscovery of G regor genetic findings , various workers attempted to s how mental retardation was inherited. Most notorious were R ichard Dugdale's (1877) s tudy of the J ukes, and G oddard's (1913) study of the K allikaks. In both cas es , multigenerational retarded families were used to argue that mental retardation was inherited and that 3609 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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was neces sary for the “preservation of the race.” S uch eugenic s cares led to court decrees and s terilization C alifornia and other states during the 1920s . Als o playing an important role in mental retardation res earch was the new science of ps ychological tes ting. G oddard, the research director at the V ineland (New J ersey) T raining S chool, was the first to us e Alfred and T héodore S imon's intelligence quotient (IQ) tests the United S tates . After testing V ineland residents over several-year period, G oddard concluded that “the vast majority of feeble-minded children are not changing are not improving in their intelligence levels,” a finding that another leading worker, W alter F ernald, called “the most significant … and the most dis couraging that we have ever known.” S ince early in the 20th century, research has the behavioral and biomedical fields . B ehaviorally, and more recent work has allowed for better diagnoses and clas sification. Nearly a century ago, ps ychologists invented tes ts of motor, nonverbal intelligence, achievement, adaptive behavior, and other skills. F ollowing s imilar work with typically developing ps ychologists have recently learned much about the development of cognitive, linguistic, s ocial, and skills in pers ons with mental retardation. In addition, studies now examine the pres ence of ps ychiatric in children and adults with mental retardation, and families , s chools , group homes, and works hops have received research attention. Much of this work has occurred from the 1960s until today, a time of s trong, often federally s upported, progress in mental behavioral res earch. 3610 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Arguably, the mos t important progress has occurred in biomedical and genetic fields . As early as 1934, the Norwegian physician, As bjorn F olling, hypothesized several of his patients with retardation were unable to metabolize phenylalanine. S uch insights later led to a dietary treatment of this inborn error of metabolis m; the phenylalanine-free diet, although not perfect, has significantly limited phenylketonuria (P K U) as a caus e mental retardation in mos t indus trialized countries. In addition, P K U can now be screened at birth through G uthrie test, after which dietary treatments can be instituted. P K U remains one of the major success mental retardation. Modern genetics constitutes another s ucces s s tory in mental retardation res earch. In 1959, J erome Lejeune, Marthe G autier, and M. R aymond T urpin dis covered most cas es of Down syndrome were due to a trisomy the 21st chromos ome. F ragile X s yndrome, the s econd most common genetic cause of mental retardation, was discovered in 1969, and its cytogenetic diagnos is was refined in the mid-1970s . With the banding techniques the 1970s and s ubs equent molecular genetic exact causes are being des cribed for many of the 1,100 different genetic disorders ass ociated with retardation. T he genetic—and, increasingly, the behavioral—characteristics of many of thes e disorders now known.

Organizations T he modern field of mental retardation is als o a his tory organizations . T he first s uch organization was the Ass ociation of Medical Officers of American Ins titutions 3611 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Idiotic and F eeble-Minded P ers ons, begun in 1876. As first profes sional group devoted exclusively to pers ons with mental retardation, the Ass ociation of Medical Officers was the forerunner to the American Mental R etardation (AAMR ), the field's most influential organization. T hrough its various journals and AAMR has been at the forefront of research, policy, legis lative advances for pers ons with mental In addition to AAMR , other groups have also played important roles , particularly concerning changes in policy toward people with disabilities. T he C ouncil for E xceptional C hildren (C E C ) was begun in 1922 and continues to champion the profess ion of s pecial and the education of all children with dis abilities . T he National Ass ociation for R etarded C itizens (NAR C ) is main parent lobbying group. NAR C was particularly influential in the pass age of the E ducation for All Handicapped C hildren Act of 1975 (P L 94–142), the law that, for the first time, mandated the “free, public education” of all children with disabilities throughout the United S tates . E ach of these groups also influential P.3078 in the pas sage of the Americans with Dis abilities Act federal legis lation that took effect in 1992 and outlawed discrimination of persons with dis abilities. F ederal agencies constitute an additional category of influential organizations. B egun during the presidency J ohn F . K ennedy (hims elf a s ibling to a woman with retardation), the National Ins titute of C hild Health and Human Development (NIC HD) have long s upported 3612 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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disability research. Other federal programs, including Univers ity-Affiliated F acilities (UAF s), Univers ityP rograms (UAP s), and Mental R etardation R es earch C enters (MR R C s ), have als o played important roles in res earch and policy. T aken together, profes sional, and federal organizations provide an important infras tructure to the mental retardation field. B efore discus sing definitional is sues, it is important to a word about terminology. In different countries throughout the world, different terms are used for retardation. In E urope, the term intellectual dis abilities long been used, and a major international journal is the J ournal of Inte lle ctual Dis abilities R es e arch. In G reat the term le arning dis ability (or learning disabilities ) is us ed, even as the term has a different meaning in the United S tates . P artly in an attempt to come to a s ingle term, the has recently decided to adopt the term intellectual dis abilitie s . One as sumes that the name of the its elf will also be changed, as will the names of the two main journals, now called the Ame rican J ournal on Me ntal R etardation and Me ntal R etardation. As such changes have yet to be implemented—and the name changes for the organization and its journals have not even been decided—this chapter continues to us e the term me ntal re tardation. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > DE F INIT ION OF ME NT AL

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R E TAR DATION P art of "34 - Mental R etardation" T he struggle to define and class ify mental retardation is long lived. E s quirol (1843) is credited as the first writer to have penned a definition, and his seminal characterization of mental retardation as a dis order of development ins tead of a disease is maintained in all modern definitions (which require an onset during childhood or adoles cence). W riting over a century ago, Wilbur (1852) reasoned that mental retardation was defined primarily by deficits in social or moral T his line of thinking has als o persis ted over time and is now woven into contemporary controvers ies about the role of s ocial adaptation vers us intelligence in defining mental retardation. S uch controversy is not entirely however. William W hite (1919) observed that “feeblemindedness , even from the standpoint of an meas uring scale, is a relative affair when express ed in behavior of an individual, and conduct which would be cons idered normal under certain conditions might well open to inquiry, as poss ibly defective, under others .” T redgold's (1922) presentation of the case of G ottfried Mind is als o illus trative: G ottfried Mind was a cretin imbecile who was born at B erne in 1768, and died in the s ame city at the age of six years. At an early age he s howed considerable drawing, and as it was obvious that he would never be able to earn his living in any ordinary occupation, his father's employer interes ted himself in providing young 3614 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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G ottfried with s ome training. He could neither read nor write, he had no idea of the value of money, his hands were remarkable for their large size and roughnes s, general appearance was so obviously indicative of defect that his walks through the city were us ually to accompaniment of a crowd of jeering children. In spite all this his drawings and water-color sketches of not cats, but of deer, rabbits, bears , and groups of children, were so marvelous ly lifelike and s o s killfully executed he acquired a E uropean fame. One of his pictures , of a cat and kittens was purchas ed by K ing G eorge IV . T hus, central to the s truggle with how to conceptualize and unders tand mental retardation is the idea that something more than cognitive deficits or low IQ scores intelligence tes ts is involved. Over the years , the P sychiatric Ass ociation (AP A) adopted definitions of mental retardation from the AAMR . Looking back to the revis ed edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-III-R ), for example, the mental retardation is virtually identical to the previous AAMR definition. Mos t recently, however, the AAMR definition has diverged somewhat from that of the edition of the DS M (DS M-IV ), thus generating some controvers y. T he cognitive and adaptive components of these definitions are firs t examined, and then how each part generates controvers y is discus sed.

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10) specify an IQ of 70 or less in their diagnostic mental retardation. IQ scores are pres umably derived standardized intelligence tes ts that meet appropriate ps ychometric criteria for reliability and validity. IQ tes ts that are commonly used to identify mental retardation summarized in T able 34-1, along with each test's age and cognitive domains . Although all are generally acceptable, diagnosticians s hould s hy away from tes ts tap a s ingle domain (e.g., receptive vocabulary) in more extensive batteries , s uch as the K aufman or tes ts , as these rely on performance across multiple cognitive domains (T able 34-1).

Table 34-1 Intelligenc e Quotient (IQ) Tes ts for Diagnos ing Mental R etardation Intelligence Tes t

Age R ange

Domains Tes ted

Wechs ler P res chool and P rimary S cale of IntelligenceR evised 1989)

3 yrs to 7 yrs 3 mos

V erbal IQ, performance IQ, F ull-S cale IQ

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Wechs ler Intelligence S cale for C hildren–III (W echs ler, 1991)

6 yrs to 17 yrs 11 mos

V erbal IQ, performance IQ, F ull-S cale IQ

Wechs ler Adult Intelligence R evised 1981)

16–74 yrs

V erbal IQ, performance IQ, F ull-S cale IQ

S tanford-B inet Intelligence F ourth E dition (T horndike et al., 1986)

2 yrs to adult

V erbal, quantitative, abstract/vis ual, short-term memory, composite s core

K aufman Ass es sment B attery for C hildren and K aufman, 1984)

2 yrs 6 mos to 12 yrs mos

S equential and simultaneous proces sing, proces sing composite

K aufman Adoles cent and Adult Intelligence T es t (K aufman K aufman, 1993)

11–85 yrs

C rys tallized and fluid scales , composite IQ

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Differential Ability S cale (E lliott,

2 yrs 6 mos to 17 yrs 11 mos

V erbal, nonverbal reasoning, spatial abilities , general conceptual ability

Das -Naglieri C ognitive Ass es sment S ys tem (Naglieri and Das , 1997)

5 yrs to 17 yrs 11 mos

P lanning, simultaneous and succes sive proces sing, fullscale s core

C olored P rogress ive Matrices a and S ummers, 1986)

5–11 yrs

F igural reasoning

C olumbia Mental Maturity S cale (B urmegerster et al., 1972)

3 yrs 6 mos to 9 yrs mos

R eas oning ability, forming and us ing concepts

T es t of Intelligence–2 (B rown et al., 1990)

5 yrs to 85 yrs 11 mos

R eas oning ability, similarities , differences, relations hips

Leiter-R (R oid Miller, 1999)

2 yrs to 20 yrs 11 mos

Nonverbal, fluid intelligence; visualization and

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reasoning; attention and memory Tes ts us ed for s c reeninga

 

 

P eabody P icture V ocabulary T es t– (Dunn et al.,

2 yrs 6 mos to 90 yrs

R eceptive vocabulary b

Draw-A-P ers on T as k (Naglieri, 1988)

2 yrs 6 mos to adult

V is ual-motor development, nonverbal functioningc

K aufman B rief Intelligence T es t (K aufman and K aufman, 1990)

4–90 yrs

Matrices , vocabulary

S loss on Intelligence T es tR evised (Nicholoson and Hibpshman,

4 yrs to adult

V ariety of verbal reasoning and memory tasks

aT hese

tes ts are best used for s creening or purpos es only and s hould not be us ed to 3619 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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mental retardation. bF or

a discus sion s ee F azio B B , J ohnston J R , R elation between mental age and vocabulary development among children with mild mental retardation. Am J Ment R e tard. 1993;97:541–545. c F or

a discus sion s ee Dykens E : T he Draw-Atas k in pers ons with mental retardation: What meas ure? R es De v Dis abil. 1996;17:1–13.

In many ways , administering IQ tes ts to people with mental retardation is quite challenging, in terms of the tes ting s ituation itself and in the choice of an IQ tes t. As people with mental retardation have ris ks of comorbid psychiatric or behavioral dysfunction, examiners need to ensure that difficulties , s uch as hyperactivity or poor frus tration tolerance, do not optimal test performance. E ven in persons without behavioral dysfunction, certain personality may interfere with testing. Many people with mental retardation, for example, look to others for s olutions to difficult problems and are quick to acquiesce or to easily discouraged by failure. C ertain techniques these problems, for example, ensuring that the succeeds with easy tas ks before administering hard or providing positive incentives for effort. C hallenges also emerge with individuals who are nonverbal, and s everal IQ tests now exis t that do not on expres sive language (T able 34-1). P eople with 3620 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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genetic s yndromes (e.g., W illiams s yndrome, Down syndrome) also pres ent unique test challenges, as show s yndrome-specific profiles of cognitive s trength weaknes s that are not easily des cribed by a global IQ P ers ons with mental retardation and cooccurring or motor deficits als o require adaptation to routine test procedures . F inally, examiners need to be extra when tes ting individuals from minority groups . S parked a s eries of lawsuits in the 1970s (e.g., L arry P . v. W . controvers ies s till rage about tes t bias and the appropriatenes s of IQ tes ting in children from minority groups ; court rulings have come out agains t and in IQ tes ts . Most ps ychologists readily agree that tes ting persons from minority groups requires extra sensitivity language and cultural is sues, as well as a multimethod approach, especially when diagnos ing pers ons with mental retardation. P.3079

Adaptive Func tioning B as ed on his pioneering work at the V ineland T raining S chool in V ineland, NJ , E dgar Doll (1935) was the first develop a formal definition and meas ure of adaptive be havior. T wo decades later, the AAMR officially deficits in adaptive behavior in its definition of mental retardation. S ince that time, deficits in adaptive have been formally included in all definitions of mental retardation. Although meanings vary, adaptive behavior typically viewed as the performance of behaviors for social and personal sufficiency. F urthermore, adaptive behavior is an inherently 3621 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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developmental and s ocial construct. Adaptive behavior changes as children grow into adoles cence and and demands for s ocial adaptation are also defined by expectations from others —from one's family, society, culture. Adaptive s kills typically change acros s various settings ; one's adaptive performance on the job or at school may differ from one's performance with friends at home. Meas urements of adaptive behavior, then, to have a developmental orientation, to be socially and culturally s ens itive, and to repres ent the many s ettings which people live, work, and play. In contras t to Doll's time, many instruments now exis t meas ure adaptive behavior acros s multiple domains community skills and personal grooming). T able 34-2 summarizes commonly used measures of adaptive behavior, their age ranges , and various domains . All acceptable meas ures of adaptive behavior in people mental retardation; yet, the V ineland probably enjoys most wides pread use. Although most of these are administered as interviews with parents or other providers , s ome of the newer meas ures are directly to pers ons with mental retardation. C entral to all is the idea that adaptive behavior is meas ured by everyday performance as oppos ed to ability. If people mental retardation are able to perform certain but, for any reason, do not routinely do s o, then they neces sarily have compromis ed adaptive functioning.

Table 34-2 C ommon Meas ures of Adaptive B ehavior 3622 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Meas ure

Age R ange (Yrs )

Domains Tes ted

V ineland Adaptive B ehavior (S parrow et al., 1984)

B irth to 18

C ommunication: receptive, expres sive, written. Daily living skills : pers onal, domes tic. C ommunity socialization: interpersonal play and leisure, coping s kills . Motor skills : fine, gross .

S cales of Independent B ehavior— R evised (B ruininks et 1996)

B irth to 80+

Motor: fine, gross . S ocial interaction and communication: interaction, language comprehension, language express ion. P ers onal living s kills : eating and meal preparation, toileting, dress ing. C ommunity living s kills : time and punctuality, money

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and value, work. American Ass ociation on Mental R etardation Adaptive B ehavior (Lambert et al., 1993)

3 yrs to 18 yrs 11 mos

Independent functioning, physical development, economic activity, school.

K aufman F unctional Academic (K aufman and K aufman,

15– 58+

F unctional math and reading skills, adminis tered directly to pers on (e.g., tes t).

S treet S urvival S kills Ques tionnaire (Linkenhoker and McC arron, 1993)

9–40+

Administered to person; basic functional s igns, health.

Definition C ontrovers ies C ognition vers us Adaptation What, then, is so controversial about cognitive and adaptive functioning? One controversy lies 3624 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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P.3080 in the relative importance of these domains in defining mental retardation. S ome workers object to the equal afforded to cognitive and adaptive deficits and argue intelligence is more important to the definition of mental retardation than adaptive behavior. F or thes e workers , IQ is the benchmark of mental retardation, and adaptive deficits are viewed as correlates or sequelae of low IQ. F urthermore, unlike adaptive behavior, intelligence has theoretical and empirical roots , evolving from G alton's pioneering work on individual differences to a host of modern views of intelligence, ranging from G ardner's multiple intelligences to R obert S ternberg's triarchy of intelligence. C ritics of adaptive behavior, then, the strong theoretical and empirical his tory of the intelligence field and ques tion if adaptive behavior has equally robus t ps ychometric properties . Y et, if people have low IQ s cores , it does not follow that they als o s how deficits in everyday behavior. P roponents of adaptive behavior argue that cognitive adaptive functioning are generally unrelated, with dramatically different theoretical underpinnings and meas urement techniques. Indeed, some s tudies of with mixed mental retardation etiologies find nonsignificant correlations between cognitive and functioning. A dis juncture between IQ and adaptive behavior may be particularly apparent in people with mental retardation. V ariable outcomes were s een, for example, in the 40-year s tudy by R obert R os s and colleagues of s tudents with mild mental retardation followed into adulthood. As adults , some of thes e 3625 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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were completely to partially independent and adapting quite well, whereas others were highly dependent and showing poor s ocial adaptation. In his s eminal book entitled T he C loak of C ompete nce , R obert E dgerton followed as many as 48 residents of a large ins titution their discharge and integration into the community. He and his colleagues obs erved that the IQ of any given individual s aid little about what to expect in the outside world, and even low IQ was no sure indicator. His case F red B arnett (ps eudonym) is illustrative. F red was the product of an uncomplicated pregnancy and delivery. Developmental miles tones were remarkable for walking 17 months of age, but he showed s lowness to talk and stammering, unclear speech. He was described as a slow, but, at 5 years of age, when verbal and learning delays became more obvious, the family became concerned. At 6 years of age, F red was injured in an automobile accident with res ultant coma for 5 days . Hos pital records at the time s uggested the poss ibility of slight neurological injury, but his mother attributed all of F red's s ubs equent problems to this accident. He was unable to keep up in school and fell into greater conflict with his younger s iblings. At 10 years of age, he out of school and, 4 years later, was admitted to the Developmental C enter. IQ testing over the years cons istently placed F red in the moderate range (middle lower 50s). W hile in the institution, F red was s eldom in trouble and worked on the wards , in the kitchen, and, occasionally, as a mess enger. After 3 years, he was discharged to the community, where, despite nearly continuous s upervision from employers and s ocial workers, he was s aid to be in frequent trouble. In all of his multiple places of employment, primarily as a 3626 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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dishwasher, his reputation was highlighted by temper, aggres sion, profanity, and booris hness . He was also involved in several minor difficulties with police, several charges of vagrancy. On one occasion, he took employer's car without permiss ion and drove it Over time, his conduct became more competent, and, 32 years of age, he pres ented as a robus t-appearing perpetually s moking a cigar who gave every being a happy-go-lucky, easygoing, altogether happy T here is nothing in his to sugges t that he is anything than a normal man, and his is likewise unexceptionable. … It only upon much closer that F red's intellectual deficit becomes apparent. T o the observer, he is an ordinary man, competent to live within the not too demanding cons traints of his life circums tances . Other studies , however, find s trong correlations cognitive and adaptive behavior, especially in people moderate to profound mental retardation. S ignificant adaptive behavior correlations are also seen in s tudies people with moderate mental retardation of mixed etiologies, as well as in studies of people with syndromes, such as fragile X s yndrome, Down P rader-Willi syndrome, and 5p– syndrome (also known cri du chat s yndrome ). 3627 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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It may thus be that IQ s ets an upper limit or ceiling to adaptive accomplis hments , thereby res olving at least some of the controversy about the relative importance these two cons tructs. If s o, this limit may be more pronounced at the lower levels of intelligence, with increased variability in adaptive outcome found in with mild mental retardation. Although many s till feel adaptive behavior does not belong in the definition of mental retardation, virtually all workers agree that adaptive skills are critical to the long-term adjus tment succes s of people with mental retardation.

AAMR 's 1992 and 2002 Definitions C ontroversies about how bes t to conceptualize mental retardation have recently been piqued by the AAMR 's definition of mental retardation. T hat P.3081 definition—and the most recent revis ion published in 2002—does not view mental retardation as an inherent characteristic of people, but as an interaction between people and their environments . W ith this as sumption, 1992 definition eliminated traditional nosology based level of cognitive impairment (i.e., mild, moderate, and profound) and instead proposed four levels of environmental s upports (intermittent, limited, extensive, and pervas ive) acros s ten different adaptive domains health and safety, s elf-care, and leis ure). T hus, ins tead diagnosing a pers on with mode rate mental re tardation, 1992 definition s pecified that a person has intermittent needs for s upports in health and safety, limited needs supports in s elf-care, and s o on, acros s ten domains . 3628 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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argued that this s ys tem was unwieldy, more pertinent practice than diagnosis , and repres ents a giant s tep backward for res earch, as it leaves researchers without meaningful way to class ify subjects . T wo other features of the new definition have been debated. T he 1992 definition extended the IQ criterion from “70 and below” to “70 or 75 and below,” opening the pos sibility for a more lenient IQ cut-off point of 75. Although a five-point increas e s eems s mall, the or bell curve, nature of the IQ distribution makes particularly important this high-end change in the IQ off point. Donald MacMillian and colleagues note that “small s hifts in the upper limit have substantial cons equences for the percentage of the population eligible to be diagnosed with mental retardation. T wice many pe ople are e ligible whe n the cut-off is 75 and than whe n it is 70 and below.” Many critics predicted followed, the 1992 definition would lead to an increase the size of the population with mental retardation, including increases in the overrepres entation of s everal minority groups. C ritics als o derided the 1992 definition's adaptive criteria, which specified that documented deficits must seen in at least two of ten adaptive domains . F actor analytical s tudies of adaptive behavior provide no empirical s upport for ten domains, ins tead revealing two to s even factors of adaptive behavior. F urthermore, single meas ure of adaptive behavior exists that taps ten particular domains, which forced workers to mix domains across two or more different tests or to rely simply on their clinical judgment. F or all these reas ons , then, the new 1992 AAMR 3629 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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generated much controvers y in the mental retardation field. Indeed, although that definition was lauded by the AAMR itself in numerous publications and workshops, definition was generally ignored by practitioners and res earchers. In examining which definition of mental retardation was being us ed in the 50 United S tates plus the Dis trict of C olumbia, Denning, C hamberlain, and P olloway found that only four states reported using the 1992 AAMR definition, with 44 s tates continuing to us e 1983 AAMR definition (three states us ed neither). res earchers also ignored the 1992 definition, with all few articles (<1 percent) continuing to clas sify bas ed the levels of impairment. In s hort, if usage of a new diagnostic s ys tem is one meas ure of its s ucces s, the AAMR definition mus t be judged a failure to policy practitioners, and res earchers . In respons e to these criticisms, the 2002 AAMR definitional-clas sificatory manual addres ses s ome of is sues. T he IQ cut-off has now been changed to “two more s tandard deviations below the mean,” which, in IQ tes ts , equals an IQ of 70 or below. However, by degree of intellectual impairment has not been reestablished, and one as sumes that researchers and likely) practitioners will continue to ignore the definition for thes e reasons . In addition to correcting some—but not all—of the deficiencies in the 1992 AAMR diagnostic criteria, the definition also adds s everal ques tionable practices . involve specificity about the cut-off scores and the of adaptive behavior. T hus, “significant limitations in adaptive behavior are operationally defined as performance that is at least two standard deviations 3630 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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the mean of either (a) one of the following three types adaptive behavior: conceptual, social, or practical, or overall s core on a standardized meas ure of social, or practical skills.” Although the 2002 AAMR definition is too new to have received formal reviews , the cut-off and the content of adaptive behavior s eem problematic. As noted in the following discus sion of prevalence rates, it is likely that fewer pers ons will be diagnosed as having mental retardation if diagnoses occur only when an individual shows intellectual and adaptive impairments that are two or more s tandard deviations below the mean. It remains unclear what the effect would be of falling two more s tandard deviations below the mean on only one three types of adaptive behavior. As far as the content of adaptive behavior, the most definition seems to have s imply changed the ass ertion from the 1992 AAMR definition that adaptive behavior ten independent factors (when it probably does not). time, the 2002 definition makes the similarly as sertion that “conceptual s kills , s ocial skills, and skills ” make up adaptive behavior. As before, this goes agains t the prevailing data. In the cas e of the manual, however, clinicians are at leas t allowed to use standardized tes ts to determine impairments in behavior. In light of the controvers ies generated by the 1992 and 2002 AAMR definitions, it is probably not surpris ing such controvers ies spread as well to ps ychiatric of mental retardation. S pecifically, the 1992 definition published just in time to create a dilemma for the AP A the DS M-IV work group on childhood disorders . T he 3631 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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of the dilemma was whether the DS M-IV s hould adopt 1992 AAMR definition—if the work group followed this organizational tradition, the DS M-IV would depart from DS M-III-R . T he s olution was, in large part, a compromise. As summarized in T able 34-3, DS M-IV IC D-10 criteria retained the IQ cut-off point of 70 and traditional level of impairment nos ology and yet the 1992 AAMR definition domains of adaptive G iven the many criticis ms of the 1992 AAMR definition, well as the changes in the 2002 AAMR definition, it unclear what future DS M (and other) diagnostic will adopt as diagnos tic criteria of mental retardation.

Table 34-3 DS M-IV-TR C riteria IC D-10 C odes for Mental R etardation DS M-IV-TR C riteria for Mental R etardation

A. S ignificantly s ubaverage intellectual an IQ of approximately 70 or below on an individually adminis tered intelligence tes t (for infants, a clinical judgment of s ignificantly subaverage intellectual functioning). B . C oncurrent deficits or impairments in present adaptive functioning (i.e., the person's 3632 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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in meeting the s tandards expected for his or her by his or her cultural group) in at leas t two of the following s kill areas : communication, s elf-care, living, s ocial or interpers onal s kills , us e of res ources , s elf-direction, functional academic work, leisure, health, and s afety. C . Ons et before 18 years of age.

IC D-10 C odes for Mental R etardation (Axis III)

F 70

Mild mental retardation

IQ of 50–9

F 71

Moderate mental retardation

IQ of 35–49

F 72

S evere mental retardation

IQ of 20–34

F 73

P rofound mental retardation

IQ <20

F 78

Other mental retardation

S ensory, phys ical, behavioral impairments preclude 3633

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standardized IQ tes ting F 79

Uns pecified retardation

 

S pe cifiers for e xte nt of be havioral impairme nt. F 7x.0

No, or minimal, impairment of behavior

 

F 7x.1

S ignificant impairment of behavior requiring attention or treatment

 

F 7x.8

Other impairments of behavior

 

F 7x.9

Without mention impairment of behavior

 

IQ, intelligence quotient. F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs : DS M4th ed. T ext rev. W ashington, DC : American 3634 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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P sychiatric Ass ociation; 2000:46 and W orld Organization. T he IC D-10 C las s ification of Me ntal B ehavioural Dis orde rs . G eneva: World Health Organization; 1992:199–202, with permiss ion.

L evels of Mental R etardation At present, the field lacks a class ification system that reflects the remarkable diversity, s trengths , and competencies of people with mental retardation. T he AAMR definition rejected traditional nos ology becaus e its emphasis on deficits within people and yet fell short developing a s ucces sful alternative based on strengths competencies. Until a viable new s cheme is developed, makes s ens e to us e traditional nosology to des cribe persons with mental retardation. Here, then, global characteristics as sociated with mild, moderate, s evere, profound mental retardation are des cribed. As people mental retardation can also be clas sified by their later s ections detail how functioning changes across divers e genetic and other etiological groups.

Mild Mental R etardation Mild mental retardation (IQ of 55 to 70) cons titutes the larges t group of people with mental retardation, as many as 85 percent of all persons with retardation. T hese individuals appear s imilar to nonretarded 3635 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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individuals and often blend into the general population the years before and after formal s chooling. Many academic s kills at the s ixth grade level or higher, and graduate from high school. As adults , many of thes e individuals hold jobs , marry, and raise families —yet, P.3082 at times, they may appear s low or need extra help negotiating life's problems and tasks. R obert was a full-term infant, the last of three children born to his 38-year-old mother, a high school music teacher, and 40-year-old father, a high school science teacher. P regnancy was unremarkable, and R obert's older s isters were healthy and developing nicely. T he family lived in a rural town in the Midwes t. R obert was an extremely fus sy newborn and had periods of crying that the pediatrician labeled clas sic At 2 months of age, the parents were told that R obert a mild case of s upravalvular aortic s tenosis, one that warranted monitoring but no s urgeries . Although became s lightly less fus sy over time, he was a picky refusing s olid foods . R obert's parents also noted that was more “high-strung” than his s iblings, often quick to or cringe when his sis ters played too loudly. Miles tones were s lightly delayed, with R obert sitting unass is ted at 10 months and walking at 18 months . Language was also delayed, and, although his first appeared at 20 months , R obert had always made his and needs known. Although his parents were that he was delayed compared to his s isters, they were reass ured by the pediatrician's s ens e that boys often 3636 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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slight delays and that he was a lively, s ocial boy who quickly catch up. When R obert was 3 years of age, his parents ins isted developmental evaluation, which s howed modes t in cognitive, linguistic, and motor functioning, with a developmental quotient (DQ) of 74. He was described friendly and engaging, a real “charmer,” with a cute that endeared him to many. R obert was enrolled in a special kindergarten, and he remained in a special education and mains treamed class es his academic career. Like his mother and sisters, enjoyed listening to music and s inging, and he took an active interest in tinkering on the piano. At 7 years of age, the s chool psychologis t evaluated and believed that he fit a “learning disability” profile. R obert had an overall IQ of 66, with close to average functioning in s hort-term memory and express ive language and pronounced deficits in visual-spatial functioning. He struggled with writing tasks and but loved science and mus ic and was amazingly conversant to anyone who would lis ten to him. Indeed, parents feared he was “too friendly,” as well as too and with transient, intense interes ts in unus ual items, as vacuum cleaners. As he entered adolescence, R obert became anxious, so much so that he occas ionally rubbed his or rocked, and he “fretted” about day to day iss ues and what would happen next. His long-term s ens itivities to loud s ounds seemed to wane slightly, but he fears of s torm clouds and dogs and refus ed as well to on elevators. He became tearful and upset after one of older s is ters left for college and worried about her 3637 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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and ability to watch the weather at college. Although R obert experienced nightmares and would occasionally pace with worry and complain of stomachaches, he attended s chool and had a s mall group of friends in the S pecial Olympics bowling league. F urthermore, he singing with the high school chorus and was delighted be routinely s elected to play the piano at school When R obert was 17 years of age, his parents watch a televis ion documentary on Williams s yndrome. T hey were overwhelmed by the s imilarities between R obert and the people described in the program. T hey later described the experience like a “jolt.” T hey had accepted R obert, quirks and all, and had stopped their doctors for reasons “why” when R obert was a preschooler. Nevertheless , they immediately called the informational number offered in the show, and, within 2 months, they had the genetic tes ts done that confirmed their s trong suspicion that R obert had W illiams Although R obert's day-to-day life did not change dramatically s ince his diagnos is , his parent's report a difference in R obert's outlook. He met new W illiams syndrome friends at a conference, he applied to go to a summer music camp for young adults with Williams syndrome, and he states that he feels less alone. parents report a mixture of feelings at having s uch a diagnosis —disappointment in their doctors , relief in knowing, and twinges of guilt. T hey are energized by having a new community of W illiams s yndrome families with whom to share their feelings and worries; like their son, they, too, feel less alone. E lisabeth is a 29-year-old widowed white mother. was the younges t of three children and was born to her 3638 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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parents after an unremarkable pregnancy and delivery. E arly development was similarly without dis tinction as met her developmental milestones as expected. in the context of her enrollment in a Head S tart some cognitive delays were noted. More s trikingly, it became clear that E lisabeth had some vis ual problems evidenced by her falling a lot and stumbling into things . An examination disclos ed that E lisabeth had significant P.3083 visual problems prompting patching and other interventions . E lisabeth was routed into s pecial clas ses from kindergarten, and, although s he was described as somewhat of a loner, never really playing with any of her many cous ins , behavioral concerns did really s urface until puberty. At that time, s he became more withdrawn into a “fantas y world.” T hus, her family recalls that imaginary friends took on new importance, such that E lis abeth would literally carry on animated conversations with them. S he would talk to pos ters on wall and even kis s them on occas ion. E lisabeth began have increas ing difficulties in s chool around this time well. Her mother recalls that E lis abeth s eemed always have a level of discomfort with s exuality, and, after menarche, E lis abeth would refus e to attend to pers onal hygiene. E lis abeth was also incapable of eating in the cafeteria with the res t of the kids. Her sister recalls that E lisabeth would invariably “start eating like a pig,” and, because of these behaviors , s he would be placed in a separate lunchroom by herself. At 17 years of age, a ps ychological evaluation was determine the level of intellectual ability. T he narrative 3639 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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that time describes how E lisabeth had been coded as having mild mental retardation but that there were factors that were of concern, notably frequent from s chool and the need to build in extra incentives to get her to attend to task. E lisabeth was described in evaluation at that time as being a cooperative tes t appearing “healthy in all respects , but s he was quiet, somewhat s hy and seemed to have difficulty which was attributed to word-finding difficulties . After her graduation from high school, E lisabeth found herself in and out of couns eling, s he became from her family, and, at 24 years of age, s he pres ented mental health clinic, where s he was described as a woman “with developmental disability who had recently given birth (two months earlier) to a s on.” S he was described as experiencing symptoms of depres sion to the suicide of her hus band approximately 1 year T he story that E lisabeth told at that time was described chaotic and confus ing, including iss ues relating to the relations hip with parents, sis ters , and other individuals her life. With the birth of R aymond, E lisabeth's first child, the recalls how they took E lis abeth back into the home to support her and the new grandchild and that they were concerned about the behaviors that they witness ed, including E lisabeth's absolute refus al to change to wash the baby's genitalia, claiming that s uch would cons titute s exual abuse. T hey observed her feeding the child and inappropriately dress ing him for weather. Ultimately, her father overheard a from an adjacent room in which E lis abeth said that she was going to do the same thing that the child's father 3640 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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(commit suicide) but that s he would take R aymond with her. T his prompted a call to the authorities and was the proximal event that led to the removal of R aymond E lisabeth's custody. Over the next several years , her family describes and volatile interactions with E lisabeth that were cons istently characterized by irritability on E lisabeth's T he family is quite clear in being unable to identify periods of time during which E lis abeth's behavior up or down into s pecific depress ive or manic epis odes. most prominent recollection is of stable and durable preoccupations with fantas y, misinterpretations , and paranoid accusations, recalling even recently how s he refused to let her brother turn on the lights because knew that the C entral Intelligence Agency (C IA) would observing the family if the lights were on. During a recent involuntary hos pitalization, the ps ychiatris t noted that E lisabeth made s poradic eye contact, that her s peech was s lurred, and that s he or giggled inappropriately as though responding to private thoughts or, perhaps, “voices.” Although s he denied hallucinations, she was convinced that her and s ister intend to kill her if they get the chance, that both have murdered others or had people do the killing for them, and that they were cons piring to s ee that E lisabeth never got her son back. During this E lisabeth was s tarted on olanzapine (Zyprexa), her firs t medication trial, at 10 mg per day, and, s ubs equently, dose was increas ed to 15 mg per day. E lis abeth that the new medicine helped her think clearly, and it observed that the delusional thinking about the and the Mental Health C enter gradually disappeared 3641 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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during the course of her hospitalization. C urrently, E lisabeth lives in an independent apartment with close monitoring from community supports. has been cooperative in participating in various that have been offered, including the recent addition of weekly swimming opportunities, as well as participation an art s tudio. T he s taff reports that they have not been aware of any changes in E lisabeth's sleep or appetite, significant changes in her weight, no changes in mood, and no ps ychotic s ymptoms . T raditionally, people with mild mental retardation were thought to s how relatively few clear-cut organic caus es their delay. Although this may s till be the cas e, recent have seen an increase in the number of people with genetic s yndromes who function in the mild range. E xamples include mos t people with P rader-Willi as well as some men and most women with fragile X syndrome. A more s triking characteristic, however, is that more people with mild mental retardation come from minority groups and low s ocioeconomic backgrounds than be expected from their percentages in the general population. T his overrepresentation of minority groups has been used to criticize IQ tests , as well as to the importance of environmental-cultural and genetic influences on mental retardation.

Moderate Mental R etardation Moderate mental retardation (IQ of 40 to 55), is seen in approximately 10 percent of the mentally retarded population and includes people with more impaired 3642 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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cognitive and adaptive functioning. P eople with mental retardation are typically diagnosed in their preschool years , and some s how a clear organic cause their delay. Many persons with Down syndrome, the common chromos omal cause of retardation, often function in this range, as do many adoles cents and with fragile X syndrome. Most children with moderate mental retardation require s pecial education services , achieving academic s kills at the second to third grade level. Needs for s upportive s ervices are continued throughout life; with proper s upports, many live, work, thrive in their local communities . In a s tudy by R os s colleagues, 20 percent of pers ons with IQs from 40 to lived independently, whereas 60 percent were partially dependent, and 20 percent were totally dependent on others . In a s imilar way, some this range are employed in the competitive job market need minimal job s upervis ion, whereas others require more extensive supervision on the job and may work in sheltered workshops or other, more segregated B ryan is a 17-year-old s ophomore with moderate retardation as sociated with Down syndrome. B ryan had significant cardiac problems in infancy and eventually required surgery to repair a ventricular septal defect. Although his energy level improved significantly thereafter, he s till had some delays in motor and other developmental milestones . Nevertheles s, throughout education, B ryan has been mains treamed with samepeers with the s upport of clas sroom aides. B ryan, is 53, has s ome difficulties with articulation, and his language mainly cons ists of two- to four-word R ecently, B ryan has made progres s 3643 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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P.3084 with reading and now can read 50 s ight words. He has some minor problems with managing his anxiety over years and can become somewhat s tubborn at times , but B ryan is well-liked by his teachers and class mates , and parents boast that B ryan has been a charming, pleas ant child from infancy. In addition to attending his clas ses at the local high school, B ryan also spends s ome time job s kills in community s ettings . He also enjoys his as the as sis tant manager for his high s chool's cross team and actively participates in S pecial Olympics .

S evere Mental R etardation S evere mental retardation (IQ of 25 to 40) occurs in approximately 3 to 4 percent of the population of people with mental retardation. Individuals at this level often one or more organic caus es for their delay, and many concurrent motor, ambulatory, and neurological as well as poorly developed communication skills. Most persons with s evere mental retardation require close supervis ion and specialized care throughout their lives . S ome individuals learn to perform simple tasks or that facilitate their s elf-care or their ability to perform in sheltered works hop or preworkshop type of s etting. Harrison is a 16-year-old res ident at a s chool for with s evere disabilities. His mother recalls that concerns were rais ed early in life when, at 2.5 years of age, lost acquired language s kills and was seen by a neurologis t who elected to introduce carbamazepine (T egretol) in light of an abnormal electroencephalogram 3644 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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(E E G ). His mother recalls that the carbamazepine to improve Harrison's overall function but als o was noteworthy for the pos itive effect it had on Harris on's sleep and activity level, both of which were fact, the hyperactivity and impulsivity later prompted a trial on methylphenidate (R italin), and Harris on's recalls that, although there may have been some initial improvement on this drug, over time, Harris on became animal” on the medication, prompting its Indeed, methylphenidate is the only medication that his mother lis ts when given the opportunity to identify that have been tried in the pas t that were clearly as sociated with a bad outcome. On the other s ide of the balance sheet, his mother lis ts carbamazepine and other antiseizure medications as having been consis tently helpful over the years. T he at Harris on's school adds that carbamazepine is unique from among the anticonvuls ants that have been tried in that there not only seemed to be benefit in terms of treating and reducing s eizure frequency, but also there seemed to be additional behavioral benefit in the form stabilization. Over the years , the dos e of has varied and has been periodically discontinued in of trials of other anticonvulsants becaus e of concerns about Harrison's borderline white blood cell counts. However, becaus e of the unequivocal behavioral that s taff and family attribute to the carbamazepine, it is currently being used again, albeit at doses that may be lower than have been us ed in the past. His mother's recollection is that a number of medication trials have been explored over the years and that each of the medications that have been introduced appears to 3645 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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conferred s ome benefit, albeit temporary. T he behavioral difficulties that have prompted changes include agitation, hyperactivity, and mood instability in the form of giddines s and, more recently, inappropriate s exual advances toward female staff. have als o been more significant aggress ive outburs ts recent years. In addition to the periods of heightened irritability and hyperactivity, there have also been that are noteworthy for diminished activity, los s of appetite, and s ignificant weight loss , s uch that weight has dropped into the range of 120 lb in spite of 6-ft., 3-in. frame. T eachers and Harrison's mother that, during these times, his interes ts als o wane, activities that he usually enjoys. Observers suggest Harrison seems to want to eat but jus t can't muster the interes t or enthus ias m when food is placed in front of In addition to carbamazepine and methylphenidate, previous medication trials have included imipramine (T ofranil), divalproex (Depakote), clonidine (C atapres ), buspirone (B uS par), clonazepam (K lonopin), s ertraline (Zoloft), melatonin, naltrexone (R eV ia), ris peridone (R is perdal), quetiapine (S eroquel), and (B enadryl). On examination, Harrison comes quite willingly into the office s etting accompanied by s taff and family. He is a and s lender young man dress ed in s weat pants that falling off his thin frame. Harrison extends his hand to acknowledge the presence of the examiner and does eye contact on occasion. His psychomotor activity is remarkable for fairly constant s tereotyped hand movements and, occas ionally, s ome vocalizations . Harrison takes a piece of paper from his mother when 3646 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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sees it and proceeds to flick it in front of his eyes , to small s trips from it, and to place them in his mouth. He readily s urrendered these bits of paper on request. Harrison's affect was full, with clear and bright s miles , es pecially when interacting with his mother. Later the visit, he seemed to become more agitated and occasionally place his hand to his mouth in a self-biting gesture or would place his face into the palm of his while vocalizing and rocking. Harris on followed s imple reques ts and was able to sign “thank you” after having been given s ome crackers from the s chool staff. When Harrison's mother was given a description of disorder, s he quite readily recalled all of thos e in her older brother; reporting, for example, that he had periods of time when his mood seemed elevated, and engaged in reckless and impulsive behaviors, and times when he would withdraw, become more aloof, even express ed suicidal thoughts at various times . A lithium (E skalith) trial was s ubs equently initiated and res ulted in a s ignificant improvement in Harris on's irritability, s leep disturbance, and hyperactivity. He remains on a relatively low dos e of carbamazepine for control of his epilepsy. His neuroleptic is gradually tapered toward discontinuation.

Profound Mental R etardation P rofound mental retardation (IQ of 25 and below) relatively few individuals (1 to 2 percent) and involves pervas ive deficits in cognitive, motor, and functioning. Impairments in sensory-motor functioning often s een from early childhood, and most individuals require extens ive training to complete even the mos t 3647 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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rudimentary as pects of s elf-care, s uch as eating and toileting. T he vast majority of people with profound mental retardation show organic caus es for their delay, and most require total s upervis ion and care throughout life. Annalise was born after a pregnancy that was unremarkable, her mother's first. Her mother recalled significant feeding difficulties in the first few weeks of with failure to thrive having been considered early in Annalise was evidently quite hypotonic, and her miles tones were delayed. S he did not walk, for until approximately 4 years of age. While she was in an early intervention program, Annalis e's progres s variable, and s he has ess entially never come to be us e s poken language. Annalise has and us es a few make her needs known and more recently has begun us e communicative devices to type in words . T he reports that Annalis e's medical history is extraordinarily complicated. Approximately 2 years ago, Annalise had P.3085 life-threatening episode of congestive heart failure requiring intubation and aggres sive treatment that now includes a β-blocker, a diuretic, and digitalis. At the s ame time, it was discovered that Annalis e was hypothyroid, s o s he has subsequently received thyroid supplementation. Approximately 1 year ago, the of diabetes was made, and Annalis e now requires daily insulin injections as well. T he family reports that there were als o s ignificant problems with what appears to been a milk allergy and wonders whether that may 3648 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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contributed to some of Annalise's difficulties in gaining weight in her early years . However, the tables turned Annalise was approximately 4 or 5 years of age, when began to become completely preoccupied with food, cons uming everything in s ight, with a particular preference for carbohydrates . G enetic testing for Willi syndrome was negative, but s ubs equent testing revealed a deletion on chromos ome 1. Annalise's his tory is remarkable for her never having particularly attentive to the thoughts or feelings of literally walking over other children when s he was able do so. T he family reports that Annalis e has many circums cribed interests, including small vignettes from Dis ney videos, which, if s he were allowed to do s o, she would view over and over again. S he also has had a preoccupation with sorting and stacking objects and, at one point, would tantrum if she was not able to stones or pebbles if she walked by a pile of them at the local beach. When Annalise was 6 years of age, a methylphenidate trial was initiated. T he dos e was evidently pushed up to 5 mg three times daily, and her family reports that, over the course of the year that Annalise received that drug, they believed that she was less emotionally available and also more ritual bound preoccupied with her limited interests. T he family has observed prominent s tereotypical behaviors, merely preoccupation with parts of objects and with s orting arranging. B ecause of Annalise's preoccupation with the family has had to lock their refrigerator and lock food in cabinets . Her family hopes that medication may help allay s ome of Annalis e's anxiety and obs es sion have and continue to pres ent significant barriers for her 3649 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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full participation in activities, particularly in the community. T hese four levels have long been used to categorize people with mental retardation, yet have come under recent attack becaus e of their focus on deficits instead competencies. How people with mental retardation are defined and clas sified—based on strengths, or s ome combination of both—has profound for studies on the epidemiology of this disorder. As detailed in the next section, prevalence estimates of mental retardation vary widely, depending on how it is defined. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > P R E V AL E NC

PR E VALE NC E P art of "34 - Mental R etardation" According to s ome es timates, approximately 1 percent the population has mental retardation. T his 1 percent figure is cited by DS M-IV and is roughly the percentage found in mos t prevalence s tudies . Y et, the widely cited percent figure hides a variety of controvers ies within mental retardation. In particular, many have reas oned mental retardation is more frequent—nearer to a 3 percent prevalence rate—whereas others ques tion whether s ome categories of mental retardation are disappearing altogether. T hes e controversies have enormous societal implications : B as ed on the current population, a difference of even 1 percent means that 3650 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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extra 2.6 million Americans have mental retardation may require s ervices.

Two G roups of Individuals with Mental R etardation T o understand the prevalence is sue, it is important to cons ider who, historically, has been thought to the retarded population. G iven a gaus sian, bell curve distribution of intelligence, 2.28 percent of individuals should fall two or more standard deviations below the general population average of an IQ of 100, which translates into IQs below 70 on mos t ps ychometric F ollowing the gaus sian distribution, most of these individuals should have IQs just below 70, and few individuals s hould have IQs that are below 55 or 40 (three or four standard deviations below the mean). percentage of persons whose IQs fall below 40 (four standard deviations below the mean) s hould equal 0.00003, or roughly 7,800 persons throughout the United S tates (0.00003 × 260 million). As early as 1960, Harvey F . Dingman and G eorge realized that many more persons with s evere and profound mental retardation exist than would be by a gaus sian distribution. T he relatively large numbers persons at the lowes t IQ levels seem due to the many persons with clear organic etiologies; mos t prevalence studies find that, as one goes lower down the IQ increasingly high percentages of individuals s how one more clear organic caus es for their mental retardation. E arlier, Leta Hollingworth had observed that “a s mall percentage of mental deficiency is due to dis ease of nervous s ys tem … res earch points to the conclus ion 3651 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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approximately 90 percent of the mentally subnormal the products of inferior germ-plasm. T he remainder are victims of organic causes, and are in a true s ense pathological cases.” In 1967, E dward Zigler proposed that there are two of persons with mental retardation. R etardation in the group was caus ed by the us ual (and so far factors that distinguish individuals across the normal of intelligence. R esearchers have variously referred to group as having cultural-familial, familial, or nons pe cific me ntal re tardation. Many of thes e individuals come poor, minority, and low-educational backgrounds, and IQs are also common in parents or s iblings . Like acros s the entire IQ spectrum, s ome interplay of environmental and organismic factors seems involved this type of retardation. Zigler referred to the second group as having organic me ntal re tardation. T he retardation of this group was caus ed by one of many different prenatal, perinatal, or postnatal causes. Over the years, increas ing numbers persons with organic mental retardation have been identified. As dis cuss ed in the following s ections, retardation has now been linked to approximately different genetic causes , and other caus es als o exis t. cases, however, these individuals have one or more organic insults that are ass ociated with their mental retardation.

1 P erc ent–vers us –3 P erc ent Is s ue B y summing percentages of the two groups , most of the 1960s and 1970s concluded that approximately percent of individuals have mental retardation. In the 3652 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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1970s , however, Mercer criticized the 3 percent figure concluded that only 1 percent of the U. S . population mental retardation. Although the 1 percent–versus –3 percent debate may not ultimately be res olvable, its details illustrate s ome of mental retardation's mos t complicated is sues. F our of thes e is sues can be highlighted.

IQ As the S ole C riterion of Mental R etardation T he 3 percent prevalence rate considers IQ as the sole criterion for mental retardation. T hat is , pers ons with below 70 are considered to have mental retardation; whos e IQs are 70 and above do not. E ven the exces s of individuals at the lowes t IQ levels are solely on the gauss ian distribution of IQ. However, IQ is not the s ole criterion of mental As previous ly dis cuss ed, to be considered to have retardation, a person must have an IQ below 70, as deficits in adaptive behavior. If the two are perfectly correlated—if every pers on with a P.3086 below-70 IQ als o has deficits in adaptive behavior— 3 percent figure becomes tenable. If the two correlate weakly or not at all, much lower prevalence rates hold. Although s trong IQ-adaptive correlations have been for some organic groups and for individuals with s evere and profound mental retardation, lower correlations probably hold for children with mild mental retardation. T hroughout the entire retarded population, a but by no means perfect—correlation probably exists 3653 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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between IQ and adaptive behavior. T o the extent that two are uncorrelated for pers ons whose IQs fall below less than 3 percent of individuals have mental In recent years , two new twists to the IQ-adaptive iss ue have arisen. T he first concerns the poss ible change in IQ cut-off criterion itself, from an IQ of 70 to an IQ of G iven the gaus sian distribution of IQ, as many people IQs between 70 and 74 as have IQs between 0 and 69. second is sue concerns the change in the AAMR adaptive criteria, from “deficits in adaptive behavior” to inadequate functioning in two of ten adaptive domains . both instances, greater numbers of persons become eligible for a diagnosis of mental retardation.

IQ R emains C ons tant T he 3 percent prevalence rate als o as sumes that each individual's IQ is perfectly constant and that IQs remain relatively s table over time. T his as sumption seems in some ways , unjus tified in others . Once children the late-preschool years , correlations between tes tings many years apart become fairly high, in samples of children with disabilities. Indeed, across entire dis tribution of IQ, a median correlation of 0.77 been s hown between testings at 4 years of age and 12 years of age. At earlier ages, however, correlations between IQ during the infancy years and later IQ scores are zero. T hat is, with the exception of infants whos e IQs extremely low, any baby's IQ score (i.e., DQ on the S cale of Infant Development) has little relation to that child's IQ during later childhood or adulthood. 3654 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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F urthermore, different groups may s how different trajectories of IQ with development. C hildren with syndrome show their highest IQ (or DQ) s cores during first year of life and then decline in IQ over the early middle childhood years . B oys with fragile X s yndrome decline in IQ, but their declines s eem to occur only beginning at approximately 10 to 15 years of age. C onvers ely, children with cerebral palsy (one-half of have mental retardation) remain remarkably stable in IQ scores over time, much like groups with mixed or nonspecific etiologies of mental retardation. T hus , cons idering IQ alone, the age of the individual mus t be kept in mind when cons idering the prevalence rates of different degrees of mental retardation.

Identific ation R ates Are E qual R ange of Variables Another related iss ue concerns identification rates . T o diagnosed with mental retardation, individuals mus t be brought to the attention of profess ionals , tested, and found to meet definitional criteria. However, the of this proces s vary widely owing to a host of factors. T he firs t factor concerns age. Nearly every s tudy finds prevalence rates are low during the years from birth to 6 years of age, increase rapidly until the adoles cent and decrease thereafter. As might be expected, the increased intellectual demands of school s eem for s uch discrepancies. However, increas ed intellectual demands are not the school variable affecting prevalence rates . S chools vary in their formal procedures for identifying children with problems, such as mental retardation. In many 3655 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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schools , these proces ses begin when the class room teacher calls the child to the attention of a S tudent T eam, a multidis ciplinary group that is designed to help teachers handle difficult children. T he team then on within-clas s changes that the teacher might try or the child for further evaluations . Unfortunately, there is currently only a general sense of why teachers refer children to S tudent S tudy T eams , why rates vary so from one s chool or district to another, or what of children who meet criteria for referral to S tudent T eams are ultimately diagnosed with mental S uch variations undoubtedly affect mental retardation prevalence rates. T hese diagnos tic is sues are further complicated by regional and local variations. S imply put, many more children are diagnos ed with mental retardation in areas of the country than in others . Using percentages children enrolled in special education s ervices acros s 50 states during 1993, only 3.2 per 1,000 s chool were identified as having mental retardation in New J ersey, and 4.5 per 1,000 were identified in C alifornia versus 31.4 in Alabama and 25.4 in K entucky. many factors probably relate to thes e inters tate differences, P hilip S . Mas sey and R ichard McDermott that three factors account for mos t of the variance: the percentage of a s tate's population with les s than a grade education, the median hous ehold income, and percentage of births to teen mothers. In addition to thes e demographic factors , policy are als o important. S ince the 1980s , there has been a marked decrease in the numbers of children diagnos ed with mental retardation. T his decrease aris es from 3656 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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sources. P articularly, in C alifornia, the L arry P . v. W . case has led to a less ened reliance on IQ tests for particularly with minority children. Many even cons ider very term me ntal re tardation s tigmatizing. P artly as a fewer children who might otherwis e be cons idered to have mild mental retardation—that is , to have IQs from to 69—are receiving the mental retardation diagnosis. Where are all the children with mild mental retardation? P artly, it s eems, thes e children now receive diagnoses learning disabilities. According to U.S . Department of E ducation statis tics, over the school years from 1976 1977 to 1992 and 1993, there was a 41 percent decline the percentage of children considered mentally by U.S . s chools , whereas the percentage of children cons idered learning dis abled jumped 198 percent. However, the move from mental retardation to learning disabilities is not the total answer. Indeed, many belowIQ children are not being diagnosed with mental retardation or learning dis abilities. T hey do not receive diagnosis of mental retardation becaus e of fear of and decreased reliance on IQ tests. However, at the time, they also do not receive a diagnosis of learning disabilities, because they do not function two or more standard deviations worse on achievement tests tes ts (the usual definition of learning disorders ). T o the underdiagnosis of these children, s ome workers called for abandoning the category of mild mental retardation. T hey sugges t that a new diagnostic be ins tituted, one that highlights this group of lowintelligence, low-achieving, but less -often s erved,

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A final as sumption of the 3 percent figure is that with mental retardation have equal life s pans to without mental retardation. T his ass umption s eems obviously incorrect, particularly for pers ons with more severe and profound levels of mental retardation. S everal variables lower life expectancies. F or example, many early deaths —sometimes for persons in their 20s and 30s —are related to ambulatory and res piratory problems . E tiology may als o P.3087 play a role. S pecifically, children with Down syndrome continue to be prone to heart problems , leukemia, and, 35 years of age, the plaques and tangles of disease. S imilarly, children with P rader-Willi syndrome prone to hyperphagia and obes ity; complications of obesity (e.g., diabetes and heart dis eas e) remain the caus e of higher death rates for persons with P radersyndrome. How many pers ons with mental retardation are there? cannot be s aid for certain. G iven a definition featuring a below-70 IQ and deficits in adaptive behavior, the prevalence rate is probably les s than 3 percent but than 1 percent. If one adopts the below-75 IQ cut-off, higher percentages might be obtained. At pres ent, it seems best to conclude that, although the 1 percent is cited by most s tudies and profess ional organizations, several difficult, poss ibly unres olvable iss ues even the s imple ques tion of how many persons have mental retardation. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins

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> T able of C ontents > V olume II > 34 - Mental R etardation > E T IOL OG IC AL C ONS IDE R AT I

E TIOL OGIC AL C ONS IDE R ATIONS P art of "34 - Mental R etardation" As noted by E s quirol in 1845, intellectual disability is disease in and of itself, but the developmental cons equence of some pathogenic process . In 1898, Ireland could class ify “idiocy” into ten categories on the basis of etiology, including “genetous, microcephalic, eclamps ic, epileptic, hydrocephalic, paralytic, cretinism, traumatic, inflammatory, and idiocy by deprivation.” recently, the AAMR offered an admittedly partial lis ting that enumerated more than 350 causes of mental retardation. With advances in medicine generally and in molecular genetics in particular, new causes of mental the genetic etiologies of formerly uns pecified are identified each year. In the past 4 years , for national databas e of genetic disorders, Mendelian Inheritance in Man, has added s ome 400 new genetic caus es of intellectual disability alone. Nearly 300 retardation syndromes have been linked to the X chromosome alone. T he most common caus es of retardation are Down syndrome, fragile X s yndrome (accounting for 40 percent of all X-linked retardation), fetal alcohol syndrome. T ogether, these three are res pons ible for approximately 30 percent of all identified cases of mental retardation. 3659 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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In addition to new etiologies being identified, additional knowledge is accumulating about underlying in causes previous ly known. F or example, at least 170 different mutations have been reported in the phenylalanine hydroxylas e gene leading to P K U. In syndrome, four critical regions on chromosome 21 to DS C R 4) have been described. T he availability of molecular markers for these and flanking regions has enabled clinicians to confirm cas es of Down syndrome the context of subtle translocations and chromos omal abnormalities other than tris omy. On the other hand, K orenberg and colleagues ' detailed studies have evidence for a s ignificant contribution of genes outside the D21S 55 region to the Down syndrome phenotype. T hus, characteris tic features involving the facies, microcephaly, s hort stature, hypotonia, abnormal dermatoglyphics , and mental retardation likely involve more than a single chromosomal region.

A nimal Models Over the pas t 100 years , advances in the basic brain organization and function and of s ome of caus es of intellectual disability are derived from and led to the development of animal models. T he hope for such modeling is its potential usefulness in eliciting underlying mechanisms, as well as s ugges ting treatments for mental retardation. R odent models have been des cribed of Down P K U, fragile X s yndrome, Lesch-Nyhan s yndrome, and tuberous s cleros is complex, as well as prenatal alcohol or cocaine. T ris omy 16 mice, a potential Down syndrome model, demonstrate vis ual-spatial and 3660 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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attendant learning deficits. Homologs of the s ingleminded gene in the fruit fly Dros ophila, have been identified in man and mous e, and the human gene to the Down syndrome critical region. Likewise, the Dros ophila minibrain gene appears to be as sociated the Down syndrome critical region. B oth of the genes in Dros ophila are involved in brain development, and their study suggests pos sible mechanis ms underlying retardation in Down s yndrome. T he curly tail mous e been a valuable model for the study of neural tube and a number of agents derived from this paradigm will likely be evaluated for their potential to prevent neural tube defects in humans . A mous e model for the fragile syndrome, in which the F MR 1 gene is molecularly out, is remarkable in that, like humans with the the knockout mice s how macroorchidism, learning hyperactivity, and sensory hypersensitivities. T hes e may help unravel the physiological role of the F MR 1 protein in humans .

E tiology of Mental R etardation As clinicians approach the etiology of mental for a particular patient, it is helpful to work from a broad framework initially. F or example, an initial distinction might be drawn in terms of congenital versus acquired etiologies. F or the latter, the timing of the insult that led retardation may be further broken down into perinatal postnatal causes. C ongenital causes might be divided genetic disorders or developmental disorders of brain formation or, more s pecifically, s till further into inborn errors of metabolis m, and so on. T he frequency with which mental retardation 3661 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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with a particular cause is highly influenced by the population s urveyed. F or example, persons drawn from institutional settings, in which severe and profound retardation and vis ible congenital anomalies are more likely to be found, are more commonly going to have identifiable chromos omal abnormality than are persons with mild dis ability res iding in community settings. T his bias can be res tated, s uch that more severe of mental retardation are likely to have an organic etiology. T able 34-4 provides an example of a scheme and ass ociated frequency es timates for mental retardation etiopathogenes is.

Table 34-4 C las s ific ation of Menta R etardation C aus es by E tiology Frequenc y E tiology

E xamples

E s timated Frequenc y

P renatal causes

 

 

   G enetic disorders

 

4–28%

      C hromos omal Down s yndrome, aberrations , tuberous

 

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monogenic mutations , multifactorial malformation syndromes due to microdeletions

   C ongenital malformations

phenylketonuria and other metabolic disorders , fragile syndrome, mental retardation, P rader-Willi syndrome, Williams syndrome, Angelman's syndrome

 

7–17%

 

      Malformations of the central nervous s ys tem, multiple malformation syndromes

Neural tube defects, C ornelia de Lange's syndrome

 

   E xposure

 

5–13%

      Maternal infections, teratogens , toxemia or

C ongenital human immunodeficiency virus , fetal

 

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placental insufficiency, other

syndrome, prematurity, radiation, trauma

P erinatal

 

2–10%

   Infections, delivery problems , other

Meningitis, as phyxia, hyperbilirubinemia

 

P os tnatal

 

3–12%

   Infections, toxins, other postnatal ps ychos ocial problems

E ncephalitis , lead poisoning, traumas, brain tumors , poverty, ps ychotic illnes s

 

Unknown

 

30–50%

Medic al Diagnos tic A pproac h to P atient with Mental R etardation C linic al His tory T he elements of a comprehensive clinical evaluation the patient with mental retardation are s ummarized in T able 34-5. As for any patient, a good history is and, in many cases , collateral informants become extremely us eful. F amily members may be able to fill in 3664 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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important aspects of the family pedigree, providing information about relatives ranging from learning problems to phys ical anomalies , developmental disabilities, and even res ponse to treatment.

Table 34-5 E lements of the E valuation of the Patient with Mental R etardation C linical his tory    P renatal and birth his tory F amily pedigree (three generations )    R elatives with learning problems , ps ychiatric disorders , mental retardation, and neurological or degenerative dis orders    F amily res emblance (reduced in aneuploidy) P hysical examination    As sess ment of minor phys ical anomalies    G rowth and phys ical development    Head circumference compared to norms 3665 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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   G rowth trajectory (comparison with earlier meas ures )    Description of facial features (micrognathia, hypertelorism, or thin upper lip)    Us e of photographs and video to document morphological variants and gait    C omplete neurological examination    Documentation of behavioral phenotype    W ood's light and dermatoglyphic examinations indicated Adjunct diagnostics    Audiological, ophthalmologic, and ps ychometric as sess ments Diagnos tic tes ts for s elective us e as indicated    S keletal radiographs    Metabolic studies for lysos omal, peroxisomal, mitochondrial disorders    Mus cle biops ies

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   Deoxyribonucleic acid molecular s tudies    C hromosome analys is    F luorescent in situ hybridization    F ragile X syndrome testing    Organic and amino acids    Imaging studies (magnetic resonance imaging computed tomography)

T he clinical examination should be performed with particular attention to the presence of minor anomalies, aberrant growth, and phys ical development. the examination polls for behavioral s ymptoms that comport with a known behavioral phenotype and help delineate a diagnosis. F or some dis orders, the clinical cours e evolves over time, and ongoing attention to the unfolding behavioral phenotype may help establish a diagnosis. A repres entative list of s uch disorders T able 34-6. T hus , a history of s ignificant early feeding difficulties as sociated with hypotonia (and P.3088 the tell-tale mus cle biops y s car), which later gives way hyperphagia and weight gain, is perhaps more useful in the diagnosis of P rader-Willi syndrome than the 3667 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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observation of hyperphagia alone.

Table 34-6 S elec ted S yndromes and C onditions in Whic h a R ec ognizable B ehavioral Phenotype E xis ts or Has B een Propos ed Aicardi syndrome Angelman's syndrome C ornelia de Lange's (B rachmann de Lange) syndrome Del (9p22) syndrome Down s yndrome F etal alcohol syndrome F ragile X s yndrome Lesch-Nyhan s yndrome Monoamine oxidase A deficiency Neurofibromatos is 1 3668 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Noonan s yndrome P henylketonuria P rader-Willi syndrome R ett's syndrome R ubins tein-T aybi syndrome S mith-Lemli-Opitz s yndrome S mith-Magenis syndrome S otos s yndrome T uberous s cleros is complex T urner s yndrome V elocardiofacial syndrome, DiG eorge syndrome (C AT C H 22) Williams s yndrome

C AT C H, cardiac defects , abnormal facial thymic hypoplasia, cleft palate, and res ults from a deletion within chromosome

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C hromos ome S tudies In general, becaus e chromos ome abnormalities are the single mos t common known caus e of mental found in unselected patients with mental retardation, a chromosome analys is is commonly obtained in the diagnostic process . T he pres ence of multiple physical anomalies and s everity of mental retardation influences the threshold with which a chromos omal s tudy is obtained. It is not uncommon to be presented with a history of birth complications , perinatal hypoxia, falls suspected injury, and s o on, only later to discover an underlying genetic etiology for mental retardation. Moreover, in s ome cases, the genetic syndrome may the stage for birth complications, with the latter being credited with the caus e of dis ability until an appropriate diagnostic procedure is obtained. T hus , in some the mere presence of developmental delay may prompt chromosomal s tudy. G iven advances in diagnostic techniques , there may be situations in which an individual pres ents with a his tory a normal chromos ome s tudy but for whom the of aneuploidy remains s us picious in light of multiple phys ical anomalies. In these situations, the clinical geneticis t may sugges t a higher-res olution study, skin biopsies , or s pecial karyotyping or molecular cytogenetic studies. W ith the advent of the ability to subtelomeric chromosomal regions with specific fluores cent in s itu hybridization (F IS H) markers , for example, microscopic deletions can be identified in upward of 7 percent of pers ons with moderate to mental retardation. T he pres ence of a history of growth retardation in utero, family history of mental retardation, 3670 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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microcephaly, s hort stature, hypertelorism, and other anomalies increas es the likelihood of finding defects.

Neuroimaging At the turn of the century, W . Hanna T homs on that “the brains of mos t idiots and of half-witted are us ually s maller and weigh less than the average of normal brains , while many men distinguis hed for their mental powers have had large and heavy brains. B ut exceptions are very numerous both ways. … No man's intellect can be judged by the size of his hat.” T homs on went on to make the case that the material the brain determines thought, feeling, and volition. Advances in brain imaging technology now enable a more refined look at the relations hip between neuroanatomy and mental retardation. P.3089 T able 34-7 s ummarizes the findings from computed tomography (C T ) and magnetic resonance imaging in groups of patients with mental retardation. G iven that mental retardation should sugges t obligate brain abnormality, it is s urprising that the percentage of individuals in imaging s tudies who are positive for abnormality is as low as 9 percent in s ome studies. On other hand, the upper range of 96 percent underscores importance of selection criteria and type of s tudy on the res ultant yield.

Table 34-7 Neuroimaging Findings 3671 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Pers ons with Nons yndromal Ment R etardation S tudy

S ubjects

Modality

Findings

Moes chler Moderate to et al. severe mental (1981) retardation no s ignificant dysmorphic features or abnormalities in head circumference

CT

One cas e of atrophy; one case of prominent prepontine cistern

Lingam al. (1982)

Nons pecific mental retardation

CT

20% atrophy; 8% other abnormalities (collosal agenes is , arachnoid cys other)

C urry et al. (1995)

Microcephaly

C T /MR I

68% abnorma

 

Normocephaly

C T /MR I

39% abnorma

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Majnemer and S hevell (1995)

Developmental delay

C T /MR I

17% cerebral dysgenes is ; 10% hypoxic is chemic encephalopat

R oot and C arey (1996)

P rofound mental retardation

C T /MR I

80% abnorma

S otoet al. (2003)

Nons pecific mental retardation

MR I

90% abnorma (dysplas ia of corpus [46%], abnormal septum pellucidum [33%], cortica dysplas ia other abnormalities )

P andey al. (2004)

Nons pecific mental retardation

MR I

64% abnorma (42% of as sisted in as signing diagnostic etiology for mental retardation)

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C T , computed tomography; MR I, magnetic res onance imaging. F rom C urry C J , S tevens on R E , Aughton D, et al.: mental retardation: R ecommendations of a C onsensus C onference: American C ollege of Medical G enetics. Am G e ne t. 1997;72:468–477, with permiss ion. In general, MR I s tudies are regarded as superior to C T that the former provides better anatomical res olution. Myelination and more s ubtle anatomic abnormalities heterotopias more eas ily yield to identification with C ontrariwis e, C T may be more useful when the intent look for poss ible intracranial calcification, for example, tuberous s cleros is complex, or abnormalities of the its elf, as in craniosynos tos is syndromes . In situations in which there is little doubt that structural brain abnormalities are present, an imaging s tudy may be us eful to s erve as a baseline agains t which to progres sion. An individual with tuberous s cleros is may followed with serial imaging s tudies to chronicle the progres s of les ions, or an individual who engages in head banging behavior may warrant a bas eline study. Other conditions in which neuroimaging is indicated include patients with seizures, microcephaly macrocephaly, the loss of previously acquired skills, neurological signs , such as spasticity, dystonia, or reflexes. 3674 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Although the value of neuroimaging investigations in normocephalic patient without localizing neurological signs was regarded as ques tionable in the late 1990s , recent advances in imaging technology are calling such conclus ion into question. Indeed, newer imaging technology, for example, the us e of in vivo proton magnetic res onance spectroscopy (H-MR S ), may be particularly useful in as signing etiological caus ation monitoring res ponse to treatment in some mental retardation syndromes .

Metabolic Tes ting T he presence of certain clinical characteris tics may the focus ed use of metabolic studies to identify inborn errors of metabolis m. A partial listing of s igns and symptoms that might raise the suspicion for a disorder appears in T able 34-8. T esting in the clinical s uspicion may include plas ma and urine amino organic acid studies, acid–base balance, thyroid tes ts , lysosomal enzyme analysis, plas ma and urine carnitine analys es , and plasma very long chain fatty among others. B ecaus e neonatal s creening picks up hypothyroidism, and galactos emia, the yield for subs equent unselected screening for inborn metabolic disorders is extremely low. In general, in the P.3090 absence of s pecific indications other than mere mental retardation, metabolic tes ting is likely to be of little additional diagnostic value.

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Table 34-8 S elec ted C linic al Findings and Laboratory Abnormalities That Inc reas e S us pic ion for Underlying Dis order Abnormal s exual differentiation Arachnodactyly C ataracts, ophthalmoplegia, corneal clouding C oars e facial features Dis turbance of consciousness , lethargy Dry skin, hyperkeratotic plaques on soles and Dys morphic features F ailure to thrive, feeding abnormalities , vomiting F lat nasal bridge G ingival hyperplasia G rowth abnormality

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Hair abnormalities (fragility) Hyperammonemia Hyperuricemia Hypo/hyperglycemia Hypocholesterolemia Hypotonia, dys tonia, ataxia Macrocephaly, microcephaly Neurodegenerative s ymptoms (regress ion or loss skills ) Organomegaly R etinal pigmentation S eizures, specific electroencephalogram abnormalities S elf-injurious behavior S keletal malformations

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F rom C urry C J , S tevens on R E , Aughton D, et al.: E valuation of mental retardation: of a C ons ensus C onference: American C ollege of Medical G enetics . Am J Med G ene t. with permiss ion.

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > G E NE T IC ME NT AL R E T AR DAT ION AND B E HAVIOR AL P HE NOT Y P E S

GE NE TIC ME NTAL R E TAR DATION AND B E HAVIOR AL PHE NOTYPE S P art of "34 - Mental R etardation" New genetic technologies have played a key part in elucidating caus es of mental retardation, and the s tudy intellectual dis ability has contributed to advancing the unders tanding of the genetics of dis eas e more broadly. Largely as a result of res earch into mental retardation syndromes, primarily fragile X and P rader-Willi novel genetic mechanisms have been identified that led to a collective rethinking of class ic Mendelian 3678 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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principles. T hese remarkable genetic advances have sparked res earch interest in the behavioral features of persons fragile X, P rader-Willi, and other genetic syndromes . In their review of behavioral aspects of chromosomal disorders in the 1970s, S eymour K ess ler and R udolf for example, dis cus s only five s yndromes. S ince that the number of dis orders for which a be havioral has been sugges ted has grown cons iderably. A good working definition of a be havioral phenotype is that propos ed by E lis abeth Dykens , namely, that of a in which the probability of the expres sion of certain behaviors , or cons tellations of behaviors, is greater that which would otherwise be expected. S tereotyped hand movements , for example, have been described in many contexts , but a particular form of s tereotyped wringing is almos t invariably seen in R ett's syndrome. Hyperphagia and obesity are nons pecific s ymptoms, without aggress ive dietary intervention, the probability an individual with P rader-Willi syndrome becoming is nearly 100 percent. T able 34-9 provides a repres entative s ample of for which behavioral phenotypes have been described, some only anecdotally and others with controlled Although the study of behavioral phenotypes is only at beginning stages , this line of work holds much promise clinicians and res earchers . Identifying syndromebehavioral patterns helps clinicians hone in on some diagnostic pos sibilities over others , and these profiles als o guide intervention and treatment. F rom a res earch s tandpoint, phenotypic work advances unders tandings of gene–brain–behavior relations hips. 3679 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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illus trate these advantages , behavioral and genetic features are reviewed in fragile X, P rader-Willi, Down, Williams s yndromes. Although not representative of all syndromes in T able 34-9, thes e s yndromes amply demonstrate the promise of phenotypic res earch for intervention and s cience.

Table 34-9 R epres entative S ample R etardation S yndromes and B e Phenotypes Dis order

Pathophys iology

C linic a and B e Phenot

Down s yndrome

T risomy 21, 95% nondis junction. Approximately 4% translocation. 1 in 1,000 live births; 1 in 2,500 in women younger than 30 yrs of age; 1 in 80 at 40 of age; 1 in 32 at 45 yrs age. P os sible overproduction of βamyloid due to defect at 21q 21.1.

Hypoto slanted fis sures depres s nasal b creas e, increas of thyro abnorm congen disease

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P as sive (25% ) h childho G reater proces s to audit proces s ris k of d and dem Alzheim adultho

F ragile X syndrome

Inactivation of F MR -1 gene at X q27.3 due to C G G base repeats, methylation. R ecess ive. in 1,000 male births, 1 in 3,000 female births . Accounts for 10–12% of mental retardation in men.

Long fa midface high arc short s t macroo mitral v joint lax strabism

 

 

Hypera inattent stereoty and lan IQ decl avers io avoidan irritabili

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disorde women retarda affected modera in men. greater perform P rader-Willi syndrome

Deletion in 15q11– region of paternal origin (75% ). S ome cas es of maternal uniparental disomy (22% ) and imprinting errors and translocations (3%). S everal candidate genes within the imprinted region may contribute to specific features of the phenotype. Hyperghrelinemia in P rader-Willi syndrome may be a contributing factor for hyperphagia. Incidence of P rader-Willi syndrome ranges from 1 in 10,000 to 1 in 25,000 live births.

Hypoto thrive in obesity and fee microor cryptorc stature, shaped and ligh face, sc orthopa problem forehea bitempo narrowi

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C ompu hyperph hoardin borderl modera retarda emotion tantrum daytime skin pic aggres s

Angelman's syndrome

Deletion in 15q11– region of maternal origin (70% ). S ome cas es of paternal uniparental disomy (3%) and intragenic mutations of the ubiquitin-protein ligas e E 3A (UB E 3A) (6% ). Approximately of cas es have as yet unidentified genetic etiology. As with P raderWilli syndrome, several candidate genes may contribute to aspects of the phenotype. Involvement of a γaminobutyric acid

F air ha eyes (6 dysmor includin smiling upper li pointed epileps charact ataxia; circumf microce

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receptor s ubunit gene may be particularly important in the pathogenes is of E stimated incidence is 1 20,000 live births . P revalence in of individuals with mental retardation is 1.4%.  

 

Happy paroxys hand fla clappin mental sleep d with nig waking, increas of autis anecdo water a

C ornelia de Lange's

Deletion in NIP B L gene (human homolog of Dros ophila “Nipped-B ” gene) at 5p13.1. S imilar phenotype has been as sociated with other

C ontinu eyebrow turning microce stature, and fee

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chromosomal deletions , including 3q26.3. P revalence is es timated be as high as 1 in

upturne antever malform limbs , f thrive.

 

 

S elf-inju speech cases, delays, being h stereoty movem severe mental

Williams syndrome

Hemizygous (autosomaldominant) deletion in chromosome band 7q11.23, including the gene for elastin (E LN). P revalence may be as as 1 in 7,500, or 6% of individuals with identifiable genetic for mental retardation.

S hort s unusua features broad fo depres s bridge, pattern widely s and full faces , r cardiov abnorm thyroid abnorm

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hyperca  

 

Anxiety hyperac outgoin verbal s than vis skills .

C ri du chat syndrome

Autosomal-dominant hemizygous deletion in chromosome 5 (5p15.2), probably involving the adherens junction δ-catenin (C T NND2), which plays a role in cell motility and is express ed early in neuronal development. E stimated prevalence is between 1 15,000 and 1 in 45,000 births .

R ound hyperte epicant slanting fis sures nose, lo microgn prenata retarda res pirat infectio heart d gastroin abnorm

 

 

S evere retarda cat-like hyperac stereoty injury.

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S mith-Magenis syndrome

Most cas es have a large inters titial genomic deletion within chromosome 17p11.2. S everal candidate genes have been s uggested. Dis turbed melatonin secretion may be implicated in the s leep disturbance ass ociated with this s yndrome. E stimated prevalence is approximately 1 in live births.

B road f midface hands ; and hoa voice.

 

 

S evere retarda Hypera self-inju hand bi banging out fing nails . S self-hug attentio aggres s disturba rapid ey movem

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R ubins tein-T aybi syndrome

Autosomal-dominant deletion involving the cyclic adenosine monophos phate element–binding protein gene (C B P ) at 16.13.3. is a trans criptional coactivator that has intrins ic histone acetyltransferas e activity but also interacts with many transcriptional factors , including nuclear receptors and signal transducers. E s timated prevalence of 1 in live births; may account for approximately 0.2% institutionalized individuals with mental retardation.

S hort s microce thumb, P romin broad n hyperte frequen feeding infancy heart d abnorm seizure

 

 

P oor co distract expres s difficult perform greater IQ. Ane happy,

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sociable to mus i stimula Older p mood la temper T uberous complex (T S C )

Autosomal-dominant disorder caus ed by a mutation in either the T S C 1 gene (hamartin) chromosome 9q34 or T S C 2 tumor s uppress or gene (tuberin) on chromosome 16p13. T hese proteins form a T S C 1–T S C 2 complex, providing an explanation for the similar phenotype in individuals with mutations in either of these genes. P revalence approximately 1 in 6,000 individuals —T S C 1 and T S C 2 (50% )—but T S C 1 may be with a milder phenotype.

E pileps hyperac impulsiv aggres s of ment from no profoun injuriou sleep d

Neurofibromatos is type 1 (NF 1)

One of the most autos omal-dominant

V ariable manifes

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disorders in humans, located at 17q11.2, and affecting 1 in 3,000 individuals . NF 1 is a gene that codes for neurofibromin, which functions as a negative regulator of R as guanos ine triphos phate proteins. NF 2 is much rarer, es timated to occur in 1 in 33,000 and the majority of thes e cases are as ymptomatic. T he gene for NF 2 to be at chromosome 22q12.2.

au lait s cutaneo neurofib nodules stature macroc 45% .

 

One-ha and lan difficult modera profoun retarda greater perform Dis tract impulsiv hyperac P os sibl

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with inc inciden and anx disorde Lesch-Nyhan syndrome

Ataxia, Defect in hypoxanthine kidney guanine phosphoribos yltrans ferase (X q26-q27.2) with secondary dopamine supers ens itivity in the striatum. R ecess ive and rare, with incidence es timated to be 1 in 38,000.

 

 

Often s biting b aggres s mild to mental

G alactosemia

Autosomal-reces sive defect in galactose-1phosphate uridylyltrans ferase gene located at 9p13. T he disorder is quite rare, occurring in as many as in 62,000 births (s lightly

V omitin infancy hepatos later ca weight refusal, intracra and inc

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more common in

seps is, failure t tubular

 

 

P os sibl retarda treatme visuosp languag reports behavio anxiety withdra shynes

P henylketonuria

Autosomal-reces sive defect in phenylalanine hydroxylas e located at 12q.24.1, or cofactor (biopterin s ynthetase, 11q22.3-q23.3) with accumulation of phenylalanine. varies by population, approximately 1 in

S ympto neonata develop seizure genera blue ey ras h.

 

 

Untreat profoun retarda delay,

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destruc injury, h Hurler syndrome

Autosomal-reces sive deficiency in α-Liduronidas e, located at 4p16.3. E stimated prevalence is 1 in births .

E arly o stature, hepatos hirsutis cloudin before Dwarfis facial fe recurre infectio to seve retarda fearful, aggres s

Hunter's syndrome

Deficiency in iduronate sulfatas e, located at E stimated prevalence is in 111,000 births.

Normal S ympto to 4 yrs T ypical with flat flaring n hearing hernia c enlarge spleen, recurre growth

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cardiov abnorm  

 

Hypera retarda of age. Loss of 10 yrs o R es tles inattent abnorm Apathe with dis progres

F etal alcohol syndrome

Maternal alcohol cons umption (third trimes ter > s econd trimes ter > firs t 1 in 3,000 live births in Wes tern countries (most common preventable caus e of mental retardation). As many as in 300 children may fetal alcohol effects.

Microce stature, hypopla palpebr upper li retrogn infancy in adole hypopla smooth

 

 

Mild to mental irritabili

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inattent impairm V elocardiofacial syndrome, DiG eorge syndrome 22)

S everal candidate genes have been identified at the 22q11.2 locus for velocardiofacial syndrome, including the T -box gene, T B X1. T genes are trans cription factors involved in the regulation of developmental T he catechol-Omethyltransferas e gene, C OMT , is als o located at the 22q11.2 region, and importance in the catabolis m of catecholamines , the neurotransmitters dopamine, epinephrine, and norepinephrine, may underlie the high incidence of ps ychosis as sociated with velocardiofacial syndrome. P revalence is in 4,000, and this is the second mos t common

C AT C H cardiac T -cell d and hyp Learnin cleft pa pharyng hypoton hands a commo

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caus e of congenital cardiac anomalies after Down s yndrome.  

 

P sycho (s chizo mood d (depres

E E G , electroencephalogram; IQ, intelligence quotient.

E xamples of B ehavioral in Mental R etardation S yndromes Fragile X S yndrome F ragile X s yndrome, the most common inherited cause mental retardation, res ults in a wide range of learning behavioral problems , with men being more often and severely affected than women. T he recently dis covered fragile X gene (F MR -1) repres ents a newly identified of human dis eas e, caus ed by an amplification (or repetition) of three nucleotide s equences (C G G ) that up deoxyribonucleic acid (DNA). Above a certain of thes e triplet repeats (approximately 200), people are fully affected with the s yndrome. Numbers of repeats between the normal thres hold of 50 and below 200 are termed pre mutations . As many as 1 in 259 women in general population may carry the premutation, with 1 in 4,000 men and 1 in 2,500 women being fully affected 3696 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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the syndrome. Many of the behavioral features in people with fragile X syndrome are a function of number of C G G repeats cascade of s ubsequent effects . T he number of repeats relates to the degree that the F MR -1 gene is and s ubs equently s ilenced or blocked from and translation. T his , in turn, impacts the amount of protein (F MR 1P ) produced, and the range of clinical expres sion in fragile X s yndrome is as sociated with the amount of F MR 1P . F ully affected, fully methylated men have no F MR 1P , whereas high-functioning men, rare, have s ome F MR 1P . In women, only one X chromosome carries the F MR 1 gene, whereas the produces some F MR 1P . B ecause all women have one chromosome that is randomly inactivated in all cells , degree of involvement in females with fragile X is related to the ratio of normally active X the total active plus inactive X chromos omes. Approximately one-half of fully affected women thus mild to moderate mental retardation, whereas one-half have average IQs . However, even among those with average intelligence, as much as 80 percent may s how specific problems in planning, memory, and attention. Neuroimaging s tudies link performance on s ome of cognitive tasks to the size of the posterior cerebellar vermis, which is smaller in men and women with fragile syndrome relative to controls .

Fragile X S yndrome and Autis m It is reported that many fully-affected men with fragile X syndrome s how autis tic-like symptoms , s uch as delay, echolalia, s tereotypies , s elf-injurious behavior 3697 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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perseveration, poor eye contact, and tactile Not s urprisingly, then, early workers tried to link fragile syndrome P.3091 P.3092 P.3093 to autism, s purred by the pos sibility of a common caus e of autism. Y et, highly variable prevalence rates res ulted from this work, owing primarily to in diagnostic criteria for autis m. T his flurry of research faded as new studies emerged suggesting that, ins tead of autis m per s e, many men showed a willingnes s to interact with others coupled social and performance anxiety and mutual gaze C ontrolled s tudies and metaanalyses now suggest that only about 5 percent of men with fragile X have autistic disorder. Instead, the majority of affected men can be placed on a s pectrum of social anxiety, shyness , and gaze avers ion. Although s ome of thes e boys have anxiety dis orders or pervas ive developmental dis order otherwis e s pecified (NOS ), others may s imply s how warm temperament s tyles, including shyness or s ocial withdrawal. S imilarly, many women with fragile X syndrome show variable levels of social dysfunction, primarily shyness , gaze aversion, and s ocial anxiety. Many of thes e meet clinical criteria for s chizotypal dis order, showing interpersonal dis comfort and difficulties in 3698 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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and s ocial relations hips. F ully affected women (with repeats in exces s of 200) are more likely to have schizotypal disorder or schizotypal features than with a premutation or appropriately matched non– X s yndrome control women. Although s hynes s is thus central feature of the fragile X s yndrome behavioral phenotype, affected women may also show increased of depress ion, even as compared to non–fragile X syndrome mothers of developmentally delayed In addition to thes e difficulties, hyperactivity and deficits are seen in the vast majority of boys and girls fragile X s yndrome. Attention-deficit/hyperactivity disorder (ADHD) symptoms are higher among fragile X syndrome boys relative to control subjects , and girls fragile X have lower prevalence rates of ADHD relative fragile X s yndrome boys . Among adults, problems in attending and in s us taining effort have been found in neurops ychological profiles of women who carry the 1 gene, which may contribute to problems in math, abstract reasoning, and planning. F ragile X s yndrome thus involves vulnerabilities toward shyness , gaze aversion, social anxiety, avoidant schizotypal disorder, ADHD, pervasive developmental disorder NOS , and, more rarely, autis tic disorder. difficulties vary in s everity but are typically found in persons acros s the IQ s pectrum, from those with mental retardation to thos e with mild learning

Prader-Willi S yndrome F irst identified in 1956, P rader-Willi syndrome affects approximately 1 in 15,000 births and is best known for food-related characteristics . W hereas babies invariably 3699 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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show hypotonia and pronounced feeding-sucking difficulties , young children between 2 years of age and years of age develop hyperphagia and food-seeking behavior, such as food foraging and hoarding. Hyperphagia is likely ass ociated with a hypothalamic abnormality res ulting in a lack of s atiety. F ood preoccupations are lifelong, and, without prolonged dietary management, affected individuals invariably become obes e. Indeed, complications of obes ity the leading caus e of death in this s yndrome. P rader-Willi syndrome is the firs t known human show the effects of genomic imprinting or the idea that genes are modified and express ed differently on whether they are inherited from the mother or the father. Approximately 70 percent of P rader-Willi cases are caus ed by a paternally derived deletion on long arm of chromosome 15. R emaining cases are attributed to maternal uniparental dis omy (UP D) of chromosome 15, in which both members of the chromosome 15 pair come from the mother. In either there is absence of the paternally derived contribution this s pecific region of the genome. When mis sing information in this s ame region of chromos ome 15 is maternally derived, it results in a completely different more s evere developmental dis order, Angelman's syndrome. Although people with P rader-Willi syndrome invariably obses s about food, a remarkably high proportion of persons also show nonfood obses sions and behaviors . T hese nonfood symptoms include skin hoarding; needing to tell, ask, or say things ; and having concerns with symmetry, exactnes s, ordering, 3700 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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cleanliness , and s amenes s in daily routine. Often, symptoms are ass ociated with dis tres s or adaptive impairment, s uggesting marked risks of obsess ivecompuls ive disorder (OC D) in this population. Indeed, it es timated that OC D is many more times likely in with P rader-Willi syndrome than in the general of people with mental retardation. In addition, even as compared to others with mental retardation, children and adults with P rader-Willi syndrome show high rates of temper tantrums, stubbornness , underactivity, excess ive daytime and emotional lability. C oupled with food seeking, impulsive behaviors often lead people with P rader-Willi syndrome to need more res trictive levels of care than would be predicted by their mild levels of mental retardation. P sychopathology and cognitive profiles may be with the individual's genetic variant of P rader-Willi syndrome. P reliminary findings from ongoing work suggest s ome behavioral differences between P radersyndrome due to paternal deletion vers us maternal C as es with deletions may show lower IQs, es pecially IQs, and more frequent or s evere problem behaviors, as skin picking, hoarding, temper tantrums, overeating, and s ocial withdrawal. Although a dampening of severity is sugges ted in many UP D cases, occas ional of more severe problems in UP D, primarily autis tic-like features and relatively low IQs, are als o observed. In addition, pers ons with UP D may do better than their counterparts with deletions on verbal tas ks but more poorly on vis ual-spatial tasks, including solving jigs aw puzzles . Indeed, although many persons with P rader3701 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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syndrome are remarkably skilled in s olving puzzles , unusual s trength seems limited to those with paternal deletions . T he mechanisms that explain such maladaptive behavior and cognition acros s genetic subtypes are unknown. Many people with P rader-Willi syndrome, then, are at increased ris k for OC D and impuls e control and disorders . Y et, even those who do not meet diagnos tic criteria for these psychiatric disorders often s how significant maladaptive behaviors that interfere with optimal adaptive functioning.

Down S yndrome Occurring in approximately 1.2 in 1,000 live births , syndrome is the most common chromos omal leading to mental retardation. It is most often the res ult nondis junction of chromos ome 21. T he syndrome has been the s ubject of cons iderable investigation. S tudies of children have shown distinctive cognitive linguistic profiles. P articular s trengths have been noted visual process ing versus auditory process ing. impairment can be extensive, with particular difficulty in expres sive language, grammar, and pronunciation. In contras t to the relative overall weakness in the arena, thos e with Down s yndrome are often described being particularly s ocially adept. However, s tudies of adaptive functioning suggest that thes e s kills are not uniform, with communication scores trailing behind meas ures of daily living s kills and s ocialization. T he stereotype of a s o-called P.3094 3702 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Down s yndrome personality as being happy, good tempered, affectionate, placid, and s tubborn has been difficult to verify. C ompared to others with mental retardation, persons Down s yndrome appear les s often and les s serious ly to experience psychopathology. Adults with Down appear somewhat less prone to ps ychiatric dis turbance than controls . T his trend seems to extend to children adoles cents as well, in whom rates of ps ychiatric and behavioral problems are greater than in the general population but appreciably les s than in other groups mental retardation. C ommonly noted problems include difficulties with attention, impulsivity, hyperactivity, and aggres sion. In contrast to these problems, depres sion seems to be les s common among children and than expected norms , although some youth appear to become increas ingly withdrawn in their adolescent F or many, this s hift toward increas ed withdrawal gradual and s ubtle, and it may be an early harbinger of later onset of depress ion or dementia in the adult Autism and pervas ive developmental dis orders appear be relatively rare.

Williams S yndrome F irst identified in 1961, W illiams syndrome is caused microdeletion on chromosome 7 that includes the gene for elastin, a protein that provides strength and to certain tis sues, such as the heart, skin, blood and lungs . Affecting approximately 1 in 20,000 births, persons with Williams syndrome often s how hypercalcemia, neuromus culos keletal and renal 3703 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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abnormalities , and characteris tic facial features as elfin-like, cute, and appealing. P eople with Williams syndrome als o typically show cardiovas cular disease, es pecially supravalvular aortic stenos is , and these problems are likely as sociated with elas tin Apart from these medical iss ues , recent attention has focus ed on the interes ting, poss ibly unique, cognitivelinguistic profile s hown by many persons with this syndrome. C hildren with W illiams syndrome show strengths in language. Indeed, for many years, it was thought that these children might even perform at chronological age levels on a variety of linguis tic tas ks . Although age-appropriate performance in language has now been found in only s mall percentages of children Williams s yndrome, these children nevertheles s show relative s trengths in language, as well as in auditory proces sing and in s ome areas of mus ic. In contras t, many children with W illiams s yndrome perform es pecially poorly on a variety of visuospatial In one recent s tudy, C arolyn Mervis and her colleagues found that 47 of 50 children with Williams s yndrome showed the pattern of weaknes s in vis uos patial tas ks relative s trength in various measures of language (vocabulary, grammar, and short-term auditory Although not every child with W illiams s yndrome s hows linguistic strengths and vis uos patial weaknes ses , the majority do present with such a pattern. T o date, studies have yet to examine fully the or ps ychiatric features of people with W illiams E arly descriptions of people with Williams syndrome hinted at a clas sic W illiams s yndrome personality, described as pleas ant, unusually friendly, affectionate, 3704 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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loquacious, engaging, and interpersonally sensitive charming. S uch qualities may change over the cours e development, with adults being more withdrawn and overly friendly than children. R ecent findings expand thes e observations . Using the R eis s P ers onality P rofiles, it has been found that, controls, adoles cents and adults with W illiams are more likely to initiate interactions with others (87 percent, of sample), to enjoy social activities (83 to be kind spirited (100 percent), caring (94 percent), to empathize with others' positive feelings (75 percent) when others are in pain (87 percent). At the s ame time, however, these subjects did not fare well in making or keeping friends and were often dangerous ly in their relating to others. Indeed, although s ociability in Williams s yndrome has generally been viewed as a strength, thes e features also seem to reflect the type of social dis inhibition that is characteristic of people who anxious, impulsive, and overly aroused. Not salient problems in Williams syndrome include hyperactivity and inattentiveness and a pronenes s for ADHD that may diminis h with age. R ecently, attention has begun to focus on anxieties fears in this population. G eneralized anxiety, worry, perseverative thinking are commonly seen in Williams syndrome, and people with the syndrome appear to unusually high levels of fears and phobias. R elative to suitably matched controls , fears in persons with syndrome are more frequent, wide ranging, and s evere and may als o be as sociated with impaired socialadjus tment. In one recent study, Dykens compared 120 people with W illiams s yndrome (6 to 48 years of 3705 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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to thos e with mental retardation of mixed etiologies. two fears , getting a s hot and going to the dentis t, were mentioned by more than 50 percent of the group with mixed caus es of mental retardation. In contras t, 50 different fears were mentioned by more than 60 subjects with Williams syndromes. S uch fears ran the gamut. S ome involved interpersonal is sues, s uch as teased, getting punis hed, or getting into arguments others . Others involved phys ical is sues , such as s hots injections, being in a fire or getting burned, or getting stung by a bee. S till others related to these children's hyperacus is or clums iness (loud nois es or s irens , from high places , or thunders torms). T hus , although every pers on with W illiams s yndrome s hows any or all these fears , the vast majority do appear to be overly compared to mos t others with mental retardation. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > DE V E LOP ME NT AL C HILDR E N W IT H ME NT AL R E T AR DAT IO

DE VE L OPME NTAL C ONS IDE R ATIONS IN C HIL DR E N WITH ME NTAL R E TAR DATION P art of "34 - Mental R etardation" T hroughout the 20th century, children with retardation have been an ongoing topic of developmental S mall groups of res earchers have examined 3706 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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of various P iagetian cognitive domains, language, skills , and even morality. B y now, physicians have a sens e of how children with mental retardation develop. B es ides providing basic milestones or natural histories , these s tudies help phys icians to understand the underlying proces ses of development. S ince the ordering of development (s equences ), the ways in levels in certain areas relate to levels in other areas domain relations ), and the points at which the speed of development (rate) changes have begun to be S uch analyses have begun to be applied to children different etiologies of mental retardation. In addition, developmental analys es have been beyond children themselves. Many developmental ps ychologists examine mother–child interactions , behaviors in families of different-aged children, and the child's ongoing interactions with peers, neighbors, and schools . T his section, then, examines child-related and environment-related as pects of development in with mental retardation.

C hild-R elated A s pec ts of Development Overview F ollowing developmental psychology's study of normal children, res earchers throughout this century have examined children with mental retardation. S uch have focused in two main areas: developments of thems elves and children's interactions with their surrounding environments . P.3095 3707 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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It is now unders tood that children with mental travers e the s ame sequences of development as do nonretarded children but that children with certain of mental retardation s how intellectual s trengths and weaknes ses not generally found in nonretarded C hildren with mental retardation als o s how certain and tas ks of particularly s lowed development; s uch slowings seem related to specific types of mental retardation, but the reasons for s uch slowings are little unders tood. When examining child–environment interactions , it has been found that mothers act the s ame and different compared to mothers of nonretarded children at s imilar levels of functioning. Mothers of children with mental retardation are s imilar in that they s horten their s peech, focus on key words, and in other ways s tructure the environment for their child's development. T hey s eem, however, to be much more didactic and intrus ive. of children with mental retardation als o differ widely from another. W hen the child with retardation shows maladaptive behavior and when the mother's style of coping is more problem focused, the result seems to less ened levels of parent and family stres s.

S equenc es Normal children show a specific, pos sibly universal, ordering to their development. F or example, in cognitive development, children proceed from sens orimotor, to preoperational, to concrete to formal operational thought. E ven within these four larger s tages, smaller orderings hold: T hus , within 3708 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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sens orimotor development, normal infants proceed in order through J ean P iaget's s ix substages in each of several s ubdomains . Do children with mental retardation also follow a sosimilar s equence to their developments ? S ince the similar sequences have been found for a variety of over many tas ks . S imilar s equences even hold for children with genetic or other organic causes for their retardation. T he only pos sible exceptions include some children with uncontrollable s eizures (where accurate tes ting is difficult) and some autistic children, who may show different orderings owing to their particular disabilities on certain social tasks. S uch sequences been noted in many areas : in almos t 20 P iagetian in symbolic play, and in linguistic grammar and pragmatics. F or almost all children and for a wide behaviors , development for children with mental retardation proceeds along similar s equences to thos e found in nonretarded children.

C ros s -Domain R elations If children with retardation proceed in the s ame developmental ordering as do nonretarded children, might they also show the even or flat profiles that of nonretarded children show from one domain to another? S uch a similar s tructure to development was propos ed by Zigler in the late 1960s . C ontrary to s imilar sequences —which hold for all with mental retardation—cross -domain s tructures may differ bas ed on which retarded group one considers . a few exceptions, children with cultural-familial mental retardation do s how even or nearly even performance 3709 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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acros s various intellectual domains. In contras t, children with different organic forms of retardation show specific intellectual strengths and weaknes ses. F or example, three s eparate groups weaknes ses in s equential—or bit-by-bit, s erial proces sing—compared to s imultaneous (i.e., ges talt or holis tic) proces sing or achievement abilities . S uch sequential deficits are found in boys with fragile X syndrome, children with P rader-Willi syndrome, and children with S mith-Magenis s yndrome. Instead, with Down s yndrome may have particular weaknes ses expres sive vers us receptive communication and problems in grammatical abilities. C hildren with syndrome show extra deficits in visuospatial skills , and some subsets of these children s how abilities in language. Different etiologies of mental retardation, then, s how different characteristic strengths and weaknes ses .

R ates A further iss ue concerns children's rates of B y definition, children with mental retardation develop slower rates than nonretarded children. Nonspecific or mixed groups show reasonably s teady rates of development, as shown by s table IQs after the early childhood years . C hildren with different types of mental retardation, however, may have periods of s peeded or slowed development. S uch times of speeded or slowed development s eem related to age-related or task-related difficulties . In agerelated slowings, mos t children with a s pecific type of mental retardation slow in their development during a 3710 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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certain age s pan. F or example, boys with fragile X syndrome show stable developmental rates until approximately 9 or 10 years of age, at which time development slows. S imilarly, in Down syndrome, sectional and s mall-scale longitudinal studies s how that these children s low over the period from 6 to 11 years age. T hroughout this age s pan, children with Down syndrome slow in their development of linguistic intellectual skills and adaptive behavior. In fragile X Down s yndromes , it remains unknown why such agerelated slowings occur, whether all children with the disorder s how s uch s lowings , or if s lowings are s een all domains . A s econd type of s lowing relates to pronounced in mastering a s pecific developmental tas k. Unlike agerelated slowings, the s lowings here occur at a variety of ages, whenever children with a particular type of retardation reach a specific developmental tas k. young children with Down s yndrome (who als o s how related slowings from 6 to 11 years of age). T hes e show difficulties in acquiring certain tas ks of infant intelligence, even after one accounts for their already slower rates of development. Later, toddlers show increasing delays in express ive, as oppos ed to language skills. As a result of age-related and tas kslowings, then, children with Down syndrome generally show their highest IQ s cores during the first year of life, after which IQs decline. An overview of development in children with mental retardation displays that children develop along the sequences. However, at the s ame time, different subgroups show exceptional strengths or weaknes ses 3711 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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one or another area and different tasks or age spans relate to particularly slowed development. W hy mental retardation groups s how such developmental patterns is s till generally unknown.

C ontextual A s pec ts of Mother–C hild Interac tions F ollowing from research on interactions between developing children and their mothers, mother–child interaction s tudies in mental retardation began during mid-1970s . Once examined, mothers of children with mental retardation showed s ome s imilarities and s ome differences from mother–child interactions with normal children of the s ame mental age (MA). S pecifically, the groups of mothers behave similarly on what might be called the s tructural as pects of be havior. In language, example, mothers s horten their s peech, simplify their vocabularies , raise their pitch, repeat key words , and generally provide the so-called motheres e that is mothers of normally developing children. As a res ult, mothers of typically developing 2-year-old children act almos t identically to mothers of children with who are at 2 years of MA. P.3096 Y et, at the s ame time, mothers of children with mental retardation s how different s tyles to their interactions. C ompared to mothers of nonretarded, MA-matched children, mothers of children with retardation are oftentimes more didactic and intrus ive. T hey more initiate the topic of interaction, take longer speaking 3712 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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talk at the same time as their child, and, in other ways , control the interaction. As a result, the child is allowed fewer opportunities to initiate and to control the conversation. It remains unclear why such stylis tic differences occur. prevailing view holds that mothers of children with retardation are worried about their child's development: their zeal to teach and to ins truct their children, these mothers might go overboard. As one mother of a child with Down syndrome explained: “It's put him on your and talk to him, that's the main object. P lay with him, speak to the child, teach him something.” However, a more didactic interactive s tyle may not, in be most beneficial for the child's development. few s tudies have yet been performed, young children retardation seem to develop faster when their mothers less intrusive. One s tudy examined mother–child interactions at 23 months of age and child outcomes at months of age. C ompared to mothers who were redirecting their child's attention, mothers who commented on the object at which the child was had higher receptive language ages at 36 months of T hese studies s uggest that the bes t s tyle for mothers might be one that responds to the child's interests and initiatives , as opposed to a s tyle that is more didactic or intrus ive.

Family R eac tions S ince the 1980s, family studies in mental retardation changed enormous ly, from a predominantly negative perspective to a more balanced perspective. B efore the early 1980s, families of children with dis abilities were 3713 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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perceived to be families in crisis. Mothers were for their mourning reactions , couples were examined divorce, and mothers , fathers , and unaffected s iblings were examined for the presence of depress ion and forms of ps ychopathology. T he basic findings were that families of children with disabilities may experience divorces , parents and s iblings are somewhat more to depress ion, and families and individual family show more difficulties when there is only one parent, when the mother receives little s upport from the or when the family is of low socioeconomic s tatus. With the early 1980s, however, family res earchers change how they conceptualized families of children mental retardation. F rom the earlier focus on family pathology, these families came to be thought of as facing increased stress . C hildren with mental might therefore add s tres s on the family s ys tem, but stress could res ult in negative or positive adaptation. change also implies a more normative view of these families : J ust as every family faces a variety of (e.g., illness or los s of job), s o too can families of with retardation be thought of as facing a s tres sful situation. T he move from a negative to a stress -coping also has other implications . F irs t, it allows for a change from a predominantly be twe en-group res earch P reviously, mos t s tudies compared families of children with dis abilities to families of typical, nondisabled of the same chronological age. R ecently, however, the between-group focus has been complemented by group s tudies . G iven that families of children with retardation vary in their ability to cope, what caus es 3714 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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adjus tment in one family and worse adjustment in another? W hat child, parent, or family characteris tics better adaptation? T o date, most work has examined child characteris tics, such as the child's age and degree of impairment. F or variables , findings have been inconsistent. S ome s tudies find it more stress ful to parent older with retardation, and some sugges t that families may experience more stress when the child begins puberty to 15 years of age) and again when the child reaches adulthood (20 to 21 years of age). However, other do not find such relations between increas ed family and the child's age. S imilarly, s ome s tudies find that it more difficult to parent children with more severe levels retardation, whereas other do not. Another, les s often examined characteris tic involves child's degree of maladaptive behavior. S o far, s trong connections have been found between child behavior and family stress in families of children with mixed etiologies, with P rader-Willi syndrome, and with (cri du chat) s yndrome. Less clear is why s uch occur. Although most researchers feel that child maladaptive behavior leads to increas es in familial increased familial stress may also elicit more child problems . Another important variable concerns the coping s tyle of the parents. Acros s s everal studies, parents who more actively, cons tructively attempt to deal with their child better than thos e parents who adopt a palliative coping style, one that dwells on or ignores parental emotions . difference in pers onality s tyle may help buffer parents 3715 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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families from the increased stress es of parenting a with mental retardation. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > P S Y C HOP AT HO LOG Y IN ME N R E T AR DAT ION

PS YC HOPATHOL OGY IN ME NTAL R E TAR DATION P art of "34 - Mental R etardation" Developmental disability is a significant risk factor for ps ychopathology in general, and, as may be inferred the previous description of caus es , this increas ed risk derive from biological vulnerabilities , as well as ris ks accrue from the environment. Moreover, individuals IQs below 70 have a two- to fivefold higher rate of ps ychiatric disorders compared to normally developing persons. A host of explanations, highlighted in T able 34-10, has been put forward in efforts to account for this added Included are developmental experiences with which individuals must contend, including perceived rejection from peers and frus tration from parents. T he repeated experiences of failure or difficulty achieving what to come naturally to normally developing peers , the recapitulation of experiences of failure with each developmental s tage, and less well-developed or less s upportive peer groups all mus t take a toll on ego development. In addition to s pecific biological vulnerabilities , 3716 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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P.3097 the common comorbidity of mental retardation with phys ical illness , for example, epileps y, may also ris k of mental disturbance.

Table 34-10 Pos s ible to Inc reas ed Vulnerability to Dis orders in Pers ons with Mental R etardation Neuropathological process res ponsible for mental retardation may also cause or increase ris k for illness . Increased likelihood of los s and separation, particularly in out-of-home placements. C ommunication deficits may predispose to or behavioral disturbance. V ulnerability to exploitation and abuse by others . Inadequate coping skills. F amily s tres s may be heightened in pres ence of with developmental disability.

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R is k of limited network of social relationships and repertoire of social s kills . R is k of reduced opportunities for development and exercise of recreational, occupational skills. Advers e effect on s elf-es teem of dis ability; dysmorphology.

Moreover, the treatments for epilepsy and other conditions may carry s ome be havioral toxicity, which increase the likelihood of diagnosed mental illness . P henobarbital (B arbita) has widely been reported to increase the risk of motoric hyperactivity and in children and in individuals with developmental disorders , and phenytoin (Dilantin) may cause toxicity, as is potentially the cas e for es sentially any of medications that are us ed for the management of or other chronic medical conditions. S tudies of the incidence of specific mental disorders reveal that individuals with developmental dis orders may the full range of mental illness es as occurs in the population in general; these dis orders are reviewed in following s ections.

A daptation of Diagnos tic C riteria Attention-Defic it/Hyperac tivity Dis order (ADHD) 3718 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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T he rates of ADHD in mental retardation are es timated be between 9 percent and 18 percent. Although cons iderable res earch has been done on the treatment ADHD, virtually all of thes e s tudies have s pecifically excluded children with cognitive dis ability. Moreover, diagnosis of ADHD is bas ed on developmental cons iderations, namely, motoric hyperactivity, and inattention that is s ignificantly greater than that expected for a given developmental age, and, thus, the threshold for diagnos is in persons with s evere to mental retardation should be elevated. F or pers ons with mental retardation, the diagnos is of ADHD is qualified as being exces sive for an individual's MA. In the context of profound mental retardation, attention s pan, distractibility, or on-tas k behavior are predictably quite variable. Individuals given the of ADHD in this context should, in comparison to their peers with s imilar levels of retardation, exhibit short attention span, exces sive psychomotor activity remarkable impulsivity, and s o on. In many cases , the clinician encounters a s ituation in which an individual not evidence remarkable ps ychomotor activity or attentional difficulties but may be unusually impuls ive. these s ituations, one should entertain the diagnosis of impulse control dis order NOS . S uch a diagnos is , for example, might be appropriate for an individual who might inexplicably s trike out at a peer in the abs ence of any identifiable environmental s tres sor.

Impuls e C ontrol Dis orders : S elfand Aggres s ion E very effort should be aimed at treating the underlying 3719 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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caus e of S IB or aggres sion, not merely to suppress the behavior. However, in some cas es , for example, stereotyped movement disorder with S IB , the symptom es sentially the diagnosis. Aggres sion and S IB are in mental retardation and increas e with greater s everity cognitive disability. S IB typically takes the form of repetitive, and frequently stereotyped behavior causing trauma. It occurs in the context of s pecific genetic syndromes, for example, s elf-biting in Lesch-Nyhan syndrome and finger and nail pulling in S mith-Magenis syndrome, but also and more commonly occurs in with unknown or nons pecific caus es for their mental retardation. In a review of ps ychiatric cons ultations in an setting, it was reported that S IB was specifically cited reason for referral in 36 percent of the 251 cases However, S IB as a presenting s ymptom is generally unhelpful in predicting the ultimate ps ychiatric T he single exception, perhaps, is the diagnos is of stereotyped movement disorder, in which the with S IB was s pecifically created to capture persons engage in S IB in the abs ence of other diagnos able ps ychopathology. As S IB and aggres sion are nonspecific symptoms, one take into account the pres ence or abs ence of a variety factors to arrive at a presumptive diagnosis . Among factors are the chronicity of the behavior, whether it serve a communicative function, whether it is invariant its topography (e.g., hitting only the right ear, thus suggesting an ear infection), whether it is s ituational, whether it occurs in concert with regress ion from a previous level of function, and whether there are 3720 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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as sociated neurovegetative s igns that correlate with its onset.

Oppos itional Defiant Dis order or C onduc t Dis order T he DS M-IV diagnos is of oppos itional defiant disorder conduct disorder also requires comparis ons be made others of s imilar MA. F urthermore, both diagnos es some degree of deliberatenes s on the part of patients example, dis obedience motivated by spite or which can be difficult to dis cern in nonverbal subjects profound cognitive deficits . As such, there is probably a lower limit in terms of severity of mental retardation which the reliability and us efulnes s of these diagnos es becomes s uspect.

Anxiety Dis orders S pecific anxiety disorders , for example, s eparation overanxious dis order, OC D, panic dis order, anxiety dis order, and so on, rely heavily on an ability to describe the subjective s ymptoms of anxiety. According to DS M-IV , concurrent pervasive disorder s pecifically precludes the diagnos is of mos t of these dis orders as well. Y et, s ome individuals are with constellations of s igns and s ymptoms that best are captured in the anxiety dis order spectrum. P atients are clearly avoidant, who exhibit autonomic arousal in face of s timuli that most of their peers would not find avers ive, and who pres ent with other features of but who cannot articulate their subjective s tates, might given a diagnosis of anxiety dis order NOS . In some cas es in which individuals engage in behavior 3721 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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appears compuls ive or driven, and for whom s uch behavior s eems ego alien, the diagnos is of OC D NOS be considered. Often times , these patients might in s elf-res traint (s ecuring their extremities in their or might cling to their parents or care providers — seemingly to prevent S IB . S imple repetitive behaviors the insis tence on s amenes s that can accompany developmental disorder should not be given a separate OC D s pectrum diagnos is. However, it may be useful to organize treatment with an additional diagnos is beyond autis m if, for example, the focus of treatment is a sleep disturbance, impuls ive aggres sion, anxiety, or the like. Although common, anxiety disorders appear to be underdiagnosed in persons with mental retardation. V ariability in prevalence rates, from 1 to 25 percent, is attributed to difficulty in making a diagnosis. Moreover, individual with mental retardation may not be able to identify subjective anxiety as an underlying cause of distress , and a patient's aggress ion or agitation may be suggestive of a dis order of impuls e control rather than reflective of underlying anxiety. Indeed, common symptoms of anxiety in the population with mental retardation include aggres sion, agitation, compulsive or repetitive behaviors , self-injury, and insomnia. P anic be expres sed as agitation, screaming, crying, or which might even pas s as delusional or paranoid P hobias may als o occur in this population and may be more common in pers ons with developmental disabilities. R yan has noted that persons with developmental disabilities are at high risk for abus e, placing this population at a greater risk for stress disorder (P T S D). With data s ugges ting that it 3722 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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seen in nearly 8 percent of the general population, an important diagnos is to cons ider in individuals with mental retardation.

E ating Dis orders B ecaus e of the reliance of diagnostic criteria on experiences , the diagnoses of anorexia nervosa and bulimia are effectively precluded for individuals with severe or profound mental retardation. F or example, would be hard press ed to identify in nonverbal patients things , s uch as class ic distortions in body image or feelings ass ociated with bingeing. F ood refusal or selfinduced vomiting would have to be viewed as atypical eating dis orders if s uch symptoms were to occur in P.3098 the abs ence of other diagnos able disorders (for depres sion or rumination). P ica is perhaps the mos t common eating disorder among persons with mental retardation.

Organic Mental Dis orders One could argue that, by definition, everyone with retardation has some organic cerebral dys function, thus, any ps ychiatric illnes s s hould be regarded as or due to a general medical condition. In his study of ps ychiatric illnes s in a sample of institutionalized with Down s yndrome, Menolas cino appropriately that ps ychiatric nosology did not have to be reinvented accommodate individuals with a tis s ue diagnos is . Moreover, he reasoned that patients with so-called diagnoses of mental illnes s and Down s yndrome need 3723 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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be dis tinguished from others with Down s yndrome T hus, the application of the diagnoses of organic syndromes and dis orders is best approached as if do not have mental retardation. T he same principle apply to Axis II pers onality disorders. T he diagnos is of organic personality dis order is bes t reserved for whos e preexis ting pers onality was altered in a pathological way by s ome additional cerebral insult. In es sence, this category was res erved for patients mental retardation is acquired, usually secondary to trauma experienced in childhood or early adoles cence.

Ps yc hos is P atients with developmental disorders are at an ris k for s chizophrenia, bipolar dis order, and other illness es that may include s ymptoms of thought and hallucinations . T he diagnosis of schizophrenia es sentially requires that a patient relate the experience delus ions or hallucinations . As has been s uggested by and others , in individuals with profound mental retardation with limited communicative ability, the diagnosis of clas sic s chizophrenia is arguably Nonetheles s, s ome individuals display pres umptive evidence of respons e to hallucinations (e.g., striking or shouting at empty s pace or throwing imaginary peers furniture) or adopt catatonic postures that can appear be ps ychotic in origin. In thes e cas es, the diagnosis of ps ychos is NOS should be cons idered if thes e s igns the absence of s ufficient evidence to warrant the of a s upervening mood disorder.

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E ven in profound mental retardation, the diagnosis of mood disorders is fairly straightforward. G enerally, a change in mood from bas eline is obvious (recent ons et lability, tearfulnes s, mood elevation, and irritability). If coupled with changes , of sufficient duration and sufficient impairment in adaptive function, in interests , activity level, s leep, appetite, or s exual behavior, the diagnoses of mania or of depres sion can be made in nonverbal patients. Mood dis orders are not uncommon in pers ons with retardation. As noted previous ly, learning problems , skills deficits, and low s elf-es teem are often ass ociated with developmental disabilities and repres ent risk for the development of mood dis orders . T here are no striking differences between the expres sion of mood disorders in pers ons functioning in the mild and range of mental retardation and their normally peers. Differences may emerge among pers ons with to profound dis ability, but equivalents of mood disturbance are easily recognizable, including crying, problems in sleep or appetite regulation, mood lability, s ocial withdrawal, and isolation. or S IB may be seen as behavioral manifes tations of dysphoria in pers ons regardless of developmental T hese symptoms for the diagnos is of depress ion, and similar modifications for other disorders , have been codified into a manual of revis ed diagnos tic criteria for with adults with mental retardation by the R oyal P sychiatrists (2001).

Other Dis orders T he diagnosis of T ourette's syndrome is made difficult 3725 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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persons with profound mental retardation. F requently, these individuals als o display s tereotyped or other movements, and it is difficult to dis criminate intentional from unintentional movements or sounds or to vocal tics from s pontaneous , stereotyped, or echolalic vocalizations in individuals frequently incapable of functional s peech. T he diagnos is of s tereotyped movement disorder might be considered in such circums tances . B ecaus e elimination disorders require a MA of 4 years cons idered, the diagnos es of functional encopres is or functional enures is are s eldom made in the context of severe intellectual dis ability. In s ome instances, appear to lose previously acquired skills, for example, urinary continence, but such loss es typically do not in is olation, suggesting alternate diagnos es (e.g., or depress ion). S omatoform dis orders, depersonalization dis orders, sexual disorders are les s frequently diagnosed in the context of mental retardation, although certainly are not precluded. S leep disorders ultimately require the subjective input of the patient regarding the adequacy res t, occurrence of nightmares, and so on. G iven the frequent history of abuse reported for people with retardation as a group, one should not overlook the poss ibility of P T S D when s leep disturbance is a problem.

Provis ional Diagnos es In many cas es, individuals may not clearly fall into a diagnostic category. C omorbidity is common. some individuals may have psychiatric symptoms that 3726 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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significantly interfere with habilitated function but that not allow for a clear dis tinction between certain It may be difficult to distinguis h between an impuls e control disorder NOS , perhaps characterized by an individual who engages in impulsive aggress ive acts , versus an anxiety dis order NOS , perhaps sugges ted by individual who s trikes out in the context of a s tres sor would go unnoticed by most people. T he clinician always make a best effort at a working diagnos is and should be prepared to make modifications as indicated data gathered through collateral s ources and from increasing familiarity with a particular patient.

A pproac h to Maladaptive As with child psychiatry in general, there is little that can be attached to a given s ymptom. P ersons with mental retardation are typically referred for evaluation because of s elf-injurious , aggres sive, impulsive, or hyperactive behavior. B ecause of the lack of diagnos tic specificity for each of these symptoms , a diagnos tic decis ion tree cannot be cons tructed. Ins tead, it is more useful to as k a series of ques tions about the expres sion of a particular behavior. If the behavior is of recent onset, one is more likely to cons ider an acute medical or ps ychiatric etiology. If the behavior is highly situational, occurring primarily in the context of the of tas k demands , the likelihood of a psychosis or mood disorder is probably reduced. If attempts are made to avoid the behavior by s elf-res traint, the inference of ego-dystonic features may be tenable. Ass ess ing the of these and collateral data leads the clinician to a presumptive diagnos is that forms the bas is for a 3727 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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plan.

Diagnos tic Ins truments and S c ales A number of diagnos tic and behavioral rating scales been developed for the population with mental retardation. Although neither diagnostic nor treatment decis ions s hould be based entirely on the results of a instrument, the s ys tematic collection of data through a s cale is a us eful adjunct to the clinical diagnostic or monitoring proces s. Among the most common general behavior rating s cales are the Aberrant B ehavior (AB C ) and the Developmental B ehavior C hecklis t T he B ehavior P roblem Inventory (B P I) is particularly for self-injurious , aggres sive, and stereotyped T he P sychopathology Inventory for Mentally R etarded Adults (P IMR A), the Diagnos tic As ses sment of the Handicapped (DAS H), the R eiss S creen for B ehavior, and, more recently, the R eiss S cale for Dual Diagnos is are all ins truments whose primary us efulnes s is to poll for the presence of mental E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > T R E AT ME N

TR E ATME NT P art of "34 - Mental R etardation" P.3099

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P reventive treatment s trategies largely focus on prevention of intellectual disability and on mitigating as sociated complications, for example, treating mental disorders . T he merits of primary prevention are obvious, and the success es enjoyed with P K U should continue to provide powerful incentive for the ongoing collaborations of basic s cientis ts and clinicians . R ecent evidence suggests that newborn metabolic screening is extremely s ucces sful in reducing the incidence and severity of s ome mental retardation s yndromes. On the other hand, the impact of more recent programs is les s clear. F or example, although folic acid s upplementation appears to significantly reduce the ris k of neural tube defects, compliance with recommendations to increas e dietary folate appears to have been disturbingly negligible. It also appears that the prevalence of 21 is likely to remain unchanged or to increase, despite availability of prenatal diagnostic programs .

Influenc e of E tiologic al F ac tors on Treatment As sugges ted previously, the approach to treatment begins with the diagnostic process . In some cas es , the underlying caus e of mental retardation may be important in cons idering treatments . F or example, in mental retardation as sociated with P K U, a number of attempts have been made to minimize or to attenuate hyperactivity and impuls ivity by dietary modification. recently, as animal models of this disorder are and explored, it appears that dopaminergic may play a particularly s alient role in the expres sion of maladaptive behaviors and, perhaps , in the des ign of specific treatments . T hus, early intervention with 3729 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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dopamine agonis ts may ultimately play a unique role in the treatment of behavioral and cognitive disturbance as sociated with P K U. Abnormalities in serotoninergic function have been reported in the context of Down syndrome. T his hypos erotonemia led to trials of serotonin replacement with mixed res ults , but s erotoninergic drugs may yet particular relevance for pers ons with Down s yndrome. the context of the P rader-Willi s yndrome, abnormalities are also being reported, as are serotoninergic agents . T aken together, the the underlying caus e of mental retardation has become increasingly important in considering biological treatments . In the same way, the diagnosis of mental disorders or s yndromes in persons with mental will guide and influence treatment s trategies. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > T R E AT ME NT O F ME NT AL

TR E ATME NT OF ME NTAL DIS OR DE R S P art of "34 - Mental R etardation" Mental retardation is a multidis ciplinary problem, and optimal treatment is multimodal. T ypically, a treatment plan includes attention to ps ychoeducational, ps ychotherapeutic, and psychopharmacological interventions .

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One s hould never as sume that a person with mental retardation cannot benefit from psychotherapeutic intervention s imply because of his or her impairment in intellectual functioning. F or example, Anton Dos en has highlighted the us efulness of psychoanalytic focus ing on developmental theories, to improve emotional expres sion, to enhance self es teem, to personal independence, and to broaden social interactions. C hris tian G aedt has s imilarly advanced us efulnes s of ego psychology, in particular, objectrelations theory, in the approach to individuals with mental retardation. In addition to psychoanalytic or developmentally bas ed approaches, it appears that cognitive therapy may benefit in the treatment of depres sion, and brief therapy may be useful in reducing anxiety, even in the context of moderate to severe mental retardation. However, for all types of individual therapies in this population, certain modifications in approach are beneficial. It is important, for example, that an active therapeutic s tance be us ed, as well as the use of and s upportive interventions and careful attention to language abilities and developmental level of the in treatment. W hen thes e types of alterations are many patients with mental retardation clearly are able benefit. B ehavioral therapies are also demons trably effective in managing many maladaptive behaviors, particularly aggres sion and s elf-injury, in pers ons with mental retardation. Interventions that should be considered almos t invariably in this context include environmental modifications, caregiver education, and applied 3731 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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analysis. T he theoretical basis and clinical practice of behavioral treatments are reviewed extens ively T ypically, a behavioral ass es sment begins with a analys is of behavior. T his applied behavioral analysis composed of a detailed examination of the variables reinforce or maintain particular behaviors . One the antecedent events and cons equences of a question and typically must tes t hypothes es to confirm res ults of a behavioral analysis by s ys tematically manipulating key variables. Mats on and colleagues recently shown that a checklis t, called the Questions B ehavioral F unction (QAB F ), could be us ed derive clear behavioral functions for most individuals percent) acros s target behaviors of self-injury, and s tereotypy. F urthermore, when the res ults of the functional analysis informed the behavior program, subjects improved s ignificantly more than those whos e behavior programs were more generic. S creening instruments may thus be quite useful in beginning to identify reinforcing variables for maladaptive behavior, a behavioral psychologis t is best trained to generate to implement a behavior program bas ed on a functional analysis of behavior. G roup therapy can be an important part of the program for persons with mental retardation, in the area of s ocial skills building. S upportive groups parents and s iblings may als o be of particular benefit. F amily therapy can be particularly us eful and provides setting for education, s upport, and cons olidation of behavioral treatment and other interventions .

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T here is a relative paucity of controlled clinical drug that include pers ons with mental retardation, individuals with the mos t s evere cognitive impairment. a result, clinicians mus t generally extrapolate from the general population with regard to pharmacotherapy in persons with mental retardation. F ortunately, there is reason to s us pect that drugs discriminate on the bas is retardation in terms of their mechanis ms of action. However, becaus e of drug–drug interactions that may affect the availability or effectivenes s of concurrent medications , individuals with mental retardation may require relatively unique dos ing s trategies . In institutionalized populations , for example, in which 30 40 percent of persons have epilepsy and as many as percent may have s ome other medical condition of significance, drug interactions become an increasingly important consideration. V arious clas ses of drugs commonly used in pers ons with mental retardation for which s alient information exis ts are highlighted in the following s ections.

Antidepres s ants T he us e of antidepres sant medications in pers ons with mental retardation appears to remain relatively low. S pecial cons iderations in the use of antidepres sant medication P.3100 include the common medical comorbidities as noted previous ly. T ricyclic antidepres sants , in particular, mus t us ed with the knowledge that the risk of lowering threshold is real. With this risk in the general population 3733 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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being on the order of 1 in 1,000, in individuals with retardation, this risk may increase to close to 1 in 5. anomalies are common in s ome mental retardation syndromes, and the anticholinergic side effects of medications may be particularly significant in persons Down s yndrome. Individuals with mental retardation require lower levels of antidepres sant drug than their normally developing peers, and disinhibition has been described even with typical antidepres sant doses of the serotonin reuptake inhibitors . T here are s ome individuals , particularly a subgroup the pervasive developmental dis order spectrum, who appear to exhibit extraordinary s ens itivity to drugs of and other clas ses. T his sens itivity, when it occurs, is manifest by dis inhibition and may pres ent as an target s ymptoms at doses of medication that might otherwis e appear quite s tandard. In this context, individuals may be converted to responders with significant dos e reductions, for example, reducing a starting dose of fluoxetine (P rozac) or citalopram from 10 mg to 1 mg, daily. A s ubgroup of persons with S IB als o exhibit selfbehaviors , for example, binding their extremities in their clothing or s eeking out helmets to wear for s elfS uch behavior might indicate an ego-dystonic quality of self-injury and suggests the pos sibility of S IB as a compuls ion. In the P rader-Willi syndrome, OC D occurs more commonly than in the general population, and compuls ive s kin picking may improve along with other compuls ive behaviors with a s elective serotonin inhibitor (S S R I). G iven these findings, trials of s erotonin reuptake 3734 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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are increasingly common among patients with S IB . F avorable experiences have been reported for paroxetine (P axil), sertraline, trazodone (Des yrel), and clomipramine (Anafranil) in this regard. However, of agents , only clomipramine has been shown to be well-controlled studies. Owing to its effect of lowering seizure thres hold, clomipramine is generally not a firsttreatment for compuls ive S IB in individuals frequently comorbid for epilepsy.

Antic onvuls ants Data on the use of anticonvulsant medications for indications other than epileps y are limited. However, cons iderable experience s uggests that, as for the population in general, some anticonvulsant drugs may improve cyclical mood dis orders and impuls ive V alproate has probably been s tudied most in this C urrent prevalence s urveys would s uggest that, acros s indications , carbamazepine is the mos t widely anticonvuls ant for persons with mental retardation. P amela C rawford and colleagues recently performed open-label, randomized, parallel group, multicenter, on study comparing gabapentin (Neurontin) with lamotrigine (Lamictal) in 109 patients with treatmentres is tant, focal epileps y and mental retardation. the gabapentin and lamotrigine groups experienced a reduction in s eizure frequency by nearly one-half. B oth drugs were equally well tolerated. G abapentin may had an edge with res pect to some behavioral indices, denoted by the investigators as communication, cooperation, and restless ness , but lamotrigine also credited with improving challenging behavior. T hus , 3735 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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medications may hold promis e for persons with mental retardation and treatment-res is tant epilepsy, and their effects on behavior s hould be the focus of additional study. Interes tingly, there is emerging experience with a s mall number of persons with P rader-Willi syndrome treated with the anticonvulsant, topiramate (T opamax), whos e skin-picking behavior improved. T he mechanis m underlying this effect is unknown and might even peripheral effects of the drug, for example, on or, perhaps , even the rate of wound healing. C onvers ely, S IB and aggress ion can also dramatically improve with the withdrawal of phenobarbital. T he potential behavioral toxicity of this and any drug s hould not be overlooked in des igning treatment s trategies for persons with mental retardation. Moreover, medical comorbidity is the rule in individuals with disabilities, and the importance of identifying and underlying medical problems or refining that treatment cannot be overs tated.

Anxiolytic s Although benzodiazepines are commonly pres cribed in treatment for anxiety in the general population, there unique concerns when used in the context of developmental disorders , particularly regarding the poss ibility of increased confusion, cognitive unsteadines s, and paradoxical excitement. J ennifer and C urt S andman reviewed dis inhibition as sociated benzodiazepines that occurred in 35 to 68 percent of institutionalized mentally retarded population as compared to controls . Nevertheles s, alprazolam 3736 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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clonazepam, and lorazepam (Ativan) are widely used the treatment of acute anxiety, particularly that with procedures . T heir us e s hould be cons idered in the absence of evidence of previous abnormal res ponses these agents . B us pirone is another s erotoninergic agent that has reported to be of benefit in s ome persons with developmental disorders . J ohn R atey and colleagues reported the us e of bus pirone in an open trial in with diagnosed anxiety dis orders manifes ted by aggres sive and S IB s. T ypical doses at which patients res ponded were on the order of 15 to 45 mg per day. In another open trial by B ryan K ing and P ablo Davanzo, it appeared that nonres ponders to buspirone remained even as the medication dos e was increased from the us ed by R atey to 60 mg daily. A s tudy from W illem V erhoeven and S iegfried T uinier also explored in the treatment of anxiety in persons with mental retardation, sugges ting that this agent s hould be those considered in treating this population. Moreover, advantages include a relatively benign s ide effect specifically the abs ence of common motor or cognitive toxicities, at doses that are us ed to treat anxiety.

Neuroleptic s Antips ychotic medications have long been used, indis criminately, in pers ons with mental retardation. Neuroleptics continue to be the most widely prescribed clas s of ps ychotropic medication, even more commonly prescribed than anticonvuls ant drugs for persons with mental retardation. G iven this ample experience with neuroleptics in pers ons with mental retardation, in 3737 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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in res idential or ins titutional settings, as many as 50 percent of individuals may be treated with this class of drug, the s ide effects are well known. Individuals with mental retardation appear to be at ris k of developing tardive dys kines ia than the general population, with recorded rates ranging from 18 to more than 30 percent. On the other hand, abnormal involuntary movements are not uncommon in this population, and this may repres ent a confound in interpreting rates of neuroleptic-induced tardive dyskinesia. T he growing availability of atypical drugs and their us e in persons with mental retardation suggest that thes e drugs may be helpful, given an apparently reduced ris k for tardive dys kinesia and extrapyramidal s ymptoms, as well as cognitive toxicity. C ons iderable evidence is accumulating to support the effectivenes s of ris peridone in treating severe behavior in children and P.3101 adoles cents with cognitive dis ability. T wo large trials in C anada and in the United S tates (collectively involving more than 200 subjects ) found that, at doses ranging from 0.02 mg/kg per day to 0.06 mg/kg per children and adoles cents with various dis ruptive disorders , the majority of whom also had ADHD, significantly. S edation and weight gain were the mos t common side effects. S tudies, although open trials involving s mall numbers of s ubjects, reporting the effectivenes s of clozapine (C lozaril), olanzapine, and sulpiride (S ulpitil, S ulparex, Dolmatil) also exist to the us e of thes e agents in individuals with mental 3738 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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retardation. T here is evidence to support the use of dopamine antagonis ts in S IB and aggres sion in theory and in F or thioridazine (Mellaril), in particular, ample exis ts to indicate that S IB and aggres sion may T ypical dos es average les s than 300 mg per day, with doses as low as 15 mg per day being reported for children. R ecent concerns about QT interval induced by thioridazine and the availability of the neuroleptics have dramatically reduced the usage of thioridazine in this population. Although s uggested by s ome, there is no convincing evidence that the mechanism of action of neuroleptics S IB or aggress ion is merely to s uppress behavior through a nons pecific s edating effect. S uch an clearly undesirable in an individual with preexis ting cognitive impairment, and many of the earlies t reports specifically note the abs ence of s edation.

Ps yc hos timulants Des pite reports of paradoxical res pons es to stimulant medications in persons with mental retardation, with higher than expected rates of emergent motor tics and emotional lability, a growing body of literature s upports the us e of stimulant drugs for the treatment of ADHD in the context of mental retardation. A problem awaiting additional s tudy concerns the likelihood of a res ponse stimulants in relation to the s everity of cognitive Data are mixed with res pect to whether IQ negatively positively predicts treatment res ponse.

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S ome individuals who self-injure appear to have pain s ens itivity, as was s uggested nearly a century ago Ireland. T his obs ervation, coupled with data indicating opioid antagonis ts can attenuate s tereotypy and s elfinjury in animal models and data indicating that opioids may modify the function of dopaminergic s ys tems, has fueled interes t in this clas s of drugs . Naltrexone is the opioid antagonis t most widely used for S IB , but the literature is mixed. T ypical doses range from 0.5 to 2.0 mg/kg per day in children and up to 200 mg per day in adults . T he relatively long half-life of naltrexone, 72 in brain, mus t be kept in mind in designing titration strategies for this drug. On balance, naltrexone be well-tolerated in persons with developmental sedation is the side effect most likely to be observed.

Nootropic s P erhaps the so-called Holy G rail of mental retardation would be drugs that positively affect cognition, or nootropic drugs . P iracetam (Nootropyl) is putative nootropic agent, but interest in this agent has largely been fueled by anecdotal Internet and media reports of its pos itive effects on learning, memory, attention, and general well-being. Nancy J . Lobaugh colleagues recently reported the firs t controlled trial of piracetam in children with Down s yndrome. T he inves tigators us ed a placebo-controlled, cross over and as sess ed the effects of piracetam (80 to 100 mg us ing neurops ychological tes ts . Unfortunately, was as sociated with a number of s ide effects , including aggres sion, agitation, s exual arous al, poor sleep, and diminis hed appetite. T here were no consistent benefits 3740 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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piracetam over placebo that were identifiable in this

Other Drugs T here is ample evidence to support an antiaggress ive effect of lithium salts in the context of mental S imilarly, there is evidence to sugges t that, in the cyclical mood disturbance, lithium may als o be helpful. T he side effects as sociated with this agent, particularly cognitive dulling that is occas ionally reported by some recipients without mental retardation, should raise the threshold for the us e of this agent in the s etting of cognitive disability. β-Adrenergic antagonists have als o been reported to us e in the population with developmental disorders . It not clear whether the mechanism is central or however. R atey and colleagues were led to explore this clas s of drugs bas ed on their perception that many individuals with developmental dis abilities appear to a low frustration tolerance for ambient stimuli. At dos es propranolol (Inderal) upward of 1,000 mg per day, the precis e mechanism of action of this drug arguably becomes nonspecific, but lower doses of this and other adrenergic antagonis ts have als o been reported A growing appreciation exis ts for the potential us efulnes s of drugs acting at glutamate receptor G lutamatergic and dopaminergic interactions in the neostriatum are the focus of research on the of a host of neuropsychiatric illness es , including schizophrenia, OC D, S IB , and aggres sion. Dextromethorphan (C ough-X), an antituss ive agent also binds to the N-methyl-D-as partate (NMDA) was reported by Leis a W elch and R obert S ovner to 3741 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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markedly attenuated S IB in a 25-year-old individual congenital rubella s yndrome. T he patient was on dextromethorphan for 16 months with sus tained benefit. S urpris ingly and perhaps ominously, no followstudies have been reported with this drug in S IB . Lamotrigine is an anticonvuls ant drug that als o appears antagonize glutamate by reducing its release. A recent case report suggests that lamotrigine may also be reducing s elf-injury in the context of a s tereotyped movement disorder. A larger study in which lamotrigine was added to the anticonvuls ant regimen of children mental retardation sugges ted that those with autism experienced gains that could not readily be attributable better s eizure control alone. A recent, double-blind, placebo-controlled trial of lamotrigine in autism was , however, negative. Amantadine (S ymmetrel) is another drug whose affinity the NMDA receptor has only recently become An open trial of the use of amantadine in children with various developmental dis abilities and disruptive behaviors was quite promising. A subsequent multisite, controlled trial in children with autism yielded mixed res ults. S leep disturbance is a little studied but often significant problem for some pers ons with mental retardation. Mohammed M. J an prescribed melatonin openly to children with moderate to s evere mental retardation of mixed etiologies. T he children ranged from 1 to 11 age. All but two of the children were characterized as dramatic responders using meas ures of hours of s leep, nocturnal awakenings , delayed s leep onset, and early morning awakening. Melatonin was administered as a 3742 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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single, 3-mg dose, 1 to 2 hours before target bedtime night. G . P illar and colleagues als o adminis tered a mg dose and monitored s leep efficiency as well activity (wris t Actigraph) in their s ample of five children (3.5 to years of age) with s evere mental retardation. S leep significantly improved in the subjects receiving and two of the subjects were still receiving melatonin long as 18 months after the completion of the s tudy. preliminary evidence s uggests that melatonin deserves broader consideration for the treatment of children with mental retardation and dis turbed circadian rhythm of sleep.

Modern-Day S ervic es and Individuals with mental retardation now have access to wide variety of s ervices . T hes e s ervices can be found throughout the United S tates and last P.3102 throughout the life span; s ee T able 34-11 for a listing of some of thes e s ervices.

Table 34-11 S ervic e Needs and R es ourc es for Families of at Different Ages Age of C hild

Needs

R es ourc es

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0–3 yrs of age

 

 

   C hild

E valuation: phys ical, motor, cognitive, linguistic, socialemotional. E arly intervention services .

Multidis ciplinary evaluation, which res ults in an IF S P , with child and family receiving center-based or home-based early intervention services for a s et amount of hours per week.

   Mother

E motional support. C aretaking behaviors .

S upport groups by disability, region, and etiology. P art early intervention evaluation, intervention, and IF S P .

   F amily

S upport. F inancial as sistance. Information.

S upport groups. Depending on problem, s tate developmental disabilities or insurance payment

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for some s ervices. Hos pitals , groups . 3–21 yrs age

 

 

   C hild

E valuation, referral, and Individualized E ducation

S chool system: involves legal proces s of evaluation and placement (notification, hearings, and appeals, if neces sary); information on transition to adult services as child nears 21 yrs of (and s chool end).

   F amily

Information. F inancial as sistance. S upport.

Local and national groups . S tate departments in some s tates. Including res pite care, camps , art (V ery S pecial Arts )

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or athletic activities (S pecial scholars hips for adoles cents with some dis abilities (deafness , blindnes s). Older 21 yrs of age

 

 

   Offs pring

R es idential services .

B oth run by state developmental disability departments (parents and offspring have major say concerning res idential or work placements are appropriate).

   F amily

S upport. Information. G uardians hip is sues.

C ontinuation of many of the services provided during the s chool years . P articularly for individuals with

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severe disabilities, provis ions for res idential and work status after parents can no longer serve as offspring's legal guardians .

IF S P , Individualized F amily S ervice P lan. F rom Hodapp R M. Deve lopme nt and Dis abilities : Me ntal, Motor, and S ens ory Impairme nts . New C ambridge University P ress ; 1998:196–197, with permis sion.

E arly Intervention E arly intervention serves individuals from birth until 3 years of age. S uch services are provided by the state, different le ad agency coordinating services in each S uch s ervices begin with early intervention specialists visiting the child's home for a few hours per week; once the child is slightly older, center-based care is also provided. With the pass age of P art H of P L 99–457—the the Handicapped Amendments of 1986—early intervention s ervices have increasingly emphasized the family. Agencies are required to develop an 3747 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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F amily S ervice P lan (IF S P ) for each family, focusing on family s trengths and needs in caring for their young with mental retardation.

S c hool F rom 3 years of age until 21 years of age, school takes services provided to the child with mental retardation. S uch educational s ervices became wides pread the pas sage of P L 94–142 (the E ducation for all Handicapped C hildren Act of 1975); this legislation has recently been extended and modified by the Individuals with Disabilities E ducation Act (IDE A) of 1990. S uch laws require that public s chool systems serve all children with disabilities and institute what are legal provis ions to do so. T his proces s provides notice the child is being considered for s pecial s ervices; a scheduled hearing at which the parents and s chool personnel discus s what is the most appropriate s chool placement and s pecialized s ervices; the right to defens e, if parents disagree with s chool pers onnel; a written decision given to the parents notifying them of school's decision; and the parents ' right to appeal this decis ion, first to the s chool itself, then to dis trict and educational authorities, and, eventually, to the courts . entire process res ults in an Individualized E ducation (IE P ), which as sess es the child's academic provides annual goals, provides instructional describes s ervices that the child will receive, and starting dates of services and when and how the child's progres s will be reevaluated. Although receiving for one's child can be complicated, educational have become a right—not a privilege—for parents of 3748 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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children with mental retardation. A further element of education law involves the right to public education “within the leas t res trictive T his phras e has led to the many debates within the education community about inclusion. E s sentially, this debate centers on whether all children should be educated in clas ses compos ed primarily of typically developing children. Inclusion advocates conceptualize education alongs ide typically developing children as child's right, whereas proponents of a continuum of argue that the child's individual educational needs be paramount.

E tiology-B as ed E duc ational Approac hes S pecial educators have long advocated noncategorical approaches to children with mental retardation. S uch approaches do not consider the cause of the child's retardation. Indeed, knowing about the child's etiology mental retardation has even been cons idered harmful, poss ibly leading to increased s tigmatization. Over the pas t few years , however, it has become that the child's etiology of mental retardation does influence behavior. As discus sed previous ly in P rader-Willi, fragile X, W illiams , and Down s yndromes, groups with each s yndrome do differ from others with mental retardation in maladaptive behaviorps ychopathology but also in relative s trengths (or weaknes ses) in language versus other abilities. S uch etiology-related profiles may eventually lead to related interventions . 3749 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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C ons ider Down s yndrome: Mos t children with Down syndrome show particular difficulties in linguis tic grammar, express ive language, and articulation, even their abilities in visual short-term memory s eem good. T hus , when as ked to recall a series of hand movements on the K aufman As ses sment B attery for C hildren (K AB C ) tes t, thes e children perform better when recalling a P.3103 series of spoken numbers or words . Using this vis ualauditory profile, various res earchers have become interes ted in teaching children with Down s yndrome to read. In short, one might be able to us e a strength to ameliorate a weakness , to us e the visual modality as a into language. S imilar suggestions pertain to other syndromes . with W illiams s yndrome generally show higher than vis uos patial abilities, and children with P radersyndrome or fragile X s yndrome s how better abilities in simultaneous (i.e., ges talt) proces sing compared to sequential (s tep-by-step, serial) process ing. In each instance, educators and tes t cons tructors have already devis ed ways to help children with one vers us another learning s tyle, and s uch s pecific, tailored educational approaches might prove particularly effective as well children with different mental retardation s yndromes. Although s uch etiology-based educational interventions hold promise, a few caveats are in order. F irst, to date, none of these interventions has been systematically tes ted. Although reading instruction in Down syndrome has been the s ubject of a few studies , as yet, no 3750 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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intervention s tudies have been undertaken that involve random as signment and that exist over a long period of time. In s hort, the field has yet to move from s hould to doe s work. S econd, such approaches will not neces sarily prove effective for every child with a particular syndrome. Not children with Down syndrome have particular in language; not all children with Williams syndrome demonstrate especially high language or low skills . Although etiology-related interventions may be helpful, they need to be cons idered in light of the child's own specific strengths and weakness es . F inally, to date, all etiology-related interventions have adopted the approach of playing to s trengths as to ameliorating weaknes ses. S uch an approach has adopted partly becaus e of recent findings that the propens ity toward a strong area generally becomes stronger as the child gets older. If s o, it may be easier more beneficial to us e and to expand on strong areas to intervene in areas of particular (and growing) T o give a few examples, in Down syndrome, visual term memory is relatively more advanced compared to auditory s hort-term memory in the teen than in the school years . S imilarly, in W illiams s yndrome, more pronounced patterns of high language and weak visuospatial s kills are seen in older children as younger children. In this sense, playing to s trengths reinforce already strong areas but, hopefully, in ways help children learn a wide variety of information and Des pite the ultimate nature of etiology-related interventions , as phys icians increasingly learn about etiology-related strengths and weaknes ses in a variety 3751 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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syndromes, such information s hould gradually become incorporated into more targeted, more effective of intervention. P.3104

Adult S ervic es Once an individual with mental retardation turns 21 of age, s ervice delivery comes under the auspices of state department of developmental dis abilities. In to educational s ervices, adult services are not federally mandated. S tates thus vary widely in their services and how they offer them. S ervices are often spread out various locations, and qualifying and getting s ervices sometimes be difficult. During the adult years, residential and vocational predominate. R esidential services run the gamut from institutional and community based and from cons tant to no supervision. More res trictive placements involve or s mall ins titutional residences , which mainly s erve lowest functioning, often multiply-impaired, individuals. G roup homes for from four to eight res idents are the most common res idential option; thes e homes typically exist within res idential neighborhoods and provide round-the-clock s taff to ensure s afety and programming. S upervis ed living arrangements us ually cons ist of apartments that are s hared by a few pers ons with mental retardation; these res idents receive visits program staff, who often ins truct res idents in cooking, cleaning, and shopping. Unsupervis ed apartments, in which individuals live by themselves or with a under little s upervis ion, mainly succeed with clients 3752 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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have les ser intellectual impairments and fewer problems . S o too do vocational services show a continuum from most to leas t res trictive. Mos t restrictive are s heltered workshops , in which individuals with retardation or test products next to others with dis abilities . employment provides a job coach or other specially trained individual to work with the client to find a job, to learn how to take public transportation to get to work, to acquire the technical and social s kills needed to the job. C ompetitive employment is the least restrictive job option for adults with mental retardation. employment involves a job like anyone else, with the pay levels and benefits that a nondis abled person have. However, it als o has the s ame press ures and P.3105 res ponsibilities for work performance. As in apartment living, competitive employment operates for the highest functioning and least behaviorally disordered individuals . In considering working and living arrangements for any young adult with mental retardation, one should also cons ider trans itional s ervices. T hes e s ervices are schools to children with dis abilities once the child turns years of age. S ervices involve the teaching of and adaptive s kills that are neces sary later on in life. P arents need to work with s chools to determine the appropriate res idential and vocational goals for each young adult.

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In addition to services provided by early intervention, school, and adult services , individuals with mental retardation and their families can also benefit from a variety of other s upports. T hese run the gamut from term or longer-term res pite care (allowing families a from full-time care), to s ummer camps , to sports programs, such as S pecial Olympics (F ig. 34-1). In at several major univers ities, s pecialty clinics exist for behavioral and medical management of certain types mental retardation.

FIGUR E 34-1 P hotographs A-D depict athletes in activities s ponsored by S pecial Olympics , whose take the oath: “Let me win. B ut if I cannot win, let me be brave in the attempt.” S pecial Olympics was founded in 1968 by E unice K ennedy S hriver. T he miss ion of the organization is to provide year-round s ports training and 3754 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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athletic competition in a variety of Olympic-type s ports individuals with mental retardation by giving them continuing opportunities to develop phys ical fitnes s, to demonstrate courage, to experience joy, and to in a s haring of gifts, s kills , and friends hip with their other S pecial Olympics athletes, and the community. A wide variety of organized groups are also helpful to affected individuals and their families. P arent groups available for parents of children with dis abilities and for parents of children with specific types of retardation. S ibling groups and networks are als o available, and the federal government fosters s ervice and advocacy the UAP s in most every state. S ee T able 34-12 for a of some of the parent and profes sional groups that help persons with disabilities and their families .

Table 34-12 Prominent Organizations in Mental R etardation Ass ociation of R etarded C itizens of the United (T he AR C ), 500 E . B order S treet, Arlington, T X (817) 261–6003 American As sociation on Mental R etardation (AAMR ), 1710 K alorama R oad, NW , W ashington, 3755 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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20009–2683, (800) 424–3688 C ouncil for E xceptional C hildren (C E C ), 1920 Ass ociation Drive, R es ton, V A 22091–1589 American As sociation of University-Affiliated P rograms for P ers ons with Developmental Dis abilities , 8630 F enton S treet, S uite 410, S ilver S pring, MD 20910 T AS H: T he As sociation for P ersons with S evere Handicaps , 29 W . S us quehanna Avenue, S uite B altimore, MD 21204, (410) 828–8274 C AP P National P arent R es ource C enter for C hildren with S pecial Needs, 95 B erkeley S uite 104, B oston, MA 02116 C learinghouse on Dis ability Information, Office of S pecial E ducation and R ehabilitative S ervices, “C ” S treet S W , R oom 3132, S witzer B uilding, Was hington, DC 20202, (202) 205–8241 National Information C enter for C hildren and with Disabilities, P .O. B ox 1492, W ashington, DC 20013, (800) 695–0285 National Organization for R are Dis orders 100 R oute 37, P .O. B ox 8923, New F airfield, C T

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Alliance of G enetic S upport G roups, 35 C ircle, S uite 440, C hevy C has e, MD 29815, (301) 5553 National P arent Network on Dis abilities , 1600 S treet, S uite 115, Alexandria, V A 22314, (703) 1205 S ibling Information Network, 1775 E llington S outh W inds or, C T 07074, (203) 648–1205 R es ources for C hildren with S pecial Needs, Inc., P ark Avenue S outh, S uite 816, New Y ork, NY (212) 677–4650 Ass ociation for C hildren with Down S yndrome, Martin Ave., B ellmore, NY 11710, (516) 221– National Down S yndrome S ociety, 666 New Y ork, NY 10012, (800) 221–4602 National Down S yndrome C ongress , 1800 S treet, P ark R idge, IL 60068, (800) 232–6372 National F ragile X S yndrome F oundation, 1441 S treet, S uite 215, Denver, C O 80206 P rader-Willi S yndrome As sociation, 6490 B lvd., E -102, S t. Louis P ark, MN 55426, (612) 1947 3757 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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P rader-Willi S yndrome International Information F orum, 40 Holly Lane, R os lyn Heights , NY (800) 358–0682 T he Williams S yndrome As sociation, P .O. B ox C laws on, MI 48017–0297, (810) 541–3630

L egal Is s ues in Mental T he ADA of 1990 spells out four aims : (1) to provide a and comprehensive national mandate for the of dis crimination against individuals with disabilities ; (2) provide clear, strong, consistent, and enforceable standards address ing discrimination agains t individuals with disabilities; (3) to ens ure that the federal plays a central role in enforcing the standards in the ADA on behalf of individuals with disabilities; and to invoke the sweep of congress ional authority, the power to enforce the 14th Amendment and to regulate commerce, to addres s the major areas of discrimination faced day to day by people with T he ADA repres ents a major turning point in the of the rights of pers ons with disabilities who, in the were frequently ins titutionalized and compuls orily sterilized in misguided efforts to protect society from population. Although the pendulum has s hifted repeatedly from attitudes of as ylum to punishment of persons with disabilities over the centuries, the paradigms in developed countries are thos e of 3758 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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integration and s upport. Disabilities law since the reflects thes e values as articulated in S ection 504 of R ehabilitation Act of 1973 and, subsequently, in the of 1990 (originally P L 94–142 of 1975) and the ADA. C ollectively, these laws ensure that all children with disabilities receive a free, appropriate public education the least restrictive environment and that reasonable accommodation is made for the employment of adults . C linicians working with this population s hould be aware their personal obligation to provide an accommodating environment but s hould als o familiarize themselves local guardians hip, informed cons ent, and abuse laws to serve bes t this population. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > S UG G E S T E D C R OS S -R E F E R E

S UGGE S TE D C R OS S R E FE R E NC E S P art of "34 - Mental R etardation" T he neural sciences are dis cuss ed in C hapter 1: neuroanatomy is dis cuss ed in S ection 1.2, principles of neuroimaging are dis cus sed in S ections 1.15 and 1.16. Neurops ychiatry and behavioral neurology are in C hapter 2, including approach to diagnosis in 2.1, neuropsychiatric aspects of epilepsy in S ection brain trauma in S ection 2.5, and movement dis orders S ection 2.6. C ontributions of the ps ychological appear in C hapter 3, including perception and cognition S ection 3.1, P iaget's approach in S ection 3.2, learning 3759 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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theory in S ection 3.3, and biology of memory in S ection 3.4. Neurops ychological and intellectual as sess ment is discuss ed in S ections 7.5 and 7.7, medical as sess ment laboratory tes ting are dis cuss ed in S ection 7.8, and ps ychiatric rating s cales are dis cuss ed in S ection 7.9. B orderline intellectual functioning and academic are covered in S ection 26.3. Abnormal and atypical patterns of behavior are also dis cuss ed in C hapter 35 learning disorders , C hapter 36 on motor s kills dis order, C hapter 37 on communication disorders . C hapter 38 covers pervasive developmental disorders , and S ection 44.2 provides an in-depth review of s tereotypic disorder. F orens ic ps ychiatry is covered in C hapter 54. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 34 - Mental R etardation > R E F E R E NC E

R E FE R E NC E S *Aman MG , Alvarez N, B enefield W , C rims on ML, G , K ing B H, R eiss S , R ojahn J , S zymanski L: E xpert C ons ens us G uideline S eries : T reatment of and behavioral problems in mental retardation. Am J Me nt R e tard. 2000;105:161–228. American As sociation on Mental R etardation. Me ntal R etardation: Definition, C las s ification, and S ys te ms S upports . W ashington, DC : American Ass ociation Mental R etardation;2002. American P s ychiatric Ass ociation. Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs . 4th ed. Was hington, DC : American P sychiatric As sociation; 1994. 3760 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Atkins v V irginia. (US S upreme C ourt 2002) (00U.S . 304 (2002) 122 S . C t. 2242 (2002). B orthwick-Duffy S A, E yman R K : W ho are the dually diagnosed? Am J Ment R e tard. 1990;94:586–595. B uckley S . P romoting the cognitive development of children with Down syndrome: T he practical implications of recent psychological research. In: J A, P erera J , Nadel L, eds . Down's S yndrome : A C urre nt K nowledge. London: W hurr P ublis hers Ltd; 1999:99–110. C hen L, T oth M: F ragile X mice develop sensory hyperreactivity to auditory stimuli. Neuros cie nce . 2001;103:1043–1050. C rawford P , B rown S , K err M: A randomized openstudy of gabapentin and lamotrigine in adults with learning disability and res is tant epilepsy. S eizure . 2001;10: 107–115. Dingman HF , T arjan G : Mental retardation and the normal distribution curve. Am J Ment De fic. 1960;64:991–994. Doll E : A genetic scale of mental maturity. Am J O rthops ychiatry. 1935;5:180–188. Down J L: Obs ervations on an ethnic clas sification of idiots . L ondon Hos p R ep. 1866;3:259–262. 3761 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Dykens E M, Hodapp R M, E vans DW : P rofiles and development of adaptive behavior in children with Down s yndrome. Am J Ment R etard. 1994;98:580– Dykens E M, Hodapp R M, W alsh K , Nas h LJ : correlates and trajectories of intelligence in P radersyndrome. J Am Acad C hild Adole s c P s ychiatry. 1992;31:1125–1130. F eins tein C , R eis s AL: P s ychiatric dis orders in retarded children and adoles cents. C hild Adole s c P s ychiatr C lin North Am. 1996;5:827–852. G reenbaum E : F orres t G ump and his box of Me nt R e tard. 1996;34:128–129. G ross man H. C las s ification in Me ntal R e tardation. Was hington, DC : American Ass ociation of Mental Deficiency; 1983. *Harris J C . Deve lopme ntal Neurops ychiatry. V ol 1, New Y ork: Oxford University P res s; 1995. Has kell P H: Mental deficiency over a hundred years. J P s ychiatry. 1944;100:107–118. *Hodapp R M. Deve lopme nt and Dis abilitie s : Me ntal, Motor, and S e ns ory Impairme nts . New Y ork: Univers ity P res s; 1998. Hodapp R M, F idler DJ : S pecial education and C onnections for the 21st century. J S pecial E duc. 3762 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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1999;33:130–137. Hodapp R M, R icci LA. B ehavioural phenotypes and educational practice: T he unrealized connection. In: O'B rien G , Udwin O, eds. B ehavioural P he notype s C linical P ractice . London: Mac K eith P res s; 151. Hodapp R M, Zigler E . P as t, present, and future the developmental approach to mental retardation. C icchetti D, C ohen D, eds. Manual of P s ychopathology. V ol 2. R is k, Dis order, and New Y ork: J ohn W iley & S ons ; 1995:299–331. J an MM: Melatonin for the treatment of handicapped children with s evere s leep disorders . P ediatric Neurology. 2000;23:229–232. J arrold C , B addeley AD, Hewes AK , P hillips C : A longitudinal as sess ment of diverging verbal and verbal abilities in the W illiams syndrome phenotype. C orte x. 2001;37:423–431. Lambert N, Nihira K , Leland H. AAMR Adaptive S cales –S chool. Aus tin, T X: P ro-ed; 1993. P.3106 Lane H. T he W ild B oy of Ave yron. C ambridge, MA: Harvard Univers ity P res s; 1976. Lejeune J , G autier M, T urpin R : E tudes des 3763 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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chromosomes s omatique de neuf enfants C ompte s R endus de l'Acade mie le s S cience s . 1959;48:1721. Lobaugh NJ , K aras kov V , R ombough V : P iracetam therapy does not enhance cognitive functioning in children with Down syndrome. Arch P e diatr Adole s c Me d. 2001;155:442–448. Luckason R , C oulter DL, P olloway E A, R eiss S , R L, S nell M, S pitalnick D, S tark J . Me ntal Definition, C las s ification, and S ys te m of S upports . Was hington, DC : American Ass ociation on Mental R etardation; 1992. MacLean W E , ed. E llis ' Handbook of Me ntal P s ychological T he ory, and R es earch. 3rd ed. E rlbaum; 1997. MacMillan DL, G res ham F M, S iperstein G N: and ps ychometric concerns about the 1992 AAMR definition of mental retardation. Am J Ment R e tard. 1993;98:325–335. Mass ey P S , McDermott S : S tate-specific rates of retardation-–United S tates , 1993. MMW R Morb W kly R ep. 1995;45:61–65. Minnes P M: F amily stress ass ociated with a developmentally handicapped child. Int R e v R e s R etard. 1988;15:195–226.

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Nirje B . T he normalization principle and its human management implications . In: R osen M, C lark G R , M, eds . A H is tory of Me ntal R e tardation. C ollected V ol 1. B altimore: Univers ity P ark P res s; 1976:361– Ogbu J . C ulture and intelligence. In: S ternberg R , E ncyclope dia of Inte lligence . New Y ork: Macmillan; 1994:328–338. P illar G , S hahar E , P eled N: Melatonin improves wake patterns in ps ychomotor retarded children. P ediatr Ne urol. 2000;23:225–228. P ober B R , Dykens E M: W illiams s yndrome: An of medical, cognitive, and behavioral features . C hild Adoles c P s ychiatry C lin N orth Am. 1996;5:929–943. P ueschel S : C linical aspects of Down s yndrome infancy to adulthood. Am J Med G e net S uppl. 56. R eis s S . Handbook of C hallenging B ehavior: Mental As pects of Me ntal R e tardation. W orthington, OH: P ublis hing C o; 1994. R eis s S , Aman MG , eds . P s ychotropic Me dication Deve lopme ntal Dis abilities : T he Inte rnational Handbook. C olumbus , OH: T he OS U Nis onger 1998. R oeleveld N, Zielhuis G A, G abreels F : T he mental retardation: A critical review of the literature. 3765 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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Dev Me d C hild Ne urol. 1997;39:125–132. *R oyal C ollege of P sychiatrists . DC -L D (Diagnos tic C rite ria for P s ychiatric Dis orde rs for Us e with Adults L e arning Dis abilitie s /Me ntal R etardation). London: G askell P res s; 2001. S cheerenberger R . A H is tory of Me ntal R etardation. B altimore: B rookes; 1983. S chroeder S R , Oster-G ranite ML, B erks on G : S elfinjurious behavior: G ene-brain-behavior Me nt R e tard De v Dis abil R es R ev. 2001;7:3–12. S parrow S S , B alla D, C icchetti DV . V ine land B ehavior S cale s . C ircle P ines, MN: American S ervice; 1984. S utherland G R : F ragile s ites on human demonstration of their dependence on the type of tis sue culture medium. S cience. 1977;197:265–266. S zymans ki LS , K ing B H, G oldberg B , R eid A, T onge C ain N. Diagnos is of mental dis orders. In: R eis s S , MG , eds . P s ychotropic Me dication and Dis abilities : T he Inte rnational C ons e ns us H andbook. C olumbus, OH: T he OS U Nis onger C enter; 1998:3– *S zymanski LS , K ing B H: P ractice parameters for as sess ment and treatment of children, adolescents , adults with mental retardation and comorbid mental disorders . J Am Acad C hild Adole s c P s ychiatry. 3766 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/34.htm

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[S uppl 12]:5S –31S . T rent J W . Inventing the F ee ble Mind: A His tory of R etardation in the U nite d S tate s . B erkeley, C A: of C alifornia P res s; 1994. United S tates Department of E ducation. S ixtee nth Annual R e port to C ongres s on the Imple me ntation Individuals with Dis abilitie s E ducation Act. DC : United S tates Department of E ducation; 1994. Wodrich DL. C hildre n's P s ychological T es ting: A Nonps ychologis ts . B altimore: B rookes ; 1997. World Health Organization. T he IC D-10 Me ntal and B e havioural Dis orde rs . G eneva: World Organization; 1992. Zigler E : Developmental versus difference theories mental retardation and the problem of motivation. Me nt Defic. 1969;73:536–556. Zigler E , Hodapp R M. Unde rs tanding Mental New Y ork: C ambridge University P ress ; 1986.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 35 - Learning Dis orders > 35.1: R eading Disorde

35.1: R eading Dis order R os emary Tannoc k Ph.D. P art of "35 - Learning Dis orders " T he clinical condition known as re ading dis order or refers to s evere problems in the mastery of reading. to understand reading dis order, it is necess ary to unders tand the skills and abilities pres umed to underlie the complex act of reading. R eading is a multicomponential skill that, in contras t to oral skills , which humans have poss ess ed for 100,000 been manifes t for only approximately 4,000 years. It requires the brain to link written markings to spoken language. C urrent unders tanding of reading and reading based almost exclus ively on alphabetical languages, particularly E nglish, but recent work on reading and reading problems in nonalphabetical languages (e.g., C hines e and J apanes e) cautions that the distinctive orthographic, and phonological features of these languages may place greater emphasis on the and automatization of different s ets of core skills. T he emphasis of this section is on reading dis orders with alphabetical languages , but, given the ethnic and cultural diversity of families s eeking clinical help, are advis ed to be attuned to critical differences in and the manifes tation of reading dis order in different 3768 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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languages . T he act of reading may be us efully conceptualized as simultaneous and intertwined sets of dynamic online proces ses: bas ic re ading s kills and re ading B as ic reading s kills include letter-sound knowledge (grapheme-phoneme mapping), word recognition and storage (logographic process ), and s imple decoding (alphabetical proces s). R eading compre hens ion, which obviously the ultimate goal of reading, is defined as the dynamic extraction and construction of the meaning of written text by means of a reciprocal exchange of ideas between the reader and the mess age in a particular B as ic reading proces s e s are rooted in oral language, reading is not a natural biological progress ion of and therefore must be taught. T his is becaus e, to or to decode the printed word or character, every child must learn the conventional orthographic s ys tem by their ancestors to map alphabetical letters or other written characters (graphemes ) to the bas ic segments sound in speech (phonemes ) that they repres ent. Acquis ition of basic reading s kills appears to proceed through three s tages in alphabetical and languages : a logographic s tage, a cipher stage, and an orthographic s tage. B riefly, at the logographic stage, children learn visual features of the individual letter (or character in nonalphabetical languages ) with the bas ic speech s ound it represents; at the cipher s tage, they gradually dis cover orthographic regularities that reduce the memory burden of having to remember each letter character individually; and, at the orthographic stage, letter s equences (or character parts) and whole words (characters ) are proces sed as whole units , which 3769 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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efficient and automatic word (character) recognition. T he writing s ys tem of some alphabetical languages is described as having a s hallow or trans parent because the phonemes of the spoken word are represented by the graphemes in a direct and manner (e.g., F innish, G erman, and W elsh). B y languages with a de e p orthography (e.g., E nglish and F rench), the relation of spelling to s ound is more in that the same letter may repres ent different in different contexts (e.g., in E nglis h, the letter h s tands the sound /h/ when it is next to some lettersas in hear, and aheadbut stands for entirely different s ounds when it is next to other letters as in /ch/ in ches t, /th/ in them, /sh/ in shine, and /g/ in ghos t. Moreover, different letters may repres ent the s ame phoneme (e.g., in the sound /f/ can be repres ented by the letters f, ff, gh, ph). As a cons equence, E nglis h (and other languages a deep orthography) contains many irregular or words , s uch as have , s hoe, once , and yacht. It is not surpris ing, therefore, that there are marked differences the normal rate of acquis ition of basic reading s kills in children from various E uropean countries , which are attributable to fundamental linguistic differences in E uropean orthographies. F or example, the rate of development of basic reading s kills in languages with deep orthographies and complex syllabic s tructure E nglis h and Danish) is more than twice as slow as in shallow orthographies (e.g., F innis h, G reek, and Als o, the rate of acquisition of C hinese characters cons iderably longer than mastery of the alphabetical principle, because C hinese orthography is vis ually complex. S pecifically, the basic graphic unit is a 3770 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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which is made up of many different s trokes (an 11 strokes per character). E ach character repres ents basic unit of meaning (i.e., morpheme), and mos t are monos yllabic. Approximately 80 to 90 percent of characters cons ist of a semantic component and a phonetic component, which occupy habitual pos itions character (pos itional regularity) and form the crux of character's orthographic structure. It has been hypothes ized that deep orthographies the implementation of dual proces ses (logographic + alphabetical), which take twice as long to es tablis h as single process required for learning a s hallow Dual proces s learning demands the engagement of a wider range of cognitive s kills than s ingle process Als o, if the dual process es are functionally (and distinct, it is pos sible that perturbations in one or both proces ses may give rise to different profiles of reading impairments and that the etiology, as sess ment, and treatment of problems in bas ic aspects of reading may vary across countries as a function of fundamental linguistic differences. F or example, recent evidence indicates that, although reading disorder manifes ts primarily as a phonological deficit in E nglis h-speaking children, it may manifest primarily as deficits in rapid naming in children whose native language is G erman F innis h and as rapid-naming deficits and orthographic difficulties in children whose native language is P.3108 R eading compre hens ion is influenced by the re ader, the te xt, and the re ading activity. C ritical characteristics of the reader include cognitive 3771 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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(attention, working memory, long-term memory, critical analytical ability, inference, visualization ability, and reading skills), motivation (a purpose for reading, in the content being read), and various types of background knowledge (vocabulary, topic knowledge, syntactic awareness and discours e knowledge, of specific comprehens ion s trategies , and navigational skills for electronic texts). C omprehension is also influenced by fe ature s of the text, including the genre (narration, description, expos ition, and pers uas ion), forms (textbooks , electronic texts , and multimedia documents), s urface code (s entence difficulty, vocabulary and s yntax), the propos itional text base units representing the mess age), and the content, including different types of mental models, cultures , socioeconomic s trata, as well as age-appropriatenes s the subject matter. Activity of re ading refers to the acts which the reader engages with a text. T his includes the purpos e for reading (s elf-generated, as in reading for pleas ure or reading to learn how to do s omething, and impos ed by others, as in reading to write a book report to prepare for a tes t), the operations involved in (e.g., reading words, reading fluently, extracting facts, generating inferences , and monitoring comprehension), and the cons equences of reading (e.g., learning new vocabulary, challenging the reader's previous ly held viewpoint, and drawing conclus ions about the writer's viewpoints and biases). R eading comprehens ion of increasing importance in the s chool curriculum from approximately fourth grade onward, when children are expected to re ad to le arn rather than le arn to re ad.

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R eading dis orde r is a diagnos tic term us ed for a developmental problem that is cognitively and behaviorally heterogeneous . It is characterized by an unexpected and s evere difficulty in the mastery of T he difficulties in learning to read are unexpected in relation to age and other cognitive and academic and cannot be attributed to a generalized disability, poor motivation, inadequate educational instruction, poor socioeconomic opportunity, or s ens ory impairment. T he reading difficulties are clinically significant, meaning that they interfere with academic, career, or life activities requiring literacy s kills . In clinical practice, the term re ading mas te ry is often interpreted solely in terms of difficulty acquiring bas ic re ading s kills (letter-sound knowledge, word and decoding single words ), giving little cons ideration re ading compre he ns ion. In part, the narrow res ults from an inadequately developed knowledge of critical factors underlying reading comprehens ion problems and inadequate tools for its as sess ment. Moreover, the medical and ps ychiatric definition of dis order is often complicated by criteria used to define eligibility for s pecial education services . T hus, a is necess ary to discus s the ongoing controversy federal government, s chool boards , clinicians , and scientis ts concerning the operational definition of dis order (and, more broadly, other types of learning disorders ).

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reading disorder and other types of learning dis orders have been strongly influenced by the federal definition le arning dis orde r adopted by the U.S . Office of 1969 and operationalized by the U.S . Office of 1977, to determine eligibility for s pecial education that must be provided by all of the public schools : S pecific learning dis ability means a dis orde r in one or of the bas ic ps ychological proce s s es involve d in unders tanding or in us ing language , s poke n or writte n, may manifes t itself in an imperfect ability to listen, speak, read, write, s pell, or do mathematical T he term includes s uch conditions as perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia, and developmental dysphas ia. T he term does include children who have learning problems which are primarily the res ult of visual, hearing, or motor of mental retardation, of emotional dis turbance, or of environmental, cultural, or economic disadvantage. T hree ess ential components are identified in the definition: (1) severe dis crepancy between and intellectual ability; (2) heterogeneity, meaning that learning disorder may manifest as a disorder in various academic domains (e.g., s peaking, listening, basic reading comprehension, mathematical calculations , mathematical reasoning, and written express ion); and exclusion, which indicates that learning dis order is not identified when the primary cause is mental retardation; emotional disturbance; s ens ory dis order; cultural, economic disadvantage; or inadequate instruction. Among the three criteria, the dis crepancy criterion is only the most controvers ial but is als o obsolete given current empirical data. P ublic Law 94-142 indicates 3774 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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designation of s pecific le arning dis ability s hould be only to those children with a severe discrepancy their potential for learning (as as sess ed by intelligence tes ts ) and their actual academic achievement and who not meet the s pecified exclus ionary criteria. C hildren do not dis play this discrepancy are not eligible for education. S pecifically, the federal definition (as well as medical definition provided by the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal [DS M-IV -T R ] and the tenth edition of the Inte rnational S tatis tical C las s ification of Dis eas es and R elated P roblems [IC D-10]) is based on the ass umption that individuals who manifes t a discrepancy between an intelligence tes t (intelligence quotient [IQ] scores ) an achievement tes t are qualitatively different, in terms cognitive s kills , res ponse to intervention, or neurobiological factors , from individuals with low achievement and comparably low IQ s cores (also s low le arne rs ). T his as sumption is challenged by a subs tantial body of empirical evidence. F or example, recent metaanalyses based on several hundred s tudies revealed that children who meet the IQachievement discrepancybas ed definition of reading disorder do not differ from those with low achievement that is not discrepant from their IQ in terms of core cognitive s kills clos ely related to reading proficiency (e.g., awarenes s). More importantly, there is no evidence or IQachievement discrepancy predicts respons e to intervention in terms of word recognition or prognosis terms of the development of bas ic reading process es . Moreover, although IQ has been found to be related to growth in reading comprehension, it is important to that the subtes ts making up the verbal IQ scale are 3775 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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commonly found to repres ent a general verbal comprehension factor, clos ely related to vocabulary. B ecaus e vocabulary is a component of IQ and a robus t correlate of reading comprehension, it is not s urpris ing that verbal IQ predicts reading comprehension. In IQ and IQachievement dis crepancy are not relevant for diagnosis or treatment planning for reading disorder (or other learning dis orders). T he heterogeneity criterion mandates (appropriately) multiple domains of achievement are as sess ed to determine eligibility for s pecial education s ervices . However, there is ins ufficient evidence to date to the distinctions between all of the s ubtypes of learning disorder s uggested by the federal definition, and it is unclear P.3109 whether all pos sible or critical types of learning are included. Moreover, the notion that a s ingle of learning dis order, bas ed on the presence of IQachievement dis crepancy and different exclus ionary criteria, can serve all of the learning disorders is inappropriate, becaus e it does take into cons ideration evidence of variations in cognitive correlates and intervention needs. S ome of the exclusionary factors in the federal learning disorder are reasonable, becaus e children mental retardation, s ens ory dis orders, or cultural and linguistic diversity may have different intervention T hese exclusionary factors s temmed from policy that involved the need to avoid the mixing of funds for special education vers us compens atory education and 3776 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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acknowledged the existence of other eligibility in Individuals with Disabilities E ducation Act (IDE A) to support children with s pecial needs , s uch as mental retardation or emotional disturbance. Moreover, thes e criteria were intended to class ify better the child's difficulties , on the ass umption that different are needed when the so-called primary caus e of the learning problem was economic disadvantage or emotional disturbance. However, in practice, the exclusionary criteria may serve to exclude children placement (e.g., culturally disadvantaged and thos e behavioral difficulties ). Moreover, some of the factors (e.g., s ocial or economic dis advantage) may factors intrinsic to the child (e.g., family history of disabilities). Other factors (e.g., behavioral difficulties) not be causal but rather reflect genetically mediated comorbid conditions in which the child has more than disability (e.g., approximately 30 to 70 percent of with reading disorder also have attentiondeficit/hyperactivity dis order [ADHD] or s evere conversely, 25 to 40 percent of children with ADHD criteria for reading dis order). B y contras t, the medical and ps ychiatric definition 35.1-1) requires evidence that the disturbance in the specific s kill produces s ignificant impairment in achievement or in activities of daily living that require skill and that the disturbance is not due primarily to specified disorders (e.g., phys ical or neurological pervas ive developmental dis order, or mental or inadequate educational opportunities . Underlying abnormalities in cognitive proces sing are cons idered to poss ible, but not invariant, features of learning 3777 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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(American P s ychiatric Ass ociation, 1987, 1994). T he medical definition als o requires evidence of a discrepancy between the individual's observed and potential level of achievement. Notably, the medical ps ychiatric definition emphasizes the handicap or education as pect of the reading problem, while us ing term dis order, which is us ed typically to imply a specific pathology and etiology. B y contrast, the federal and definition refers to dis abilitie s a term that typically emphasizes the handicap or education aspectbut a s pecific pathology (i.e., a disorder in one or more of basic ps ychological proces ses).

Table 35.1-1 DS M-IV-TR and IC DDiagnos tic C riteria for R eading Dis order DS M-IV-TR C riteria for 315.00 R eading Dis order

IC D-10 Diagnos tic C riteria for F81.0 S pec ific R eading Dis order

A. R eading achievement, as meas ured by individually adminis tered

A. E ither of the following must be present:

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standardized tes ts of reading accuracy or comprehension, is subs tantially below that expected given the person's chronological age, meas ured and age-appropriate education.

 

(1) A score on reading accuracy or comprehension, or both, that is at least two standard errors of prediction below the expected on the basis of the child's chronological age and general intelligence, with skills and IQ ass es sed an individually adminis tered tes t standardized for the child's culture and educational system.

B . T he disturbance in C riterion A

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interferes with academic or activities of daily living that require reading skills. C . If a s ens ory deficit present, the reading difficulties are in of thos e usually as sociated with it.

C oding note: If a general medical (e.g., neurological) or s ensory deficit is present, code the condition on Axis III.

 

 

   (2) A history of s erious reading difficulties , or scores that met C riterion A(1) at an earlier age, a s core on a s pelling that is at least two standard errors of prediction below the expected on the basis of the child's chronological age and IQ.

 

B . T he disturbance described in C riterion A significantly interferes with academic achievement or with

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activities of daily living that require reading  

C . T he disorder is not direct res ult of a defect visual or hearing acuity, or of a neurological disorder.

 

D. S chool experiences within the average expectable range (i.e., there have been no extreme inadequacies in educational

 

E . Mos t commonly used exclusion clause. IQ is below 70 in an individually adminis tered standardized tes t.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P s ychiatric Ass ociation; 2000; and W orld Health T he IC D-10 C las s ification of Me ntal and Dis orde rs : Diagnos tic C riteria for R es earch. World Health Organization; 1993, with 3781 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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HIS TOR Y A ND C OMP A R A TIVE NOS OL OG Y His torically, reading dis order was firs t noted in adults in the latter half of the 19th century (along with the term dys le xia us ed to refer to the clinical condition) and in children in 1896. T hese problems were viewed initially type of aphas ia. Over the next 100 years , a variety of were used to refer to the condition of specific reading problems , including re ading blindnes s , word blindne s s , dys le xia, congenital word blindne s s , s tre phos ymbolia, re ading dis ability, re ading dis ability, s pecific dis ability, une xpe cte d re ading failure , s pe cific re ading re tardation, and poor re ading. In the 1920s, the neurologist S amuel Orton postulated neurological bas is of the disorder, sugges ting that development of s pecialization of the left hemis phere for language was potentially causal. However, it was not the 1970s that an adequate knowledge bas e was es tablis hed that localized the difficulties at the s inglelevel and pinpointed the caus e, in most cas es , as based deficits in phonological process ing. More than a century after its initial des cription, the etiology, and treatment of dyslexia remains an iss ue of cons iderable controvers y. However, converging from behavioral, cognitive, and neuroimaging s tudies indicates that, in contrast to popular belief, individuals with reading dis order are not unus ually prone to s e eing letters or words backward. R ather, they have difficulty naming the letters , mapping the letter-sound corres pondence, and holding the s equence of letters and sounds in s hort-term memory while reading the whole word. 3782 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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P.3110 T hus, they might read s aw as was . C onverging from cross -cultural s tudies indicates that the core in reading dis order (at least for alphabetical languages ) linguis tic and not visual. T he firs t DS M des criptions of reading disorder (called de ve lopmental re ading dis orde r) occurred in the DS Mand the DS M-III-R under the general category of s kills dis order on Axis II. T he DS M-IV -T R now codes disorder as a learning dis order on Axis I. T here was no compelling logic for the coding s hift from Axis II to Axis but the shift may serve to render thes e impairing disorders more salient for diagnosticians , whos e practice focus es primarily on other types of mental problems . Most notable in the DS M-III-R definition was its that reading problems may manifes t as problems in accuracy, s peed, or comprehens ion. R ecognition of the multidimens ional nature of the dis order is als o reflected the current definitions of reading dis order in the DS MT R (re ading dis orde r) and the IC D-10 (s pecific re ading dis order). An important addition in the DS M-IV -T R description of the diagnostic features of reading the reference to s lowness and inaccuracy of comprehension in oral and s ilent reading, thereby acknowledging the developmental s hift from reading aloud to s ilent reading. However, the DS M definition not reflect the developmental s hift in manifes tation of reading disorder from childhood to adolescence and adulthood, as does the IC D-10. S pecifically, many adoles cents and adults with a clear his tory of reading 3783 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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disorder in childhood may develop compens atory strategies that enable them to recognize and to decode single words accurately and to comprehend factual information in short pass ages (requirements of mos t standardized tes t of comprehens ion), albeit s lowly and with effort. T ypically, their primary manifes tations slow but fairly accurate decoding of single words; continued spelling deficits that impair written poor comprehension, which often necess itates sentences and paragraphs and gives rise to problems extracting key points and making inferences ; and avoidance of activities that place heavy demands on reading, including reading for pleas ure or to obtain information. T hus , many adoles cents and adults with reading disorder may meet IC D-10 criteria but not T R diagnostic criteria. It is concerning that the DS M-IV -T R and IC D-10 continue to require evidence of a s ubstantial between scores on reading achievement tests (i.e., accuracy or comprehens ion) and meas ured B oth clas sification systems s pecify (in the text or in the definition its elf) that the magnitude of the discrepancy should be at leas t two s tandard deviations between achievement and IQ. Adherence to this dis crepancy requirement means that many individuals with reading disorder do not meet diagnostic criteria and thus may deemed ineligible for s pecial education s ervices and intervention programs . Accordingly, given the recent advances in the unders tanding of reading disorder and problems with the dis crepancy criterion, a of this res trictive criterion is warranted and s hould be incorporated into the next editions of the DS M and 3784 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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E P IDE MIOL OG Y R eading dis order is the most common and most studied of the learning disorders , affecting at leas t 90 percent of all individuals identified as having a learning disorder. It is es timated that two out of five children in special education are s o placed becaus e of reading difficulties . E pidemiological data indicate that reading disorder fits a dimensional model, like hypertension obesity. T hat is , it represents the lower tail of a normal distribution of reading ability. Its prevalence is cons ervatively es timated to range between 4 percent 10 percent in the general, school-aged population in United S tates , although rates as high as 17 percent been reported. S everal factors influence prevalence es timates, the geographical location, dis tribution, and age of the sample, how reading disorder is defined, and normal developmental and cros s -cultural variation in the rate early literacy acquisition. F or example, the rates of disorder are higher in inner city populations (e.g., approximately 6 percent vs . 3 percent in urban populations) and when reading dis order is defined by achievement only without reference to IQ (17 to 20 percent vs. 4 to 10 percent when an IQachievement discrepancy definition is us ed). Also, prevalence appear to vary around the world (e.g., rates of as high percent are reported in E nglis h-speaking countries ; 10 percent in S candinavian countries; 5 percent in and, reportedly, 1 percent in J apan and C hina). cross -linguistic research indicates that these variations prevalence partly reflect differences in the complexity the orthography, as well as in the relative emphas is 3785 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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to phonological vers us orthographic coding and to accuracy versus fluency of reading, or naming s peed. not surpris ingly, the s lowes t rates of acquisition of fundamentals and the highes t rates of reading disorder occur in countries with languages that have the orthographies (e.g., E ngland, F rance, and Denmark) lowest in countries with the s hallowes t orthographies (F inland, G reece, Italy, S pain, Norway, and G ermany). It is important to note that the preceding prevalence es timates refer typically to disorders in the acquis ition basic reading s kills rather than basic reading and comprehension. S ome studies s uggest that prevalence rates of reading disorder would be much higher if comprehension were included, because it has been es timated that approximately 10 percent of children experience s ignificant, s pecific, and unexpected with reading comprehension, despite having accurate fluent reading accuracy and good phonological skills . Als o, recent evidence (2002) indicates that 37 percent of fourth-grade s tudents and 25 percent of and 12th-grade s tudents in the United S tates cannot at the bas ic level, meaning that they cannot unders tand what they have read. It is generally believed that reading disorder affects boys than girls (e.g., three or four boys to every girl affected), but the iss ue of male vulnerability to reading disorder (and other neurodevelopmental disorders ) remains controversial. One sample s urvey of a selected population of children found s imilar rates of reading disorder in boys and girls and attributed the prevalence to an artifact of referral bias driven by more frequent behavior problems among boys . B y contras t, 3786 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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findings from recent, large-scale, epidemiological which are not reliant on clinical referral or special education services , reveal that reading disorder is common in boys as girls, irres pective of race, s everity disability, or exclus ion of children with attentional problems or high activity levels .

E TIOL OG Y C onverging evidence from cognitive, neuroimaging, genetic s tudies indicates that reading disorder is a neurobiological dis order with a genetic origin. It is to be related to a deficiency in a s pecific component of language system for proces sing s ounds of the s poken language. T his deficit, in turn, gives ris e to difficulties in decoding (reading) and coding (writing out or s pelling) written words. However, the precis e etiological mechanisms remain elus ive, despite remarkable over the past few years .

Neurologic al S ubs trate C onverging evidence from functional neuroimaging studies (e.g., functional magnetic res onance imaging [fMR I]) demonstrates that, when engaged in reading, individuals with serious reading problems show a brain activation profile that is uncommon among individuals who have never experienced reading problems . T ypically, adult readers of alphabetical languages activate three s ys tems in the left s ide of the brain during basic word reading: (1) an anterior s ys tem the left inferior P.3111

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frontal region, which activates during phoneme production (vocalizing words silently or out loud); (2) a temporoparietal s ys tem that is critical for analyzing the written word in terms of transforming the orthography into the underlying linguis tic structures (s yllables and phonemes ; linking letters and corresponding s ounds ); (3) a left occipitotemporal s ys tem that activates during automatic word recognition. B y contras t, individuals reading disorder demonstrate a relative underactivation both posterior systems (left temporoparietal and left occipitotemporal) and increased activation in the right temporal and temporoparietal region and inferior frontal gyrus . T hat is , a dis ruption occurs in specific parts of a widely dis tributed neural system relating s poken to the written word (temporoparietooccipital brain regions). T o compens ate, children and adults with disorder rely more heavily on right-sided posterior brain systems that process visual clues in the written (e.g., accompanying pictures and orthography) and left inferior frontal areas that are critical in articulation and may help develop an awarenes s of the s ound s tructure the word by forming the word with lips, tongue, and apparatus. It is poss ible that this pattern of relative underactivation of posterior areas coupled with relative overactivation of anterior areas may be a neural for phonological difficulties characterizing reading disorder. T hese neurobiological findings are cons istent with the current consensus that the central problem in reading disorder reflects a deficit within the language system.

Genetic Fac tors T hree converging lines of evidence (from family, twin, 3788 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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molecular genetic s tudies ) indicate the involvement of genetic factors in reading disorder. F amily studies that the ris k for reading disorder is s ignificantly greater among relatives of a proband with reading dis order in the general population. F or example, as much as 50 percent of children of parents with reading disorder, 50 percent of siblings of a child with reading disorder, and percent of parents of children with reading dis order have the disorder. T he knowledge that reading disorder runs in families provides clinicians with us eful opportunities for early identification of reading disorder younger s iblings and also for identification (albeit of affected adults. T win studies have reported high concordance rates heritability es timates for reading disorder and readingrelated abilities . F or example, genetic factors account 69 to 87 percent of individual differences on phoneme awarenes s, word recognition, phonological decoding, orthographic coding, with the remaining variance (13 to 30 percent) being explained by environmental factors. Moreover, some s tudies sugges t that orthographic is a partly independent and genetically influenced component s kills in word recognition. T hes e findings highlight the need to ass es s phonological and orthographic s kills and suggest that differential approaches to intervention may be required for children exhibiting deficits in only one s et of s kills versus those manifests deficits in both sets of s kills . Molecular genetic s tudies of reading dis order thus far indicate risk loci on s everal chromos omes, including 2, 15, and 18. T he most promising risk locus that has linked with reading disorder in the majority of studies 3789 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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spans the human leukocyte antigen (HLA) region of chromosome 6p21.3. No candidate genes for reading disorder have been identified to date; however, one study that us ed a combination of cytogenetic and genetic and population-genetic approaches has DY X1C 1 in chromos ome 15q21 as one candidate susceptibility gene for reading disorder. T his was bas ed on evidence that the dis ruption of DY XC 1 cosegregated with dys lexia in the family with the translocation. Notwithstanding the importance of this discovery, confirmation from other laboratories and in families from different populations s peaking different languages is required. Als o, given the evidence that genetic factors may have pleiotropic influences on disorder and ADHD, which frequently cooccur, it is neces sary to inves tigate whether the pleiotropic of DY XC 1 includes an ADHD or inattentive phenotype, well as reading disorder.

C ognitive Fac tors Diverse hypothes es exist for the underlying cognitive deficits in reading disorder, including the phonological deficit hypothes is (and its extension to double-deficit triple-deficit hypothes es ), the visual-magnocellular hypothes is, and cerebellar or general s ens orimotor dysfunction hypothesis.

P honologic al Theory Among the various models, the phonological deficit is most widely accepted. According to this model, the difficulty in reading disorder acros s languages and is a s pecific deficit in the repres entation, s torage, or 3790 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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retrieval of s peech s ounds, or a combination of these. phonological impairment hinders the learning of graphemephoneme corres pondences , which is the foundation of reading alphabetical languages, res ulting the obs erved behavioral deficits in s ingle-word reading. T hus, phonological theory pos tulates a straightforward between an underlying cognitive deficit and the behavioral problem to be explained. At the neurological level, the origin of reading disorder is ass umed to be a genetic or congenital dys function of left-hemis phere perisylvian brain areas that support phonological representation or the linking between phonological and orthographic repres entations. However, the critical but yet unres olved iss ue is whether a s poken language (phonological awarenes s) that is independent of the reading proces s can play a causal role in the reading. R elated models include the double-deficit hypothes is , which propos es that phonological and naming s peed deficits are two separable sources of reading failure. Naming s pe ed deficit refers to an unus ually s low rate in recognition and retrieval of the names of visually presented linguis tic material. T he combination of both types of deficit leads to a more profound form of disorder than the presence of only one type of deficit. addition of an orthographic deficit extends the doubledeficit model to a triple-deficit model. T he use of orthographic information alters the unit of perception by allowing readers to shift from process ing letters to letter sequences. Individuals with orthographic deficits have difficulty in recalling s ight words and are slow to fluency and automaticity but may be able to decode 3791 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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ps eudowords phonologically.

R apid A uditory P roc es s ing Theory T he rapid auditory proces sing model challenges the primacy of the phonological deficit by proposing that it secondary to a more bas ic auditory deficit in the perception of short or rapidly varying s ounds. S upport this theory comes from s tudies demonstrating that individuals with reading dis order perform poorly on auditory tasks (e.g., frequency dis crimination, temporal order judgment) and exhibit abnormal res ponses to various auditory s timuli. More recently, model has been extended to include perceptual deficits the proces sing of acous tic s tructure at the level of the syllable, which is bes t described as rhythm detection. involves detection of slow amplitude modulation of the speech waveform (amplitude envelope onset

C erebellar Theory T he claim is that dysfunction of the cerebellum in individuals with reading disorder gives rise to a range motoric and cognitive problems as sociated with F or example, the cerebellum is known to play a role in motor control and, therefore, in speech articulation, could lead to deficient phonological representations . the cerebellum plays a critical role in s pecific timing required for some aspects of P.3112 speech perception (e.g., dis tinguis hing between the medial s ounds in the words rapid and rabid). Moreover, cerebellum plays a role in the automatization of 3792 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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such as typing, driving, and reading. A weak capacity automatize would, for example, impair learning and fluency in grapheme-phoneme matching. B rain imaging studies have revealed anatomical, metabolic, and activation differences in the cerebellum of individuals reading disorder. Also, impairments in balance, time perception (a nonmotoric cerebellar tas k), and poor performance on a range of cerebellar motor tas ks have been reported in studies of individuals with reading disorder. However, many of these studies failed to for comorbid ADHD, which is als o as sociated with structural and functional cerebellar anomalies and problems in motor tas ks and time perception.

Vis ual/Magnoc ellular Theory V is ual perceptual and visual memory deficits have the most ubiquitous and influential theories of dys lexia. T he visual theory does not exclude a phonological but emphasizes a vis ual contribution to reading in some individuals with reading disorder. P ropos ed problems include uns table binocular fixations and poor visual tracking, abnormalities in perception of visual motion and in a trans ient visual s ys tem, and poor sens itivity. T he underlying biological mechanis m is postulated to be a disruption of the magnocellular pathway, which is one of two dis tinct pathways that different roles and properties: the parvocellular and magnocellular pathways. T he vis ual tracking theory been discredited, but the transient s ys tem and motion perception deficits, which are linked to functional anomalies in the magnocellular visual subsystem, further cons ideration. 3793 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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T he magnocellular theory, a generalization of the vis ual theory, propos es that the magnocellular dysfunction is res tricted to the vis ual pathways but is generalized to visual, auditory, and tactile modalities . B ecaus e the cerebellum receives mas sive input from various magnocellular s ys tems in the brain, it is als o believed affected by the general magnocellular defect. One suggestion is that deficits anywhere along the magnocellular pathway can affect the s patiotemporal gating functions that are ess ential for reading a text. C entral to this s cheme is the propos ition that a fas tpathway arising from magnocellular cells in the retina acting through an attentional mechanism has a gating function in s potlighting the individual letters or letter strings of a text in a sequential fashion. T he occurrence gating at the level of primary visual cortex is s upported recent physiological evidence concerning attentional mechanisms. On the one hand, this theory is unique in ability to account for all manifes tations of reading but, on the other hand, it is unable to explain the of sensory and motor dis orders in a s ignificant of individuals with reading disorder.

C L INIC A L FE A TUR E S , P R OB L E MS , A ND DIA G NOS IS C linic al Features T he defining feature of reading dis order at the level is a bas ic deficit in learning to decode print, which unexpected given the individual's general cognitive and education. T his problem in word identification is in most cas es , to more bas ic deficits in acquiring phonological analysis s kills and mastering the 3794 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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code. However, these deficits manifest a pattern and thus are apt to change across the life s pan. C ommon features of reading dis order at major developmental s tages are listed in T able 35.1-2.

Table 35.1-2 C ommon R is k for and S igns of R eading P res chool    Lack of interes t in playing games with language sounds (e.g., repetition and rhyming)    T rouble learning nurs ery rhymes    F requent use of baby talk and mis pronunciation words    F ailure to recognize letters in own name    T rouble remembering names of letters , or days of the week K indergarten    Unable to recognize and to write letters , to write own name, or to use invented s pelling

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   T rouble breaking down spoken words into (e.g., cowboy into cow and boy)    T rouble recognizing words that rhyme (e.g., cat, bat, and hat)    T rouble connecting letters with their s ounds letter b makes the s ound /b/)    Unable to recognize phonemes (e.g., does not know which of a set of words [e.g., dog, man, and car] s tarts with same sound as cat) P rimary grades (grades 13)    R eports of not doing well in s chool    C ontinues to have problems recognizing and manipulating phonemes    Unable to read common one-syllable words, as mat or top    R eading errors indicate problems in connecting sounds and letters (e.g., big for got)    Unable to recognize common irregularly s pelled words (e.g., s aid, two)    Difficulty s equencing numbers and letters 3796 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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   C omplains that reading is hard and avoids or refuses to do it Middle grades (grades 46)    Mis pronounces or skips parts of long, words (e.g., s ays conible for conve rtible or aminal animal)    C onfus es words that sound alike (e.g., tornado volcano)    T rouble remembering dates, names, and numbers    T rouble reading s mall function words (e.g., that, the , an, in)    G ets first part of word correct, then gues ses (e.g., reads clove r as clock)    P oor comprehens ion with or without s low, effortful, and inaccurate reading    T rouble completing homework or tests on time    T errible s pelling; poor and minimal written work    F ear of (refuses) reading aloud; avoids reading

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High school, college, and work    S low, effortful reading of single words and connected text    T rouble pronouncing multis yllable words    T errible s pelling    F requent need to reread material to unders tand to get the main point    T rouble making inferences from written text    Avoids activities that demand reading (reading pleas ure, reading ins tructions) G eneral    F irs t-degree relative (parents , s ibling) with reading disorder or his tory of reading disorder    S low in learning to talk

In the pres chool child, significant risk factors for disorder include a positive family history, a history of delayed onset of talking, not attending closely sounds of words (e.g., trouble playing rhyming games , confusing words that s ound alike, trouble learning to 3798 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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recognize and name letters of the alphabet, and linking the letters with their s ounds). In s chool-age children, typical pres enting problem concerns poor s chool performance (e.g., not doing well at schoolwe don't why). C linical investigation typically reveals a his tory of language delay, failure to learn letters in kindergarten failure to learn to read by the end of first grade. T he puzzling picture for many parents and teachers is that child appears intelligent and often succeeds in other as pects of the curriculum (e.g., oral discus sion, art, and geometry) that do not depend on fluent reading. many children may als o experience major difficulties in mathematics , particularly given recent curricular P.3113 changes that emphas ize word problems requiring mediation throughout all grade levels. In adolescence young adulthood, the clinical picture may shift to one of avoidance of reading, laborious and slow reading and writing, terrible spelling, and laborious and ineffective note taking, with failing grades in other aspects of the curriculum that depend on reading to learn. T hus, the es sential diagnostic criteria for reading disorder in adoles cents and adults are a history of phonologically based language difficulties plus current lack of automaticity in reading (s low and effortful reading), than inaccurate decoding. Another example subtypes on the bas is of the number of reading-related cognitive deficits (single, double, or triple deficits). C hildren with deficits in phonological coding and rapid serial naming (double deficits ) are generally from those with single deficits (in phonological 3799 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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or in rapid serial naming) in terms of severity but may exhibit a differential res ponse to treatment. S everal subtypes of reading dis order have been based on two frames of reference. One focus es on the reading problem itself and is based on hypothes es or models about the reading proces s. T he best exemplar this type is bas ed on the dual-route model of reading postulates two subtypes of reading disorder: s urface dyslexia and phonological dys lexia. S urface dys lexia manifests as a selective impairment in lexical and orthographic process ing and is characterized by specific difficulty in word recognition, particularly words . B y contras t, phonological dys lexia is ass ociated with a s pecific impairment in s ublexical procedures and characterized by deficits in decoding nonwords. most individuals with reading disorder are impaired in reading irregular words and nonwords compared to matched normal readers . T he second frame of reference considers reading as a manifes tation of a complex disorder involving multiple dimens ions of cognitive and related proces ses. S ubtypes are typically derived from clus ter analysis. exemplar of this approach identified s even s ubtypes of reading disorder; two of the s ubtypes manifest global deficits in language s kills ; four subtypes showed impairments in phonological awareness with variations verbal short-term memory and rapid serial naming of familiar vis ual stimuli, such as letters or digits; and the remaining subtype was characterized by deficits in proces sing s peed. T he firs t s ubtyping s cheme (dual-route s ubtypes) is partially s upported by external validation data, 3800 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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preliminary evidence of electrocortical differences in res ponse to irregular words and nonwords, as well as evidence that the genetic contribution to the reading deficit is much greater in the phonological dys lexics in the surface dyslexics . V alidation of the subtypes from clus ter analys is is limited, but there is s ome that the subtypes may differ in treatment res ponse. F or example, children with only linguistic deficits or mixed linguistic and vis ual-memory deficits res pond poorly to phonological intervention. However, currently, the subtyping s chemes lack adequate validation to be from a clinical perspective.

As s oc iated Problems F rom a clinical pers pective, it is us eful to note that problems (and reading dis order) are common in ps ychiatric disorders, particularly in ADHD and conduct disorders . F or example, epidemiological and clinical studies sugges t that the overlap between reading and ADHD is greater than expected by chance. F or example, as much as 40 percent of children with ADHD also meet diagnostic criteria for reading disorder, but major link appears to be between the inattention dimension of ADHD and reading dis order. Als o, epidemiological s tudies indicate that approximately 30 50 percent of individuals in juvenile or adult jus tice systems have learning disabilities , particularly reading disorder. Moreover, reading disorder is widely with affective dis orders, particularly depres sion. evidence indicates high rates of depress ive moods and feelings of lack of control and poor s elf-es teem among learning-disabled school populations , most of whom reading disorder. R eading disorder also cooccurs with 3801 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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other learning dis orders, including mathematics disorder of written expres sion, and communication disorders (primarily with mixed receptive-expres sive language disorder), as well as developmental disorder. F rom a clinical pers pective, it is helpful to recall that, approximately 500 years ago, reading was a relatively and unders ubs cribed s kill, restricted to monks and a group of scholars . It was the advent of the printing that permitted reading to become a more universal of information exchange. R apid technological advances and cultural developments have rendered the acquisition of literacy skills a prerequisite in civilized countries , with the inference that thos e who cannot or cannot read well are somewhat less er or inferior beings . T hus , a diagnos is of reading disorder may still a s tigma and may invoke a negative connotation of intellectual ability and poor attitude (lazines s and oppos ition), despite the publicized succes s s tories of famous people with dyslexia (T homas E dison, Agatha C hris tie, and T om C ruise, to name a few).

C riteria for Diagnos is R eading dis order is a clinical diagnos is , based on a synthes is of clinical information from multiple s ources , including developmental history, school reports , observation, and direct psychometric as ses sment. T he difficulties in reading are unexpected for the person's level of education, and cognitive abilities. C urrently, neuroimaging methods are not us eful for clinical diagnosis. As indicated in T able 35.1-1, DS M-IV -T R explicitly that the diagnos is requires the us e of 3802 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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adminis tered tes ts of reading accuracy or T he current wording in DS M-IV -T R also implies that a meas ure of intelligence is required for a diagnosis of reading disorder, but, as discus sed previous ly, IQ are not relevant to the diagnosis, given at least intellectual abilities . Although primary care physicians may be able to for reading disorder by listening to the individual read aloud from an age-appropriate text, diagnosis of disorder does require psychological evaluation by providers . One of the bes t meas ures of bas ic readingrelated skills (e.g., phonological awarenes s, coding, working memory, and rapid naming) is the C omprehens ive T es t of P honological P rocess ing which is designed and s tandardized for children from 5 years of age to young adulthood. Ass ess ment of the accuracy of decoding s ingle words and ps eudowords is es sential as sess ment component for school-aged Widely us ed measures of this ability include the Woodcock-J ohns on III (W J III) T es ts of Achievement Woodcock-J ohns on R eading Mas tery T es t. However, adoles cents and adults , it is must be emphas ized that most common error in the diagnos is of reading disorder the failure to recognize or to measure the lack of automaticity in reading. T he s ole use of tests relying on accuracy of word identification is inappropriate for diagnosing reading disorder in adolescents and adults. T hus, it is es sential to include a measure of singlereading efficiency, such as the T est of Word R eading E fficiency (T OW R E ), which requires s peeded and naming of single words and ps eudowords. R eading fluency and comprehens ion (i.e., rate of reading 3803 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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text for meaning) s hould als o be as ses sed in and young adults , us ing meas ures such as the G ray R eading T es t, Nelson-Denny R eading T est, or the S ilent R eading T est. However, it is important to P.3114 unders tand that neither these nor the majority of the widely us ed meas ures of the comprehens ion provide a sens itive or effective evaluation of the ability to read expos itory texts for meaningwhich is the primary in high s chool, the univers ity, and the workplace. T hus, scores on these reading comprehens ion tes ts may not adequately reflect the functional problems encountered on a daily basis by adolescents and adults with reading disorder. J . B . was an 11-year-old boy who was referred for evaluation of increasing problems at school, including failing to complete in-clas s as signments and failing tests in reading, spelling, and arithmetic; clas ses ; and s ome truancy. F or the past 2 years and 6), he had been attending a special education every morning in the local community school, based on placement recommendations from a prior as ses sment when he was in grade 2. At that time, he did not meet DS M-IV -T R criteria for any externalizing disorder but not doing well in s chool, and a s pecific learning was queried. A s ubs equent psychoeducational by a clinical ps ychologist confirmed reading problems , he did not meet the s chool board's criteria for learning disorder, which was bas ed on IQachievement T hus, he was not eligible for s pecial education 3804 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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change in the following year in the s chool board's regarding the need for a discrepancy-based definition learning disorder meant that J . B . was now eligible for special education, whereupon he started attending the half-day program. He was in a class with eight other students ranging from 6 to 12 years of age. C linical interview with his parents revealed a normal pregnancy but a his tory of language delay. In and kindergarten, he was reported to have had with rhyming games and s howed a marked lack of in books and preferred to play with cons truction toys. In the primary grades , he had more difficulty learning to than other boys in his clas s and continued to have problems pronouncing multisyllabic words (e.g., he aminals for animals and sblanation for explanation). history was positive for reading disorder and ADHD. S pecifically, J . B .'s father admitted a his tory of reading problems but commented that, although he s till cannot read too well (and never for pleas ure), he runs a business . T he older brother, 15 years of age, had which was responding fairly well to stimulant T he parents' main concern was that J . B . seemed to be getting just like his brother and not focus ing on school work, and they queried whether he als o had ADHD. In clinical interview with J . B ., it was noted that he rarely made eye contact with the clinician, mumbled a lot, and struggled to find the right word (e.g., manifes ted many false starts, hes itations, and nons pecific terms , s uch as thing that you draw um pencilno um lines with). He admitted to s kipping clas s and s ometimes school, the comment: R eading is boring and s tupidI'd rather be cycling. He also complained about the amount of 3805 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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he had to doeven in mathand commented R eading so much time. B y the time I figure out a word, I can't member what I just read and so have to read the stuff again. P sychological and psychoeducational ass es sment the W echs ler Intelligence S cale for C hildren-IV , C linical E valuation of Language F undamentals -IV (C E LF -IV ), Wechs ler Individual Achievement T est-II, and s elfof anxiety, depres sion, and self-es teem. R esults low-average verbal and above average performance poor word attack and word identification s kills (below percentile), poor comprehension (below ninth poor s pelling (below s ixth percentile), weak comprehension of oral language (below 16th elevated but subthres hold s cores on the C hildren's Depress ion Inventory, and low s elf-es teem. Although J . manifested s everal marked symptoms of inattention, res tless nes s, and oppositional behavior (particularly at school), he did not meet criteria for ADHD or any other internalizing or externalizing dis order. However, he did meet DS M-IV -T R criteria for reading disorder and receptive-expres sive language disorders . C omparison res ults from the previous ps ychoeducational revealed that, although he had made s ome small had not clos ed the gap between his reading s kills and those of his peers , despite being in s pecial education years . R ecommendations included continuation in education plus attendance at a s ummer camp in children with reading disorder, as well as ongoing monitoring of self-es teem and depres sive traits. At 1-year follow-up, J . B . and his parents reported improvements in his reading, overall school 3806 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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mood, and self-es teem, which they attributed to the specialized instruction provided during the summer T he program had provided one-on-one focus ed and explicit instruction for 1 hour a day for a total of 70 J . B . explained that he had been taught a s et of decoding strategies to use in a systematic way (like a plan) and challenged the clinician to give him a really tough long word to read. He demons trated the that he us ed to read the word unconditionally and also explained what it meant. T o boost his fluency in and reading comprehension, the clinical team recommended the use of repeated reading, reading with audio taped (unabridged) versions of his favorite books , us e of graphic organizers to facilitate reading comprehension, and further participation in the summer camp reading program.

DIF FE R E NTIA L DIA G NOS IS A diagnosis of reading disorder is not us ually made the child is approximately 6 or 7 years of age, because evidence of failure to learn to read is required. Mental retardation, developmental coordination dis order, other learning disorders , communication disorders, ADHD, conduct dis order, hearing or vis ual problems , and prematurity are all as sociated with difficulties in When reading disorder cooccurs with disorder of expres sion or mathematics dis order, or both, then disorder s hould be diagnosed as a learning dis order otherwis e s pecified (T able 35.1-1). In a child with visual hearing deficits , the reading problems mus t be in the difficulty typically ass ociated with these sensory disorders . R eading disorder is frequently as sociated 3807 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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ADHD. A concurrent diagnosis is permiss ible, but needed to confirm that the symptoms of ADHD do not occur solely during reading contexts at home and (e.g., only during homework or only until the teacher read the written instructions to the child, but not while child is working). Inadequate ins truction as the primary explanation for reading problems may be able to be determined detailed interview with parents and teachers . P robes the number of s chools attended, abs enteeis m owing to illnes s or vacation; required owing to class or school s us pensions and expulsions ), and type of instruction provided at the s chools in the primary may be informative. However, differential diagnos is be complicated by parental history or current manifestation of reading dis order, because parents reading disorder would be less likely to be able to the neces sary early reading experiences for the child.

C OUR S E A ND P R OG NOS IS R is k factors for reading disorder may be evident in the few days of life. F or example, electrophys iological of newborn infants with P.3115 and without familial risk for reading disorder have marked differences in the event-related brain response speech s ounds in the high-ris k group (e.g., increased activity in right hemisphere). Notably, infants with and without risk for reading dis order typically do not differ meas ures of gros s motor and cognitive development, do they necess arily exhibit early language impairments 3808 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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meas ured by some s tandardized tes ts. R ather, late talking and s horter-than-expected s entence length at 2 years of age appear to be the first language markers of for reading dis order. However, prospective studies of children with familial ris k for reading disorder reveal although children born into families with reading have an increased risk for literacy problems , the risk is continuous, and the behavioral manifes tations of the disorder vary, depending on the extent to which skills beyond phonology are affected. S ymptoms of reading dis order may be evident as early years of age (e.g., inability to distinguish among and to name common letters and inability to link phoneme printed letter). However, referral and formal diagnosis rarely occur until a couple of years later, in s econd when the children have failed to respond to formal clas sroom ins truction in reading. R eading disorder is a persis tent and chronic condition that remains with the individual for his or her entire life. P roblems in bas ic reading abilities , s uch as phonological coding, typically persis t into adulthood, at which time the problems are manifest primarily in terms of speed rather than of decoding single words and pseudowords. R eading disorder does not represent a developmental lag: good and poor readers tend to maintain their relative positions along the spectrum of reading ability over (and, in s ome cases , despite the provision of s pecial education or s pecific intervention programs). Y oung with pers is tent problems in reading accuracy and appear to develop compensatory mechanis ms to cope with reading, such as the greater reliance on memorybased strategies rather than analytical strategies to 3809 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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in word identification. T he clinical cours e of reading dis order is often further by comorbidity with other mental health such as ADHD and conduct dis order, as well as low es teem, anxiety, and depres sion. T he caus al between reading problems and the various comorbid disorders are unknown, and exis ting longitudinal epidemiological s tudies sugges t that the relations hips complex. F or example, two large-scale epidemiological studies in Aus tralia and New Zealand revealed dual developmental pathways to reading problems in adoles cence. One pathway s tarted from early reading difficulties and progres sed to continuing reading and attention difficulties in high s chool, as well as school with no qualifications, even after controlling for early cooccurring s ymptoms of ADHD. T he other started from early s ymptoms of ADHD (particularly inattention), which progress ed to ongoing s chool difficulties and problems with reading, as well as inattention in adoles cence. A s imilar developmental trajectory from inattention in kindergarten to reading problems in grade 5 (after controlling for hyperactivity, emotional problems , IQ, and first-grade reading level) also revealed in a U.S . community s ample of children followed longitudinally. C onversely, a recent C anadian longitudinal s tudy reported that low reading at school entry increas ed the risk of pers is tent conduct problems 30 months later, even after controlling for income, maternal depres sion, family functioning, conduct disorder s ymptoms , and gender. Moreover, on an odds ratio analysis, the investigators s uggested intervention programs des igned to improve literacy 3810 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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may result in a 20 percent reduction in the risk for later conduct problems .

TR E A TME NT Multiple consensus reports provide convincing about the nature of effective instruction for s tudents at for reading problems as a res ult of reading dis order or economic disadvantage. C ritical features include an effective and knowledgeable teacher, integration of key instructional components in the primary grade differentiated ins truction for s tudents with reading disorder, explicitness of ins truction (es sential for thos e with reading dis order), and s trategies for bridging the between research and practice. Ins tructional components mus t focus on phonemic awarenes s and the alphabetical principle, reading by mapping s peech sounds to parts of words, reading words rapidly, developing an understanding of word meanings , achieving fluency in reading connected text, and building comprehens ion through the development concepts , background knowledge, vocabulary, and the application of comprehension strategies (summarizing, predicting, and monitoring). E xplicit instruction that directs the s tudent's attention to the s ound structure of oral language and to the connections between speech sounds and s pelling is es sential to build the early foundations. E xplicit instruction requires the teacher to model and to teach s kills and concepts , rather than on whole word ins truction, learning through discovery, requiring the s tudent to draw inferences that might be challenging and confus ing in students with reading disorder. Moreover, growing evidence indicates the 3811 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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to include instructional components aimed at self-regulation s trategies for paying attention to verbal instruction. Notably, recent evidence s uggests that and focus ed ins truction that promotes the development phonological awarenes s and decoding s kills may, in induce s ignificant changes in the aberrant brain profiles observed in children with reading disorder. Moreover, the changes appear durable in that, at 1 after intervention, the children's brain activation res embled those of normal models. One of the major problems is that the s tandard in regular class rooms is too little, too general, and nonsystematic. F or example, one large-scale s tudy that children receiving special education over a 1-year period advanced in reading by only 0.04 s tandard deviations per year, which means that it would take at least 8 years to rais e these students' s cores from the percentile to the ninth percentile. B y contras t, s tudents with reading disorder, who received 1 to 2 hours daily intens e and focused intervention for a total of 35 to 70 hours ins truction, s howed dramatic gains in on standardized measures of decoding and comprehension, which were maintained for s everal after intervention. T he ins truction programs were and visible, were conducted in s mall interactive groups children matched for reading abilities that promoted engaged and repeated reading of connected text, were presented in a way that controlled tas k difficulty, and included ins truction in bas ic reading abilities (e.g., teaching phoneme-to-grapheme correspondences), as well as the application of metacognitive strategies for decoding unfamiliar words and comprehending 3812 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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connected text. T hus , clinicians need to be aware that recommendations for placement in s pecial education not be sufficient to improve reading skills. R ather, they need to advocate for the provision of intens e, focused, explicit reading instruction. T he use of as sistive should be cons idered for older adolescents and adults with heavy reading demands. T ext-to-speech s oftware programs, such as K urzweil 3000, allow text to be into the computer, convert the text into audible sound, and then read the text aloud.

S UG G E S TE D C R OS S R eceptive and expres sive language impairments are discuss ed under communication disorders in S ections 37.2, and 37.3. Mental retardation P.3116 is the focus of C hapter 34, attention-deficit disorders the focus of C hapter 39, and anxiety disorders are the focus of C hapter 14.

R E F E R E NC E S Aylward E H, R ichards T L, B erninger V W , Nagy W E , K M, G rimme AC , R ichards AL, T homson J B , Ins tructional treatment as sociated with changes in brain activation in children with dyslexia. Neurology. 2003;61:212219. B ennett K J , B rown K S , B oyle M, R acine Y , Offord D: low reading achievement at s chool entry cause problems ? S oc S ci Me d. 2003;56:243248. 3813 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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B reier J I, S imos P G , F letcher J M, C astillo E M, P apanicolaou AC : Abnormal activation of temporoparietal language areas during phonetic analysis in children with dys lexia. Neurops ychology. 2003;17:112. C as tles A, C oltheart M: Is there a causal link from phonological awarenes s to s ucces s in learning to C ognition. 2004;91:77111. Denton C A, V aighn S , F letcher J M: B ringing based practice in reading intervention to s cale. Dis abil R es P ract. 2003;18:201211. F letcher J M, F oorman B R , B oudous quie A, B arnes S catschneider C , F rancis DJ : Ass es sment of learning disabilities: A res earch-based interventionoriented approach. J S chool P s ychol. 2002;40:2763. F letcher J M, F rancis DJ , R ourke B P , S haywitz S E , S haywitz B A: T he validity of dis crepancy-based definitions of reading disabilities. J L earn Dis abil. 1992;25:555573. F oorman B R , B reier J I, F letcher J M: Interventions at improving reading success : An evidence-based approach. Dev Ne urops ychol. 2003;24:613639. G ayn J , Olson R K : G enetic and environmental on individual differences in printed word recognition. E xp C hild P s ychol. 2003;84:97123. 3814 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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G oswami U, T homps on J , R ichardson U, S tainthorp Hughes D, R osen S , S cott S K : Amplitude envelope onsets and developmental dyslexia: A new P roc Natl Acad S ci U S A. 2002;99:1091110916. *G rigorenko E L: Developmental dys lexia: An update genes , brains , and environments . J C hild P s ychol P s ychiatry. 2000;42;91125. Hecker L, B urns L, E lkind J , E lkind K , K atz L: as sistive reading software for students with attention disorders . Ann Dys lexia. 2002;52:263272. Ho C S -H, C han DW -O, Lee S -H, T s ang S -M, Luan C ognitive profiling and preliminary s ubtyping in C hines e developmental dys lexia. C ognition. 2003;91:4375. Hos kyn M, S wans on HL: C ognitive process ing of achievers and children with reading dis abilities: A selective meta-analytic review of the published literature. S chool P s ychiatr R ev. 2000;29:102119. Loo S K , F isher S E , F rancks C , Ogdie MN, MacP hie Y ang M, McK racken J T , McG ough J J , Nelson S F , AP , S malley S L: G enome-wide s can of reading affected s ibling pairs with attentiondeficit/hyperactivity dis order: Unique and s hared genetic effects. Mol P s ychiatry. 2003;18:19. McG ee R , P rior M, W illiams S , S mart D, S ans on A: long-term s ignificance of teacher-rated hyperactivity 3815 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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and reading ability in childhood: F indings from two longitudinal studies. J C hild P s ychol P s ychiatry. 2002;43:10041017. Molfese DC : P redicting dyslexia at 8 years of age neonatal brain res pons es . B rain L ang. 2000;72 National R eading P anel. R eport of the National P ane l: T e aching S tudents to R e ad: An E vide nce As s es s ment of the S cientific R e s earch L ite rature on R eading and Its Implications for R e ading Ins truction: R eports of the S ubgroups . B ethes da, MD: National Ins titutes of C hild Health and Human Development, National Ins titutes of Health; 2000. P apanicolaou AC , S imos P G , F letcher J M, F oorman F rancis D, C astillo E M, Davis R N: B rain reading in children with and without dyslexia: A of studies of normal development and plas ticity. Dev Neurops ychol. 2003;24:593612. P aules u E , Demonet J F , F azio F , McC rory E , B runswick N: Dyslexia: C ultural diversity and unity. S cience. 2001;291:21652167. P ub L No. 94-142. F e deral R egis te r. 65083 1977;42:4247542679. R amus F : Developmental dyslexia: S pecific deficit or general sensorimotor dys function? C urr Neurobiol. 2003;13:212218.

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R and R eading S tudy G roup. R eading for S anta Monica, C A: R AND; 2002. *R utter M, C aspi A, F ergus on D, Horwood LJ , R , Maughan B , Moffitt T E , Meltzer H, C arroll J : S ex differences in developmental reading disability: New findings from 4 epidemiological s tudies . J AMA. 2004;291:20072012. S eymour P H, Aro M, E rs kine J M: F oundation acquisition in E uropean orthographies . B r J P s ychol. 2003;94:143174. *S haywitz B A, S haywitz S E , B lachman B A, P ugh F ulbright R V , S kudlars ki P , Menel WE , C onstable Holahan J M, Marchione K E , F letcher J M, Lyon G R , J C : Development of left occipitotemporal systems skilled reading in children after a phonologically intervention. B iol P s ychiatry. 2004;55:926933. S haywitz S E , E s cobar MD, S haywitz B A, F letcher Makuch R : E vidence that dys lexia may repres ent lower tail of a normal distribution of reading ability. N E ngl J Me d. 1992;326:145150. S haywitz S E , S haywitz B A: Dyslexia (s pecific disability). P ediatr R e v. 2003;24:147153. *S haywitz S E , S haywitz B A: T he s cience of reading dyslexia. J AAP O S . 2003;7:158166. S haywitz S E , S haywitz B A, F letcher J M, E s cobar 3817 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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P revalence of reading dis ability in boys and girls. R es ults of the C onnecticut Longitudinal S tudy. 1990;264:9981002. S nowling MJ , G allagher A, F rith U: F amily ris k of is continuous: Individual differences in the reading s kill. C hild De v. 2003;74:358373. S pencer LH, Hanley J R : E ffects of orthographic transparency on reading and phoneme awarenes s children learning to read in W ales . B r J P s ychol. 2003;94:128. *S tuebing K K , F letcher J M, LeDoux J M, Lyon G R , S haywitz S E , S haywitz B A: V alidity of IQclas sifications of reading disabilities: A metaAm E duc R es J . 2002;39:469518. T aipale M, K aminen N, Noploa-Hemmi J , Haltia T , Myllyluoma B , Lyytinen H: A candidate gene for developmental dys lexia encodes a nuclear tetratricopeptide repeat domain protein dynamically regulated in brain. P roc Natl Acad S ci U S A. 2003;100:1155311558. V idyas agar T R : Neural underpinnings of dyslexia as disorder of visuo-spatial attention. C lin E xp O ptom. 2004;87:410. Y uill N, Oakhill J V . C hildre n's P roblems in T e xt C omprehe ns ion. C ambridge, UK : C ambridge P res s; 1991. 3818 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/35.1.htm

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Ziegler J C , P erry C , Ma-Wyatt A, Ladner D, S chulteG : Developmental dyslexia in different languages : Language-specific or univers al? J E xp C hild 2003;86:169193.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order Motor S kills Dis order: Developmental C oordination Dis order

36 Motor S kills Dis order: Developmental Dis order C aroly S . Pataki M.D. S arah J . S pence M.D., Ph.D. C hildren exhibiting developmental coordination struggle with daily motor activities in which other of the same age s how proficiency, s uch as jumping, hopping, or running, and agonize to perform fine motor skills , such as writing letters , tying their s hoelaces, or utens ils . C hildren with any of thes e difficulties are often referred to as clums y. S ome form of coordination affects as much as approximately 6 percent of schoolchildren. Although motor coordination difficulties can occur in the abs ence of any other disorders , they often emerge along with another learning dis order, such as a communication dis order, or a disorder of written expres sion. Michael E . S pagna, Dennis P . C antwell, Lorian B aker devoted a significant portion of their to the study of these comorbid dis orders, and many of their insights and conclus ions are included in this 

DE F INIT ION 3820

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

HIS T OR Y

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C OMP AR AT IV E NOS OLOG Y

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E P IDE MIOLOG Y

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E T IOLOG Y



DIAG NOS IS AND C LINIC AL F E AT UR E S

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C OUR S E AND P R OG NOS IS

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T R E AT ME NT

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S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order DE F INIT IO N

DE FINITION P art of "36 - Motor S kills Dis order: Developmental C oordination Dis order" T he es sential feature of developmental coordination disorder, according to the revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs IV -T R ), is less proficient motor coordination than what expected for an individual of a given chronological age and intellectual level, causing impairment in academic achievement or activities of daily living. E xamples of common symptoms of motor coordination dis order include marked delays in achieving motor milestones , as walking, crawling, and s itting; constantly dropping objects; and poor handwriting, in the abs ence of other pervas ive developmental delays or medical conditions 3821 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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would account for the motor problems. C hildren with developmental coordination disorder perform motor coordination tasks at levels markedly below thos e of of the same chronological age and intellectual capacity. S pecific manifes tations of the dis order are des cribed in T able 36-1. T he definition of de ve lopmental dis order s pecifies that the motor difficulties are not due a general medical condition, s uch as cerebral pals y, hemiplegia, or muscular dystrophy, and it is not in the pres ence of a diagnos is of a pervas ive developmental disorder.

Table 36-1 Manifes tations of Developmental C oordination Dis order G ross motor manifes tations    P reschool age       Delays in reaching motor milestones , such as sitting, crawling, and walking       B alance problems : falling, getting bruis ed frequently, and poor toddling       Abnormal gait

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      K nocking over objects , bumping into things, destructiveness    P rimary-school age       Difficulty with riding bikes , s kipping, hopping, running, jumping, and doing s omersaults       Awkward or abnormal gait    Older       P oor at s ports, throwing, catching, kicking, hitting a ball F ine motor manifestations    P reschool age       Difficulty learning dres sing s kills (tying, zipping, and buttoning)       Difficulty learning feeding s kills (handling fork, or spoon)    P rimary-school age       Difficulty as sembling jigsaw pieces , using building with blocks , drawing, or tracing

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   Older       Difficulty with grooming (putting on makeup, blow-drying hair, and doing nails )       Mess y or illegible writing       Difficulty us ing hand tools, s ewing, and piano

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order HIS T O R Y

HIS TOR Y P art of "36 - Motor S kills Dis order: Developmental C oordination Dis order" T he signs and s ymptoms of developmental disorder were not identified as an entity until the early 1900s . B efore that time, movement abnormalities, particularly abnormal motor movements , were within the medical profess ion as a part of neurological disorders . In 1911, motor s igns of clumsines s were documented under the terminology of motor de ficie ncy s yndrome . T his syndrome was characterized by voluntary actions , exces sive tendon reflexes , mild hypertonicity, and neurological overflow movement. 3824 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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this s yndrome was identified, investigation of motor coordination behaviors in children continued through systematic observation of reasonably complex motor given to children systematically. B y the early 1920s , as sess ment instruments were developed to evaluate motor awkwardness in children; most influential device was created in 1922 at the Neurological Institute. T he term clums y child s yndrome appeared in the literature in the 1930s to describe a set symptoms ass ociated with clums y motor behaviors that did not res ult from overt neurological damage. T he observation was made that many children with motor coordination difficulties als o exhibited other forms of learning disorders . During the 1940s , remedial were established in an attempt to correct and to academic learning through treatment of coordination difficulties obs erved in children. In the 1960s, the clums y child s yndrome was officially distinguished from other categories of learning F rom this period to the mid-1980s , significant inves tigations were conducted into pos sible perceptualsens ory causes for motor impairments , as well as and emotional problems as sociated with s uch impairments . Over the pas t decade, s cholars have to inves tigate the presence of s everal subsyndromes, suggesting that clumsines s might be a condition warranting syndrome-specific intervention remedial programs . C urrently, children who exhibit clums y behavior are to have delayed development in fine and gross motor coordination skills. T he motor s kills of clums y children to be imprecise or mildly affected rather than gross ly 3825 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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impaired. In addition, clumsy children tend to have problems in peer relations hips and s ocial adjustments frequently experience language and other learning difficulties . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order C OMP AR AT IV E NO S O LOG Y

C OMPAR ATIVE P art of "36 - Motor S kills Dis order: Developmental C oordination Dis order" Many different terms have been applied to the of clums ines s in a child. T erms us ed in the past that with a description of developmental coordination include conge nital maladroitne s s , choreiform ps ychomotor s yndrome , de ve lopmental apraxia, de ve lopmental dys praxia, congenital clums ine s s , de ve lopmental agnos ia, and de ve lopmental dys praxiadys gnos ia. It is only appropriate to make a diagnos is of developmental coordination disorder after any of a neurological disorder is ruled out. In the DS M-IV is specified that developmental coordination disorder cannot be diagnos ed when a general medical for example, cerebral palsy or any other neurological disorder, can P.3131 better account for the impaired coordination. Although, currently, this s yndrome is s till occas ionally referred to clums y child s yndrome , de velopme ntal coordination 3826 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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and s pecific de ve lopmental dis orde r of motor function more appropriate terms . T he disorder was not included in the third edition of the DS M (DS M-III) as a s eparate s yndrome, although coordination problems were noted as common features for most of the childhood developmental disorders . Developmental coordination disorder has included as a s eparate diagnosis in the revis ed third edition of the DS M (DS M-III-R ) and appears in the same form in the fourth edition of the DS M (DS MT he tenth edition of the Inte rnational S tatis tical C las s ification of Dis eas es and R elated He alth 10) als o includes the disorder, but the slightly more formalized definition requires an intelligence quotient of at least 70 and performance at least two s tandard deviations below the mean on a s tandardized tes t of motor coordination. Although DS M-IV -T R and IC D-10 view the dis order as unitary undifferentiated s yndrome, s everal inves tigators have sugges ted that there may actually be several subtypes . S upporting that view is the interindividual variation in s ymptomatology, only s ome of which is age related. One recent attempt to subclas sify developmental coordination disorder propos ed such as ataxic syndrome (marked by uns teadiness and mild tremors ), hypotonic s yndrome (characterized by below-average res ting muscle tone), tens ion syndrome (manifested by cons tant and excess ively high levels of muscle tone), dyspraxic s yndrome (identified by the inability to chain together a series of s ubmovements neces sary to execute s mooth motor movements), graphic s yndromes (two s eparate manual s yndromes , 3827 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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marked by inadequate dexterity but adequate ability to reproduce written symbols and the other characterized adequate dexterity but inability to reproduce written symbols accurately using fine motor movements), perceptual clumsiness (ranging from ocular-motor problems involving inefficient movement of eye to severe retinal deterioration), and mixed s yndromes combination of s ymptoms already pres ented under the aegis of the previous s ix class ifications ). It is always important to keep in mind that s ignificant ataxia, hypotonia, or any asymmetry between left and right muscle function may be an indicator of a neurological disorder and requires a neurological ass es sment. T R clas sifies developmental coordination disorder as only motor s kills disorder. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order E P IDE MIOLO G Y

E PIDE MIOL OGY P art of "36 - Motor S kills Dis order: Developmental C oordination Dis order" T he prevalence of developmental coordination dis order has been es timated to be as high as 6 percent of between 5 years of age and 11 years of age. Developmental coordination dis order has been noted in E urope, As ia, Africa, Aus tralia, and North America. Although many learning disorders have been as sumed occur more frequently in boys, two recent studies that the prevalence figures for developmental 3828 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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coordination dis order are the s ame for male and children. Discrepancies between thes e findings and es timates of gender differences have been attributed to number of causes . One major contributing caus e is the trend for schools to refer more boys than girls for evaluations for s pecial education often triggered by disruptive behavior that is more commonly exhibited by male school-aged children, so more boys are receiving tes ting and, in the proces s, are identified with difficulties . Additionally, there are greater s ocietal press ures for boys to excel at physical tasks at earlier than girls , which may lower the threshold for a boy to identified as having developmental coordination E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order E T IO LOG Y

E TIOL OGY P art of "36 - Motor S kills Dis order: Developmental C oordination Dis order" T he caus es of developmental coordination disorder are not s pecifically known. S cientific s tudies yield evidence support hypothes es that prenatal and perinatal factors may increas e risk of this dis order. E vidence indicates biological-organic and cognitivedevelopmental correlates of developmental disorder. T he biological-organic factors ass ociated with disorder include various birth and perinatal problems , as low birth weight, prematurity, hypoxia, and neonatal malnutrition. S ome inves tigators have pos tulated a 3829 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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continuum of reproductive casualty. T here are also suggestions of incomplete cerebral dominance or lateralization, neurochemical abnormalities in the brain, and s tructural les ions in the parietal lobes . C ognitive-developmental problems s ometimes with developmental coordination disorder include language dis orders and delays, hyperactivity, distractibility, impulsivity, and academic and learning difficulties . Apparently, the ass ociation between language problems and coordination problems is quite strong. S tudies of children with motor coordination have frequently reported delays in s peech and development; similarly, s tudies of children with specific language impairment have frequently reported motor delays and difficulties. One recent study of 82 s choolchildren with s pecific, severe speech and language disorders revealed that 90 percent were clums y, and percent had walked late (after 18 months of age). Whether the ass ociation between coordination and s peech-language difficulties is global or is limited specific as pects of coordination and communication is known. However, the literature s uggests that the as sociations may be rather specific. One longitudinal of children with language impairments revealed a continuing correlation between peg-moving and language P.3132 performance. Another study found that fine motor skills, res ponse speed, and upper limb speed were with language disturbances , whereas gross motor coordination and vis ual motor control were not. 3830 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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F urthermore, evidence indicates that articulation are related to motor impairment, even though the motor impairment is not neces sarily dyspraxia. Observation has s hown that factors that affect the development of the fetus and perinatal environment increase the risk of developmental coordination but do not cause developmental coordination dis order. T herefore, developmental coordination disorder mos t likely has multiple causes . One recent s tudy of motor coordination, speed, and inhibition in poor achievers suggested two underlying process es : s pecific motor deficits and developmental motor lags. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order DIAG NO S IS AND C LINIC AL F E AT UR E

DIAGNOS IS AND C L INIC AL FE ATUR E S P art of "36 - Motor S kills Dis order: Developmental C oordination Dis order" T he es sential feature of developmental coordination disorder is poor s kill in daily motor activities for a given child's age and intellectual level. Impairments may be observed in gros s motor activities, s uch as running, kicking, or catching a ball, as well as in fine motor coordination, res ulting in poor ability to write letters neatly, to drink from a cup, or to use a knife and fork C hildren with developmental coordination dis order function more competently in some expected motor 3831 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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whereas they may manifes t s ignificant impairment in others . C oordination problems may be obs erved while a child engaged in a variety of tas ks requiring the use of muscle groups. B ecause there is a wide range of motor ability within the normal developmental spectrum, and motor s kills continue to become refined with age, it not be immediately apparent that a given child has a coordination dis order. Often, the evaluation of an occupational therapist and a phys ical therapist can provide valuable information in determining whether a child's motor and coordination ability is outside the normal range of expectation for that child's age. Any of following s ymptoms , when significant, are abnormal in child, and a neurological examination is usually to rule out medical disorders ; if no medical conditions found to account for the s ymptoms, a diagnosis of developmental coordination disorder can be made. S ymptoms of developmental coordination dis order may be broken down into the following categories : synkinesia, hypotonia, hypertonia, tremors, and as ymmetries. Dys praxia describes a child's exhibiting s equenced, coordinated motor movements when pres ented with an oral reques t. Movements identified as s ynkine s ia are best described as muscle movements , also termed motor ove rflow. movements, such as finger twitching on the opposite when the child is asked to perform a finger oppos ition or facial grimaces when the child is as ked to make movements, are examples of synkinetic motor actions. T wo categories that des cribe mus cle tone are hypotonia and hype rtonia. Hypotonia can be 3832 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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in all parts of the body and is characterized by a flaccid sleepy quality in the child's facial express ion and muscle tone. C hildren with this condition may exhibit posture and obesity. C hildren with hypotonia often to be floppy and weak, but, on actual muscle strength tes ting, they may have normal mus cle s trength. describes generally high levels of mus cle tone in a F or example, a child with hypertonic movement cannot finis h drawing a line at a given point, instead the intended s topping point. Another example is a child who tends to throw a ball too hard and inaccurately at short distances. T he movement category of tre mors is marked by unsteadines s in motor movements observed in tasks requiring walking or drawing, or both. F or example, formed letters might reveal, on clos er inspection, rapid tremors in the actual lines themselves. Unsteadines s be exhibited in the child's gait as high-amplitude fluctuations in leg muscle movement. T he category of impe rs is tence refers to the child's to sus tain and to maintain various body postures for reasonable periods of time. As king a child to stick out or her tongue is an example of a tas k used often to inves tigate impers istent motor movements. In this example, the clinician would keep track of how long the child could maintain this tongue position. T he final movement category, as ymme trie s , describes motor behaviors that affect only one side of the body. category includes unus ual flexions or muscle both, on one s ide of the body or general mus cle in the limbs on one side. T hes e as ymmetrical mus cle movements can be obs erved by requiring a child to 3833 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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laterally in a rapid manner (“like a basketball player on defens e, not cros sing your feet”). If the child executes movement more fluidly on one s ide than on the other, it might indicate an asymmetry. A child who is obs erved have asymmetrical motor movements is likely to be referred for a magnetic resonance imaging (MR I) study rule out an organic cause for this s ymptom. If the neurological workup is negative, then this symptom be considered a part of a developmental coordination disorder. S pecific manifes tations vary across individuals ; thus, is no typical clums y child. In s ome instances, manifestations may be quite s pecific; one case report describes a child who could sew and do jigsaw puzzles without difficulty but could not write neatly. T he most common way to identify developmental coordination dis order is through the obs ervation of in achieving motor miles tones (e.g., s itting, standing, crawling, and walking). G ros s motor coordination manifestations may be seen in difficulties with such as sitting, walking, running, balancing, throwing, kicking. F ine motor coordination manifes tations may be identified through difficulties in performing tasks, s uch us ing utensils , tying laces , buttoning or zipping drawing, and, es pecially, printing or writing. During tas ks , children with developmental coordination may exhibit overflow movements in unsupported limbs, mirror movements , s light abnormalities of reflex, or ability to make movements smooth. S ome manifes tations of developmental coordination disorder are age dependent. Y oung children show symptoms, such as delayed development in early 3834 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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miles tones and delayed acquisition of self-help s kills , as s elf-dress ing (i.e., tying ties, fastening s naps , zippers, buttoning, and unbuttoning) or self-feeding (handling a knife, fork, or spoon). P res chool-age may als o have balance problems , awkward gait, and a history of frequently bumping into objects , falling down, and getting bruised. P roblems with balance, hopping, jumping, catching and bouncing a ball, and tracing to be among the more common symptoms of s choolchildren with developmental coordination disorder. A common sign of developmental coordination disorder among school-age children is avoidance of s ports owing to poor performance or teasing by clas smates . In addition, children with developmental coordination disorder frequently have comorbid communication and learning difficulties. Among the more common of thes e difficulties are expres sive language dis order, mixed receptive-expres sive language disorder, phonological disorder, reading disorder, disorder of written and mathematics disorder. S econdary complications for children with coordination dis order often involve rejection from peers who are critical of their poor abilities in s ports activities and other tasks. Over time, children who are “picked last” for sports teams and who are unable to up phys ically with their peers may become demoralized depres sed. T he DS M-IV -T R diagnostic criteria for developmental coordination disorder are listed in T able 36-2. P.3133 T he IC D-10 diagnostic criteria for specific 3835 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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disorder of motor function are pres ented in T able 36-3.

Table 36-2 DS M-IV-TR Diagnos tic C riteria for Developmental C oordination Dis order A. P erformance in daily activities that require coordination is substantially below that expected given the pers on's chronological age and intelligence. T his may be manifested by marked delays in achieving motor miles tones (e.g., crawling, and s itting), dropping things , poor performance in s ports , or poor handwriting. B . T he disturbance in C riterion A s ignificantly interferes with academic achievement or activities daily living. C . T he disturbance is not due to a general condition (e.g., cerebral pals y, hemiplegia, or muscular dystrophy) and does not meet criteria pervas ive developmental disorder. D. If mental retardation is present, the motor difficulties are in excess of those usually with it. C oding note: If a general medical (e.g.,

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condition or s ens ory deficit is present, code the condition on Axis III.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 36-3 IC D-10 Diagnos tic C riteria for S pec ific Dis order of Motor Func tion A. T he s core on a s tandardized tes t of fine or motor coordination is at least two standard deviations below the level expected for the child's chronological age. B . T he disturbance des cribed in C riterion A significantly interferes with academic or with activities of daily living. C . T here is no diagnosable neurological disorder. D. Most commonly used exclusion clause. IQ is

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70 on an individually administered s tandardized

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion.

Differential Diagnos is Informal observation by parents, teachers, and gross motor coordination (e.g., hopping, jumping, and standing on one foot), fine motor coordination (e.g., tapping and s hoelace tying), and hand-eye (e.g., catching a ball and copying letters) is the mos t common initial s creen for identification of coordination difficulties . However, given the vast normal variation in motor s kills , it is often not easy to make a diagnosis of developmental coordination disorder. W hen difficulties interfere with academic achievement or activities of daily living, however, formal tes ting and evaluation of these skills is recommended (T able 36-4).

Table 36-4 Motor S igns and S ymptoms Indic ating R eferral for C omprehens ive Neurologic al E valuation 3838 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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Hypertonia

C horea

Hypotonia

Weakness

Ataxia

Asymmetry

T remor

 

Differential diagnos is must rule out medical disorders may account for coordination problems, such as neurological dis orders (cerebral pals y or lesions), developmental disorders , and s evere mental C hildren with physical–neurological dis orders tend to exhibit more severe coordination difficulties . A child mental retardation may meet diagnostic criteria for developmental coordination disorder if the motor difficulties are greater than expected for that condition. When neurological disorders and medical conditions been ruled out, then formal tests of motor coordination are indicated. Motor coordination evaluation may be performed by a combination of occupational therapists , phys ical therapists, and psychologis ts. C ommonly used formal tes ts of motor s kill include the B ruininks T es t of Motor Development, the F ros tig Movement T es t B attery, the S loss on Drawing C oordination T est, S outhern C alifornia S ensory Integration T es t, and the T es t of Motor Impairment, which provide a comparative meas ure of a child's abilities. 3839 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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P oor motor coordination frequently coexis ts with disorders and disruptive behavior dis orders, such as attention-deficit/hyperactivity disorder (ADHD), particularly in children with high levels of impulsivity. A child may meet criteria for developmental coordination disorder and ADHD. T he tendency for children with developmental coordination disorder to be accident prone, to fall down, to hurt thems elves , and to break objects may, at times , be cons trued as the school s etting, a child's motor difficulty with holding pencil and writing legibly may result in great frustration the child and the teacher. F or children whose impaired writing ability and poor production are inadvertently interpreted as lack of motivation, demoralization is common, and an evaluation for s pecial educational services may be warranted. P eter was brought for evaluation of poor coordination years of age after complaining to his parents that he being teas ed by peers for being “bad” in sports , and he was always picked last for the team. His friends him, becaus e he always dropped the ball even when was able to initially catch it, and he looked “funny” running. He was s o upset about ridicule from peers that no longer wanted to play baseball or basketball with his friends . A developmental his tory obtained from his revealed that P eter's development had been delayed sitting, which he could not do until 10 months of age, he was not able to walk without falling over until 24 months of age. His parents reported an awareness that was somewhat clumsy, but they believed that he would outgrow that. On questioning about P eter's current function, his parents reported that, during meal times , 3840 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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P eter still constantly s pilled his drinks and was when he used a fork. His food often fell off of a fork or spoon before it reached his mouth, and he had great difficulty using a knife and a fork. A comprehensive ass es sment of fine and gros s motor yielded the following results: P eter was able to hop, but could not skip without briefly s topping after each s tep. P eter could stand with both feet together but could not stand on tiptoe. Although P eter could catch a ball, he a ball bounced to him at ches t level, and he could not catch a ball bounced to him on the ground from a of 15 ft. P eter's agility and coordination were meas ured with the B ruininks -Oseretsky T es t of Motor which revealed functioning levels commens urate with those of an average 6-year-old child. P eter was referred to a neurologist for a evaluation, because he appeared to be generally weak, and his mus cles s eemed floppy. Neurological was negative for diagnosable P.3134 neurological dis orders, and his muscle s trength was actually found to be normal, in spite of his appearance. B as ed on the negative neurological examination and finding of the B ruininks -Oseretsky T est of Motor Development, P eter was given a diagnos is of developmental coordination dis order. P eter's included mild hypotonia and fine motor clumsines s. After the diagnos is of developmental motor was made, a treatment plan was developed that private s ess ions with an occupational therapist who perceptual-motor exercis es to improve his fine motor 3841 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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skills , targeting particularly writing and use of utens ils, a request for an individualized evaluation from the with a goal of adminis tering an adaptive physical education program. He was also enrolled in a program us ing motor imagery training to improve clumsines s, adminis tered by a ps ychologist. P eter was relieved to be receiving help, es pecially for writing and for sports activities, becaus e these were areas in which his peers had teased him. Over a period months of treatment, P eter s howed significant improvement in the legibility of his handwriting, he remained a slow writer. He felt much better with this improvement, becaus e he was receiving more prais e his teachers and parents , and his clas smates were him less . As he began to feel better about hims elf, he began to play sports informally with his peers , although not competitively. He was given a modified physical education program in school, and he was not required play on teams, but he practiced throwing and catching ball and playing basketball. P eter continued to have some degree of clumsines s in fine motor s kills over the next few years, but he was cooperative with the occupational therapy and he showed continual improvement. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order C OUR S E AND P R OG NOS IS

C OUR S E AND PR OGNOS IS P art of "36 - Motor S kills Dis order: Developmental 3842 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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C oordination Dis order" T he outcome of motor coordination disorder is by the s everity of the impairment, the age of initiation duration of therapeutic interventions , and the presence comorbid dis orders. A recent s tudy of preschool with developmental coordination dis order at 7 to 8 of age revealed that thos e children who had significant impairment at 5 years of age continued to show impairment 1.5 years later. Longer-term s tudies have shown that motor coordination improves over the long term in at leas t 50 percent of children when they reach adoles cence. A 2-year follow-up study of children of primary s chool age who had failed a motor tes t battery revealed motor performance that, although improved, still inferior to that of controls. T he children with motor impairments als o s howed poorer educational than controls . A recent 10-year follow-up of clums y children and their age-matched, sex-matched peers was done in children over a period of 8 to 9 years . W hen first identified, the clumsy children were approximately 6 years of age; at follow-up, they ranged from 15 to 17 years of age. up tes ting indicated that the clumsy children were s till significantly below the controls in most motor s kills dexterity, ball s kills , balance, cutting with s cis sors, catching, and walking backward) and in global ratings phys ical education teachers. T he clums y adolescents showed higher rates of dysgraphesthes ia, and motor s lownes s. In addition, the educational achievements of the clumsy adoles cents were poorer, and they had significantly lower perceived 3843 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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competence than their nonclumsy peers. T hat finding subs tantiates reports of continuing secondary including peer problems , low self-es teem, and struggles in children and adoles cents with s ignificant coordination difficulties. A long-term follow-up of children with developmental coordination disorder and thos e with ADHD and developmental coordination disorder at 22 years of age suggests that there are ps ychos ocial ramifications into adulthood. P s ychos ocial adjustment difficulties pres ent the young adults with only developmental coordination disorder and those who were comorbid for ADHD unemployment, use of s ubs tances , continued with reading, and legal problems. Developmental coordination dis order tends to improve most individuals over time, and those with more severe impairment at a younger age, as well as those for additional psychiatric dis orders, have the poores t prognos es . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order T R E AT ME NT

TR E ATME NT P art of "36 - Motor S kills Dis order: Developmental C oordination Dis order" Widely accepted treatment of motor coordination often includes multisensory modalities , including visual, auditory, and tactile materials , with a goal of perceptual motor training for a variety of specific motor tas ks . 3844 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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treatments , s uch as motor imagery training for in children, have received attention recently, based on res ults from controlled investigations of this modality compared to perceptual motor interventions. A recent study us ed a success ful motor imagery intervention through C D-R OM, which contained s ix main training components, for children with coordination difficulties . T he components included vis ual imagery exercis es involving predictive timing, relaxation and mental preparation, visual modeling of fundamental motor mental rehears al of s kills from an external perspective, mental rehears al of s kills from an internal perspective, overt practice. T his model of treatment is based on the notion that deficits in a child's ability to internally represent the movement tasks contribute to poor motor coordination. T he ability for visual imagery of objects is impaired in children with developmental coordination disorder. T he previous ly mentioned training exercis es designed to improve the timing and accuracy of a given child's ability to visualize motor tasks, as well as to muscle tens ion while imagining completing the given motor task. F inally, the children were trained in rehears ing the tas k before actually practicing it. More traditional perceptual-motor training consists of a combination of gross motor, fine motor, and perceptual motor activities related to a given child's actual daily tas ks , s uch as hopping, s kipping, jumping, climbing moving through hoops , climbing ladders, and jumping a trampoline, to practice competency. S pecific tas ks addres sing fine motor skills, such as handwriting, activities to improve grip of a pencil, wris t rotation, and posture. T he res ults of the previously mentioned s tudy were extremely notable in that the mental imagery 3845 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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treatment was as efficacious as traditional perceptual motor training exercis es in improving a given child's coordination. Another recent s tudy of a s chool-based occupational therapy intervention for s chool-aged children with poor handwriting legibility showed efficacy in improved legibility of letters . C hildren with handwriting difficulties this s tudy received direct traditional perceptual on writing letters for approximately 30 minutes per for approximately 7 months. T his cons isted of a variety handwriting interventions, such as using vibration or res is tance to writing to increase appropriate grip and writing on a chalk board or a vertical s urface to arm strength and s tability while writing. At the end of period, children made significant gains in handwriting legibility, compared to a control group that did not the intervention. Handwriting speed in the children who received the treatment increased from 32 to 37 letters minute. Although this was a trend toward s peed, this not represent a statis tically s ignificant increase in S ome s tudents in the treatment group wrote their with a greater degree of deliberate care, and, although increased legibility, it may have actually diminis hed speed. Overall, the increas e in legibility applied to more than numbers but did not significantly increase writing s peed. P.3135 Motor training programs gained wide acceptance in remediating various types of learning disorders in the 1960s , 1970s , and early 1980s, Although there is s till a paucity of data indicating long-term academic 3846 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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improvement from these programs , two programs have been widely us ed in s chools to address the motor individuals with developmental coordination disorder: adaptive physical education and sensory integration programs. Adaptive phys ical education programs are basically physical education programs modified to help students with developmental coordination disorder exercise, recreation, and leisure activities . S uch us ually emphas ize inclusion of movement games into phys ical education regimen (e.g., serving a volleyball kicking a football). F or this approach to be effective, it recommended that adaptive physical education be available at leas t two to five times a week, in lasting from 40 minutes to an hour. T here is s ome controvers y among researchers and clinicians as to whether sensory integration problems as an independent entity or rather as components of a pervas ive developmental dis order. When these are observed, it is recommended that a comprehensive ps ychiatric evaluation be initiated to determine the diagnosis. In either cas e, however, s ens ory integration therapeutic interventions have been us ed to improve coordination and proprioceptive abilities in children with poor motor skills. S ensory integration programs are often delivered as a related s ervice to children with developmental coordination dis order under the direction of therapists . T hese programs prescribe specific phys ical therapies that attempt to modify the motor and sensory functioning of these children. T he entire set of are bas ed on the notion that s ens ory integration interfere with body movements and body awareness . 3847 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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Activities are designed to target the tactile, vestibular, proprioceptive s ys tems. S ome children with developmental coordination disorder, for instance, experience tactile de fens ivene s s (discomfort when by another person). In address ing a disorder affecting tactile s ys tem, occupational therapists might us e a integration program that includes touching and rubbing skin surfaces, using creams , and brushing s kin working with infants ). A s ens ory integration program addres ses disorders affecting the proprioceptive (bumping into walls and inability to button, to skip, or to write) might involve using s cooter boards to improve balance and body awareness . A recent study of children with developmental coordination dis order has s hown that, when playing a computer game designed to improve their ability to a ball virtually on the s creen, they were able to and to use a vis ual cue to help them virtually catch the without realizing that the cue was given. T hat is, thes e children were able to improve their computer s core implicitly by practicing the game and to make us e of a perceptual cue without having to be specifically on how to improve. T his has implications for treatment that, in addition to providing direct ins truction to with motor coordination problems, improvement can occur with practice through environmental cues that not neces sarily identified. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 36 - Motor S kills Dis order: Developmental C oordination Dis order S UG G E S T E D C R O S S -R E F E R E NC

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R E FE R E NC E S P art of "36 - Motor S kills Dis order: Developmental C oordination Dis order" Mental retardation is dis cuss ed in C hapter 34, developmental disorder is dis cus sed in C hapter 38, attention-deficit disorders are dis cuss ed in C hapter 39. R eading dis order is covered in S ection 35.1, disorder is covered in S ection 35.2, disorder of written expres sion is covered in S ection 35.3, express ive disorder is covered in S ection 37.1, mixed receptiveexpres sive language disorder is covered in S ection and phonological disorder is covered in S ection 37.3.

R E FE R E NC E S B enders ky M, Lewis M: E nvironmental ris k, ris k, and developmental outcome. Dev P s ychol. 1994;30:484. B lums ack J : Neurodevelopmental precurs ors to disabilities: A preliminary report from a parent L e arn Dis abil. 1997;30:228. C andler C , Meeuwsen H: Implicit learning in children with and without developmental coordination Am J O ccup T he r. 2002;56:429. C as e-S mith J : E ffectivenes s of s chool-based occupational therapy intervention on handwriting. 3849 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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O ccup T he r. 2002;56:17. C rawford S G , Wilson B N, Dewey D: Identifying developmental coordination disorder: C onsis tency between tes ts. P hys O ccup T he r P ediatr. Dewey D, K aplan B J , C rawford S G , W ils on B N: Developmental coordination dis order: Ass ociated problems in attention, learning, and ps ychosocial adjus tment. Hum Mov S ci. 2002;21:905. *Dunford C , S treet E , O'C onnell H, K elly J , S ibert referrals to occupational therapy for developmental coordination dis order appropriate? Arch Dis C hild. 2004;89:143. Dunn J M. S pe cial P hys ical E ducation: Adapted, Individualized, De ve lopme ntal. 7th ed. Madis on, WI: B rown and B enchmark; 1997. E verhart B : Ass es sing motor and sport s kill performance: T wo practical procedures. J P hys R ecre ation Dance . 1996;67:49. G illberg C , K adesjo B : W hy bother about T he implications of having developmental disorder (DC D). Neural P las t. 2003;10:59. G ueze R H, J ongmans MJ , S choemaker MM, S mits E ngels man B C : C linical and res earch diagnostic for developmental coordination disorder: A review discuss ion. Hum Mov S ci. 2001;20:7. 3850 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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Hadders -Algra M: E arly brain damage and the development of motor behavior in children: C lues for therapeutic intervention? Neural P las . 2001;8:31. *Hay J A, Hawes R , F aught B E : E valuation of a instrument for developmental coordination dis order. Adoles c H ealth. 2004;34:308. *Hols ti L, G runau R V , W hitfield MF : Developmental coordination dis order in extremely low birth weight children at nine years. J De v B e hav P ediatr. Leemrijs e C , Meijer OG , V ermeer A, Ader HJ , T he efficacy of LE B on Depart and S ens ory treatment for children with developmental coordination dis order: A randomized s tudy with s ix single cases. C lin R ehabil. 2000;14:247. Mandich AD, P olatajko HJ , Macnab J J , Miller LT : T reatment of children with developmental disorder: W hat is the evidence? P hys O ccup T he r 2001;20:51. Mandich AD, P olatajko HJ , Miss iuna C , Miller LT : C ognitive s trategies and motor performance in with motor coordination disorder. P hys O ccup T he r P ediatr. 2001;20:125. Miller LT , P olatajiko HJ , Mis siuna C , Mandich AD, J J : A pilot trial of a cognitive treatment for children developmental coordination dis order. Hum Mov S ci. 3851 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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2001;20:183. Munroe K J , G iacobbi P R , Hall C , W einberg R : T he of imagery us e: W here, when, why, and what. S port P s ychol. 2000;14:119. O'Hare A, K halid S : T he as sociation of abnormal cerebellar function in children with developmental coordination dis order and reading difficulties . 2002;8:234. P less M, C arls son C , S undelin C , P erss on K : P rechildren with developmental coordination disorder: perceived competence and group motor skill intervention. Acta P e diatr. 2001;90:538. P less M, C arls son M, S undelin C , P ers son K : children with developmental coordination disorder: A short-term follow-up of motor status at s even to years of age. Acta P e diatr. 2002;91:521. *R asmus sen P , G illberg C : Natural outcome of with developmental coordination disorder at age 22 years : A controlled, longitudinal, community-based study. J Am Acad C hild Adole s c P s ychiatry. R aynor AJ : S trength, power, and coactivation in with developmental coordination dis order. Dev Me d C hild Ne urol. 2001;43:676. S hort S E , Afremow J , Overby L: Us ing mental enhance children's motor performance. J P hys E duc 3852 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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Dance. 2001;72:19. S kinner R A, P iek J H: P sychosocial implications of motor coordination in children and adolescents. Mov S ci. 2001;20:73. S mits-E ngels man B C , Niemeijer AS , van G alen G P : motor deficiencies in children diagnosed as DC D on poor grapho-motor ability. Hum Mov S ci. 2001;20:161. S mits-E ngels man B C , V an G alen G P : Dys graphia in children: Las ting ps ychomotor deficiency or transient developmental delay? J E xp C hild P s ychol. S pagna ME , C antwell DP , B aker L. Motor s kills Developmental coordination dis order. In: B J S adock, S adock, eds. K aplan & S adock's C ompre he ns ive of P s ychiatry. 7th ed. P hiladelphia: Lippincott Wilkins ; 2000. *S ugden DA, C hambers ME : Intervention in children with developmental dis order: T he role of parents teachers. B r J E duc P s ychol. 2003;73:545. V is ser J : Developmental coordination disorder: A of research on subtypes and comorbidities . Hum S ci. 2003;22:479. Wilson P H, McK enzie B E : Information process ing as sociated with developmental coordination A meta-analysis of res earch findings. J C hild 3853 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/36.htm

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P s ychiatry. 1998;39:829. Wilson P H, T homas P R , Maruff P : Motor imagery ameliorates motor clumsines s in children. J C hild 2002;17:491. Woodward S , S winth Y : Multisens ory approach to handwriting remediation: P erceptions of schooloccupational therapists . Am J O ccup T he r. Ziviani J , P ouls en A, O'B rien A: C orrelation of the B ruininks -Oseretsky T es t of Motor P roficiency with S outhern C alifornia S ensory Integration T es ts . Am J O ccup T her. 1982;36:519.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 37 - C ommunication Dis orders > 37.1: E xpress ive Language

37.1: E xpres s ive L anguage Dis order C arla J . J ohns on Ph.D. J os eph H. B eitc hman M.D. P art of "37 - C ommunication Dis orders " C ommunication disorders are among the mos t problems exhibited by young children. Nonetheless , communication dis orders often go unrecognized, particularly when they cooccur with other psychological behavioral disorders , as they often do. T hus , child ps ychiatris ts, ps ychologists , and other clinicians need alert to the potentially damaging impact of communication problems on a child's overall wellP roficiency in s poken communication is critical to in virtually all human activities and is therefore highly valued in society. A child with a communication may be unable to participate fully and competently in everyday interpersonal and learning s ituations . Limited participation in such key life activities may further growth in communication and related domains. T o develop effective communication, children mus t language, the conventional code used to expres s ideas about the world, and speech, the complex and rapid movements that trans late s uch ideas into spoken T he distinction between language and speech is the clas sification of communication disorders, which 3855 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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affect language or speech, or both. T he revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ) recognizes five diagnostic of communication dis orders . T wo categories concern language dis orders (express ive and mixed receptiveexpres sive), two categories include speech disorders (phonological disorders and stuttering), and the final category covers communication disorders not specified.

DE F INITION A ND C OMP A R A TIVE NOS OL OG Y C hildren with expres sive language dis orders exhibit problems in us ing s poken language to communicate needs , thoughts, and intentions . In particular, these children may (1) produce few s poken utterances; (2) vocabularies that are limited in s ize and variety; (3) us e sentences that are s hort, incomplete, or and (4) provide stories or des criptions that are disorganized, confusing, or uns ophis ticated. T hese children typically s how a slow rate of express ive development. Many features of their language those characteris tic of younger children. T he language problems are evident, des pite performance within the normal range on meas ures of hearing acuity, nonverbal intelligence, and unders tanding (comprehension, reception) of spoken language. As many other childhood mental disorders , the definition diagnosis of expres sive language disorder involves complex and often controversial iss ues . A key categorical distinction in DS M-IV -T R is that expres sive language disorder, which affects only 3856 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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production of spoken language, and mixed receptiveexpres sive dis order, which als o affects unders tanding (comprehension, reception) of spoken language. T hese two diagnos tic categories are commonly used in practice and show differences in prognos es and conditions. Many experts , however, feel that this dichotomous clas sification may not be justified. Instead, they view language dis orders on a continuum, with express ive language dis orders repres enting les s s evere manifestations of the s ame core problems as mixed receptive-expres sive dis orders. K nown differences in prognos es and comorbidity are thought to reflect differences in overall s everity. T his view als o fits with evidence that children with express ive language often s how mild concomitant deficits in receptive language and express ive language features similar to those shown in mixed disorder. C ons equently, much of relevant literature deals with developmental language disorder (or specific language impairment), a larger category that encompas ses express ive and mixed receptive-expres sive dis orders. DS M-IV -T R does not include a diagnos tic category for children who s how impaired receptive language but expres sive language. P resumably, the rationale for this exclusion is that language comprehension usually precedes production during normal development. children, however, do s how a pattern in which comprehension s kills appear to be weak relative to productive abilities. F urther study of thes e children with poss ible receptive deficits may help des cribe and the unique nature of their language difficulties . 3857 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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DS M-IV -T R recognizes two types of expres sive disorder. B y far, the most common is the type, which has no known caus e and is characterized delayed ons et and a gradual, slow rate of express ive language development. Much rarer is the acquired which aris es suddenly from a known neurological such as dis eas e or head trauma. Although the two are s imilar in certain express ive language their inclus ion within the s ame diagnostic category may caus e confusion for clinicians by obs curing potentially important differences in etiology, prevalence, course, prognos is , treatment, and comorbid conditions . Another controversial aspect of the DS M-IV -T R its us e of cognitive referencing, the requirement that nonverbal cognitive performance be s ubs tantially than language performance for a language dis order (expres sive or mixed) to be diagnos ed. Until recently, cognitive referencing was a widely accepted practice in defining language disorders , becaus e it presumably identified children whose language growth was not keeping pace with their nonverbal cognitive T his practice is now being increasingly challenged on theoretical and ps ychometric grounds. One frequent argument is that nonverbal cognitive functioning does limit a child's potential for language growth, as is by cognitive referencing. In particular, the extent to children benefit P.3137 from language intervention is not related to the size of discrepancy between nonverbal and verbal s cores. C hildren with small discrepancies between s cores 3858 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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as much or more from intervention than those with discrepancies. A related concern is that children with language levels and commens urate cognitive levels be deemed ineligible for intervention services , because they do not meet the discrepancy criterion. Y et, suggests that these children may be at greater ris k for advers e academic, social, and behavioral outcomes those who meet a dis crepancy criterion. A final concern about cognitive referencing is ps ychometric in nature. S pecifically, if practitioners do not adequately cons ider effects of measurement error, then invalid decisions be made about the pres ence or abs ence of in performance on language and cognitive tests . S uch concerns are multiplied if the language or cognitive meas ures are not, themselves, psychometrically F urther theoretical and empirical efforts are needed to res olve thes e is sues adequately. In the meantime, it be recognized that res earch and clinical definitions of language dis order do not always corres pond to the IV -T R criteria. T he DS M-IV -T R clas sification s cheme for language disorders is identical to that of the fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs IV ). T he DS M-IV -T R s cheme is also similar to that of tenth edition of the Inte rnational S tatis tical Dis e as es and R e late d H ealth P roble ms (IC D-10). and IC D-10 recognize mutually exclus ive categories for expres sive and mixed receptive-expres sive language disorders , although the latter are termed re ceptive language dis orders in IC D-10. T he inclusion of types of language disorder is unique to DS M-IV -T R ; developmental types are cons idered in IC D-10. 3859 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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Although the dichotomous clas sification us ed by DS MT R and IC D-10 is the mos t widely accepted scheme for clas sifying developmental language disorders , there various other schemes that have been proposed for clas sification or s ubtyping of childhood language disorders . T hese schemes include divers e terms that to types and subtypes of childhood language disorders (de ve lopmental dys phas ia, auditory verbal agnos ia, s e mantic-pragmatic dis orde r), many of which do not corres pond in a s traightforward manner to the DS M-IV categories . Moreover, additional work is required to es tablis h the validity and adequacy of various schemes , including that used in DS M-IV -T R .

E P IDE MIOL OG Y Developmental Type Approximately 10 to 15 percent of children younger years of age s how delayed ons et and s low initial in expres sive language development. B ecaus e of the range of normal variability in the language production skills of young children, it is not yet clear whether an delay consistently warrants a diagnosis of expres sive language dis order. T he majority (50 to 80 percent) of late talkers eventually acquire language s kills within the normal range, but s ome s how persistent language difficulties into adulthood. In children of school age, the prevalence of the developmental type of express ive language dis order ranges from 3 to 7 percent, DS M-IV -T R . T hes e figures are generally consistent res ults from the few s tudies in which expres sive disorders have been identified s eparately from mixed receptive-expres sive dis orders. V ariations in 3860 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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es timates are a function of the s pecific language and definitional criteria us ed, the age of the children surveyed, and the nature of the sample tested or clinic referred). Developmental language dis orders , including language disorders , are more common in boys than in girls. In s ome s tudies , boys outnumbered girls by ratios high as 5 to 1. In others, the s ex imbalance was less pronounced, with ratios of 2 to 1 or even les s being observed. T he discrepancies likely reflect differences in sampling practices , testing procedures , and definitional criteria. S everal studies s ugges t familial aggregation and heritability of developmental language disorders , but there are few relevant data specific to express ive One research group found no evidence of familial aggregation in a s ample of 2-year-old children with expres sive delays (but not necess arily disorders ). study of older children yielded higher rates of familial aggregation for children with expres sive dis orders than those with mixed receptive-expres sive language F urther work is needed to identify the specific genetic environmental contributions to such familial effects.

Ac quired Type It is rare for children to experience acquired language disorders , particularly thos e s pecific to expres sive language. P revalence rates , gender ratios , and familial aggregation data are not available for the category of acquired express ive language dis orders, although they are available for certain specific 3861 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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(e.g., s troke and head injury).

E TIOL OG Y Developmental Type T heoretical and empirical efforts to understand etiology us ually have focused on developmental language disorders in general, not on express ive disorders in particular. A variety of biological and environmental risk factors have been identified. None, however, appears present in all cases , nor have they been confirmed as caus al agents. T hus , the caus es of developmental language dis orders currently are unknown and are heterogeneous .

Ac quired Type Acquired language dis orders are the res ult of known neurological insults , such as stroke, head injury, poisoning, or nearly drowning. T hese disorders aris e suddenly, at any age. Initially, acquired dis orders often impair receptive and expres sive language. During a of spontaneous recovery, the receptive difficulties may res olve, so that residual problems are primarily in nature. Occas ionally, a focal injury to the left hemis phere, for example, from a stroke or a bullet may als o res ult in a s elective express ive deficit.

DIA G NOS IS A ND C L INIC A L E xpres sive language disorder is diagnosed when a exhibits a s elective deficit in express ive language development relative to nonverbal intelligence and receptive language s kills (T able 37.1-1). T hus, the diagnostician mus t appreciate the course of normal 3862 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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development in verbal and nonverbal domains. T able 2 provides an overview of typical miles tones in and nonverbal development. Miles tones are listed only as old as 8 years of age, but it is commonly recognized subs tantial growth in vocabulary, grammar, and us e continues through adolescence and even into adulthood.

Table 37.1-1 DS M-IV-TR C riteria for E xpres s ive L anguage Dis order A. T he s cores obtained from s tandardized individually adminis tered meas ures of express ive language development are s ubs tantially below those obtained from s tandardized meas ures of nonverbal intellectual capacity and receptive language development. T he disturbance may be manifest clinically by symptoms that include a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity. B . T he difficulties with expres sive language with academic or occupational achievement or social communication. C . C riteria are not met for mixed receptive3863 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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language dis order or a pervas ive developmental disorder. D. If mental retardation, a speech-motor or deficit, or environmental deprivation is present, language difficulties are in exces s of those noted with thes e problems . C oding note: If a s peech-motor or sens ory a neurological condition is present, code the condition on Axis III.

F rom American P sychiatric As sociation: and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 37.1-2 Normal of S peec h, L anguage, and Nonverbal S kills in C hildren S peech and L anguage Development

Nonverbal Development

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1 yr of age

 

R ecognizes own name

S tands alone

F ollows simple directions accompanied by gestures (e.g., bye-bye)

T akes firs t s teps with support

S peaks one or two words

Uses common objects (e.g., cup)

Mixes words and jargon sounds

R eleas es objects willfully

Use communicative (e.g., s howing, pointing)

S earches for in location where last s een

2 yrs of age

 

Uses 200300 words

Walks up and stairs alone but without alternating feet

Names mos t common objects

R uns rhythmically but is unable to stop or start smoothly 3865

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Uses two-word or longer phrases

E ats with a fork

Uses a few prepos itions in, on), pronouns (e.g., you, me), verb endings (e.g., s, -ed) and plurals (-s), but always correctly

C ooperates with adult in s imple household tas ks

F ollows simple commands not accompanied by

E njoys play with action toys

3 yrs of age

 

Uses 9001,000 words

R ides tricycle

C reates three- to four-word sentences, usually with subject and verb, but structure

E njoys s imple make-believe play

F ollows two-step

Matches primary colors

R epeats five- to sevensyllable s entences

B alances momentarily on one foot

S peech is us ually by family members

S hares toys with others for s hort 3866

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periods 4 yrs of age

 

Uses 1,5001,600 words

Walks up and stairs with alternating feet

R ecounts s tories and from recent pas t

Hops on one foot

Understands most about immediate environment

C opies block

Uses conjunctions (e.g., if, but, because)

R ole plays with others

S peech is us ually by strangers

C ategorizes objects

5 yrs of age

 

Uses 2,1002,300 words

Dres ses s elf as sistance

Dis cus ses feelings

C uts own meat knife

Understands most

Draws a 3867

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prepos itions referring to space (e.g., above, beside, toward) and time (e.g., before, after, until)

recognizable person

F ollows three-step commands

P lays purposefully and cons tructively

P rints own name

R ecognizes partwhole relations hips

6 yrs of age

 

Defines words by function and attributes

R ides a bicycle

Uses a variety of wellcomplex sentences

T hrows a ball well

Uses all parts of s peech verbs , nouns , adverbs, adjectives, conjunctions , prepos itions )

S us tains attention to motivating tas ks

Understands letter-sound as sociations in reading

E njoys competitive games

8 yrs of age

 

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R eads s imple books for pleas ure

Understands cons ervation of liquid, number, length, etc.

E njoys riddles and jokes

K nows left and right of others

V erbalizes ideas and problems readily

K nows differences and s imilarities

Understands indirect reques ts (e.g., It's hot in unders tood as request to open window)

Appreciates that others have different perspectives

P roduces all s peech in an adult-like manner

C ategorizes same object into multiple categories

Adapted from Owens R E . L anguage Introduction. 5th ed. Needham Heights , MA: Allyn and B acon; 2001. C hildren with expres sive language dis orders do speaking s kills but generally at a much s lower rate than their peers . T hus, affected children typically s how expres sive language characteristics that res emble younger children who are developing language at a 3869 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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normal rate. C ertain language features , s uch as the grammatical marking of tens e, aspect, number, gender, case, may be es pecially difficult for children with disorders to acquire. R esearchers are currently cross -linguistic res earch in an attempt to better unders tand what thes e features are and why they are extraordinarily difficult for children with language disorders to acquire.

Developmental Type C ontent, form, and us e are domains of express ive language that may be affected, to various degrees, in expres sive language disorder. P roblems with content be P.3138 reflected in a limited vocabulary and in difficulty expres sing abs tract or complex ideas . Difficulties with form of language may be evident in s hort, incomplete, ungrammatical s entences or in problems with learning correct us e of certain grammatical forms, s uch as or modal verbs (e.g., is , were , could), plurals (e.g., ge e s e ), verb tens e endings (e.g., -ing, -s , -ed), and (e.g., he , s he , they). Deficits in the use of language res trict the expres sion of a range of communicative purpos es (e.g., protest, explain, ques tion) or the ability sustain and to extend convers ational topics . C onnected discours e, which requires extens ive coordination of content, form, and us e, may be particularly challenging. T hus, stories , explanations , or arguments may be formulated, uninformative, and difficult to follow. Moreover, the s pecific manifes tations of expres sive 3870 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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language disorder may change with maturation. T hus , critical that language as sess ments encompas s tasks activities that permit a determination of a child's ability us e language for a variety of age-appropriate J osh was an alert, energetic 2-year-old, whose vocabulary was limited to only four words (mama, hi, and more ). He used these words one at a time in appropriate situations . He s upplemented his infrequent verbal communications with pointing and other simple gestures to reques t desired objects or actions . He communicated, however, for other purpos es (e.g., commenting or protes ting). J osh appeared to be developing normally in all other areas , except for expres sive language. He sat, stood, and walked at the expected times . He played happily with other children, enjoying activities and toys that were appropriate for 2year-olds. Although he had a history of frequent ear infections, a recent hearing tes t revealed normal Importantly, he s howed age-appropriate for the names of familiar objects and actions and for simple verbal instructions (e.g., P ut that down, G et shirt, and C lap your hands). Of cours e, at his age, comprehension testing had to be carefully conducted to ensure his attention and motivation. Des pite J osh's slow start in language development, specialists would be reluctant to diagnos e an language dis order at his young age. P ros pective on the development of late talkers like J osh has demonstrated that mos t of them s pontaneous ly their initial slow start in language development. A report meas ure of vocabulary comprehens ion has 3871 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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promis e as a prognos tic indicator that can be used as as 10 months of age. Amy was a s ociable, active 5-year-old, who was with express ive language disorder. S he often played Lisa, her kindergarten clas smate. During pretend play day, each girl told the s tory of Little R ed R iding Hood to her doll. Lisa's s tory began: Little R ed R iding Hood was taking a basket of food to her grandmother who was A bad wolf stopped R ed R iding Hood in the fores t. He to get the basket away from her but she wouldn't give it him. B y contras t, Amy's story illus trated her marked in verbal expres sion: R iding Hood going to grandma house. Her taking food. B ad wolf in a bed. R iding Hood what big ears , grandma? Hear you, dear. What big grandma? S ee you, dear. W hat big mouth, grandma? you all up! Amy's s tory contained many features characteristic of children with express ive dis orders at her age, including short, incomplete s entences, s imple s entence omis sion of grammatical function words (e.g., is and and inflectional endings (e.g., pos sess ive -'s and tense verb -s ), problems in question formation, and incorrect use of pronouns (e.g., he r for s he ). However, performed as well as Lisa did in unders tanding the and plot of the R iding Hood tale, as long as she was with methods that did not involve verbal res ponding. also demonstrated adequate comprehension s kills in kindergarten clas sroom, where s he readily followed the teacher's complex, multistep verbal instructions (e.g., you write your name in the top left corner of your 3872 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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get your crayons and s ciss ors, put your library books your chair, and line up at the back of the room.). J ulio was a quiet, sullen 8-year-old whos e express ive language problems were no longer obvious in cas ual, social convers ations . His speech now rarely contained incomplete s entences and grammatical errors that evident when he was younger. His expres sive however, still surfaced in tasks involving elaborate or abstract uses of language, like those required in much his third-grade academic work. An example was J ulio's explanation of the outcome of a recent s cience experiment: T he teacher had s tuff in some jars. He it, and it got pink. T he other thing made it white. each s entence was grammatical, his explanation as a whole was difficult to follow, because key ideas and were omitted or poorly explained. J ulio also s howed problems in word finding, that is, in using s pecific for the concepts and actions he was describing. relied on vague and nons pecific terms , such as thing, and got. In early elementary grades, J ulio had kept pace with clas smates in reading, writing, and other academic B y third grade, however, the increasing demands for written work began to negatively affect his overall academic s tanding. His written work was characterized problems similar to those noted in his oral express ion, such as poor organization and lack of s pecificity. C las smates als o began to tease him about his and he reacted quite aggress ively, s ometimes to the of fighting. Nonetheles s, J ulio continued to show good comprehens ion 3873 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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P.3139 of spoken language, including class room lectures concerning abstract concepts. He also comprehended sentences that were grammatically and conceptually complex (e.g., T he car the truck hit had hubcaps that stolen. Had it been pos sible, she would have notified us mail or by phone.). Many children with expres sive language disorder experience difficulties only in the domain of expres sive language. It is not uncommon, however, for some to cooccurring problems in other domains , s uch as learning, motor skills, and behavior. T he mos t common cooccurring disorder in preschoolers is phonological disorder, which may persist into the early school years . Written language problems may become evident at age. R eading disorder is the most common of these, but disorder of written expres sion may als o occur. Developmental coordination dis order is als o a pos sible comorbid condition. C omorbid ps ychiatric disorders may also be obs erved in many as one-half of the children with persis tent language dis orders. Attention-deficit/hyperactivity (ADHD) is the mos t P.3140 commonly diagnos ed psychiatric problem in s chool-age children, and other externalizing disorders in boys or internalizing disorders (anxiety dis orders ) may als o be observed. F rank neurological s ymptoms (e.g., seizures or 3874 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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rarely obs erved in children with developmental language dis orders. However, s oft neurological signs , as problems in perception, motor control, and attention, may be present. F or example, one recent study that children with express ive language dis orders frequently showed difficulties in fine, gros s, and oral control, as well as in balance and coordination. T he presence of neurological signs or symptoms does not, however, preclude diagnos is of developmental disorder, unles s their ons et is clearly attributable to a known, acquired brain insult.

Ac quired Type Acquired express ive dis orders typically manifest than developmental dis orders. In particular, after initial spontaneous recovery, express ive grammar skills (language form) may be relatively preserved, so that sentences are of similar length and grammatical complexity to thos e of same-aged peers . T he most common problems are found in word finding and discours e organization, and they may be exacerbated attention, memory, and emotional s equelae as sociated with the brain injury. T he varied etiologies that result in acquired dis orders are also ass ociated with qualitative differences in language us e and ass ociated s ymptoms. Moreover, a s imilar brain lesion may have quite effects on language in a child than in an adult, because the brain regions that are critical for language development are not necess arily those involved in language use. K aren developed normally until 10 years of age, when had a s troke that res ulted in focal left hemisphere 3875 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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Immediately after the s troke, K aren was unable to and s howed limited unders tanding of language. In addition, she demonstrated hemiparesis, a partial on the right side of her body. K aren quickly recovered receptive language s kills in the weeks after the s troke regained her expres sive language s kills more s lowly. initially us ed short, telegraphic utterances with few grammatical function words or inflectional endings . Her speech was also slow, labored, and s lurred, reflecting mild dys arthria. W ithin 6 months , the complexity of her sentences and the rate and precis ion of her s peech gradually returned to normal. Her hemipares is also res olved. K aren continued, however, to s how s ubtle res idual express ive problems, particularly in word during dis course. S he often s truggled to find the word wanted, relying ins tead on vague substitutes (e.g., s ome where or s tuff) or circumlocutions (that thing you in the rain for umbre lla). S he also inadvertently words that s he intended to s ay with others that were clos ely related in meaning (e.g., lion for tiger) or sound (e.g., s ymphony for s ympathy). Although K aren's skills returned to almost normal levels , she s howed res idual memory and attention problems that interfered with her academic performance in fifth grade. K aren an excellent student before her s troke but now became easily frustrated with her changed and incons is tent performance. A neurological ins ult may als o affect cognitive, gross motor, and speech motor skills, temporarily or permanently. As in K aren's cas e, children with acquired disorders may recover well enough to score within the normal range on structured intelligence tes ts but may 3876 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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function well in less s tructured settings, such as s chool home. As one might expect, overt neurological occur more frequently with acquired disorders than with developmental ones . Other cooccurring problems may include s peech dis orders, learning dis orders, and behavioral and emotional difficulties that are s evere enough to warrant psychiatric diagnos is .

P A THOL OG Y A ND L A B OR A TOR Y E X A MINA TION Developmental Type T here are no laboratory tests that can provide a of developmental express ive language dis order. Neuroimaging techniques, such as magnetic imaging (MR I) and functional MR I (fMR I), s ometimes structural or functional brain abnormalities as sociated developmental language dis order. However, s uch abnormalities are not found in all cases, nor have their poss ible etiological or diagnostic values been

Ac quired Type T he only laboratory tests that may be informative in of acquired expres sive language dis order are those may be required to identify an underlying medical condition that is res ponsible for the neurological ins ult (e.g., encephalitis or poisoning). Neuroimaging may be used to document the site and extent of the brain les ions and of changes that may occur during the cours e of recovery.

DIF FE R E NTIA L DIA G NOS IS S tandardized evaluations of express ive language, 3877 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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receptive language, and nonverbal intellectual are required for differential diagnosis of developmental expres sive dis order (T ables 37.1-1 and 37.1-2). W hen appropriate standardized tests are not available (e.g., if child speaks a language for which tests have not yet developed), it is acceptable to substitute a thorough functional as sess ment of language abilities. In either expres sive language development must be s hown to subs tantially below (1) the normal range of express ive performance for a child's age, (2) receptive language performance, and (3) nonverbal intellectual T he expres sive language difficulties must als o be enough to impair academic performance or s ocial communication. S tandardized testing is often supplemented with obs ervational techniques and of spontaneous language us e to ass es s whether the clinical s everity criterion is met. T he diagnosis of expres sive language disorder is by documented deficits in receptive language or nonverbal intelligence. S uch deficits generally warrant diagnosis of other disorders that affect language T he diagnosis of mixed receptive-expres sive dis order made when express ive and receptive deficits occur in presence of normal nonverbal intelligence. T he of mental retardation is appropriate when language and nonverbal functioning are substantially below age level expectations . If express ive language deficits are in of thos e expected for a given degree of mental retardation, a concurrent diagnosis of expres sive disorder may be made. T he diagnostic protocol should include a hearing tes t whenever express ive language disorder is sus pected. 3878 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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hearing tes t detects a mild hearing loss that may be a transient or persis tent accompaniment to the regular infections or allergies experienced by many children expres sive language problems. Once identified, appropriate medical treatment and monitoring can minimize the potentially damaging effects of hearing problems on future language learning. T he hearing tes t may als o identify more severe hearing impairments , for which hearing aids , cochlear implants , or other P.3141 amplification devices may be chos en to foster learning. If expres sive language deficits are greater expected for a given degree of hearing loss , a diagnosis of expres sive language dis order may be E nvironmental deprivation, pervasive developmental disorders , and s elective mutism must als o be poss ible diagnoses in cases of language delay. A history helps rule out extreme environmental including child abuse or neglect, exces sive school or absences, or mental illness or s ubs tance abus e in parents . Obs ervations of unus ual repetitive behaviors, well as atypical social interaction and communicative intent, suggest pervasive developmental dis order. Documentation that a child refus es to s peak in s ome situations (e.g., school) but produces fairly normal expres sive language in other s ituations (e.g., home) is evidence of selective mutis m. A particular diagnostic challenge aris es in evaluating children from diverse linguistic and cultural S pecifically, it may be difficult to decide whether language characteris tics reflect the presence of 3879 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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merely the typical errors that occur in the acquis ition of second language. C ultural and linguistic barriers may impede communication with the child during the as sess ment procedures and with the family in the collection of history and the presentation of res ults. A recent s tudy, however, revealed that bilingual children who were referred for emotional and difficulties als o s howed a high rate of uns uspected language dis orders, replicating similar findings from monolingual children. T hus, it is important to conduct thorough a language as sess ment as poss ible. If inconclusive results are obtained, the child can be monitored periodically to as sess language progress . Acquired express ive language disorder is a s udden onset of language symptoms, ass ociated known neurological insult. Neuroimaging techniques generally us ed to document the nature and extent of damage.

C OUR S E A ND P R OG NOS IS Developmental Type C ons iderable variability is evident in the severity, and outcomes s hown by children with developmental expres sive language disorders . P ros pective s tudies focus ed on late talkers (children with normal cognitive functioning who us e fewer than 50 words and no word combinations at 2 years of age). Although experts on whether late talkers actually meet criteria for the diagnosis of expres sive language disorder, their delays often provoke parental concern and referral. Outcomes are generally favorable, with 50 to 3880 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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percent of late talkers achieving language skills within normal range during the pres chool years. Mild residual deficits in grammar and discourse organization persis t, but mos t late talkers who recover during are at little risk for s evere learning and behavioral problems . A few, however, may experience reading problems , generally of a mild nature. P os sible outcome include the severity of the initial express ive the amount and variety of early communicative and the levels of receptive language and nonverbal intelligence. F urther work is required to validate thes e predictors . P rognos is becomes les s favorable when expres sive language dis orders persist into the late pres chool or school-age years . E xpres sive language growth to lag behind age-level expectations , limiting communicative effectivenes s in interpers onal and academic s ituations. Other ass ociated problems may appear in the early school years , particularly reading spelling difficulties and attention-deficit disorders . B y adoles cence, most individuals with expres sive disorders acquire sufficient language skill to function reasonably well in most daily communication activities . T hey may, however, continue to evidence s ubtle deficits in more demanding speaking tas ks , which precis e vocabulary and complex explanations . Overall, however, persistent express ive dis orders result in more favorable long-term outcomes than mixed receptiveexpres sive dis orders.

Ac quired Type C ours e and prognosis are also variable for children 3881 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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acquired language dis orders. S ome spontaneous generally occurs rapidly within days or weeks of the neurological ins ult, but additional improvements may show a protracted course over months or even years . Approximately two-thirds of children with acquired disorders eventually recover language functioning that broadly within the normal range, although s ubtle may pers ist. T hose who do not attain normal language functioning s how pers istent language and cognitive deficits of varying severity. P rognosis depends on factors , including the s everity, extent, and location of damage, the s pecific etiology, the age of ons et, the of preinjury language development, and the existence other preinjury dis orders.

TR E A TME NT Developmental Type E xperts disagree about the timing of intervention for expres sive language dis order. S ome advocate a waitsee attitude for young children with early expres sive delays (late talkers ), because mos t acquire normal language functioning during the preschool years . T hey argue that intervention should be provided only to with pers is tent expres sive delays at 4 or 5 years of Others s uggest that early intervention might prevent or minimize later language, academic, and behavioral difficulties . Unfortunately, few relevant data are on the efficacy of early versus late language R es earch on the efficacy of language intervention is accumulating but is not yet comprehensive. F ew studies have focus ed specifically on children with 3882 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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expres sive dis orders. T he available experimental however, indicate that various intervention techniques promote improved short-term us e of s pecific language features (e.g., pronouns, ques tion forms , tense markers , complex s entence forms, or narrative coherence). S everal recent s tudies sugges t that late may s how gains, not only for targeted language goals , also for other areas that were not specifically treated. remains to be shown, however, is whether intervention can accelerate the overall rate of long-term language growth and, perhaps, prevent or ameliorate the academic and ps ychosocial outcomes sometimes as sociated with persistent language disorders . Direct and mediated interventions have been shown to promote s hort-term language growth in children with developmental language dis orders (express ive and In direct interventions, the primary intervention agent is profes sional (us ually a speech-language pathologis t) works directly with the child to improve language functioning. In mediated interventions , the primary intervention agents are parents, teachers , or paraprofess ionals , who have been taught by the language profess ional to deliver the intervention to the child. Mediators are encouraged to incorporate facilitation techniques into daily activities and routines, thereby providing regular, naturalis tic opportunities for children to us e newly learned language features. F urther research on treatment efficacy is needed to addres s important outs tanding is sues. F or example, studies are required to as ses s (1) the ways in which interventions might be tailored to addres s the s pecific P.3142 3883 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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language needs of individual children, (2) the long-term merits of early intervention for children with express ive delays, and (3) the extent to which the benefits of intervention achieved in laboratory s tudies can also be demonstrated in routine community-based One recent study of routine early interventions that s ys tematic efforts may be required to improve their effectivenes s.

Ac quired Type F ew s tudies have systematically evaluated the efficacy language intervention for acquired expres sive children, perhaps becaus e these dis orders occur s o A critical concern is to facilitate the integration of who have experienced brain insults back into their and s chool environments. S uggestions in the literature deal with common express ive language s ymptoms , as word-finding and discours e organization problems , with as sociated cognitive, motor, and emotional of brain damage. F or older children with acquired expres sive dis orders, it may be reasonable to rely on evidence-based intervention guidelines that intervention techniques that have been shown to be effective for adults with acquired language disorders .

S UG G E S TE D C R OS S Mixed receptive-expres sive dis order (S ection 37.2) is similar in many res pects to express ive language P honological dis order (S ection 37.3) and reading (S ection 35.1) are clos ely related dis orders. S everal disorders may be considered in the differential 3884 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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of expres sive language dis order, including mental retardation (C hapter 34), pervasive developmental disorder (C hapter 38), and s elective mutism (S ection Dis orders that may cooccur with express ive language disorder include mathematics dis order (S ection 35.2), disorder of written expres sion (S ection 35.3), developmental coordination disorder (C hapter 36), stuttering (S ection 37.4), and attention-deficit disorders (C hapter 39).

R E F E R E NC E S B eitchman J H, Nair R , C legg M, F ergus on B , P atel P revalence of psychiatric dis orders in children with speech and language disorders . J Am Acad C hild P s ychiatry. 1986;25:528. B eitchman J H, Nair R , C legg M, P atel P G : speech and language dis orders in 5-year-old the Ottawa-C arleton region. J S pee ch He ar Dis ord. 1986;51:98. *B eitchman J H, W ild J , K roll R . An overview of speech and language dis order. In: Noshpitz J D, NE , eds. Handbook of C hild and Adoles ce nt V ol 4. New Y ork: W iley; 1997. B is hop DV . Language development after focal brain damage. In: B is hop D, Mogford K , eds . L anguage Deve lopme nt in E xce ptional C ircums tance s . E rlbaum; 1992:203. C antwell DP , B aker L. P s ychiatric and 3885 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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Dis orde rs in C hildre n with C ommunication Dis orde r. Was hington, DC : American P sychiatric P res s; 1991. *C hapman R : C hildren's language learning: An interactionis t perspective. J C hild P s ychol 2000;41:35. C ohen NJ , Davine M, Horodezky N, Lips ett L, Uns uspected language impairment in ps ychiatrically disturbed children: P revalence and language and behavioral characteristics . J Am Acad C hild Adole s c P s ychiatry. 1993;32:595. C onti-R amsden G , C rutchely A, B otting N: T he which psychometric tes ts differentiate subgroups of children with S LI. J S pee ch L ang He ar R e s . C rowe LK , Norris J A, Hoffman P R : T raining facilitate communicative participation of preschool children with language impairment during s torybook reading. J C ommun Dis ord. 2004;37:177. E is erman W , Weber C , McC oun M: P arent and profes sional roles in early intervention: A comparis on of the effects of two intervention configurations. J S pec E duc. 1995;29:20. E nderby P , E merson J . C hildren with speech and language dis orders. In: E nderby P , E mers on J , eds. S pe e ch and L anguage T herapy W ork? A R e view of L iterature. London: W hurr; 1995.

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F ey M, C leave P , Long S : T wo models of grammar facilitation in children with language impairments : P hase 2. J S pee ch L ang He ar R e s . 1997;40:5. F rancis D, F letcher J , S haywitz B , S haywitz S , Defining learning and language dis abilities : and ps ychometric is sues . L ang S pe ech H ear S e rv 1996;27:132. G irolametto L, P earce P , Weitzman E : E ffects of intervention on the phonology of late talkers. J Hear R e s . 1997;40:338. G logowska M, R oulstone S , E nderby P , P eters T : R andomised controlled trial of community bas ed speech and language therapy in preschool children. Me d J . 2000;321:923. Law J , B oyle J , Harris F , Harkness A, Nye C : and natural his tory of primary speech and language delay: F indings from a systematic review of the literature. Int J L ang C ommun Dis ord. 2000;35:165. Nas s R , B oyce L, Leventhal F , Levine B , Allen J , C , S alsberg D, S arno M, G eorge A: Acquired children after s urgical res ection of left-thalamic tumours. Dev Me d C hild N eurol. 2000;42:580. *Nels on NW . C hildhood L anguage Dis orde rs in Infancy through Adole s ce nce . 2nd ed. B os ton: Allyn B acon; 1998. 3887 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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Noterdaeme M, Mildenberger K , Minow F , Amoros a Quantitative and qualitative evaluation of behavior in children with a specific speech and language dis order. Infant C hild Dev. 2002;11:3. Olswang L, R odriguez B , T imler G : R ecommending intervention for toddlers with s pecific language impairment: W e may not have all the answers , but know a lot. Am J S pe ech L ang P athol. 1998;7:23. *Owens R E . L anguage De ve lopment: An ed. Needham Heights , MA: Allyn and B acon; 2001. P aul R , F ountain R : P redicting outcomes of early expres sive language delay. Infant T oddler Interv. 1999;8:123. P aul R , Murray C , C lancy K , Andrews D: R eading metaphonological outcomes in late talkers. J L ang He ar R es . 1997;40:1037. R es corla L: Language and reading outcomes to age late-talking toddlers . J S pee ch L ang He ar R e s . 2001;45:347. R obertson S B , W eis mer S E . E ffects of treatment on linguistic and social skills in toddlers with delayed language development. J S pee ch L ang He ar R e s . 1999;42:1234. R us sell N: E ducational considerations in traumatic injury: T he role of the speech-language pathologis t. 3888 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/37.1.htm

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L ang S pe ech H ear S e rv S ch. 1993;24:67. T hal D, O'Hanlon L, C lemmons M, F ralin L: V alidity parent report measure of vocabulary and s yntax for preschool children with language impairment. J L ang He ar R es . 1999;42:482. T hal DJ , R eilly J , S eibert L, J effries R , F ens on J : development in children at risk for language impairment: C ros s -population comparis ons . B rain 2004;88:167. T omblin J B , R ecords N, B uckwalter P , Zhang X, O'B rien M: P revalence of specific language in kindergarten children. J S pee ch L ang He ar R e s . 1997;40:1245. T omblin J B , Zhang XY , B uckwalter P , O'B rien M: stability of primary language disorder: F our years kindergarten diagnos is. J S pee ch L ang He ar R e s . 2003;46:1283. T oppelberg C , Medrano L, P ena Morgens L, NietoC as tanon A: B ilingual children referred for services : As sociations of language dis orders , skills , and ps ychopathology. J Am Acad C hild P s ychiatry. 2002;41:712. *T oppelberg C , S hapiro T : Language disorders : A year research update review. J Am Acad C hild P s ychiatry. 2000;39:143.

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Weismer S E : Intervention for children with developmental language delay. In: B is hop DV , LB , eds . S pe e ch and L anguage Impairme nts in C aus es , C haracte ris tics , Inte rvention, and Hove, E ast S uss ex: P sychology P ress ; 2000.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 38 - P ervas ive Developmental Dis orders > 38 - P ervas ive Dis orders

38 Pervas ive Developmental Dis orders Fred R . Volkmar M.D. Ami K lin Ph.D. R obert T. S chultz Ph.D. 

DE F INIT ION

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AUT IS T IC DIS OR DE R

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R E T T 'S S Y NDR OME

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C HILDHOOD DIS INT E G R AT IV E DIS OR DE R

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AS P E R G E R 'S S Y NDR OME



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AT Y P IC AL AUT IS M/P E R V AS IV E DIS OR DE R NOT OT HE R W IS E S P E C IF IE D S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 38 - P ervas ive Developmental Dis orders > DE F INIT IO

DE FINITION P art of "38 - P ervas ive Developmental Dis orders" 3891 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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T he pervas ive developmental dis orders are early-onset conditions characterized by delay and deviance in the development of s ocial, communicative, and other s kills . contrast to the lack of interest in the s ocial unusual s ensitivity to the inanimate environment is T his might include various motor manneris ms (s tereotypies ), res is tance to change, and idiosyncratic interes ts and preoccupations. In the revis ed fourth of the Diagnos tic and S tatis tical Manual of Me ntal (DS M-IV -T R ), this category includes autis tic disorder, syndrome, childhood disintegrative dis order, syndrome, and pervas ive developmental dis order not otherwis e s pecified/atypical autis m. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 38 - P ervas ive Developmental Dis orders > AUT IS T IC

AUTIS TIC DIS OR DE R P art of "38 - P ervas ive Developmental Dis orders"

Definition Autistic dis order, als o known as childhood autis m, autis m, and early infantile autis m, is, by far, the best of the pervasive developmental disorders . In this condition, there is marked and s us tained impairment in social interaction, deviance in communication, and res tricted or s tereotyped patterns of behavior and Abnormalities in functioning in each of these areas be pres ent by age 3. Approximately 70 percent of individuals with autism function at the mentally retarded level, and mental retardation is the mos t common 3892 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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comorbid diagnos is . DS M-IV -T R criteria for autis tic are lis ted in T able 38-1.

Table 38-1 DS M-IV-TR C riteria for Autis tic Dis order A. A total of s ix (or more) items from (1), (2), and with at leas t two from (1) and one each from (2) (3).    (1) Qualitative impairment in s ocial interaction, manifested by at least two of the following:       (a) marked impairment in the us e of multiple nonverbal behaviors such as eye-to-eye gaze, expres sion, body postures, and ges tures to social interaction       (b) failure to develop peer relationships appropriate to developmental level       (c) a lack of s pontaneous seeking to s hare enjoyment, interests , or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)       (d) lack of s ocial or emotional reciprocity

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   (2) Qualitative impairments in communication manifested by at least one of the following:       (a) delay in, or total lack of, the development spoken language (not accompanied by an to compensate through alternative modes of communication such as ges tures or mime)       (b) in individuals with adequate s peech, impairment in the ability to initiate or sus tain a conversation with others       (c) stereotyped and repetitive us e of language idios yncratic language       (d) lack of varied s pontaneous make-believe or s ocial imitative play appropriate to developmental level    (3) R es tricted repetitive and s tereotyped of behavior, interests , and activities , as by at leas t one of the following:       (a) encompass ing preoccupation with one or more s tereotyped and restricted patterns of that is abnormal either in intens ity or focus       (b) apparently inflexible adherence to specific, nonfunctional routines or rituals

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      (c) stereotyped and repetitive motor (e.g., hand or finger flapping or twis ting, or whole body movements)       (d) pers istent preoccupation with parts of B . Delays or abnormal functioning in at least one the following areas , with ons et before age 3: (1) social interaction, (2) language as used in social communication, or (3) s ymbolic or imaginative C . T his dis turbance is not better accounted for by R ett's syndrome or childhood disintegrative disorder.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

His tory In 1943, Leo K anner first des cribed 11 cas es of what termed autis tic dis turbance s of affective contact. In cases, there was a congenital “inability to relate” to in us ual ways . K anner als o noted unus ual res ponses to environment, which could include both s tereotyped manneris ms and res istance to change or insistence on samenes s, as well as unusual aspects of the child's 3895 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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communication skills, such as pronoun revers al and tendency to echo language (echolalia). K anner's phenomenologically based description of this condition remains worthy of review. However, at the s ame time, was mistaken about s ome as pects of the condition, early mis conceptions took some time to clarify. F or example, K anner believed that the condition was not as sociated with mental retardation because the looked “intelligent” and did well on some parts of intelligence quotient (IQ) tests . As time went on, it clear that mos t children function in the mentally range. However, consistent with K anner's original observation, it continues to be the cas e that marked scatter in skills—with occas ional “splinter s kills ”—is observed. K anner mentioned that, in his original cas es , parents were unusually well educated or s ucces sful in occupations . T his led to the notion that autis m might somehow res ult from pathological patterns of care. C ons iderable evidence s uggests this is not the cas e. is no particular bias in terms of s ocial class distribution autis m if factors that control for case as certainment are controlled for. It is also the case that parents of autis tic children do not exhibit specific deficits in parenting or other aspects of child care and are not likely to have ps ychiatric disabilities at an increas ed rate, with the exception of mood disorders and a range of developmental difficulties . F inally, K anner's use of the autis m was reminiscent of E ugen B leuler's earlier us e term to des cribe the quality of s elf-centered thinking typically s een in schizophrenia. Although K anner believed that autism and s chizophrenia were unrelated, us e of this word became a source of confusion for years . T here was an as sumption of continuity bas ed on 3896 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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severity—that is , because autism was so s evere, it was as sumed to s omehow be on a continuum with schizophrenia. In his report, K anner was careful to provide a developmental context for his obs ervations. He emphasized the centrality of deficits in social as well as unusual behaviors in the definition of the condition. During the 1960s , there was much confusion about the nature of autism and its etiology. In the early 1960s , a growing body of evidence began to to s uggest that the condition resulted from a neuropathological proces s. Difficulties in cons ensual definitions and confusion regarding the similarities and differences between autism and childhood were complications. B y the 1970s, a cons iderable body evidence began to accumulate sugges ting the neurobiological bas is of the disorder. T his included rates of s eizures as children were followed over time, observation of persis tence of unus ual “primitive” and other neurological signs . F ollow-up studies of large groups of “ps ychotic” children als o revealed a bimodal distribution of onset of this poorly defined set of cas es. early-onset group, noted by Israel K olvin, Michael and others appeared to have many of the described by K anner. C hildren with later-onset “ps ychos is ” (after age 5 or 6) s eemed to res emble with schizophrenia in that they had delusions , hallucinations , and so forth. F amily his tory als o discriminated the late-onset groups with higher rates of schizophrenia in family members . A landmark in clas sification occurred in 1978 when Michael R utter propos ed a definition of autis m bas ed on 3897 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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1. S ocial delay and deviance (not jus t due to mental retardation) 2. C ommunication problems (not jus t due to mental retardation) 3. Unus ual behaviors , s uch as stereotyped and manneris ms (insistence on sameness ) 4. Onset before age 30 months R utter's definition and the growing body of work on autis m were influential in the definition of the condition DS M-III. In DS M-III, the condition was firs t recognized placed in a new clas s of dis orders—the pervasive developmental disorders .

C omparative Nos ology In the firs t and second editions of DS M (DS M-I and autis m was not officially recognized; rather, it was as being on s ome continuum with schizophrenia. It now recognized that childhood s chizophrenia, particularly early–onset childhood P.3165 schizophrenia, is quite rare. However, in the 1950s and 1960s , a broad view of schizophrenia predominated. T he definition of autis m in DS M-III was based largely R utter's s ynthes is of K anner's original description and subs equent research. T he name of the dis order autis m emphasized its early ons et and als o reflected a certain lack of developmental orientation in the and criteria for it. C riteria for the condition were monothetic and mos t appropriate to younger children 3898 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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with autism; a category, residual infantile autism, was available for children, adolescents, and adults who had met criteria for the condition but no longer did s o. concept was problematic in several res pects and the lack of a developmental orientation. In DS M-III-R , the concern about the lack of emphasis was addres sed. Age of onset could be before or after 36 months . T he condition was on the bas is of a set of 16 very detailed criteria the traditional three categories of social disturbance, communicative disturbance, and res tricted and behaviors . T he greater developmental orientation of III-R also resulted in a broader diagnostic concept that probably overinclus ive. An additional change in DS Mwas the multiaxial placement of autism and other pervas ive developmental dis orders. In DS M-III-R , the condition was moved to Axis II, and only the two diagnoses of autistic disorder and pervasive developmental disorder not otherwise specified were included. T he term pe rvas ive de ve lopmental dis orde r has been topic of s ome debate. It was originally coined in 1980 new term for the class of dis orders to which autism was as signed. T he term was chos en to reflect the fact that multiple areas of functioning are affected in autis m and related conditions. However, some inves tigators and clinicians have objected to the term becaus e it seems imply a greater degree of s everity than is always individual cas es . However, it is clear that, by the time DS M-III-R , the term had come into general usage, and us ed as a category for the tenth revision of S tatis tical C las s ification of Dis eas es and R e lated 3899 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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P roblems (IC D-10). In IC D-9, the category of psychoses with onset in childhood included the subgroup of infantile autism, among others. T he use of the term ps ychos is in IC D-9 perpetuated the mistaken impres sion that autis m was related to adult schizophrenia. In IC D-10, the pervas ive developmental disorder category includes childhood autis m, atypical autis m (in which there is a failure to the behavioral or ons et criteria), R ett's s yndrome, other childhood disintegrative disorder, overactive disorder mental retardation and stereotyped movements, Asperger's s yndrome, other pervasive developmental disorder, and pervasive developmental disorder unspecified. In contras t to DS M-IV -T R , there is an even greater attempt to differentiate s ubgroups of pervas ive developmental disorders . However, the validity of thes e conditions has been the topic of s ome debate, and definitive data are lacking. Des pite the concerns about such dis tinctions , the working group respons ible for IV decided, partly on the basis of a large international trial, to try to achieve as much consistency with IC D-10 poss ible. In the end, this was largely achieved, there are some differences in terms of emphas is . F or DS M-IV , potential new criteria, as well as DS M-III DS M-III-R and pending IC D-10 criteria, were evaluated an international, multisite s tudy including nearly 1,000 cases evaluated by more than 100 raters . In DS M-IV autis m is defined on the bas is of behavioral features age of ons et; age of onset must be before 3 years . B ehavioral difficulties mus t include some feature of disturbance, communicative disturbance, and res tricted interes ts or repetitive behaviors . T he definitions of 3900 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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in both IC D-10 and DS M-IV -T R are conceptually T here was an explicit attempt to avoid the overinclusivenes s of DS M-III-R criteria for autistic In addition, the disorder was returned to Axis I. T he number and detail of criteria were also reduced in Interrater reliability was as sess ed for autis m and conditions and was generally good to excellent, particularly for experienced clinicians . T he DS M-IV -T R provides updated text for autism and related disorders .

E pidemiology Prevalenc e T he firs t epidemiological s tudy of autis m was by V ictor Lotter in 1966, who reported a prevalence 4.5 in 10,000 children among the entire 8- to 10-yearpopulation of Middlesex, a county northwes t of London. S ince then, more than 30 epidemiological s tudies have appeared (T able 38-2). T he median prevalence rate of these studies is 8.7 in 10,000. However, rates tend to higher in s tudies with smaller s amples and also tend to higher more recently. If one excludes s maller and older studies, the median rate is s lightly higher— 9.5 in 10,000. V ariability among s tudies reflects methodological is sues, s uch as s ample s ize, s yndrome definition, and s tudy design. Increased awarenes s of P.3166 condition on the part of health profes sionals and educators may also have contributed to increased case detection. P os sible reas ons for the increas ed rate in recent studies involves the adoption of definitions of autis m more applicable to the entire range of syndrome 3901 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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expres sion, as well as use of s maller target S ome s tudies have focused on the broader pervas ive developmental disorder spectrum rather than on autism more narrowly defined. It is reasonable to say that approximately 1 in every 1,000 children may have with an even larger number exhibiting some features of the condition. T he is sue of whether autis m is frequency—that is , if there is truly a s ecular change in of autism—has been the object of much debate. Unfortunately, the data available to addres s this is sue limited. T here are marked variations in prevalence, for studies conducted at the same point in time. It is that at least s ome of the apparent increase may be accounted for by other factors ; prospective surveillance data are needed to address this is sue.

Table 38-2 S elec ted E pidemiolog S tudies of Autis m S tudy, Year

C ountry

S ize of Target Population

C riteria Us ed B as ed On

Preva R ate ( 10,000

Lotter, 1966

United K ingdom

78,000

K anner, 1943

4.5

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Wing et 1976

United K ingdom

25,000

K anner, 1943

4.8

Hos hino et al., 1982

J apan

609,848

K anner, 1943

2.3

G illberg et al., 1984

S weden

128,600

DS M1980

4.0

C ialdella & Mamelle, 1989

F rance

135,180

DS M1980

4.5

G illberg et al., 1991

S weden

78,106

DS MR,

9.5

F ombonne et al.,

F rance

325,347

IC D1992

5.3

G . B aird et al., 2002

United K ingdom

16,235

IC D1992

30.8

C hakrabarti United K ingdom & F ombonne, 2001

15,500

IC D1992

16.8

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S tudies based on both clinical and epidemiological samples have s uggested a higher incidence of autis m boys than in girls, with ratios reported averaging 3.5 or 4.0 to 1. T his ratio varies, however, as a function intellectual functioning. S ome studies have reported of up to 6.0 or higher to 1 in individuals with autism without mental retardation, whereas ratios within the moderately to severely mentally retarded range have reported to be as low as 1.5 to 1. It is s till unclear why females are underrepres ented in the nonretarded One poss ibility is that males have a lower threshold for brain dys function than females , or, conversely, that severe brain damage would be required to caus e a girl. According to this hypothesis, when the person autis m is a girl, s he is more likely to be s everely impaired.

S oc ial C las s Although a few early studies s upported K anner's impres sion of an as sociation between autism and socioeconomic s tatus , mos t epidemiological s tudies published in the 1980s and 1990s have failed to reveal such as sociation. In addition to the bias for more and s ucces sful parents to seek referral, it seems likely families from disadvantaged backgrounds are still underrepres ented in clinically referred s amples. initiatives are s till needed to provide equal acces s to diagnostic and intervention services to children from all socioeconomic backgrounds . Autism clearly is s een in social class es and in all countries.

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Ps yc hos oc ial Theories K anner's s peculation that emotional factors might be involved in the pathogenesis of autism led others to conclude that the condition was always caus ed by the experience of a “refrigerator” mother who was not res ponsive to the child's emotional needs . In this view, intens ive ps ychotherapy was needed for mother and or, sometimes, the child was removed from the family attempt to remediate the presumed deficits. Unfortunately, there was no evidence that s uch efforts were efficacious. A generation of parents was by the experience of being blamed for their child's condition.

B iologic al Theories As children with autis m were followed, various factors suggested a biological bas is of the condition. T hes e included the high rates of mental retardation and disorders and the recognition that various medical and genetic conditions were s ometimes as sociated with autis m. T he current cons ens us is that autis m is a behavioral s yndrome caus ed by one or more factors on the central nervous s ys tem (C NS ). Although the underlying biological abnormalities of autism are unknown, efforts are now under way to delineate more precis ely testable neuropathological mechanis ms .

Genetic Fac tors T he early impress ion was that genetic factors had no in the pathogenesis of autism. However, the condition relatively rare, and cases did not s eem to reproduce. S tudies of twins indicated high levels of concordance, 3905 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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es pecially for monozygotic same-sex twin pairs , with a reduced level of concordance for fraternal or dizygotic same-sex twin pairs . T here was also a finding that suggested high rates of cognitive difficulties in the unaffected monozygotic twin were ass ociated with perinatal complications in the autis tic co-twin, a perinatal insult related to autism in the face of s ome inherited liability for the disorder. In general, family have demonstrated a rate of recurrence in families of approximately 2 to 7 percent of autis m cas es among siblings . T his is , however, a 50- to 200-fold increase in rate of autism relative to the general population. E ven when not affected with autis m, siblings are at increased ris k for various developmental difficulties , including problems in language and cognitive development. It remains unclear whether what is inherited is a s pecific predis pos ition to autis m or a more general to developmental difficulties . R ecent work on the family members of autis tic individuals finds higher rates of and anxiety problems and increased frequency of difficulties . Although the role of genetic factors in now well established, s pecific modes of inheritance unclear. E fforts are under way to identify potential genetic mechanisms in autis m, and promis ing leads have been identified through linkage analyses on s everal chromosomes, including regions on chromos omes 7, 2, 15, and 19. V arious candidate genes have also been evaluated. It now appears likely that an es timated four five genes are involved, and it is likely that s ome forms of autis m will be identified over the next few P.3167 3906 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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Other Medic al C onditions and Autism has also been as sociated with other conditions with a s trong genetic component, most notably fragile syndrome and tuberous s cleros is. In fragile X, a marker chromosome is noted to be “fragile” in that, when in a special medium deficient in folic acid, there is a that commonly fractures. T he fragile X mutation triplet repeat of cytosine-guanine-guanine, which may amplify with s ucceeding generations. P hysical s igns of condition include characteris tic facies , enlarged as sociated mental retardation, and s ome autis tic B ehavioral difficulties include attention problems, impulsivity, and anxiety. Initially, there was great enthus ias m for the notion that fragile X might account most cases of autis m in boys . In fact, only percent of individuals with autis m are affected. T his condition remains the s econd mos t important known chromosomal etiology of mental retardation after Down syndrome. T uberous s cleros is is characterized by abnormal tiss ue growth, or benign tumors (hamartomas), which affect various organ systems . T his autosomal dominant is as sociated with a range of phenotypes , including retardation and seizure disorder. S tudies of individuals with autism find tuberous s cleros is in between 0.4 and percent of cas es , a s ignificant elevation over the rate of condition in the general population. R ates of autis m in individuals with this disorder are high.

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S everal studies have shown increas ed rates of pre-, and neonatal complications in children with autism. of the difference relates to obs ervation that s omething unusual is noted about the child at birth; this may the operation of genetic, as well as perinatal, factors . genetic predis pos ition to autis m may interact with perinatal factors in producing the s yndrome.

OTHE R E TIOL OG IE S V arious reports have as sociated autism with a host of conditions. However, these reports usually reflect cases rather than controlled s tudies. S everal have been of interest—for example, autis m ass ociated with phenylketonuria, neurofibromatos is, and rubella. However, it is clear that when children with congenital rubella who were initially thought to have autis m were followed over time, their “autis tic-like” features tended to diminish; als o, such children exhibit range of sensory deficits and mental retardation, both which complicate the diagnostic process . T here has much interes t in recent years regarding whether a increase in autism might be linked to environmental or other factors; the data supporting s uch as sociations not presently s trong.

Pos tmortem and Neuroimaging S tudies At one point or another, disturbance in nearly every system in the brain has been proposed to be a fundamental mechanism caus ing autism. T heories typically derive from beliefs about the mos t salient behavioral and ps ychological features of the dis order, 3908 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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sometimes with explicit cons ideration of developmental cours e. F or example, thos e who emphasize difficulty complex information process ing as the principal characteristic of autis m postulate widespread cortical abnormalities s paring early sensory and emotional proces ses as the neural bas is of autis m. On the other those who focus on the emotional deficits and their role social difficulties often highlight the limbic system in the pathogenes is of autism. T he social, language, and behavioral problems that with autis m s ugges t that the syndrome affects a functionally divers e and widely distributed s et of neural systems . At the same time, however, the affected must be dis crete, because autism spares many and cognitive s ys tems. F or example, autis m is not incompatible with normative intelligence or even visual perceptual and other neurops ychological skills talents. E ven though the full s yndrome likely involves insults to multiple systems , it remains pos sible that the initial insult is localized, branching off into more impairments becaus e of the highly interdependent of developmental process es . C urrent data are not yet specific enough to point to any one theory in clear favor over others , although there is good postmortem and neuroimaging evidence for abnormalities of the limbic system and circuitry within the temporal and frontal (T able 38-3).

Table 38-3 B rain R egions of Potential Importanc e in Autis m 3909 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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B rain Area

Func tion

Amygdala

E motional arousal and emotional learning

 

   P art of the subcortical network (retina ↑ superior colliculus ↑ pulvinar ↑ amygdala) for detecting emotionally relevant s timuli (e.g., fearful faces )

E xtended amygdala, ventral

S ocial reward circuitry

   S triatum and nucleus accumbens

 

Hypothalamus

Attachment

F us iform gyrus (es pecially lateral as pect of the right fus iform)

F ace (pers on) recognition

 

S ocial cognition 3910

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S uperior temporal sulcus

Interpreting biological movement as a nonverbal communication, including direction of eye gaze; facial expres sions ; hand, head, body ges tures

Orbital prefrontal cortex

E motional learning

Medial prefrontal cortex

S ocial cognition (interpreting what others might be thinking and feeling)

P os tmortem studies of a s mall number of individuals autis m have revealed a range of abnormalities , significant decreas e in the number of P urkinje cells and granule cells in the cerebellum. T he precise nature of abnormalities , including a lack of gliosis indicative of scarring, s uggests a prenatal origin. T he role of these abnormalities in autistic symptoms remains to be es tablis hed. A s eries of magnetic resonance imaging studies focus ing on the cerebellar vermis revealed an initial finding of a decreas e in the mids agittal area of vermal lobules V I and V II, but thes e findings have not independently replicated in studies controlling for age IQ effects. Moreover, pos tmortem evidence does not include neurons of the vermis. Other neuroimaging of the pos terior fos sa have, likewis e, failed to yield 3911 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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cons istent results . P os tmortem studies als o implicate the limbic system in pathophys iology of autism. T here is cons is tent for decreas ed neuronal s ize, decreased dendritic arborization, and increas ed neuronal packing dens ity of neurons in the amygdala, hippocampus , s eptum, cingulate, and mammillary bodies. T hes e abnormalities suggestive of a curtailment of normal development. affected regions are s trongly interconnected, and, together, they comprise a majority of the limbic system. T he limbic s ys tem, especially the amygdala, is part of a neural system that s upports social and emotional functioning. T hes e postmortem findings , therefore, are often heralded as the first good entrance points for unders tanding the pathobiology of the autis m s pectrum disorders . T he orbital and medial prefrontal cortices dense reciprocal connections , with the amygdala providing the architecture P.3168 for a s ys tem that can regulate s ocial–cognitive A parallel s et of amygdala–cortical circuitry in the lobes focus es on s ocial–perceptual proces ses. One hypothes is is that autis m is largely caused by abnormalities in both of thes e amygdala–cortical loops . T here is s upportive evidence for an amygdala theory of autis m from lesion s tudies in nonhuman primates . Des tructive lesions made to the amygdala or just after birth produce some of the cardinal features of autis m over the first year of life. T he sequelae include social isolation, lack of eye contact, expres sionless and motor s tereotypies. However, there remain 3912 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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is sues with thes e s tudies, including the extent to which autis tic-like sequelae may be due to damage of fibers pass age rather than cell bodies of the amygdala and extent to which the outcomes are adversely influenced nursery as oppos ed to mother rearing. Importantly, lesions in adulthood fail to produce autistic-like T his s et of data s upports a developmental model of that res ts on faulty emotional learning. S tructural MR I studies of the amygdala and have failed to find cons istent differences in the volume these structures. F unctional MR I (fMR I), on the other has s hown the amygdala to be hypoactive across a number of s tudies that us ed neurops ychological probes involving s ocial and affective judgments . of the amygdala is intriguing because of its connections and functional relations hips to both earlier and later sens ory process ing systems and to areas of the frontal believed to be involved in higher-order s ocial T he amygdala receives inputs from a s ubcortical visual system, from the occipital–temporal cortical visual and, also, from aspects of the medial and orbital frontal lobes . T he cortical connections are reciprocal. E ach s et connections participates in different aspects of information process ing, and each may have a different level of importance during different s tages of child development. It is not yet known how these detailed interactions may relate to the pathophysiology of However, additional fMR I s tudies show that both frontal and ventral temporal areas have abnormally low levels of functional activity during a variety of s ocial T he best-replicated functional finding concerns underactivation of a region of the fus iform gyrus on the 3913 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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ventral s urface of the temporal lobe during face perception tas ks (F ig. 38-1). B ecause of the s pecificity this area for faces , it has come to be known as the face area. Approximately s ix studies by different have shown that older children, adolescents , and with autis m have reduced levels of res ponsivity to the human face in the fus iform face area, es pecially in the hemis phere. T hes e data are cons is tent with an ps ychology literature documenting performance deficits face and facial express ion recognition in autism, and provide an important key to unders tanding the core deficits in autism.

FIGUR E 38-1 C ompos ite functional magnetic res onance image comparing a group of 14 normal controls (NC s ) and 14 individuals with autism or Asperger's s yndrome (autism), matched on age and intelligence quotient. C omposite images s how areas preferentially activated by faces (a,c) and nonface 3914 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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objects (b,d). Note that the fusiform “face area” has been defined by a green box in a. Among individuals with autism or Asperger's syndrome, there is underactivation of the fus iform gyrus during face perception and compens atory activation of a region lateral to the fusiform. T his more lateral region was most strongly activated by the object task among the NC s. Hypoactivation of the fusiform face area is the best-replicated functional neuroimaging finding in literature. (S ee C olor P late.) (Adapted from S chultz G authier I, K lin A, et al.: Abnormal ventral temporal cortical activity during face discrimination among individuals with autism and As perger syndrome. G e n P s ychiatry. 2000;57:331-340.) Aspects of frontal lobe integrity and function also have been implicated in the pathogenesis of autis m. primate s tudies have documented abnormal s ocial res ponsivity and loss of social position within the s ocial group after les ions to orbital and medial prefrontal Older human s tudies using lower-res olution techniques reported general hypoactivation of the lobes . More recent data s uggest that subregions of the prefrontal cortices with es pecially strong connectivity to limbic areas are critical for s ocial cognition—that is , thinking about other's thoughts , feelings , and Deficits in s uch “theory of mind” abilities are common in autis m and, als o, in neurovascular accidents, causing bilateral les ions to orbital and medial prefrontal cortex. P reliminary functional imaging evidence in autis m spectrum conditions s uggests altered functional 3915 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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representation in prefrontal cortices regions during of mind tasks. Moreover, medial prefrontal activity was shown in one study to be s ignificantly reduced. One of the more intriguing findings to emerge in the few years is that overall brain size appears to be in autism (by 2 to 10 percent). It is not yet unders tood whether all brain regions and s ys tems are equally by the expansion or whether this finding applies to all levels of cognitive functioning. T here is als o s ome variability in the s ize of the effect with age; some suggest that the enlargement is especially pronounced childhood, perhaps affecting white matter more than matter. It is als o not clear how whole-brain would s erve as a risk factor for autism, as it could be a marker for a disturbance in the fine s tructure of the that actually caus es autistic s ymptoms. Increas ed brain might come at the expense of interconnectivity specialized neural s ys tems, giving ris e to a more fragmented proces sing s tructure. In fact, some suggests that the corpus callosum, the major fiber pathway between the hemispheres , is reduced in s ize autis m. Moreover, one positron emis sion tomography (P E T ) s tudy found a reduction in coordinated brain Less neural integration would be consistent with one influential theory that attributes autistic symptoms to a lack of “central coherence,” a cognitive process ing that makes integration of parts into wholes problematic.

Neuroc hemis try B eginning in 1961, a number of studies have reported approximately one-third of children with autis m have 3916 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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increased peripheral levels of the neurotransmitter serotonin. T his has been the focus of much res earch, the significance of this finding remains unclear, as the finding is not s pecific to autism, and the relation of peripheral levels to central levels of serotonin is P.3169 Another line of work has focused on other neurotransmitters such as dopamine. A hyperdopaminergic functioning of the brain might the overactivity and s tereotyped movements s een in autis m. T his would be consistent with the general observation that administration of s timulants , which increase levels of dopamine, s ometimes worsens behavioral functioning in autis m. S tudies of fluid (C S F ) of dopamine metabolites and metabolites have been incons is tent. It is clear that that block dopamine receptors are effective in reducing the stereotyped and hyperactive behaviors of many autis tic children. T he endogenous opioids have been investigated, given the poss ibility that thes e compounds —enkephalins and endorphins —might lead to social withdrawal and sens itivities to the environment. T his was the rationale us e of opioid antagonis ts s uch as naltrexone (Depade) treating children with autis m. Although it does appear there may be a modes t effect of thes e agents on the levels of activity and agitation overall, res ults have disappointing.

IMMUNE THE OR IE S OF A UTIS M S ome work has s uggested a pos sible role of 3917 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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immunological factors in autis m. T here has been a suggestion that maternal antibodies directed against fetus may be produced in utero. T here als o have been reports of autis m as sociated with viral infections. C ons iderable controversy has arisen over the ques tion whether exposure to the measles -mumps-rubella immunization might be a caus ative factor. T his res ts largely on cas e reports that report the apparent of autism with the immunization; however, it has long been known that a s mall number of children with present with a developmental regres sion, and the bulk the available evidence does not s upport a causative as sociation with immunization. T he potential negative effect of an increas e in children not immune to measles cons iderable.

Diagnos is and C linic al F eatures A diagnosis of autis tic dis order requires at least six behavioral criteria, one from each of the three areas of disturbance in s ocial interaction, communication, and res tricted patterns of behavior and interes t (T able 38T here is a marked range of syndrome express ion in Among the lowes t-functioning children, the child is largely or entirely mute, is is olated from social interaction, and makes few s ocial overtures . At the next level, the child may accept social interaction pass ively does not s eek it out. At this level, some s pontaneous language may be observed. Among the higherfunctioning and s omewhat older children, the child's style is different, in that he or s he may be interes ted in social interaction but cannot s ustain it in typical ways . social s tyle of such individuals has been termed “active odd,” in that they often have difficulty regulating social 3918 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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interaction once it has commenced. G iven the range of syndrome express ion and variations in pres entation age, there is cons iderable potential for mis diagnosis . E valuation of the child with autis m s hould include a detailed his tory, comprehensive medical and developmental examination, and ps ychological testing.

Age at Ons et T he onset of autis m is almost always before age 3 (F ig. 2); parents typically are concerned between the ages and 18 months as language fails to develop. Although there may be concern that the child is deaf, the parents also note the child may res pond quite dramatically to sounds in the inanimate environment; occas ionally, parents report, in retros pect, that the child was “too made few demands, and had little interes t in social interaction. T his is in stark contrast to normally infants, for whom the human face and s ocial interaction are among the most interes ting and salient features in world. Occas ionally, parents report that the child to develop s ome language, and, then, his or her either plateaued or was los t; s uch a history is reported perhaps 20 to 25 percent of cases . Often, detailed of early developmental his tory or of videotapes of the child at a younger age will reveal s ome earlier and true regress ive autis m (i.e., with a dramatic ons et symptoms in a previous ly normal child) is probably uncommon. Almos t always, parents report being by age 2 and, inevitably, by age 3 (ons et of the after age 3 would res ult in a diagnosis of atypical

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FIGUR E 38-2 Age of recognition in autis m in a 174 cons ecutive cases.

Qualitative Impairments in S oc ial Interac tion Normally developing infants have a marked interes t in social interaction and the s ocial environment from birth. T his predisposition is an important foundation for development of other skills. In infants and young with autism, the human face holds little interes t; disturbances are s een in the development of joint attention, attachment, and other as pects of s ocial interaction. F or example, the child may not engage in us ual games of infancy, may have difficulties with imitation, and may lack usual play skills. T hese deficits highly distinctive and are not jus t due to as sociated developmental delay. S ocial interes t may increas e over time. T here is often a 3920 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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developmental progress ion, with younger and more impaired individuals being avoidant or aloof from interaction, whereas somewhat older or more individuals are willing to pass ively accept interaction do not seek it out. Among the mos t able individuals autis m, there is often social interest, but the person has difficulty in managing the complexities of social interaction; this often leads to an unus ual or eccentricappearing social style.

Qualitative Impairment in Verbal and Nonverbal C ommunic ation and Play As many as 40 percent of individuals with autism never speak. Delays in the acquis ition of language are the frequent presenting complaint of parents . Usual of language acquisition (e.g., playing with s ounds and babbling) may be abs ent or infrequent. Infants and children with autis m may take the parent's hand to a des ired object without making eye contact (i.e., as if hand, rather than the pers on, is obtaining the item). In contrast to the child with a language dis order, there is P.3170 no apparent motivation to engage in communication or attempt to communicate via nonverbal means . When individuals with autis m do speak, their language remarkable in various ways. T hey may echo what they have heard (echolalia). S peech tends to be less for example, there is no appreciation that change in perspective or s peaker requires pronoun change; this to pronoun reversal. S peech may be nonreciprocal in nature—for example, the child produces language that 3921 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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not meant as communication. Although the s yntax and morphology of language are relatively spared, and s emantic s kills may be slow to develop and the social uses of language (pragmatics) are difficult for individuals with autis m. T hus , humor and sarcasm may be a s ource of confus ion, as the pers on autis m may fail to appreciate the s peaker's intent, res ulting in an overly literal interpretation of the utterance. Often, intonation is monotonic and robotDeficits in play may include a failure to develop us ual patterns of s ymbolic–imaginative play. T he autistic may explore nonfunctional aspects of play materials tas te or s mell) or use as pects of materials for s elfstimulation (spinning the tires on a toy truck).

Markedly R es tric ted Ac tivities and Interes ts C hildren with autism often have difficulty tolerating change and variation in routine. F or example, an to alter the sequence of s ome activity may be met with what appears to be catas trophic distress on the part of child. P arents may report that the child insists that they engage in activities in very particular ways . C hanges in routine or in the environment may elicit great or ups et. T he child may develop an interes t in a activity—for example, collecting strings and using them for s elf-stimulation, memorizing numbers , or repeating certain words or phrases . In younger children, to objects , when they occur, differ from us ual objects in that the objects chosen tend to be hard than s oft, and, often, it is the class of object, rather the particular object, that is important—for example, 3922 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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child may ins ist on carrying a certain kind of magazine around with him or her. S tereotyped movements may include toe walking, finger flicking, body rocking, and other manneris ms ; these are engaged in as a s ource of pleas ure or self-soothing. T he child may be with s pinning objects —for example, he may spend long periods watching a ceiling fan rotate.

As s oc iated Features In contras t to K anner's early belief that children with autis m had good cognitive potential, approximately 70 percent are mentally retarded (F ig. 38-3). T he typical profile on psychological testing is marked by s ignificant deficits in abs tract reasoning, verbal concept formation, and integration skills, and on tas ks requiring a degree social understanding. T herefore, on the Wechs ler for example, weakness es are usually obtained on the S imilarities and C omprehension s ubtests. In contrast, relative s trengths are us ually obs erved in the areas of learning and memory skills and visual–spatial problem solving, particularly if the tas k can be completed piecemeal—that is , without having to infer the context, G estalt, of the task. T hus, performance on the B lock and Digit R ecall subtes ts of the W echsler s cales corres pond to peak performances . T he typical for rote and s equential, rather than reasoning and integrative, tasks usually carries the implication that individuals with autism fail to see “the trees from the leaves,” a difficulty that cuts acros s functioning modalities—from cognitive testing to communication social interaction. G iven the ubiquity of verbal deficits autis m, performance on the W echs ler scales is usually characterized by higher performance than verbal 3923 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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particularly in the individuals s coring in the mentally retarded range. Interestingly, s ome s tudies have suggested the oppos ite pattern in individuals with Asperger's s yndrome.

FIGUR E 38-3 F ull-scale intelligence quotient (IQ) in series of individuals with autis m. S everal influential ps ychological theories of the social dysfunction in autism have been proposed. One hypothes is pos its that there is a lack of a central drive coherence, with the consequent focus on dis sociated fragments rather than integrated “wholes ,” leading to a fragmentary and overly concrete experience of the Another hypothesis posits deficits in executive functioning—that is , in the capacity for abs tracting inhibiting irrelevant res ponses , s hifting attention and profiting from feedback, and maintaining a focus on multiple as pects of information in decis ion making. As executive functions are thought to be mediated by areas, this hypothes is highlights the s imilarities 3924 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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autis m and conditions res ulting from frontal lobe Y et another hypothes is , and, probably the most thus far, posits that autis m is caused by the child's to attribute mental s tates (e.g., beliefs and intentions ) others . Devoid of s uch a theory of mind, individuals autis m are presumed to be unable to infer the thoughts and motivations of others, thus failing to predict their behavior and adjust accordingly with a resulting lack of reciprocity in communication and s ocial contact. all of thes e hypotheses are informative and have had impact on both clinical practice and the neuroscience social dys function in autis m, is sues related to interrelations hips acros s thes e poss ible mechanisms of sociability, and developmental and neurofunctional correlates are only beginning to be clarified. More eye tracking technology has been us ed to s tudy very emerging s ocial skills, such as preferential orientation salient aspects of social s timuli that typically facilitates social engagement (F ig. 38-4). T his line of res earch is suggesting that s ocial development is pos sibly derailed very early on in the lives of children with autis m, a cas cade of developmental events having an impact subs equent s ocial cognitive miles tones and on brain specialization. C ollectively, these various ps ychological hypothes es continue to inform the inves tigation of brain systems affected in autis m and the s earch for more endophenotypes within inheritability patterns documented in genetic research.

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FIGUR E 38-4 E ye tracking data from a typically developing young adult (top line ) and a young, highfunctioning man with autism (bottom line ). T he man with autism focus es almos t exclusively on the mouth the person speaking, avoiding the upper part of the face and not noticing the emotional respons es of the listener. (F rom K lin A, J ones W, S chultz R : Defining quantifying the s ocial phenotype in autis m. Am J P s ychiatry. 2002;159:895-908, with permiss ion.) One of the most fas cinating cognitive phenomenon in autis m is the presence of s o-called islets of s pecial or s plinter skills—in other words, pres erved or very developed s kills in s pecific areas that contrast with the child's overall deficits in cognitive functioning. It is not unusual, for example, for children with autism to have great facility in decoding letters and numbers, at times precociously (hyperlexia), even though comprehension what is read is much impaired. P erhaps as many as 10 percent of individuals with 3926 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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P.3171 autis m exhibit a form of “savant” skills —that is , high, sometimes prodigious performance on a specific s kill in presence of mild or moderate mental retardation. T his fas cinating phenomenon us ually relates to a narrow of capacities —memorizing lis ts or trivial information, calendar calculation, vis ual–spatial s kills s uch as musical skills involving a perfect pitch or playing a piece music after hearing it only once. Interes tingly, autis tic individuals represent a disproportionate majority of all savant persons.

Motor and S ens ory Abnormalities One of the prototypical aspects of autism is the display motor s tereotypies such as hand flapping, body rocking, finger twiddling or waving in front of the eyes, as well as other repetitive and purpos eless motor manneris ms as toe walking and the as sumption of odd postures. S tereotypies are also s een in other conditions , severe mental retardation and sensory impairments blindnes s and deafness , but are clearly more common autis m, often emerging around the ages of 3 and 4. often decreas e in adolescence and adulthood and in with higher intellectual functioning. S ome children with autis m may copy other people's motor movements (echopraxia) without neces sarily learning the purpos e of that movement; this is , to s ome extent, the motor equivalent of echolalia. Normative motor skills are preserved relative to the child's intellectual level, this may not be the case in the higher-functioning who can be clums y and ill-coordinated, or when the 3927 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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as pects of the activity become more important as the becomes older. Overactivity is common in autis m, particularly in the preschool years . At the s ame time, a of curios ity in the environment and pas sivity, or hypoactivity, may also be observed in children with autis m. T he two may alternate for the s ame child in different s ettings or in relation to different activities. engagement and attention are important cons iderations in educational programming. B oth hyper- and hypos ens itivity to s ens ory stimuli are typical of children with autism. T heoretical models have propos ed that aberrant s ens ory modulation aris es from impaired brainstem attentional mechanisms or from excess ive amounts of striatal beta-endorphin. C hildren with autism may be acutely sensitive to sounds (hyperacus is ); they may, for example, cover their ears hearing a dog bark or the nois e of a vacuum cleaner. autis tic children may appear oblivious to loud nois e or people calling them but are fascinated by the faint of a wris twatch or the sound of crumpling paper. B right lights may be distress ing, although some autis tic are fas cinated with light stimulation and may, for move an object back and forth in front of their eyes . may be extreme s ensitivity to touch (tactile including major reactions to s pecific fabrics or social/affectional touch, whereas there are many children who appear insensitive to pain and may not after a severe injury. Many autistic children are by certain s ens ory stimuli, s uch as s pinning objects or parts that can spin, whereas s ome enjoy vestibular sens ations such as twirling, engaging in this action apparently becoming dizzy. 3928 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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S L E E P ING A ND E A TING P R OB L E MS S leeping and eating disturbances can be very taxing family life, particularly during childhood. C hildren with autis m may dis play erratic s leep patterns with recurrent awakening at night for long periods . E ating may involve avers ion to certain foods because of their texture, color, or s mell, or ins is tence on eating a very limited choice of foods and refusal to try new foods . In more s everely cognitively impaired children, pica may pose a range of safety is sues, including the risk of lead toxicity. S omewhat surpris ingly, failure to thrive is uncommon.

MOOD A ND A F F E C TIVE P oor affect modulation, as well as the dis play of that are inappropriate to a given s ocial situation, is frequent. S ome individuals may s how s udden mood changes, laughing or crying, or giggling to thems elves no apparent reason. Higher-functioning individuals may display intens e anxiety in s ocial situations ; they may develop depress ion in adolescence, usually as a res ult their negative social experiences over the years and partial insight into their condition, knowing that they are different from others without fully understanding their own contribution to the rejecting or otherwise is olating reactions of their peers.

S E L F -INJ UR Y A ND A G G R E S S ION S ome children with autism may engage in self-injurious behaviors —for example, biting their hands or wris ts or banging their heads. At times , this leads to s ignificant phys ical injury and may neces sitate the use of helmets 3929 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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other protective devices . C hildren may als o pick the pull the hair, bang their ches ts, or hit thems elves . decreased sense of danger, which, along with may lead to injuries . T emper tantrums are common, particularly in reaction to demands placed (e.g., to with a task), changes in routine, or otherwis e events. Lack of understanding or inability to or s heer frustration may occasionally prompt outburs ts .

P hys ic al C harac teris tic s With autis m, there is a higher incidence of minor anomalies s uch as ear malformations . S uch anomalies reflect the embryological period in which the factors res ponsible for autis m act—for example, ears are at around the s ame time as older regions of the brain develop. However, most young children with autism are often described as attractive and do not exhibit any of stigmata. P hys ical attractiveness may diminis h in adoles cence and adulthood, as the various disabilities unusual behaviors have an impact on phys ical

P athology and L aboratory E xamination E lec troenc ephalography and Dis orders A variety of electroencephalographic (E E G ) may be s een in P.3172 autis m, including diffuse and focal spikes , paroxys mal spike-and-wave patterns, multifocal spike activity, and 3930 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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mixed discharge. T he incidence of E E G abnormalities autis m (in the absence of a clinical s eizure dis order) from 10 to 83 percent and depends on the number of recordings and the nature of the sample obtained. T he incidence of abnormal E E G s is significantly higher in mentally retarded autistic individuals. T he finding of incidence of E E G abnormalities and seizure disorders autis m was one of the firs t compelling pieces of supporting a biological bas is for the condition. B oth early and more recent studies on auditory evoked potentials in autis m indicate that if children with underlying neurological conditions are excluded and and gender are controlled, there is no evidence for abnormalities in the auditory brains tem pathways. However, abnormalities of cognitive potentials, particularly the auditory P 300 (which repres ents the proces sing of s ens ory stimuli), have been s hown to be abnormal in autis m. T his presumably reflects in higher auditory proces sing and neural pathways . T he development of epileps y in autis m occurs in approximately 10 to 35 percent of the autis tic by young adulthood, bas ed on the occurrence of identifiable major motor seizures (F ig. 38-5). Although there is evidence of seizure onset at all ages , early childhood and adolescence have been reported to be peak periods (F ig. 38-5). Lower-functioning individuals at increas ed risk. T he onset of s eizures may be with deterioration.

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FIGUR E 38-5 R ates of first s eizure (incidence rate 1,000) in s amples of individuals with autism. Data cases with autis m (V olkmar F , Nels on D: S eizure disorders in autism. J Am Acad C hild Adole s c 1990;29:127-129) and from cas es with developmental disorder (Deykin E Y , MacMahon B : incidence of seizures among children with autis tic symptoms. Am J P s ychiatry. 1979;126:1310-1312), compared to rates in a normative sample (C ooper E pilepsy in longitudinal s urvey of 5000 children. 1965;1:1020).

Neuroimaging S tudies As noted previous ly, a growing body of work has on the neuroanatomical and neurophys iological subs trates of autism us ing neuroimaging and other techniques. However, neuroimaging studies are not 3932 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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routinely needed as part of the evaluation of a child potential autism in the abs ence of a s pecific indication.

Differential Diagnos is Autism must be differentiated from other pervasive developmental disorders , as well as from other developmental disorders (e.g., mental retardation and language dis orders) and s ens ory impairments, deafness . B oth his tory and current examination are in differentiating autis m from other dis orders in the pervas ive developmental dis order class (T able 38-4). Usually, in autis m, the ons et is well before the third birthday. T he unus ual patterns of ons et noted in R ett's syndrome and childhood disintegrative dis order are not observed. T here is s ome potential for confusion Asperger's s yndrome, given the fact that autis m, if it be diagnosed, takes precedence over As perger's syndrome. T he early pres ervation of language s kills in Asperger's s yndrome and the later age at which become concerned are helpful diagnostic features . S ometimes , extensive ques tioning elicits the that parents noted some minimal abnormality or oddity the child with Asperger's syndrome in the first 3 years life; us ually, this s hould not be s ufficient to make it that the child meets criteria for autis m (T able 38-4).

Table 38-4 Differential Diagnos tic Nonautis tic Pervas ive Devel

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Feature

Autis tic Dis order

As perger's S yndrome

R ett's S yndrom

Age at recognition (mos)

0–36

Usually

5–30

S ex ratio

Male > F emale

Male >> F emale

F emale ( Male)

Loss of s kills

V ariable

Usually not

Marked

S ocial skills

V ery poor

P oor

V aries age

C ommunication skills

Usually

F air

V ery poo

C ircumscribed interes ts

V ariable Marked (mechanical) (facts )

NA

F amily history— problems

S ometimes

F requent

Not us ually

S eizure

C ommon

Uncommon

F requent

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Head growth decelerates

No

No

Y es

IQ range

S evere MR to normal

Mild MR to normal

S evere

Outcome

P oor to fair

F air to good

V ery poo

>>, Much greater than; IQ, intelligence quotient; MR , me Adapted from V olkmar F R , C ohen D. Nonautistic pervas et al., eds. P s ychiatry. Lippincott-R aven; 1985:4. In mild to moderate mental retardation, s ocial s kills are us ually cons is tent with abilities in the areas of cognition and communication. In individuals with severe and profound retardation, the frequency of both autis m and autis tic-like behaviors increas es . A P.3173 common source of diagnos tic error is the confusion of stereotypies in such individuals. In higher-functioning individuals , there is potential confus ion relative to those personality disorders that involve social is olation (e.g., schizoid personality disorder). In obtaining a his tory, the us e of videotapes or other to memory may be helpful. It als o may help if the 3935 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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as ked to recall the child at certain particular dates (e.g., third birthday). In mos t cases of autis m, there is not a history of normal development, although, in a s mall of cas es (20 to 25 percent), parents may report an period of normal, or near-normal, development before either developmental stagnation or developmental regress ion; careful review is indicated in thes e cases. times , s ome abnormality in development or behavior have antedated parental concern. A history of clearly normal development rais es the pos sibility of s elective mutis m, R ett's s yndrome, childhood dis integrative disorder, language disorder, s chizophrenia, and degenerative C NS disorders . T ypically, children who experienced severe neglect exhibit delayed or deviant social s kills , but other features of autis m are not and the social deficits remit with appropriate care. In childhood-onset schizophrenia, there usually has been long period (many years) of normal or near-normal development before the onset of characteris tic hallucinations , and so forth. In some ins tances , the diagnosis can be clarified with certainty only over time. J ohn was the s econd of two children born to middleparents after normal pregnancy, labor, and delivery. As infant, J ohn appeared undemanding and relatively motor development proceeded appropriately, but language development was delayed. Although his indicated that they were firs t concerned about his development when he was 18 months old and s till not speaking, in retrospect, they noted that, in comparison their previous child, he had s eemed relatively in social interaction and the s ocial games of infancy. S tranger anxiety had never really developed, and J ohn 3936 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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not exhibit differential attachment behaviors toward his parents . T heir pediatrician initially reas sured J ohn's parents that he was a “late talker,” but they continued be concerned. Although J ohn s eemed to respond to unusual s ounds, the pediatrician obtained a hearing when J ohn was 24 months old. Levels of hearing adequate for development of s peech, and J ohn was referred for developmental evaluation. At 24 months, motor s kills were age appropriate, and J ohn exhibited some nonverbal problem-solving skills close to age His language and s ocial development, however, were severely delayed, and he was noted to be resistant to changes in routine and unus ually sensitive to as pects the inanimate environment. His play skills were quite limited, and he us ed play materials in unusual and idios yncratic ways . His older s is ter had a history of learning difficulties, but the family his tory was negative. A comprehensive medical evaluation normal E E G and computed tomography (C T ) scan; screening and chromosome analys is were normal as J ohn was enrolled in a special education program, in he gradually began to s peak. His s peech was by echolalia, extreme literalness , a monotonic voice quality, and pronoun reversal. He rarely us ed language interaction and remained quite isolated. B y school age, J ohn had developed s ome evidence of differential attachments to family members ; he also had developed number of s elf-stimulatory behaviors and engaged in occasional periods of head banging. E xtreme change continued. Intelligence testing revealed marked scatter, with a full-scale IQ in the moderately retarded range. As an adoles cent, J ohn's behavioral functioning 3937 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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deteriorated, and he developed a seizure disorder. adult, he lives in a group home and attends a sheltered workshop. He has a rather pas sive interactional s tyle exhibits occasional outburs ts of aggres sion and self(F rom V olkmar F . Autism and the pervas ive disorders . In: Lewis M, ed. C hild and Adole s ce nt C omprehe ns ive Approach. 2nd ed. B altimore: W illiams Wilkins ; 2002:489–502, with permis sion.)

C ours e and P rognos is Autism is a lifelong disability, with mos t individuals needing s ignificant family and community support. It appear to be the case that, with earlier intervention, term outcome improves for many individuals , with perhaps 15 percent able to achieve independence and self-sufficiency in adulthood and, perhaps, another 20 percent of individuals able to function with occasional support. W ith age, mos t individuals s how improvement social relatednes s, communication, and self-help s kills , a major long-term goal s hould be facilitating acquis ition important adaptive s kills , with the aim of maximizing potential for independence. V arious factors predict long-term outcome. T hese in particular, the presence of s ome communicative by the age of 5 or 6 and higher nonverbal intellectual Overall cognitive ability in the normal range is a prognos tic s ign. T he relationship of s everity of autis tic symptomatology in early childhood to adult symptoms somewhat less clear. With early intervention, s ome children make s ignificant gains , whereas other children provided with s uch intervention may not. G ains in s ocial compliance and communication are 3938 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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made during elementary s chool years, particularly if structured, individualized, and intensive interventions in place. During adolescence, s ome autis tic children exhibit behavioral deterioration; for a minority among these, the decline in language and social s kills may be as sociated with the onset of a s eizure disorder. V arious interactional styles can be observed, ranging from aloof pass ive to eccentric (e.g., children who make attempts initiate contact with others but do so in a very awkward rigid fashion); these styles are related to developmental level. Depress ive and anxiety symptoms may appear in higher-functioning adolescents, who become painfully aware of their inability to form friendships des pite a to do s o and begin to experience the cumulative effect years of failed contact with others and teasing by

Treatment T he goals of treatment for children with autism are to reduce disruptive behaviors and promote learning, particularly in the areas of language acquisition and communication and self-help s kills . T hese goals are achieved once a comprehensive ass es sment has determined a profile of strengths and needs and a structured and individualized intervention program is in place address ing the child's weaknes ses while maximizing his or her ass ets . S uch a program should us ually take place within a special education s etting should be carried out by profess ionals experienced in work with children with autis m. A recent review of treatment s tudies highlighted the importance of and early intervention in individual outcome. T reatment goals should be updated regularly, as different iss ues should be prioritized as a function of the child's rate 3939 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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profile of progress and age (e.g., vocational training independent living skills s hould be aggres sively in adolescence). Additionally, ps ychopharmacological treatments may be beneficial when s pecific s ymptoms not amenable to other treatment modalities.

E duc ational Approac hes Autistic children require intens ive and highly s tructured special education from as early as the child is able to P.3174 tolerate a s chool routine. G iven the challenges involved teaching children with autism, a class room s etting with low student to teacher ratio is usually ess ential. F or the more impaired children, a typical hierarchy of priorities should include the ability to (1) tolerate individual adult guidance in performing tasks, (2) cons istently follow a daily routine, (3) develop communication intent and communication means , and (4) move from ass ociative conceptual learning. Learning s hould take place in an environment that minimizes distractions (e.g., nearby windows, richly decorated walls); for the more children, individual workstations and forceful adult intrus ion may be neces sary. T he use of highly and cons is tent routines is neces sary to eventually the child's own internal s ens e of order, s cheduling, and organization of experiences , thus promoting more systematic learning. C hildren with autis m often learn in a highly circums cribed fas hion, exhibiting a capacity only in a very concrete and s pecific s etting. T herefore, important to ensure that the child both begins to us e skill s pontaneous ly (e.g., us es new words for 3940 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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an unprompted fashion) and generalizes from the setting in which the s kill was acquired to a different (e.g., uses the new words acquired at home, as well as other s ettings in which the words would be B oth the ability to better predict impending activities the ability to better express one's wishes and protes ts us ually beneficial in reducing frustration and as sociated disruptive behaviors . T he focus of s peech-language therapy is on the us e of words for the purpos e of meaningful communication. C hildren with autism may acquire a cons iderable vocabulary that is dis sociated from the act of communication. T herefore, language acquisition should go hand-in-hand with the promotion of the child's intent to communicate with others. F or this purpose, the vocabulary expans ion should be on words that are relevant to the child's attempt to negotiate the demands of everyday life. C hildren who do not vocalize s hould engaged in programs focused on alternative forms of communication, including s igns, communication or other forms of augmentative communication. T he of nonvocal forms of communication should not the simultaneous us e of words in children whose vocalizations are jus t emerging and for whom vocal communication is a realistic goal. F or older or higherfunctioning children, the core of the educational should be an intensive focus on s ocial and skills training. P os itive actions in frequently situations may have to be rehearsed and s cripted; social and communication skills —including eye gaze, voice modulation, ges tural communication, posture, proximity, greeting behaviors, rules of conversation, 3941 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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social expectations—may have to be taught in a very explicit fas hion. T he s etting for the social and communication skills therapy may have to alternate between small group instruction (in which appropriate behaviors can be practiced and s upportive feedback be gained) and naturalistic s ettings (in which the newly acquired s kill can be put to practice or additional problematic behaviors can be identified for practice in small s etting). S ucces sful techniques used for this include modeling of behaviors by an ins tructor, s elfobservation, role playing, and the use of individualized social s tories.

B ehavior Therapy T his treatment, based on learning theory principles , behavior-modification techniques to es tablis h desired behaviors and eliminate problem behaviors. Mos t educational programs for children with autism us e behavioral management techniques , although they terms of how integrated these procedures are in the comprehensive educational program. B ehavior therapy particularly useful in the management of disruptive behaviors , which range from difficulties in attention and compliance to tantrums and self-injurious behaviors . a functional analys is of the target behavior is and patterns of reinforcement are identified, techniques such as shaping, prompting, and extinction are used to promote the desired behavioral alternative, which is reinforced by increas ingly mature rewards . B ehavior therapy is also used for the facilitation of learning, including the promotion of early cognitive s kills such as categorization and elicitation of vocalization and G iven the autis tic child's tendency to learn things in 3942 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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is olation, it is imperative that s kills learned through behavior interventions are both relevant to the child's adaptation and are increas ingly us ed s pontaneous ly different s ettings . T hus, an appropriate behavior curriculum s hould place s pecial emphasis on generalization and s elf-initiated skills. Although it is relatively uncontrovers ial that children with autis m profit from behavior therapy, it is s till unclear whether some claims of extraordinary good outcome for autis tic receiving intens ive behavior treatment are jus tified. It is also important to ensure that higher-level forms of teaching are not more appropriate to a given child—for example, a more intellectually able child—before mos t the educational resources are focus ed on behavior therapy.

Ps yc hotherapy With the s hift from a psychogenic to a biological unders tanding of autis m, it became clear that ps ychodynamic psychotherapy and uns tructured play therapies, in general, were not appropriate in the treatment of young children. Individual psychotherapy may be appropriate for higher-functioning individuals may pres ent with anxiety and depres sive s ymptoms as they grow older and become more aware of their differences and difficulties relating to others . In these cases, psychotherapy should focus on rather explicit problem-solving s kills rather than being insightwith the goal to promote better adjus tment and s elfsatis faction.

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No pharmacological agent has proven curative, but medications may be of benefit with regard to specific symptoms. S uch target s ymptoms may include selfaggres sion, s tereotyped movements, and overactivity. B ecaus e individuals with autis m are often enrolled in educational and behavioral programs , it may be to have s taff participate (e.g., by collecting behavioral that can be us ed to monitor effectiveness of the drug). with all medications , the potential benefits and s ide should be considered (e.g., with the major tranquilizers, there is potential for over s edation, which can be for a positive therapeutic res ponse). B efore beginning drug treatment, bas eline laboratory s tudies (tes ts of and renal function, electrocardiogram [E C G ], urinalysis, blood count, weight, and blood press ure) should be conducted; typically, an examination for abnormal movements is performed (typically us ing the Abnormal Involuntary Movements S cales [AIMS ]).

MA J OR TR A NQUIL IZE R S Major tranquilizers have been the mos t extens ively agents in autis m. At relatively low dos es, they may decrease stereotyped behaviors and agitation and may help the individual profit from remedial programming. S ome data s ugges t that the combination of these with behavior therapy is more effective than either treatment alone. S ide effects may limit the usefulnes s these agents (e.g., sedation, withdrawal, and tardive dyskinesia). T he higher-potency neuroleptics have been used given the lower likelihood of s edation, these agents do carry increased ris k for dystonias. interes t has centered on the atypical neuroleptics , and these agents appear to offer cons iderable potential 3944 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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promis e; a large double-blind, placebo-controlled s tudy one of thes e agents has shown significant benefit in reducing agitation and other problematic behavioral difficulties .

S S R IS S everal reports sugges ted the potential us efulness in autis m and related conditions of the selective s erotonin reuptake inhibitors (S S R Is ). T he potential us e of such agents was sugges ted by the obs ervation of higher peripheral serotonin levels in autism. In s everal studies, thes e medications have proven s uperior to placebo relative to s ymptoms such as repetitive and impulsive aggress ion. T here is a sugges tion that seizure dis orders may be exacerbated in s ome cas es. Occasionally, children become activated on these P.3175

C L ONIDINE G iven the apparently high levels of arous al in autis m, of clonidine (C atapres ) was suggested. T his agent, an adrenergic agonist, reduces noradrenergic activity. may be a modes t effect on activity levels, although sedation and hypotension can pres ent serious side

NA L TR E X ONE Interes t in the endogenous opioid system was by early s tudies that reported high endogenous opiate levels. T he opiate receptor antagonis t naltrexone has evaluated in several s tudies. T he major effect of this appears to be a mild decreas e in activity levels. 3945 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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social engagement is not observed. T here also be no facilitation of learning.

OTHE R A G E NTS V arious other agents have been reported to s ometimes effective in treating at leas t s ome of the symptoms of autis m. S uch evidence is usually based on single case reports , and controlled studies are often lacking. (E skalith) is generally not clearly helpful unles s there is personal or family history of bipolar illness . Although available data are limited, it appears that, in general, stimulants exacerbate behavioral difficulties in autis m, probably acting through their effect on dopamine. βB lockers have been used in s everal open trials with reducing aggres sive, self-injurious , and impulsive behaviors . T hese agents may act to decrease arousal and positive res ponses have been noted, although the potential for s erious side effects has limited their more general us e. P arents often are interes ted in s o-called alternative treatments , including diet and vitamin therapy, among others . Although the focus of much interest, data are lacking. Usually, a single case report or uncontrolled study is reported, and tremendous enthus ias m follows, but controlled s tudies do not subs tantiate the claims made; this was recently for secretin, a gut peptide, which, in a series of doubleblind, controlled s tudies, failed to offer s ignificant improvement over placebo. V arious somatic treatments have not proven clinically us eful. In general, pursuit of unproven treatments be avoided, particularly if they are pursued at the 3946 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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of educational and behavioral interventions that are known to be efficacious. In s ome instances, treatments that pose actual danger to the child have been and, clearly, should be avoided. G iven the relatively prognos is as sociated with autis m, parents are eas ily attracted by treatments that propos e a rapid cure. should be encouraged to purs ue treatments with efficacy. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 38 - P ervas ive Developmental Dis orders > R E T T 'S S Y NDR O

R E TT'S S YNDR OME P art of "38 - P ervas ive Developmental Dis orders"

Definition R ett's syndrome is a progres sive condition that after s ome months of apparently normal development. Head circumference is normal at birth, and early developmental milestones are unremarkable. B etween and 48 months (us ually between 6 months and 1 year), head growth begins to decelerate. P urpos eful hand movements are lost, and characteristic midline handwringing or hand-was hing stereotypies develop. E xpres sive and receptive language skills become impaired and are ass ociated with marked mental retardation. In the preschool years , gait apraxia and apraxia and ataxia develop. A loss of social skills is frequently obs erved during the pres chool but social interest often increases later. Originally, the condition was thought to be confined to girls, but boys 3947 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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with the dis order, or something quite clos e to it, have been described. Diagnostic criteria for the disorder are presented in T able 38-5.

Table 38-5 DS M-IV-TR C riteria for R ett's S yndrome A. All of the following:    (1) apparently normal prenatal and perinatal development    (2) apparently normal ps ychomotor through the firs t 5 months after birth    (3) normal head circumference at birth B . Ons et of all of the following after the period of normal development:    (1) deceleration of head growth between ages and 48 months    (2) loss of previous ly acquired purpos eful hand skills between ages of 5 and 30 months , with the subs equent development of stereotyped hand movements (e.g., hand wringing or hand

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   (3) loss of s ocial engagement early in the (although often social interaction develops later)    (4) appearance of poorly coordinated gait or movements    (5) severely impaired express ive and receptive language with s evere psychomotor retardation

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation, 2000, with permiss ion.

His tory C as es of R ett's syndrome were first reported in 1966 Andreas R ett. His initial report noted the characteris tic history and clinical findings , s uch as gait and truncal and apraxia, breathing difficulties, E E G abnormalities, occasional seizures . He also obs erved s ome features suggestive of autis m. S ubs equently, B engt Hagberg colleagues reported s imilar findings in a new s eries of cases. T he presence of some s ymptoms s uggestive of autis m, particularly in the pres chool years, is the major rationale for placement of this condition in the developmental disorders class of dis orders in both T R and IC D-10.

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C omparative Nos ology R ett's original report provided guidelines for the that were subsequently revis ed at a 1984 conference the condition. T hese V ienna criteria included features were necess ary for the diagnos is , those that s upported and those that were exclus ionary. F eatures that the diagnosis but are not neces sarily present include breath-holding s pells , periodic hyperventilation, apnea, growth retardation, E E G abnormalities and dystonia, spas ticity, scolios is, and peripheral problems . F eatures that mitigate agains t the diagnosis include demons trable prenatal growth retardation or postnatal C NS trauma. T he definitions in DS M-IV -T R IC D-10 are ess entially the s ame and focus on the features for diagnosis .

E pidemiology E stimates of the prevalence of the condition range from in 15,000 to 1 in 22,000 females. S everal thous and are now regis tered with the International R ett's Ass ociation. Although there have been several males reported to have some features of the condition, to no such male has yet clearly met all criteria for the condition.

E tiology R ett originally speculated that the condition was as sociated with high peripheral ammonia levels, but did not prove to be the case. T he role of genetic factors been s uggested by reports of the condition in monozygotic twins and extended family members , but most cas es appeared to be s poradic in nature. 3950 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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gene, ME C P 2, has been found to be involved in mos t

Diagnos is and C linic al F eatures T he DS M-IV -T R diagnostic criteria for the condition are presented in T able 38-5. E arly development of the child normal. T he onset of the condition may be ins idious follow a period of developmental s tagnation and delay recognition s lightly. Over time, the developmental decelerated head and body growth, and diminis hed interes t in the environment P.3176 become quite striking. P revious ly acquired abilities are lost, including purposeful hand movements. T he lack of social interest and potential for misdiagnosis of autism greates t in the pres chool years , as , us ually, by the time child reaches s chool age, the autistic-like features are prominent and development plateaus for a time. At this point, s evere mental retardation, s eizures , and motor problems are areas of major concern. During this or “ps eudostationary” phase, breathing difficulties , bruxis m, motor problems , and early scoliosis may be noted. Apneic epis odes may alternate with hyperventilation. Most children remain ambulatory until final period of motor deterioration. E E G is frequently abnormal and s eizures are common. Darla was born at term after an uncomplicated An amniocentes is had been obtained becaus e of age and was normal. At birth, Darla was in good weight, height, and head circumference were all near 50th percentile. Her development during the firs t 3951 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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of life was within normal limits. At approximately 8 of age, her development s eemed to s tagnate and her interes t in the environment, including the social environment, waned. Her developmental miles tones became markedly delayed; s he was just starting to her second birthday and had no s poken language. E valuation at that time revealed that head growth had decelerated. S ome s elf-stimulatory behaviors were present. Marked cognitive and communicative delays noted on formal tes ting. Darla began to los e purpos eful hand movements and developed unusual handstereotyped behaviors. B y age 6, her E E G was and purpos eful hand movements were markedly S ubsequently, she developed truncal ataxia and holding s pells , and motor s kills deteriorated further. V olkmar F . Autis m and the pervasive developmental disorders . In: Lewis M, ed. C hild and Adole s ce nt C omprehe ns ive Approach. 2nd ed. B altimore: W illiams Wilkins ; 2002:489–502, with permis sion.)

P athology and L aboratory E xamination V arious nonspecific abnormalities have been reported R ett's s yndrome and have included elevated levels of copper and ammonia in the blood, cortical atrophy on brain s can, E E G abnormalities, and s o forth. In s ome neuropathological s tudies, decreas ed brain weight and loss of neurons has been noted with changes in the subs tantia nigra and caudate nucleus. T he res ults of neurochemicals (e.g., of endorphins , cortis ol, and dopamine) have been contradictory. As previously the obs ervation of a gene ass ociated with R ett's 3952 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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in at leas t s ome cases does rais e the poss ibility of specific diagnostic tests.

Differential Diagnos is Diagnos is of the condition is mos t straightforward in somewhat older individuals (i.e., of s chool age) but can made reliably early in life. T he condition differs from autis m in its unus ual pattern of developmental loss and characteristic clinical features. T he potential for diagnosis of autis m is greatest in the preschool years , when many patients with R ett's s yndrome may have degree of deterioration of s ocial skills. T he onset of childhood disintegrative disorder is typically later than of R ett's s yndrome, and the period of normal is us ually much more prolonged in that condition, which also usually affects males. In As perger's s yndrome, cognitive and language skills are preserved and there not a marked los s of abilities.

C ours e and P rognos is R ett's syndrome is a progres sive neurodegenerative condition. As adults, patients may be nonambulatory to motor problems and scolios is. T here is increased sudden death.

Treatment T here are no specific treatments for R ett's s yndrome. S pecial education, behavior modification, physical, and res piratory therapies may be us eful. No specific pharmacological treatments are available. G iven the rate of seizure disorder, caution is needed with use of medications that lower the s eizure thres hold. As with 3953 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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pervas ive developmental dis orders, cons ideration also be given to supporting the parents and siblings of affected individuals. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 38 - P ervas ive Developmental Dis orders > C HILDHOOD DIS OR DE R

C HIL DHOOD DIS OR DE R P art of "38 - P ervas ive Developmental Dis orders"

Definition C hildhood dis integrative dis order is a rare condition characterized by a marked regress ion in multiple areas development after several years of normal

His tory C hildhood dis integrative dis order was firs t described by educator, T heodore Heller, in 1908; he reported a cases that displayed a marked and pers is ting developmental regres sion after 3 or 4 years of normal development. He originally termed the condition infantilis ; s ubs equently, it has als o been termed dis integrative ps ychos is or Heller's s yndrome . In the after his report, more than 100 cas es have been Although the condition is certainly quite rare, it has probably als o been underrecognized.

C omparative Nos ology IC D-9 included a category for dis integrative ps ychos is 3954 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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defined on the basis of “normal or near normal development in the first years of life, followed by a los s social s kills and of speech together with a s evere of emotion, behavior, and relationships .” T he condition was not included in DS M-III or DS M-III-R , on the presumption that the condition was almost invariably as sociated with s ome identifiable general medical condition or progres sive neuropathological proces s; however, review of cases reported s uggests that, in that is not us ually the cas e. R eview of cas es als o important potential differences from autism—for in terms of cours e and outcome. In DS M-IV -T R and IC D-10, the definitions of the are very s imilar. T he IC D-10 definition notes that a loss of interest in the environment may be obs erved 38-6).

Table 38-6 DS M-IV-TR C riteria for C hildhood Dis integrative A. Apparently normal development for at least the first 2 years after birth, as manifested by the presence of age-appropriate verbal and communication, social relations hips, play, and adaptive behavior. B . C linically significant loss of previously acquired skills (before age 10 years ) in at leas t two of the 3955 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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following areas :    (1) expres sive or receptive language    (2) social s kills or adaptive behavior    (3) bowel or bladder control    (4) play    (5) motor s kills C . Abnormalities of functioning in at leas t two of following areas :    (1) qualitative impairment in s ocial interaction impairment in nonverbal behaviors , failure to develop peer relationships, lack of s ocial or emotional reciprocity)    (2) qualitative impairments in communication delay or lack of spoken language, inability to or s us tain a convers ation, stereotyped and us e of language, lack of varied make-believe    (3) res tricted, repetitive, and s tereotyped of behavior, interests , and activities , including stereotypies and mannerisms D. T he disturbance is not better accounted for by 3956 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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another specific pervas ive developmental or by s chizophrenia.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

E pidemiology Although available data are limited, the dis order to be quite rare. A prevalence es timate of 1 in 100,000 children has been s uggested. More recent case series suggest a preponderance of the condition in boys. It is likely that some early cases of the condition in girls actually cases of R ett's syndrome.

E tiology S everal lines of evidence s uggest the importance of neurobiological factors in the pathogenes is of disintegrative disorder. In approximately one-half of the E E G is reported to be abnormal, and s eizures are sometimes obs erved. T he condition has been with various general medical conditions (e.g., the neurolipidos es, metachromatic leukodystrophy, S childer's dis eas e, and s ubacute sclerosing panencephalitis ). Although an intens ive s earch for such conditions is always indicated, they are, however, not found. S uch conditions are more likely if the ons et 3957 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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later (after age 6). Data on other as pects of the neurobiology of the condition are very limited.

Diagnos is and C linic al F eatures T he DS M-IV -T R diagnostic criteria for childhood disintegrative disorder are presented in T able 38-6. development must be normal for at least 2 years; this should include normal communication and s ocial skills. B efore age 10, there is a significant los s of previously acquired s kills , in at P.3177 least two (usually many) of the following areas : communication, social interaction, bowel and bladder control, and motor abilities. T he child also develops symptoms s imilar to thos e s een in autism. T here is potential confus ion for children with autism who have regress ive presentations . T he onset of the condition is us ually between the ages and 4 and may be either abrupt or gradual. T here may nonspecific agitation or anxiety before developmental deterioration. F igure 38-6 provides a s ummary of features. T he loss of social and communicative s kills is , unders tandably, of great concern to parents. behaviors , problems with trans itions and change, and nonspecific overactivity often develop. Deterioration in self-help s kills can be s triking and is in contrast to in which s uch skills are acquired somewhat later than but typically are not lost.

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FIGUR E 38-6 C linical features in childhood disintegrative disorder. (Adapted from V olkmar F R , K oenig K , S tate M. C hildhood dis integrative C ohen DJ , V olkmar F R , eds. Handbook of Autis m P ervas ive De ve lopme ntal Dis orde rs . 2nd ed. New Wiley; 1997:47.)

B ob's early his tory was within normal limits. B y age 2, was s peaking in sentences , and his development to be proceeding appropriately. At age 40 months, he noted to exhibit, abruptly, a period of marked regress ion shortly after the birth of a sibling. He los t previous ly acquired skills in communication and was no longer toilet trained. He became uninteres ted in social interaction, and various unusual s elf-stimulatory became evident. C omprehensive medical examination failed to reveal any conditions that might account for 3959 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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developmental regres sion. B ehaviorally, he exhibited features of autism. At follow-up at age 12, he s till was speaking, apart from an occasional s ingle word, and severely retarded. (F rom V olkmar F . Autism and the pervas ive developmental dis orders. In: Lewis M, ed. and Adoles ce nt P s ychiatry: A C ompre he ns ive ed. B altimore: W illiams and W ilkins; 2002:489–502, permis sion.)

Differential Diagnos is C hildren with autism typically exhibit difficulties before age 2 and almost always before age 3. In autis m, early development is usually not unequivocally normal, although occasional children with autism are reported either stagnate in their development or experience a developmental regres sion. T he us e of aids such as books or early home movies/videos may help es tablis h that early development was normal. In R ett's there is characteristic head growth deceleration, as clinical features s uch as unus ual hand movements. In instances, childhood dis integrative dis order may be confused with schizophrenia, but, us ually, the characteristic findings of s chizophrenia on clinical examination clarify the diagnosis. In the syndrome of acquired aphasia with epilepsy (Landau-K leffner syndrome), s ocial interest is preserved and nonverbal communicative skills may be extens ive. S pecific on examination or in the his tory may help guide diagnostic evaluation.

C ours e In approximately three-fourths of the cas es, the child's 3960 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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behavior and development deteriorate to a much lower functional level and then s tabilize with no further deterioration but only minimal subsequent gains . In cases, there is more recovery of previous skills ; a few cases have made very good recovery. In cases, particularly those ass ociated with a progres sive neuropathological proces s, deterioration is progres sive and death may result. Otherwis e, life expectancy is In general, the outcome appears to be worse than that autis m.

Treatment As with autism, us e of special education and treatments is indicated to help encourage reacquisition skills . T here are no specific pharmacological E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 38 - P ervas ive Developmental Dis orders > AS P E R G E R 'S

AS PE R GE R 'S S YNDR OME P art of "38 - P ervas ive Developmental Dis orders"

Definition Asperger's s yndrome is characterized by impairments social interaction and restricted interes ts and behaviors seen in autis m, but its early developmental cours e is marked by a lack of any clinically s ignificant delay in spoken or receptive language, cognitive development, self-help s kills , and curiosity about P.3178 3961 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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the environment. All-absorbing and intens e interes ts , as well as motor clumsines s, are typical of condition but are not required for diagnosis. C riteria for Asperger's s yndrome are given in T able 38-7.

Table 38-7 DS M-IV-TR C riteria for As perger's S yndrome A. Qualitative impairment in s ocial interaction, as manifested by at least two of the following:    (a) marked impairment in the us e of multiple nonverbal behaviors such as eye-to-eye gaze, expres sion, body postures, and ges tures to social interaction    (b) failure to develop peer relations hips appropriate to developmental level    (c) a lack of s pontaneous seeking to share enjoyment, interests , or achievements with other people (e.g., by a lack of s howing, bringing, or pointing out objects of interest to other people)    (d) lack of s ocial or emotional reciprocity B . R es tricted, repetitive, and s tereotyped patterns behavior, interes ts, and activities , as manifes ted

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at least one of the following:    (a) encompas sing preoccupation with one or stereotyped and restricted patterns of interes t abnormal either in intens ity or focus    (b) apparently inflexible adherence to specific, nonfunctional routines or rituals    (c) s tereotyped and repetitive motor (e.g., hand or finger flapping or twisting, or whole body movements)    (d) persis tent preoccupation with parts of C . T he disturbance causes clinically significant impairment in s ocial, occupational, or other important areas of functioning. D. T here is no clinically s ignificant general delay language (e.g., single words us ed by age 2, communicative phrases us ed by age 3). E . T here is no clinically s ignificant delay in development or in the development of ageappropriate s elf-help s kills , adaptive behavior than in social interaction), and curiosity about the environment in childhood. F . C riteria are not met for another s pecific 3963 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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developmental disorder or s chizophrenia.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

His tory In 1944, Hans As perger, an Aus trian pediatrician with interes t in s pecial education, des cribed four children had difficulty integrating s ocially into groups. Unaware K anner's des cription of early infantile autism published the year before, Asperger called the condition he described autis tic ps ychopathy, indicating a s table personality disorder marked by s ocial is olation. Des pite preserved intellectual s kills , the children showed paucity of nonverbal communication involving both gestures and affective tone of voice; poor empathy and tendency to intellectualize emotions ; an inclination to engage in long-winded, one-sided, and s ometimes incoherent speech; rather formalistic s peech (he called them “little profess ors ”); all-absorbing interes ts unusual topics that dominated their convers ation; and motoric clumsines s. Unlike K anner's patients, these children were not as withdrawn or aloof; they also developed, s ometimes precociously, highly speech and could not, in fact, be diagnos ed in the first years of life. Dis carding the pos sibility of a 3964 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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origin, As perger highlighted the familial nature of the condition and even hypothesized that the personality traits were primarily male trans mitted. Asperger's work, originally published in G erman, only became widely known to the E nglis h-speaking world in 1981, when Wing published a series of cas es showing similar symptoms. Her codification of the s yndrome, however, blurred somewhat the differences between K anner's Asperger's descriptions , as s he included a s mall girls and mildly mentally retarded children, as well as children who had presented with s ome language their first years of life. S ince then, several studies have attempted to validate Asperger's syndrome as distinct from autis m without mental retardation, although comparability of findings has been difficult due to the of consensual diagnos tic criteria for the condition. Although As perger's s yndrome was firs t granted official recognition in IC D-10 and appears as Asperger's in DS M-IV -T R , its nosological s tatus is s till uncertain.

C omparative Nos ology Asperger's s yndrome was not accorded official before the publication of IC D-10 and DS M-IV -T R , it was first reported in the G erman literature in 1944. Asperger's work was known primarily in G ermancountries , and it was only in the 1970s that the firs t comparis ons with K anner's work were made, primarily Dutch researchers s uch as Dirk V an K revelen, who familiar with both E nglish and G erman literatures . T he initial attempts at comparing the two conditions were difficult becaus e of major differences in the patients described—K anner's patients were both younger and more cognitively impaired. Als o, As perger's 3965 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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conceptualization was influenced by accounts of schizophrenia and pers onality disorders, whereas had been influenced by the work of Arnold G esell and developmental approach. Attempts at codifying Asperger's prose into a categorical definition for the condition were made by s everal influential res earchers E urope and North America, but no cons ens ual emerged until the advent of IC D-10. G iven the reduced empirical validation of the IC D-10 and DS M-IV -T R the definition of the condition is likely to change as new and more rigorous studies emerge in the near future. text description of the condition has been considerably revis ed in DS M-IV -T R .

E pidemiology G iven the lack of consensual definitions of the until recently, it is not s urprising that the prevalence of condition is unknown, although a recent review that a rate of 1 to 2 in 10,000 is likely. T here is little that the condition is more prevalent in males than in females, with a reported ratio of 9 to 1. In the pas t few years , there has been a proliferation of parent s upport organizations organized around the concept of syndrome, and there are indications that this diagnos is being given by clinicians much more frequently than just a few years ago. T here are also indications that Asperger's s yndrome is currently functioning as a diagnosis given to normal-intelligence children with a degree of s ocial disabilities who do not fulfill criteria for autis m, overlapping in this way with the DS M-IV -T R pervas ive developmental dis order not otherwise T his pattern has diluted the concept. E mpirical of specific diagnostic criteria is badly needed, although 3966 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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this will have to await reports of rigorous s tudies us ing standard diagnos tic procedures and validators truly independent of the diagnostic definition, s uch as neurops ychological, neurobiological, and genetic data.

E tiology As in autism, the cause of As perger's s yndrome is unknown. A few case studies reporting the pres ence of autis m and As perger's s yndrome in different family members, as well as some recent s tudies sugges ting Asperger's s yndrome may be one of the conditions the autistic spectrum, s uggest that autism and syndrome may be related genetically. R ecent reports suggested an even s tronger genetic contribution in Asperger's s yndrome than in autis m, with more family members, and sometimes the child's father, either criteria for the condition or having s imilar social Hans As perger had alluded to some children who were much more s everely involved than the cases he and P.3179 who had varying degrees of mental retardation. His that these were cas es of autis tic ps ychopathy who had experienced a degree of brain damage has been taken by some authors , although there are still no neuroanatomical or neurofunctional data to this view; in fact, there are a few reports of brain in individuals with Asperger's syndrome with otherwise normal or s uperior IQs.

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T he diagnosis of Asperger's syndrome requires the demonstration of qualitative impairments in s ocial interaction and res tricted patterns of interest, criteria are identical to autis m. In contrast to autis m, there are criteria in the cluster of language and communication symptoms, and ons et criteria differ in that there should no clinically significant delay in language acquis ition, cognitive, and s elf-help s kills . T hose symptoms result significant impairment in social and occupational functioning. In some contrast to the s ocial pres entation in autism, individuals with Asperger's syndrome find thems elves socially isolated but are not usually withdrawn in the presence of others , typically approaching others but in inappropriate or eccentric fas hion. F or example, they engage the interlocutor, usually an adult, in one-sided conversation characterized by long-winded pedantic speech about a favorite and often unusual and narrow topic. T hey may expres s interes t in friends hips and in meeting people, but their wishes are invariably by their awkward approaches and ins ens itivity to the person's feelings , intentions , and nonliteral and implied communications (e.g., s igns of boredom, haste to and need for privacy). C hronically frustrated by their repeated failures to engage others and form some individuals with As perger's syndrome develop symptoms of a mood disorder that may require B ecaus e of their difficulties in relating to others, they convey a sens e of ins ens itivity, formality, or disregard the other person's emotional express ions . T hey may be able to describe correctly, in a cognitive and often formalistic fas hion, other people's emotions, expected 3968 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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intentions , and s ocial conventions; yet, they are unable act on this knowledge in an intuitive and s pontaneous fas hion, thus losing the tempo of the interaction. T heir poor intuition and lack of s pontaneous adaptation are accompanied by marked reliance on formalis tic rules of behavior and rigid social conventions . T his largely responsible for the impress ion of s ocial naïveté behavioral rigidity that is so forcefully conveyed by individuals . Although s ignificant abnormalities of s peech are not typical of individuals with Asperger's syndrome, at leas t three aspects of thes e individuals ' communication patterns are of clinical interes t. F irst, speech may be marked by poor prosody, although inflection and intonation may not be as rigid and monotonic as in T hey often exhibit a constricted range of intonation patterns that is used with little regard to the communicative functioning of the utterance (ass ertions fact, humorous remarks, and so on). R ate of speech unusual (e.g., too fas t) or may lack in fluency (e.g., speech), and there is often poor modulation of volume (e.g., voice is too loud des pite physical proximity to the conversational partner). T he latter feature may be particularly noticeable in the context of a lack of adjus tment to the given social s etting (e.g., in a library, noisy crowd). S econd, s peech may often be tangential circums tantial, conveying a sense of loos eness of as sociations and incoherence. E ven though, in a very number of cas es , this s ymptom may be an indicator of poss ible thought disorder, the lack of contingency in speech is a res ult of the one-sided, egocentric conversational s tyle (e.g., unrelenting monologues 3969 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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the names , codes , and attributes of innumerable stations in the country), failure to provide the for comments and to clearly demarcate changes in and failure to suppres s the vocal output accompanying internal thoughts. T hird, the communication style of individuals with Asperger's syndrome is often characterized by marked verbos ity. T he child or adult talk incess antly, us ually about a favorite s ubject, often complete dis regard to whether the listener might be interes ted, engaged, or attempting to interject a or change the s ubject of convers ation. Despite s uch winded monologues , the individual may never come to point or conclus ion. Attempts by the interlocutor to elaborate on is sues of content or logic or to shift the interchange to related topics are often unsucces sful 38-7). T ake, for example, the following statement of a child with Asperger's S yndrome:

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FIGUR E 38-7 Drawing produced by “R obert E dwards ” during his evaluation that illustrates his interes t in time. T he drawing illustrates the his tory of the univers e, from moment of its creation (12 midnight), through geological time, the advent of bacteria (6:30), and so forth. T he illus trates, on the one hand, the patient's profound (and knowledge) regarding this topic, which tended to 3971 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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all encompass ing, as well as his less -developed fine abilities . (F rom V olkmar F R , K lin A, S chultz R T , et al: case conference. Am J P s ychiatry. 2000;157:262–267, permis sion.) My name is R obert E dwards . I am an intelligent, but adaptable pers on. I would like to dis pel any untrue rumors about me. I am not edible. I cannot fly. I cannot telekines is . My brain is not large enough to destroy the entire world when unfolded. I did not teach my longhaired guinea pig, C hronos , to eat everything in sight is the nature of the long-haired guinea pig). Individuals with Asperger's syndrome typically amass a large amount of factual information about a topic in a intens e fashion. T he actual topic may change from time time but often dominates the content of social interchange. F requently, the entire family may be immersed in the subject for long periods . T his behavior peculiar in the s ens e that extraordinary amounts of information are learned about very circums cribed (e.g., s nakes , names of stars , televis ion guides , deep fryers, weather information, personal information on members of C ongres s) without a genuine of the broader phenomena involved. T his s ymptom not always be eas ily recognized in childhood, as s trong interes ts in certain topics , such as dinosaurs or fictional characters , are so ubiquitous . However, in younger and older children with Asperger's syndrome, special interes ts typically become more unusual and narrowly focused. 3972 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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Individuals with Asperger's syndrome may have a of delayed acquisition of motor s kills such as pedaling bike, catching a ball, opening jars, and climbing play equipment. T hey are often vis ibly awkward and poorly coordinated and may exhibit stilted or bouncy patterns and odd posture. Neurops ychologically, there often a pattern of relative s trengths in auditory and skills and rote learning, and s ignificant deficits in motor and vis ual–perceptual skills and conceptual learning. Many children exhibit high levels of activity in early childhood, and the commones t reported comorbid symptoms in adolescence and young adulthood are anxiety and, particularly, depres sion—sometimes with suicidal ideation. T om was an only child. B irth, medical, and family were unremarkable. His motor development was somewhat delayed, but communicative milestones within normal limits . His parents became concerned him at age 4 when he was enrolled in a nurs ery school was noted to have marked difficulties in peer that were so pronounced that he could not continue in program. In grade s chool, he was enrolled in s pecial education clas ses and was noted to have some problems . His greates t difficulties arose in peer interaction—he was viewed as markedly eccentric and no friends. His preferred activity, watching the weather channel on televis ion, was pursued with great interest intens ity. On examination at age 13, he had markedly circums cribed interests and exhibited pedantic and odd patterns of communication with a monotonic voice quality. P sychological testing revealed P.3180 3973 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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an IQ within the normal range, with marked s catter F ormal communication examination revealed ageappropriate s kills in receptive and express ive language marked impairment in pragmatic language skills. (F rom V olkmar F . Autis m and the pervasive developmental disorders . In: Lewis M, ed. C hild and Adole s ce nt C omprehe ns ive Approach. 2nd ed. B altimore: Williams Wilkins ; 2002:489–502, with permis sion.)

Differential Diagnos is Unlike children with As perger's s yndrome, the great majority of children with autism experience early delays and deviance in language acquisition and cognitive impairment. T he differential diagnos is is more difficult when the comparis on is made with children with autism without mental retardation. Asperger's syndrome differs from the latter in that the onset is us ually later and the outcome more pos itive. In addition, s ocial and communication deficits are less s evere and motor manneris ms are usually absent, whereas circums cribed interes t is more conspicuous , motor clumsines s is more frequently seen, and family his tory of similar problems is more frequently as certained. In both IC D-10 and DS MT R , if the child meets criteria for autis m, this s hould take precedence over a diagnosis of Asperger's syndrome. distinction between As perger's s yndrome and atypical autis m (IC D-10) or pervasive developmental dis order otherwis e s pecified (DS M-IV -T R ) is more difficult, the latter are basically subthres hold or res idual without specific defining criteria. R eports attempting to draw a distinction between them have indicated that the 3974 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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social impairment is more severe, and the deficits and deviance are les s pronounced in syndrome than in atypical autis m/pervasive developmental disorder not otherwise s pecified. reports have also emphasized the ass ociated features all-absorbing and interfering circumscribed interes ts , verbos ity, and motor clumsines s in As perger's Individuals with schizoid pers onality disorder do not the level of s everity of social impairment or the early developmental patterns s een in Asperger's syndrome. combination of verbosity and s evere pragmatic deficits (involving long-winded, one-sided, and incoherent conversational patterns marked by failures to changes of topic, to provide background, or to adhere communicative mess age) may lead to the erroneous diagnosis of schizophrenia. However, in the vas t of cas es , these symptoms reflect a communication dysfunction rather than a thought disorder. Again, a detailed developmental his tory documenting early and continuity of s ymptoms may be important in the differential diagnosis. Although s ome individuals with Asperger's s yndrome have been des cribed as antis ocial behaviors, it is, in fact, more likely that thes e individuals are victims of practical jokes or other forms aggres sion.

C ours e and P rognos is T here are no systematic long-term follow-up studies of children with Asperger's syndrome as yet, partially of nos ologic is sues. Many children are able to attend regular education class es with additional support although thes e children are especially vulnerable to seen as eccentric and being teased or victimized; 3975 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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require special education s ervices, usually not because academic deficits but becaus e of their s ocial and behavioral difficulties . As perger's initial description predicted P.3181 a pos itive outcome for many of his patients, who were often able to use their special talents for the purpos e of obtaining employment and leading self-supporting His obs ervation of s imilar traits in family members (i.e., fathers ) may als o have made him more optimis tic ultimate outcome. Although his account was tempered somewhat over time, As perger continued to believe more positive outcome was a central criterion differentiating individuals with his syndrome from those with K anner's autism. Although s ome clinicians have informally concurred with this s tatement, particularly in regard to gainful employment, independence, and es tablis hment of a family, no studies s pecially the long-term outcome of individuals with As perger's syndrome are currently available. T he s ocial (particularly the eccentricities and s ocial ins ens itivity) is thought to be lifelong.

Treatment As in autism, treatment of Asperger's syndrome is es sentially s upportive and s ymptomatic and, to a great extent, overlaps with the treatment guidelines to individuals with autis m unaccompanied by mental retardation. One initial difficulty encountered by families proving eligibility for special s ervices. As these children often very verbal and many of them do well 3976 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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educational authorities might judge that the deficits — primarily social and communicative—are not within the scope of educational intervention. In fact, thes e two as pects should be the core of any educational and curriculum for individuals with this condition. In regard to learning s trategies, s kills , concepts, procedures , cognitive s trategies, and behavioral norms may be more effectively taught in an explicit and rote fas hion, using a parts -to-whole verbal instruction approach, in which the verbal s teps are in the correct sequence for the behavior to be effective. Additional guidelines s hould be derived from the individual's neurops ychological profile of ass ets and deficits . T he acquisition of s elf-sufficiency s kills in all areas of functioning s hould be a priority. T he tendency of individuals with Asperger's syndrome to rely on rigid and routines can be used to fos ter positive habits and enhance the person's quality of life and that of family members. S pecific problem-solving strategies , us ually following a verbal algorithm, may be taught for handling the requirements of frequently occurring, troubles ome situations (e.g., involving novelty, intense s ocial or frustration). T raining is usually necess ary for situations as troublesome and for s electing the bes t available learned s trategy to us e in such situations . and communication skills are best taught by a communication specialist with an interes t in pragmatics speech in the context of both individual and s malltherapy. C ommunication therapy s hould include appropriate nonverbal behavior (e.g., the us e of gaze social interaction, monitoring and patterning of of voice), verbal decoding of nonverbal behaviors of others , social awareness , perspective-taking s kills , and 3977 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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correct interpretation of ambiguous communications nonliteral language). Often, adults with Asperger's syndrome fail to meet entry requirements for jobs in area of training (e.g., college degree) or fail to maintain job because of their poor interview s kills , s ocial eccentricities , or anxiety attacks . It is important, that they are trained for and placed in jobs for which are not neurops ychologically impaired and in which will enjoy a certain degree of support and shelter. It is preferable that the job does not involve intensive social demands, time press ure, or the need to quickly or generate solutions to novel s ituations. T he little experience available with s elf-support groups sugges ts that individuals with As perger's s yndrome enjoy the opportunity to meet others with similar problems and develop relations hips around an activity or s ubject of shared interes t. S pecial interests may be used as a creating s ocial opportunities through hobby groups . S upportive psychotherapy, as well as pharmacological interventions , may be helpful in dealing with feelings of despondency, frustration, and anxiety, although a more direct, problem-solving focus is thought to be more beneficial than an insight-oriented approach. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 38 - P ervas ive Developmental Dis orders > AT Y P IC AL DE V E LO P ME NT AL DIS OR DE R NOT O T HE R W IS E S P E C

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NOT OTHE R WIS E P art of "38 - P ervas ive Developmental Dis orders" Atypical autism in IC D-10 and the equivalent pervas ive developmental disorder not otherwise specified in T R es sentially refer to a residual category with minimal defining criteria. T he diagnos is is us ed to denote a subthreshold form of autism or a manifestation of that is atypical in terms of onset patterns or symptomatology. T he terms atypical autis m and de ve lopmental dis orde r not othe rwis e s pe cifie d are describe a rather large and heterogeneous group of children who do not meet s trict criteria for autism or pervas ive development disorders but exhibit a pattern developmental and behavioral dys function s imilar to observed in autis m. S uch children typically exhibit sens itivities and affective respons es in the presence of more differentiated social relatednes s and better and communicative s kills than do most autis tic is very likely that regularity patterns or new definable syndromes will be identified in this group in the future, thus reducing the unfortunate fact that a large number children with s ocial dis abilities are given what is, es sentially, an undefined diagnosis. S ome studies attempted to delineate reliable and s pecific criteria for group, whereas others have proposed new s yndromes . T he relations hip between s ubthres hold autis m and a broader constellation of difficulties remains an topic for research.

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Leslie was the oldes t of two children. S he was noted to a difficult baby who was not eas y to cons ole but whos e motor and communicative development seemed appropriate. S he was s ocially related and sometimes enjoyed s ocial interaction, but was eas ily S he was noted to exhibit some unus ual sensitivities to as pects of the environment and, at times, out of excitement, exhibited some hand flapping. Her parents sought evaluation when s he was 4 years old because difficulties in nurs ery school. Leslie was noted to have problems with peer interaction. S he was often preoccupied with poss ible adverse events . At she was noted to have both communicative and functions within the normal range. Although differential social relatednes s was present, Les lie had difficulty her parents as sources of s upport and comfort. rigidity was noted, as was a tendency to impose on social interaction. Les lie was enrolled in a nursery s chool, in which she made significant gains in social s kills . S ubsequently, s he was placed in a kindergarten and did well academically, although problems in peer interaction and unusual affective res ponses persisted. As an adolescent, she describes herself as a “loner” who has difficulties with s ocial interaction and tends to enjoy s olitary activities. (F rom V olkmar F . Autis m and the pervas ive developmental disorders . In: Lewis M, ed. C hild and Adole s ce nt C omprehe ns ive Approach. 2nd ed. B altimore: W illiams Wilkins ; 2002:489–502, with permiss ion.) E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 38 - P ervas ive Developmental Dis orders > S UG G E S T E D R E F E R E NC E S

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S UGGE S TE D C R OS S R E FE R E NC E S P art of "38 - P ervas ive Developmental Dis orders" Mental retardation is dis cuss ed in C hapter 34 and disabilities in C hapter 35. Normal child development is discuss ed in S ection 32.2. Detailed information on behavior therapy is pres ented in S ection 30.2, on principles of ps ychopharmacology in S ection 31.1, and medication-induced movement dis orders in S ection P.3182 T he ps ychiatric treatment of children is discus sed in C hapter 32. P erception and cognition is covered in 3.1

R E FE R E NC E S Asperger H. “Autistic psychopathy” in childhood U, translator]. In: F rith U. Autis m and As perge r C ambridge: C ambridge University P ress ; 1991:37. B regman J . B ehavioral interventions. In: C ohen D, V olkmar F , P aul R , K lin A, eds . Handbook of Autis m P ervas ive De ve lopme ntal Dis orde rs . 3rd ed. New Wiley (in pre s s ). F arrington C P , Miller E , T aylor B : MMR and autis m: F urther evidence against a caus al ass ociation. 3981 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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2001;19:3632–3635. *F ombonne E . E pidemiology of autis m and related conditions. In: C ohen D, V olkmar F , P aul R , K lin A, Handbook of Autis m and P e rvas ive Deve lopme ntal Dis orde rs . 3rd ed. New Y ork: W iley (in pre s s ). Harris S L, Handleman J S . Helping children with enter the mainstream. In: C ohen D, V olkmar F , P aul K lin A, eds. Handbook of Autis m and P ervas ive Deve lopme ntal Dis orde rs . 3rd ed. New Y ork: W iley pre s s ). Heller T : Dementia infantilis. Ze its chrift E rfors chung B ehandlung J ugenlichen S chwachs inns . Hermelin B . B right S plinte rs of the Mind: A P e rs onal of R e s e arch with Autis tic S avants . London: J es sica K ingsley; 2001. Howlin P . Outcomes in autism spectrum dis orders. C ohen D, V olkmar F , P aul R , K lin A, eds. Handbook Autis m and P ervas ive Developme ntal Dis orde rs . 3rd New Y ork: W iley (in pre s s ). K anner L: Autistic disturbances of affective contact. C hild. 1943;2:217. K lin A, J ones W , S chutlz R , V olkmar F R , C ohen DJ : Defining and quantifying the s ocial phenotype in autis m. Am J P s ychiatry. 2002;159:895–908.

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K lin A, J ones W , S chulz R , V olkmar F R , C ohen DJ : fixation patterns during viewing of naturalis tic social situations as predictors of social competence in individuals with autism. Arch G e n P s ychiatry. 2002;59:809–816. Lord C : F ollow-up of two-year-olds referred for autis m. J C hild P s ychol P s ychiatry. 1996;36:1065– *Lord C . Diagnos tic instruments in autis m spectrum disorders . In: C ohen D, V olkmar F , P aul R , K lin A, Handbook of Autis m and P e rvas ive Deve lopme ntal Dis orde rs . 3rd ed. New Y ork: W iley (in pre s s ). Machado C J , B achevalier J : Non-human primate of child ps ychopathology: T he promise and the limitations . J C hild P s ychol P s ychiatry. 2003;44:64– McC racken J T , McG ough J , S hah B , C ronin P , Aman MG , Arnold LE , Lindsay R , Nash P , Hollway McDougle C J , P os ey D, S wiezy N, K ohn A, S cahill Martin A, K oenig K , V olkmar F , C arroll D, Lancor A, T ierney E , G human J , G onzalez NM, G rados M, R itz L, Davies M, R obins on J , McMahon D: children with autis m and serious behavioral N E ngl J Me d. 2002;347:314–321. *McDougle C J . P sychopharmacology. In: C ohen D, V olkmar F , P aul R , K lin A, eds . Handbook of Autis m P ervas ive De ve lopme ntal Dis orde rs . 3rd ed. New Wiley (in pre s s ). 3983 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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National R es earch C enter. E ducating Y oung with Autis m. W ashington, DC : National Academy 2001. R ett A: Uber ein eigenartiges hirntophis ces bei hyperammonie im K inders alter. W e in Med W oche ns chr. 1966;118:723. R utter M: Diagnos is and definitions of childhood autis m. J Autis m De v Dis . 1978;8:139. R utter M, B ailey A, B olton P , Le C outer A: Autism known medical conditions: Myth and s ubs tance. J P s ychol P s ychiatry. 1994;35(2):311. *R utter M, B ailey A, S imonoff E , P ickles A. G enetic influences in autis m. In: C ohen D, V olkmar F , P aul A, eds. Handbook of Autis m and P ervas ive Dis orde rs . 3rd ed. New Y ork: W iley (in pre s s ). S chultz R T I, G authier I, K lin A, F ulbright R K , AW, V olkmar F , S kudlarski P , Lacadie C , C ohen DJ , J C : Abnormal ventral temporal cortical activity face dis crimination among individuals with autis m Asperger syndrome. Arch G e n P s ychiatry. 2000;57 (4):331–340. T owbin K E . P ervasive developmental dis order not otherwis e s pecified. In: C ohen D, V olkmar F , P aul A, eds. Handbook of Autis m and P e rvas ive Dis orde rs . 3rd ed. New Y ork: W iley (in pre s s ). 3984 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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V an Acker R . R ett's Dis order. In: C ohen D, V olkmar P aul R , K lin A, eds. Handbook of Autis m and Deve lopme ntal Dis orde rs . 3rd ed. New Y ork: W iley pre s s ). V olkmar F . Autis m and the pervasive developmental disorders . In: Lewis M, ed. C hild and Adole s ce nt P s ychiatry: A C ompre he ns ive Approach. 2nd ed. B altimore: W illiams and W ilkins; 2002:489–502. V olkmar F , C ook E H J r, P omeroy J , R ealmuto G , P : P ractice parameters for the ass es sment and treatment of children, adoles cents, and adults with autis m and other pervasive developmental Am Acad C hild Adole s c P s ychiatry. 1999;38[12 S uppl]:32S –54S . V olkmar F R , K lin A, S iegel B , S zatmari P , Lord C , C ampbell M, F reeman B J , C icchetti DV , R utter M, W, et al: F ield trial for autis tic disorder in DS M-IV . P s ychiatry. 1994;151:1361. V olkmar F R , K lin A, S chultz R T , et al: C linical C ase C onference. Am J P s ychiatry. 2000;157:262–267. *V olkmar F R , K oenig K , S tate M. C hildhood disintegrative disorder. In: C ohen D, V olkmar F , K lin A, eds. Handbook of Autis m and P e rvas ive Deve lopme ntal Dis orde rs . 3rd ed. New Y ork: W iley pre s s ). V olkmar F R , Lord C , B ailey A, S chultz R T , K lin AJ : 3985 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/38.htm

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and pervas ive developmental dis orders. J C hild P s ychiatry. 2004;45:135–170. Wing, L: As perger's s yndrome: A clinical account. P s ychol Me d. 1981;11:115.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 39 - Attention-Deficit Dis orders > 39.1: AttentionDis order

39.1: AttentionDefic it/Hyperac tivity Lily Hec htman M.D., F.R .C .P.(C ) P art of "39 - Attention-Deficit Disorders "

B A C K G R OUND A ND HIS TOR IC A L P E R S P E C TIVE Attention-deficit/hyperactivity dis order (ADHD) has received a great deal of clinical, scientific, and public attention in recent years . In fact, as Margaret W eis s G abrielle W eiss point out, between 1957 and 1960, one articles were published on hyperactivity in children, whereas since 1996, there have been about 400 year on ADHD. T he increas e in the rate of publication continuing. One s hould be aware that this is not a new condition, however. In 1902, G eorge S till described children who were restles s, impuls ive, and inattentive, with intense affect and conduct problems . S till believed a of organic and environmental factors res ulted in the inhibitory control and inattention, which he thought the primary deficits of the syndrome. After the influenza pandemic and the epidemic of encephalitis lethargica in 1919 to 1920, children who survived frequently developed severe behavior 3987 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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similar to those des cribed by S till. T he condition was thought to be caus ed by organic brain damage, and minimal brain damage s yndrome was frequently us ed diagnose such children, even though s uch damage not be demonstrated. T his diagnosis was quite stigmatizing without clear proof of brain abnormality. C . B radley in 1937 s howed that benzedrine (D- and Lamphetamine) reduced restless nes s and improved concentration and motivation in children with behavior problems in a res idential treatment center. It was the evidence of the effectiveness of stimulants for these symptoms. However, this finding was largely ignored almos t three decades , until K eith C onners and his colleagues in 1967 used dextroamphetamine in a double-blind placebo trial for children with learning disabilities and s chool behavior problems . In the early 1960s , in an attempt to veer away from the brain damage concept, the condition was renamed minimal brain dysfunction. However, this too was stigmatizing, and the s pecific brain dysfunction could be documented. In the late 1960s, there were attempts to create more scientifically valid and reliable clas sification, and both ninth revision of the Inte rnational S tatis tical Dis e as es and R elate d He alth P roble ms (IC D-9) and second edition of the Diagnos tic and S tatis tical Manual Me ntal Dis orde rs (DS M-II) adopted more des criptive for the conditione.g., hype rkine tic s yndrome of hype ractive child s yndrome . T hes e terms reflected the prevailing belief that hyperactivity was the condition's disabling s ymptom. 3988 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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In the 1970s, further res earch s uggested that the main difficulties of children with this condition involved problems with s us tained attention and impulse control, with hyperactivity being secondary. T hus, the DS M-III renamed the condition atte ntion-de ficit dis order. T he diagnosis of attention-deficit disorder in the DS M-III included three symptom categories and required a number of pos itive items in each categorye.g., (three of five items), impuls ivity (three of six items ), and hyperactivity (two of five items ). T here were also three distinct subtypes : attention-deficit disorder with and without hyperactivity and the res idual s ubtype that included adults or others who had dis abling symptoms who no longer met full criteria for the condition. In the 1987 revised vers ion of the DS M (DS M-III-R ), name of the disorder changed slightly to atte ntionde ficit/hype ractivity dis order, and the criteria changed significantly. P atients receiving the diagnosis had to at least eight of 14 poss ible s ymptoms of hyperactivity, impulsivity, and/or inattention in any combination. behaviors needed to be present before 7 years of age occur considerably more frequently in patients than in most people of the s ame mental age, and they needed persis t for at leas t 6 months. T here were no s ubgroups, and attention-deficit disorder without hyperactivity was no longer a diagnostic category. A committee of the field constructed the DS M-III and DS M-III-R criteria. T he resulting criteria reflected the consensus compromises of these experts but were not based on objective controlled field trials. In preparation for the fourth edition of the DS M (DS M-IV ), multis ite field trials involving 600 clinic-referred children were initiated to 3989 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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define the validity of propos ed ADHD symptoms structured diagnos tic instruments and uns tructured clinical interviews . It can be s een that this condition has existed for more 100 years . Over time, there have been changes in regarding its underlying caus es , key s ymptoms , and diagnostic criteria. T his chapter provides a s napshot of current understanding of the etiology, clinical picture, treatment of ADHD. T his understanding may well in future years as new etiological evidence and come to light.

E P IDE MIOL OG Y ADHD is believed to be the mos t common ps ychiatric disorder in children, affecting 3 to 5 percent of the age population. It is als o a condition whose prevalence been documented in many other parts of the world, as G ermany, P uerto R ico, and T aiwan. R ecent results the National C omorbidity S urvey replication s tudy conducted on close to 10,000 people in the United suggested an adult prevalence rate of 4 percent.

E TIOL OG Y T he etiology of ADHD has s till not definitively been out. However, there is a growing consensus that the condition has neurobiological underpinnings . S everal excellent recent reviews on the s ubjects by J os eph B iederman and T homas S pencer, Xavier C as tellanos, P.3184 Lily Hechtman, and Allan Zametkin clearly illus trate the complexity of the area, the diverse findings, and the 3990 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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questions yet to be resolved. T he s ymptoms of ADHD not unidimensional and therefore involve various interrelated neuroanatomical and neurochemical T hus, it is unlikely that one brain area or one neurochemical s ys tem will emerge as the sole or caus e of any particular symptom or group of However, the current evidence for the neurobiological underpinning of this condition is briefly summarized. S pecifically, the genetics and the neuroanatomical and neurochemical s ys tems implicated in ADHD are

Genetic s F amily genetic studies, including twin, s ibling, adoption, and family s tudies , have all sugges ted that genetic play an important role in ADHD.

Twin S tudies G enerally, twin s tudies have s hown that monozygotic twins are much more concordant for ADHD symptoms inattention, hyperactivity, and impulsivity than s amedizygotic twins. S pecifically, the concordance rate for symptoms among monozygotic twins ranges from 59 to 92 percent, whereas the concordance rate in dizygotic twins ranges from 29 to 42 percent.

S ibling and Half-S ibling S tudies An early s tudy evaluated 53 hyperactive children and siblings and compared them with 38 nonhyperactive control s ubjects and their s iblings. T he hyperactive syndrome, or ADHD, was more common among the brothers of hyperactive children vers us the brothers of control s ubjects (26 percent vs . 9 percent). In addition, 3991 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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hyperactive subjects and their brothers presented with more s ymptoms of anxiety and depres sion than did the control s ubjects (16 percent vs. 6 percent). F inally, probands, but not their siblings , were more likely to antis ocial s ymptoms compared with the control T hese findings lent s upport to familygenetic risk in this condition and suggest that hyperactive children are more likely to be comorbid for anxiety and depres sion. Another early s tudy compared the incidence of ADHD 29 full-sibling and 22 half-sibling pairs , in which one member of each pair was known to have minimal brain dysfunction, currently known as ADHD. E ach pair had raised together by a common mother. More than half of the 19 full-sibling pairs were concordant for ADHD, compared with only two of the 22 half-sibling pairs . significant difference between full and half s iblings supports a genetic component in ADHD.

A doption S tudies A number of adoption s tudies have s hown that relatives of ADHD children are more likely to have as sociated dis orders and perform wors e on meas ures of attention than adoptive relatives of ADHD children. In a study of international adoptees, aged 10 15 years, E . S . V an den Oord and colleagues genes accounted for 47 percent of the variance of inattention s cores on the C hild B ehavior C hecklis t.

F amily S tudies F amily s tudies of children with ADHD are based on the as sumption that a genetic component in this condition reflected in higher rates of the disorder in families of 3992 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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probands vers us families of control or comparis on subjects . T his , in fact, has been the cas e. G enerally, degree relatives of children with ADHD have a 20 to 25 percent ris k for ADHD compared with 4 to 5 percent for the relatives of control s ubjects. In summary, twin, sibling, adoption, and family s tudies suggest a strong genetic component in the of hyperactivity, inattention, and impulsivity. F igure clearly s hows that these s tudies sugges t heritability ranging from .6 to .98. T his still leaves questions the role and importance of environmental factors and mode of inheritance.

FIGUR E 39.1-1 E s timates of heritability from twin family genetic studies . (Modified from F araone S V , B iederman J . Neurobiology of attention deficit 3993 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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hyperactivity disorder. B iol P s ychiatry. 1998;44:951.)

Mode of Inheritanc e T he strong evidence of genetic influences in ADHD has res ulted in s everal hypotheses of mode genetic transmis sion. G . S . Omenn explored the poss ibility of linked transmis sion becaus e of the male the condition. However, he concluded that this was unlikely because of the high frequency of father-to-son transmis sion. J . L. Morris on and S tewart s uggested a polygenic mode of inheritance but could not it becaus e of limitations of their sample s ize. S . H. colleagues pos tulated a polygenic multiple threshold model after analyzing s ex differences in the extensive Aus tralian twin and s ibling-pair s tudy. A number of have presented data cons istent with the effects of a gene. However, differences in fit between genetic were modest. T his was particularly true for comparison multifactorial and s ingle-gene inheritance. T his has res ulted in the s uggestion that s ymptoms of ADHD caus ed by s everal interacting genes of modes t effect. hypothes is is consistent with ADHD's high population prevalence and high concordance in monozygotic twins but modes t recurrence ris k for first-degree relatives. T o date, a s pecific definitive mode of inheritance has been es tablis hed, but work in this area is proceeding. However, diagnos tic uncertainty impedes progres s in developing genetic models that addres s the type of genetic trans mis sion involved. Longitudinal s tudies of prospectively identified s ubjects and careful 3994 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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of their offs pring are the best ways to res olve s ome of thorny methodological problems of family and genetic studies.

Molec ular G enetic S tudies T here has been increasing interes t in attempting to identify the s pecific genes and their abnormalities that may be implicated in ADHD.

THYR OID R E C E PTOR B G E NE E arly molecular genetic studies s howed that mutation the thyroid receptor B gene, which caus es generalized res is tance to thyroid hormone, was as sociated with rates (61 percent) of hyperactivity and impulsivity (but inattention) in affected individuals . However, only one 2,500 patients with ADHD had this thyroid abnormality, which generally was very rare. T hus , this gene could a major caus e of ADHD.

DOPAMINE TYPE D 2 R E C E PTOR G E NE (DR D2) Another early gene s tudied was the dopamine type D 2 receptor gene. T he gene was not s pecific to ADHD percent) but was als o s een with increas ed frequency in autis m (54.5 percent), alcoholis m (42.3 percent), and posttraumatic stress P.3185 disorder (P T S D) (45.7 percent) vers us normal controls percent). In light of the fact that fewer than half of the affected ADHD subjects had this gene, it was not to be a primary caus e of this disorder; rather, it was 3995 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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believed to modify the express ion of other genes symptoms better or wors e). More recently, D. C . R owe colleagues found no significant linkage between with ADHD and this gene. S imilarly, B . G . Winsberg E . C omings, exploring dopamine genes and their relations hip to methylphenidate (R italin) res pons e in African American children with ADHD, found no relations hip between the DR D2 gene and methylphenidate res pons e.

DOPAMINE TR ANS POR T G E NE (DAT1) A number of studies by E d C ook and coworkers , I. D. Waldman and colleagues , G ill and his team, and G . and coworkers have shown an as sociation between and dopamine transport gene 1 with 480base pair However, it must be noted that not all s tudies have this pos itive as sociation. Other studies found no as sociation or evidence of linkage or linkage disequilibrium between DAT 1 and ADHD. However, the dopamine transport gene remains a promising one for ADHD and merits further investigation.

DOPAMINE 4 R E C E PTOR G E NE (DR D4) A number of studies (both population- and familystudies) have shown a pos itive ass ociation between dopamine 4 receptor 7-repeat allele gene and ADHD. However, as with the DAT 1 gene, the findings are not cons istent, and a number of s tudies have s hown res ults and the absence of an as sociation between receptor gene and ADHD. Like the dopamine transport gene, the dopamine 4 receptor gene holds s ome promis e in clarifying the 3996 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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basis of ADHD. However, these genes may exert their influence in ADHD in combination with other genes and conjunction with other neurotransmitter systems .

OTHE R G E NE S Other genes implicated in ADHD include the dopamine hydroxylas e gene (DB H), dopamine 5 receptor gene (DR D5), catechol-O -methyltransferas e gene (C OMT ), androgen receptor gene, immune function and genes (null allele of C 4B gene and B -1 allele or DR All these reflect s ingle studies and thus need

S ummary of Molec ular G enetic Most of the molecular genetic studies to date have focus ed on dopamine-related genes (e.g., DR D2, DR D4, DB H, DR D5, DR D1). P ositive as sociations with have been replicated most often with the DAT 1 and 7-repeat allele genes. However, these pos itive are not limited to ADHD but occur with other conditions well and so are not specific to ADHD. F urthermore, for each of these genes, there are studies that do not the as sociation with ADHD. C learly, much work be done in unraveling the s pecific genes involved in condition and their mechanism of action.

Neuroanatomic al As pec ts A. Mirs ky clearly pointed out that attention is not a function but may involve focusing, executing, and s hifting of attention. F urthermore, Mirs ky indicated that these different functions involve different brain regions that are interconnected and organized into a system. T his attentional system is wides pread and thus 3997 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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vulnerable to damage and dysfunction. Mirsky thus implicated the s uperior and temporal cortices and striatum in focus ing of attention; the exterior parietal corpus s triatal regions in motor executive function; the hippocampus in encoding; the prefrontal cortex in from one s alient aspect of the environment to another; and the tectum, reticular formation, and reticular nuclei in s ustaining attention. S teven F araone and B iederman proposed a s imilar outline. A comprehensive review of neuroimaging s tudies in involving computed tomography (C T ), magnetic res onance imaging (MR I), functional MR I (fMR I), emis sion tomography (P E T ), glucose metabolis m, cerebral blood flow, and single photon emiss ion tomography (S P E C T ) s tudies was compiled by A certain cons is tency emerges from these s tudies . Neuroimaging s tudies sugges t decreased s ize and in the frontal lobes , particularly the prefrontal area. A corpus callosum and cerebellum and decreased in the anterior cingulate have been s uggested. activity in striatal areas and substriatal structures e.g., thalamus and hippocampushas also been s hown. and less active globus pallidus and caudate nucleus also been documented. It is therefore not surpris ing overall s maller brains in ADHD children have been documented by C as tellanos and colleagues .

Neurotrans mitters in ADHD Although s ome brain areas have been clearly with certain neurotrans mitters for example, the caudate nucleus and corpus striatum with dopamine and the median raphe area with s erotoninneuroanatomical 3998 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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of neurotrans mitters have proved very complex. T he complexity stems from the fact that any particular area be involved with different neurotransmitters or receive projections from various neurotransmitters pathways or nuclei. T herefore, there is rarely a one-to-one corres pondence between a particular area and a sole neurotransmitter that exerts exclus ive influence on this area. It is thus likely that more than one system is involved in ADHD. However, for the s ake of clarity, each neurotransmitter is discus sed s eparately.

Dopamine S ys tem Dopamine appears to be very important in ADHD. T he neuroanatomical areas implicated in ADHD (corticals triatal-thalamic-cortical network) are known to areas of dopamine concentration. Molecular genetic studies have s uggested the involvement of a dopamine transport gene and various dopamine receptor genes , particularly DR D4 and DR D2 genes. S timulants, which very effective for ADHD s ymptoms , are involved in dopamine transporter and thus preventing reuptake of dopamine into presynaptic nuclei.

Noradrenergic S ys tem T he evidence for involvement of the noradrenergic is present but less strong compared with the dopamine system. It has been hypothesized that an imbalance in tonic epinephrine formation would dis rupt the normal inhibition of locus ceruleus neurons, res ulting in inattention, s leeping difficulties , and s ome cognitive deficits , and that this may be the underlying problem in ADHD. S everal s tudies have reported plasma and 3999 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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elevations of norepinephrine and epinephrine or their metabolites in children with ADHD compared with controls. A review of a large number of studies plasma and urinary levels of epinephrine concluded children with ADHD may s how higher levels of norepinephrine activity and lower levels of epinephrine activity. T here have also been s tudies showing the of noradrenergic agents such as tricyclic (T C As ), bupropion (W ellbutrin), monoamine oxidas e inhibitors (MAOIs), atomoxetine (S trattera), and α2 noradrenergic agonist (clonidine and guanfacine) in subjects with ADHD. T hus , the noradrenergic system been implicated in the condition.

S erotonergic S ys tem T here is weak evidence for the significant involvement serotonin in ADHD. T he support for the s erotonin hypothes is comes from the fact that s ome drugs (e.g., T C As and MAOIs ) that affect s erotonin metabolism are moderately effective in ADHD. However, others for example, selective s erotonin reuptake inhibitors have not been shown to be effective. T hus , if serotonin plays a role in ADHD, it is not likely P.3186 to have a central role but rather an adjunctive role to or more other neurotransmitter s ys tems.

Nons pec ific C atec holamine It has been s uggested that ADHD is bes t unders tood the interaction and balance between various neurotransmitters, particularly dopamine and 4000 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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norepinephrine.

Other Neurotrans mitters Other neurotransmitters, s uch as γ-aminobutyric acid (G AB A), which is thought to be a predominantly neurotransmitter in the central nervous system (C NS ), histamine, which acts centrally and peripherally, have implicated. However, to date, there is little res earch involving thes e or other neurotrans mitters , s o their role remains hypothetical.

E nvironmental Fac tors E nvironmental factors such as high lead exposure, pregnancy and delivery complications , and maternal smoking during pregnancy have been implicated in increased rates of ADHD. F or children who live in chronically s tress ful circums tances , it is difficult to determine whether the symptoms reflect express ion of underlying anxiety or depres sion, a problem with parenting or s ocialization, a genetically influenced biological problem, or s ome interaction of a number of thes e factors. Only with further multifaceted res earch will there be a clearer, more comprehens ive unders tanding of the poss ible etiology, development, and treatment of this condition.

DE S C R IP TION OF THE DIS OR DE R Most children with ADHD are referred between the 6 to 12. T herefore, s ymptoms of the disorder are mainly for this age group. However, it s hould be noted that ADHD can be problematic in the pres chool age 4001 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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and continues into adolescence and adulthood. speaking, hyperactivity decreas es with age, but and impulsivity may continue to be problematic and be evident in different forms for example, driving infractions. In addition, comorbidity increas es with age, thus s ignificantly complicating the clinical picture.

Hyperac tivity T wo aspects of activity need to be address ed in ADHD: quantity and quality of the activity. It has been clearly shown via actometer readings over 7 days that children with ADHD have significantly more activity, both while awake and asleep, when compared with matched children. T he quality of the activity has often been described as disruptive and purpos eless . W ith age, the level of gros s motor activity may decrease, and and res tless nes s may be s een instead.

Attentional Diffic ulties Attentional problems may not always be evident and not be seen when the child is expos ed to highly novel, interes ting, and rewarding material. However, concentration problems usually become evident under environmental conditions that include elements of boredom, distraction, fatigue, repetition, and low levels reinforcement and motivation. T hus, children with are described as forgetful, dis organized, prone to things , daydreaming, being off-tas k, and failing to complete tas ks without s upervision.

Impuls ivity Impulsivity can be expres sed in a number of ways. It 4002 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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include engaging in physically dangerous activities , out in class , difficulty waiting one's turn, and or intruding on others in convers ations or games. Impulsive behavior may also res ult in difficulties with peers, parents , and teachers , with the escalation of frequent verbal and, at times, physical fights . T his may to peer rejection. C hildren with ADHD have impuls ive cognitive s tyles, as seen in res ults of the Matching F igures T est (MF F T ) or E mbedded F igures T est (E F T ). cognitive s tyles affect learning and s chool the child has problems taking his or her time to figure things out systematically and tends to respond impulsively.

As s oc iated Fac tors C hildren with ADHD may have areas of impairment are not part of the key s ymptoms of hyperactivity, impulsivity, and inattention. T hes e as sociated areas include behavioral, cognitive, affective, and s ocial

B ehavioral G enerally, children with ADHD do better in one-to-one settings with an adult than in group settings with peers . T hey need clear and immediate cons equences and reinforcements and a good deal of supervis ion. C hildren with ADHD often lack pers istence. T hey start projects without finishing them. T hey begin a game or activity, become bored quickly, and leave it impuls ively. T hey often have problems with delayed gratification do not persist if gratification is long in coming. C hildren with ADHD may show very variable on academic or other tas ks . T his variable performance 4003 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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leads to frustration and a fragile s ens e of self.

C ognitive It has been s hown that people with ADHD have an impaired sense of time and thus have problems in dependent tas ks and tes ts. A poor sense of time problems with planning, waiting, and playing. S hortmemory may als o be affected. Impuls ive cognitive also affect cognitive functioning.

E motional ADHD is often as sociated with dys regulation of affect, res ulting in temper outburs ts, mood lability, and Moods can change dramatically for no apparent environmental reason, and they can be explos ive, and infectious. T he reaction of others and the cons equences are often not well unders tood by the individual with ADHD, who has moved on to s omething else and does not see what all the fus s is about.

S oc ial C hildren with ADHD often have problems with peers, siblings , parents, and teachers . Individuals with ADHD have problems accurately reading s ocial cues; they misinterpret s ocial situations , and they often react inappropriately. C hildren with ADHD are often described as boss y, intrus ive, and insensitive to the needs of other people. T hey have problems cooperating with other children, res pecting s ocial hierarchies , and following rules . T hey may experience rejection and teasing and become and phys ically aggres sive. T hese children may 4004 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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situations. T hey are unable to let go of an argument or out of trouble with other children. T hey often do better alone with an adult or playing with children younger or older than themselves. T hes e s ocial problems may significant long-term impact on development and s elfes teem and thus need to be addres sed.

A S S E S S ME NT A ND DIA G NOS IS C urrently, the diagnosis of ADHD is mos t often made DS M-IV -T R criteria. T hes e criteria are outlined in T able 1.

Table 39.1-1 DS M-IV-TR C riteria for AttentionDefic it/Hyperac tivity Dis order A. E ither (1) or (2):   (1) S ix (or more) of the following s ymptoms of inattention have pers is ted for at least 6 months degree that is maladaptive and incons is tent with developmental level:   Inatte ntion     (a) often fails to give close attention to details makes careless mis takes in s choolwork, work, or other activities

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    (b) often has difficulty s ustaining attention in or play activities     (c) often does not s eem to listen when s poken directly     (d) often does not follow through on and fails to finish schoolwork, chores , or duties in workplace (not due to oppos itional behavior or failure to understand ins tructions)     (e) often has difficulty organizing tasks and activities     (f) often avoids , dislikes , or is reluctant to in tas ks that require sus tained mental effort (s uch schoolwork or homework)     (g) often los es things necess ary for tasks or activities (e.g., toys, school as signments , pencils , books , or tools)     (h) is often eas ily distracted by extraneous     (i) is often forgetful in daily activities   (2) S ix (or more) of the following s ymptoms of hyperac tivity impuls ivity have pers is ted for at 6 months to a degree that is maladaptive and inconsistent with developmental level: 4006 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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    Hype ractivity     (a) often fidgets with hands or feet or s quirms seat     (b) often leaves seat in clas sroom or in other situations in which remaining s eated is expected     (c) often runs about or climbs exces sively in situations in which it is inappropriate (in or adults, may be limited to subjective feelings of res tless nes s)     (d) often has difficulty playing or engaging in leisure activities quietly     (e) is often on the go or often acts as if driven motor     (f) often talks excess ively     Impuls ivity     (g) often blurts out answers before questions been completed     (h) often has difficulty awaiting turn     (i) often interrupts or intrudes on others (e.g., into convers ations or games) 4007 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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B . S ome hyperactiveimpulsive or inattentive symptoms that caus ed impairment were present before age 7 years . C . S ome impairment from the symptoms is in two or more s ettings (e.g., at school [or work] at home). D. T here mus t be clear evidence of clinically significant impairment in social, academic, or occupational functioning. E . T he s ymptoms do not occur exclusively during cours e of a pervasive developmental dis order, schizophrenia, or other psychotic disorder and not better accounted for by another mental (e.g., mood dis order, anxiety dis order, disorder, or a personality dis order). C ode based on type:   Attentiondefic it/hyperac tivity dis order, combined type: if both C riteria A1 and A2 are for the past 6 months .   Attention-defic it/hyperac tivity dis order, predominantly inattentive type: if C riterion A1 met but C riterion A2 is not met for the pas t 6 months.

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  Attention-defic it/hyperac tivity dis order, predominantly hyperac tive-impuls ive type: if C riterion A2 is met but C riterion A1 is not met for past 6 months .   C oding note: F or individuals (es pecially adoles cents and adults ) who currently have symptoms that no longer meet full criteria, in remis sion s hould be s pecified.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; copyright 2000, with permis sion. P.3187

L imitations of DS M-IV-TR K ey terms in the DS M-IV -T R criteria for ADHD are not specifically defined. F or example, many symptoms be pres ent often, but often is not s pecific. It is that there is a pers is tent pattern of inattention and/or hyperactivity/impuls ivity that is more frequent and than is typically obs erved in individuals at a level of development. Impairme nt is also not clearly defined. Impairment can be evaluated relative to a person's es tablis hed potential or relative to general appropriate development of norms . T hus, a child with 4009 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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intelligence quotient (IQ) of 130 who is barely pas sing school may be impaired relative to his or her potential unimpaired relative to general peer norms . there are few objective measures of impairment, s o clinicians rely on subjective reports from parents , and patients. T he DS M-IV -T R criteria were derived from field trials school-aged children and thus are not developmentally appropriate for adolescents and adults . Adoles cents adults with ADHD are less motorically active but to have attentional and organizational problems , impulsivity, poor anger management, job ins tability, problems with s ocial relations hips and s elf-es teem. difficulties are not well tapped by DS M-IV -T R developed for school-aged children. R ecalling before age 7 is als o difficult for adoles cents and adults. F inally, comorbidity, which increases with age in individuals with ADHD, affects the clinical picture and is not addres sed by DS M-IV -T R criteria.

Differential Diagnos is and In diagnos ing ADHD, one must address the is sues of differential diagnoses and comorbidity. T he distinction between thes e two situations is not always clear and simple. G enerally, if the dis abling symptoms are fully accounted for by another condition, that other condition merits the diagnosis and not ADHD. One is often left, however, with the impress ion that the condition in question coexists with ADHD, and both conditions are contributing to the clinical picture. In this latter case, ADHD is comorbid with the other condition. It has been es timated that more than 50 percent of 4010 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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children with ADHD are comorbid for another condition. It has als o been shown that rates and types comorbidity increas e with age. F urthermore, rates of comorbidity in clinical samples are generally higher rates in epidemiological s amples. T hus , comorbid rates vary depending on age, s ex, and s ource of the patient population. G enerally, ADHD and comorbid oppositional defiant disorder coexis t in 30 to 40 percent of ADHD patients . ADHD and conduct disorder have been reported as cooccurring in 30 to 50 percent of patients. However, recent multisite multimodal treatment s tudy of children with ADHD (Multimodal T reatment S tudy of C hildren ADHD [MT A]), which involves 576 ADHD (combined children 7 to 9 years of age, found that only 14.3 were comorbid for conduct dis order. R eported rates of comorbid depress ion in patients with ADHD range from to 38 percent. T he MT A rate was 3.8 percent. Anxiety disorders cooccurring with ADHD have been reported 25 percent. T he MT A rate was 33.5 percent. T he lower of conduct disorder and depress ion in the MT A s tudy be a function of the younger age of the children (e.g., 7 9 years vs. 6- to 12-year range in many other ADHD studies). It may be that thes e younger children have yet developed the conduct dis order or depres sion s een older children with ADHD. P.3188 T here has been much controversy regarding the rate of comorbidity of ADHD with mania or bipolar dis order. In fact, few studies dealing with ADHD children reported comorbidity with bipolar dis order or mania. T he recent 4011 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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significant changes in the diagnostic criteria for bipolar disorder in children (which are not based on controlled, empirical data) and the s ignificant problem numerous overlapping s ymptoms and ass ociated between bipolar dis order or mania and ADHD probably account for this controversy. G enerally, the rate of disorder or mania in children with ADHD is thought to low. R eported rates of comorbid learning dis order have from 9 to 30 percent among children with ADHD. T he rate was 15.5 percent. Ass es sment of comorbidity is crucial becaus e may affect the following: 

T he level and type of pathology encountered



T he long-term outcome



What type of treatment s hould be used



R es pons e to treatment

G enerally, the level of ps ychopathology is much higher children who have ADHD and other comorbid compared with thos e with ADHD alone. F or example, children with ADHD and conduct dis order have more severe ADHD s ymptoms, higher aggress ion, anxiety, rejection, and increased ris k for maternal ps ychopathology. A number of advers e adolescent and adult outcomes may be as sociated with childhood comorbidity, suggesting a more serious clinical cours e. S ome s tudies have s uggested that comorbidity may be linked to the persistence of ADHD. T hus, the pres ence comorbidities may dis tinguish individuals repres enting 4012 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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different s ubgroups of ADHD with different developmental cours es . T here is s ome evidence to sugges t that children who comorbid may show a differential response to S ome s tudies have s uggested that children who are comorbid for anxiety or more generally internalizing disorders may be les s res ponsive to s timulant More recent longer-term treatment s tudies have s hown that children with and without comorbid anxiety s howed similar medication-related improvement in ADHD symptoms. F or children with ADHD and conduct stimulant treatment s howed cognitive and attentional improvement and reductions in aggress ive behavior. C hildren with ADHD and multiple comorbidities appear benefit most from combined stimulant medication and behavioral treatment. T hus , comorbidity may influence treatment choice and res ponse. As illustrated in T able 39.1-2, the differential diagnos is ADHD is extremely broad. Many of the conditions listed may als o be comorbid with ADHD, and this fact needs be kept in mind during a comprehens ive as ses sment.

Table 39.1-2 Differential for ADHD Organic dis orders    S ens ory dis orders, especially deafness , visual 4013 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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impairment    Medication-induced attention deficit (e.g., antihistamines , beta-agonis ts , phenobarbital)    S eizure disorder    T hyroid abnormality    Learning dis ability    Mental retardation    F rontal lobe abs ces s, neoplasm    S ubs tance abus e    Lead intoxication    P ervasive developmental disorder F unctional disorders    Oppos itional dis order    C onduct disorder    Mood disorder    Anxiety dis order 4014 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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   Adjus tment dis order with disturbance of    T ourette's dis order/multiple tic disorder    P ersonality dis order    Obs es sive-compuls ive disorder (OC D)    Mania or mania bipolar disorder Developmental disorder    Age-appropriate overactivity S ituation, environmental, or family problems    Inappropriate school placement (e.g., gifted in regular class room, learning-disabled or developmentally delayed child in regular    F amily and social disruption (divorce, abuse, neglect)    P arental pathology or abs ence    C haotic home setting, ineffective discipline    Abus e or neglect or both

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Adapted from G arfinkel and C hild Adole s c C lin N Am. 1992;1:325.

Organic conditions such as sensory deficits (hearing vision), petit mal epilepsy, hyperthyroidism and hypothyroidism, infections, neoplas ms , and drug need to be considered and inves tigated if the his tory or clinical picture s uggests these difficulties . F unctional disorders such as conduct disorders , oppos itional defiant disorder, mood disorders , anxiety disorders , and adjus tment disorders need to be for both differential diagnosis and comorbidity. T he poss ibility of developmentally appropriate and inattention mus t be kept in mind, particularly for preschool age group, who may show symptoms that in 3 to 6 months. S tudies have s hown that only 50 of hyperactive preschool children followed since age 3 had a diagnos is of ADHD at age 9. persis tence included s everity of initial s ymptomatology and early dis cordant parentchild interactions. One needs to evaluate s ituational, environmental, and family problems to determine if problems in thes e are a caus e of the difficulties described or occur with ADHD. F or example, a child may be in the wrong 4016 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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setting because of s ignificant learning disabilities. However, the s ame child may also have ADHD, which, when combined with learning disabilities, results in greater academic handicap and more severe reaction the inappropriate academic s etting. S imilarly, a chaotic home environment and ineffective dis cipline may give to inappropriate, disruptive clas sroom behavior. children with ADHD may do wors e in a chaotic environment and are much more difficult to discipline effectively. T hus, the evaluation of the s chool and situation as a poss ible caus e of problems or an adjunct ADHD or other conditions is mos t important for and treatment purpos es .

As s es s ment ADHD is a clinical diagnosis. T here is no diagnos tic definitive test for ADHD. G iven that the differential diagnosis (T able 39.1-2) for ADHD is extremely broad that the rate of comorbidity is very high, as sess ments make the diagnos is need to be comprehens ive and multiple domains, informants, methods, and s ettings .

C linic al Interview T he clinical interview of the child and family is one of corners tones of the as sess ment process in diagnos ing P.3189 ADHD. T he interview should include an extensive history that explores the incidence of symptoms of and other psychiatric disorders in the parents and extended family members. T he family s ituation and the level of parental stress and ps ychos ocial adversity 4017 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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(poverty, family conflicts , illness es of parents and available s upports ) should be explored. A description of onset, development, and symptoms s hould be obtained from both the parents the child, in conjunction with the exploration of social, and emotional functioning. Areas pertaining to antis ocial behavior, s ubs tance abus e, and internalizing disorders (depress ion and anxiety) are often more accurately reported by the child when interviewed S tandardized, s tructured interviews and rating s cales addres s these various domains are outlined in T able T hey generally cannot replace the clinical as sess ment can add s ome rigor, s tandardization, and a quantifiable dimension to the areas being evaluated.

Table 39.1-3 As s es s ment Meas Domain

Meas ure (Author and

Informant

E xternalizing symptomatology

S tructured interview

P, C

   G eneral

Diagnos tic Interview S chedule for

 

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C hildren (DIS C 3.0) (S haffer et al., 1996)  

R ating s cales

 

 

C hild B ehavior C hecklis t (Achenbach, 1991)

P, T

 

S toney B rook

P, T, C

   ADHD

C onners ' R ating S cales 1997)

P, T, A

 

Attention Deficit Dis order E valuation (ADDE S ) (McG arney,

P, T

 

   B ehavioral Ass es sment for C hildren (T eacher) (P arent) (C hild) (R eynolds and K amphaus,

P, T, C

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S wans on, Atkins , M-F lynn, P elham S cale (S K AMP ) (C las sroom B ehavior) (S wans on,

T

 

C onners -LoneyMilich S cale (C LAM) (S wans on,

P, T

   Oppos itional disorder and conduct disorder

DS M-IV ADHD/ODD S cale (S NAP (S wans on,

P, T

 

DS M-IV Dis order C hecklis t (American P sychiatric Ass ociation, 1994)

P, T, C

 

S elf-R eport Antisocial B ehavior et al., 1989)

C

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Observations and direct meas ures

 

 

C las sroom observations (Abikoff et al., 1980)

O

 

P layroom observations (Handen et al., 1998)

O

 

Actograph P edometer

 

Internalizing symptoms

S tructured interview

 

 

Diagnos tic Interview S chedule for C hildren (DIS C 3.0) (S haffer et al., 1996)

P, C

 

R ating s cales

 

 

Multidimens ional

C

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Anxiety S cale C hildren (March et al., 1997)  

C hild Inventory (K ovacs, 1995)

C

 

C hild B ehavior C hecklis t (Achenbach, 1991)

P, T

 

C onners ' R ating S cales 1997)

P, T

C ognitive

 

 

   Intelligence

Wechs ler Intelligence for C hildren III (W IS C III) (W echs ler,

C

 

S tanford-B inet

 

   Academic achievement

Wechs ler Individual

C

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Achievement T es t (W IAT ) (W echlser,  

Wide R ange Achievement T es t, R evis ed

C

 

WoodcockJ ohns on

C

   Academic tests

R es tricted Academic T as k (F isher and Newby, 1998)

C

 

B arkley S chool S ituation Ques tionnaire

P, T

 

S chool P erformance R ating S cale (R aggio and P ierce, 1999)

 

   Attentional/vigilance tes ts

C ontinuous P erformance (C P T ) (Halperin al., 1991,

C

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and S taff, 1994)  

P os ner V isual Orientation T est (S wans on et al., 1991)

C

 

V is ual and auditory preschool vigilance tests (B yrne et al., 1998)

C

 

T es t of of Attention (T OV A) 1998)

C

 

S top-signal task (S chachar and Logan, 1990)

 

   F iltering stimuli

S troop C olor Word T es t

 

 

E mbedded F igures T est

 

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Matching F amiliar F igures T es t

 

   E xecutive functioning

Wiscons in C ard S ort

 

 

 

T ower of London T es t (C ulberts on and Zillmer, 1998)

P eer/social

S ocial S kills R ating S cale (S S R S ) and E lliott,

P, C, T

 

S ociometrics

P eers

P arentchild interaction/parenting

Home S ituation Ques tionnaire (B arkley, 1987)

P

 

P arentC hild R elationship Ques tionnaire (F urman and

P, C

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G iberson, 1995)  

Alabama P arenting Ques tionnaire (S helton et al., 1996)

P, C

 

Alabama Daily P hone R eport (S helton et al., 1996)

P

 

P arenting Inventory (Abidin, 1986)

P

 

V ideotaped parentchild interaction (P fiffner et al., 1994)

P, C

Impairment

C olumbia Impairment (B ird et al.,

P

 

Impairment rating scale (P elham et al.,

 

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1996)

ADHD, attention-deficient/hyperactivity disorder; C , child observer; ODD, oppos itional defiant disorder; P , parent; Adapted from Hins haw S P , March J S , Abikoff H, et al.: C omprehens ive as ses sment of childhood attention defic hyperactive dis order in context of a multisite multimodal trial. J Attention Dis ord. 1997;1:217.

Medic al E valuation Medical evaluations s hould include a complete medical history and a comprehensive physical examination. medical his tory needs to include a prenatal, perinatal, postnatal, and developmental history. C omplications or ris k factors during pregnancy, s uch as maternal alcohol, or drug us e and maternal illnes s (e.g., malnutrition, eclampsia), need to be explored. delayed, or difficult deliveries s hould be documented. Developmental histories are often characterized by advanced gros s motor development (e.g., early running) and delayed fine motor and language development. P roblems with s leep and regularity have also been reported. Medical his tory needs to include an exploration of any s ignificant trauma, illnes s, and toxin expos uree.g., accidents , previous head trauma, ear or eye infections , meningitis , as thma, allergies , or other seizures, and lead exposures. His tory of 4027 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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us e of pres cribed, over-the-counter, and illicit drugs should be obtained. Antihistamines , β-agonis ts , and such as phenobarbital can affect attention. A complete medical examination s hould include for hearing or vis ual deficits . Any hint of impairment in these areas needs to be further as sess ed with a more complete audiographical and ophthalmological examination. S imilarly, suggestions of lead expos ure may require meas urement of lead level. C linical findings or history indicative of thyroid dysfunction requires thyroid tes ts . C omprehens ive neurological examination s hould include ass es sment of tics , coordination, and the poss ibility of petit mal epilepsy. Again, clinical of the pos sibility of s eizures s hould be followed by electroencephalographic (E E G ) tes ting. E ven though sophisticated neurophysiological tests s uch as computerized E E G measures, brain mapping, eventpotentials , and neuroimaging are us ed in a variety of res earch s tudies , their use in routine clinical practice is premature. C urrently, these tes ts still lack diagnos tic specificity, are costly, and are not readily available. signs s uch as pulse, blood pres sure, height, and need to be taken to obtain bas eline measures to future medication effects on thes e areas .

S c hool-R elated A s s es s ment P sychoeducational tes ting to ass ess intellectual ability, academic achievement in key s ubjects, and pos sible learning disabilities need to be carried out. R eports the teacher regarding behavior, learning, and should be obtained as well as grades and tes t s cores. 4028 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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Again, s tructured interviews and teacher rating s cales tap ADHD and other symptoms are available and in T able 39.1-3. Observations of the child in the class room and in les s structured s ituations can provide important information regarding the child's behavior, the teacher's style, and other characteris tics of the academic environment. T hes e observations can be clinical or systematized, with blind raters who code behavior of ADHD and a matched control child in the s ame at regular or predetermined intervals.

S oc ial F unc tioning A view of the child's social functioning can be obtained reports and ratings from the child, the parents , and the teacher. In addition, observations at school, home, or the playground can also tap the child's s ocial behavior. F inally, sociometric evaluation via ratings from or other peers are another valuable meas ure of s ocial functioning, although they are rarely feas ible in routine clinical practice.

R ating S c ales , Tes ts , and Meas ures T able 39.1-3 outlines some key s tandardized us ed in the ass ess ment of ADHD. T he various meas ures (with authors), informants, and, for s ome meas ures , time needed to complete the tes ts are presented. T his list is by no means exhaus tive but the reader with an overview of some available and their references , s o more detailed exploration is poss ible.

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C UR R E NT TR E NDS A ND FUTUR E DIR E C TIONS IN A S S E S S ME NTS Defic it of B ehavioral Inhibition and E xec utive Func tioning R us sell B arkley proposed the theory that the deficit in ADHD is one of behavioral inhibition that significantly impairs the development of executive functioning, such as working memory (verbal and nonverbal), s elf-regulation of affect, motivation, and recons titution, all of which influence s elf-control goal-directed behavior. T here is the as sumption that problems of behavioral inhibition are linked to abnormalities in the frontal lobes and other brain structures , s uch as the caudate nucleus and globus pallidus . T here has been considerable interes t in this theory in recent years and a greater focus on executive functions. T o date, there are only a few wellstudied tests of executive function (e.g., W is consin S orting T es t, T ower of London T est). Working memory often address ed by s ubtests of the various intelligence tes ts . It is evident that neurops ychological tes ts usually meas ure an as pect of executive function and not the range of activities s ubs umed under this important area. date, there is no definitive test of executive function. theory, although interesting and promising, needs to be subs tantiated and validated by much more extensive rigorous testing. F inally, it is not at all clear that the of executive functioning would be s pecific to ADHD and not a component of other conditions as well.

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As indicated previously, neuroimaging studies have that there are differences between brain s tructures the prefrontal lobes , caudate nucleus , and globus in subjects with ADHD compared with matched normal controls. G enerally, s tudies sugges t that these are smaller in individuals with ADHD. However, the differences have not always been cons istent in the studies. F urthermore, thes e differences are not pathognomonic for ADHD, as they have been other conditions as well. F or thes e reasons, the routine of neuroimaging s tudies in the evaluation of ADHD is premature. However, as technology improves and as knowledge about the anatomy and function of various brain areas expands, eventually a consistent unique pattern of differences in brain structures in ADHD may evolve. At P.3190 P.3191 that point, neuroimaging may provide an additional valuable diagnostic avenue for the condition.

Genetic S tudies As des cribed previously, twin, s ibling, family, and studies have s uggested that there is a strong genetic component to ADHD. R ecently, there have been to identify the gene or genes involved. T o date, DR D2, DAT 1, and DR D4 have been explored. T his genetic res earch is continuing and, it is hoped, will prove fruitful the future. E ventually, a genetic test for ADHD may but, currently, the specific genetic abnormality in ADHD 4031 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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still unknown, and no such test exists.

TR E A TME NT Medic ation Treatment S timulants In 1937, C . B radley reported the benefits of benzedrine improving behavior and school performance in some institutionalized children. T his finding remained until the 1960s, when double-blind, placebo-controlled studies began to be carried out. S ince then, there have been more than 350 well-designed placebo-controlled studies (involving 3,000 children) that showed that stimulant medication (dextroamphetamine and methylphenidate) improve impulsivity, inattention, behavior, and social and family functioning in 75 to 80 percent of children with ADHD. T hree-fourths of with ADHD respond to the first medication trial. Of the children who do not res pond, most (90 percent) with a change of dose and/or a trial of the other Des pite the proven effectiveness of stimulants for symptoms, there has been increas ing concern the significant rise in s timulant use in recent years . It been reported that prescriptions for s timulants had doubled every 5 years and an es timated 1.5 million children were receiving medication for ADHD. the increase in prescriptions does not necess arily corres ponding increase in use, as many pres criptions filled but not taken or renewed. Nevertheles s, stimulant use has increased in adoles cents , and adults . T here has als o been an the us e of s timulants for the inattentive ADHD 4032 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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percent in 1970 to 20 percent in 1990). S timulants are also used to treat children with ADHD and various comorbid dis orders, such as anxiety, depres sion, T ourette's s yndrome, oppos itional defiant disorder, conduct dis order, and mental retardation. T he concern that s timulants are overused is balanced by the fact given the 5 percent prevalence of ADHD in the s choolaged population, s timulants may be underused.

PHAR MAC OLOG Y AND PHAR MAC OK INE TIC S Methylphenidate and amphetamine increas e the of dopamine and norepinephrine from their s torage in nerve terminals and block their reuptake (by of dopamine trans port protein). T his increases the availability of dopamine in the s ynaptic cleft. S timulant effects on serotonin metabolism seem minimally the clinical efficacy of stimulants . T he maximum therapeutic effects of stimulants occur during the absorption phase of the kinetic curve, approximately 2 hours after ingestion. T he absorption phase parallels the acute releas e of neurotransmitters the s ynaptic cleft. S timulant effects , particularly action, are modified by its different isomers e.g., D of methylphenidate is three times more potent. Dextroamphetamine is more potent than methylphenidate and las ts somewhat longer. T hus, half the dose of dextroamphetamine is required for equivalence with methylphenidate. Adderall (a mixture dextroamphetamine and amphetamine) salts als o las t longer than methylphenidate, with two dosages of methylphenidate covering the s ame time frame as one 4033 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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dose of Adderall. E fficacy and s ide effects of the two are comparable. Adderall and Dexedrine s pansules not been compared. R ecently, new, long-acting s timulant preparations have come on the market. C oncerta in an oral os motic system (OR OS ) is a methylphenidate preparation; XR is a long-acting Adderall compound. B oth report coverage for 10 to 12 hours , thus requiring only onceday dosing. Direct comparis on of thes e two long-acting stimulants regarding efficacy and side effects has not carried out (see T ables 39.1-4 and 39.1-5 for details of stimulants).

Table 39.1-4 S timulant Preparation and Daily Dos es  

T ablet S ize and P reparation

Half-Life (

Medication (B rand Name)

S hortActing

Long-

S erum

B

D-, L-Amphetamine (Adderall,

5 mg

10, 15, 20, 30 mg

1220

3

 

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B enzedrine, B iphetamine)

(Adderall)

 

 

5, 10, 15, 25, 30 mg (Adderall XR )

 

1

Dextroamphetamine (Dexedrine)

5 mg

5, 10, 15 (s pans ule)

1220

2

Methylphenidate (R italin)

5,10, 20

10 and 20 mg (s ustainedreleas e)

36

2

Methylphenidate (C oncerta)

18, 54 mg (OR OS preparation)

210

1

Magnesium pemoline (C ylert) a

18.75, 75 mg

714

6

OR OS , oral osmotic release system. a S econd

line.

F rom C hild Adole s c P s ychiatry C lin N Am. Attention def disorder. 2000;9:577, with permiss ion. 4035 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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Table 39.1-5 New S timulant Formulations B rand Name

Des c ription

F ocalin

A refined form of R italin, is olating the effective D is omer; three times more potent, less toxic

R italin LA

Once-daily formulation of R italin that mimics b.i.d. dosing and duration designed to last the school day

Adderall XR

E xtended-releas e formulation of amphetamines that mimics b.i.d. dosing (12 hrs )

Metadate

Methylphenidate formulation designed to mimic b.i.d. duration (89 hrs )

C oncerta

Methylphenidate formulated to mimic t.i.d. duration (12 hrs )

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Abs orption of s timulants is generally not affected by Individual s erum levels vary greatly and therefore do correlate well with clinical efficacy or toxicity. Amphetamines are metabolized in the liver and in the urine. T his excretion is affected by urinary pH. T herefore, the inges tion of as corbic acid (vitamin C and orange juice) may s horten plasma half-life and clearance of amphetamine, resulting in decreased

E FFIC AC Y As indicated previously, 75 to 80 percent of children ADHD res pond positively to stimulants , and 90 percent the nonres ponders become res ponders to another stimulant medication. However, the placebo respons e can be high, ranging from 2 to 39 percent.

C OG NITIVE E FFE C TS S timulants have been shown to improve cognition, vigilance, reaction time, s hort-term memory, and of verbal and nonverbal material in children with Des pite early reports to the contrary, recent studies suggested a linear P.3192 res ponse curve between cognitive meas ures and dose up to ranges of 0.7 to 0.9 mg/kg with no evidence overfocus ing. E arly s tudies also failed to show that with ADHD improved in their academic functioning with stimulant treatment. However, recent studies s howed improvements in school-based productivity and in s timulant-treated children with ADHD. 4037 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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B E HAVIOR AL E FFE C TS S timulants have been shown to improve impuls ive behavior, nois ines s, noncompliance, dis ruptivenes s, motherchild interaction, peer perceptions of the child ADHD, and the child's self-perception. T hus, behavioral changes due to s timulants have far-reaching s ocial and emotional effects.

TR E A TME NT OF A DHD A ND ITS C OMOR B IDITIE S Tic Dis order C hildren with ADHD and T ourette's s yndrome, or tic disorder, can benefit s ignificantly from stimulants. However, rates of tic exacerbation range from 10 to 36 percent. R ates of s timulant discontinuation because of exacerbation range from 0 to 15 percent. Of greatest concern is that, for a s mall number of children (0.1 percent), tics do not decreas e after medication is discontinued. T hus, careful titration and monitoring of stimulant medication are recommended in thes e comorbid circumstances.

S eizure Dis order T he cooccurrence of s eizure dis order and ADHD is not uncommon. T he fact that stimulants can theoretically lower seizure thres hold has resulted in concern about us e of stimulants in this population. A few s tudies no increase in E E G epileptiform activity, incidence of seizures , or significant interaction with levels of anticonvuls ants. T his sugges ts that stimulants can be safely in children with s eizures and ADHD, provided 4038 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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the seizure disorder is adequately treated and careful titration and monitoring are in place.

Aggres s ion and C onduc t Dis order S everal controlled studies s howed dose-dependent stimulant improvement in ADHD and aggres sive symptoms (physical and nonphysical) at home and at school in children with ADHD. S timulants also reduced negative social interactions and covert antisocial (s tealing and vandalis m but not cheating). T he shortlong-term cons equences of these reductions are important, as continued conduct disorder and antis ocial behavior predisposes to later drug and alcohol abuse generally more negative outcome.

Anxiety Dis order S ome s tudies have s uggested that children with ADHD and comorbid anxiety dis order are les s respons ive and experience more side effects to s timulant medication children without this comorbidity. More recently, the study showed that children with ADHD and comorbid anxiety were as res ponsive to stimulants as children ADHD without this comorbidity. S low, careful titration res ult in fewer s ide effects and better respons e.

Mood Dis order It has als o been sugges ted that children with ADHD comorbid depres sion benefit les s from s timulant medication than children with ADHD without this comorbidity. S ome open-label studies report that S S R Is to s timulant medication for children with ADHD depres sion improves their res ponse. More controlled 4039 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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studies are needed to es tablis h the safety and of this combination. It has been s uggested that children with mania and should first be put on mood s tabilizers, and then stimulants should be introduced very s lowly.

Developmental Dis orders ADHD-like symptoms of inattention and hyperactivity seen in children with mental retardation and autis mspectrum dis orders. S timulants have been s hown to be beneficial in both these groups , particularly in the IQ and better-functioning children. However, thes e populations may also be more s usceptive to adverse effects of stimulants, such as s tereotypy, delusions , fearfulnes s, and aggress ion. T hus, careful titration and monitoring are required when s timulants are used in treating these children. T he combination of s timulants the newer antips ychotic agents (e.g., risperidone) may required for some of these children.

Advers e E ffec ts S hort-Term S everal reviews by R uss ell B arkley, R achel K lein, and G reenhill focus ed on s ide effects of stimulant S hort-term s ide effects of s timulants are usually mild, decrease after the child has been on medication for a or two, and can often be dealt with by either changing time or dose of the medication, or both. C ommon side effects include decreased appetite, loss , delayed ons et of sleep, headaches , slight increase in puls e and blood pres sure, and s ome 4040 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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increased irritability and crying. Infrequent s ide effects include motor tics , T ourette's syndrome, and rebound. R ebound, defined as a deterioration (exceeding that which is pres ent at or during placebo conditions ) that occurs in the late afternoon or evening after daytime administration of stimulant medication, has been reported to be as high 30 percent in some s amples . T he magnitude of the rebound varies greatly from day to day. T he use of acting preparations or adding small dos es of s timulants before ons et of the rebound us ually results in adequate management of this s ide effect. S timulants may occas ionally produce choreiform movements and s elf-directed behavior, such as lip lip biting, and light picking of fingertips . R educing the dose often eliminates thes e behaviors . R are side effects include toxic ps ychos is with tactile delus ions, thought disorganization, press ured speech, marked anxiety. T his mos t often occurs at very high dosages. R are cas es of bone marrow suppres sion and thrombocytopenia may be as sociated with stimulant Medication s hould be discontinued in these very rare events. P emoline (C ylert) has been dis continued as a firs t-line therapy for ADHD because of reports of liver toxicity some reports of liver failure, resulting in deaths. P.3193

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E FFE C TS ON G R OWTH It has been s uggested that s timulants may s uppress and weight gains of children receiving thes e T he suppress ion effect, which appeared to be dose was more pronounced with dextroamphetamine and occurred predominantly in the first year of treatment. initial s uppress ion is often followed by rebound in or habituation of this effect, and there is generally no effect on overall adult height or weight. T his is true if drug holidays, which allow growth rebound, are of the treatment regimen. E ffects on growth are thought to be s econdary to appetite s uppress ion, although studies have found a direct effect on blood levels of growth hormone. G enerally, it is recommended that clinicians monitor height and weight of children treated with stimulant medication and institute drug holidays during summer school vacations so as to increase the probability of growth rebound.

S UB S TANC E AB US E T here is little evidence that ADHD per s e or that treatment of children with ADHD increases the ris k of subs tance abus e. In fact, studies s uggest that patients treated with s timulants in childhood are le s s likely to subs equently have substance abus e.

S ummary of S timulant Medic ation S timulant treatment of children with ADHD is both effective and s afe. E ffective, long-acting s timulants recently been developede.g., C oncerta, Adderall XR providing coverage for most of the day with one morning dose. Most s hort-term s ide effects can be 4042 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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with by adjustment of dos e and/or times of of the medication. Long-term s ide effects such as suppress ion are minor and are helped by drug which permit growth rebound. S timulant medication treatment tends to decreas e rather than increase subs tance abus e. However, small proportions of either do not res pond to stimulants or have prohibitive side effects . Other medication treatment needs to be cons idered for this population.

Nons timulant Medic ation in the Treatment of C hildren with ADHD E ven though there is general agreement that cons titute the first-line treatment choice for children ADHD, becaus e s ome children do not res pond to stimulants or may have prohibitive s ide effects , other medications may need to be us ed. However, is emerging as a first-line treatment choice by many clinicians and families . G enerally, thes e s econd-order drugse.g., T C As, bupropion, clonidine, and less effective and have more serious s ide effects than stimulants. However, they have longer duration of and no rebound or insomnia in their s ide effect profile.

A tomoxetine HC I Atomoxetine is a norepinephrine reuptake inhibitor. precis e mechanism by which atomoxetine produces its therapeutic effects in ADHD is unknown but is thought involve selective inhibition of pres ynaptic transporter. Atomoxetine is well absorbed after oral administration is minimally affected by food. High-fat meals may 4043 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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the rate but not the extent of abs orption. Maximum plasma concentrations are reached approximately 1 to hours after ingestion. At therapeutic concentrations, 98 percent of atomoxetine in plas ma is bound to protein, mainly albumin. Atomoxetine has been shown to be effective with to ADHD s ymptoms and behaviors in children, adoles cents , and adults . C ommon s ide effects include abdominal discomfort, decreas ed appetite with weight loss , dizziness , vertigo, irritability, and mood swings ; rare, minor increas es in blood pres sure and rate have als o been observed. T hus, weight, height, press ure, and puls e s hould be regularly monitored. Atomoxetine is metabolized by the cytochrome P 450 2D6 hepatic enzyme system and usually has a half-life approximately 5 hours. A fraction of the population (approximately 7 percent of whites and 2 percent of African Americans ) are poor metabolizers of C Y P 2D6metabolized drugs . F or such individuals , the concentration (at similar doses ) may be five times and the plasma half-life may be 24 hours as opposed hours. T hus , determining if a patient is a poor is us eful. Alternatively, very s low initial titration may be required to prevent exces sive dos ing of these patients. P atients taking other medications that inhibit C Y P 2D6, such as fluoxetine (P rozac), paroxetine (P axil), and quinidine (C ardioquin), may experience decreas ed metabolism of atomoxetine and require dos age adjus tments . S tudies that directly compare the efficacy of to s timulants have not been carried out yet, so it is if this medication is as effective as are stimulants. It 4044 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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supposedly provides 24-hour coverage and thus offers us eful alternative to stimulants.

Tric yc lic A ntidepres s ants T homas S pencer reviewed 29 studies in which children with ADHD were treated with T C As. S ignificant pos itive res ponse was s een in 22 of these s tudies . Imipramine, nortriptyline, and amitriptyline but not clomipramine been found to be effective in ADHD. P atients with who do not respond to one T C A may res pond to G enerally, much lower dosages of T C As are used in treatment of ADHD versus depres sion (less than 100 per day vs. 300 mg per day). P las ma level guides for depress ion, and depres sion dosages are thus not relevant or appropriate for ADHD. Imipramine is the most frequently used T C A, s o it is an example. However, s imilar is sues apply to all T C As . minimize s ide effects , T C As should be given in divided dosages, morning and evening, or three divided can be us ed if s edation and fatigue are problematic. G enerally, one begins with 10 mg twice a day for children, 20 mg twice a day for older ones , and 25 mg twice a day for adoles cents. T he dos e can be similar amounts every 2 weeks until improvement is to a maximum daily dose of 100 or 150 mg per day. medication s hould be discontinued by gradually decreasing the dose over several weeks .

C ONTR AINDIC ATIONS T C As should not be used in patients with a his tory of cardiac conduction problems or in conjunction with MAOIs . T C As may also lower the s eizure thres hold, s o 4045 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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should be us ed with great caution in patients with disorder.

S IDE E FFE C TS T he most frequent side effects are fatigue and which often decreas e over time as acclimatization place. However, if these side effects persist, they can dealt with by dividing the dose still further, decreasing dosages, or changing to another T C A. C holinergic side effectse.g., cons tipation, dry mouth, or blurred also be a problem. If they persist, the medication may to be discontinued. T he cardiovascular s ide effects of involve the slowing of cardiac conduction, thus the P R and the QR S intervals, increas ing the ris k of arrhythmias and, poss ibly, heart block. T hese cardiovascular effects have resulted in significant concerns . S everal cases of sudden death have been reported in children taking T C As . E ven though it has been proven that T C As were involved in thes e deaths , now recommended that electrocardiogram (E C G ) be obtained at baseline and at optimal dose to evaluate changes in the P.3194 QT interval. Increas es in blood press ure and heart rate should also be monitored. T he fact that T C As are les s effective than stimulants ADHD and have a more negative s ide effect profile fatigue, s edating, and cardiovascular side effects) have made them less popular with patients and clinicians .

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B upropion is a non-T C A antidepres sant that has shown some efficacy in ADHD but is les s effective than T C As stimulants. It s eems to be more effective in than in children and is therefore not recommended for children. S tarting dose for young adolescents is 75 mg twice a day to a maximum of 200 to 300 mg per day. medication can be increas ed every 7 to 10 days until improvement is noted. S ide effects of bupropion fatigue, dry mouth, insomnia, headaches, naus ea, vomiting, cons tipation, tremor, and skin ras h. S eizures have been reported at high dos ages. Again, this medication is less effective than stimulants and has a negative side effect profile. It is currently available in an extended-releas e preparation (Wellbutrin S R ), which permits once-daily dos ing.

α-A drenergic A ntagonis ts T here have been s ome reports that clonidine and guanfacine (T enex), α-adrenergic antagonis ts, are effective in children with ADHD. T hese medications to decreas e impuls ivity and hyperactivity but have less impact on inattention. C lonidine is very s edating, and may need to s tart at 0.025 mg. If daytime sedation a problem, it needs to be discontinued. At very low dosages, the impact on blood press ure and pos tural hypotens ion is minimal. However, blood pres sure and pulse need to be monitored. C lonidine needs to be discontinued very s lowly to prevent rebound adrenergic overdrive, with hypertension, agitation, fever, ches t pain, s leep disturbance, nausea, and vomiting. can create a problem when parents go on holiday and forget the medication. P otential cardiac effects and poss ible deaths from the combination of clonidine and 4047 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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stimulants have raised concerns and have res ulted in recommendations that clonidine not be us ed in the presence of preexisting cardiac or vas cular dis eas e. G uanfacine is s lightly less sedating than clonidine and may be tried if s edation with clonidine is a significant problem. Its s ide effect profile is similar to that of

Other A lternative Medic ations Anticonvulsants (carbamazepine [T egretol]), mood stabilizers (lithium [E skalith]), S S R Is, and antipsychotic drugs have not been s hown to be effective for primary symptoms of ADHD. T hey may, however, be us eful in treating s ome comorbid conditions that children with ADHD often have.

S ummary of Medic ation Treatment In general, most children with ADHD respond to medication, which remains the first-line choice in these children. However, if s timulants are ineffective or have prohibitive side effects, T C As can be tried, mind contraindications and significant sedation and cholinergic and cardiovas cular s ide effects . B upropion less effective than the T C As or s timulants , with a risk of seizures at high dos ages. Atomoxetine, a s elective norepinephrine reuptake inhibitor, has also been be effective in ADHD and provides an additional alternative to stimulants. Detection of s low cytochrome (C T P 2D6) hepatic enzyme metabolizers and/or careful slow initial titration may be required for this medication. C lonidine and guanfacine are quite sedating and have significant cardiovas cular s ide effects . F or all these careful monitoring and s low, cautious discontinuation 4048 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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es sential.

P S YC HOS OC IA L TR E A TME NT OF C HIL DR E N WITH A DHD P s ychos ocial tre atment of children with ADHD refers to nonmedication treatment one can include, such as ps ychoeducation, academic organization skills and remediation, parent training, behavioral modification, cognitive-behavioral therapy, s ocial skills training, and family and individual therapy. Of these modalities , training, behavior therapy, and, more recently, s ocial training have shown efficacy in controlled trials . E ven though stimulants have been s hown to be very effective in the treatment of children with ADHD, many such children continue to have s ocial, academic, and emotional difficulties des pite treatment with ps ychos timulants . Many studies have shown the added benefit of combined medication and ps ychosocial treatment compared with either one alone. T hus, many children with ADHD require a variety of ps ychos ocial intervention in addition to medication.

Ps yc hoeduc ation P s ychoe ducation can refer to educating the child and family about ADHD and its pos sible etiology, treatments , s ide effects , and prognos is . T his proces s may also addres s iss ues of comorbidity and deficits the child experiences, as well as s tres ses on child, parents , and family as a whole. T his as pect of treatment is crucial and lays the groundwork for a res pectful relations hip between the child, family, and therapist. 4049 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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P s ychoe ducational inte rve ntions can als o refer to intervention at s chool designed to improve s chool behavior, academic productivity, and achievement. interventions , after a functional as sess ment, can have antecedent-oriented clas sroom management which are proactive and meant to prevent undes irable behavior by optimizing conditions for appropriate adaptive behavior. S uch intervention can include reduction in task demands, making tas ks more (e.g., via computers), and providing s tudents with related to academic work, resulting in increased engagement. C lass room interventions also include cons equent-oriented programs (e.g., token and res ponse cos t to improve behavior). A daily report card, lis ting des ired behaviors and academic is completed by the teacher at school and rewarded by parents at home. In older children and adolescents , can be replaced by contingency contracting, which s till to have tas ks that are readily attainable and rewards are meaningful to the adolescent and delivered with relatively s hort delays (within the day). G enerally, thes e programs are effective when they are carried out. However, efficacy decreases when they are

Ac ademic Organizational S kills and R emediation ADHD symptoms , s uch as inattention, impulsivity, and hyperactivity, affect school behavior, learning, and academic performance. F urthermore, children with tend to be comorbid for learning disabilities, with rates ranging from 10 to 92 percent, with us ual quoted rates approximately 20 to 25 percent. T hus , children with are known to have experienced poor academic 4050 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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achievement, more tutoring, more grade repetition, and more frequent placement in special education class es. academic problems of children with ADHD have been documented. S timulants improve academic productivity but do not addres s all the academic handicaps , as the lack of improvement in long-term academic achievement. T he us efulnes s P.3195 of remedial tutoring in reading-disabled non-ADHD children has been demonstrated. S timulants added reading performance, but arithmetic improved significantly. A multipus h program for children with us ed by J ames S atterfield included educational therapy and res ulted in greater-than-expected gains in achievement. Overall, these findings s uggest that with ADHD, who are often far behind academically, benefit from remedial tutoring and academic organizational s kills . T herefore, these components included by Lily Hechtman and Howard Abikoff in their multimodal treatment study of 103 children aged 7 to 9 years randomly ass igned to multimodal, attentional control, and medication-only treatment. All groups received stimulant medication and made significant academic gains . However, there were no significant treatment group differences . T hese res ults may be due the fact that children with severe learning disabilities excluded. T o participate in this 2-year program, had to be very motivated and better functioning. S uch families may have tried to help their children with academic organizational s kills and academic C hildren with ADHD, greater learning problems, and 4051 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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involved and helpful families may well benefit from academic interventions .

Parent Training in B ehavior Therapy P arents of children with ADHD often have difficulty in effectively managing their child's behavior. P arent is an intervention that teaches parents how to a contingency management behavioral program. involves providing parents with an overview of s ocial learning and behavior management principles . of behavioral management, s uch as identifying target behaviors , instituting (with the child's input) a reward s ys tem, contingency attention, time-out, and res ponse cos t, are all taught. T he intervention can be carried out with individual parents or groups of parents . P arent groups are more efficient and provide added acceptance and support, but techniques and s trategies learned in the group often need to be reinforced in individual parent sess ions to be effectively used at P arent groups s hould be relatively s mall, with no more than eight s ets of parents per group. T raining sess ions us ually held weekly for 8 to 20 weeks . P arents are reading material and ass igned homework, which is documented in behavioral and reinforcement charts to chronicle their efforts , experiences , s ucces ses , and T he more active the parents' participation, the better res ults. P arents with ADHD may have problems with organizational s kills , paying attention to details, outlines, and being consistent. T hey have great carrying out a behavioral program unles s they, too, are treated. P arent training has been shown to be effective but les s 4052 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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than s timulant medication. However, parent training is helpful in improving home functioning and the overall home environment. It seems somewhat more effective younger (e.g., preschoolers ) than in older children. from parents indicate that parent training increas es sens e of parental efficacy and confidence. As with ps ychos ocial interventions , efficacy tends to decrease when the acute intervention is discontinued. T herefore, William P elham advocates a program of maintenance relaps e prevention via continued intermittent contact.

Family Therapy F amily conflict is frequently pres ent in families of with ADHD. Less effective family coping s tyles may be to such factors as parental s kill deficits (due to parental pathology or poor parenting skills) or the s tres s of parenting a difficult child. In a family treatment intervention s tudy involving adolescents with ADHD their families, B arkley compared three different approaches: s tructured family therapy, communication training, and problem-solving training. All three treatments significantly reduced family conflict, anger during conflict, negative communication, and externalizing and internalizing s ymptoms. S chool adjus tment ratings also improved. T here were no significant treatment group differences, and effects maintained at 3-month follow-up. However, only 5 to 30 percent of the adoles cents actually improved, reflecting only a modes t effect size. T hus, thes e adolescents need more than just a family intervention. F amily therapy may be helpful in decreas ing conflict stress in the s hort-term; however, good control studies 4053 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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lacking, and long-term efficacy of this intervention is unknown.

C ognitive-B ehavioral Therapy C ognitive-behavioral therapy attempts to modify dysfunctional as sumptions and maladaptive behavior self-talk and s elf-regulation. P rograms were des igned teach children techniques of problem s olving, dealing anger and frustration, persistence, and s ocial s kills . programs were not very success ful. T here were no differences in meas ures of self-control, attention, impulsivity, aggress ion, self-concept, and social competence at posttreatment or follow-up. Abikoff's critical review also indicated that cognitive-behavioral therapy for children with ADHD showed little benefit treatment was discontinued. Linda P fiffner pointed out poss ible reasons for this lack of efficacy. T hes e the following: 







Inadequate focus on generalization in s tudies involved. Immature verbal executive control in ADHD given this training. S elf-instruction may be inadequate to deal with the severity of impulsivity and affective instability in ADHD. S elf-instruction and cognitive approaches do not provide training and practice in specific social s kills .

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S oc ial S kills Training P oor social functioning is one of the most dis abling as sociated features of ADHD in children. Impaired functioning and the accompanying peer and adult rejection significantly affect self-es teem and influence long-term outcomes. However, social impairment is difficult to treat effectively. S ocial skills programs are us ually carried out in s mall groups , with the advantage of providing opportunities peer modeling and practicing s kills with peers. S ocial training combines both cognitive-behavioral and behavioral interventions . T echniques such as didactic ins truction, s ymbolic play with puppets, in vivo practicing role play, and behavioral rehears al are used. P os itive reinforcement, s elf-management, and self-evaluation help reduce negative s ocial interaction increase pos itive s ocial behavior. More recently, more emphasis has been placed on generalization us ing parents and teachers. F . F rankel's program included 12 weekly s ess ions that taught skills s uch as conversational s kills , group entry, handling teas ing and rejection, negotiating s kills for changing activities, and prais ing others . P arents were taught coaching strategies to us e with their child in interactions with peers at home. B enefits were seen in parent and teacher ratings. P fiffner and K eith McB urnett's program used a motivational system to reduce performance problems; increase awareness and unders tanding of verbal and nonverbal social cues ; and promote generalization by involving parents and teachers in the treatment used at 4055 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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home, school, and the playground. S ix s pecific were used. P.3196 1. G ood sportsmanshipfollowing directions, and s taying with the game, taking turns , following game rules , and s aying nice things to peers 2. Accepting consequencesgracefully accepting a perceived negative cons equence as a choice for dealing with frustration 3. Ass ertions dis tinguishing between pass ive, and as sertive responses and using ass ertive communications 4. Ignoring mild provocations by inhibition verbal and nonverbal interactions 5. P roblem solvingusing a five-step approach for identifying and s olving a problem 6. R ecognizing and dealing with feelings identifying feelings in s elf and others and dealing with anger A coordinated token reinforcement system was us ed social s kills groups , home, and school. T eachers getting along with peers in the daily report card. T his other peer interactions were rewarded by the parents home. S ignificant improvement in s ocial interactions seen, and thes e gains were maintained 3 to 4 months treatment ended. S ocial skills training is still evolving. P rograms need to individualized, taking age, gender, and comorbidity into account. T hey s hould take place in the child's natural 4056 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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settinge.g., s chool and homeand need to focus on generalization involving parents and teachers .

Individual Ps yc hotherapy No well-controlled studies have evaluated the efficacy individual psychotherapy for children with ADHD. It is unlikely to be effective for ADHD s ymptoms . However, individual therapy can help the child unders tand what ADHD is and how the s ymptoms may be affecting his her functioning. Is sues of poor s elf-es teem and a is olation and alienation can also be dealt with in P sychotherapy can explore the child's feelings about unders tanding of s timulant medication, its s ide effects , and what it can and cannot do. S ome individual quite structured, with the particular areas to be clearly delineated; others are more open-ended. being able to confide worries and vulnerabilities to a knowledgeable, nonjudgmental, s upportive adult who provides an optimis tic view that change is poss ible may res ult in improvement of secondary symptoms s uch as self-es teem, anxiety, and depres sion. T hes e s econdary symptoms are often comorbid with ADHD. Individual therapy with the child can als o establish the foundation a long-term, although at times intermittent, therapeutic relations hip, which contributes to better long-term treatment of the child with ADHD and his or her family this chronic, lifelong condition.

Multimodal Treatment R ecently, at leas t two well-controlled treatment s tudies have tried to address the multiple deficits in emotional, social, and academic functioning of children with ADHD 4057 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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via a multimodal treatment approach. T he firs t of these studies by Hechtman and Abikoff was two-center s tudy involving 103 children with ADHD 7 to 9) who res ponded to s hort-term methylphenidate were randomized for 2 years to receive one of three treatments : 1. Methylphenidate alone, which was well titrated and carefully monitored 2. Methylphenidate plus psychosocial treatment, included parent training and couns eling, social training, psychotherapy, and academic s kills and remediation 3. Methylphenidate plus attentional control which controlled for the profess ional attention in the multimodal group but did not provide the s pecific interventions E ach of the ps ychos ocial treatments was provided in the first year, with monthly boos ters in the s econd in the context of a clinic-based after-school program. C hildren were ass es sed through parent, teacher, and ps ychiatris t ratings and direct school observations in academic and gym class es . R es ults s howed that all three groups improved significantly in academic, social, and emotional T he improvement was s een at 6 months and throughout the 2 years, even when treatments became less intens e in the second year. However, there were significant differences in the three groups . T he authors concluded that for motivated, well-functioning families 4058 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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which children are not severely comorbid, well-titrated medication (the optimal dose of which was determined an individual basis for each child), given three times day, 7 days per week, resulted in significant in all domains , which was maintained for 2 years. T he second s tudy (the MT A study) involved six s ites 579 children with ADHD combined type, aged 7 to 9.9 years . S ubjects were randomly as signed to four groups for 14 months of treatment: (a) a medication management group (careful titration, followed by monitoring); (b) an intensive behavioral treatment that received teacher consultation, a daily report rated the teacher but rewarded by the parents , parent and counseling, a comprehens ive 8-week s ummer treatment program, and an aide in the clas sroom half 5 days per week for 12 weeks ; (c) a combined group receiving both the medication and behavioral treatment components, and (d) a group that received s tandard community care by community providers . Outcomes as sess ed in academic, s ocial, and emotional domains . R es ults after 14 months of treatment s uggested that, most ADHD s ymptoms , even though all four groups improved, combined treatment and medication management groups s howed s ignificantly greater improvement than intens ive behavioral treatment and community care, with no significant differences combined and medication treatment or between behavioral treatment and community care. F or other symptoms, such as oppos itional and aggres sive symptoms, internalizing symptoms , teacher-rated skills , parentchild relations , and reading achievement, combined treatment was s uperior to behavioral 4059 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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and community care, whereas medication was not. In addition, s tudy medication s trategies were superior to community care treatments des pite the fact that two-thirds of the community-treated group received medication. F or composite meas ures , combined treatment was followed by medication management, and then by behavioral, and finally, by the community care group. C hildren with comorbid anxiety and single-parent particularly benefited from the behavioral components the combined group. P sychos ocial treatment appears to be an important adjunct to medication treatment for children with E fficacy for parent training, behavioral therapy, and social s kills training has been documented. F amily may be beneficial in decreasing family conflict and improving the emotional climate at home. Individual therapy may help in areas of self-es teem and problems of depres sion and anxiety. However, the interventions have not been rigorous ly studied. benefits noted with ps ychosocial interventions once acute treatments are dis continued. C ombining ps ychos ocial treatments with medication and providing booster s ess ions to maintain treatment gains and relaps e appear to be promising approaches to ensure better long-term outcome. P.3197 F or mos t individuals, ADHD is a chronic condition that continues in adolescence and adulthood. F or this the clinical vignette pres ented here but taken from 4060 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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and T rokenberg-Hechtman (Hype ractive C hildre n Up: ADHD in C hildre n, Adoles ce nts , and Adults , 1993, 211214) illus trates this lifelong cours e and its Anthony was firs t referred to a child psychiatric clinic at age 7. R easons for referral included the following: 

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S evere restles sness and hyperactivity s ince he to walk P oor concentration Dis obedient, not listening (teachers liked Anthony wanted him out of the class ) P oor speech articulation R epeating grade 1 V ery untidy and disorganized

Anthony's birth his tory was uneventful, and his E E G neurological examination were normal. Anthony's Wechs ler Intelligence S cale for C hildren (W IS C ) (F ull was 115, with marked scatter. He was found to have image and visuomotor difficulties . P s ychiatric revealed a friendly, good-looking, 7-year-old boy with speech (i.e., articulation) difficulties who was restless hyperactive. T he parents stated they were happily and there were two older sisters , both doing well. T he father was a s ales executive and traveled a great deal, mother a homemaker. T heir ethnic origin was AngloS axon. A diagnosis of ADHD was made.

FIVE -YE AR FOLL OW-UP: 14 YE AR S OF AGE T his evaluation was delayed because Anthony had away at boarding s chool for 3 years, and we had to until he was on holiday. He had received stimulants for only a s hort period because he was noncompliant, as 4061 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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hated the dampening effects. At 14 years, Anthony seemed very immature and was s till res tless and distractible. His learning difficulties made s chool a regular clas sroom almos t impos sible, but Anthony happy-go-lucky attitude about his failures. T here was stealing or other indication of antis ocial behavior, but Anthony had no close friends . His mother believed he wors e because he did not accept respons ibility and goals for the future. He was very poor at spelling and behind in reading and found s choolwork boring. he lacked any insight into his difficulties , he was found be friendly and likable. R epeat W IS C IQ (F ull S cale) unchanged.

TE N-YE AR FOLL OW-UP: 20 YE AR S OF AGE Anthony was seen late als o for the 10-year follow-up because his parents had moved overseas, where his had s tarted a busines s. W e wrote to Anthony there, sending him numerous s elf-rating scales and a his tory him to complete. T he former included the C alifornia P ers onality Inventory (C P I), a self-rating scale that all subjects completed. W e did not hear from Anthony for years after the forms were mailed and gave up on him lost s ubject. One day, Anthony knocked at G . W .'s door and announced hims elf and his girlfriend, S ally. said he had come from New Zealand to s ee us with let us know that the C P I was a truly crazy tes t and was no way that he could ever complete 500 dumb questions . W hen asked what he was really doing here, said he had told us the truth, then gave a report of his 5 years and agreed to complete the whole 10-year up evaluation. While still living with his parents overseas, Anthony had 4062 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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refused to continue s chooling, but he had completed grade 9 in Montreal. He worked intermittently at various menial jobs and lived with his parents . (His las t job was collecting s tray cats and dogs for the local S ociety for P revention of C ruelty to Animals .) He believed his looked down on this job even though he had told that any hones t job is OK . He obviously didn't mean it, Anthony added. Anyway, I got laid off, and s ince I have ants in my pants , I went to New Zealand. He planned perhaps to find work, perhaps for a holiday. B ut there met S ally, who s ugges ted that he could try mowing people's lawns for some income. S ally and Anthony lived together, and s he helped Anthony s ettle down. encouraged him to work hard, and soon he had s aved $1,500. T hey borrowed another $1,000 and bought a second-hand lawnmowers . T hey then employed boys to mow lawns, and a year later had saved $5,500 paid back the debts. I gave up the lawnmower because one day I just found it boring and tense, and I wanted to quit and travel. Als o, I wanted to see you to show you how crazy this test that you sent me is. Anthony appeared happy and as impulsive as ever and had great charm. He had s ucceeded in getting S ally a in Montreal, which was extremely difficult at the time, telling the immigration department that if they did not give her a work permit, he would marry her, and then would have to give her one anyway. T hey would feel to have made him marry so young (S ally got her work permit). S ally turned out to be a bright, quite delightful, stable young woman who appreciated Anthony's and had a strong influence on him. S he made appointments for him and made s ure he was on time 4063 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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them. T hey planned to return to New Zealand after a months in Montreal but s ee the world on the way back.

FIFTE E N-YE AR FOLL OW-UP: 25 YE AR S OF We could not go to New Zealand to interview Anthony, but we were able to meet with his parents, who were visiting Montreal. T hey had recently visited Anthony in New Zealand and were in close touch with him and S ally. Anthony was now taking a university degree in communications. It seemed that where he ended up, could enter university as a mature student without completing high school (he had completed only grade He was pursuing his cours es with some difficulties but pass ing in s pite of concentration problems . He was interes ted in what he was doing. Anthony and S ally still living together and were planning on getting During this time, S ally had had a malignant lump from her breast. Anthony's parents stated that he and had an excellent relationship and that they had dealt their grief and anxiety over her diagnosis well. S ally, stated, s till takes charge of organizational family and helps Anthony with his writing as signments. T he friends they have are made by S ally, as Anthony lets take all the initiative with friends; however, he is well by them. His parents believe that in the past year, a result of S ally's medical problems , Anthony has greatly. He was described as s till impulsive, still very res tless , but he lis tens to S ally. He still talks too much has a big mouth. He has occas ionally lost part-time because of this . T he couple has no debts , and Anthony plans to s tart an advertis ing business when he receives university degree. His father s tated he would help him financially but still would not trust him to handle money 4064 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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res ponsibly. Anthony hims elf is not close to the friends couple has, but he feels clos e to S ally. Although S ally obviously done a great deal for Anthony, it was that the relationship is complementary rather than neurotic. We asked Anthony's parents what they believed were reasons for Anthony's good outcome because they extremely happy about his progress . His father stated, E ven while Anthony was hyperactive and a discipline problem as a child, he was very lovable. In school, he couldn't learn becaus e he felt so inferior. At 17 years , sent him to S witzerland to learn a trade, but this did not work out. At 18 years , we gave him a one-way ticket to New Zealand and s aid to him, if you want to come back you P.3198 have to earn the money for your ticket. S ally was the turning point for Anthony. S he gave him what we confidence in hims elf and a s ens e of direction. S he had always loved him and even way back believed in his when we frankly did not. S ally and Anthony are now to buy a hous e, and we send them money toward this , we always s end it to S ally. S he keeps the books. It s eemed clear to us that Anthony without his fiance would not be functioning as well as he is and would s till having many life difficulties related to the ADHD (F rom W eis s G , T rokenberg-Hechtman L. Hype ractive C hildre n G rown U p: ADAD in C hildre n, Adole s ce nts , Adults . New Y ork: G uilford P res s; 1993:211214.)

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Adult manifes tations of attention-deficit disorders are discuss ed in S ection 39.2. C onduct disorder and oppos itional defiant disorder are discus sed in C hapter and T ourette's disorder is discus sed in C hapter 42. P harmacotherapy for children is dis cuss ed in S ection individual ps ychotherapy for children in S ection 48.1, family therapy in S ection 48.5.

R E F E R E NC E S Abikoff H: E fficacy of cognitive training intervention with hyperactive children: A critical review. C lin R ev. 1985;5:479. B arkley R . ADHD and the Nature of S e lf C ontrol. G uilford P ress ; 1997. B arkley R A, McMurray MB , E delbrock C S , R obbins effects of methylphenidate in children with attention deficit hyperactivity disorder: A systemic, placebocontrolled evaluation. P ediatrics . 1990;86:184. B iederman J , S pencer T : Attention deficit disorder (ADHD) as a noradrenergic dis order. B iol P s ychiatry. 1999;46:1234. C as tellanos F X: T oward a pathophysiology of deficit hyperactivity dis order. C lin P ediatr (P hila). 1997;36:381. C as tellanos F X, Lee P P , S harp W , J effries NO, DK , C lasen LS , B lumenthal J D, J ames R S , E bens Walter J M, Zijdenbos A, E vans AC , G iedd J N, 4066 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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Developmental trajectories of brain volume abnormalities in children and adolescents with attention-deficit hyperactivity dis order. J AMA. 2002;288:1740. *F araone S V , B iederman J . Neurobiology of deficit hyperactivity dis order. In: C harney DS , B unney B S , eds. Neurobiology of Mental Illnes s. Y ork: Oxford Univers ity P res s; 1999:788. G reenhill L, Halperin J M, Abikoff H: S timulant medication. J Am Acad C hild Adole s c P s ychiatry. 1999;38:503. *Hechtman L: Ass es sment and diagnos is of deficit/hyperactivity dis order. C hild Adole s c C lin N Am. 2000;9:481. *Hechtman L. Developmental neurobiological and ps ychos ocial as pects of hyperactivity, impuls ivity attention. In: Lewis M, ed. C hild and Adole s ce nt P s ychiatry: A C ompre he ns ive T e xtbook. 3rd ed. Lippincott, W illiams & W ilkins ; 2002:366. Hechtman L, Abikoff H. Multimodal treatment plus s timulant vs . s timulant tre atment in ADHD children: R es ults from a two ye ar comparative tre atme nt P aper presented at the Annual Meeting of the Academy of C hild and Adolescent P s ychiatry, New Orleans, October 1995. Hechtman L, Abikoff H: Methylphenidate and 4067 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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multimodal treatment in attention deficit hyperactive disorder. In: J ens en P , Hibbs E , eds . P s ychos ocial T re atme nt R e s e arch with C hildre n and Adole s ce nts . Was hington, DC : AP A P ress ; 1996:341. Hins haw S P , Marsh J S , Abikoff H, Arnold LE , C onners C K , E lliott G , Halperin J , G reenhill L, L, Hoza B , J ens en P , Newcorn J , McB urnett K , R ichters J , S evere J , S chiller E , V ereen D, W ells K , C omprehens ive as ses sment of childhood attention deficit hyperactive dis order in context of a multisite multimodal clinical trial. J Attention Dis ord. K lein R G , B es sler AW : S timulant s ide effects in In: K ane J M, Lieberman J A, eds . Advers e E ffe cts of P s ychotropic Drugs . New Y ork: G uilford P res s; *MT A C ooperative G roup: J ens en P , Arnold LE , H, C antwell D, C onners K , E lliott G , G reenhill L, Hechtman L, Hins haw S , Hoza B , K raemer H, March Newcorn J , P elham W, R ichters J , S chiller E , S wans on J , V ereen D, Wells K : A 14-month clinical trial of treatment s trategies for attention hyperactivity disorder (ADHD). Arch G e n P s ychiatry. 1999;56:1073. P elham WE , W heeler T , C hronis A: E mpirically ps ychos ocial treatments for attention deficit hyperactivity disorder. J C lin C hild P s ychol. P fiffner L, C alzada E , McB urnett K : Interventions to enhance s ocial competence. C hild Adole s c 4068 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/39.1.htm

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C lin N Am. 2000;9:698. *S pencer T , B iederman J , W ilens T , Harding M, O'Donnell D, G riffin S : P harmacotherapy of attention deficit disorder across the life cycle. J Am Acad Adoles c P s ychiatry. 1996;35:409. Weiss G , T rokenberg-Hechtman L. Hype ractive G rown Up: ADHD in C hildre n, Adole s ce nts , and New Y ork: G uilford P res s; 1993. Weiss M, Weiss G . Attention deficit hyperactivity disorder. In: Lewis M, ed. C hild and Adole s ce nt A C ompre he ns ive T e xtbook. 3rd ed. B altimore: Lippincott: W illiams & W ilkins ; 2002:645. Zametkin A, Liotta W : T he neurobiology of attentiondeficit/hyperactivity dis order. J C lin P s ychiatry. 1998;59:17.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 40 - Dis ruptive B ehavior Dis orders > 40 - Dis ruptive B ehavior

40 Dis ruptive B ehavior C hris topher R . Thomas M.D. Oppositional and antis ocial behaviors are the mos t frequent referral concern for youths seen in mental clinics , accounting for one-third to one-half of all cases, it is not altogether s urprising that there is a separate diagnostic category, the disruptive behavior dis orders. fact, the origins of child and adolescent psychiatry as a subs pecialty in the United S tates are intertwined with study and treatment of these dis orders with the es tablis hment of the J uvenile P sychopathic Ins titute by William Healy in 1909. Disruptive behaviors in youths continued to be a major focus of clinical investigation the pas t century, and they repres ent one of the most thoroughly studied conditions in childhood and adoles cence. T he category currently consists of the diagnoses of oppositional defiant dis order and conduct disorder in the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M). T hese dis orders do not represent antis ocial acts alone, but rather reflect persistent of behavior that demonstrate the qualitative and quantitative features of a syndrome. C ontroversy about these dis orders, with some profes sionals even questioning the validity of a mental disorder by antis ocial behaviors. T hey argue that it is not appropriate to define a diagnos is that often reflects 4070 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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conditions or where the s ymptoms are a res ult of mental disorder. C urrent guidelines rule out the us e of these diagnos es in situations in which the behaviors reaction to social s urroundings or s ymptomatic of other underlying mental illness . In addition, numerous have demons trated the diagnoses to be descriptive, predictive, and distinct from other conditions . Debate has als o focus ed on whether the dis orders primarily from individual features or environmental conditions. Myriad factors have been identified that contribute to the risk for thes e disorders , including cons titutional and s ocial features . T he prevailing view that the disorders most likely originate from multiple sources and repres ent the critical interaction of individuals with their s urroundings. As descriptions of predictive and s table patterns of disruptive behavior, diagnoses are conceptually related to antisocial personality dis order. Longitudinal s tudies have shown disruptive behavior in childhood and adoles cence is a cons istent feature of adults with antis ocial pers onality disorder. In contrast, many youths with disruptive do not continue to demonstrate these behaviors as V arious subcategories have been propos ed to better account for the differences in outcome and other T he variegated nature of the disorders and differences conceptualization fuel the continuing debate as to the best organization of class ifications . C ontinued and ps ychological res earch will, it is hoped, provide a accurate understanding of the s pecific mechanisms ps ychopathology of these dis orders.

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OP P OS IT IONAL DE F IANT DIS OR DE R

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C ONDUC T DIS OR DE R

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S UG G E S T E D C R OS S -R E F E R E NC E S

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 40 - Dis ruptive B ehavior Dis orders > O P P O S IT IONAL DE F IANT

OPPOS ITIONAL DE FIANT DIS OR DE R P art of "40 - Dis ruptive B ehavior Dis orders"

Definition Oppositional defiant disorder is characterized by negativis tic, defiant, dis obedient, and hostile behavior over a period of at leas t 6 months. Although these are otherwis e normative behaviors at certain stages or in s pecial circums tances , in this dis order they more s evere and frequent than expected and must in significant functional impairments . T he difficulties caus ed by the disorder can be in s ocial, academic, or occupational functioning. C onflicts with others are typically s truggles for control. R eques ts or limits on behavior invariably elicit a s harp reaction from those the disorder. T he behaviors are most often evident in interactions with authority figures. T hos e with the us ually view their defiance as a justified and res ponse to others . Although often annoying and unpleasant for others, there is no major violation of as seen with conduct dis order. 4072 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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His tory T he C ommittee of C hild P s ychiatry of the G roup for the Advancement of P sychiatry introduced the concept of oppos itional pers onality for children in the 1966 report, “P sychopathological Dis orders in C hildhood: C ons iderations and a P ropos ed C lass ification.” the cardinal s ymptoms of negativism and dis obedience were highlighted, the propos ed dis order characterized oppos itional behaviors as generally pas siveT he third edition of the DS M (DS M-III, 1980) included oppos itional dis order as a diagnosis dis tinct from disorder. Diagnosis required two of five s ymptoms, including minor rule violations, tantrums , arguments , provocative behavior, and stubbornness . It was also conceptually linked to pass ive-aggres sive pers onality disorder, indicating that diagnos is should be for individuals older than age 18. T he revis ed third of the DS M (DS M-III-R , 1987) added the term “defiant” the label, increas ed the lis t of symptoms to nine, and raised the required number of s ymptoms for diagnos is five. T hes e changes were prompted in part to improve specificity of the diagnosis. T he new s ymptom list did add new criteria but rather provided a more detailed description of s pecific behaviors cons idered to be oppos itional. In addition, oppositional defiant disorder grouped for the first time with conduct dis order under disruptive behavior dis orders, and the ass ociation with pass ive-aggres sive pers onality disorder was dropped. modifications s temmed from evidence that oppos itional behaviors were closely related to more s evere behaviors . 4073 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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C omparative Nos ology In the development of the fourth edition of the DS M IV ), s erious consideration was given to combining oppos itional defiant dis order and conduct dis order as developmentally linked s ubtypes into an overall behavior dis order. T he proposed combined disorder compared to the exis ting DS M-III-R diagnoses for cons istency and diagnos tic validity on both clinic and community populations . Although the results showed two s ys tems were comparable, the DS M-IV committee P.3206 decided to retain the dis tinction between oppos itional defiant disorder and conduct dis order because of of discriminate validity between the two diagnoses from other s tudies . T he DS M-IV retained the criteria list from DS M-III-R except for dropping the symptom of frequent swearing or obs cene language (T able 40-1). T he required symptoms for diagnosis was also reduced to R es earch has s hown that the DS M-IV diagnos tic oppos itional defiant dis order poss es s internal and both positive and negative predictive value.

Table 40-1 DS M-IV-TR Diagnos tic C reteria for Oppos itional Defiant Dis order A. A pattern of negativis tic, hostile, and defiant 4074 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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behavior las ting at leas t 6 months , during which (or more) of the following are present:    1. Often los es temper    2. Often argues with adults    3. Often actively defies or refus es to comply adults ' requests or rules    4. Often deliberately annoys people    5. Often blames others for his or her mistakes misbehavior    6. Is often touchy or easily annoyed by others    7. Is often angry and res entful    8. Is often s piteful or vindictive    Note: C onsider a criterion met only if the occurs more frequently than is typically observed individuals of comparable age and developmental level. B . T he disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

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C . T he behaviors do not occur exclus ively during cours e of a ps ychotic or mood dis order. D. C riteria are not met for conduct dis order, and if the individual is age 18 years or older, criteria are met for antis ocial pers onality disorder.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T he Inte rnational S tatis tical C las s ification of Dis eas es R elated He alth P roblems (IC D) included oppos itional defiant disorder as a diagnosis for the firs t time in the tenth revision, under the category of conduct dis orders. Unlike the DS M-IV , the IC D-10 does view oppos itional defiant disorder as a les s s evere form of conduct characteristically seen in children younger than 10 Although the IC D-10 is descriptive in defining conduct disorders , the IC D-10 diagnostic criteria for res earch provide a more operational approach to diagnosis. T he symptoms listed for conduct disorders in the IC D-10 diagnostic criteria for research (T able 40-2) are roughly comparable to the combined DS M-IV s ymptom lists for oppos itional defiant dis order and conduct dis order. As the DS M-IV , at least four separate s ymptoms mus t be present for 6 months for diagnosis of oppos itional disorder under the IC D-10, but only two must come 4076 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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the nine s ymptoms on the lis t devoted to oppositional defiant behaviors . T here have been no s tudies the DS M-IV and IC D-10 to evaluate these two different approaches to diagnosis .

Table 40-2 IC D-10 Diagnos tic C reteria for R es earc h F91 C onduc t dis orders G1. T here is a repetitive and pers is tent pattern of behavior, in which either the basic rights of others major age-appropriate societal norms or rules are violated, las ting at least 6 months, during which some of the following symptoms are present (s ee individual s ubcategories for rules or numbers of symptoms). Note: T he s ymptoms in 11, 13, 15, 16, 20, 21, need only have occurred once for the criterion to fulfilled. T he individual:    1. Has unusually frequent or severe temper tantrums for his or her developmental level;    2. Often argues with adults;

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   3. Often actively refuses adults ' reques ts or rules;    4. Often, apparently deliberately, does things annoy other people;    5. Often blames others for his or her own or mis behavior;    6. Is often “touchy” or eas ily annoyed by others;    7. Is often angry or res entful;    8. Is often s piteful or vindictive;    9. Often lies or breaks promis es to obtain favors or to avoid obligations;    10. F requently initiates phys ical fights (this not include fights with s iblings );    11. Has us ed a weapon that can caus e s erious phys ical harm to others (e.g., bat, brick, broken bottle, knife, gun);    12. Often s tays out after dark despite parental prohibition (beginning before 13 years of age);    13. E xhibits phys ical cruelty to other people ties up, cuts , or burns a victim); 4078 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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   14. E xhibits phys ical cruelty to animals ;    15. Deliberately des troys the property of others (other than by fires etting);    16. Deliberately sets fires with a risk or intention caus ing serious damage;    17. S teals objects of nontrivial value without confronting the victim, either within the home or outside (e.g., shoplifting, burglary, forgery);    18. Is frequently truant from s chool, beginning before 13 years of age;    19. Has run away from parental or parental surrogate home at leas t twice or has run away for more than a single night (this does not include leaving to avoid phys ical or sexual abuse);    20. C ommits a crime involving confrontation the victim (including purs e-snatching, extortion, mugging);    21. F orces another person into s exual activity;    22. F requently bullies others (e.g., deliberate infliction of pain or hurt including pers is tent intimidation, tormenting, or molestation);

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   23. B reaks into s omeone else's hous e, building, car. G2. T he disorder does not meet the criteria for diss ocial pers onality disorder, s chizophrenia, episode, depres sive episode, pervasive developmental disorders , or hyperkinetic criteria for emotional dis order are met, the should be mixed disorder of conduct and It is recommended that the age of ons et be specified: C hildhood onset type: ons et of at leas t one problem before the age of 10 years ; Adoles cent-onset type: no conduct problems the age of 10 years. S pec ific ations for pos s ible s ubdivis ions In addition to thes e categorizations , it is recommended that cases be des cribed in terms their s cores on three dimens ions of dis turbance: Hyperactivity (inattentive, restless , behavior); E motional dis turbance (anxiety, depress ion, obses sionality, hypochondriasis); and

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S everity of conduct disorder:   Mild: F ew if any conduct problems are in excess those required to make the diagnosis, and problems caus e only minor harm to others ;   Moderate: T he number of conduct problems and the effects on others are intermediate between “mild” and “severe”;   S evere: T here are many conduct problems in of thos e required to make the diagnos is , or the conduct problems caus e cons iderable harm to others —e.g., s evere phys ical injury, vandalism, theft. F91.0 C onduct dis order c onfined to the family context T he general criteria for conduct disorder (F 91) be met. T hree or more of the symptoms listed for F 91 C riterion G 1 must be present, with at least three from items 9–23. At leas t one of the symptoms from items 9–23 have been pres ent for at leas t 6 months. C onduct dis turbance mus t be limited to the family 4081 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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context. F91.1 Uns ocialized c onduc t dis order T he general criteria for conduct disorder (F 91) be met. T hree or more of the symptoms listed for F 91 C riterion G 1 must be present, with at least three from items 9–23. At leas t one of the symptoms from items 9–23 have been pres ent for at leas t 6 months. T here mus t be definitely poor relationships with individual's peer group, as s hown by isolation, rejection, or unpopularity and by a lack of las ting clos e reciprocal friendships. F91.2 S oc ialized conduct dis order T he general criteria for conduct disorder (F 91) be met. T hree or more of the symptoms listed for F 91 C riterion G 1 must be present, with at least three from items 9–23. At leas t one of the symptoms from items 9–23 have been pres ent for at leas t 6 months. 4082 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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C onduct dis turbance mus t include s ettings the home or family context. P eer relationships are within normal limits. F91.3 Oppos itional defiant dis order T he general criteria for conduct disorder (F 91) be met. F our or more of the s ymptoms lis ted for F 91 C riterion G 1 mus t be pres ent, but with no more two s ymptoms from items 9–23. T he symptoms in C riterion B must be and inconsistent with the developmental level. At leas t four of the s ymptoms must have been present for at leas t 6 months .

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1992, with permis sion.

E pidemiology R eports on the prevalence of oppos itional defiant have varied greatly, ranging from 2 to 16 percent in 4083 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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community samples. S ome of the variation is due to changes in diagnos tic criteria, with one study showing percent reduction in prevalence in the s ame population when us ing the DS M-III-R instead of the DS M-III. A study comparing DS M-III-R and DS M-IV criteria found overall difference in prevalence in a community sample but that the DS M-IV criteria identified a more disturbed group of children. R eports of prevalence are als o influenced by s ocial and economic factors , as the is more often found among children from lowsocioeconomic-status families . Although data are reported rates of oppos itional defiant disorder among boys are only s lightly higher than among girls before age of 13, and there is no apparent difference after that age. T he typical age of onset appears to be around 6 old, when most children have outgrown earlier, oppos itional behaviors .

E tiology E tiological s tudies have principally cons idered the origins of dis ruptive behaviors rather than s pecifically focus ing on oppositional defiant disorder in particular. B as ed on current evidence, it appears that these are developmental, with multiple factors influencing the ris k and cours e. Although no comprehensive has been established, s everal models have been to account for the various features and integrate the different perspectives. Mos t of thes e models view the interaction between s pecific cons titutional factors and surrounding environmental factors as critical to the appearance of oppositional defiant dis order in an individual. B ecause thes e factors may vary, there are 4084 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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poss ibly further and more us eful s ubtypes to be

B iologic al T he frequent clus tering of dis ruptive behaviors in and biological relatives supports the impres sion that genetic factors may play a role in these dis orders, but genetic s tudies on oppositional defiant dis order have reported mixed findings. Neurobiological studies have tended to cons ider the full continuum of aggres sive behaviors rather than oppositional and defiant alone. T hese reports mus t be interpreted cautious ly because there is a clear dis tinction between behaviors and more s erious physical aggres sion, but have specifically s tudied oppositional behaviors apart more s evere behaviors. In one s tudy, elevated levels of dehydroepiandros terone s ulfate (DHE A-S ) were found children with oppos itional defiant disorder in with children with attention-deficit/hyperactivity dis order (ADHD) and normal controls. T he elevated DHE A-S also dis tinguis hed between children with oppositional defiant disorder and ADHD, whereas reports from the parents us ing the C hild B ehavior C hecklis t did not. One interpretation is that the elevated DHE A-S indicates a in adrenocorticotropic hormone–beta-endorphin functioning in the hypothalamic-pituitary-adrenal axis to early s tres s or genetic factors. Another study that increased s erotonin levels might be ass ociated aggres sive behaviors, as elevated prolactin res ponse fenfluramine hydrochloride was found in boys with and comorbid oppos itional defiant dis order or conduct disorder but not ADHD alone. T his finding is in contras t other s tudies that report decreased serotonin level to predictive and as sociated with aggress ion as 4085 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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5-hydroxyindoleacetic acid (5-HIAA) levels in fluid (C S F ), but this may reflect the influence of other factors s uch as comorbid ADHD, family, and age. inves tigation is needed that focus es on oppositional defiant disorder apart from conduct disorder to any ass ociated or underlying biological features .

Ps yc hologic al As with biological studies, mos t ps ychological res earch cons iders oppos itional behavior included with other antis ocial or phys ically aggres sive s ymptoms. T emperament is often invoked in explanations of behaviors in children, es pecially in their relationships others , but the evidence of a relations hip P.3207 of temperament and later development of behavior problems is incons is tent. P art of the difficulty in this res earch is the wide range of qualities in the definition the difficult temperament. In the preschool years , boys who are overreactive or have difficulty calming down more likely to have the diagnosis . Longitudinal studies have considered temperament in the development of oppos itional behaviors generally support the view that represents a s pecific risk dependent of other environmental factors. G iven the importance and P.3208 clear role relationships play, attachment theory offer a plausible understanding in the development of oppos itional behaviors . Ins ecure attachment does to be ass ociated with the diagnosis of oppos itional 4086 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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disorder. As with temperament res earch, the findings attachment theory studies are mixed, with insecure attachment predictive of behavior problems in schoolchildren but not preschool children. An interpretation of the data is that s ecure attachment is a protective factor the face of other ris ks for the development of the One of the most active areas of ps ychological of oppos itional and defiant behaviors is in cognition, es pecially social information process ing by K enneth Dodge and others . T his work has concentrated on how children develop a hostile worldview as a res ult of early negative experiences . In turn, these children are hypervigilant for hos tile cues from others and prone to react in a defiant or negative fas hion. In addition, they have other deficits in s ocial problem solving, us ing les s pertinent s ocial information and generating fewer alternative reactions . R es earch s hows these cognitive features are clearly ass ociated with dis ruptive behavior disorders , but s tudies on the connections between experiences and the development of these cognitive patterns are mixed.

S oc iologic al A wide variety of environmental factors are as sociated increased ris k for oppos itional defiant disorder. As previous ly noted, lower s ocioeconomic s tatus appears be a risk factor, although this is probably mediated through family interactions and stress es . Numerous attributes are correlated with higher rates of behaviors , including poor parenting practices, parental discord, domestic violence, low family cohes ion, child abuse, and parental mental disorder. Mos t theories, including dynamic, behavioral, and cognitive, 4087 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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posit that the parental res ponse to normal oppositional behavior in toddlers is critical in s haping either appropriate social s kills or increas ed defiance and negativis m. S o, it would s eem reasonable that any impairment to parental functioning would potentially increase the risk for oppositional defiant dis order. P atterson's coercion model focus es on how deviant behavior may be reinforced in parent–child interactions over time. In this model, if a parent drops a demand or limit in respons e to a negative reaction by the child, the res ponse is reinforced. Although this occurs in all it becomes critical when it is a predominant interaction. R es earch confirms that inconsistent limit setting is predictive of later oppos itional and antis ocial behaviors. addition to direct interaction, s ocial learning theory also view expos ure to models of negative and hos tile encounters between others as a significant contribution developing behavior patterns. S o domes tic violence not only impair the parent's ability to deal with child misbehavior, but also s erves as an example of deviant interpersonal behavior for the child. It must also be mind that the influences of parent–child interactions go both ways, and the pres ence of extreme negative behaviors in a child may contribute to family conflict parental s tres s.

Diagnos is and C linic al F eatures C hildren with oppositional defiant dis order typically present to the clinic by age 8. T he DS M-IV -T R criteria are listed in T able 40-1. P roblem behaviors are us ually confined to home and interactions with parents but may be described in other s ettings with more cases. T his typically occurs in s ituations in which 4088 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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figures place demands on the child's behavior, as at with teachers. Negativis m may be evident in or refus al to compromise in relationships with both and other children. T antrums and outbursts are precipitated by any refus al of the child's reques ts . S ymptoms are most often evident in relations hips with those familiar to the child, so they may not be observed during clinical examination. On interview, the child generally does not s ee his or her behavior as abnormal invariably blames others for any difficulties . T herefore, information from the parents or other obs ervers is in as ses sing the presence or abs ence of specific J ared, age 8, was brought to the clinic for evaluation of misbehavior by his mother. S he complains that he has frequent tantrums, usually in res ponse to limits on his behavior or not getting his way. S he des cribes the tantrums as cons is ting of shouting, curs ing, crying, slamming doors , and s ometimes throwing books or objects on the floor. S he s tates that thes e outbursts almos t daily. S he feels that sometimes it s eems as he is trying to provoke her. R ecently, he was kicking foot against his mother's chair and she as ked him to He looked at her and continued to kick her chair. S he that s he has given up on as king him to pick up his help with chores , as it inevitably results in an argument. J ared appears sullen and irritable on interview. He that it was his mother's fault and s he is always after about one thing or another. He interrupts her s everal during the joint interview, s aying that she was lying or giving his vers ion of events . His grades at school are excellent, and there are no reports of any behavior problems or disobedience at school. His mother s ays 4089 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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he does not have many friends, as he has difficulty his things and tends to be boss y. He had a s eries of infections as an infant and occas ionally experiences seas onal allergies but is otherwis e in good health, with normal physical development. His mother des cribes being fus sy as an infant and difficult to comfort when upset. He is an only child, and his parents separated divorced when he was 3. He has had no contact with father s ince then. His mother was depres sed for a year after the divorce until she s ought treatment. S he has always felt guilty that his father is not in his life and that he blames her for not having his father around. believes his behaviors have become wors e s ince s he recently started dating again.

P athology and L aboratory E xamination No diagnos tic laboratory s tudies or tests exis t for this condition. E ducational testing may be helpful if the symptoms are ass ociated with s choolwork, as it may indicate the pres ence of a learning dis order. V arious scales for oppos itional and antis ocial behaviors exist may ass is t in treatment planning by identifying s pecific target s ymptoms and measuring the initial s everity and subs equent respons e to intervention. T ypically, the and range of functional impairment as well as the and frequency as sis t in identifying the disorder, as oppos ed to age-appropriate behavior.

Differential Diagnos is and Dis orders B ecaus e diagnos is is bas ed on s everity of normative 4090 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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behaviors for certain age groups , it is critical to this condition from developmentally appropriate S tudies have shown that the diagnosis can be reliably made in contrast to normal oppos itional behaviors in preschool populations of children. Oppositional may als o reflect a trans ient reaction to a specific and therefore are more appropriately diagnos ed as an adjus tment disorder with disturbance of conduct. T he presence of more deviant antisocial behaviors should clinicians to the poss ibility of conduct dis order. Oppositional defiant disorder behaviors are less severe do not include physical aggress ion or violations of the T he diagnosis of oppos itional defiant disorder s hould be made in the presence of conduct disorder, even youths with conduct dis order usually have many of the symptoms and often meet criteria for oppos itional P.3209 defiant disorder. ADHD is the most frequently comorbid dis order with oppositional defiant dis order, it can be difficult at times to differentiate and attribute behaviors between the two disorders . C onvers ely, children with ADHD are als o diagnosed with defiant disorder. C hildren with ADHD may be described disobedient when, actually, their poor compliance is to inattention or dis tractibility. R egardles s of the circums tances , the poss ible presence of s ymptoms of ADHD mus t be inves tigated in evaluating any of dis ruptive behaviors . Another important is the pos sible presence of an anxiety dis order. anxiety dis order and obsess ive-compuls ive disorder may initially pres ent with complaints of s evere 4091 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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addition, studies indicate that children with oppos itional defiant disorder appear to be at higher risk for having a comorbid anxiety disorder. S imilar consideration should given to the mood disorders, as antagonis tic and disobedient behaviors are often ass ociated features for children with mood dis orders, and both clinic and community samples s how that children with defiant disorder are at increas ed risk for a comorbid disorder. Although psychotic and pervas ive developmental disorders may als o exhibit hos tile and negativis tic interactions , the pres ence of more bizarre symptoms usually discriminates thes e dis orders from oppos itional defiant disorder.

C ours e and P rognos is Oppositional defiant disorder demons trates high over time, and longitudinal studies have shown that children diagnos ed with the disorder are at significant for continued dis ruptive behavior s ymptoms at later stages of development. S tability of the dis order with the s everity of the s ymptoms . C hildren with oppos itional defiant dis order are als o at ris k for later development of conduct dis order, although mos t do not progres s to the more severe condition. Longitudinal has s hown that boys who developed conduct dis order higher numbers of oppositional defiant dis order symptoms than thos e who did not, that oppos itional defiant disorder predicted the onset of conduct and that the symptoms of oppos itional defiant disorder typically pers ist after the ons et of conduct dis order. socioeconomic s tatus and parental s ubs tance abus e appear to increase the ris k of progres sion to conduct disorder for boys with oppositional defiant disorder. 4092 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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as conduct dis order is a ris k for development of personality disorder, so oppositional defiant disorder appears to be a ris k for development of conduct T he presence of oppos itional defiant disorder is also predictive of later comorbid ADHD. T here is limited information about the progres sion to other disorders in children with oppos itional defiant disorder, but it that they are at ris k for later anxiety and mood

Treatment T he numerous identified risk factors , contributing conditions, and theories of development for this indicate the range of opportunities for intervention as as the complexities in determining treatment efficacy. Numerous reports and metaanalysis reviews have indicated several promising treatment approaches . Of these, parent management training and child problemsolving skills training have been demons trated to be effective interventions for children with oppos itional defiant disorder. P arent management training, as the name implies, focuses on improving parent s kills in with negative acts and promoting des ired behaviors . Although there are s everal variations, mos t cover a standard s et of behavioral s kills and techniques with or both parents over 6 to 8 weeks . Attention is also to correcting parental practices that reinforce deviant behaviors . P arent management training can be implemented individually or with groups. Obs tacles for this intervention include lack of interes t or motivation in the parents or parental dis cord. C hild problem-solving skills training is bas ed on cognitive-behavioral therapy techniques in correcting dysfunctional practices in interactions. T raining with the child seeks to delay 4093 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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impulsive respons es , increase cons ideration for solutions , cons ider cons equences of choices , and self-as sess ment of behaviors. In addition to the s tudies indicating efficacy for both these approaches are significant additional improvement when used together oppos ed to us ing one or the other alone. As with most conditions, early intervention appears to improve the chances for improvement. No evidence exis ts to an indication for specific medication us e with defiant disorder, except for the indicated treatment of a comorbid dis order. F or example, studies have noted concurrent improvement in oppos itional and defiant behaviors with stimulant treatment for comorbid ADHD. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 40 - Dis ruptive B ehavior Dis orders > C O NDUC T DIS OR D

C ONDUC T DIS OR DE R P art of "40 - Dis ruptive B ehavior Dis orders"

Definition C onduct dis order in children and adolescents is characterized by a repetitive pattern of behaviors that violate the rights of others or major s ocietal rules. T he antis ocial acts are typically present in a variety of and res ult in significant functional impairment at home, school, or work. T here is no pathognomonic or symptom for diagnos is , but, rather, a range of acts that define the condition by their number, severity, and persis tence for at least 12 months. T he behaviors as symptoms of the disorder are grouped into four 4094 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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categories : phys ical aggress ion or threats of harm to people or animals , destruction of property, acts of deceitfulnes s or theft, and serious violations of ageappropriate rules. A variety of subtypes have been propos ed based on concepts about development or prediction of outcome. Although these behaviors may res ult in legal charges for s ome youths, conduct should not be confus ed with the legal term of

His tory B enjamin R ush des cribed in 1812 consulting on three cases —two young men and “a daughter of a citizen”—who exhibited a “total perversion of moral faculties .” He s peculated “in all of thes e cas es of preternatural moral depravity, there is probably an defective organization in thos e parts of the body which occupied by the moral faculties of the mind.” S cientific thought continued through mos t of the 19th century to focus on detecting and des cribing some inherent traits phys ical defects that marked the criminal character. the beginning of the 20th century, increas ing cons ideration of the development of antisocial and the influence of environmental conditions among those working with juvenile offenders. In 1896, Douglas Morris on wrote, “Unless a man has acquired criminal habits in early life, it is comparatively seldom he degenerates into a habitual criminal … J uvenile arises out of the adverse individual or s ocial conditions the juvenile offender, or out of both s ets of conditions acting in combination.” He defined the important individual factors as gender, age, phys ical, and mental, the important s ocial factors as parental and economic. application of ps ychoanalytic theory by August Aichorn 4095 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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the 1930s further s hifted emphasis and attention from cons titutional to social influences in the caus ation of antis ocial behavior. V iewing dis ruptive behavior as the unregulated expres sion of primitive instinctual without regard for the s urrounding world, Aichorn that interventions s hould concentrate on remedial to help adjus t to the demands of s ociety. Although this approach continued in the 1950s with the work of F ritz R edl and others, renewed interest in cons titutional features appeared in the s tudies on temperament by C hes s and Alexander P.3210 T homas. T he introduction of longitudinal s tudies and genetic, physiologic, and biological research in the half of the 20th century greatly expanded the s cope of inves tigation and unders tanding of this disorder.

C omparative Nos ology Although not termed conduct dis orde r, antis ocial and disruptive behaviors first received mention in the DS M1968 with the diagnoses of runaway, uns ocialized aggres sive, and group delinquent reactions of or adolescence. T hes e disorders were bas ed on the subtypes first described by R ichard J enkins and Les ter Hewitt in the 1940s from their dimens ional analys is of problem behaviors in a clinic-referred sample of children. T he application of a descriptive set of offered a more objective class ification system and improved definition of s ubgroups. Herbert Quay this line of research with the application of multivariate analysis in the 1960s . T his technique was es pecially 4096 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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important in research on prediction of outcome, as demonstrated by the work of Lee R obins during the decade. Her finding of predictive value in the s ymptom phys ical aggres sion was combined with the dimens ion socialization to delineate four subtypes in the DS M-III. us e of specific problem behaviors as criteria and the conduct dis orde r as a diagnos tic label were also firs t introduced with the DS M-III. Although clinical studies supported the matrix of four categories created by the axes of s ocialization and aggres sion, the s ubtypes found to have poor reliability and were dis carded with DS M-III-R . Instead, a list of s pecific antis ocial developed and, through field-tes ting, resulted in 13 defined criteria s ymptoms , with the requirement of being pres ent for at least 6 months to meet the T his approach was supported by research that showed variety of antisocial acts was a s tronger predictor for continued disruptive behavior than the s pecificity. R did retain an altered form of subtypes , with the designation to the diagnosis of socialized or group, aggres sive, or undifferentiated types as descriptive T he development of the DS M-IV involved reanalys is of exis ting data as well as field trials of the propos ed modifications. Although attempts were made to reduce the criteria list, all the s ymptoms were found to to the definition of the disorder, and it was increased to symptoms (T able 40-3). Although the minimum number remained at three, the time frame increas ed to 12 with at leas t one in the pas t 6 months . T his change attempt to deal with the differing frequencies in occurrence of the various behaviors , es pecially the severe acts . DS M-IV -T R s ubtypes for conduct disorder now bas ed on age of ons et, either before or after the 4097 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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of 10, which is predictive of outcome. C hildhood-onset conduct dis order youths are more likely to exhibit persis tent antis ocial behaviors as well as higher rates aggres sion and family members with externalizing disorders in comparison with those with the onset s ubtype. Additional des cription is added for severity, although there is no specific differential weighting between the more common symptoms , s uch lying, and the less frequent but severe symptoms , s uch armed robbery. T he use of specific antisocial behaviors making the diagnos is of conduct dis order has been criticized as too legalis tic and drifting from the concepts that characterize adult antis ocial pers onality disorder, this method has proved to be a reliable and predictive means of diagnos is .

Table 40-3 DS M-IV-TR Diagnos tic C retria for C onduc t Dis order A. A repetitive and persistent pattern of behavior which the basic rights of others or major ageappropriate societal norms or rules are violated, manifested by the presence of three (or more) of following criteria in the past 12 months, with at one criterion pres ent in the past 6 months:    Aggres s ion to people and animals    1. Often bullies, threatens , or intimidates others 4098 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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   2. Often initiates physical fights    3. Has us ed a weapon that can cause s erious phys ical harm to others (e.g., a bat, brick, broken bottle, knife, gun)    4. Has been phys ically cruel to people    5. Has been phys ically cruel to animals    6. Has stolen while confronting a victim (e.g., mugging, purs e s natching, extortion, armed robbery)    7. Has forced someone into s exual activity    Des truc tion of property    8. Has deliberately engaged in fire s etting with intention of caus ing serious damage    9. Has deliberately des troyed others ' property (other than by fire s etting)    Dec eitfulnes s or theft    10. Has broken into s omeone else's hous e, building, or car    11. Often lies to obtain goods or favors or to 4099 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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obligations (i.e., “cons ” others )    12. Has s tolen items of nontrivial value without confronting a victim (e.g., s hoplifting, but without breaking and entering; forgery)    S erious violations of rules    13. Often s tays out at night despite parental prohibitions, beginning before age 13 years    14. Has run away from home overnight at leas t twice while living in parental or parental s urrogate home (or once without returning for a lengthy period)    15. Is often truant from s chool, beginning age 13 years B . T he disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C . If the individual is age 18 years or older, not met for antisocial personality dis order. S pe cify type bas ed on age at ons et:    C hildhood-ons et type: onset of at leas t one criterion characteris tic of conduct dis order prior to 4100 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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age 10 years    Adoles cent-ons et type: absence of any characteristic of conduct dis order prior to age 10 years    Uns pecified ons et       S pe cify s everity:       Mild: few if any conduct problems in excess those required to make the diagnosis and problems cause only minor harm to others       Moderate: number of conduct problems and effect on others intermediate between “mild” and “severe”       S evere: many conduct problems in exces s of those required to make the diagnosis or conduct problems cause considerable harm to others

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T he firs t inclus ion of conduct dis order as a diagnos tic category in the IC D was with the ninth revis ion in 1977. 4101 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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T here were five s ubtypes, including s ocialized and unsocialized dis turbances of conduct that roughly matched the DS M counterparts. T he other three were compuls ive conduct dis order, mixed disturbance of conduct and emotions, and dis turbance of conduct not otherwis e s pecified. T he IC D-10 diagnostic criteria for res earch, as mentioned earlier, combine the diagnoses oppos itional defiant dis order and conduct dis order by us ing a common list of 23 behaviors with which the various s ubtypes are defined (T able 40-2). T he five categories of conduct disorder were revis ed to include socialized, unsocialized, other, unspecified, and to the family context. S ome of thes e have no DS M equivalent, and although the s ymptom list is to the DS M-IV -T R , there are s ignificant differences. DS M, each of the conduct disorder categories requires presence of at least three of the more serious P.3211 but only one need be pres ent for the past 6 months. In addition, the IC D-10 diagnostic criteria for res earch differential weighting for s ome of the more serious symptoms, such as mugging, where one occurrence the criterion. T he IC D-9 category of mixed disturbance conduct and emotions is now separate and s pecifies criteria for the presence of mood dis order s o that a diagnosis is given rather than listing comorbid as with the DS M.

E pidemiology R eported prevalence of conduct disorder has ranged 1 to 16 percent, with most studies indicating a general 4102 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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population rate of approximately 5 percent. As with the meas ure of prevalence of oppos itional defiant dis order, rates for conduct dis order vary, depending on which edition of the DS M is us ed to make the diagnos is as other characteristics of the population sample. In comparing prevalence in the same population, the rate conduct dis order was 44 percent less using the DS Mthan with the DS M-III criteria. C omparisons of the and DS M-III-R conduct dis order criteria have found slightly lower prevalence rates , which is not s urprising view of the minor differences between them. S ome have found no differences in prevalence of conduct disorder by age, whereas others sugges t a slight from childhood to adolescence. T here are conflicting trends when looking at the prevalence of s pecific symptoms with respect to age. F or example, overall prevalence of phys ical fighting tends to decrease from childhood to adoles cence, but more s erious ass aults, as rape or robbery, tend to increas e. A cons is tent over time is that conduct disorder is more common children and adolescents from low-socioeconomicfamilies and from neighborhoods with high rates of and s ocial dis organization. C omparisons in prevalence rates between rural and urban areas have produced res ults. Another consis tent finding is that conduct dis order is prevalent among boys than girls , with rates three to times higher in mos t s tudies of children and S ome have sugges ted that the diagnostic criteria be modified for girls , as their antis ocial behaviors tend to less aggres sive than boys, consisting of mainly acts. A final important concern is whether the 4103 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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of conduct disorder is changing over time. B ecause environmental influences appear to influence the rate prevalence, it is not unreas onable to expect that in those factors will lead to changes in overall T he increases in rates of juvenile arres ts for violent offens es in the United S tates from 1984 to 1994 and res ults of some studies s upported the impres sion that there was an increas e in aggres sive acts, but juvenile rates for nonviolent offens es during the same period relatively cons tant. Arres ts for violent crime as well as national high school s urveys of self-reported behaviors showed a decline in rates toward the end of 1990s . S everal other s tudies have s uggested that the difference in prevalence by gender has dropped over with increasing rates of antis ocial behaviors in girls .

E tiology B ecaus e conduct dis order is a diagnos is defined by no single attribute but rather a combination of behaviors from a wide potential range, it is not s urprising that a specific caus e has yet to be identified that accounts for cases. Instead, an impress ive number of factors have defined with s ubs tantial res earch s upport that describe conditions of increased ris k for onset and further development of the disorder. Many of these ris k factors may s erve as or be as sociated with causal T here is no common agreement on a s ingle model, and several have been propos ed to test theories that take account the interaction of multiple factors that may in dis ruptive behaviors . It is generally accepted that this heterogeneous dis order is developmental in nature, the diagnosis appears through advers e environmental influences on a vulnerable individual at critical s tages 4104 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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growth.

B iologic al T he occurrence of cas es within families and ris k by gender support the view of pos sible genetic influences on the disorder. Although monozygotic and dizygotic twin s tudies clearly s upport the role of genetic influences in adult antisocial behavior, the evidence is from clear in childhood. E arlier twin studies indicated shared environment appeared to have a greater on ris k of conduct disorder than genetic factors , but recent studies have sugges ted that the relative of genetic and environmental influences may vary for different components of the disorder. Adoption s tudies another approach to studying the relative influence of genetic and environmental effects. Although the influences reported are less than in twin studies, studies demons trate significant interactions between genetic heritage and adverse environment. T he risk for conduct dis order and aggres sion in the children of biological parents with antis ocial behaviors was a of the relative advers e environment in the adoptive A relatively new area of promis ing research is genetics . Attention has focus ed on the gene for monoamine oxidase type A (MAO A ), an enzyme the metabolis m of s everal neurotransmitters. Among abused boys , those with a variant gene for low MAO A activity appear to be twice as likely to develop conduct disorder than thos e without. E nvironmental influences this pos sible genetic vulnerability are critical, as when there is no history of abuse, boys with the low activity MAO A gene s eem to be at no greater ris k than other nonabused boys for the later development of antisocial 4105 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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behavior. T he cleares t heritable risk factor is gender in view of the higher prevalence among boys . T he sex difference has resulted in far more res earch on than on girls with conduct dis order, although recent studies have begun to focus on girls. T he role of specific androgens has been of interest, especially with res pect to aggres sive behaviors, but the findings are inconsistent in youth. G ender differences are als o not solely genetic, reflecting other s ocial attitudes and conditions. Interestingly, both twin and adoption studies do not show any differences by s ex in the extent or influence for either genetic or environmental influences. G enetic factors alone cannot account for the s udden changes over time in the prevalence of the disorder or component behaviors , s uch as aggres sion, as that require generations to occur. T he twin and adoption studies als o s how that families can influence behaviors other ways. T here is most likely no one gene or even genes res pons ible for all the various behaviors with the dis order. R ather, it is more plausible that controlling s pecific features such as impulsivity and aggres sion or other ris k factors such as attention contribute to the potential for conduct dis order in any individual. R es earch has als o found the presence of a number of biological and phys iological features correlated with conduct dis order and antisocial behavior in youth. Neurotrans mitter differences are of obvious interes t, es pecially those that play a role in s ympathetic arous al, the findings have been inconsistent. C ontrary reports on the level of activity of both norepinephrine and dopamine metabolites in as sociation with both conduct 4106 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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disorder and aggres sive behaviors . S ome of thes e inconsistencies may be the res ult of the differences in groups studied or the relatively small numbers of Likewise, studies on serotonin metabolites have both increased and decreased central nervous s ys tem activity in antisocial youth depending on the type of meas urement used. More promis ing has been the on physiological markers of s ympathetic arous al. have shown that low res ting heart rate is cons is tently as sociated with and predictive of antis ocial behavior in boys , es pecially physical aggres sion. T here are contradictory reports as to whether the pres ence of low res ting heart rate repres ents a greater ris k to boys P.3212 with or without advers e s ocial influences . F urther study also needed to determine whether the presence of low res ting heart rate is a res ult of habituation to early controls and conditioning. J ust as with the genetic biological and physiological research stress es the importance of interactions between the individual and or her s urroundings . Many of the differences found represent alterations brought about by adverse events influences at s pecific s tages of development. T here is growing evidence from animal and human studies of lasting phys ical and metabolic changes in the brain res ulting from severe stress or abus e, which is of relevance in the understanding of biological factors affecting antis ocial behavior.

Ps yc hologic al S everal areas of ps ychological impairment and 4107 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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have been identified as increasing the risk for conduct disorder. A consis tent finding in s tudies looking at other areas of functioning in youths with conduct dis order is poor academic performance. T his as sociation may reciprocal relations hip, as youths frustrated with poor school achievement act out in an antis ocial fas hion and the presence of disruptive behaviors interferes with academic work. A related area of res earch cons iders relations hip between low IQ and antis ocial behaviors. studies have found that this is an as sociation that only appears over time, with no significant correlation in preschool-age children, mixed findings in s chool-age children, and pos itive correlation in adolescence. More striking is the relationship between conduct disorder impaired verbal ability. Deficit verbal IQ is significantly as sociated with antis ocial behaviors even after for other pos sible confounds , including race, socioeconomic s tatus , and academic achievement. exploring a poss ible caus al relationship between verbal abilities and antis ocial behaviors have been but indicate that a critical factor is the additional of attention problems . Other problems with executive functions have been linked conduct dis order, es pecially those individuals with comorbid ADHD, including anticipating and planning, inhibition of impulsive behaviors , and abstract reas oning. Longitudinal s tudies have found that the presence of thes e deficits appears be related to the early ons et as well as s ubs equent persis tence of antis ocial behaviors . Overall, neurops ychological tests indicate frontal and temporal lobe dys function in youths with antisocial behaviors . As seen in youths with oppos itional defiant disorder, disorder youths typically lack ess ential skills in 4108 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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confrontations and exhibit significant differences in cognition when compared with other youths. T hey perceive others as hostile, miss important s ocial cues, generate fewer alternative res ponses , and react impulsively in s ocial interactions . Although res earch has not generally focused on diagnosed disorder, traits of negative emotionality, s uch as overreactivity, are ass ociated with antisocial behaviors appear to be influenced by other environmental factors . T here is also evidence that the presence of and s timulation seeking in early childhood is predictive later aggres sion. A final individual characteristic with increased ris k for conduct dis order is chronic illness and disability. C ompared with healthy children, those with chronic illnes s are three times more likely to have conduct misbehaviors, and the risk increases to times more likely if the illness involves the central system.

S oc iologic al E xtens ive res earch has identified numerous ris k factors for conduct disorder, including family and neighborhood characteris tics. Y ouths subjected to maltreatment, hars h discipline, and phys ical or sexual abuse are at greater ris k for developing antisocial behaviors . P hysical abuse and neglect are particularly as sociated with later aggress ive and violent behavior. study found that s exually abused children were 12 more likely to develop conduct disorder even when controlling for other factors. Other poor parenting practices are es pecially salient in the development of conduct disorder, including parental rejection, neglect, and lack of involvement. Deviant behaviors are als o 4109 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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reinforced by incons is tent attempts at dis cipline and capitulation to coercive behavior in children. Other problems apart from parent–child relationships are as sociated with increas ed occurrence of conduct including poverty, marital dis cord, domestic violence, parental alcohol or s ubs tance abus e, and parental illness . C ommunity studies s how that low status appears to exert influence on the development antis ocial behaviors at both a family and community Higher rates of conduct dis order are found in disadvantaged neighborhoods characterized by poor housing, crime, substance abuse, and disorganization. T hese factors may operate by placing the family under stress as well as presenting negative role models and influences to children. E xposure to violence is a cons istently reported ris k factor in the development of aggres sion and other antisocial behaviors , whether it is the family, in the neighborhood, or through television movies. Numerous s tudies have s hown that repeated viewing of violent behavior leads to direct imitation and generally increased aggress ive behavior. Another source of deviant and aggres sive role models is antis ocial peers . Long recognized as a common conduct dis order youths , antis ocial peers figured in attempts at s ubclas sification. In contrast, evidence indicates that deviant peers may significantly influence cours e and development of the adolescent-onset disorder but figure les s with childhood onset.

Protec tive Fac tors T here is less res earch available on protective factors on ris k factors, but s ome information exis ts . T hese have been sought, as it is evident that many children 4110 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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not develop conduct dis order despite the presence of overwhelming risk. Most of the identified protective factors are the converse of specific ris k factors, as in female, having a high IQ, having high autonomic or having an easy temperament. S ome of the factors be unders tood as counterbalancing certain ris k for example, having a positive relations hip with at least one parent or adult can compensate for other negative influences. Having a relationship with a nondeviant and supportive partner or mate als o provides a positive and corrective influence. Other protective factors include having areas of competence outside of school, good academic s kills , and us ing planning to handle various situations. One important area of protection appears to good interpers onal skills, such as being able to relate others . F urther s tudy is necess ary to confirm the exact nature of protective factors within high-ris k groups.

R is k and Development As indicated earlier, no s pecific risk factor is an predictor of antis ocial behavior. T he best predictive models cons ider cumulative risk, as it increas es with additional negative influence. T here is emerging from longitudinal studies that certain risks exert more less influence depending on the age of the child or the stage of the disorder. T his would explain some of the differences in findings between s tudies that cons idered the same factors on dis similar populations. R isk factors interact or mediate the influence of other factors , such marital discord leading to inconsistent discipline. It is important to cons ider that ris k factors are not s tatic, as seen in the development in parents of incons istent or harsh discipline as a dys functional reaction 4111 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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P.3213 to the difficult temperament of the child. T he of the various ris ks for any one individual, then, is not single point of origin but in the accrual and progres sion influences over the unfolding genes is of antis ocial behaviors .

Diagnos is and C linic al F eatures T he types of behavior involved and the circums tances the examination complicate the evaluation of conduct disorder. S tudies s how there is low correlation among different informants, but each contributes to unders tanding the entire cas e. T herefore, it is interview as many observers as poss ible, including the youth, parents or guardians , and teachers . W ith lying a common feature, it is unders tandable to mistrust information provided by the youth, but research that s elf-report provides critical information on behaviors , es pecially covert acts, as well as es sential to as ses sing impairment. Interview that facilitate examination of antisocial youths include a nonjudgmental attitude, avoidance of pejorative terms, clarifying the purpos e of the interview, and letting the youth tell his or her side of the story. E valuations by s chools , s ocial agencies, or the court are is important to clarify the role as consultant with the referral source and the family. W hen attending ordered evaluations under duress , families are often and s uspicious . It is important for clinicians to and addres s thes e is sues to facilitate the interview. T he DS M-IV -T R diagnostic criteria are lis ted in T able 4112 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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Numerous checklists and s cales for dis ruptive and antis ocial behaviors exist that may facilitate the as sess ment. In addition to the s pecific types of acts that may be pres ent, it is important to ass ess their onset and frequency. It is helpful to start with ques tions about minor behaviors and then progres s to more acts, us ing the descriptions provided by the youth to further information. It is also es sential to determine whether the acts are intrins ic or reactive to s ocial such as running away from abuse. G iven the frequent occurrence of phys ical aggress ion or abuse, particular attention mus t be paid to safety is sues . Y ouths with conduct dis order may also exhibit s uicidal ideation and behavior even in the abs ence of other s ymptoms of depres sion, s o it is important to explore this. T he occurrence of comorbid illnes s, especially in girls , careful s creening for other dis orders. J ohn, age 12, was referred for outpatient evaluation being picked up by police for running away from home. states that he jus t wanted to get out of the hous e and his friends. His mother s ays that he has been out of the home overnight on three other occasions in the pas t but us ually returns the next morning. S he complains he is constantly in trouble. He has s hoplifted on s everal occasions that she knows of, with the first time at age S he suspects that he als o s teals from neighbors or as there are always items at home that he claims he T he police have been involved only for his running from home. He has a quick temper, and she knows he involved in several fights over the past year in the neighborhood. He is particularly cruel to his younger brother, constantly taunting and teas ing him. S he 4113 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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that he lies constantly, s ometimes for no apparent When he was 6 years old, he was fas cinated with fire set s everal small fires at home, fortunately with no injury or damage. S he ended by saying that J ohn is his no-good father and that she wis hed she never had J ohn initially refus ed to ans wer ques tions but gradually began to talk. He presented a tough image with an indifferent attitude about the various problems. He any abus e at home, s aying that he ran off as he was He acknowledged his mis behaviors, but dis miss ed just having fun. He explained the fights as provoked by others and denied the use of any weapons, although bragged about breaking the nose of another youth. His record indicates that he was evaluated for symptoms of ADHD when he was in firs t grade. Methylphenidate (R italin) was pres cribed; however, the family did not continue with treatment, and he is currently on no medication. He is currently in s ixth grade special clas ses , having failed and repeated fifth grade. His grades are failing, and he may have to repeat s ixth He admits to truancy on s everal occas ions this year in addition to his problems with completing s choolwork. previous evaluation indicates that child protective evaluated the family for pos sible neglect when he was years old after he and his brother were found barefoot unkempt on the s treet late one evening. Apparently, family was referred for counseling and never attended, the case was eventually dismis sed. B oth of J ohn's have a history of drug and alcohol abuse. His birth was unplanned, and his mother us ed drugs during His parents separated s oon after his birth, and his returned to live with her parents briefly. He and his moved to live with her boyfriend when J ohn was 3 4114 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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old after s he became pregnant with his younger T his relations hip ended within a year, and only J ohn, mother, and his brother live in their apartment. S he has worked s everal different jobs, and J ohn thinks she s till a drinking problem.

P athology and L aboratory E xamination Although as already described, there are biological and phys iological measurements as sociated with conduct disorder, none together or alone can be considered diagnostic. A careful physical examination and medical history s hould be obtained, with particular attention to potential evidence of abus e, trauma from phys ical and the health-related consequences from the high-ris k behaviors of substance abuse and sexual promiscuity. poss ibility of academic difficulties and learning impairments requires ps ychoeducational evaluation for deficits in intellectual functioning, developmental disorders , and other neuropsychological deficits . Neuroimaging s tudies have been conducted to poss ible differences in frontal or temporal lobe but are not indicated for routine evaluation.

Differential Diagnos is and Dis orders Antisocial behaviors can be part of many conditions merit careful cons ideration. A single occurrence of behavior or minor incidents of misbehavior may is olated antisocial acts or normative risk-taking P sychotic disorders can s ometimes mimic the of conduct dis order, with symptoms of physical 4115 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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or other antisocial acts . Oppositional defiant disorder not have antisocial behaviors , but appearance of those behaviors that do not yet meet criteria for diagnosis indicate the onset of conduct disorder. ADHD can be marked by extremely disruptive behaviors that do not conform to rules or expectations , and the relations hip between it and conduct dis order is the focus of res earch. In view of the cooccurrence of the two it was s ugges ted that they represented a s ingle but clinical res earch has resulted in the generally view that they are two separate but related dis orders. P ros pective s tudies on the relative risk in children with ADHD alone for later development of conduct disorder have been mixed. T here is evidence that when conduct disorder does appear in children with ADHD, the ons et antis ocial behaviors is earlier than us ual and that the subs equent cours e is more severe. Numerous reports indicate a s trong as sociation between s ubstance use conduct dis order and that there is a reciprocal Most studies indicate that P.3214 the ons et of conduct dis order is before or coincides the ons et of s ubs tance use. Mood and anxiety also have important interactions. C hildren and with conduct disorder appear to be at increas ed risk for anxiety dis orders, although children with anxiety without behavioral problems are at low risk for conduct disorder in adolescence. S ymptoms of and antis ocial behaviors frequently occur together in adoles cents , but reports on the comorbid ris k for major depres sion and conduct dis order have been mixed. 4116 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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R eports of reduction in antis ocial behaviors with the res olution of depress ive s ymptoms indicate that there interactions when they do occur together. Although is a s imilar overlap in s ymptom presentation for bipolar disorder and conduct dis order, there is limited on the relationship between the two diagnoses. B ased the available information regarding the cours e and interplay of conduct dis order and various comorbid conditions, Loeber and others outlined a model of the poss ible developmental s equences and influences for involved conditions (F ig. 40-1). T he risk for comorbid disorders is not uniform across all youths conduct dis order. C hildhood-onset conduct disorder youths appear to have a different risk profile than adoles cent-onset youths , including higher rates of low IQ, and other neuropsychiatric disorders . T he difference by gender is mos t s ignificant, as girls with conduct dis order are at far greater risk for comorbid disorders , including ADHD, anxiety dis orders, mood disorders , and substance us e.

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FIGUR E 40-1 Developmental s equences between disruptive behavior dis orders and comorbid conditions. T he dotted arrow indicates a relations hip in which attention-deficit/hyperactivity disorder (ADHD) s erves to hasten the ons et and worsen the severity of conduct disorder (C D), but only in the pres ence of oppositional defiant disorder (ODD). Lines without arrowheads relations hips in which the direction is not clear. personality dis order (AP D) in young adulthood is a likely outcome of the dis ruptive behavior disorders pathway. (F rom Loeber R , B urke J D, Lahey B B , et al.: Oppositional defiant and conduct dis order: A review of past 10 years , P art I. J Am Acad C hild Adole s c 2000;39:1468, with permiss ion.)

C ours e and P rognos is Longitudinal studies have shown that conduct dis order 4118 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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very s table diagnosis over time, with reports of 45 to 90 percent s till meeting criteria for diagnosis after 3 to 4 P ros pective longitudinal s tudies have also provided information regarding the early stages and poss ible pathways in the development of dis ruptive behavior disorders . T he appearance of antis ocial behaviors occur in a random fas hion but follows a predictable in most cases . Ons et is typically heralded by minor and severe acts . As time progres ses, more severe appear, in addition to the continuation of the already es tablis hed early behaviors. T here als o appear to be specific clus ters of behaviors that develop in sequence, us ually referred to as overt, authority conflict, and behaviors . Overt behaviors include phys ically acts and progress from bullying to physical fighting and then on to more s evere ass aults. Authority conflict with stubbornnes s and progress es to more defiant behaviors , s uch as running away or truancy. C overt behaviors typically begin with lying or s hoplifting and advance to include vandalis m and burglary. Loeber propos ed a model bas ed on evidence from longitudinal studies that describes the developmental progress ion these clusters (F ig. 40-2). T he early behaviors appear have a typical age of onset, with authority conflict the earliest of the three. Although many children exhibit level behaviors , fewer and fewer progress to each succes sive s tage of antisocial acts . T he further a youth progres ses down any given pathway, the more likely behavior from the other pathways will appear. youths with the most s evere behaviors often exhibit the widest variety of antisocial acts . T his model may some of the difficulties with previous attempts in 4119 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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subcategories of conduct disorder.

FIGUR E 40-2 T hree developmental pathways to disruptive behaviors . (F rom Loeber R , Hay DF . Developmental approaches to aggress ion and conduct problems . In: R utter M, Hay DF , eds. Deve lopme nt L ife: A Handbook for C linicians . Oxford: B lackwell 1994:488, with permiss ion.) R es earch reports indicate that approximately 40 those diagnosed with conduct dis order go on to have 4120 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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antis ocial pers onality disorder, and among those who not, most manifest s ignificant functional impairment in relations hips and work. C onduct disorder has also linked to other advers e adult outcomes , including subs tance use and other ps ychiatric dis orders. It to be s hown whether the adult problems with and mental disorders are a direct res ult of conduct disorder, a consequence of ass ociated conditions and impairments , such as academic failure and or both.

Treatment A wide variety of treatments have been attempted with conduct disorder, as it is not only one of the most but also among the mos t costly dis orders to society. Unfortunately, few are effective. P art of the difficulty treatment of conduct dis order is that the impairments affect many different domains and areas of functioning, and interventions must be able to address the critical involved for each individual. A further complication is the many difficulties of the disorder typically require the involvement of multiple s ocial services , including education, mental health, juvenile justice, and child protection, so treatment mus t deal with various s ys tem is sues and coordination of care. Also, a host of conditions may confound and interfere with P erhaps the greates t obs tacle to treatment is the heterogeneous nature of the dis order, where even types of symptoms may have multiple origins that different approaches for intervention. T he majority of reported therapies for conduct dis order have not been properly studied. T here are numerous 4121 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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evaluations on a wide P.3215 range of treatments , and several metaanalys is reports shown s ome promising directions, with s everal types of intervention demons trating s ignificant, albeit modes t, effect. T hese include behavioral s kills training and based programs or combinations of thes e techniques. Metaanalysis has als o s hown that certain treatments— shock interventions and boot camps—are not only ineffective but als o may actually exacerbate antis ocial behaviors . T wo of the most effective treatments for conduct are parent management training and problem-solving skills training, described in the treatment of defiant disorder. P arent management training with conduct dis order is typically of longer duration, from 12 25 weeks, than is treatment of oppos itional defiant disorder. It is als o modified in some vers ions to include video modeling to ass ist in educating parents on and techniques. P arent management training is mos t effective with children or les s s evere cas es, as the from us e with adolescents is mixed and apparently influenced by the s everity of their symptoms. P roblemsolving skills training for conduct disorder is s imilar to for oppositional defiant dis order. T reatment effect to be less with problem-solving skills training for with comorbid dis orders, intellectual impairments , or extreme family dysfunction. T wo additional treatments with s ubs tantial evidence of efficacy are functional family therapy and multis ys temic therapy. F unctional family therapy focus es on 4122 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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unders tanding and altering problematic interactions communications between family members that to the family's inability to effectively deal with the child's antis ocial behavior. All family members attend, and the therapist concentrates on improving family communication patterns. E valuations of functional therapy with severe delinquents and in comparis on other traditional interventions have demons trated clear and s ustained improvements in behavior. Multisystemic therapy, as the name implies, cons iders antis ocial as a result of the various s ys tems that the adolescent interacts with, including peers, s chool, neighborhood, family, and s eeks to alter the influences of thos e through the family. It is intensive, home-based, and typically 3 months in duration. S tudies have found it superior and cos t-effective in comparison with services and a viable alternative to res idential No evidence exis ts to s upport the us e of medication to treat conduct dis order. Indicated medications for the treatment of any comorbid disorder that is pres ent be considered and potentially offers improvement of conduct dis order symptoms . T here is evidence that stimulant medication in the treatment of ADHD can reduce some antisocial behaviors , including Apart from the treatment of comorbid conditions , medications have primarily been us ed in conduct to treat physical aggres sion, but mos t of the research been uncontrolled studies. Medications that have been tried include lithium (E s kalith), antips ychotics , anticonvuls ants, clonidine (C atapres), and propranolol (Inderal). G iven the relative serious nes s and frequency of these 4123 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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behaviors , various prevention programs have been with both general and at-ris k populations . Most include elements from established treatments , s uch as parent management or individual skills training. V arious programs have been developed to target s pecific P.3216 antis ocial behaviors, such as truancy or youth violence. P reliminary s tudies indicate that s ome of the schoolprograms can reduce expected rates of disruptive in comparis on. Other prevention efforts directed at enrichment, s uch as Head S tart, have also been found reduce expected rates of later antisocial behaviors in ris k groups . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 40 - Dis ruptive B ehavior Dis orders > S UG G E S T E D C R OS S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "40 - Dis ruptive B ehavior Dis orders" Antisocial behavior in children and adoles cents in 49.6; antis ocial pers onality disorder in C hapter 23; S ection 39.1; learning disorders in C hapter 35; subs tance abus e in S ection 49.9; normal child development in S ection 32.2; normal adolescent development in S ection 32.3; psychiatric examination the infant, child, and adolescent in C hapter 33; forens ic child and adoles cent ps ychiatry in S ection 49.10; behavioral ps ychotherapy in S ection 48.3; family 4124 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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in S ection 48.5; pediatric ps ychopharmacology in 48.6; community-based treatments in S ection 48.9; and ps ychiatric treatment of adoles cents in S ection 48.10.

R E FE R E NC E S Angold A, C os tello E J : T oward es tablis hing an basis for the diagnos is of oppositional defiant J Am Acad C hild Adole s c P s ychiatry. 1996;35:1205. B ehan J , C arr A. Oppos itional defiant disorder. In: ed. W hat W orks with C hildre n and Adole s ce nts ? : A R eview of P s ychological Inte rve ntions with C hildre n, Adoles ce nts and the ir F amilie s . P hiladelphia: T aylor F rancis Inc.; 2000. *B loomquis t ML, S chnell S V . Helping C hildren with Aggre s s ion and C onduct P roble ms : B e s t P ractice s Inte rve ntion. New Y ork: G uilford; 2002. C ampbell M, G onzalez NM, S ilva R R : T he treatment of conduct dis orders and rage outbursts . P s ychiatr C lin N orth Am. 1992;15:69. C as pi A, McC lay J , Moffitt T E , Mill J , Martin J , C raig T aylor A, P oulton R : R ole of genotype in the cycle of violence in maltreated children. S cience . C onnor DF . Aggre s s ion and Antis ocial B e havior in C hildre n and Adoles ce nts : R e s e arch and T re atme nt. Y ork: G uilford; 2002. E gger HL, C ostello E J , Angold A: S chool refus al and 4125 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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ps ychiatric disorders: A community s tudy. J Am C hild Adole s c P s ychiatry. 2003;42:797. F onagy P , K urtz A. Disturbance of conduct. In: T arget M, C ottrell D, P hillips J , K urtz Z, eds. W hat for W hom? : A C ritical R evie w of T re atme nts for and Adoles ce nts . New Y ork: G uilford P ublications; F rick P J . C onduct Dis orde rs and S e vere Antis ocial B ehavior. New Y ork: P lenum; 1998. G reen R W , Ablon J S , G oring J C : A transactional oppos itional behavior: Underpinnings of the collaborative problem s olving approach. J R es . 2003;55:67. Hechtman L, Offord DR : Long-term outcome of disruptive disorders . C hild Adole s c P s ychiatr C lin Am. 1994;3:379. Henggeler S W , S choenwald S K , B orduin C M, MD, C unningham P B . Multis ys te mic T re atme nt of Antis ocial B e havior in C hildre n and Adole s ce nts . Y ork: G uilford P ress ; 1998. *Hill J , Maughan B . C onduct Dis orde rs in C hildhood Adoles ce nce . C ambridge, UK : C ambridge University P res s; 2001. *K azdin AE . C onduct Dis orde rs in C hildhood and Adoles ce nce . 2nd ed. T hous and Oaks , C A: S age;

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Loeber R , B urke J D, Lahey B B , W inters A, Zera M: Oppositional defiant and conduct dis order: A review the pas t 10 years , part I. J Am Acad C hild Adole s c P s ychiatry. 2000;39:1468. *Loeber R , F arrington DP . S erious and V iolent O ffenders : R is k F actors and S ucces s ful T hous and Oaks, C A: S age P ublications; 1998. Loeber R , F arrington DP , S touthamer-Loeber M, K ammen W B . Antis ocial B e havior and Mental P roblems : E xplanatory F actors in C hildhood and Adoles ce nce . Mahwah, NJ : Lawrence E rlbaum Ass ociates; 1998. Loeber R , K eenan K , R uss o M, G reen S M, Lahey T homas C . S econdary data analys es for DS M-IV on symptoms of oppos itional defiant disorder and disorder. In: W idiger T , F rances A, P incus H, R os s M, Davis, W , K line M, eds. DS M-IV -S ource book. V ol Was hington, DC : American P sychiatric As sociation; 1998. Loeber R , Lahey B B , T homas C : T he diagnostic conundrum of oppositional defiant dis order and conduct dis order. J Abnorm P s ychol. 1991;100:379. Marmorstein N, Iacono W : Major depress ion and conduct disorder in a twin s ample: G ender, and ris k for future ps ychopathology. J Am Acad Adoles c P s ychiatry. 2003;42:225. 4127 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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Mason W A, K osterman R , Hawkins J D, Herrenkohl Lengua LJ , McC auley E : P redicting depress ion, phobia, and violence in early adulthood from behavior problems. J Am Acad C hild Adole s c 2004;43:307. Maughan B , R owe R , Mes ser J , G oodman R , C onduct dis order and oppos itional defiant disorder national s ample: Developmental epidemiology. J P s ychol P s ychiatry. 2004;45:609. Moffitt T E , C aspi A, R utter M, S ilva P A. S ex Antis ocial B e haviour: C onduct Dis order, V iolence in the Dune din L ongitudinal S tudy. UK : C ambridge University P res s; 2001. P atterson G R , R eid J B , Dishion T J . Antis ocial B oys . E ugene, OR : C astalia; 1992. P epler DJ , R ubin K H. T he Deve lopme nt and C hildhood Aggres s ion. Mahwah, NJ : Lawrence Ass ociates; 1991. *Quay H, Hogan A. Handbook of Dis ruptive Dis orde rs . New Y ork: K luwer Academic/P lenum P ublis hers ; 1999. R ey J M: Oppositional defiant disorder. Am J 1993;150:1769. R obins LN. A 70-year history of conduct dis order: V ariations in definition, prevalence and correlates. 4128 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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C ohen P , S lomkows ki C , R obins LN, eds. His torical G e ographical Influe nce s on P s ychopathology. NJ : Lawrence E rlbaum As sociates ; 1999. R outh DK . Dis ruptive B e havior Dis orde rs in New Y ork: P lenum; 1994. R utter M, G iller H, Hagell A. Antis ocial B e havior in P eople . C ambridge, UK : C ambridge University 1998. S holevar G P . C onduct Dis orde rs in C hildren and Adoles ce nts . W ashington, DC : American P sychiatric P res s; 1995. S imonoff E , E lander J , Holmshaw J , P ickles A, R utter M: P redictors of antis ocial pers onality. B r J P s ychiatry. 2004;184:118. S teiner H: P ractice parameters for the ass ess ment treatment of children and adoles cents with conduct disorder. J Am Acad C hild Adole s c P s ychiatry. [S uppl]: 122S . S toewe J K , K rues i M, Lelio D: P s ychopharmacology aggres sive s tates and features of conduct dis order. C hild Adole s c P s ychiatr C lin North Am. 1995;4:359. S toff DM, B reiling J , Mas er J D. Handbook of B ehavior. New Y ork: W iley; 1997. van G oozen S HM, van den B an E , Matthys W , 4129 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/40.htm

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K ettenis P , T his sen J HH, van E ngeland H: adrenal androgen functioning in children with oppos itional defiant dis order: A comparison with ps ychiatric and normal controls. J Am Acad C hild P s ychiatry. 2000;39:1446.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 41 - F eeding and E ating Dis orders of Infancy and E arly F eeding and E ating Dis orders of Infancy and E arly C hildhood

41 Feeding and E ating of Infanc y and E arly C hildhood Irene C hatoor M.D. T he term fe e ding dis order is commonly us ed to the dyadic nature of eating problems in infants and children. T he term des cribes a variety of conditions ranging from food refus al, food s electivity, eating too food avoidance, delay in s elf-feeding, problem during feeding, pica, and rumination. T he fourth revis ed edition of the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ) lists three different diagnos es related to feeding problems : (1) feeding dis order of and early childhood, (2) rumination disorder, and (3) E ach of these dis orders is discus sed s eparately. 



F E E DING DIS OR DE R OF INF ANC Y AND E AR LY C HILDHOOD S UG G E S T E D C R OS S -R E F E R E NC E S

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 41 - F eeding and E ating Dis orders of Infancy and E arly F E E DING DIS OR DE R OF INF ANC Y AND E AR LY C H ILDHO

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FE E DING DIS OR DE R OF INFANC Y AND E AR LY C HIL DHOOD P art of "41 - F eeding and E ating Disorders of Infancy E arly C hildhood" T he DS M-IV -T R diagnostic criteria for feeding dis order infancy or early childhood (T able 41-1) is rather broad does not addres s the s pecificity of various feeding disorders . It s erves as an umbrella diagnos is for the specifically defined feeding dis orders des cribed by the author in this chapter.

Table 41-1 DS M-IV-TR Diagnos tic C riteria for Feeding Dis order of Infanc y or E arly C hildhood A. F eeding dis turbance as manifested by failure to eat adequately with s ignificant failure to gain weight or s ignificant los s of weight over at 1 month. B . T he disturbance is not due to an as sociated gastrointestinal or other general medical 4132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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(e.g., es ophageal reflux). C . T he disturbance is not better accounted for by another mental dis order (e.g., rumination or by lack of available food. D. T he onset is before the age of 6 years .

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. American P sychiatric As sociation, Was hington, DC , 2000, with permiss ion.

His tory and C omparative B efore the inclusion of the diagnostic category of disorder of infancy or early childhood in the DS M-IV , were no nationally defined criteria for the diagnosis of feeding disorders . In the abs ence of a recognized different authors have used s everal labels for feeding problems : picky eaters , choos y eaters, s elective problem eaters , food refus al, feeding res is tance, food phobia, food avers ion, and dysphagia. However, none these diagnostic labels has been operationalized. T he of feeding dis orders has been further complicated by fact that feeding dis order and failure to thrive have us ed interchangeably. T he term failure to thrive refers inadequate weight gain bas ed on s tandard growth His torically, failure to thrive has been dichotomized 4133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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organic and nonorganic axes . W hereas the former attributes growth failure to a medically diagnos able the latter has commonly been thought to reflect deprivation or neglect. A third category was later added and represents a mixture of organic and environmental etiological factors of growth failure. C oncerns about the usefulnes s of the label failure to as a “catch-all” diagnosis for all feeding disorders have been express ed. F irs t, the overlap between failure to and feeding disorders is confus ing because not all with failure to thrive have feeding dis orders and not all infants with feeding disorders have failure to thrive. S econd, R ichard G oldbloom pointed out that the term failure to thrive is purely descriptive and does not the proces s that caused the infant to grow William B ithoney and colleagues s ugges ted failure to thrive as a diagnos tic term in favor of “growth deficiency” as a purely descriptive label. Although other authors agree that failure to thrive s hould be as a s ymptom rather than a diagnos is, failure to thrive continues to be used as a diagnos tic label, particularly the pediatric and psychological literature. B ecaus e of the heterogeneity in the etiology of feeding problems that may or may not be ass ociated with deficiency, the author has developed clinical criteria for six s eparate feeding dis orders: (1) feeding disorder of state regulation, (2) feeding disorder of reciprocity, (3) infantile anorexia, (4) sensory food avers ions, (5) posttraumatic feeding disorder, and (6) feeding disorder ass ociated with a concurrent medical condition. T he differentiation of thes e various feeding disorders is important because a treatment that may be 4134 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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very helpful for one feeding disorder may be ineffective the next or make the feeding problems even worse.

E pidemiology It is estimated that 25 percent of otherwis e normally developing infants and up to 80 percent of those with developmental handicaps have feeding problems . more common feeding difficulties may range from too little, refusing certain types of food, to objectionable mealtime behaviors . S evere feeding problems with poor weight gain such as refus al to eat or vomiting have been reported to occur in 1 to 2 percent of infants and toddlers. A few s tudies have s hown that approximately 70 percent of infants who demonstrate food refusal in the firs t year of life continue to have problems when followed up to school age. P icky eating and gastrointestinal s ymptoms in early childhood have been linked to anorexia nervosa. P ica and problem behaviors during mealtime have been ass ociated with bulimia nervosa during the adoles cent years . B ecaus e the etiological factors are believed to differ for various feeding dis orders, the author dis cuss es differential diagnosis, and treatment for each of six feeding disorders . T he res earch diagnos tic criteria presented in this chapter were developed by the author this chapter with the help of a work group of s pecialis ts infant ps ychiatry and ps ychology (supported by the F orce on R es earch Diagnostic C riteria: Infancy and P res chool of the American Academy of C hild and Adoles cent P s ychiatry, 2003).

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Feeding Dis order of S tate C linic al F eatures F eeding disorder of state regulation (T able 41-2) the pos tnatal period and is characterized by irregular, feedings and inadequate food intake by the infant. P.3218 with this feeding disorder exhibit difficulties in state regulation, which interfere with their ability to feed effectively. T hey have difficulty reaching and state of calm alertness neces sary for feeding. S ome irritable and cry exces sively and cannot calm for feeding. Others are too sleepy and cannot wake up stay awake long enough to feed adequately. T he may be anxious , may be depres sed, or may present more s evere psychopathology. Mother–infant during feeding are characterized by irritability and/or sleepiness of the infant, maternal tension, and poor engagement between mother and infant.

Table 41-2 Diagnos tic C riteria for Feeding Dis order of S tate R egulation A. Has difficulty reaching and maintaining a calm state of alertness for feeding; is either too s leepy too agitated and/or dis tres sed to feed. 4136 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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B . T he feeding difficulties s tart in the newborn period. C . S hows s ignificant failure to gain weight or weight loss .

F eeding disorder of state regulation can be s een in without any organic problems, but it is frequently as sociated with prematurity or dysmaturity or gastrointestinal, cardiac, or pulmonary disease.

Differential Diagnos is T his feeding dis order needs to be differentiated from organic disorders that can interfere with the regulation state of the infant. As described previous ly, organic problems can trigger the feeding dis order and s hould always be address ed firs t before making the diagnos is feeding disorder of state regulation.

E tiology and C ours e T here are no empirical studies that have explained why some infants have more difficulty in regulation of s tate than others . However, the foundation for the regulation feedings, which is s o clos ely linked to the regulation of state, is further developed in the firs t months of life. with feeding problems during the early months trigger anxiety in their mothers and frequently continue to difficulty in s elf-regulation of their food intake during the 4137 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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transition to s elf-feeding in the second year of life. Up 70 percent of infants with feeding difficulties and food refusal in the firs t year of life were obs erved to have problems during childhood.

Treatment T reatment needs to be individualized and can be toward the infant, toward the mother, and toward the mother–infant interaction. If the infant tires easily and is unable to take in adequate calories to grow, tube feedings might have to be used to supplement feedings. On the other hand, if the mother is overly anxious , or depress ed, the mother's difficulties to be address ed to enable her to be more effective with her infant. V ideotaping the feedings and obs erving the tape with the mother is frequently helpful to heighten the mother's awarenes s of the infant's cues and to explore alternative methods she can us e to facilitate the infant's regulation of s tate and ability to feed. T homas was 3 months old when he was referred for a ps ychiatric evaluation becaus e of his feeding difficulties and poor weight gain since birth. His parents were educated, and both had pursued their profes sional until T homas was born. Although T homas was full-term and weighed 7 pounds at birth, he had difficulty from the breast. When he was 4 weeks old, his mother reluctantly s witched him to bottle feedings because he was losing weight. Although his intake improved somewhat on bottle feedings, he gained weight very slowly and was still les s than 8 pounds at 3 months of 4138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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His mother appeared tired and described how T homas would drink only 1, 2, or 3 ounces at a time; wiggle and and refuse to continue with the feeding. B ut after a few hours, he might cry again as if he were hungry. she could not s ettle him to feed and he would continue cry inconsolably. T he mother described that s he would attempt to feed him on an average of 10 to 15 times in 24-hour period, that T homas would cry a lot during the day and at night, and that everybody in the family was getting very little s leep. T he observation of mother–infant interactions during feeding and play revealed that T homas was a very and wiggly baby who had difficulty s ettling in his arms. W hile drinking from the bottle he would kick his and move around with his arms , and s oon the nipple of bottle would slip out of his mouth. T his upset him, and started crying. His mother appeared anxious and tried res tart him by changing his pos ition in various ways , this only agitated him more. After repeated attempts to continue the feeding, mother and baby appeared exhausted, and the mother gave up. T he as sess ment revealed that T homas was a very and excitable baby who had difficulty keeping calm feedings. After reviewing the videotape with the the therapist explored ways in which the mother could better facilitate calming during feedings. Us ing a quiet corner in the hous e, s waddling T homas in a blanket singing to him before starting the feeding were the us eful s uggestions . T homas s tayed calm during was able to drink larger amounts of milk, and waited longer between feedings . T his, in turn, relieved the mother's anxiety and helped both to have calmer 4139 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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interactions.

Feeding Dis order of C aregiver– R ec iproc ity C linic al Features F eeding disorder of caregiver–infant reciprocity (T able 3) is characterized by a lack of engagement between mother and infant, leading to inadequate food intake growth failure of the infant. T he onset of the growth is us ually between 2 to 8 months of age. T he infant lack of age-appropriate social res ponsivity—e.g., lack smiling res pons e, lack of vocal reciprocity, lack of anticipatory reaching out when about to be picked up, lack of molding and cuddling when held. T he mother frequently pres ents with acute or chronic depress ion, or alcohol abus e, and/or high ps ychos ocial stress , appear to interfere with her care of the infant. Mother– infant interactions are characterized by a lack of mutual engagement and lack of pleasure in their relations hip. mother frequently appears detached and in her respons es to the infant's cues .

Table 41-3 Diagnos tic C riteria for Feeding Dis order of C aregiverInfant R ec iproc ity A. S hows lack of developmentally appropriate of s ocial reciprocity (e.g., vis ual engagement, 4140 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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smiling, or babbling) with the primary caregiver during feeding. B . S hows s ignificant growth deficiency. C . T he growth deficiency and lack of relatednes s not due solely to a phys ical dis order or a developmental disorder.

P.3219

Differential Diagnos is F eeding disorder of caregiver–infant reciprocity needs be differentiated from organic conditions that lead to a lack of weight gain and weakness of the infant. mother and infant usually s how better mutual engagement, and the infant res ponds more readily to examiner.

E tiology and C ours e F eeding disorder of caregiver–infant reciprocity has referred to in the literature as “maternal deprivation” or “deprivation s yndrome.” It has been pos tulated that emotional nurture and infrequent feedings lead to the growth failure and developmental delays of thes e C haracteris tically, infants with this feeding dis order become engaging and gain weight when admitted to hospital and are in the care of a nurturing nurse. 4141 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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T his feeding dis order has also been referred to as “nonorganic failure to thrive,” and in the DS M-III, this disorder was defined as “reactive attachment disorder infancy” as sociated with failure to thrive. However, in DS M-IV , the s ame diagnosis was changed to only problems in relatednes s without growth failure. S everal studies of infants with the diagnosis of “nonorganic failure to thrive” have demons trated very high rates of insecure attachment, ranging from 50 to percent of the infants studied. However, not all infants with ins ecure attachment are failing to thrive. It appears that only a s evere degree of a dis turbance in the attachment process of the infant to the caretaker or, as what some authors des cribe as “nonattachment,” the severe disturbances in relatedness and growth seen in infants with this feeding dis order. C hildren with a feeding disorder of caregiver–infant reciprocity are at high ris k for delayed cognitive and disturbed emotional development. W hen followed up to school age, deficits in cognitive performance, organization, ego control, ego res iliency, and symptoms have been reported.

Treatment Depending on the severity of the growth deficiency and the evidence of neglect, various interventions have suggested. In cases of no evidence of deprivational behavior on the part of the mother or if the parents sought medical care in the pas t and have some the extended family or the community, an outpatient approach may be safe. However, if the growth more s evere, if there is s erious hygiene neglect, if the 4142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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mother is abus ing drugs or alcohol, or if the mother chaotic lifestyle, immediate hospitalization is indicated. During the hospitalization, it is critical to as sign a warm and nurturing nurse to engage the infant during While the nutritional, emotional, and developmental rehabilitation of the infant takes place, a more in-depth evaluation of the mother and the mother–infant relations hip needs to be address ed as well. Many of mothers have experienced unsatis factory relationships with their own caretakers when they were growing up, and, cons equently, they are dis trus tful and avoidant of profes sionals. It is important to identify any positive behavior the infant s hows toward the mother to see whether the mother has any potential to engage in a mutually satis fying relations hip with her infant. In the mother's support system and her ability to become engaged with a therapis t need to be explored before returning the infant to her care. In s ome situations of severe neglect and ass ociated abus e, protective need to be involved, and the infant has to be placed in fos ter care. Dis charge from the hos pital is a critical time when all services need to be in place to ensure follow-through of the treatment plan. T he treatment plan should be individualized and may range from home vis its by a care profes sional, day care for the infant, and mother– infant ps ychotherapy to family therapy for the parents . Anna was 8 months old when s he was admitted to the hospital through the emergency department because of res piratory tract infection and s evere failure to thrive. she had recovered from the infection and a medical 4143 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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workup for her malnutrition was negative, a psychiatric cons ultation was reques ted. After repeated attempts, the psychiatrist finally reached the parents set up an appointment to obtain more his tory and to observe mother and infant during feeding. T he parents explained that the father had difficulty obtaining time off from his construction job and that the mother did not any means of transportation to the hospital. T he couple was not married because the father had not gotten his divorce from his firs t wife, but they lived together with Anna in one room in a hous e that they shared with nine other members of the father's extended family. T he mother, who became pregnant with Anna during last year in high school, described Anna as a quiet and denied any feeding problems . However, when the mother temporarily left the room, the father turned to therapist and complained that the mother did not give enough attention to Anna, that s he would talk on the phone or read from a magazine while feeding the baby. T he observation of mother and infant during feeding revealed that the mother looked sad and preoccupied while s he held the baby loos ely on her lap. T he infant a “surrender position” with her arms raised beside her head, and she looked away while drinking from the However, when s he looked at her mother, the mother looked away as if she could not stand to have eye with her infant. F urther evaluation of the mother revealed that s he felt very lonely and depres sed. S he was unable to finis h school becaus e of the pregnancy with Anna. Her family had abandoned her for becoming involved with a man. S he described the father's family as hos tile 4144 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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her. T he baby's father worked long hours and was around. T he telephone calls the mother made to her girlfriends from high school were the only relief in her unhappy life. During the hospitalization, Anna gained weight, more engaged, and rewarded her favorite nurse with frequent smiles. After the s ocial worker had arranged transportation for the mother, she came regularly for appointments with the social worker and s pent more with Anna. While nurturing the mother and trying to her work on her s ituation with her own family and the father's family, the social worker als o s pent time with mother and infant during play. S he would point out how the baby was making progress , how she was trying to her mother's attention, and how she had that s pecial for her mother. After 4 weeks in the hos pital, Anna s eemed stronger, her mother s eemed committed to continue working with the social worker. T he hos pital s taff felt comfortable discharging Anna. W hile at home, a vis iting nurse the home twice a week to check on mother and infant, the mother vis ited weekly with Anna at the hos pital to the social worker. After 6 months , the visiting nurse less frequently, but the mother and Anna s tayed in treatment with the s ocial worker for another year when both s eemed engaged and comfortable with each P.3220

Infantile A norexia C linic al Features 4145 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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Infantile anorexia (T able 41-4) is characterized by food refusal of the infant, leading to inadequate food intake acute and/or chronic malnutrition. T he food refus al of infant usually begins or worsens between 9 and 18 of age, during the trans ition to s poon- and s elf-feeding. T he food refusal of the infant may vary from meal to and with different caretakers . T he infant may drink from the bottle or from the breast and primarily refus e s olid food. Mos t parents report that thes e infants s how any s ignals of hunger and s eem more interested in exploring and playing than in eating. T he food refusal the infant causes intens e anxiety in the mother or both parents . Us ually, the parents resort to coaxing, bribing, distracting, and offering different foods at all times . W hen desperate, they may res ort to threatening force-feeding. Obs ervation of mother–infant during feeding revealed that mothers and infants with feeding disorder engage in more conflict and s truggle control during feeding and use more talk and during feeding than mothers and infants without problems .

Table 41-4 Diagnos tic C riteria for Infantile Anorexia A. R efusal to eat adequate amounts of food for at least 1 month. B . Ons et of the food refusal before 3 years of 4146 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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C . Does not communicate hunger signals, lacks interes t in food, but s hows strong interest in exploration and/or interaction with caregiver. D. S hows s ignificant growth deficiency. E . T he food refus al did not follow a traumatic F . T he food refus al is not due to an underlying medical illnes s.

T his feeding dis order interferes with the development somatops ychological differentiation, the ability to differentiate phys iological s ens ations of hunger and satiety from emotional feelings and needs —e.g., of anger and the need for affection. T he mothers are us ually so anxious that they offer food, the bottle, or at any time, regardles s of whether the infant is hungry distress ed. F requently, the infants refus e to eat if they cannot have their way, if they cannot get out of the high chair, or if they are not offered the food they want. or not eating becomes increasingly controlled by the interactions between the infant and the instead of internally by feelings of hunger and fullness .

Differential Diagnos is Infantile anorexia needs to be differentiated from other feeding disorders that are characterized by food T he posttraumatic feeding disorder usually has a more 4147 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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sudden onset of the food refus al after a traumatic event the oropharynx or gastroes ophageal tract—e.g., severe gagging or vomiting, or the insertion of feeding endotracheal tubes. T he infant with a pos ttraumatic feeding disorder may refuse all food, or only s olid food, only the bottle, depending on what mode of feeding the infant ass ociates with the traumatic experience(s). with sensory food aversions consistently refuse specific foods but eat well if offered preferred foods. Infants feeding disorder ass ociated with a concurrent medical condition us ually start feeding without difficulty until experience distress s econdary to their medical illnes s, then they refus e to continue feeding.

E tiology and C ours e No s ys tematic data on the etiology and course of anorexia are available at this time. S tudies from which infants with food refusal in the firs t year of life followed up to s chool age showed that 70 percent of children continued to have feeding problems at 4 years age, and, by 6 years of age, the eating problems were noted not only in the home but in the school as well. A follow-up study by the author of 20 children, 6 months years after they had completed treatment, that 17 children had changed considerably. T he conflict the parent–child relationship over the child's food was completely gone. T he children had learned to recognize hunger and increased their food intake, led to weight gain and improved growth. However, the parents reported that many of the children continued to lose their appetite when they were excited, if they had houseguests , if they had a birthday party, or if they traveled. Once they calmed thems elves , they would 4148 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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their appetite and usually make up for the lost meals . T here were three children who continued to struggle their parents over their poor eating. In two cas es , day seemed to be too stimulating to allow these children to relax enough for eating. In the third case, the home situation was very overcrowded and disorganized. In the author's clinical experience, children who have untreated and who pres ent for the first time with the diagnosis of infantile anorexia during s chool age are us ually thin and short for their age. However, their size and their intellectual development appear normal their chronological age.

Treatment T he author has developed a treatment model that is on a transactional model for the development of anorexia. According to this model, the infant's difficult temperament characteristics of emotional intensity, stubbornness , lack of hunger cues , irregular feeding, sleeping patterns evoke conflicts over is sues of control, autonomy, and dependency in vulnerable parents who insecure with regard to limit s etting. T he treatment addres ses the infant's temperament and the parents ' anxiety with regard to limit s etting to facilitate internal regulation of eating by the infant. 1. T he infant's temperament is discus sed with the parents to help them understand that the infant's curios ity and emotional intens ity interfere with the infant's awarenes s of hunger. B ecaus e the infant is strong-willed and has learned that food refusal is a powerful tool to control the parents ' attention, 4149 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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by the parents to dis tract or entertain the infant to him or her to eat only perpetuate the problem by getting the infant more exited. 2. T he parents ' source of anxiety with regard to limit setting is explored. S ome parents have been by previous los ses of pregnancies, by infertility problems , or by the harshnes s and/or emotional unavailability of their own parents. Understanding parents ' sensitivity in regard to limit s etting is critical help them to be more effective in this area with infant. 3. After this groundwork has been laid, the parents trained with res pect to changing their behavior to facilitate internal regulation of eating by their infant. T o boost the infant's biological rhythms of hunger satiety, the parents are encouraged to feed the only at regular 3- to 4-hour intervals and not to offer anything but water in between thes e regular T hey are helped to understand that it is important encourage the infant's s elf-feeding by commenting the infant's feeding skills (“you get the s poon in mouth all by yourself”), but they are not to comment on how much or how little the infant eats . T he infant has to learn to regulate his or her food intake by his her internal signals of hunger and satiety. E ating should not be a performance for the parents . T here should be no dis tractions during feedings and no television or games s o that the infant is kept on eating. If the infant engages in inappropriate behaviors during feeding (climbing out of the high chair, throwing food P.3221 4150 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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or feeding utensils) the parents need to learn to us e the “time-out” procedure. T his three-step intervention with the parents is bes t accomplis hed in double sess ions lasting 2 hours each grouped clos e together within a few weeks . T he of this brief intervention facilitates a close therapeutic alliance between the therapis t and the parents and enables many parents to make major shifts in their interactions with their infants . Many of thes e parents only a few follow-up sess ions to deal with some questions that may arise. F requently, after the infant changed his or her eating pattern, the parents as k for concerning the s leeping problems many of these have as well. However, there are some families who more deeply entrenched in maladaptive interactional patterns with their infants, and some infants are s o severely malnouris hed that more intensive or hos pitalization may be required. R achel was 18 months old when s he was referred by pediatrician because of food refus al and malnutrition. mother looked exhausted as she described how had never been a big eater from birth but that s he in the 25th percentile for weight and height on the chart until s he was approximately 10 months of age. refusal to be fed by s poon became s o s trong that her intake of solid food became less and less . S he primarily on bottles with milk for her nutrition. In spite of all of the parents' efforts to distract R achel during to offer different foods, and to feed her whenever s he would accept anything (including at night) and their 4151 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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desperate efforts to force food into her mouth, R achel's food refusal had become worse, and s he had fallen the fifth percentile on the growth chart for weight and height. T he mother admitted that trying to feed R achel had taken over her entire life and that she felt and envious when she watched her friends' children without any effort on the part of the parents . T he observation of mother and infant during feeding play revealed that R achel was a thin little girl who “all eyes ,” observing everything in the room, including pictures on the wall and her image in the mirror. B ut paid little attention to the food. S he ate s ome finger but refused to open her mouth and arched her back her mother tried to feed her by s poon. After a few she appeared bored sitting in the high chair, threw the food, and indicated by grunting that s he wanted to be taken out of the chair. Once she had her freedom, s he around the room entertaining herself by exploring the furniture while her mother sat in her chair looking and defeated. T he treatment addres sed R achel's s pecial characteristics , her intens e curiosity and emotional intens ity, her strong will, and her poor awarenes s of hunger, which s eemed to have led to her increasing refusal. T he parents were helped to unders tand that had a child with s pecial temperament characteristics required special parenting with special emphasis on setting. T hen specific ins tructions were discus sed on to handle mealtime, how to deal with R achel's food and how to use “time-out” with a young child. Although the mother struggled initially with how to s et limits to R achel's inappropriate behaviors —e.g., 4152 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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her from throwing food and keeping her in the high chair—the parents supported each other in the new feeding ins tructions and were pleas ed with the change in R achel's behavior. Once R achel realized screaming did not change the rules , she s tayed in the chair without protes t and became interested in feeding herself with the spoon. W ithin a few weeks , s he more aware of hunger, and her food intake increased accordingly. When s een for follow-up a year later, there was no more conflict over R achel's eating. R achel had gained weight and grown in length, which brought her back to the tenth percentile on the growth chart.

S ens ory and F ood A vers ions C linic al Features S ensory food avers ions (T able 41-5) are common. However, whereas s ome children refus e to eat only a specific foods , others may refus e most foods and take only a limited diet of a few foods . T he diagnosis of a feeding disorder s hould be made only if the food selectivity res ults in nutritional deficiencies, and/or has to oral motor delay.

Table 41-5 Diagnos tic C riteria for S ens ory Food Avers ions A. C onsistently refuses to eat specific foods with specific tastes , textures , and/or s mells . 4153 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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B . Ons et of the food refusal during the of a different type of food (e.g., may drink one of milk but refuse another, may eat carrots but green beans ; may drink milk but refuse baby C . E ats without difficulty when offered preferred foods . D. T he food refus al caus es specific nutritional deficiencies or delay of oral motor development.

Within this disorder, food refusal is related to the taste, texture, or smell of particular foods . When the infant is specific foods , the infant's avers ive reactions range grimacing, s pitting the food out, and wiping the tongue mouth to gagging and vomiting. After an initial aversive reaction, the infants usually refus e to continue eating specific food. In addition, infants tend to generalize and refuse to even try foods of s imilar color, appearance, or smell. Occas ionally, s ensory food avers ions become apparent in the newborn period when the infant is switched from breas t milk to formula or from one to another. However, most commonly, infants begin to show avers ive reactions when introduced to baby with different flavors and different textures or in the second year of life, during the introduction of different table foods. After the initial avers ive reactions , s ome infants s how s uch intens e food refus al that they limited to eating only a small variety of foods . T hey 4154 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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refuse to eat whole food categories , such as fruits, or meats. In extreme cas es, they even may eat a preferred food if it touched a “feared” food on the plate or if the food is not prepared by a specific or company. C hildren who refuse to eat vegetables and fruits usually develop vitamin deficiencies , and children who refuse to drink milk or eat meats may develop zinc, and/or iron deficiencies. In addition, children who refuse to eat foods that require more chewing—e.g., and hard vegetables or fruits—present with delay in motor development that may be ass ociated with articulation difficulties. In addition to their sens ory food aversions , many of children experience hypersensitivities in other sensory areas as well. P arents frequently report that thes e do not like to get their hands “mess y”; become when as ked to walk on grass or sand; and do not like wear socks or s hoes, certain fabrics , or labels on Many of thes e children are also hypersensitive to and s ome may have difficulty with loud s ounds.

Differential Diagnos is T his feeding dis order needs to be differentiated from oppos itional food refus al, which is common during the toddler years. T oddlers who like to exercis e control their parents may state that they do not want to eat a certain food and demand s omething els e to eat. the food choices of oppos itional toddlers are and vary according to the mood of the toddler, whereas toddlers with s ens ory food aversions are us ually in their food choices, and they become dis tres sed the parents insis t that they eat a certain food that is 4155 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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avers ive to them. P.3222 S ensory food avers ions als o need to be differentiated a pos ttraumatic feeding dis order, which is the child's refusal to eat all solid food or to drink from bottle, depending on what mode of eating the child as sociates with the traumatic event(s).

E tiology and C ours e No empirical s tudies have examined the etiology of sens ory food avers ions in young children. However, res earch with older children and adults has related tas te sensitivities to strong food preferences and to the number of taste buds on the individual's tongue (thos e with strong taste s ens itivities , the “super tas ters,” have significantly more tas te buds than “nontas ters ”). S ome studies have documented that parents and their children can share taste sensitivities, and various heritability—e.g., incomplete penetrance, a two-locus model, and multilocus and multiallele models —have suggested. In addition, certain aspects of the eating environment have been linked to the development of preferences —e.g., parents with strong tas te may offer a res tricted range of food to their children, limited exposure to a variety of foods may enhance the toddlers' food s electivity. T here are no longitudinal data available outlining the cours e of this feeding dis order. A s mall follow-up study the author of 46 children (8 to 10 years of age) who been part of a larger survey of 1,500 toddlers indicated that approximately one-third of the children who were 4156 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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res tricted in their food choices as toddlers continued to only a res tricted number of foods during school age. children with s ens ory food avers ions may experience social anxiety and try to avoid s ocial activities (parties, sleep overs , s ummer camp) that involve eating. children with s ens ory food avers ions often report that were unable to eat a variety of foods as young children and that they learned to eat new foods primarily during their adolescent or young adult years , when they to fit in with their peers .

Treatment R es earch by Leann B irch and colleagues indicates that repeated exposures to new foods enhances young acceptance not only of that food but also of other foods . However, toddlers required more than ten expos ures of the same new foods until acceptance was reached. In addition, it is very difficult to get toddlers to new foods if they are reluctant to do so. B irch and colleagues demons trated that coercive techniques— threatening children to s it at the table until they finish eating everything on their plate or depriving them of certain privileges unless they try the new food—have a significant negative effect. On the other hand, toddlers very respons ive to modeling by their parents. T hey are more willing to try a new food if they observe their eating it but do not offer the food to them. B ecaus e no empirical s tudies have s ys tematically examined how to best treat infants and young children with sensory food aversions , clinical experience by the author sugges ts that if infants or toddlers s how s trong avers ive reactions to a new food—e.g., gagging or 4157 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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vomiting—the parents are bes t advised to give up on having the child eat this food. On the other hand, if the infant jus t grimaces or spits out the food, the parents expos e the infant to the new food at another time and a s mall amount of the avers ive food with a preferred A gradual increase of the avers ive food over several may allow the infant to get used to the new food. Modeling eating new foods by the parents and waiting until the toddler asks to try a new food seem more effective than putting new foods on the toddler's plate and reques ting the toddler to try them. If the parents neutral as to whether the toddler likes the requested or not, toddlers remain neutral as well and do not to become scared of trying new foods . Once children to try new foods , their diet becomes more and more limited, and by 3 years of age, mos t young children are swayed by what their parents eat. Occas ionally, children may be willing to try new foods in a pres chool setting, but, more often, they become anxious in s ocial situations and try to avoid eating with others . J ohn was brought for an ass es sment by the multidis ciplinary feeding disorders team because he refused to eat vegetables , fruits , and meats . His had s tarted to give him a multivitamin daily, but they worried that he was miss ing other es sential nutrients in limited diet, and they were concerned that his was so poor that nobody outside of the family could unders tand what he was s aying. At the age of 2½ daily diet cons is ted of C heerios or pancakes in the morning, peanut butter sandwiches , some cheese had to be American chees e), pasta, cake, crackers , ice cream, and milk during the rest of the day. His feeding 4158 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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problems started when he was introduced to baby He accepted baby food sweetened with fruit but when given baby food with vegetables and spat it out. gagged when introduced to baby food with lumps of meat, and he refus ed to accept any baby food after 9 months of age, J ohn was offered s oft table foods , he ate only if he could finger feed hims elf. He had episode of gagging when introduced to green beans at months of age and consequently refused to touch any green vegetables and fruits. He never tried any meats , he became very distress ed when his parents put any on his plate that he did not want. W hen his parents insis ted that he should at leas t try one bite of a new before he could get off from the table, J ohn cried throughout the whole meal and ate nothing, not even preferred foods. T he parents had strong disagreements about how to handle J ohn's food refus al. T he father similar food dis likes as a child and wanted to leave him alone. T he mother was very concerned about J ohn's because of his limited diet, and s he tried everything bribing, coaxing, distracting, and threatening, jus t to get J ohn to try new foods . B oth parents experienced as very s tres sful, and believed that J ohn was becoming increasingly rigid about his food likes and dis likes . T he observation of feeding revealed intense conflict between J ohn and his mother regarding the various he refused to eat. T he nutritional as sess ment s howed although J ohn was taking in adequate calories, he was getting enough zinc and iron from his diet, and without the multivitamin, his diet was deficient in vitamins . T he oral motor ass es sment revealed that J ohn us ed an immature chewing pattern that was believed to be due 4159 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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his lack of practice with chewing crunchy and chewy foods . T his oral motor delay was believed to account his articulation problems. T he parents were ins tructed to obtain vitamins with zinc and iron to compens ate for the nutrients in J ohn's diet. T hey were also offered speech therapy J ohn to help with his articulation problems . In addition, the parents were given a few parent training sess ions help them to emotionally neutralize mealtime. After the mother's anxiety about J ohn's health was alleviated, was able to offer J ohn his preferred foods without attempting to get him to eat new foods. T he parents instructed to eat their regular diet in front of J ohn offering him any of their food and to give him only a piece of their food if he were to ask for it. T hey were praise him if he liked the food nor become dis appointed he did not want to have it any more. After having offering J ohn any new food for approximately 2 J ohn surprised his mother by as king her to have s ome her peach. He liked it and asked for more on another G radually, he began to eat s oft fruits without the peel, after s everal months , he tried chicken nuggets. His diet increased in variety very s lowly, and when he entered preschool, he tried a number of foods at s chool that he had not touched at home. His diet became more However, J ohn was not able to eat the variety of foods res t of his family enjoyed. P.3223

P os ttraumatic F eeding Dis order 4160 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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C linic al Features P os ttraumatic feeding dis order (T able 41-6) may with total food refus al, refus al to s wallow solid food, or refusal to drink from the bottle depending on what kind feeding the infant ass ociates with the traumatic event. onset of the food refus al is frequently rather s udden follows traumatic experiences that involve the or gastrointestinal tract—e.g., s evere gagging, choking, vomiting, insertion of feeding or endotracheal tubes , or force-feeding. F requently, the parents are not aware the event was s o frightening to the infant that it the food refusal because other infants who may the same experience do not necess arily develop a posttraumatic feeding disorder. It appears that infants develop a pos ttraumatic feeding disorder are more to anxiety and/or are more s ens itive to pain than the average infant. Older children who refused to eat solid food after an incident of gagging or choking reported they were afraid that the food would get stuck in their throat and choke them to death. Infants and young children express this fear through their behavior by in anticipation of being fed, when seeing the highchair, the bottle, or the s poon. S ome infants or children are enough to put the food in the mouth but cannot bring thems elves to s wallow it. T hey keep the food in their cheeks and/or s pit it out. In severe cases , the infants to feed all together. T hes e infants are in acute danger dehydration because the fear of eating appears to any awareness of hunger or thirs t.

Table 41-6 Diagnos tic C riteria for 4161 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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Pos ttraumatic Feeding Dis order A. F ood refus al follows a traumatic event or traumatic ins ults to the oropharynx or gastrointestinal tract (e.g., choking, severe reflux, insertion of nasogas tric or endotracheal tubes , suctioning) that trigger intens e distress in infant. B . C onsistent refusal to eat manifests in one of following ways:    1. R efuses to drink from the bottle, but may food offered by spoon. (Although consistently refuses to drink from the bottle when awake, may drink from the bottle when sleepy or asleep.)    2. R efuses s olid food, but may accept the    3. R efuses all oral feedings . C . R eminders of the traumatic event(s) caus e as manifested by one or more of the following:    1. S hows anticipatory dis tres s when positioned feeding.    2. S hows intense resistance when approached bottle or food. 4162 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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   3. S hows intense resistance to s wallow food in the infant's mouth. D. T he food refus al poses an acute or long-term threat to the child's nutrition.

Often the food refusal of thes e infants is s o intense that parents react with s evere anxiety to the infant's food refusal. T hey worry about the infant's nutrition. they try to coax and dis tract the infant, they offer types of food, and they try to feed the infant day and without success . However, s ome very young infants are afraid to drink from the bottle when they are awake may drink when they are as leep and not aware of what they are doing. However, if they wake up and s ee the bottle, they usually push it away and cry. In general, food refusal of these infants pos es an acute threat to health, and they require acute intervention.

Differential Diagnos is T his feeding dis order needs to be differentiated from infantile anorexia and from food refusal because of food avers ions. Infantile anorexia is characterized by inconsistent pattern of food refus al depending on the mood of the infant. Anorectic infants are not afraid to and can eat all types of food if they want to eat. food avers ions usually involve foods with a certain texture, and/or smell. Usually, the food refus al is more 4163 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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selective and not as global as s een in a posttraumatic feeding disorder.

E tiology and C ours e T he observation of infants with a posttraumatic feeding disorder reveals that their food refusal s eems to be by fear. However, no empirical s tudies have been done explain why only some infants with distress ing experiences to the oropharynx react with a feeding disorder. Also, no systematic longitudinal data the cours e of this feeding disorder are available. individual cas e s tudies indicate that many infants and children become locked into their fears of eating. S ome drink milk from the bottle and eat pureed food only until they reach school age, when the s ocial embarras sment their eating behavior causes the parents to seek help. extreme cas es, when the infants refus e all food, gastrostomy feedings have to be implemented. T o some of thes e children depend on gastrostomy for years.

Treatment B ecaus e of the complexity of many of thes e cas es, particularly those that res ult from trauma inflicted by unavoidable medical procedures (e.g., intubation, suctioning), a multidis ciplinary team cons is ting of a pediatrician or gas troenterologist, nutritionis t, occupational therapist, and ps ychiatrist is best to meet the needs of thes e infants. In cases of total refusal, the infant is in acute medical danger of dehydration, and intravenous fluids need to be given. It important to as sess whether the infant might be coaxed 4164 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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into accepting any form of food or whether nasogas tric tube feedings need to be ins tituted. T he ins ertion of feeding tubes can intens ify the fear of feeding, and, if this is the case, the infant is better s erved by a gastrostomy tube. In any case, the infant's nutritional requirements mus t be addres sed before the implementation of the ps ychiatric treatment. T he ps ychiatric treatment of patients who exhibit total partial food refus al centers on the desensitization of the infant to the fear of eating. B ehavioral techniques of positive reinforcement of food acceptance and negative reinforcement of food refus al are instituted in the initial management of these infants. E ncouragement of selffeeding is frequently helpful for thes e infants to gain mastery over the anticipatory anxiety of eating. W hen infant begins to accept food from the s poon, it is important to proceed s lowly when advancing the of food to avoid any incident of gagging, which may s et back the infant. T he behavioral manipulation of the infant's eating frequently leads to external regulation of eating in respons e to the reinforcers. Once the infant overcome the fear of eating, it is important to phase out the external reinforcers and to encourage eating to internal signals of hunger and s atiety. T he same principles described above in facilitating internal regulation of eating in infants with anorexia should also applied in this final s tage of the treatment. R obert was 7 months old when he was referred by a gastroenterologis t for an urgent ps ychiatric evaluation because of s evere crying when offered the bottle and refusal to drink unles s he was almost fully asleep and 4165 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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seemed unaware of his feeding. T he mother reported R obert was an 8-pound, full-term baby who had a suck and was feeding well from birth. However, after a weeks he s tarted to spit up during and after feedings, by 3 months he developed projectile vomiting. In s pite the vomiting, he gained weight until he was about 4 months of age, when he was referred to a gastroenterologis t and diagnosed with reflux. S everal P.3224 medications were tried; however, the vomiting and by 6 months of age R obert s tarted to arch hims elf during feedings as if he were in pain. He would cry and refuse to continue with the feeding. S oon afterward, the mother noticed that he would s tart to cry at the s ight of the bottle, and he refus ed to accept the bottle totally as long as he was awake. T o s tave off starvation, the relied on feeding him during the night when he was as leep. His food intake greatly diminished, and he to lose weight. T he mother tried to introduce s olid food, but R obert seemed to have difficulty moving the food to his throat and s pit most of it out. At the time R obert referred, his mother was exhaus ted and frightened because of R obert's continued weight los s. A recent examination by the gas troenterologist had s hown that reflux was markedly improved and that R obert's feeding difficulties could not be explained by his condition. T he observation of mother and infant during feeding revealed that R obert became dis tres sed the moment mother pos itioned him for feeding, and he started to cry 4166 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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and arch hims elf as soon as he s aw the bottle. His put the bottle away and tried to comfort him, but it took more than 10 minutes until he could settle in her arms . When the mother got the bottle and tried to feed him again, he cried even louder and would not be calmed the bottle was out of his s ight. B ecaus e it was obvious R obert was too frightened to feed from the bottle, the mother tried to feed him in his infant seat with the but he batted the s poon away and did not want to have anything put in his mouth. As the firs t step of treatment, the parents were made aware that infants as young as R obert can make as sociations between pain, vomiting, or other dis tress feeding and cons equently become frightened of T he parents were ins tructed to get R obert on a regular naps and to feed him from the bottle only when appeared almost asleep to prevent any further of his fears while looking at the bottle. After a attempt at the hos pital to feed R obert in the highchair with a s poon in his hand and lots of encouragement to it in his mouth, the mother was able to us e another and put some food in R obert's mouth. C ons equently, was encouraged not to focus on the amount of food was able to get into him but to look at the feedings as practicing s ess ions to help R obert overcome his fear of feeding and to develop oral motor skills that would him to handle solid food. In the firs t 2 weeks , R obert would cry and refus e to continue feeding if he woke up and saw the bottle. However, gradually he seemed to realize that it was drink from the bottle. T he mother reported that after 4 weeks, she could even s tart the bottle feeding when 4167 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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R obert was still awake. R obert als o progress ed quickly from accepting very little food from the tip of the spoon eating up to s everal spoonfuls . After 3 weeks, R obert eating a whole jar of baby food at one meal. W hen was 9 months old, the mother called to report that was feeding and thriving well.

Feeding Dis order A s s oc iated with C onc urrent Medic al C ondition C linic al Features S ome medical conditions are not readily diagnos ed, food refusal may be the leading symptom (T able 41-7). example, food allergies can be difficult to diagnos e in infants, and “silent” gastroesophageal reflux without vomiting can be overlooked because vomiting is the leading s ymptom that alerts pediatricians to this condition. T ypically, infants with reflux can drink 1 to 2 ounces until the reflux becomes activated. However, reflux occurs , the infants experience dis tres s and may cry, and refuse to continue feeding. S ome infants can calmed and resume feeding, but others may become increasingly agitated while their caretakers continue to offer the bottle or food. Infants with respiratory distress may feed for a while and take a few ounces until they out and stop feeding. In general, the feeding difficulties these infants lead to inadequate food intake, failure to weight, or loss of weight.

Table 41-7 Diagnos tic C riteria for Feeding Dis order As s oc iated 4168 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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C onc urrent Medic al C ondition A. R eadily initiates feeding but s hows dis tres s the cours e of feeding and refus es to continue feeding. B . Has concurrent medical condition that is to cause the dis tres s. C . Medical management improves but does not alleviate the feeding problem. D. F ailed to gain adequate weight or may even weight.

Differential Diagnos is T his feeding dis order needs to be differentiated from feeding disorders characterized by food refusal—e.g., infantile anorexia, s ens ory food avers ions, and posttraumatic feeding disorder. W hat helps in unders tanding this feeding disorder is the observation feeding that reveals that the infant initiates feeding without difficulty and that mother and child engage in pleas ant reciprocal interactions until the infant experiences dis tres s and stops feeding.

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F ailure to thrive of infants and young children was believed to be caus ed by either organic or nonorganic caus es (e.g., maternal deprivation). In 1981, C harles and S tephan Ludwig described a third category of to thrive that is caused by a combination of various organic and nonorganic problems . S ince then, it has accepted that organic conditions can be complicated ps ychological difficulties and lead to severe feeding problems and growth failure. However, although many young infants experience gastroes ophageal reflux, only small percentage develop s econdary s evere feeding difficulties . C linically, thes e infants appear particularly and s ens itive. However, no empirical studies have done to explore why these infants develop severe reactions to their reflux, whereas others hardly seem bothered by it. Only a few studies have been reported on the follow-up these infants. F ortunately, modern technology allows gastric tube feedings over a long time to safeguard the survival of thes e children. However, the regulation of feedings is often very difficult, and even after the condition has been success fully treated, it may take months or even years until the child learns to eat independently.

Treatment B ecaus e of the interaction of organic and ps ychological factors contributing to the s evere feeding difficulties of these children, collaboration between the pediatrician pediatric specialist and the psychiatrist is critical. medical treatment of the child's illnes s is necess ary ps ychological interventions can be success ful. Direct 4170 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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observation of infants with their primary caregiver feeding is most helpful to monitor how well the medical condition is res ponding to the treatment. In addition, observations during feeding can guide the therapis t in helping the parents to develop more appropriate strategies that allow infants to calm instead of their distress during feeding. However, in s ituations in which the medical illnes s cannot be adequately treated and the infant continues to experience dis tres s during feedings, supplemental nutrition through nasogastric or gastrostomy tubes mus t be considered. T hen, the must work with the parents to maintain P.3225 the infant's oral feeding skills while most of the nutrition given via tube feedings . T he parents need to learn to the infant to the point of discomfort but not beyond it. R eviewing the videotape of the infant's feeding and discuss ing the infant's cues with the parents is us ually helpful in sorting out how to best feed the infant. In general, these are very difficult cases that require individualized attention by an experienced multidis ciplinary team. S arah was 6 months old when s he was referred by her pediatrician to the multidis ciplinary feeding disorders team becaus e of severe food refusal and poor growth. mother reported that, since birth, S arah occasionally up” a little during and after feedings, but during the last weeks she had become increasingly difficult to feed. Usually, s he took an ounce or two of her formula, and she s tarted to arch, and s he pus hed the nipple out from 4171 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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her mouth. If the mother tried to continue feeding she cried and became increasingly agitated until the mother picked her up and comforted her by holding her on the mother's shoulder and walking her. S ometimes after 10 to 20 minutes , the mother could resume S arah, but often, S arah started to cry again after from the bottle for a few minutes only. In s pite of the mother's efforts to feed S arah every 2 hours, S arah only half of the formula that s he was s upposed to take for her age, and, in recent weeks , s he had s tarted to weight. T he observation of feeding revealed pleasant mother– infant interactions at the beginning of the feeding, but after a few minutes of s uckling, S arah pus hed the the bottle out of her mouth, arched her back, and to cry when the mother tried to get her back to feeding. T he harder the mother tried, the more agitated S arah became, and mother and baby looked very dis tres sed gave up feeding. T hes e feeding interactions raised concerns that S arah experienced gas troes ophageal that caus ed her pain and interfered with her feeding. F urther medical testing confirmed the diagnosis of moderate gastroes ophageal reflux, which was surpris ing to the pediatrician and the gas troenterologist because S arah had not shown any vomiting, the most common symptom of reflux. S arah was treated with medications for reflux, and her food intake doubled quickly. However, if she drank than 3 or 4 ounces at a time, the s ymptoms recurred. However, once the mother understood the reason for S arah's food refus al, she learned to ease S arah's difficulties by thickening the formula and feeding her 4172 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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smaller amounts at more frequent intervals . G radually, S arah tolerated larger amounts of formula at each and at 15 months of age, s he was found to have the gas troesophageal reflux.

R umination Dis order C linic al Features S ome infants can be observed to put the thumb or the whole hand in the mouth, to suck their tongue rhythmically, or to arch the back to initiate regurgitation. However, s ome infants ruminate when left alone, after they have been placed in the crib to s leep (T able 41-8). T hey are frequently found in a puddle of vomitus , which then falsely attributed to s ome organic problem. T he type of rumination is most commonly observed in who have received little emotional stimulation and who have learned to s timulate and s oothe thems elves rumination. Although, initially, mos t of the regurgitated food is vomited, some infants gradually learn to hold of the food in the mouth, to rechew, and to reswallow it. “E xperienced” ruminators are able to bring up the food through tongue movements and res wallow it without losing any of it. T heir rumination can be discovered observing the movements of their cheeks and the foul odor.

Table 41-8 DS M-IV-TR Diagnos tic C riteria for R umination Dis order

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A. R epeated regurgitation and rechewing of food a period of at least 1 month after a period of functioning. B . T he behavior is not due to an as sociated gastrointestinal or other general medical (e.g., es ophageal reflux). C . T he behavior does not occur exclusively the cours e of anorexia nervosa or bulimia symptoms occur exclus ively during the cours e of mental retardation or a pervasive developmental disorder, they are sufficiently severe to warrant independent clinical attention.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. American P sychiatric As sociation, Was hington, DC , 2000, with permiss ion.

Differential Diagnos is R umination needs to be differentiated from vomiting secondary to organic conditions . B ecaus e reflux and rumination frequently coexist, it is important to observe the infant in different situations to actually s ee the initiation and the rhythmic movements of the activity.

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E pidemiology R umination is believed to be a rare disorder. It appears occur more often in males than in females and also in individuals with mental retardation. T here are a few reports of adults who had eating dis orders and who developed rumination.

E tiology and C ours e V arious mechanis ms of etiology have been propos ed. S everal authors have attributed rumination to or a disturbed mother–infant relations hip—e.g., lack of res ponsiveness or neglect by the mother s econdary to stress ful family relations or life events . Others have cons idered rumination a s ymptom of gas troesophageal reflux. S everal authors have postulated that rumination learned behavior that is maintained by special attention the regurgitation. In more recent years , opiate receptor insensitivity or reduced endorphinergic transmis sion been implicated in rumination. T he author has proposed a biopsychosocial model by which rumination is s een along a continuum wherein infant may have gas trointes tinal pathology and little ps ychopathology at one end of the s pectrum, or the oppos ite in which an infant may have no organic pathology and severe ps ychopathology in the mother– infant relationship at the other end of the spectrum. F requently, vomiting s econdary to gas troesophageal reflux or vomiting as sociated with an acute illnes s precedes the beginning of rumination. It appears that, some point, the infant learns to initiate vomiting and to rechew the food to achieve relief of tens ion, to s elf4175 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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and/or to s elf-stimulate. It seems that in s ituations in the infant fails to elicit or los es either caring attention or tension-relieving res ponses from the mother, becomes a means of s elf-regulation. Once the infant experienced rumination as a means of s elf-soothing or self-stimulation, the rumination develops into a habit is difficult to break. T he onset of rumination is frequently in infancy, mos t commonly in the first year of life. However, rumination may s tart at any point in life. It has been reported to later in childhood in individuals with developmental delays or in adulthood in individuals with eating It is believed that, in s ome individuals , the disorder spontaneously. However, s ome infants experience complications —e.g., electrolyte imbalance, and weight los s —and, in earlier reports, mortality rates high as 25 percent have been des cribed.

Treatment Depending on the theories of the etiology of different treatments have been suggested. T hese from P.3226 mechanical res traints as des cribed in the early and s urgical interventions to prevent reflux, to and ps ychodynamic treatments. B as ed on the as sumption that rumination is a learned habit that is reinforced by the increas ed attention given the regurgitation, unlearning by behavioral techniques been s uggested. T hes e treatments range from the use avers ive tas te s timuli (lemon juice or hot s auce), oral 4176 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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hygiene, differential reinforcement of incompatible behaviors , to electric s hock. P roponents of the that rumination is based on an unsatis factory mother– infant relations hip have s uggested a ps ychodynamic approach. A mother s ubstitute who feeds the infant the mother is helped through psychotherapy has been propos ed. After a thorough evaluation that should include the as sess ment of the infant and the mother, the therapis t needs to individualize the treatment. In severe the infant is malnourished and continues to lose most the food through rumination, a jejunal tube may have to be ins erted before any psychosocial treatment can F requently, a combination of ps ychodynamic and behavioral interventions to enhance the mother–infant relations hip in general and to treat the symptom of rumination, in particular, is most effective. J ustin was 9 months old when he was referred by a gastroenterologis t for a ps ychiatric evaluation because concerns that he continued to vomit becaus e of rumination. J ustin was born full-term and had nicely until he was approximately 6 weeks old, when he began to vomit increasing amounts of milk during and after feedings . He was diagnosed with reflux, which was treated with thickened feedings and medication. J us tin res ponded well to the treatment; he stopped vomiting almost completely and gained weight adequately. B ecause J us tin was doing s o well, his decided to go back to work when J ustin was 8 months S he trans itioned his care to a young woman who would come to the hous e during the mother's working hours. 4177 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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J ustin s tarted to vomit soon after his mother left the house. T he vomiting s eemed to increase from day to frequency and in intensity, and, after 2 weeks of the mother's return to work, J ustin vomited several times and was los ing weight. He was seen by a gastroenterologis t, and during the barium s wallow, it noticed that J us tin put his hand in his mouth, which seemed to trigger vomiting. J us tin was put back on medication for gastroes ophageal reflux, but he to vomit with increas ing frequency, which led to the ps ychiatric consultation. Observation of mother and infant during feeding that, as s oon as J us tin finis hed feeding, he put his his mouth and vomited. When his mother restricted his hand, J us tin moved his tongue back and forth in a rhythmic manner until he vomited again. T his repeatedly, and J ustin continued the rhythmic tongue movements even when he could not bring up any more milk. B ecaus e of his poor nutritional s tate and moderate dehydration, J ustin was admitted to the hospital, and a nasojejunal tube was ins erted for feedings . When was awake, a special nurs e or the parents played with and tried to distract him whenever he attempted to put hand in his mouth or thrust his tongue rhythmically. became increas ingly engaged, and his ruminatory decreased accordingly. After 1 week in the hos pital, feedings were s tarted; however, J ustin tried to again, and the oral feedings had to be s topped. At this point, the mother decided to s top working and take home to continue the treatment at home. T he mother started small feedings , played with J ustin after 4178 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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and was able to keep him from ruminating. After 4 of slow increments in his feedings , J ustin was able to all his feedings by mouth without ruminating, and the nasojejunal tube could be removed.

P ic a C linic al Features Y oung children with pica (T able 41-9) typically eat paper, paint, cloth, hair, insects , animal droppings, pebbles, and dirt. Many of the children engage in other oral activities —e.g., thumb sucking or nail biting—that they s eem to us e for relief of tension and for selfT he pica may lead to anemia, diarrhea/cons tipation, infes tation, toxoplasmosis, lead poisoning, and malnutrition. In s ome cases, it may lead to intestinal obstruction as the res ult of hairball tumors .

Table 41-9 DS M-IV-TR Diagnos tic C riteria for Pic a A. P ersis tent eating of non-nutritive substances period of at least 1 month. B . T he eating of non-nutritive substances is inappropriate to the developmental level. C . T he eating is not part of a culturally s anctioned practice. 4179 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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D. If the eating behavior occurs exclus ively during the cours e of another mental dis order (e.g., retardation, pervasive developmental dis order, schizophrenia), it is s ufficiently s evere to warrant independent clinical attention.

F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. American P sychiatric As sociation, Was hington, DC , 2000, with permiss ion.

Differential Diagnos is B efore the age of 18 to 24 months , mouthing, and sometimes eating of nonnutritive s ubs tances , can be relatively common and should be diagnosed as pica it is pers is tent and inappropriate for the developmental level of the child.

E pidemiology A s urvey of a large clinic population with a wide range ethnic backgrounds revealed that 75 percent of 12old infants and 15 percent of 2- to 3-year-old toddlers reported by their parents to put nonnutritive s ubs tances their mouth. However, the true incidence of pica is not known. Among individuals with mental retardation, the prevalence of the dis order appears to increase with the severity of the retardation. T he prevalence of pica institutionalized mentally retarded individuals has been 4180 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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es timated to range from 10 to 33 percent.

E tiology and C ours e Organic, ps ychodynamic, s ocioeconomic, and cultural factors have been implicated in the etiology of pica. Inadequate intake of iron and calcium has been shown rats to induce pica and has been cons idered to lead to abnormal cravings and pica in humans . P s ychos ocial factors —e.g., poverty, maternal neglect and abuse, disorganized family s ituations with inadequate and s upervis ion of the children—have been implicated the etiology of pica. T he cultural acceptance of pica in certain population groups has also been considered to play a role in the etiology of pica. S ome authors have propos ed a multifactorial model of etiology by which organic, familial, s ocioeconomic, and cultural factors interact with each other. In mos t instances, the dis order is believed to last for several months and then remit. It may occasionally continue into adoles cence or, les s frequently, into adulthood. However, s everal authors have pointed to seriousness of the developmental impact of the T he younger children s howed delays in their s peech ps ychos ocial development. Half of the adolescents observed to have depress ion and/or pers onality engage in other forms of disturbed oral activities (e.g., thumb sucking and nail biting), and P.3227 abuse tobacco, alcohol, or drugs . More recently, some authors pointed to a s trong relationship of pica during early childhood and bulimia nervos a during the 4181 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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years .

Treatment A variety of treatments have been proposed. T hes e from phys ical restraints and avers ive and nonavers ive behavior therapy to environmental enrichment and individual and group therapy for the children and their mothers. It is important to conduct a comprehensive evaluation of the child, the caretakers, and their environment to develop an individualized treatment T his s hould include helping the adults to become the s hort- and long-term dangers of pica, providing a free and childproof environment, facilitating a more satis fying parent–child relationship, and applying behavioral techniques to extinguish the maladaptive behavior of pica. S us an was 3 years old when her mother took her to the pediatrician because of abdominal pain and lack of appetite. T he mother complained that S us an put everything in her mouth but did not want to eat regular food. T he pediatrician obs erved that S usan looked thin, and withdrawn. S he sucked her thumb and quietly looked down while her mother reported that S usan to chew on news papers and put plaster in her mouth. T he medical examination revealed that S us an was and s uffered from lead poisoning. S he was admitted to hospital for treatment, and a ps ychiatric cons ultation obtained. F urther exploration of the history and the observation mother and child during feeding and play revealed that the mother was overwhelmed with the care of three 4182 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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children and had little affection for S usan. T he mother unmarried and lived with her three children and five family members in a three-bedroom apartment in an housing project. Her 4-year-old s on was hyperactive demanded almos t cons tant supervision. T he 18-monthinfant was an engaging and active little girl, whereas would s it quietly, rock herself, s uck her thumb, or chew news paper. T he treatment plan included the involvement of social services and protective s ervices to remove any lead from the walls in the present apartment and to look for better living arrangements for the family. T he mother helped to enroll S usan and her brother in a preschool program that provided them with more structure and stimulation and gave the mother a few hours of relief every day. In addition, S usan was seen with her and her younger s ister in play therapy to help the unders tand the different temperament of the two and to make her more respons ive to S usan's weak attempts to engage her mother. Once the mother felt more s upported and less overwhelmed by her she became more empathic and understanding of When S usan put s omething in her mouth, the mother able to engage her in a play activity rather than at her and s colding her for whatever she was doing. the period of 1 year, the relationship between S us an her mother gradually improved, and S us an seemed need of putting her thumb or inedible things in her E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 41 - F eeding and E ating Dis orders of Infancy and E arly S UG G E S T E D C R O S S -R E F E R E NC

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S UGGE S TE D C R OS S R E FE R E NC E S P art of "41 - F eeding and E ating Disorders of Infancy E arly C hildhood" T he general topic of eating disorders is covered in 19. P s ychological as pects of gastrointestinal disorders discuss ed in S ection 24.2. R egarding relevant modalities, see S ection 30.2 on behavior therapy and S ection 31.30 on electroconvulsive therapy. Normal development is reviewed in S ection 32.2. P s ychiatric examination of infants and children is discus sed in 33. V arious other psychiatric disorders of childhood are topics of C hapters 35,36,37,38,39,40 and E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 41 - F eeding and E ating Dis orders of Infancy and E arly R E F E R E NC E S

R E FE R E NC E S *B enoit D, W ang E , Zlotkin S : Discontinuation of enteros tomy tube feeding by behavioral treatment in early childhood: A randomized control trial. J 2000;137:498. B enoit D, Zeanah C H, B arton ML: Maternal disturbances in failure to thrive. Inf Me ntal He alth J . 1989;10:185. B irch L: Development of food preferences . Annu 4184 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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Nutr. 1999;19:41. B irch L, Zimmerman S , Hind H: T he influence of affective context on the formation of children's food preferences . Appe tite . 1998;30:283. B ithoney W , Dubowitz H, E gan H: F ailure to thrive/growth deficiency. P ediatr R e v. 1992;13:453. B lack MM, Hutcheson J J , Dubowitz H, B erensonJ : P arenting style and developmental status among children with non-organic failure to thrive. J P e diatr P s ychol. 1994;19:689. *C hatoor I: F eeding dis orders in infants and Diagnos is and treatment. C hild Adole s c P s ychiatr Am. 2002;11:163. *C hatoor I, C onley C , Dickson L: F ood refusal after incident of choking. J Am Acad C hild Adole s c 1988;27:105. C hatoor I, Dicks on L, E inhorn A: R umination: and treatment. P ediatr Ann. 1984;13:924. C hatoor I, G aniban J , Harrison J , Hirs ch R : T he observation of feeding in the diagnosis of posttraumatic feeding disorder of infancy. J Am C hild Adole s c P s ychiatry. 2001;40:595. C hatoor I, G aniban J , Hirs ch R , B orman-S purrell E , Mrazek D: Maternal characteristics and toddler 4185 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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temperament in infantile anorexia. J Am Acad C hild Adoles c P s ychiatry. 2000;39:743. *C hatoor I, G etson P , Menveille E , B ras seaux C , O'Donnell R , R ivera Y , Mrazek D: A feeding scale res earch and clinical practice to ass es s motherinteractions in the first three years of life. Inf Me nt J . 1997;18:76. C hatoor I, Hirs ch R , P ersinger M: F acilitating regulation of eating: A treatment model for infantile anorexia. Inf Y oung C hild. 1997;9:12. C hatoor I, K erzner B , Zorc I, P ersinger M, S imenson Mrazek D: T wo-year-old twins refus e to eat: A multidis ciplinary approach to diagnosis and Inf Me nt He alth J . 1992;13:252. Dahl M, R ydell A, S undelin C : C hildren with early to eat: F ollow-up during primary school. Acta S cand. 1994;83:54. Dellert S , Hyams J , T reem W, G eertsma M: F eeding res is tance and gastroes ophageal reflux in infancy. J P ediatr G as troe nte rol N utr. 1993;22:200. Dello S trologo L, P rinicpato F , S inibaldi D, Appiani T erzi F , Dartois AM, R izzoni G : F eeding dysfunction infants with severe chronic renal failure after longnasogastric tube feeding. P ediatr N ephrol. Dunitz M, S cheer P , T rojovsky A, K as chnitz W, K vas 4186 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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Macari S : C hanges in ps ychopathology of parents of NOF T (non-organic failure to thrive) infants during treatment. E ur C hild Adole s c P s ychiatry. 1996;5:93. E vans S L, R einhart J B , S uccop R A: F ailure to study of 45 children and their families . J Am Acad P s ychiatry. 1972;110:44. F lanagan C H: R umination in infancy-past and Am Acad C hild P s ychiatry. 1977;16:140. F raiberg S , Anders on E , S hapiro U: G hosts in the nursery. J Am Acad C hild P s ychiatry. 1975;14:387. G oldbloom R : G rowth in infancy. P ediatr R e v. Harper L, S anders K : T he effect of adults ' eating on young children's acceptance of unfamiliar foods . J C hild P s ychol. 1975;20:206. Haynes C , C utler C , G ray J , K empe R : Hospitalized of non-organic failure to thrive: T he scope of the problem and the s hort term lay health visitor intervention. C hild Abus e Ne gl. 1984;8:229. Homer C , Ludwig S : C ategorization of etiology of to thrive. Am J Dis C hild. 1981;135:848. Lindberg L, B ohlin G , Hagekull B , T huns trom M: food refusal: Infant and family characteristics . Inf Health J . 1994;15:262.

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Lourie R S : P ica and lead pois oning. Am J O rthops ychiatry. 1977;41:697. *Marchi M, C ohen P : E arly childhood eating and adolescent eating disorders . J Am Acad C hild Adoles c P s ychiatry. 1990;29:112. McNally R : C hoking phobia: A review of the C ompr P s ychiatry. 1994;35:83. Nels on S , C hen E , S yniar G , C hris toffel K : One-year follow-up of s ymptoms of gastroes ophageal reflux during infancy. P ediatrics . 1998;102:E 67. Olson J , B oehnke M, Neis wanger K , R oche A, Alternative genetic models for the inheritance of the phenylthiocarbamide (P T C ) taste deficiency. G e ne t E pidemiol. 1989;6:423. R obins on B A, T olan W , G olding-B eecher O: pica. S ome as pects of the clinical profile in J amaica. W e s t Indian Me d J . 1990;39:20. S auvage D, Leddet I, Hameury L, B arthelemy C : rumination: Diagnos is and follow up s tudy of twenty cases. J Am Acad C hild P s ychiatry. 1985;24:197. S tarin P S , F ugua R W: R umination and vomiting in developmentally disabled: A critical review of the behavioral, medical and ps ychiatric treatment R es De v Dis abil. 1987;8:575. 4188 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/41.htm

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T as k F orce on R esearch Diagnos tic C riteria: Infancy P res chool. R es earch diagnos tic criteria for infants preschool children: the process and empirical Am Acad C hild Adole s c P s ychiatry. 2003;42:1504–

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > 42 - T ic Dis order

42 Tic Dis orders Lawrenc e S c ahill M.S .N., Ph.D. J ames F. L ec kman M.D. T ourette's s yndrome is a chronic, potentially disabling, neurops ychiatric disorder of childhood onset defined by multiple, involuntary motor and phonic tics. Although chronic, the tics of T ourette's syndrome show a waxing and waning course with a tendency to decrease by adulthood. As knowledge of T ourette's s yndrome increases, s o does appreciation for the pathogenic complexity of this disorder and the challenges with its treatment. Advances in neuros cience have led new models of pathogenes is, whereas clinical studies reinvigorated earlier hypothes es . T he interdependent of genes and environment in dis eas e formation is presumed to underlie T ourette's syndrome, but this interaction has yet to be fully elucidated. R ecent epidemiological s tudies have s timulated debate about diagnostic thres hold for T ourette's syndrome. of this is sue will inform the determination of prevalence and the relative public health importance of T ourette's syndrome. T he absence of ideal anti-tic medications combined with the knowledge that uncomplicated of childhood T ourette's syndrome often have a outcome has prompted changes in the care and of patients with T ourette's s yndrome. T his chapter 4190 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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the diagnosis of T ourette's s yndrome, common conditions, natural his tory, epidemiology, etiology, neurobiology, and clinical management of patients with T ourette's s yndrome. 

DE F INIT ION AND NAT UR AL HIS T OR Y



C OMOR B IDIT Y



AS S E S S ME NT AND DIF F E R E NT IAL DIAG NOS IS



E P IDE MIOLOG Y



E T IOLOG Y



P HAR MAC OT HE R AP Y



B E HAV IOR AL INT E R V E NT IONS



T R E AT ME NT OF ADHD IN T HE P R E S E NC E OF



F UT UR E DIR E C T IONS



S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > DE F INIT ION AND NAT UR AL HIS T

DE FINITION AND NATUR AL HIS TOR Y P art of "42 - T ic Dis orders " In the revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ), tic disorders are defined by the type and duration of tics . diagnosis of T ourette's disorder (here the historically 4191 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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common term T ourette's syndrome is used), the patient must have multiple motor tics and at least one phonic for at leas t 1 year, with onset before 16 years of age. If motor or phonic tics are present for a year, the term chronic tic dis orde r is applied. T he diagnos is of dis order is given when tics are present for less than 1 T ics are abnormal movements or vocalizations that from s imple to complex and may mimic voluntary T he most common motor tics of T ourette's s yndrome involve the mus cles of the face and neck, such as eye blinking, grimacing, head jerking, or head shaking. C ommon vocal tics include throat clearing, coughing, grunting, and s norting. In mild cases, the tics may be confined to these simple movements and vocalizations ; they may not be obvious in all s ettings and may go unnoticed by nonfamily members. In cas es of greater severity, other mus cle groups are invariably involved, s uch as the s houlders , arms , legs, and tors o. Movements may be more complex, s uch as arm twis ting at the wais t, leg kicking, or stomping, as well skipping or hopping. More complex vocalization may include hooting, chirping, barking, repeating words or parts of words , using s hort phras es , and s howing spontaneous changes in the pitch or volume of speech. Approximately 10 to 15 percent of patients blurt out words or socially inappropriate words, s uch as body or racial epithets . T ics tend to occur in clus ters or T hese bouts may involve the repetition of the s ame tic an orches trated s eries of tics, s uch as an arm jerk, grimace, head jerk, and a barking noise occurring simultaneously. T ics that involve larger muscle groups, multiple muscle groups , or more complex vocalizations, 4192 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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a combination of these, are indeed noticed by others may interrupt activities of daily living. Many patients, children as young as 10 years of age, des cribe an urge premonitory s ens ation immediately before the of a tic. Attempts to resis t the performance of the tic invariably lead to an intens ification of the premonitory sens ation. P erformance of the tic, on the other hand, satis fies the urge or quiets the s ens ation—at least temporarily. T hes e premonitory phenomena distinguish T ourette's s yndrome from s everal other movement disorders , such as P arkinson's disease, Huntington's chorea, and hemiballis mus , in which there is no urge before the abnormal movements. W hether thes e premonitory s ens ations are secondary phenomena evolving from perceived or actual social cons equences tics or inherent in the pathophys iology of T ourette's syndrome is unknown. T he bout-like occurrence and the waxing and waning pattern of tics over time are hallmark features of syndrome that have engendered much curiosity but are still poorly understood. F or example, the bout-like of tics may reflect the puls atile firing of s pecific neurons in the bas al ganglia. T he waxing and waning pattern obs erved over time may be a recapitulation of bouts of tics witness ed in s horter time frames. In aged children, two to three exacerbations of tics per are not unus ual, regardless of whether the child is on suppress ing medication. Agains t the backdrop of the waxing and waning pattern of tics s een in children with T ourette's s yndrome, there is a general decline in tic severity after puberty, s uch that, by young adulthood, many patients report only mild tics. J ames Leckman 4193 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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colleagues evaluated 36 young adults with T ourette's syndrome who were between the ages of 17 and 20 All of the cas es had been seen in a specialty clinic childhood. T wenty-five patients (69 percent) in the had a lifetime diagnosis of attention-deficit/hyperactivity disorder (ADHD), and 13 patients (36 percent) had a lifetime diagnos is of obsess ive-compuls ive disorder T he mean age of onset of tics was approximately 6 and the mean age of wors t-ever tics was approximately years . Only three patients reported a worst-ever tic after puberty, and nearly one-half (N = 17) were tic free the face-to-face follow-up interview. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > C OMOR B IDIT

C OMOR B IDITY P art of "42 - T ic Dis orders " In addition to tics, approximately two-thirds of children with T ourette's s yndrome in clinical settings have problems with inattention, P.3229 impulsiveness , or hyperactivity, or a combination of these—that is , the cardinal symptoms of ADHD. Oneor more of clinical cas es exhibit obs es sive-compuls ive symptoms, such as recurring unwanted thoughts or repetitive behavior, or both, with as many as one-third meeting diagnostic criteria for OC D. Other children with T ourette's s yndrome may exhibit an enduring pattern of 4194 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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noncompliance, aggres sion, explosive behavior, or prominent anxiety, or a combination of thes e.

Tourette's S yndrome and A DHD T he as sociation of T ourette's syndrome with disruptive and impulsive behavior, as well as learning problems, been observed in clinical s amples for more than two decades. C lear interpretation of the findings from early studies is limited, because the samples were often not characterized with res pect to comorbid diagnos es — particularly ADHD. T hus , it has been difficult to whether the disruptive behavior or learning problems were part of T ourette's syndrome or due to cooccurring ADHD. S everal recent s tudies with well-characterized samples have s hown that T ourette's syndrome with is as sociated with greater functional disability, higher levels of s ocial and behavioral problems , and lower academic performance compared to T ourette's alone. F urthermore, children with T ourette's syndrome ADHD have s ocial, behavioral, and academic profiles are es sentially indis tinguis hable from children with alone. In addition, children with T ourette's s yndrome ADHD show greater neuropsychological deficits in such as visual motor integration, response inhibition, not surpris ingly, inattention. T hese neuropsychological deficits are corroborated by neuroimaging s tudies in which the differences in basal ganglia and cortical between T ourette's s yndrome s ubjects and unaffected controls are greatest in the group with T ourette's syndrome with ADHD.

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Data from clinical studies indicate that obsess ivecompuls ive s ymptoms occur in 33 to 66 percent of patients with T ourette's s yndrome. S everal s tudies that there are differences between tic-related and non– related forms of OC D. S pecifically, OC D patients with a personal his tory of tics are more likely to report touching, counting, ordering and arranging, and a need for symmetry than OC D patients without tics. B y non–tic-related OC D is more often as sociated with contamination and harm coming to the s elf or family members. T he accompanying compuls ive habits, which are typically directed at removing contamination or preventing harm, also appear to be more common in non–tic related form of OC D. T his differentiation may clinical implications in that the tic-related form of OC D may be less res ponsive to monotherapy with antiobses sional medications . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > AS S E S S ME NT AND DIF F E R E NT IAL

AS S E S S ME NT AND DIFFE R E NTIAL DIAGNOS IS P art of "42 - T ic Dis orders " T here are no medical tests for the diagnosis of syndrome, although s pecific laboratory tests may be needed to rule out other conditions in s ome cases. E lectroencephalography (E E G ) is unneces sary, except when seizures are sus pected or to evaluate a sleep disorder. Us ing various neuroimaging techniques, s uch 4196 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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magnetic res onance imaging (MR I), positron emis sion tomography (P E T ), or s ingle photon emis sion tomography (S P E C T ), s ubtle differences between T ourette's s yndrome patients and controls have been observed in s everal res earch s tudies . However, these imaging techniques are not part of the standard evaluation in T ourette's s yndrome. In the abs ence of a definitive laboratory tes t, the of a tic disorder including T ourette's syndrome relies on history and observation. Other than tics, the examination is us ually normal, although soft s igns may present. T he clinical interview s hould examine the motor and phonic tics and s hould carefully review the types and cours e of tic symptoms over time, as well as overall burden impos ed by the tics . T he child's past res ponse to pharmacological treatments often provides additional information about the severity of tics. A common challenge in the ass ess ment of tic disorders is distinction between tics and behavioral s ymptoms. F or example, a 10-year-old child yells out inappropriate comments in the clas sroom, rais ing the question of whether this is a tic or provocative behavior. Unhurried dialogue between the clinician, patient, and family es tablis h a common vocabulary about the tics , which, turn, helps clarify the diagnosis and the meaning of specific s ymptoms. S ymptom checklists completed by patient and, in the case of a child, parent and teacher rating scales can augment data gathered from the interview and direct observation. In addition, selected ratings may be useful to evaluate change with (T able 42-1). Although convenient, self-reports , as well parent and teacher ratings, are s ubject to 4197 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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overendors ement or underendors ement. T hus , tic based on direct interview and obs ervation by an experienced clinician are generally regarded as the method of quantifying tic s everity, although they take more time to adminis ter.

Table 42-1 C linic al As s es s ment Too Dis orders Domain

Type

R eliability and Validity

Se to Ch

Tic s

 

 

 

T ic S ymptom S elfR eport

P arent/s elf

G ood

Ye

Y ale G lobal T ic S everity S cale

C linician

E xcellent

Ye

P arent/teacher E xcellent

Ye

Attentiondefic it/hyperac tivity dis order S wans on, Nolan, P elham-IV

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Abbreviated Ques tionnaire

P arent/teacher E xcellent

Ye

Y ale-B rown Obsess ive C ompulsive S cale and C hildren's Y aleB rown Obses sive C ompulsive S cale

C linician

E xcellent

Ye

National Ins titute of Mental Health

C linician

E xcellent

Ye

General

 

 

 

C hild B ehavior C hecklis t

P arent/teacher E xcellent

Obs es s ivecompuls ive

No

A comprehensive ass es sment of a patient referred for evaluation of T ourette's s yndrome also includes a of perinatal history, early development, medical his tory, and family history. T hese his torical elements may point the need for specific laboratory tes ts, ass is t in the diagnosis of comorbid conditions, and dis tinguis h from atypical cases. F or example, a 35-year-old with an unremarkable medical his tory who shows a 4199 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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pattern of weight los s and ataxia s hould be evaluated neuroacanthocytosis. A 7-year-old boy with tics accompanied by delayed and deviant language, lack of interes t in others , and a fascination with trains may warrant a diagnos is of pervasive developmental the presence of which may influence school placement other treatment choices. Alertnes s to the features of any comorbid condition is of any ps ychiatric evaluation. T his is also true in the evaluation of a patient with a tic disorder. B ecaus e of common occurrence in patients P.3230 with T ourette's syndrome, the symptoms of ADHD and OC D warrant detailed review. In addition to their or abs ence, it is als o of interes t to evaluate the impact these ass ociated problems on the patient and the T he patient's functional s tatus as evidenced by and occupational s ucces s, s ocial competence, and of interpersonal relationships should also be reviewed.

HIS TOR Y T odd, age 8, came to the T ourette S yndrome C linic for evaluation of tics, hyperactivity, and impulsive He is a third-grade s tudent in a regular class at the public s chool. B efore the consultation, parent and ratings , including the C hild B ehavior C hecklist (C B C L), S wans on, Nolan, and P elham-IV (S NAP -IV ), C onners' and T eacher Ques tionnaires , T ic S ymptom S elf-R eport (T S S R ), and medical history s urvey, were s ent to his (T able 42-1). His mother and the class room teacher him well above the norm for hyperactivity, inattention, 4200 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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impulsiveness . He was failing in school, often argued adults , was occasionally aggress ive, and had few His tics were rated as mild. T odd's mother recalls difficulties with overactivity and reckless behavior since pres chool. At age 5, his kindergarten teacher encouraged the family to obtain cons ultation for his behavior. T he family's pediatrician made a diagnosis of ADHD and recommended a trial of methylphenidate (R italin), which eventually occurred in the firs t grade. W ithin 2 weeks of s tarting medication, behavior s howed a dramatic improvement. He was stay in his seat and complete his work and was more to wait his turn on the playground. T he next s everal months went well. After a dosage increas e in the spring his first-grade year, however, he began showing motor phonic tics consisting of head jerking, facial coughing, and grunting. T he medication was stopped, and although the tics s ubs ided, they did not away. In hinds ight, T odd's mother recalled that he had shown blinking and throat clearing before starting methylphenidate, but she had dismis sed these tics as unimportant. Off medication, the second grade did not go well, and T odd was placed in s pecial education class . At his insis tence, T odd returned to the regular class for third grade. However, his adjus tment to the third-grade clas sroom was poor. T he family went back to the pediatrician, who made the referral to the T ourette S yndrome C linic. T odd is healthy with no history of serious illness or T he pregnancy, labor, and delivery were and his developmental milestones were achieved at 4201 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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appropriate times . Intelligence tes ting completed by the school psychologist revealed average intellectual His appetite is good. His mother notes that T odd has standing trouble falling asleep but s leeps through the night. Although he is des cribed as argumentative and easily frustrated with frequent outbursts of temper, his mood is generally upbeat.

B E HAVIOR AL OB S E R VATIONS T odd is of average height and weight with no features. His speech is rapid in tempo but normal in and volume. His dis course is coherent and developmentally appropriate, and there is no evidence thought disorder. He does not appear depres sed and denies worries about everyday is sues s uch as friends school performance, although he recognizes that not going so well. He also denies recurring worries contamination or harm coming to him or family or fears of acting on unwanted impulses. Other than touching habits involving the need to touch objects with each hand three times or in combinations of three, he denies repetitive rituals . S everal tics were obs erved the evaluation s ess ion, including blinking, facial head jerking, and grunting. He was res tless and eas ily distracted throughout the ses sion and often needed as sistance with entertaining himself when not directly involved in conversation.

IMPR E S S ION G iven the history of enduring motor and phonic tics, are confirmed by direct obs ervation, T odd meets for T ourette's syndrome. B as ed on his tory, he als o criteria for ADHD, combined type. 4202 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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TR E ATME NT PLAN Although recent studies have shown that children with tic disorder can tolerate stimulant medication without inducing an exacerbation in tics , some children s how increase in tics on expos ure to s timulants . T hus, guanfacine, 0.5 mg, is recommended with planned increases of 0.5 mg every 4 to 5 days as tolerated to a maximum of 3 mg per day in three divided dos es . press ure, puls e, sleep, appetite, energy level, and tics be monitored every 2 weeks during the dos e phase. P arent and teacher ratings will be obtained at 4 8 weeks to ass es s respons e. P arents will be given educational materials about T ourette's s yndrome and ADHD and referred for parent training. T he parent training will focus on dis tinguising between tics and oppos itional behavior, how to modify disruptive bahavior, and how to cultivate positive behavior. W ith the parent's permiss ion, the school will informed of the diagnosis , and a special education clas sification in the “other health impaired” category is likely. Although T odd may remain in the regular he may benefit from a teacher's aide to monitor his behavior and help him organize his school work. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > E P IDE MIOLO G

E PIDE MIOL OGY P art of "42 - T ic Dis orders " T ics are common in children, affecting 12 to 18 percent 4203 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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the s chool-aged population. T raditionally, the of T ourette's syndrome has been considered relatively ranging from 3 to 5 per 10,000. B ecause thes e were bas ed on clinically as certained cas es , it is likely milder cases that did not come to clinical attention were not counted. T hus , these s tudies almos t certainly underes timated the true prevalence of T ourette's syndrome. T o correct this bias in ascertainment, recent studies have us ed community sampling methods, have resulted in higher estimates of prevalence in mos t studies. Another approach taken by more recent the us e of direct parent interview or observation of the child, or both, to confirm the presence of tics rather rely on previous ly identified cas es . B as ed on these more recent studies, the prevalence of T ourette's s yndrome in children ranges from 5 to 300 10,000. T he differences acros s these studies are due differences in the age group s tudied (studies of older teenagers find lower prevalence), as sess ment methods (parent report versus direct observation, with direct observation cons is tently finding higher prevalence), the diagnostic thres hold us ed to define a cas e. F or example, in the late 1960s , Michael R utter and evaluated a s ample of 3,000 children that included all to 12-year-old children in the Is le of W ight. Although percent of the children in this s ample were identified as having tics , no cases of T ourette's syndrome were identified. If this s tudy had us ed current definitions of T ourette's s yndrome, it is all but certain that some with tics would have been identified with T ourette's syndrome. B y contrast, in the mid-1990s , a s tudy in C arolina involving more than 4,000 children used the 4204 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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revis ed third edition of the DS M (DS M-III-R ) criteria reported a prevalence of 4.2 percent for all tic disorders combined (transient, chronic tic dis order, and syndrome). T ourette's s yndrome was relatively uncommon, in the range of 10 per 10,000. T he these es timates from R utter's class ic Isle of Wight (4.4 percent for tics) and the G reat S moky Mountains project by E lizabeth C ostello and colleagues (4.2 for tic dis orders) is striking and implies differences in clas sification rather than true differences in thes e two samples . P.3231 T he surveys reporting the highes t es timates of syndrome us ed direct obs ervation to identify higher prevalence. F or example, R oger K urlan and colleagues reported a prevalence of 80 cases per 10,000, and Ann Mason and colleagues reported a prevalence of 300 10,000. Direct observation is an appealing method for study of tics in a community setting, in that it reduces probability of miss ing mild cas es . Nonetheless , there serious threats to the validity of the findings from these studies. T he study by Mas on and colleagues bas ed es timate on a sample of 150 children. K urlan and colleagues set out to as certain a large randomly sample through public s chool rosters. However, only percent of the randomly s elected s ample agreed to participate. F urthermore, it seems likely that families of children with tics could have been overrepresented among study participants. T aken together, the findings from community-based samples sugges t that tic are relatively common in school-aged children and may 4205 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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undetected. T he best estimate for T ourette's s yndrome probably in the range of 10 to 80 per 10,000 in s choolaged children. An important remaining public health cons ideration is whether the pres ence of tics or even a mild tic dis order places a child at higher ris k for other problems with behavior or learning, or both. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > E T IO LOG Y

E TIOL OGY P art of "42 - T ic Dis orders "

Neurobiology T he exact pathophys iology of T ourette's syndrome is unknown. B eginning with the clinical obs ervation in the 1960s that potent dopamine-blocking medications , as haloperidol (Haldol), are effective in reducing tics, dopamine and its pathways have been regarded as centrally involved. T hrough the 1980s and 1990s , has been learned about the anatomy of the bas al and the functional organization of the dopamine C orticobas al ganglia circuits are organized into a of parallel loops that are dedicated to s pecific motor, sens orimotor, and cognitive functions . T hese pathways connect multiple cortical and subcortical structures, including frontal cortex and the basal ganglia. T he ganglia, which include the s triatum (caudate and putamen), globus pallidus, subthalamic nucleus, subs tantia nigra, ventral tegmental area, and nucleus accumbens, are a group of highly interconnected nuclei 4206 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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located at the bas e of the cerebrum. T hrough their connections with the cortex, thalamus, and brainstem, these structures modulate a range of motor, and cognitive functions . T o illustrate the relevance of these cortical-subcortical circuits in T ourette's syndrome, it is useful to examine motor pathway, s tarting with the motor region of the frontal cortex. T he motor regions in the frontal cortex excitatory input to the s triatum in a somatotropic (i.e., conforms to the anatomical body plan). T hese are proces sed within the basal ganglia to balance facilitatory and inhibitory output from the globus to the brainstem and thalamus to execute intended movement and to inhibit unintended movement. F ailed inhibition at the level of the globus pallidus could tics. T he neurochemistry of this circuitry is complex and beyond the s cope of this chapter. B riefly, excitatory pathways are mediated by glutamate, and inhibitory pathways are mediated by γ-aminobutyric acid (G AB A). Dopamine has excitatory and inhibitory effects, on the type of dopamine receptor. T he s triatum dopaminergic input from specialized cells of the subs tantia nigra. T hat dopamine is ess ential for normal movement is illus trated by the pathophys iology of P arkins on's dis ease, in which los s of dopaminecells caus es the motor s ymptoms of the disease. In T ourette's s yndrome, dopamine appears to play a modulating role. T hus , despite the predictable benefits dopamine-blocking agents , tics are unlikely to be due too much or too little dopamine.

G enetic s 4207 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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T win and family genetic s tudies provide compelling evidence that genetic factors are involved in the transmis sion of T ourette's syndrome and related within families. However, the nature of the vulnerability genes that predis pos e individuals to develop T ourette's syndrome is unknown. Multiple genes are likely C larity about the s tructure and normal express ion of a few of the T ourette's s yndrome s us ceptibility genes is likely to provide a major s tep forward in understanding pathogenes is of this condition. F uture progress may depend on the identification of endophenotypes (i.e., biological markers that are ass ociated with specific vulnerability genes ). T he pattern of vertical transmiss ion among family members is s uggestive of major gene effects, and segregation analyses are cons is tent with models of autos omal transmis sion. Until recently, efforts to susceptibility genes within high-density families using traditional linkage s trategies have met with limited succes s. However, inves tigators studying a large C anadian family have now reported evidence for 11q23. Nonparametric approaches using families in which two more s iblings are affected with T ourette's s yndrome also been undertaken. T his s ibling-pair approach is suited for dis eas es with an unclear mode of inheritance and has been used s ucces sfully in studies of other disorders , such as type I diabetes mellitus and hypertens ion. In the one affected s ibling-pair s tudy of T ourette's s yndrome, two areas were s uggestive of one on chromosome 4q and another on chromosome Another genome scan using hoarding s ymptoms (a 4208 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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component of OC D that can be s een in some syndrome patients) as a quantitative phenotype was conducted on the same T ourette's syndrome–affected sibling-pair data collected by the T ourette S yndrome Ass ociation International C ons ortium for G enetics. S ignificant allele s haring was observed for hoarding phenotypes for markers at 4q34–35, 5q35, and 17q25 T he 4q site is in clos e proximity to the region linked to T ourette's s yndrome in the same families. Identity-by-descent (IB D) approaches have als o been in population isolates in S outh Africa, T he Netherlands, and C os ta R ica. T hes e techniques ass ume that a few founde r individuals contributed the vulnerability genes are now distributed within a much larger population. far, the S outh African study has implicated regions the centromere of chromos ome 2, as well as regions 8q, 11q, 14q, 20q, and 21q. T he marker on in the F rench-C anadian family that was as sociated with highes t logarithm of odds (LOD) s core was the same marker for which s ignificant linkage disequilibrium with T ourette's s yndrome was detected in the Afrikaner population of S outh Africa. Only in one instance (8q22) was there any overlap between the chromosomal in which cytogenetic abnormalities have been found to cosegregate with T ourette's s yndrome phenotypes and regions that have als o s hown evidence for linkage in high-density families. F inally, a number of candidate genes have been in T ourette's s yndrome, including various dopamine receptors (DR D1, DR D2, DR D4, and DR D5), the transporter, various noradrenergic genes (ADR A2A, ADR A2C , and DB H) and a smaller number of 4209 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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genes (5-HT T ). It appears unlikely that genetic any one of these loci is a major s ource of vulnerability T ourette's s yndrome, but, acting in concert, thes e may have a s ignificant cumulative effect.

E nvironmental F ac tors T he higher concordance in monozygotic vers us twin pairs s upports a genetic etiology in T ourette's syndrome. Although monozygotic twins are more likely be mutually affected, concordant twins may show differences with res pect to severity. T hes e differences severity sugges t that environmental factors also play a in the expres sion of T ourette's syndrome. F or example, perinatal factors, including common obstetrical complications , maternal stress during pregnancy, first trimes ter naus ea and vomiting, and low birth weight, been ass ociated with increas ed tic severity in monozygotic twins with T ourette's s yndrome. F urthermore, in a series of 16 monozygotic twin pairs , T homas Hyde and colleagues obs erved 94 percent concordance for tic dis orders. In 12 of 13 twin pairs differing weights at birth, the more severely affected cotwin was the one with the lower birth weight. P.3232 Life s tres s, anxiety, excitement, selected states of relaxation (e.g., after school or watching televis ion), fatigue have all been reported to increase tic severity. contrast, focused activities, mental and physical, may as sociated with a decrease in tics . F or example, the year-old Little League player may report a flurry of tics before batting but few tics while batting. As many as 25 4210 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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percent of patients report increas ed tics on expos ure to heat. S everal medications , particularly the s timulants , have described as increasing tic s everity. B ased on cas e and controlled s tudies , approximately 10 to 20 percent children with ADHD treated with s timulants report newonset tics. However, these reports are confounded by waxing and waning nature of tics and the later age of onset of tics compared to ADHD. Moreover, several placebo-controlled studies in children with tics and treated with s timulants did not observe group in tic severity. However, tic flare-ups leading to discontinuation of the s timulant did occur in a few subjects . T he long-term impact of s timulants on tic has been evaluated in few s tudies . T hese studies s how some children with tics and ADHD can tolerate over long-term intervals , s uch as 1 year. Once again, however, a minority of children s hows an unacceptable increase in tics , which typically subs ide with discontinuation. T aken together, the preponderance of available evidence s uggests that the presence of tics T ourette's s yndrome is not an abs olute contraindication for the use of s timulants . T he poss ibility of increased warrants careful monitoring and should be dis cus sed the family. Another class of medications that has been implicated wors ening of tics is the androgenic s teroids . T his observation may help explain the preponderance of patients with tics . However, treatment with the antiandrogen compound flutamide (E ulexin) was not effective in suppres sing tics . T here has als o been interest in the poss ible role of 4211 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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infectious agents —es pecially group A β-hemolytic streptococcus. T he models for this putative mechanism are rheumatic fever and S ydenham's which are es tablis hed pos tstreptococcal complications an untreated infection. T he propos ed mechanis m, to as mole cular mimicry, posits that antibodies to fight off the infection cros s-react with the host's own tis sue to produce symptoms. In the case of rheumatic fever, cardiac s ymptoms predominate. G iven the movements ass ociated with S ydenham's chorea, most inves tigators have focused attention on the basal E xtending this theory to T ourette's s yndrome and conditions, such as OC D and ADHD, has unfolded gradually since the 1990s. S us an S wedo and followed up an outbreak of rheumatic fever and S ydenham's chorea and showed an increased ris k of in individuals with chorea compared to thos e with symptoms only. S ubsequent case studies reported onset or acute exacerbations of tics or obses sivecompuls ive s ymptoms, or both, after a known streptococcal upper respiratory infection. T his led to propos al that some cases of T ourette's s yndrome or could be related to s treptococcal infection under the rubric of P ANDAS (pediatric autoimmune dis orders ass ociated with s treptococcal infections ). E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > P HAR MAC OT HE R A

PHAR MAC OTHE R APY P art of "42 - T ic Dis orders " 4212 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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T he decis ion to use medication for the treatment of a patient with T ourette's s yndrome follows from the identification of target s ymptoms that are caus ing impairment and fit with specific medication choices. In some cases , the target symptoms may be easily such as tics, impuls ivenes s, hyperactivity and or obs ess ive-compuls ive s ymptoms. In cas es with problems , however, it may be more difficult to identify which s ymptom clus ter is mos t impairing. In other pharmacotherapy for the appropriately s elected target symptom may worsen some other as pect of the clinical picture. F or example, as noted previous ly, stimulants may not induce an exacerbation in all with T ourette's syndrome and ADHD, but s ome with T ourette's syndrome show an increas e in tics after expos ure to s timulant medication. T his s ection reviews current pharmacological treatments for tics and ADHD children who also have tics .

Typic al A ntips yc hotic s Haloperidol and pimozide (Orap) are the best s tudied cons idered the most effective medications for the treatment of tics. S everal head-to-head comparis ons suggest that thes e two drugs are equally effective, with greater s ide effect burden for haloperidol. B ecaus e studies used much higher dosages of thes e than are currently used in practice, thes e comparis ons have limited application. F or example, early studies range of 2 to 20 mg per day for haloperidol and a range 2 to 48 mg per day for pimozide. T he dos e range in clinical practice is typically 1 to 5 mg per day for haloperidol and 2 to 10 mg per day for pimozide. F urthermore, haloperidol and pimozide are as sociated 4213 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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with a variety of adverse effects , including acute akathisia, parkins onis m, sedation, dulled thinking, gain, depress ed mood and s ocial phobia, and, rarely, tardive dyskinesia. T hus, us e of the lowes t poss ible effective dos e is an es sential principle when treating with these potent medications . T he total daily dose of haloperidol ranges from 0.75 to mg in most cases . T he therapeutic effects and adverse res ponses s hould be monitored clos ely during the dos e adjus tment phas e. T he us e of low starting dos e and gradual increases protects agains t acute dys tonic reactions , although parents s hould be educated about poss ibility. If dys tonic reactions occur, antiparkinsonian agents , s uch as benztropine (C ogentin), s hould be Other adverse effects can often be managed by the dos e. β-B lockers, such as propranolol (Inderal) or pindolol (V isken), may be us eful to treat akathis ia. P imozide is available in a 1-mg tablet and 2-mg tablet. B ecaus e pimozide has a long half-life, it can be given a day in mos t cases. T he total dos e in children typically ranges from 2 to 4 mg per day and is perhaps s lightly higher in adults. Although rare at low dos es , pimozide a potential for QT interval prolongation. T herefore, electrocardiograms (E C G s) at baseline, during dos e adjus tment, and annually during maintenance therapy recommended. C oncomitant treatment with drugs that inhibit the cytochrome P 450 3A4 isoenzyme (e.g., erythromycin [E -Mycin] and ketoconazole [Nizoral]) be avoided because of the potentially dangerous rise in pimozide s erum levels. T he traditional antips ychotic, fluphenazine (P rolixin), not been evaluated in a placebo-controlled study for tic 4214 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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suppress ion, but it appears to be common in practice. open-label trial in 21 refractory patients (7 to 47 years age) s howed that approximately one-half of the (11 of 21) had a pos itive respons e. T he mean dos e of fluphenazine was 7 mg per day (range from 2 to 15 Interes tingly, of the s ix patients who reported akathisia haloperidol, only one reported akathisia on In children, the likely dos e range is 2 to 4 mg per day in divided dos es. T iapride and s ulpiride are substituted benzamides with selective dopamine type 2 (D 2 ) receptor blocking properties. T his family of antipsychotics also includes amis ulpride, raclopride, remoxipride, and the metoclopramide (R eglan). T o date, tiapride is the only in this clas s to be evaluated in a placebo-controlled for tics. T wo small s tudies involving a total of 27 with T ourette's syndrome showed that tiapride was superior to placebo, achieving a 30 to 44 percent in tics. E ach s tudy was 6 weeks in duration, with dos es ranging from 5 to 6 mg/kg of body weight per day. In a retrospective study of 37 T ourette's s yndrome patients (age range from 10 to 68 years of age), investigators reported that 60 percent (22 of 37) had a positive to sulpiride. T reatment began with 100 mg twice daily was gradually increas ed as needed to achieve control. T he modal daily dose P.3233 among res ponders was 400 mg (range from 200 to mg) per day. C ommon s ide effects included akathisia, depres sed mood, amenorrhea, and weight B ecaus e one-third of the patients were als o receiving 4215 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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medications for tics, thes e res ults are difficult to

Additional C ons iderations for Antips yc hotic Treatment in S yndrome Although the potent dopamine-blocking antips ychotic medications are the most effective drugs for tics in T ourette's s yndrome, the value of these agents the long-term management of children with the dis order unclear. F irst, most clinical trials with antipsychotic medications for tics have been of brief duration (6 to 12 weeks). T hus, it is unclear whether the gains achieved short-term s tudies endure over time and offset the effects ass ociated with long-term us e of these medications . S econd, as noted previous ly, tics in T ourette's show a waxing and waning cours e. T he average period exacerbation has been estimated to be approximately weeks. F urthermore, even though short-term efficacy studies have s hown that haloperidol and pimozide are superior to placebo in reducing tics, it is not clear that either of these drugs alters the waxing and waning of T ourette's syndrome. Over time, therefore, there a gradual ratcheting upward of the medication to periods of exacerbation. In the abs ence of data from term prospective studies, it may be advisable to reduce dose of the antips ychotic drug during a quies cent F uture s tudies may provide more guidance for clinical practice on the duration of antipsychotic treatment in children with T ourette's s yndrome. However, that the ris k of advers e effects increas es as a function dose and duration, the lowest dos e to achieve 4216 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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res ults is the proper goal for treatment rather than tic eradication. T hird, becaus e the duration of drug treatment for tics is not es tablis hed, and because chronic us e of medications may cause a variety of advers e effects, practice in T ourette's s yndrome tends to res trict the the traditional antips ychotics (such as haloperidol or pimozide) to patients with severe tic s ymptoms. T he atypical antips ychotics (risperidone [R isperdal] and zipras idone [G eodon]) appear to be better tolerated the older, high-potency dopamine-blocking agents (haloperidol and pimozide) in the short term. In there is accumulating evidence that risperidone and zipras idone are effective in reducing tics in short-term studies. However, the long-term risks and efficacy of atypical antips ychotics in T ourette's s yndrome are unknown. F or example, although the ris k of side effects and, perhaps , tardive dyskinesia may be with the atypical antipsychotics, they may be with weight gain, increas ed blood lipids, and glucose dysregulation. Nonetheles s, the perceived lower risk of advers e s ide effects for the atypical antips ychotics is contributing to their wides pread us e in T ourette's syndrome.

A typic al A ntips yc hotic s T he atypical antips ychotics (clozapine [C lozaril], ris peridone, olanzapine [Zyprexa], quetiapine aripiprazole [Abilify], and ziprasidone) have been extensively in schizophrenia. As a group, they major advance in the treatment of schizophrenia of the lower risk of neurological s ide effects . T o varying 4217 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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degrees , thes e drugs block D 2 receptors and serotonin type 2 (5-HT 2) receptors . Indeed, the differences these atypical antipsychotics appear to be the relative potency of the D 2 and 5-HT 2 receptor antagonis m. that D 2 receptor blockade is an es sential feature of the most effective tic-suppress ing medications , the potency D 2 receptor blockade is probably relevant to the of T ourette's syndrome. F or example, clozapine, which weak D 2 receptor blocker and a more potent blocker at 5-HT 2 receptor, was not effective in the treatment of Other than small case series , olanzapine, quetiapine, aripiprazole have not been evaluated for the treatment tics and are not discus sed further. R is peridone is an atypical antipsychotic with potent D 2 5-HT 2 receptor blocking properties . Until recently, ris peridone was only evaluated in open-label trials. At doses ranging from 1 to 3 mg per day, thes e studies provided promis ing res ults for ris peridone in the treatment of tics. R isperidone and pimozide were equivalent in a randomized, double-blind study of 50 patients with T ourette's s yndrome (age range from 11 50 years of age). T o date, there are only two placebocontrolled studies of risperidone for the treatment of T hese two s tudies involved a total of 80 s ubjects from 62 years of age. B oth s tudies showed risperidone to be superior to placebo in doses ranging from 1.0 to 3.5 mg per day in two divided doses. T he mos t common effect was sedation. T wo subjects reported new onset social phobia, requiring a dose reduction in one s ubject and discontinuation in the other. E xtrapyramidal symptoms were rare, but the potential for weight gain evident in both trials . T his advers e effect clearly 4218 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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clinical monitoring and more s tudy. Zipras idone also has potent 5-HT 2 and D 2 blocking properties. In addition to thes e familiar pharmacological properties, ziprasidone als o has serotonin type 1A (5receptor agonist properties and modes t norepinephrine and s erotonin reuptake blocking effects. T he clinical impact of these additional pharmacological properties unclear. Zipras idone was evaluated in a double-blind in 28 children (age range from 7 to 17 years of age) moderate to severe tics and proved to be superior to placebo. After 8 weeks of treatment at a mean dose of mg per day given in two divided dos es , the 16 randomized to active drug s howed an average 35 decrease in tics . S ide effects of ziprasidone included transient s edation, insomnia, and akathis ia. T here were clinically significant changes in cardiac conduction as meas ured by E C G . T here was no difference in weight acros s the two treatment groups .

Nonantips yc hotic s C lonidine (C atapres) is an α-2 agonist that has been the treatment of T ourette's s yndrome s ince the late C lonidine acts presynaptically in the locus ceruleus and ultimately turns down the noradrenergic system. controlled study has s hown that clonidine is superior to placebo, achieving a 35 percent reduction in tics on average. However, an earlier study failed to observe benefit from clonidine. Despite thes e inconsistent clonidine is commonly used in T ourette's syndrome. clinical argument in favor of clonidine is that it does not raise concerns about long-term s ide effects as sociated with antips ychotics . 4219 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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In school-aged children, clonidine is us ually started single 0.05-mg dose (0.025 mg in smaller children) and increased by an additional one-half tablet every 3 to 4 to a total of 0.15 to 0.2 mg per day. B as ed on its brief duration of action, clonidine is typically given three four times per day. S edation is common when first initiated, but it may als o be present in ongoing treatment. Other s ide effects include dry mouth, mids leep awakening, and increased irritability. may be es pecially prominent as the medication is off; hence, clinicians should look for patterns in the behavior. Although clonidine was developed as an antihypertens ive, low blood pres sure is rarely a Abrupt discontinuation, however, has been ass ociated with rebound increas es in blood press ure and should avoided. C lonidine also comes in a transdermal patch, this preparation has not been well studied in children adoles cents . P ergolide (P ermax) is a mixed D 2 –dopamine type 1 receptor agonist that was developed for the treatment P arkins on's dis ease. In conditions such as P arkinson's disease with decreas ed dopaminergic activity, acts as dopamine agonist. G iven the presumed P.3234 heightened dopaminergic tone in T ourette's s yndrome, pergolide may indirectly have dopamine antagonist effects. T he typical daily dose is 300 μg per day (range, to 450 μg) given in three divided doses. In two placebocontrolled studies involving 76 subjects between the of 7 and 17 years, pergolide s howed a modest 25 to 30 percent decrease in tics over placebo. 4220 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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B as ed on s ucces s in the treatment of dystonia, dilute botulinum toxin have als o been used in open studies and one placebo-controlled trial in T ourette's syndrome patients. T he injections are given directly the muscle of the target tic and, if effective, are given 3 months to s ustain the benefit. T aken together, thes e trials have included only approximately 50 patients with T ourette's s yndrome. T hus far, beneficial effects be moderate for the treated tics . Advers e events pain at the s ite of injection and weakness in the muscle. T he added benefit of nicotine chewing gum in combination with haloperidol has been reported in two open-label studies. S ubsequent open trials evaluated us e of transdermal nicotine patches with T wenty-four–hour expos ure to the 7-mg patch provides added benefit for approximately 1 to 2 weeks. recent controlled trial showed only limited benefit for treatment s trategy. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > B E HAV IO R AL INT E R V E NT I

B E HAVIOR AL P art of "42 - T ic Dis orders " Inves tigators have used a number of specific techniques (e.g., mas s practice, habit reversal, hypnotherapy, relaxation, and biofeedback techniques) reduce tics. In addition, there is a growing us e of alternative treatments (e.g., acupuncture and dietary 4221 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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supplements ). Of these, relaxation, mass practice, and biofeedback appear to be uns ucces sful in reducing Only a few case reports support the use of T he most promis ing of these approaches is habit training (HR T ). Azrin and Nunn developed HR T for the treatment of tics and other habits in the 1970s. S ince there have been s everal attempts to apply thes e techniques to T ourette's s yndrome, with some s ucces s. originally described, HR T cons is ted of s everal components. T he five active components of HR T (1) respons e description, in which the s ubject is trained describe tic occurrences in detail and to reenact tic movements while looking in a mirror; (2) respons e detection, in which the therapis t points out each tic immediately as it occurs ; (3) practices aimed at helping patient identify the earliest signs of tic occurrence; (4) a functional analysis to identify the s ituations in which are most likely to occur; and (5) competing respons e practice that consists of teaching individuals to produce incompatible phys ical response contingent on the urge perform a tic. Individuals are instructed to contract ticoppos ing muscles for 1 to 3 minutes or until the urge to has pass ed. T his intervention may be us eful for some individuals , but to date, only small clinical trials have undertaken. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > T R E AT ME NT OF ADHD IN T H E

TR E ATME NT OF ADHD IN PR E S E NC E OF TIC S 4222 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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P art of "42 - T ic Dis orders " T he treatment of ADHD dis order in patients with a personal his tory of tics is common, complex, and controvers ial. In addition to class room interventions small clas ses, close monitoring, preferential seating in clas sroom, ass ignment of a teacher's aide, and other accommodations) and behavioral interventions at (e.g., parent management training and behavioral modification are often es sential when the child disruptive behavioral problems ), medications are often indicated to reduce the impact of ADHD on the child's development. S timulants , s uch as methylphenidate and amphetamine preparations , are the firs t-line treatments ADHD. Until recently, however, stimulants were contraindicated in children with tic disorders . T his contraindication was bas ed on multiple clinical reports which tics increased after expos ure to s timulants . observations fit with findings from animal s tudies the emergence of s tereotypical movement in res ponse stimulants. Despite this body of data, results of s everal recent s tudies have s hown that short-term and longstimulant treatment does not invariably increas e tics in children with T ourette's s yndrome and ADHD. T hus, stimulants need not be ruled out completely in children with ADHD and a tic disorder. Although thes e drugs be us ed s afely in s ome individuals with tics, in a s mall percentage of cas es , they can precipitate de novo tics can exacerbate preexisting tics. C onsequently many clinicians begin with clonidine or guanfacine (T enex), which, although not as potent as the s timulants , appear less prone to exacerbating tics . Other nonstimulant medications with empirical s upport include des ipramine 4223 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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(Norpramin), bupropion (Wellbutrin), deprenyl and atomoxetine (S trattera). G uanfacine and clonidine are α-2 agonists that were developed as antihypertens ive agents . As noted previous ly, clonidine has been used in the treatment of since the late 1970s . G uanfacine is newer compound has only recently been evaluated in children. T he α-2 agonis ts s timulate presynaptic adrenergic receptors in LC brain. T hese specialized cells in the LC are the source of norepinephrine in the brain. Once released, norepinephrine influences prefrontal cortical function long axons. Dysregulation of the norepinephrine believed to contribute to inattention, dis tractibility, and poor impulse control. T he beneficial effects of clonidine were pres umed to be due to its regulatory effects on firing. More recent evidence from several lines of suggests that the α-2 agonists may have direct effects on prefrontal function.

C lonidine E arly s tudies showed modest benefit for clonidine for treatment of ADHD. T hes e s tudies offered little to clinicians owing to s mall s ample sizes and study problems . T he most common advers e effect of sedation. Other s ide effects include irritability and sleep disturbance. T he typical dose of clonidine ranges from to 0.30 mg per day in three or four divided doses . Des pite the inconclusive evidence, clonidine alone or in combination with stimulants has become an accepted treatment among practicing clinicians. T he of four children who had been treated with clonidine methylphenidate, however, rais ed questions about the 4224 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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safety of this combination. Although there is agreement that neither drug, nor the combination, was res ponsible for thes e s udden deaths, there were no s tudies on the us efulnes s and safety of clonidine and until recently. T he T ourette S tudy G roup recently completed a double-blind trial in which 136 s ubjects were randomly as signed to one of four groups : clonidine alone, methylphenidate alone, clonidine plus and placebo. Methylphenidate and clonidine were superior to placebo. T he largest treatment effect was as sociated with the combined treatment, which s howed approximately a 40 percent improvement over placebo. T here was no significant increase in tics for the methylphenidate group. Nonetheles s, study clinicians, who were blind to treatment as signment, opted not to increase the dos e of methylphenidate in one-third of cases due to concern about causing tics .

G uanfac ine G uanfacine is a longer-acting α-2 agonist that is les s to have sedative side effects. Accumulating data from animal s tudies provide convincing evidence that guanfacine is more s elective for direct action in cortex than clonidine. T hree early, open-label studies showed s omewhat incons is tent, although overall encouraging, results for guanfacine in ADHD. was well tolerated, with no advers e effects on heart blood pres sure. Mild sedation early in treatment was most common s ide effect. P.3235 4225 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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T o evaluate the efficacy and s afety of guanfacine in children with ADHD and a tic dis order, the author and colleagues randomly ass igned 34 children to placebo under double-blind conditions . After 8 weeks treatment, guanfacine was ass ociated with a s ignificant improvement of 37 percent on the ADHD R ating S cale compared to an 8 percent improvement for placebo. B y contrast, there was only a modest difference in ADHD symptoms bas ed on parent rating. T he tics in this were relatively mild. Nonetheless , guanfacine was as sociated with a 30 percent improvement compared no change in the placebo group. One guanfacine with sedation withdrew at week 4. G uanfacine was as sociated with ins ignificant decreas es in blood and puls e. T he dose of guanfacine is likely to fall 1.5 to 4.0 mg per day given in three divided dos es. A typical schedule for a middle school child might be 1 given before s chool, 1 mg immediately after s chool, mg at bedtime. It may take 4 weeks to get to this dose. P os itive findings from early randomized, clinical trials of the s pecific norepinephrine reuptake blocker, have been replicated by a recent 6-week, placebocontrolled study in 41 children with ADHD and a tic disorder. At a mean dos e of 3 mg/kg per day in two divided dos es, desipramine was ass ociated with a 50 percent decline in clinician-rated ADHD s ymptoms for active treatment group compared to a 4.5 percent decrease in the placebo group. T he study als o s howed desipramine was ass ociated with a 31 percent drop in severity, which was s ignificantly better than the 3 decline in the placebo group. Des pite these res ults, many clinicians remain reluctant to us e 4226 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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desipramine owing to concerns about prolonged conduction times. Atomoxetine (S trattera), which is a compound with a s imilar mechanis m of action without as sociated cardiac conduction concerns, is of interes t has s hown promis ing results in preliminary s tudies. T he novel antidepres sant, bupropion, has been s tudied several controlled trials . T he larges t and most recent compared bupropion to placebo in a controlled study K eith C onners and colleagues. In that s tudy, bupropion was significantly better than placebo on a teacher ADHD s ymptoms, achieving approximately 27 percent improvement compared to 9 percent reduction in the placebo group. T here was a s mall, statis tically difference between groups on the parent rating. In ranging from 150 to 250 mg per day in two divided bupropion was generally well tolerated. F our s ubjects bupropion were withdrawn owing to a skin ras h with urticaria; three s ubjects s howed mild and probably related changes in the E E G . T his is of interest becaus e seizures have been reported in children treated with bupropion. T he E E G changes and s eizure activity are presumed to normalize after discontinuation of the E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > F UT U R E DIR E C T IO

FUTUR E DIR E C TIONS P art of "42 - T ic Dis orders " T ourette's s yndrome is a chronic dis order of childhood onset that cons is ts of multiple motor and phonic tics . 4227 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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show a waxing and waning pattern in childhood, with a tendency for a gradual decline by early adulthood. C omorbid conditions, particularly ADHD and OC D, are relatively common in clinically as certained cas es . Other comorbid conditions include oppositional and defiant behavior, aggress ive behavior, anxiety, and explos ive behavior. W hen present, thes e comorbid features may produce greater impairment than tics . T he etiology remains unknown, and genetic and environmental influences play a role. T he of T ourette's syndrome involves s ubtle dysregulation of cortical-striatal-thalamocortical circuits. Although there likely to be variations on a theme, this dys regulation appears to involve failed inhibition of output pathways from the basal ganglia. T he contemporary approach to treating children and adoles cents with tic disorders begins with identification target s ymptoms . When tics are the target of pharmacotherapy, the goal is to reduce the tics rather than complete elimination of tics , which likely res ults in the accumulation of unwanted advers e Although traditional antips ychotics may still repres ent standard treatment for tics , many clinicians are us e these agents , owing to concern about the potential short-term and long-term s ide effects . T hus, the data s howing that the atypical antips ychotics , s uch as ris peridone and ziprasidone, are effective for tics are of interest. A handful of nonantipsychotics, including clonidine, guanfacine, tetrabenazine, and botulinum toxin injections, have shown s ome for suppres sing tics , but more s tudy is needed. C omorbid ADHD is common in children with T ourette's 4228 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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syndrome; treatment with s timulant medications somewhat controversial, although recent data s uggest that s timulants may be us ed in s ome children with T ourette's s yndrome without adverse effects . S everal nonstimulant medications have been us ed in the treatment of ADHD with s ome s ucces s. W hen pres ent, OC D s hould be treated in a s imilar manner to OC D in patients without tics . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > S UG G E S T E D C R OS S -R E F E R

S UGGE S TE D C R OS S R E FE R E NC E S P art of "42 - T ic Dis orders " S ection 44.2 discus ses s tereotypic movement disorder. OC D is covered in C hapter 14, and S ection 2.6 the neurops ychiatric as pects of movement disorders . F urther dis cus sion of various drugs us ed to treat tic disorders is given in S ection 31.5 on clonidine, S ection 31.16 on dopamine receptor antagonists, and S ection on medication-induced movement dis orders. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 42 - T ic Dis orders > R E F E R E NC

R E FE R E NC E S B ruggeman R , van der Linden C , B uitelaar J K , G S , Hawkridge S M, T emlett J A: R is peridone versus pimozide in T ourette's dis order: A comparative 4229 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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blind parallel-group s tudy. J C lin P s ychiatry. C omings DE : C linical and molecular genetics of and T ourette s yndrome. T wo related polygenic disorders . Ann N Y Acad S ci. 2001;931:50. Devor E J , Magee HJ : Multiple childhood behavioral disorders (T ourette s yndrome, multiple tics, ADHD OC D) pres enting in family with balanced translocation. P s ychiatr G e net. 1999;9:149. Dion Y , Annable L, S andor P , C houinard G : in the treatment of T ourette syndrome: A doubleplacebo-controlled trial. J C lin P s ychopharmacol. 2002;22:31. F ord R , G reenhill L. S timulant medication in the treatment of ADHD. In: Martin A, S cahill L, Leckman C harney D, eds . P rinciple s and P ractice in P e diatric P s ychopharmacology. New Y ork: Oxford P ress ; G ilbert DL, Dure L, S ethuraman G , R aab D, Lane J , F R : T ic reduction with pergolide in a randomized controlled trial in children. Neurology. 2003;60:606. J ankovic J : T ourette's s yndrome. N E ngl J Me d. 2001;345:1184. *K ing R A, S cahill L, Lombroso P , Leckman J F . syndrome: P harmacotherapy. In: Martin A, S cahill L, Leckman J F , C harney D, eds . P rinciple s and P ediatric P s ychopharmacology. New Y ork: Oxford 4230 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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2003. K urlan R , McDermott MP , Deeley C , C omo P G , E apen S , Andres en E M, Miller B : P revalence of tics schoolchildren and as sociation with placement in special education. Neurology. 2001;57:1383. Leckman J F : T ourette's syndrome. L ance t. 2002;360:1577–1586. *Leckman J F , Zhang H, V itale A, Lahnin F , Lynch K , B ondi C , K im Y S , P eterson B S : C ourse of tic T ourette syndrome: T he firs t two decades. 1998;102:14. Mason A, B anerjee S , E apen V , Zeitlin H, R oberts on T he prevalence of T ourette syndrome in a school population. Dev Me d C hild Ne urol. Mink J W : Neurobiology of bas al ganglia circuits in T ourette syndrome: F aulty inhibition of unwanted motor patterns? Adv Neurol. 2001;85:113. Murphy T K , S ajid M, S oto O, S hapira N, E dge P , Lewis MH, G oodman WK : Detecting pediatic autoimmune neuropsychiatric dis orders ass ociated with streptococcus in children with obsess ivecompuls ive disorder and tics . B iol P s ychiatry. P auls DL: Update on the genetics of T ourette Adv Neurol. 2001;85:281.

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P eterson B S , Leckman J F , Arns ten A, Anderson S taib LH, G ore J C , B ronen R A, Malison R , S cahill L, DJ . Neuroanatomical circuitry. In: Leckman J F , DJ , eds . T ourette 's S yndrome—T ics , O bs e s s ions , C ompuls ions : Developme ntal P s ychopathology and C linical C are . New Y ork: J ohn Wiley & S ons, Inc; P eterson B S , Leckman J F , Lombroso P , Zhang H, K , C arter AS , P auls DL, C ohen DJ . E nvironmental protective factors . In: Leckman J F , C ohen DJ , eds . T ourette 's S yndrome—T ics , O bs e s s ions , Deve lopme ntal P s ychopathology and C linical C are. Y ork: J ohn W iley & S ons , Inc; 1999. P eterson B S , T homas P , K ane MJ , S cahill L, Zhang B ronen R , K ing R A, Leckman J F , S taib L: B as al volumes in patients with G illes de la T ourette syndrome. Arch G e n P s ychiatry. 2003;60:415–424. P iacentini J , C hang S : B ehavioral treatments for T ourette syndrome and tic disorders : S tate of the Adv Neurol. 2001;85:319. S allee F R , K urlan R , G oetz C , S inger H, S cahill L, Dittman V M, C happell P B : Ziprasidone treatment of children and adoles cents with T ourette's s yndrome: pilot study. J Am Acad C hild Adole s c P s ychiatry. 2000;39:292. P.3236 S cahill L, C happell P B , K im Y S , S chultz R T , 4232 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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S hepherd E , Arns ten AF , C ohen DJ , Leckman J F : A placebo-controlled study of guanfacine in the treatment of children with tic dis orders and attention deficit hyperactivity disorder. Am J P s ychiatry. 2001;158:1067. S cahill L, K ing R A, S chultz R T , Leckman J F . us e of diagnostic and clinical rating ins truments. In: Leckman J F , C ohen DJ , eds . T ourette 's O bs e s s ions , C ompuls ions : De velopme ntal P s ychopathology and C linical C are. New Y ork: J ohn & S ons, Inc; 1999. S cahill L, Leckman J F , S chultz R T , K atsovich L, B S : A placebo-controlled trial of ris peridone in syndrome. Neurology. 2003;60:1130–1135. S cahill L, T anner C , Dure L: T he epidemiology of T ourette s yndrome in children and adolescents. Adv Neurol. 2001;85:261. S imonic I, G ericke G S , Ott J , W eber J L: genetic markers ass ociated with G illes de la syndrome in an Afrikaner population. Am J Hum 1998;63:839. S imonic I, Nyholt DR , G ericke G S , G ordon D, N, Ledbetter DH, Ott J , W eber J L: F urther evidence linkage of G illes de la T ourette s yndrome (G T S ) susceptibility loci on chromos omes 2p11, 8q22 and 11q23–24 in S outh African Afrikaners. Am J Med 2001;105:163. 4233 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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S pencer T , B iederman J , C offey B , G eller D, B earman S K , T arazi R , F araone S V : A double-blind comparis on of desipramine and placebo in children adoles cents with chronic tic disorder and comorbid attention-deficit/hyperactivity dis order. Arch G e n P s ychiatry. 2002;59:649. S pencer T , B iederman J , C offey B , G eller D, Wilens T : T ourette disorder and ADHD. Adv Neurol. 2001;85:57. S pencer T , Heiligens tein J H, B iederman J , F aries K ratochvil C J , C onners C K , P otter W Z: R esults from proof-of-concept, placebo-controlled s tudies of atomoxetine in children with attentiondeficit/hyperactivity disorder. J C lin P s ychiatry. 63:1140. *S ukhodols ky DG , S cahill L, Zhang H, P eterson B S , R A, Lombroso P J , K ats ovick L, F indley D, Leckman Dis ruptive behavior in children with T ourette's syndrome: As sociation with ADHD comorbidity, tic severity, and functional impairment. J Am Acad Adoles c P s ychiatry. 2003;42:98. *T he T ourette S yndrome Ass ociation International C ons ortium for G enetics: A complete genome sib-pairs affected with G illes de la T ourette Am J Hum G ene t. 1999;65:1428. *T he T ourette's S yndrome S tudy G roup: T reatment ADHD in children with tics: A randomized controlled 4234 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/42.htm

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trial. Neurology. 2002;58:527. Zhang H, Leckman J F , P auls DL, T sai C P , K idd K K , C ampos MR : T he T ourette S yndrome As sociation International C onsortium for G enetics : G enome wide scan of hoarding in s ibling pairs both diagnosed with G illes de la T ourette s yndrome. Am J Hum G ene t. 2002;70:896.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 43 - E limination Dis orders > 43 - E limination Dis order

43 E limination Dis orders E dwin J . Mikkels en M.D. 

E NUR E S IS



E NC OP R E S IS

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S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 43 - E limination Dis orders > E NUR E S I

E NUR E S IS P art of "43 - E limination Dis orders " Although references to enuresis date back almost to beginning of recorded history, it has only been within recent decades that there has been s ubs tantial the unders tanding and treatment of the dis order. A literature s earch using the key terms enures is and (0 to 18 years) for the past ten years yielded 822 T his s us tained level of published literature is reflective the significant advances that have been made in the treatment of this dis order, as well as the increas ed into its etiology. F or example, the long-standing observation that enuresis tends to run in families has 4236 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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evolved into s tudies of large pedigrees , which have pointed toward s pecific genetic loci. R es earch into the mechanism of action of desmopres sin acetate which has become the predominant pharmacological treatment, has led to increas ed unders tanding of the pathophys iology of the dis order. T his evolution of knowledge illustrates how the s ys tematic application of scientific methods can, over time, yield significant into a developmental disorder that was mis understood centuries .

Definition E nure s is is currently defined as the involuntary or intentional voiding of urine. T he severity is determined the frequency of urination; quantity is not a diagnostic cons ideration per se. Quantity can become a factor in treatment decisions if a child emits only s mall urine; in actual practice, quantity usually does not heavily in the treatment plan. F requency, however, can important in planning a hierarchy of treatment approaches. T he major diagnostic qualifier relates to of ons et. F inally, the definition precludes a phys ical for the disorder. T he length of time before continence is considered es tablis hed varies in the literature between 6 months 1 year. T he revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ) addres s that s pecific chronological is sue but rather to “a ‘primary’ type in which the individual has never es tablis hed urinary continence, and a ‘secondary’ type which the disturbance develops after a period of es tablis hed urinary continence.” In practical terms, 4237 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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children who have never maintained continence for than 1 year are referred to as having primary e nure s is , whereas children who have achieved continence for 1 or longer and then have lost it are referred to as having s e condary e nure s is . T he disorder is also further defined according to the of the epis odes throughout the day. E pisodes occurring only at night are referred to as nocturnal; daytime is labeled diurnal. Mos t children dis play only nocturnal enures is , but s ome manifest diurnal or nocturnal and diurnal patterns.

His tory A s cholarly review of the history of enures is found references dating back to the P apyrus E bers of 1550 T he term itself actually derives from the G reek word enoure in, which means to void urine. In retros pect, the treatment approaches that were us ed in the past appear almos t sadis tic in nature. Although some of interventions may have been mis guided but wellintentioned therapies (such as the use of leeching for disorders ), they may als o reflect the commonly held that the disorder is s omehow under the (direct or control of the child and that punis hment would lead to cess ation. A confluence of s omewhat dis parate observations has contributed to the evolution of current understanding of enures is . Although each of these is discus sed in more detail in the following sections , a brief reference to here helps provide an overview of the various lines of res earch and their relative contributions to present unders tanding of the disorder. T he long-standing 4238 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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observation that enuresis tends to run in families into the observation that a positive family history was a positive prognos tic indicator for respons e to pharmacological interventions and, ultimately, to sophisticated research with large pedigrees pointing toward s pecific genetic loci and modes of trans miss ion. T he observation that imipramine (T ofranil) was an treatment for enures is ushered in the modern era of res earch, as the efficacy of imipramine suggested biological contributions to the etiology of the disorder. Imipramine has now been largely supplanted by a pharmacological treatment modality, and related res earch into its mechanis m of action has contributed interes ting insights into the pathophysiology of the disorder. J uxtaposed with the research into pharmacological treatment and organic contributions to the disorder has been the impres sive literature, which dates back s everal decades, indicating that behavioral treatment in the form of the bell-and-pad method of conditioning is equally effective to the two leading pharmacological interventions for the dis order. T he observation that the wetting episodes usually occur at night has als o led to decades of research investigating relation between sleep architecture and the occurrence enuretic events. Although none of thes e lines of has provided a parsimonious explanation, each has provided important contributions to the evolving unders tanding of the disorder.

C omparative Nos ology T he variety of differing nosological and diagnostic schemas s een with many dis orders does not exist for enures is . T he behavior is concrete and definite: T he 4239 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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wets or does not. T hat criterion makes it pos sible to integrate research data from different countries , and treatment centers with a greater reliability than is poss ible for many other dis orders. T he efficacy of a treatment is reported in terms of its impact on the frequency of enuretic events . T he primary differences regard to diagnosis concern the frequency required to make a diagnosis P.3238 of enuresis as a pathological state and the period of continence necess ary to s eparate primary from enures is , with a duration of 6 months occasionally us ed ins tead of 1 year. Only s light differences exist between the tenth edition of the Inte rnational S tatis tical C las s ification of Dis e as e s and R e late d H ealth 10) and the DS M-IV -T R . IC D-10 states that enures is not ordinarily be diagnos ed in a child under the age of years or with a mental age under 4 years .” T his is different from the DS M-IV -T R cut-off of 5 years for chronological and mental age. However, the tables that accompany IC D-10 indicate the s ame 5-year cutoff for chronological and mental age as is found in DS M-IV T he IC D-10 als o notes a change in required frequency enures is after 7 years of age (at leas t twice a month and once a month after).

E pidemiology T he firs t comprehens ive data concerning the incidence enures is came from the Is le of W ight study. In that was found that 15.2 percent of boys (7 years of age) enuretic less than once a week, whereas 6.7 percent 4240 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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wetting at leas t once a week or more. In 7-year-old the frequency was 12.2 percent for thos e wetting les s once a week and 3.3 percent with a frequency of once week or more. B y 9 and 10 years of age, 6.1 percent of boys were wetting les s often than once a week, and percent were wetting once a week or more. T he corres ponding figures for 9-year-old and 10-year-old were 3.5 percent wetting less than once a week and percent wetting once a week or more. T he frequency boys decreas ed considerably by 14 years of age, at time 1.9 percent were wetting les s than once a week, 1.1 percent were wetting at a frequency of once a week more. T he rates als o decreased for girls by 14 years of with 1.2 percent wetting less than once a week and 0.5 percent wetting once a week or more. A New Zealand s tudy involving 8-year-old children the prevalence of nocturnal enuresis to be 7.4 percent, with 3.3 percent labeled primary and 4.1 percent secondary. A s imilar large S candinavian s tudy year-old children reported a prevalence of 9.8 percent, with the highest prevalence (6.4 percent) involving children with nocturnal enures is, 1.8 percent with enures is , and 1.6 percent with mixed nocturnal and enures is . A report from Australia des cribed an 5.1 percent for children in the range from 5 to 12 years age. T he point prevalence figures cited in DS M-IV -T R are 7 percent of boys and 3 percent of girls at 5 years of age, dropping to 3 percent of boys and 2 percent of girls by years of age. Only 1 percent of boys s till wet at age 18 years of age, and still fewer girls wet at this age. DS Malso cites a s pontaneous remiss ion rate of between 5 4241 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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percent and 10 percent per year after 5 years of age. S econdary enuresis may occur at any time but most commonly begins between 5 years of age and 8 years age.

E tiology Inclusion in the DS M-IV -T R definition of enuresis of children who wet intentionally with thos e whose is involuntarily can be problematic. T he vast majority of enuretic children do not wet intentionally or even on a subcons cious ly motivated bas is. Increas ingly, the is pointing toward caus al factors that may involve irregularities in physiological process es. C learly, who wet intentionally are in a different grouping than thos e who do s o on an involuntary basis, even if they do meet the other diagnos tic requirements. T he most likely explanations for voluntary intentional wetting are an oppos itional defiant dis order or a disorder. T here are also a s mall number of children originally have enuretic events involuntarily and subs equently manifes t the behavior on a voluntary learned basis as well. T here is a correlation between enures is and disturbance that increas es with age. T his as sociation is even more significant for enuresis, which persis ts into adoles cence. C hildren living in s ocially disadvantaged situations and experiencing psychosocial s tress have a greater frequency of enuresis than thos e who are not. type and range of behavioral disturbance seen in with enuresis are broad, and no marker can reliably differentiate between behaviorally dis turbed and nondis turbed enuretic children. T hus, the ass ociated 4242 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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behavioral disturbances are nonspecific and may a coincidental or secondary relationship rather than a caus al correlation. F urther s upporting a secondary correlation are the repeated findings that children with enures is have s ignificantly more developmental delays than nonenuretic children, compared to controls and other children attending a ps ychiatric clinic. One comprehensive effort reviewed the ps ychodynamic literature concerning enuresis and encopres is to define concepts conveyed in that literature and then to determine empirically how often thos e concepts were verified and s upported by the analysis of clinical T he literature review yielded 24 generalizations that cons istently applied to enuretic and encopretic subs equent s tatistical analysis of the clinical material, 2 of the 24 generalizations reached statis tical One of the most comprehens ive s tudies in this regard a s tandardized behavioral rating scale, the E yberg B ehavior Inventory (E C B I), which was applied to with primary nocturnal enuresis (P NE ) (N = 92), a nonclinical control s ample (N = 92), and a clinical (N = 92). T he res ults indicated that the children with had higher scores than the nonclinical control s ample significantly lower s cores than the clinical s ample. However, the mean score for the children with P NE actually lower than the clinical cut-off score that had determined for the E C B I. R elated to the iss ue of the as sociation between disturbance and P NE are s tudies that address the frequency of diagnos tic comorbidity. T he most reported comorbid diagnos is is attentiondeficit/hyperactivity dis order (ADHD). In general, 4243 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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have reported that the cooccurrence of ADHD and approximately 30 percent greater than the frequency would be expected from chance alone. A large contemporary study found that 32 percent of children diagnosed with ADHD als o met diagnos tic criteria for enures is , whereas only 14 percent of a control group the criteria. T his finding was statis tically s ignificant at (P <.001) level. T he rates of primary and secondary were not significantly different in the two groups . T his study then investigated the degree of ps ychopathology and impairment in the ADHD children (with and without comorbid enuresis) and found no significant S imilar findings were reported for the rates of ps ychopathology when the control children with were compared to those without. T hus , the diagnosis of enures is did not appear to increase the risk of ps ychopathology for the controls or the degree of impairment in the children who also had a diagnosis of ADHD. However, there was a higher incidence of disabilities and impaired academic performance in the control children with enuresis when compared to the control children without enures is . T his difference in the incidence of learning disabilities was not found when ADHD children with enures is were compared to those without the comorbid disorder, s o the cooccurrence of enures is did not appear to increas e the ris k of learning disabilities in children with ADHD. Another investigation used a family pedigree methodology to s tudy the transmis sion of enures is in relatives of index family members who were diagnosed with P NE and in control probands who were diagnosed with ADHD, as compared to thos e without this 4244 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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T he res ults indicated that the transmis sion of the two disorders were independent of each other. An attempt to as certain the incidence of comorbid enures is in children with s elective mutis m (as controls) reported that 7.4 percent of the control group had enures is , as compared to P.3239 29.6 percent of the children who were diagnosed with selective mutism. T he as sociation between behavioral dis turbance and enures is is s tronger with secondary enures is . T his has demonstrated by controlled s tudies and anecdotal of an ass ociation between the ons et of enures is and loss of a parent through divorce or death. However, it should be noted that a large s tudy from the reported similar rates of ps ychopathology in children primary enures is , as compared to those with s econdary enures is . T he prevalence of psychodynamic factors in children with s econdary enures is would intuitively make sens e as they have, by definition, demonstrated the phys iological competence to maintain continence for a prolonged period of time before los ing that ability. T he most specific study of this as sociation indicated that expos ure to four or more stress ful life events in a year delayed acquis ition of nocturnal continence were risk factors for the development of s econdary enuresis. An as sociation between the occurrence of traumatic and the development of s econdary enuresis has also demonstrated. T here has been one innovative attempt to explore the 4245 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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poss ible relation between phys iological and factors . S pecifically, it was postulated that children with enures is who did not present with a concomitant behavioral disturbance would be thos e with or abnormal bladders, whereas those with a behavioral disturbance would be more apt to have normal T he study found the convers e to be true; the group with behavioral disturbance had more dysfunctional with lower volumes. T he behaviorally disturbed group had a greater number of developmental delays. A subs equent investigation reported no difference in bladder size between controls , children with P NE , and those who had been diagnos ed with P NE but who were now continent. It has also been demons trated by two independent investigations that fluid loading can precipitate enures is in children who have no prior of enuretic events . T he observation that enuresis tends to occur in family members has been made for some time. A large S candinavian study involving more than 3,000 children found that a child's ris k for developing enuresis was 5.2 times greater if the mother als o had the disorder and times greater if the father had the disorder, lending support to a genetic influence. DS M-IV -T R notes that concordance rate for enures is is greater in twins than in dizygotic twins , and 75 percent of children with enuresis have a s imilarly affected first-degree biological relative. W ithin the las t few years, there have been tremendous advances in regard to the genetic transmis sion of enuresis, which sugges ts that genetic contributions are likely to be s ignificant in families with multigenerational histories of enuresis. A S candinavian 4246 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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group identified 11 families that manifested P NE over three generations in a pattern that was s uggestive of autos omal-dominant inheritance, with penetrance than 90 percent. G enetic linkage s tudies with thes e families indicated markers on chromos ome 13q. designed studies have als o implicated chromos omes 12Q, and 22, s ugges ting genetic heterogeneity. A large multigenerational study, which s pecifically inves tigated chromosome 22, found that only 39.3 percent of had linkage to genetic markers on this chromos ome. genetic modes of transmis sion that have been include s poradic, autos omal reces sive, and autosomal dominant. T he most recent linkage s tudies have the pos sibility of mutation in the aquaporin-2 (AQP 2) water channel locus in families with a dominant mode transmis sion of primary enures is , because AQP 2 be es sential for concentrating urine. One particularly important etiological hypothes is was urinary tract obs truction frequently caused enures is. significance of that belief evolves around the related implications for surgery to correct the obs truction. E xtens ive review of the relevant literature found no for concluding that bladder neck repair or urethral was a reasonable or effective treatment for enuresis. generalization does not apply to patients with s pecific anatomical or pathophys iological findings. R es earch into the ass ociation between sleep and enuretic events has evolved s teadily s ince the T he res earch can be s een as evolving through the following four s tages. During the firs t phase of the res earch, it was postulated that enuretic events were dream equivalents that occurred in deep sleep. T he 4247 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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second major theory grew out of the obs ervation that enuretic events originated in delta sleep and followed arousal s ignals . T hus, enures is was seen as a dis order arousal, which led to the hypothes is that enuretic who were not ps ychologically dis turbed did not produce arousal s ignals , whereas behaviorally dis ordered did but failed to respond to them. T he third phas e of sleep research is represented by the larges t controlled s tudies, both of which found that, the time of night is als o cons idered, enuretic events in all sleep stages in proportion to the amount of time spent sleeping in each stage. A fourth phas e of inves tigation has attempted to couple cystometry with sleep studies in an attempt to identify s ubtypes . A long-debated is sue has been whether children with nocturnal enures is are more difficult to awaken from than other children. E arlier literature had sugges ted anecdotal reports from the parents of children with enures is that they were difficult to arouse stemmed their lack of experience in attempting to arouse their children, who did not have enures is , from a deep sleep. However, recent s tudies have s uggested that children enures is may, in fact, be more difficult to arouse than control children. T he efficacy of DDAV P as a treatment for enuresis has to the theory that some children lack the ability to concentrate urine produced during the night and thus cannot reduce urine volume and manifest enuretic episodes as a result. T hat hypothesis has led to inves tigating the circadian variation of plas ma atrial natriuretic peptide (ANP ). C hildren with enuresis have cons istently been found to differ from controls with 4248 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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to ANP . In one s tudy, 14 of 55 children with enuresis lower ANP concentrations than controls , and 9 of the children had an excellent respons e to treatment with DDAV P . An investigation into the concentration of vasopres sin in plasma and urine in 18 children with and 20 matched controls found the concentration of vasopres sin in plasma at 8:00 AM was s ignificantly the enuretic group. T otal 24-hour urinary vasopres sin excretion was als o lower in the enuretic group but not significantly s o. Another hypothesis that has been inves tigated is that endogenous arginine vas opress in (AV P ) levels would different in children with enures is who res pond to as oppos ed to those who do not. T his would sugges t exis tence of a s pecific s ubgroup of children with based on their endogenous AV P levels and their res ponse to DDAV P . A s tudy involving a s mall number subjects s upported this hypothes is by indicating that levels in the morning differentiated between controls children with enures is , as well as between DDAV P res ponders and nonres ponders . However, a large that also controlled for water intake over 72 hours and sampled AV P more frequently found that only 14 of the children with enures is had a s ignificant decrease in when compared to controls . Of these, nine had a significant positive res ponse to DDAV P . F urther complicating this line of res earch is the finding that not secreted in a continuous manner over 24 hours, but rather is s ecreted in a pulsatile pattern, sugges ting that definitive s tudies of this variable require frequent sampling. Inves tigations that have adopted this methodology have yielded conflicting results, in that 4249 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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reported no differences between DDAV P res ponders nonres ponders , whereas another s tudy with a s mall P.3240 number of s ubjects that used hourly meas urements that in the 11:00 P M to 4:00 AM time period, children enures is (N = 9) had significantly lower AV P levels than controls (N = 8). T here have als o been related studies into the role of os molality. One hypothes is is that a decreas ed ability concentrate urine could contribute to an increase in the volume of urine. In general, thes e s tudies have that children with enuresis do have lower urinary gravities (as compared to controls ), but not to a level reaches s tatistical significance. It has also been that the levels of AV P can be increased in controls and children with enures is by fluid restriction and, that plasma osmolality can effect AV P s ecretion. In this regard, a comparis on of controls , DDAV P and DDAV P res ponders indicated that fluid deprivation produced an increase in AV P levels in all groups , but res ponse was les s robus t in the DDAV P responders the other groups . Another variation on this line of research is that enures is pers is ting into adolescence and adulthood be secondary to a relative ins ens itivity to AV P , which be pos itively effected by DDAV P . T hes e observations contribute to the hypothes is that the primary pathophys iology of enures is may occur at the receptor level, and this may also explain why some children do res pond to DDAV P . 4250 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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T here have als o been inves tigations that have tubular mechanisms with regard to the urinary of potass ium and sodium by children with enuresis . Although this research has primarily focus ed on the poss ible mechanism of action of DDAV P , it has als o reanalys is of imipramine's mechanis m of action. Imipramine can produce a decrease in the excretion of sodium and potas sium, which then produces a in os molal clearance and a decreas e in urinary output. has also been reported that imipramine can affect the secretion of nocturnal urinary antidiuretic hormone and that this may account for its efficacy.

Diagnos is and C linic al F eatures T he DS M-IV -T R diagnosis criteria for enures is are T able 43-1. T hes e criteria are virtually unchanged from prior fourth edition of the DS M (DS M-IV ) criteria. T he concreteness and s implicity of enuresis make the relatively easy. T he DS M-IV -T R continues the s ame criteria that were us ed in DS M-IV by s pecifying that the diagnosis is not made in a child whos e chronological or mental age is younger than 5 years of age. T he s tated rationale is that, by this age, continence can be to have occurred. As noted by the reference to a age of 5 years of age, children with developmental disabilities may have a greater chronological age. T he wetting mus t occur at leas t twice per week for at least 3 cons ecutive months, or, if les s frequent, it mus t significant dis tres s or functional impairment. P hysical caus es, such as a bladder infection, must be excluded. Qualifiers to the diagnosis indicate whether it is primary secondary enures is . As previously noted, primary refers to those children who have never maintained 4251 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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continence for any length of time, whereas s e condary enures is refers to those who had achieved continence at least 6 to 12 months and then res umed wetting. T he other qualifiers refer to the timing of the enuretic event during the day. Although most children exhibit only nocturnal enuresis, s ome have daytime (diurnal) or a combined nocturnal and diurnal pattern.

Table 43-1 DS M-IV-TR Diagnos tic C riteria for E nures is A. R epeated voiding of urine into bed or clothes (whether involuntary or intentional). B . T he behavior is clinically significant as by a frequency of twice a week for at least 3 cons ecutive months or the pres ence of clinically significant dis tres s or impairment in s ocial, (occupational), or other important areas of functioning. C . C hronological age is at leas t 5 years of age (or equivalent developmental level). D. T he behavior is not due to the direct effect of a substance (e.g., a diuretic) or a medical condition (e.g., diabetes, spina bifida, or seizure disorder).

4252 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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S pe cify type :    Noc turnal only    Diurnal only    Noc turnal and diurnal

F rom the American P s ychiatric As sociation. Diagnos tic and S tatis tical Manual of Me ntal 4th ed. T ext rev. W as hington, DC : American P sychiatric Ass ociation; 2000, with permiss ion. T he inclusion of children who wet intentionally (with who wet involuntarily) under the same diagnos tic can be problematic, as that distinction has s ignificant clinical implications. C hildren who are wetting intentionally almost certainly are doing so as a manifestation of a ps ychological disturbance. Although there is an as sociation between behavioral disturbance and involuntary enuresis, the nature of the correlation relatively nons pecific. T hus , although the coexis tence other behavioral problems is not a diagnostic iss ue per it is of clinical importance. T he IC D-10 criteria for nonorganic enures is are pres ented in T able 43-2.

Table 43-2 IC D-10 Diagnos tic C riteria for Nonorganic E nures is 4253 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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A. T he child's chronological and mental age is at least 5 years . B . Involuntary or intentional voiding of urine into bed or clothes occurs at least twice a month in children younger than 7 years of age and at least once a month in children 7 years of age or older. C . T he enures is is not a cons equence of epileptic attacks or of neurological incontinence and is not direct cons equence of structural abnormalities of urinary tract or any other nonpsychiatric medical condition. D. T here is no evidence of any other ps ychiatric disorder that meets the criteria for other IC D-10 categories . E . Duration of the dis order is at leas t 3 months.

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioral Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion.

J ohn was a 10-year-old boy who had consistently wet bed throughout his life. He averaged three to four 4254 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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nocturnal episodes per week, and his longest period of continence was a few weeks. T hus, J ohn warranted a diagnosis of primary enures is . J ohn's father had been enuretic until 12 years of age, as were his father and a paternal uncle. Accordingly, he had always ass umed this was a genetic hereditary dis order that J ohn could control. In keeping with this perception, J ohn's parents had never adopted a punitive approach to the T he wetting was handled in a matter-of-fact manner, J ohn washing his sheets every morning and showering before going to s chool. T he family s ought cons ultation at this time, becaus e was increasingly being as ked to sleep overnight at the homes of friends and als o wanted to attend an B oy S cout camp. T hese concerns led the family to with their pediatrician, who s ugges ted a trial of the belland-pad method of conditioning. T his approach was effective, in part becaus e the family lived in cramped quarters and the alarm that was meant to awaken J ohn also woke his two brothers who shared the bedroom him. At this point, the family's pediatrician s ugges ted that meet with a child psychiatrist with whom s he worked. child ps ychiatris t described the clinical literature on DDAV P . However, when J ohn's father indicated that health ins urance did not cover pres criptions and that family was having difficulty covering their hous ehold expenses on his income, which was only moderately minimum wage, the ps ychiatris t felt compelled to the relative cos ts of DDAV P and imipramine, which only a fraction of the cost of DDAV P , because it was available in generic form. However, the psychiatrist 4255 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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indicated that J ohn would require a bas eline electrocardiogram (E C G ) (which his insurance could and that imipramine had more potential adverse P.3241 Ultimately, the family decided that J ohn would need medication only for brief discrete periods (overnights at friends and 1 to 2 weeks of summer camp), because had worked out an acceptable plan for responding to wetting on a day-to-day basis. F urthermore, they that, within approximately 2 years, J ohn would a s pontaneous remis sion of his enures is , as this was family pattern. T hus, they decided that, becaus e has a rapid onset of action, they would pay out of for the relatively s mall amounts of DDAV P that would needed for thes e discrete periods over the next 2

P athology and L aboratory E xamination B ecaus e urinary tract infections can produce enures is , urinalys is s hould be part of every evaluation. Using radiographic procedures with contrast media to detect anatomical or phys iological cause for the enures is is problematic, as the procedures are invasive and and the diagnostic yield is low. A large s tudy carried a pediatric primary care setting found a 3.7 percent incidence of obs tructive les ions in children with Others have reported s imilar findings.

Differential Diagnos is As sugges ted previously, the primary differential 4256 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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is a urinary tract infection. T his is es pecially true for who are more prone than boys to urinary tract A urinary tract infection s hould be the first for a girl who has been continent for a cons iderable of time and has recently begun wetting. Although the diagnostic yield is s maller with boys , a urinalys is still be carried out. E nuresis can result from anatomical malformations or obstructive lesions , but the percentages are relatively If the his tory and interviews with the child sugges t that enures is is intentional, then it is almos t certainly related an underlying ps ychological dis turbance. T he relation between psychological dis turbance and involuntary enures is is les s clear. T he coexis tence of another behavioral disturbance should be noted and attended clinically. T he most common comorbid ps ychiatric is ADHD. It has als o been documented that enures is has a impact on s elf-image and that enuretic children have negative feelings about their disorder, as compared to children who have other chronic illness es .

C ours e and P rognos is T he natural his tory of enuresis is s ignificant, as self-limited dis order, which can s pontaneous ly remit. fact that the diagnosis is not made until 5 years of age takes into account children who have delays in toilet training that are not outside the accepted range 2 and 5 years of age). T he prevalence of enures is is relatively high between 5 and 7 years of age and then drops off s ubs tantially. T he vast majority of enuretic children experience a s pontaneous res olution of the 4257 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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problem at some time, and only a few remain enuretic adulthood. B y 14 years of age, only 1.1 percent of boys once a week or more. T he greates t rates of remis sion occur after 7 years of age and again after 12 years of age. DS M-IV -T R cites a remis sion rate of 5 to percent per year after 5 years of age. T he peak ages secondary enures is is between 5 and 8 years of age.

Treatment T he methods for the treatment of enures is that have empirically proven to be effective are primarily and pharmacological. P s ychotherapy may be useful for ameliorating some of the as sociated behavioral that can be s een with enuresis , es pecially s econdary enures is . A particularly common clinical s cenario for secondary enures is is the development of wetting after loss of a parent through death or divorce. In thes e ps ychotherapy is the primary treatment modality. A of the efficacy of psychotherapy for primary enures is a 20 percent s ucces s rate, which is probably not significantly greater than would be expected by the rate spontaneous remiss ions and random chance.

B ehavior Therapy A comprehensive review of several s tudies determined succes s rate for behavioral interventions as 75 percent. R ecent studies have yielded comparable respons e T he primary behavioral intervention is the bell-and-pad method of conditioning. A pad is placed on the bed, wire running to a bell. W hen the child wets , the completes a circuit in the pad, ringing the bell and the child. With repeated use, the child learns to awaken 4258 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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before wetting occurs. B uzzer ulcers were a potential advers e effect of the treatment, but the frequency has decreased considerably with improved technology. S everal studies have indicated that concomitant behavioral disturbance reduces the likelihood of behavioral interventions . R ecent behavioral studies have focused on of the s tandard method and comparisons with different methods. F or example, no difference was found an audio alarm versus a vibratory alarm. A s tudy that compared the bas ic bell-and-pad method with methods which the bell-and-pad were coupled with more contingencies for wetting vers us not wetting found no statis tical difference other than a s lightly lower relaps e with the adjunctive us e of reward contingencies. One innovative s trategy involved replacing the bell-and-pad with an alarm clock timed to go off after 2 to 3 hours of sleep, when maximum bladder capacity would be expected. T he authors reported res ponses that were to results with the standard bell-and-pad method. T he relationship between bladder capacity and to behavioral treatment has als o been inves tigated. study found that bladder capacity did not affect with the bell-and-pad method of conditioning, whereas another found that children with smaller bladder capacities tended to do s lightly better when retentioncontrol training was linked to the bell-and-pad method. meticulous inves tigation into which treatment variables might relate to the efficacy of the bell-and-pad found the inability to be awoken by the alarm correlated significantly with failure, as did low-functional bladder capacity. 4259 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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T here is s ome evidence to support the use of for children who have small bladder capacities and unstable detrusors and who have been refractory to treatment. T he newes t advance in this behavioral methodology P.3242 has been the use of an external ultras onic monitor that attached to a waistband. T he monitor then s ignals the alarm when the bladder reaches maximal capacity. res earch with this device has yielded success rates to thos e with the basic bell-and-pad and has also increases in bladder capacity. T he bell-and-pad approach has als o been coupled with us e of DDAV P for children who have been refractory to prior treatment owing to family dysfunction or a concomitant behavioral disorder, or both. Although the bell-and-pad is the most intensively method of behavioral intervention, it is not the only type of behavioral treatment. A recent comprehensive this s ubject also noted other behavioral methods , s uch evening fluid res triction, nighttime toileting, rewards, overlearning, and retention-control training.

Pharmac otherapy T he initial description of imipramine's efficacy for was followed by more than 40 double-blind studies that confirmed its therapeutic value. T his marked the the pharmacological era of the treatment of enures is , imipramine being the dominant pharmacological entity us ed for more than two decades . Although imipramine now been largely replaced by DDAV P , there are s till 4260 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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reasons to include a discuss ion of its use in a comprehensive review of enuresis. Imipramine is still a cons ideration for children who are refractory to other forms of treatment. T here is also a s ignificant cost differential between imipramine and DDAV P , s o that imipramine may well be the first pharmacological for thos e families who do not have any form of and who have limited financial resources. Later s tudies with imipramine have focused on the between res ponse and concentration of imipramine in blood. Although one study found no connection positive res ponse and imipramine concentration alone in combination with its metabolite desipramine (Norpramin), three s tudies found a s ignificant relation between pos itive respons e and total concentration of imipramine and des ipramine. More s pecifically, optimal res ponse was found above combined concentrations (imipramine plus desipramine) of 60 ng/mL in one and above 80 ng/mL in another. T he most recent s tudy also found that efficacy was related to increas ing but noted tremendous variation in serum among individual children receiving the same dos age. advers e effect of dry mouth also correlates with concentration in blood, providing clinicians with a crude index of blood concentration in children who are extremely reluctant to have their blood drawn. C linically, when one encounters a his tory of a lack of res ponse to imipramine, one must ascertain the dose used, as nonres ponse is frequently related to P rimary care phys icians often pres cribe only 25 to 50 day. However, low-dose responders do exis t, and it is reasonable to s tart treatment at a daily dos e of 25 mg, 4261 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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titrating up by 25 mg every 4 to 7 days . T his enables identification of the low-dose responders, as the to imipramine usually occurs within a day or two. T he majority of children exhibit a pos itive respons e in the range from 75 to 125 mg. T he standard maximal limit dosage is 5 mg/kg body weight, and E C G monitoring is recommended at doses greater than 3.5 mg/kg. A pretreatment baseline E C G is also recommended. concentration values may als o be clinically us eful if dosages fail to elicit a res pons e. T here is the risk of overdose by the enuretic child and younger s iblings. C hildren can engage in magical and there have been reports of children who believed if taking a few pills would stop the wetting for a night, cons uming the whole bottle would make it disappear forever. T hus, parents s hould be advis ed to control the medication carefully and to store it in a secure place. S evere overdos es may require treatment with phys ostigmine (Antilirium), whereas more moderate overdoses may be treated by the symptomatic management of arrhythmias and s eizures. B ecaus e the vast majority of children at s ome point experience s pontaneous remiss ion of the enuresis, it not make sense to prescribe medication for years checking for a s pontaneous remis sion. One solution to problem is to taper the imipramine dosage at 3-month intervals . S hould enures is reappear as imipramine is tapered, it can simply be returned to the optimal level for another 3-month period. C linically, one often finds more children remain dry after 3 to 6 months of than can be expected from s pontaneous remis sion In general, treatment with imipramine s hould be viewed 4262 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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neces sary until spontaneous remiss ion occurs . T hree clinical s ubtypes of enuretic response to exis t: true nonres ponders , true res ponders who res ponse over time, and transient responders who for a few weeks and then resume wetting. Increasing dosage for transient responders us ually recaptures the res ponse but only for another few weeks , and, one reaches a point at which the dosage cannot be increased further. However, the initial transient can be replicated after a medication-free interval; thus , can use the medication for especially important, timelimited s ocial events , s uch as summer camp. As indicated previously, DDAV P has now surpas sed imipramine as the first-line pharmacological approach enures is . A thorough review done as early as 1993 18 randomized, controlled trials , including a total of 689 subjects . Many subjects had been refractory to treatment for enures is . DDAV P reduced enuretic by 10 to 91 percent in these studies . P os itive factors were age older than 9 years of age and lower pretreatment frequency of enuretic events . In mos t studies, wetting resumed after the medication was discontinued. F ollow-up studies indicated that 5.7 of children remained dry after ces sation of medication, many of those could have been due to s pontaneous remis sion. T he mos t common reported adverse effects were mild abdominal pain, epistaxis, headache, and stuffines s. S everal s ubs equent studies attempted to factors that might predict or relate to an increas ed likelihood of a pos itive respons e to DDAV P . No one appears to predict a positive res ponse, but larger functional bladder capacity and a pos itive family his tory 4263 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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enures is appear to be pos itively correlated with succes s. F actors that are not reliably related to outcome are urine osmolality, plas ma os molality, ADH secretion, urine production, and nocturnal AV P concentration. However, individual studies can be that link thes e factors with a pos itive outcome. A large contemporary, multicenter follow-up treatment study of DDAV P from S weden (N = 399) used a 4baseline obs ervation phas e, a 6-week dose titration (range from 20 to 40 μg), and a 1-year follow-up T he study des ign also included an as sess ment for the of spontaneous remis sion by means of a 1-week medication-free period every 3 months . S ixty-one (N = 245) of the children met the requirement of at 50 percent reduction in frequency during the dose titration period that was required to enter the 1-year follow-up phase of the s tudy. T he average frequency of enuretic events in the baseline obs ervation period was events per week, and this declined to 0.8 nights by the of the year-long follow-up period. As with other s tudies , older age was a pos itive prognostic sign. Of interest the observation that 77 children experienced a remis sion of their enures is within the firs t 6 months of active treatment phas e. T here has been one report of attempt to increas e the rate of spontaneous remiss ion aggres sively titrating the dosage until cess ation of is obtained and then maintaining this dose for 4 to 6 weeks before beginning to decreas e the dosage by 10 month until it is discontinued. T he authors reported by us ing this s trategy, complete remis sion was for 71 percent of the children. T he median length of follow-up was 18 months, and the mean dose of 4264 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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was 20 μg. S tudies have als o s pecifically inves tigated the efficacy DDAV P for children who were refractory to conditioning treatment and imipramine. One of these involving 52 children (dos e range from 20 to 40 μg intranas ally) complete cess ation of wetting in 53 percent, a partial res ponse in 19 percent, and minimal or no response in percent. A long-term, follow-up study (mean length of follow-up of 13 months) of children treated with DDAV P found no hematological or hormonal adverse effects . However, there P.3243 have been an increas ing number of cas e reports of hyponatremic seizures with prolonged us e. A review of articles that reported data on serum sodium in DDAV P -treated patients and 11 articles that reported individuals who developed altered cons cious nes s or a seizure while taking DDAV P for enures is concluded hyponatremia is a potential advers e effect of DDAV P treatment. T he authors als o noted that exces s fluid was a contributing factor in 6 of the 11 case reports. concluded that patients receiving DDAV P for nocturnal enures is should be advised not to consume more than of fluid on nights when DDAV P is administered. T he on hyponatremia als o s uggest that periodic monitoring serum sodium concentration would be prudent. T reatment with DDAV P has been compared to the belland-pad method of conditioning. T he difference in res ponse rate was not s tatistically s ignificant; 86 improved with the bell and pad, and 70 percent with DDAV P . Another investigation comparing the 4265 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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combined us e of the bell-and-pad method and DDAV P with placebo indicated that the combination achieved significantly more dry nights . S imilar res ults were found a s tudy comparing alarm monotherapy to alarm coupled with DDAV P . T he combination proved es pecially for children with severe, almos t nightly, T he newest innovation in DDAV P treatment is the introduction of oral tablets, which were introduced for treatment of diabetes ins ipidus and are now us ed for as well. T he nasal spray was difficult for some children us e, and this could (in some cas es) contribute to adminis tration. A controlled multicenter s tudy found no difference in respons e between oral DDAV P and the traditional nasal spray. A dos age of 400 μg produced dry nights than did a 200-μg dos e. A s ignificant dos e-effect correlation was found in a placebo-controlled study that us ed 200-, 400-, and oral dosages . In a s eparate follow-up study (7 years ), rate of spontaneous remis sion at 2 years and 7 years reported as greater than would be expected s olely on basis of spontaneous remiss ion. As with other modalities, consistent findings in the clinical literature concerning positive res ponses to DDAV P are older larger bladder capacity, and lower pretreatment of enures is .

General Treatment C ons iderations T he res ults of the studies reviewed in conjunction with natural history of enures is can help the clinician des ign decis ion tree tailored to a given child. T he first decision whether to treat at all. T hat decis ion is affected by the frequency of the wetting, the age of the child, and the 4266 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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amount of ps ychological dis tres s that the wetting the child. E nuresis has a negative impact on the selfes teem of affected children, and self-es teem improves after s ucces sful treatment. One may choose not to child who is wetting infrequently and who is at an age which a spontaneous remiss ion may be expected. If one does elect to treat, it makes sense firs t to use the bell-and-pad method of conditioning, becaus e its has been repeatedly demonstrated, and because a up behavioral technique is considered less invasive pharmacological approaches. A large follow-up study, which compared obs ervation only with imipramine, DDAV P , and the bell and pad, indicated that, although of the active treatments were s ignificantly s uperior to observation alone, the positive res ponse was much likely to be s ustained after treatment ces sation with the bell and pad than with either pharmacological Des pite these apparent advantages , one large based inves tigation revealed that only a relatively small number of enuretic children (38 percent) actually saw a phys ician, and, of that number, only 3 percent were treated with the bell-and-pad method of conditioning, whereas more than one-third received pharmacological treatment. A more geographically restricted s urvey of primary care phys icians yielded s ignificantly different res ponses , in that 80 percent of physicians indicated they recommended the bell-and-pad method of conditioning. W hen the bell-and-method of treatment is unsuccess ful or not feasible, it makes sense to pharmacological treatment, ass uming that the enuresis severe enough to warrant pharmacological F or decades, imipramine was the firs t choice for 4267 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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pharmacological treatment. Although precis e figures not available for its relative us e in the treatment of DDAV P appears to have s urpas sed imipramine as the popular pharmacological treatment. T he popularity of DDAV P will likely expand further, becaus e the oral preparation has been found to be as effective and safe the nas al spray. Only recently, with the impact of managed care, have articles appeared that address the financial cos t of the various treatments for enures is. T he bell-and-pad of conditioning appears to be the most cos t-effective treatment; it is as effective as the pharmacological approaches, is more likely to lead to sustained improvement after the ces sation of active treatment, requires only the initial expense of the apparatus and replacement pads . R ecent s uggested retail prices for basic apparatus ranged from $59.95 to $114.89, on the brand chos en. T he replacement moisture pads ranged in price from $13.99 to $21.39. Other expenses to be considered are the time of the who counsels the parents on its use and the parental involved. Imipramine is available generically, s o its cost is quite modest. A recent review of pharmacy retail prices revealed that the cos t for 100 of the generic 50imipramine tablets ranged from $69.00 to $75.38. costs would be the phys ician's time and the cost of a baseline E C G , periodic monitoring of E C G , and blood concentration determinations . DDAV P in tablet form is available generically. A recent inquiry into pharmacy prices revealed a range of $303 to $375 for 100 of the mg (200-μg) tablets . T he nasal s pray is now available generically. T he prices range from $100 to $143 for a 4268 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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bottle of the 0.01% DDAV P nas al s olution. R elated would be the phys ician's time and monitoring for serum sodium and urine os molality. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 43 - E limination Dis orders > E NC OP R E S

E NC OPR E S IS P art of "43 - E limination Dis orders " Unfortunately, encopres is does not generate the res earch interest that is found for enuresis. A recent literature s earch limited to human s tudies using the key terms encopre s is and children yielded 165 citations the current decade—as compared to 822 citations over the same time period for enuresis . T his dis parity likely represents the lower incidence of encopresis or the fact that res earch into the etiology of encopresis has not as rewarding as has the res earch with regard to or both.

Definition T he DS M-IV -T R criteria are virtually unchanged from of DS M-IV and define encopre s is with four related (1) the repeated inappropriate pas sage of feces, involuntary; (2) occurrence at least once a month for at least 3 months; (3) a chronological or mental age of 4 of age; and (4) exclus ion of a substance or medical condition as a caus e. F or several years , the clinical and res earch literature concerning encopres is has dis tinguished between 4269 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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retentive and nonretentive encopresis. DS M-IV -T R recognizes this distinction and lis ts two s ubtypes : with cons tipation and overflow incontinence and without cons tipation and overflow incontinence. T he s ubtype cons tipation and overflow incontinence corresponds to retentive encopres is and is des cribed by DS M-IV -T R follows : “F eces are characteristically (but not poorly formed and leakage can be infrequent to continuous, occurring mos tly during the day and rarely P.3244 during sleep. Only part of the feces is pass ed during toileting and the incontinence resolves after treatment the cons tipation.” T he subtype without cons tipation and overflow incontinence corres ponds to nonretentive encopresis and, as DS M-IV -T R notes , “feces are likely of normal form and consistency and s oiling is F eces may be deposited in a prominent location.” S ome clinicians refer to a primary type in which the has never es tablished fecal continence and a type in which the disturbance develops after a period of es tablis hed fecal continence. DS M-IV -T R discus ses distinction in the s ection on encopres is but does not elevate it to the level of a diagnos tic modifier.

His tory T he history of encopresis is not as richly detailed as is of enures is , poss ibly because encopresis affects fewer children, and the events are less frequent. Unless the are particularly fluid, it may also be eas ier for children hide the s ymptoms . A high frequency of encopresis enures is was found in children who were separated 4270 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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their parents in W orld W ar II, thus documenting the of environmental factors . T he more contemporary his tory of encopresis is noteworthy for the es tablis hment of a treatment methodology that involves cathartics to rees tablis h dynamics (coupled with education), which has proven be quite s ucces sful. An innovative use of biofeedback technology s howed much initial promise after its introduction in the 1980s , but it now appears that it is more effective than the older method.

C omparative Nos ology T he DS M-IV -T R has adopted the widely held clinical distinction between retentive and nonretentive encopresis, as did DS M-IV , although the terminology differs slightly. Although the current DS M-IV -T R includes voluntary and intentional encopres is , that is obviously a distinction of major clinical importance. IV -T R s tates that nonretentive encopresis (without cons tipation and overflow incontinence) “is us ually as sociated with the presence of Oppos itional Defiant Dis order or C onduct Dis order or may be the of anal masturbation.” T his s tatement appears to the exis tence of a rather s ubs tantial s ubgroup of with nonretentive encopres is who are encopretic they cannot adequately control the anal sphincter or do not recognize the need to defecate in time. T he most comprehens ive categorization of encopresis distinguishes three types of patients: (1) intentional— children who do have bowel control but intentionally depos it feces in inappropriate places for psychological reasons; (2) involuntary—those who cannot adequately 4271 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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control the sphincter or lack an awarenes s of the or both; and (3) involuntary—those whos e s oiling is related to exces sive fluid from retentive overflow (75 percent of this category), diarrhea, or anxiety. T hus, clas sification schema incorporates the retentive and nonretentive dichotomy and the dis tinction between voluntary and involuntary incontinence. T he IC D-10 diagnostic clas sification for encopresis es sentially follows this schema and allows notation of three s ubtypes. T he primary differences with the DS MT R criteria are the ability to code for three s ubtypes than two and a duration of 6 months at a frequency of least once a month, as oppos ed to the DS M-IV -T R of 3 months at a frequency of at least once a month. IC D-10 als o s tates that if encopres is coexis ts with “the coding of the encopresis s hould have

E pidemiology T wo large epidemiological s tudies have yielded res ults. T he Is le of W ight study reported a prevalence percent for boys and 0.3 percent for girls 10 to 12 age s oiling at leas t once a month. A large s tudy 8,863 children found a 1.5-percent prevalence rate for 7 years of age and 8 years of age. In that s tudy, the boys to girls was more than 3 to 1. A s ignificant relation between encopresis and enures is has also been found. DS M-IV -T R cites the prevalence of encopresis as 1 in 5-year-old children, with boys being more commonly affected than girls .

E tiology T he dramatic nature of fecal s oiling has contributed to 4272 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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ps ychodynamic s peculation. T he term chronic ne urotic encopre s is has been us ed to des cribe the s mall children whose encopres is is predominantly T he clinical characteristics described in these children (1) a distant father and neurotic mother, (2) early and harsh bowel training, and (3) a history of neurological delay. T he one s ys tematic s tudy that attempted to the clinical features us ually attributed to enuretic and encopretic children in the literature by analyzing actual case material could not substantiate the existence of the 22 factors developed through the literature review. with enuresis, the distinction between primary and secondary encopres is relates to the iss ue of ps ychopathology. A study involving 63 boys with encopresis found that boys with primary encopresis more likely to have developmental delays and enures is , whereas thos e with secondary encopres is more likely to have experienced higher levels of ps ychos ocial stress ors and to be diagnosed with disorder. Another large s tudy examined s everal ps ychological and phys iological variables in children chronic cons tipation, compared to children with encopresis unrelated to constipation. T he group with cons tipation had s ignificantly longer colonic transit whereas both groups had relatively high frequencies of abnormal defecation dynamics . No correlation between encopresis and s ocial class reported in two independent studies. T he iss ue of neurological competence as a contribution to has been investigated. One s tudy found no of anal-rectal motor or sensory function but did find that significant number of encopretic boys had abnormal 4273 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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rectal expuls ion dynamics. A sophis ticated study us ing a triple-lumen catheter attached to a manometry infus ion system found that age of ons et, frequency, and duration of encopres is were all highly correlated with the amount of anal s phincter s pas m occurred when defecation was attempted. T he amount pain reported with bowel movements correlated with frequency of encopres is and invers ely with squeeze pres sure. An investigation involving the concentrations of gastrointestinal (G I) hormones in controls and children with retentive encopres is that the latter had higher concentrations of pancreatic polypeptide after a meal and les s of a motilin res ponse. However, the authors noted that thes e abnormalities could be the result of, or the cause of, the chronic cons tipation. An extensive series of s tudies concerning phys iological factors and the interplay of phys iological and ps ychological factors has been carried out. T he phys iological findings were (1) 56 percent of children retentive encopres is could not defecate rectal balloons (res earch technique used to as ses s sphincter and most had abnormal anal sphincter contractions ; (2) only 14 percent of those who could not defecate the balloons were found to have responded to treatment at year follow-up compared to a 64 percent s ucces s rate those who could; (3) at 1-year follow-up, 70 percent of children who could relax the anal sphincter at the time initial evaluation were improved, as opposed to 13 of thos e who could not; and (4) none of the children initially presented with an abdominal fecal mass was improved at 1-year follow-up, regardless of other 4274 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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P.3245 One s ubs et of these studies physiologically compared cons tipated children to controls during the act of bearing down. All of the control children displayed decreas ed sphincter activity when bearing down, compared to 58 percent of the constipated children who could defecate balloon and 7 percent of constipated children who could not defecate the balloon. T he constipated children who could not defecate the balloon were also significantly likely to res pond to laxative treatment. Nonrelaxation of anal s phincter was found in 75 percent of encopretic children, as opposed to 13 percent of a control group in study, which used anal electromyography. T his s tudy reported lower press ures for the encopretic children, at and on squeezing; this observation has als o been by other investigators. An attempt was also made to as sess the relative impact phys iological and ps ychological factors . S pecifically, rectal manometric and electromyographic ass es sments were correlated with behavioral and s ocial competence profiles as related to treatment outcome. P sychological variables were not found to be predictive of outcome, phys iological variables were.

Diagnos is and C linic al F eatures T he DS M-IV -T R diagnostic criteria for encopres is are in T able 43-3. T he rather objective and concrete nature the encopretic event makes diagnosis relatively eas y uncomplicated from a phenomenological pers pective, if the child meets the frequency, duration, and age requirements s et forth in the DS M-IV -T R . T he 4275 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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versus intentional dichotomy is not a requirement or reason for s ubclass ification according to DS M-IV -T R , has important clinical implications. S imilarly, the versus nonretentive schema has clinical usefulness . Differentiating between primary and s econdary is important, as one might expect medical or factors to play a greater role in s econdary encopres is . IC D-10 criteria for inorganic encopresis are presented T able 43-4.

Table 43-3 DS M-IV-TR Diagnos tic C riteria for E nc opres is A. R epeated pass age of feces into inappropriate places (e.g., clothing or floor) whether involuntary intentional. B . At least one s uch event a month for at leas t 3 months. C . C hronological age is at leas t 4 years of age (or equivalent developmental level). D. T he behavior is not exclus ively due to the phys iological effects of a s ubs tance (e.g., or a general medical condition, except through a mechanism involving cons tipation.

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C ode as follows :    With cons tipation and overflow    Without c ons tipation and overflow inc ontinence

F rom the American P s ychiatric As sociation. Diagnos tic and S tatis tical Manual of Me ntal 4th ed. T ext rev. W as hington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Table 43-4 IC D-10 Diagnos tic C riteria for Nonorganic A. T he child repeatedly pass es feces in places are inappropriate for the purpose (e.g., clothing or floor), involuntary or intentionally. (T he disorder involve overflow incontinence s econdary to functional fecal retention.) B . T he child's chronological and mental age is at 4 years of age.

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C . T here is at least one encopretic event per D. Duration of the disorder is at leas t 6 months. E . T here is no organic condition that constitutes a sufficient caus e for the encopretic events .

F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioral Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion.

Henry was an 11-year-old boy with almost-daily and a number of ass ociated behaviors, including hiding the feces around the hous e. He res ided in a fos ter care setting, having been removed from his biological parents at 7 years of age because of sexual abus e. B oth parents were involved with abuse, and his early history is not well documented. However, the parents did indicate that he had never exhibited s ustained bowel continence for several Henry had also been enuretic until 6 years of age, but had res olved to an occasional nocturnal epis ode every 6 months . Henry also qualified for a diagnos is of oppositional disorder. Although he had experienced physical and abuse, he did not have flashbacks or other symptoms would meet the criteria for posttraumatic s tres s 4278 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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(P T S D). Henry als o had ADHD and was being treated with 10 mg of methylphenidate (R italin) twice a day. T he fos ter family res ided in an urban area that had to a nationally recognized children's hospital. T he ambulatory care department had a s pecialized encopresis program that coupled the bowel training method with a psychoeducational component and ps ychotherapy. T he psychiatric cons ultant to the specialized foster care program doubted that this would be s ucces sful for Henry, because he had s o as sociated psychopathology, and the feces were often depos ited around the hous e in a s ymbolic manner. the encopres is was not of the retentive-overflow type, the feces were always well formed. However, becaus e apparent harm could come from the referral, the cons ulting child psychiatrist agreed to it. Much to the surpris e of the cons ultant, the s everal-week outpatient bowel training cours e coupled with the component and ps ychotherapy resulted in a completeces sation of the encopres is. On one of her to the home, Henry proudly showed his cas e manager diagram of the functioning of the digestive system that was part of the ps ychoeducational program. In it appeared that, although there were symbolic as pects Henry's encopretic behavior, the soiling was egoand he was highly motivated to change the behavior, although this motivation could not be prospectively detected by the treatment team because of his oppos itional defiant manner of responding to adults .

P athology and L aboratory 4279 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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E xamination T he extens ive, detailed physiological studies cited previous ly s uggest that physiological factors are of importance in many encopretic children, as they with treatment outcome at 6-month and 1-year followHowever, that does not imply that a physiological that is this thorough is required for every encopretic who pres ents clinically. T he clinician needs to rule out definite phys iological illness es, such as Hirs chsprung's disease. B eyond that, clinicians might consider more detailed phys iological inves tigations, such as thos e the experiments des cribed previous ly, for children who prove refractory to conventional treatment. T hat type of specialized testing could also be difficult to obtain of an academic research center. A simple plain roentgenogram may aid in the diagnosis and of retentive encopres is. In one s tudy, 78 percent of children who met the diagnostic criteria for encopres is the revis ed third edition of the DS M (DS M-III-R ) also roentgenographic criteria, whereas 22 percent did not. It has recently been obs erved in the pediatric literature that s ome children with a condition referred to as s low trans it cons tipation may pres ent with intractable encopresis. Although the etiology of this disorder is not fully understood, a percentage of the children P.3246 appear to have abnormal innervation of the colon. signs of this disorder include severe constipation within the first year of life and refractory encopres is at an age. C olonic transit s tudies are necess ary to confirm 4280 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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diagnosis. P sychological tes ting can be us eful for thos e children exhibit concomitant behavioral problems or who are intentionally encopretic. F inally, clinicians s hould not overlook the importance of a detailed history obtained from the parents and the child that documents the time cours e, frequency, and circums tances s urrounding the encopresis.

Differential Diagnos is E ncopresis can be a symptom of other process es or a s yndrome in its elf, as described previously. T he illness es that need to be ruled out include stenos is of rectum or anus , endocrine abnormalities , s mooth disease, and Hirs chs prung's diseas e. T he child's ps ychological profile should be considered, children with mental retardation or pervas ive developmental delay may have epis odes of s oiling to thos e process es. C hildren with impuls e-control disorders or attention-deficit disorder may at times episodes of soiling related to lack of attention. A history and psychiatric as sess ment s hould make it to identify those children, as well as thos e children who soil on an intentional-oppos itional bas is . E xtreme may als o provoke encopretic epis odes in children who otherwis e functioning well.

C ours e and P rognos is As with enuresis , continued maturation provides increasing numbers of spontaneous remiss ions with T hat trend s hould be factored into the as sess ment of efficacy of any long-term intervention. T he results from 4281 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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relatively s imple behavioral interventions involving educational, behavioral, and phys iological components striking (78 percent), sugges ting that the disorder res ponds to treatment in mos t cases.

Treatment T he firs t clinical approach to encopres is is primarily behavioral, with educational and physiological components. T hat method entails initial educational interventions with the child and family around bowel function. T he process is meant to correct that the family may have and to diss ipate anxiety that develop around the soiling. T he physiological is instituted next with an initial bowel catharsis, by daily doses of laxatives or mineral oil. T he element of the program entails daily timed intervals on toilet, with success being rewarded. F ollow-up s tudies have reported a 78 percent success rate for this T he phys iological res earch findings concerning defecation dynamics in children with encopres is led to interes t in biofeedback training as an adjunctive treatment. Although this treatment received positive reports from uncontrolled studies, a review of studies indicated that biofeedback training did not additional benefit over conventional treatment. A large, long-term controlled outcome study that compared conventional treatment with biofeedback training plus conventional treatment indicated that the positive for both groups were high and quite s imilar. the conventional method yielded an 86 percent improvement rate, as compared to 87 percent for the combined group. T his suggests that the combination treatment was no better than the conventional 4282 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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alone. However, it was als o found that length of time at follow-up its elf was a powerful factor, as it significantly correlated with improvement for the group as a whole the (P <.01) level. T his indicates that the pass age of an important variable to be cons idered in any inves tigation of treatment approaches. One element of the aforementioned phys iological namely, the ability to defecate a rectal balloon, has shown to correlate with treatment outcome. A s tudy involving 139 children with constipation and encopres is and 20 controls found that all of the controls were able defecate the balloon, as compared to 47 percent of the encopretic group. One year after beginning treatment, 51 percent of the children who could defecate the balloon at baseline cons idered to be recovered, but only 34 percent of who could not defecate the balloon were improved. Although the group comparisons were cons idered significant, the balloon tes t alone could not predict res ponse to treatment on an individual bas is. P sychotherapy may be of us e for children who have concomitant behavioral problems and those with ps ychodynamic factors that appear to be es pecially and are contributing to the dis order. Naturally, ps ychotherapeutic approaches are of primary for children who are intentionally s oiling or depos iting feces in inappropriate places around the home. P harmacological treatment for encopresis has not been extensively s tudied or reported. T here are six cas e (encompas sing 15 individual patients) that have imipramine as effective for encopresis. T welve of the 4283 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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patients were boys . T he therapeutic effect had rapid onset (as it does with enures is ), occurring within few days to 2 weeks , us ually at doses of 25 to 75 mg. Although the subtype of encopres is is not clearly delineated in all of the case reports, one would that, if imipramine were to be helpful, it would be in with nonretentive encopres is. T here is one wellstudy that subs tantiated the efficacy of the prokineticpropulsive agent cisapride (P ropuls id). T his agent is no longer commercially available in the United S tates, been removed from the market owing to concerns side effects . T he relatively high success rate of the combined educational, phys iological, and ps ychological approach described makes it a reasonable first approach once diagnoses have been ruled out. P sychotherapeutic and pharmacological approaches could be considered for children who prove refractory to that form of treatment. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 43 - E limination Dis orders > S UG G E S T E D C R O S S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "43 - E limination Dis orders " S ection 1.20 covers the basic s cience of s leep, S ection discuss es learning theory, C hapter 20 reviews the disorders , S ection 30.2 discus ses behavior therapy, S ection 31.29 covers tricyclic and tetracyclic drugs . 1.17 discus ses population genetics , and S ection 1.18 4284 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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covers genetic linkage analysis. P s ychotherapy with children is dis cus sed in S ections 48.1 and 48.2. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 43 - E limination Dis orders > R E F E R E NC

R E FE R E NC E S Aikawa T , K as hara T , Uchivama M: C ircadian plasma arginine vas opress in concentration, or vasopres sin in enuresis. S cand J Urol Ne phrol. 1999;202:47. B ailey J N, Nrnitz E M, G ehricke J G , G abikian P , S malley S L: T ransmis sion of primary nocturnal and attention deficit hyperactivity disorder. Acta P ae diatr. 1999;88:1364–1368. B enninga MA, V os kuijl W P , Akkerhius G W, B uller HA: C olonic transit times and behaviour in children with defecation disorders . Arch Dis C hild. 2004;89:13. *B orowitz S M, C ox DJ , S utphen J L, K ovatchev B : T reatment of childhood encopres is: A randomized comparing three treatment protocols. J P e diatr G as troente rol Nutr. 2002;34:357. *B utler R J , R obinson J C : Alarm treatment for nocturnal enures is : An investigation of withintreatment variables. S cand J Urol Ne phrol. C ollier J , B utler R J , R edsell S A, E vans J H: An of the impact of nocturnal enuresis on C hildren's 4285 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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C oncept. S cand J Urol Ne phrol. 2002;36:204. *Deen P M, Dahl N, C aplan MJ : T he aquaporin-2 channel in autos omal dominant primary nocturnal enures is . J Urol. 2002;167:1447. Di Lorenzo C , B enninga MA: P athophys iology of pediatric fecal incontinence. G as troente rology. [S uppl 1]:S 533. E iberg H, S haumburg HL, von G ontard A, R ittig S : Linkage s tudy of a large Danis h 4-generation family with urge incontinence and nocturnal enuresis. J 2001;166:2401. E idlitz-Markus T , S huper A, Amir J : S econdary P os t-traumatic s tres s disorder in children after car accidents. Is r Me d As s oc J . 2000;2:135. P.3247 E l-Anany F G , Maghraby HA, S haker S E , AbdelAM: P rimary nocturnal enuresis: A new approach to conditioning treatment. Urology. 1999;53:405. G riffiths P , Dunn S , E vans A, S mith D, B radnam M: P ortable biofeedback apparatus for treatment of sphincter dystonia in childhood soiling and cons tipation. J Me d E ng T ecnol. 1999;23:96. Hjalmas K , Hanson E , Hells trom AL, K ruse S , S illen Long-term treatment with desmopress in in children 4286 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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with primary monos ymptomatic nocturnal enures is : open multicentre study. S wedis h E nures is T rial G roup. B r J Urol. 1998;82:704. Hunnsballe J M, Hansen T K , R ittig S , P edersen E B , Djurhuus J C : T he efficacy of DDAV P is related to circadian rhythm of urine output in patients with persis ting nocturnal enuresis. C lin E ndocrinol. 1998;49:793. Hunnsballe J M, R ittig S , P edersen E B , Djurhuus J C : deprivation in enures is: E ffect on urine output and plasma arginine vas opress in. S cand J Urol Ne phrol. 1999;202:50. Huts on J M, McNamara J , G ibb S , S hin Y M: S low cons tipation in children. J P aediatr C hild He alth. 2001;37:426. K ris tensen H: S elective mutis m and comorbidity with developmental disorder/delay, anxiety disorder, and elimination dis order. J Am Acad C hild Adole s c 2000;39:249. Lackgren G , Lilja B , Neveus T , S tenberg A: in the treatment of s evere nocturnal enuresis in adoles cents : A 7-year follow-up study. B r J Urol. 1998;81:17. Landgraf J M, Abidari J , C ilento B G J r., C ooper C S , S chulman S L, Ortenberg J : C oping, commitment, attitude: Quantifying the everyday burden of 4287 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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on children and their families. P ediatrics . Loening-B aucke V : P olyethylene glycol without electrolytes for children with constipation and encopresis. J P e diatr G as troe nterol Nutr. Longs taff S , Moffatt ME K , W halen J C : B ehavioral self-concept changes after six months of enures is treatment: A randomized, controlled trial. P ediatrics . 2000;105:935. Mikkels en E J : E nures is and encopresis: T en years progres s. J Am Acad Adole s c P s ychiatry. Muller D, Marr N, Ankermann T , E ggert P , Deen Des mopres sin for nocturnal enuresis in nephrogenic diabetes ins ipidus . L ance t. 2002;359:495. Natochin Y V , K uznetsova AA: Defect of renal function in nocturnal enuresis. S cand J Urol Nephrol. 1999;202:40. *Norgaard J P : A clinical and pharmacological model explaining res ponse to desmopress in. S cand J Urol Nephrol. 1999;202:53. Nurko S , G arcia-Aranda J A, W orona LB , Zlochis ty C is apride for the treatment of cons tipation in A double-blind study. J P e diatr. 2000;136:35. P ennes i M, P itter M, B orduga A, Minis ini S , B ehavioral therapy for primary nocturnal enuresis. J 4288 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/43.htm

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Urol. 2004;171:408. P retlow R A: T reatment of nocturnal enures is with an ultras ound bladder volume controlled device. J Urol. 1999;162:1224. T obias NE , McC ain G C : A comparis on of two alarms . Urol Nurs . 2001;21:349. T omas i P A, S iracusano S , Monni AM, Mela G , Decreas ed nocturnal urinary antidiuretic hormone excretion in enuresis is increas ed by imipramine. B r Urol. 2001;88:932. T ullus K , B ergstrom R , F os dal I, W innergard I, E fficacy and s afety during long-term treatment of primary monosymptomatic nocturnal enuresis with desmopres sin. Acta P ae diatr. 1999;88:1274. van G ingel R , R eits ma J B , B uller HA, van W ijk MP , T aminiau J A, B enninga MA: C hildhood constipation: Longitudinal follow-up beyond puberty. G as troente rology. 2003;125:357. *von G ontard A, S chaumburg H, Hollmann E , E iberg R ittig S : T he genetics of enuresis: A review. J Urol. 2001;166:2438. Wolanczyk T , B anasikows ka I, Zlotknows ki P , A, P aruszkiewicz G : Attitudes of enuretic children towards their illnes s. Acta P ae diatr. 2002;91:844.

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Wolfis h NM, B arkin J , G orodzins ky F , S chwarz R : C anadian E nuresis S tudy and E valuation: S hortlong-term s afety and efficacy of an oral preparation. S cand J Urol Ne phrol. 2003;37:22. Y ouss ef NN, Di Lorenzo C : C hildhood cons tipation: E valuation and treatment. J C lin G as troe nte rol. 2001;33:199.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 44 - Other Dis orders of Infancy, C hildhood, and Adolescence > R eactive Attachment Dis order of Infancy and E arly C hildhood

44.1: R eac tive Attac hment Dis order of Infanc y and C hildhood Neil W. B oris M.D. C harles H. Zeanah J r. M.D. P art of "44 - Other Dis orders of Infancy, C hildhood, and Adoles cence" R eactive attachment dis order of infancy and early childhood is one of the few disorders in the revised edition of the Diagnos tic and S tatis tical Manual of Dis orde rs (DS M-IV -T R ) that is applicable to children younger than 5 years of age. S ince this dis order firs t appeared in the third edition of the DS M (DS M-III), the criteria have been subs tantially revised. T he rationale DS M-IV -T R and the tenth edition of the Inte rnational S tatis tical C las s ification of Dis e as e s and R e late d P roblems (IC D-10) criteria for the disorder clearly from converging lines of res earch on institutionalized maltreated infants and young children. However, little systematic res earch validates thes e criteria, and attachment disorder of infancy and early childhood is rarely cited in the literature. T he normal development of the infant and young child's attachment s ys tem, firs t elucidated by J ohn B owlby, is 4291 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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marker agains t which behavior indicating dis ordered attachment is compared (T able 44.1-1). T wo general patterns of deviant s ocial respons es have been in publis hed case studies , and reviews of the literature disturbances of attachment in ins titutionalized or maltreated infants and young children are reflected in current criteria for the dis order. Other less well-studied more s ubtle patterns als o appear to exis t. Although the development of primary attachment relationships in childhood is reciprocal, criteria clearly specify that this disorder occurs as a res ult of gross ly pathogenic care.

Table 44.1-1 Developmental Featur C hildhood  

B irth to 2 of Age

27 Mos of Age

712 M Age

P hase of attachment

Limited discrimination.

Dis crimination with limited preference.

P refe attach

Infant differentiates among different interactive

C lear expre prefer for a s numb

C haracteris tics P hysical attributes of babyishnes s attract caregivers, 4292

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infant expres sions preference limited to olfactory and auditory and require experimental conditions to demonstrate.

partners ; infant may seem more comfortable with primary caregiver but is willing to interact readily with other s ocial partners .

careg adults separ protes strang warine are norma

A number of important is sues regarding reactive attachment disorder remain unresolved. F irs t, can the disorder be reliably diagnos ed? Does the disorder exis t within the child or within the relations hip? C an the disorder exis t when gross ly pathogenic care cannot be documented? W hat other abnormal attachment are dis turbed enough to be considered disordered? is the prevalence and natural history of the disorder? 4293 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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is the disorder related to other disorders , particularly pervas ive developmental dis orders?

DE F INITION R eactive attachment dis order of infancy and early childhood as described in DS M-IV -T R is characterized markedly disturbed and developmentally inappropriate social relatedness in mos t contexts . T hes e findings occur in the context of gros sly pathogenic care. T he disorder mus t begin before 5 years of age to meet and cannot be accounted for s olely by developmental delay. C hildren who are mentally retarded are thus to diagnose; those who meet criteria for pervasive development dis order are explicitly excluded from cons ideration for reactive attachment disorder. T wo s ubtypes are s pelled out in the DS M-IV -T R first pattern, generally linked in the literature to early childhood maltreatment, is characterized by inhibition the normal developmental tendency to seek comfort a s elect group of caregivers . R es ponses to social interactions are excess ively inhibited, hypervigilant, or highly ambivalent, reflecting the overall inhibition of the attachment s ys tem in affected children. T he s econd pattern, linked to ins titutionalization or exposure to multiple caregivers before 5 years of age, is by a relative dis inhibition of the attachment s ys tem, res ulting in diffus e and unselective attachments , and patterned behavior labeled indis criminate s ociability.

Attac hment and Development Attachment, as des cribed by B owlby in his influential trilogy, refers to a biobehavioral system whose goal is 4294 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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coordinate the balance between the need for s afety in proximity to a caregiver or s et of caregivers with the tendency for exploration and autonomy in infancy and early childhood. B owlby argued that human infants motivated by this heritable attachment system to s eek external goal of s afety in proximity to a s mall number of identified caregivers (usually with the infant's mother) an internal goal of fe lt s e curity. T his internal subjective sens e of security is influenced heavily by the the caregiver's emotional and physical availability in of need and is modified by the infant's own temperamental makeup. F rom the us ual biobehavioral shift at 7 to 9 months of age through the first 3 years of infants are thought to begin to form internal representations of their relations hips with important caregivers. T hes e repres entations (B owlby called them internal working mode ls ) form the basis for the intens e emotional bond between infants and their primary caregivers and behavior in later relationships . T his link provides evidence that attachment is s alient throughout the cours e of development. Although these representations are relatively s table, they may be by s ignificant experiences or relations hips later in life. B owlby's theoretical framework, refined from the early 1950s to the 1970s , has evoked much research since 1980s on the development of patterns of secure and insecure attachment in early childhood. T he normal developmental progres sion of attachment, captured in attachment-related behaviors , is s ummarized in T able 44.1-1. Although little of this res earch has been toward defining clinical dis orders of attachment, much it is germane to clinical medicine; ass es sment of 4295 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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attachment has become necess ary for infant mental profes sionals. P.3249 Deviant patterns of attachment like thos e reflected in criteria for reactive attachment dis order have been recognized in populations rais ed in environments by extreme deprivation. T he normative tendency to comfort actively from a res tricted number of familiar caregivers in times of distress , a hallmark of secure attachment, is commonly not apparent in many of children. Moreover, a series of anomalous behaviors in these relationships are evident and are reflected in the criteria for reactive attachment disorder. T hese anomalous behaviors are als o the hallmark for a pattern of attachment labeled dis organize d-dis oriente d. T his pattern of attachment has been identified by us ing standardized laboratory as sess ments . R ecent res earch s ugges ts that dis organized-disoriented attachment in infancy is a ris k factor for the of psychopathology. F urthermore, the antecedents of pattern of attachment are primarily environmental that impact early relationship formation. T hese findings s ugges t that subsyndromal attachment, s uch as disorganized-disoriented exis t on a s pectrum. T he findings als o s uggest that clinicians should be familiar with ris k factors impacting early caregiverinfant interactions that are related to the development of dis organized-disoriented attachment. Maternal psychopathology, child maltreatment, family violence, and poor parental s ens itivity to infant cues 4296 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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been linked to the development of disorganizeddisoriented attachment.

HIS TOR Y T he importance of early experience on infant was recognized as far back as the 13th century when Holy R oman E mperor F rederick II ordered that no one should s peak to or interact with a group of infants . His experiment, designed to see what language the would learn to s peak, ended with the premature death all its s ubjects. Notes ins cribed at the time by a monk document the devastating s ocial and emotional effects that this lack of s ocial interaction had on the infants. T his crude experiment was one of the firs t des igned to the relative importance of nature versus nurture in influencing development. T he nature-versus -nurture theme is as evident in the his tory of philos ophy as it is today in the field of experimental developmental ps ychology. T he work of Aris totle and P lato includes reflection on the relative importance of biology and environment in influencing development. T he E nlightenment in the 17th and 18th centuries brought more interest in the origins of personality; the eminent E nglis h philosopher J ohn Locke argued that the mind the infant was a tabula ras a on which layers of were imprinted to create a person with a unique personality. T his view was countered by J ean-J acques R ous seau, among others , who viewed infants as being endowed at birth with inherent goodnes s that would naturally develop, except in circums tances marked by parenting deficiency. B y the 19th century, C harles 4297 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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had s uggested that complex individual traits , including intelligence, could be largely accounted for by factors . T he continued interes t in the relative importance of and nurture has shaped much of the research in early childhood development in this century. T he relatively common practice of ins titutionalization of infants in orphanages in the firs t half of the century unwittingly provided more evidence of the detrimental effects of has been called maternal de privation. P ediatricians long argued agains t the practice of institutionalization, particularly becaus e of the high mortality rates related failure to thrive, but health care providers did not take notice of the effects of institutionalization on social and emotional development until R en S pitz in the 1940s J ames and J oyce R oberts on in the 1950s conducted rigorous s tudies (including control groups ). F ilms that showed the effects of prolonged separations from caregivers and of ins titutionalization heightened in this s ocial problem. T hese studies also led S pitz to propos e a diagnostic entity that he called anaclitic de pres s ion, which fores hadowed the DS M-III criteria reactive attachment dis order and is cons is tent with of the features of the DS M-IV -T R inhibited subtype. Anaclitic depres sion s eemed to follow prolonged separation of infants from their caregivers and was severe if the infants were old enough to have preference for that caregiver. T he eventual recognition the clinically meaningful cons equences of institutionalization led to a marked decreas e in s tateorphanages in many industrialized countries . However, recent influx of international adoptees into North 4298 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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and E urope has renewed interest in s tudying this population of children. R ecognition of the scope of the problem of child maltreatment, on the other hand, did not begin until relatively recently, spurred initially by C . Henry clas sic 1962 article on the battere d child s yndrome . the early 1960s, there has been a great deal of the development effects of maltreatment on children. Although this research is confounded by the number of competing variables influencing obs erved outcome, disturbed attachment patterns have been consistently documented in a range of s amples of young children. the other hand, it is not yet clear what percentage of P.3250 children might meet criteria for an attachment disorder any given developmental s tage.

C OMP A R A TIVE NOS OL OG Y T he criteria for reactive attachment disorder have markedly s ince the diagnosis was first introduced in III. T his early version of the disorder included growth failure and lack of s ocial res pons ivity as central T he diagnosis had to start by 8 months of age (the age which preferred attachment to a res tricted set of caregivers is us ually just beginning to be evident) and could not res ult from a diagnosable medical condition. G ross neglect of the infant's physical and emotional had to be evident, and, as with later criteria, pres ence autis m or mental retardation precluded the diagnosis. P ertinent behaviors cited in the criteria included poor tone, weak cry, exces sive s leep, lack of interes t in the 4299 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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environment, and weak rooting and grasping when feeding. Although s o-called nonorganic failure to thrive remains important diagnos tic entity in infant mental health, the res trictive age range of this s et of criteria and the requirement for growth failure made the DS M-III difficult to apply in many cases . F urthermore, it is rarely poss ible to rule out autistic dis order or mental in severely malnouris hed infants younger than 1 year age. T he link between failure to thrive and reactive attachment disorder was dropped in the revised third edition of the DS M (DS M-III-R ), and the age of ons et changed to the firs t 5 years of life. T he two subtypes of disorder, inhibited and disinhibited, were introduced DS M-III-R and have pers isted in DS M-IV -T R . T he link between the disorder and evidence of pathogenic at the hands of the young child's primary caregivers the exclusion of children whose symptoms might be accounted for by cognitive delay or one of the developmental disorders remained an emphas is of the criteria. Although reactive attachment dis order was not the ninth edition of the IC D (IC D-9), it does appear in 10in a form largely cons onant with DS M-IV -T R criteria. IC D-10 criteria do not explicitly link the dis order to pathogenic care, but a warning against making the diagnosis without evidence of abuse or neglect is in the clinical des cription attached to the criteria. IC Dlists the two s ubtypes from DS M-IV -T R as s eparate disorders (T able 44.1-2), and neither explicitly excludes children with mental retardation nor with pervasive developmental disorders . However, the clinician is 4300 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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required to document that the child s hows elements of normal social relatednes s with nondeviant adults.

Table 44.1-2 IC D-10 Diagnos tic C riteria for Dis orders of S oc ial Func tioning with Ons et S pec ific C hildhood or Adoles c enc e E lec tive mutis m Note : T his dis order is als o referred to as s e le ctive mutis m. A. Language expres sion and comprehens ion, as as sess ed on individually adminis tered tes ts , is within the twos tandard deviation limit for the child's age. B . T here is demons trable evidence of a failure to speak in s pecific s ocial situations in the child would be expected to s peak (e.g., in school), des pite speaking in other s ituations . C . Duration of the elective mutism exceeds 4 D. T here is no pervasive developmental disorder. E . T he disorder is not accounted for by a lack of

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knowledge of the s poken language required in social s ituation in which there is a failure to R eac tive attac hment dis order of c hildhood A. Ons et is before 5 years of age. B . T he child exhibits s trongly contradictory or ambivalent s ocial res ponses that extend acros s social s ituations (but that may show variability relations hip to relations hip). C . E motional dis turbance is s hown by lack of emotional res ponsiveness , withdrawal reactions , aggres sive respons es to the child's own or distress , or fearful hypervigilance, or a of thes e. D. S ome capacity for s ocial reciprocity and res ponsiveness is evident in interactions with adults . E . T he criteria for pervas ive developmental are not met. Dis inhibited attac hment dis order of c hildhood A. Diffus e attachments are a pers is tent feature during the firs t 5 years of life (but do not persis t into middle childhood). Diagnos is requires 4302 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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relative failure to s how s elective social manifest by the following:    (1) A normal tendency to s eek comfort from when dis tres sed.    (2) An abnormal (relative lack of s electivity) in people from whom comfort is s ought. B . S ocial interactions with unfamiliar people are poorly modulated. C . At leas t one of the following must be present:    (1) G enerally clinging behavior in infancy.    (2) Attention s eeking and indis criminately behavior in early or middle childhood. D. T he general lack of s ituation s pecificity in the previous ly mentioned features mus t be clear. Diagnos is requires that the s ymptoms in C riteria and B are manifest across the range of s ocial contacts experienced by the child. Other c hildhood dis orders of s oc ial C hildhood dis order of s oc ial functioning uns pec ified

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F rom W orld Health Organization. T he IC D-10 C las s ification of Me ntal and B ehavioural Diagnos tic C rite ria for R e s earch. G eneva: World Organization; 1993, with permis sion.

DS M-IV -T R and IC D-10 criteria for attachment have been criticized in the literature on a number of F irst, the implication that the disorder is reactive is problematic. A temporal as sociation of factors , such as maltreatment and inhibition, should not imply a link. F rom a practical perspective, one cannot always what experiences children might have had with their caregivers, and the limits of what is or is not care are unclear. S ome children might meet criteria for reactive attachment disorder without having extreme deprivation or abuse. S econd, the exclus ion of infants and children with pervasive developmental disorders and mental retardation, os tensibly on that each has a different cause, s uggests that these disorders cannot coexist. C ertainly, children with a age of younger than 8 months of age are unlikely to develop a focus ed s et of attachments with caregivers . However, in children with milder cognitive impairment, the clinical distinction between these disorders is occasionally difficult, particularly when caregiving deficiencies are notable. T he criteria emphasize the general s ocial behavior of 4304 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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affected children across relationships rather than more specific attachment-related behaviors . T hes e latter behaviors might include comfort s eeking, compliance caregiver requests, exploratory behavior, and attempts control the caregiver by acting in a caregiving role or by being bos sy and punitive. R espons es to reunion, used succes sfully to class ify patterns of attachment, may reveal extreme affective responses (e.g., ignoring, angry, or affectles s reunions) that are clinically A final concern is raised by the clear evidence that act differently in different relations hips. DS M-IV -T R and IC D-10 criteria require that the aberrant behavior be evident acros s relationships , which excludes children whos e behavior is clearly compromis ed in P.3251 the presence of their primary caregivers but not in the other relations hips they might have. C hanging this would compel the clinician to identify a relations hip disorder rather than a pervasive pattern of abnormal behavior, which might identify more children and requiring intervention. T his approach, however, flies in face of current conceptualizations of psychiatric namely, that they exist within individuals , not between them. T hese concerns about DS M-IV -T R and IC D-10 criteria led a group of res earchers and clinicians to propose a series of alternate criteria designed to redress most of these concerns. C riteria have been propos ed for s ix separate attachment disorders , beginning with of nonattachment that can be diagnosed in any child a mental age of 10 months of age or older (i.e., the age 4305 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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which children typically s how preferred attachments ). T hese dis orders follow DS M-IV -T R criteria in including inhibited and dis inhibited subtypes . However, the link pathogenic care is dropped and evidence of less social behavior in relationships with caregivers other the primary caregiver does not disqualify the child for diagnosis. A second general type of dis order is also propos ed, dis rupted attachment disorder, which applies when a child experiences the s udden loss of the it includes behaviorally anchored criteria that are cons istent with the descriptions B owlby and others originally documented. T he third general type of so-called s ecure base distortions, aris es from clinical with young children. T hree types have been identified: attachment disorder with s elf-endangerment, disorder with inhibition, and attachment dis order with revers al. In each of thes e disorders , the child has a preferred attachment figure, but the relations hip with figure is markedly dis torted in one of thes e three ways. Unfortunately, none of the available criteria, including those from DS M-IV -T R and IC D-10, has been res earch aimed at validation, and reactive attachment disorder remains a little-us ed and poorly s tudied phenomenon.

E P IDE MIOL OG Y V irtually no data exis t on the prevalence and clinical cours e of reactive attachment dis order. R etrospective chart reviews of cons ecutive patients sugges t that the diagnosis can be made reliably in a clinic-referred population. In 2004, a study established that reliable diagnosis was poss ible by review of videotaped 4306 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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as sess ments of high-ris k young children interacting their caregivers and a stranger coupled with review of a semistructured interview of the caregiver. B ecaus e pathogenic care is often as sociated with broad-ris k such as poverty, family dis ruption, and low s ocial in clinical samples , these may be considered frequent conditions ass ociated with the diagnosis. However, reactive attachment dis order appears to exist across socioeconomic s trata.

E TIOL OG Y Although reactive attachment dis order typically occurs the context of gross ly neglectful or overtly abus ive the critical elements of this care and their relation to the onset of the disorder are unclear. C ertainly, children institutionalized in the s ame facility or s iblings raised together in a markedly disturbed family may have divergent outcomes. Individual temperamental or personality factors may combine with corrective experiences to yield a nonpathological outcome in children who experience extremes of care. T he fit between neglectful or abusive adults and their or children may be critical in determining which children develop s ymptoms that are cons istent with an disorder. Although res earch on what caus es caregivers to be abusive or neglectful is limited, caregiver from s evere personality disturbance to appear to be important. P arental mental retardation poor basic parenting skills, particularly in the context of little social s upport, may als o lead to pathogenic care. Infants who are cared for by multiple caregivers in 4307 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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succes sion, as is common in the foster care s ys tem in United S tates , are als o at increased ris k for attachment disorders . T he traumatic experience of prolonged separation from a caregiver in early childhood, documented by S pitz, the R obertsons, and B owlby, is enough to caus e attachment disturbance. R epeated prolonged separations typically caus e more s evere symptoms, and, when thes e s eparations are by abuse or neglect, or both, attachment dis orders to be particularly likely. C hildren raised in ins titutions those adopted out of institutions are at increased ris k.

DIA G NOS IS A ND C L INIC A L T he diagnosis of reactive attachment dis order is contingent on documenting clear evidence of pervas ive disturbance in s ocial relatedness that began before 5 of age (T able 44.1-3). T he pattern of behavior should fit one of the two different s ubtypes described in the T he inhibited subtype is characterized by hypervigilant and fearful behavior (often recognized as a pattern of compuls ive compliance with the abus ive caregiver) or extreme ambivalence and contradictory P.3252 behavior in relations hips. Mixtures of approach and avoidance may be apparent, and frozen watchfulness be noted. T he disinhibited subtype is marked by a lack selectivity in choos ing social partners, resulting in attachments and a peculiar overfriendlines s that has labeled indiscriminate sociability. C aregivers may on their own s ubjective sense that the child is not truly attached to them. 4308 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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Table 44.1-3 DS M-IV-TR C riteria for R eac tive Attac hment Dis order of Infanc y or E arly C hildhood A. Markedly disturbed and developmentally inappropriate s ocial relatednes s in most contexts, beginning before 5 years of age, as evidenced by or (2):    (1) P ers is tent failure to initiate or to respond in developmentally appropriate fas hion to most interactions, as manifest by excess ively inhibited, hypervigilant, or highly ambivalent and contradictory res pons es (e.g., the child may to the caregiver with a mixture of approach, avoidance, and resistance to comforting or may exhibit frozen watchfulnes s).    (2) Diffuse attachments as manifes t by indis criminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excess ive familiarity with relative strangers or selectivity in choice of attachment figures). B . T he disturbance in C riterion A is not accounted solely by developmental delay (as in mental retardation) and does not meet criteria for a 4309 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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pervas ive developmental dis order. C . P athogenic care as evidenced by at least one the following:    (1) P ers is tent dis regard of the child's basic emotional needs for comfort, stimulation, and affection.    (2) P ers is tent dis regard of the child's basic needs .    (3) R epeated changes of primary caregiver that prevent formation of s table attachments (e.g., frequent changes in foster care). D. T here is a pres umption that the care in is res ponsible for the disturbed behavior in A (e.g., the disturbances in C riterion A began following the pathogenic care in C riterion C ). S pe cify type :    Inhibited type: if C riterion A1 predominates in clinical presentation.    Dis inhibited type: if C riterion A2 predominates the clinical presentation.

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F rom American P sychiatric As sociation. and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

It is difficult to make the diagnos is of reactive disorder without a multisess ion evaluation, particularly when the caregiver's behavior is not known to be or when the child's history does not include multiple placements. Ascertaining whether the child has les s deviant behavior in the presence of the clinician or another trus ted adult is important and may take time. child's relations hip with the primary caregiver can be adequately as sess ed with a combination of free play, structured teaching tasks that s tres s the dyad, and a separation and reunion. V ideotaping the as sess ment is us eful way to document s ocial respons es , and the introduction of a clinically trained person whom neither partner has met is often informative. C hildren who criteria for this disorder may look quite different depending on their developmental s tage. A 26-month-old girl, recently placed in fos ter care, was referred by s tate child protective services with her biological and foster families to as sist with long-term management. Her his tory included two admiss ions for failure to thrive in the firs t year of life and a third 4311 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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at 13 months of age that revealed retinal hemorrhage a s ubdural hematoma from suspected s haken baby syndrome. No perpetrator was conclusively identified. When s een with her biological mother in a comfortable, toy-filled room, s he stood completely s till and little facial expres sion. S he complied completely and in rote fas hion with her mother's often angry ins tructions, maintaining no s ustained eye contact with her mother the examiner. W hen briefly s eparated from her mother, she s howed little reaction, looking up briefly with an grimace when her mother returned to the room. Her mother confirmed that her behavior had been similar when she had lived in her home; the child s poke infrequently and rarely s ought comfort when When s een with her foster mother of 3 months , she markedly more animated, although frequently irritable. S he engaged in play freely and referenced her foster mother and the examiner during play. S he stopped playing and stared blankly when separated from her mother, although s he actively reengaged her fos ter mother on her return. T he biological mother's parental rights were eventually terminated, and, although the was placed in two more homes, she showed the to engage with her new caregivers each time. T he girl diagnosed with reactive attachment disorder, inhibited type. A 6-year-old boy was referred by his adoptive parents because of hyperactivity and dis ruptive behavior at He had been adopted at 5 years of age, after living his life in a R omanian orphanage in which he received from a rotating shift of caregivers . Although he had below the fifth percentile for height and weight on 4312 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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he quickly approached the tenth percentile in his new home. However, both of his adoptive parents were frus trated by their inability to reach him. T hey had worried about a hearing disturbance, although testing his capacity to engage many adults and children suggested otherwis e. He showed interest in anyone would often follow strangers willingly. He showed little empathy when others were hurt and blandly resisted redirection in school. He was frequently injured seemingly reckles s behavior, although he had an extremely high tolerance for pain. Intensive intervention focus ed on problem behaviors at home decreas ed his endangering behavior, although he remained oddly overfriendly and unempathic at home and in school. boy was diagnosed with reactive attachment disorder, disinhibited type.

DIF FE R E NTIA L DIA G NOS IS C hildren with marked dis interes t in social interaction altogether may require cognitive testing for developmental delay or a neurological workup. of stereotypies, gros sly res tricted range of interes ts, poor res ponse to changes in routines s uggest the spectrum of pervasive developmental disorders ; impairment is frequently moderate to severe in these children. Interviews with the caregivers of thes e us ually yield little evidence of inappropriate care, and cons istent blunting of social interactions outside the family unit is common. However, many children with pervas ive developmental dis orders or mental form s ecure attachments with their primary caregivers, despite an overall restriction in the range of 4313 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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related behaviors . Y oung children who are hyperactive and impulsive may also appear s ocially dis inhibited. F urthermore, is known to increase the risk for inattention or hyperactivity and indiscriminate reactive attachment disorder. T he s ocial dis inhibition of reactive attachment disorder s hould not be accompanied by inattention or hyperactivity, however. C hildren with severe receptive and express ive delays may present clinically with difficulty in social relatednes s. Often, the clinical picture includes externalizing behavior that heightens as uns ucces sful attempts to communicate are made; rarely does this behavior fit the reactive attachment disorder s ubtypes, and gross ly inappropriate care is uncommon in this population. As communication improves, social interactions improve. T emporary or permanent los s of a primary caregiver to whom a young child is already attached is ass ociated significant dis turbance. B owlby described a common progres sion of reactions in this instance: protes t, and detachment. T he clinical picture may mimic the inhibited form of reactive attachment disorder, although pathogenic care is not apparent in these cases . T hese children may quickly form new attachments to sensitive caregivers, particularly if they had some familiarity with replacement caregiver before the loss . T he clinician diagnose depress ion in these cas es , although the for depress ion in infancy are not fully consonant with DS M-IV -T R criteria for major depress ive disorder. Although growth failure and disorders of attachment 4314 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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sometimes evident in institutionalized or neglected children, there is no evidence of a direct link between reactive attachment dis order and failure to thrive. It is likely that mos t children with reactive attachment are not failing to thrive, and most children with failure to thrive do not meet criteria for reactive attachment disorder. C omorbid ps ychiatric conditions appear to be common older children whos e history is cons is tent with reactive attachment disorder. Dis organized patterns of behavior in the first 6 years of life appear to be with dis ruptive behavior dis orders in later childhood; may also be true for children with reactive attachment disorder.

C OUR S E A ND P R OG NOS IS B ecaus e a sizable cohort of patients with reactive attachment disorder has never been followed, the cours e and prognosis for P.3253 this dis order are not clear. It is likely that ass ociated conditions from the nutritional and neurological of ps ychosocial deprivation to the stability of later relations hips are critical in influencing the outcome. P os sible outcomes range from death in the mos t cases to relatively normal functioning with intervention leading to the es tablis hment of healthy relationships. T here have been s everal recent s tudies of currently institutionalized children indicating that s igns of emotionally withdrawn or inhibited reactive attachment disorder and indis criminate or disinhibited reactive 4315 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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attachment disorder are readily apparent. F urthermore, other recent controlled s tudies of children adopted from R omanian institutions into C anada and the United K ingdom have demons trated that the emotionally withdrawn pattern of reactive attachment dis order is barely detectable, but the indis criminate or disinhibited pattern is identifiable and may pers is t for years. A subs ample may be at risk for externalizing dis orders. the other hand, des pite their his tories of severe it appears that a majority of thes e international rapidly ass imilate after s table placement and have few ongoing psychiatric s ymptoms. Nevertheles s, quality of interpersonal relations hips for a s ubs tantial minority is compromised. F actors that are cons is tently related to these dis parate outcomes have yet to be identified. T here are few long-term, controlled follow-up studies of children and adults who were rais ed primarily in institutional settings. T he few available s tudies als o suggest that indiscriminate s ociability may pers is t and the choice of marital partners in later life s trongly influences eventual adult psychological functioning. link between early dis turbances of attachment and antis ocial tendencies , particularly a lack of empathy, first made by B owlby; longitudinal studies of this as sociation are needed to firmly es tablis h this pathway.

TR E A TME NT T he firs t cons ideration in the as sess ment of children expos ed to gross ly inadequate care is the child's C hild maltreatment is as sociated with significant morbidity, and mortality is not uncommon, particularly children younger than 48 months of age. E arly 4316 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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involvement of child protective s ervices is often and as sess ment of parental fitnes s may be a of the evaluation. In some cas es, placement of the may be necess ary, and reunification of parent and child may not be warranted. C hildren in this s ituation often not had appropriate medical care, and medical referral almos t always indicated. Unfortunately, the foster care system and the family court system may lead to placements in the first years of life and thus increase likelihood of an attachment disorder. T he clinician may play a crucial role in s taying involved with the child who placed in foster care, providing expert tes timony in and individual or family treatment. Once the child is in a relatively s table placement and is medically healthy, full attention can be paid to ps ychos ocial intervention, which must often be tailored the individual. P oss ible interventions include individual ps ychotherapy for the child or caregiver, parent training with emphas is on developmental expectations, family therapy, and caregiverchild dyadic therapy, which is perhaps most specifically directed toward dis turbances attachment and in many ins tances is the treatment of choice. As described by Alicia Lieberman, this weaves together developmental training and guidance with an active attempt to address pres sing ins trumental is sues (e.g., poor hous ing and inadequate medical and insight-oriented ps ychotherapy with the child T he complexity of this approach reflects the complexity the clinical problem. Long-term interventions are neces sary in these cases , and ps ychiatric treatment be bolstered by early intervention programs and medical care for the child. 4317 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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S UG G E S TE D C R OS S T he role of early experience in development is different contexts in S ection 4.1 on anthropology and ps ychiatry, S ection 5.4 on animal res earch and its relevance to psychiatry, and S ection 6.1 on T he role of early experience in personality formation is discuss ed in C hapter 23 on personality disorders . Neurops ychological and intellectual ass es sment of children is dis cus sed in S ection 7.5. Mood disorders presented in C hapter 13. F eeding and eating disorders infancy or early childhood are discuss ed in C hapter 41. Aspects of phys ical and s exual abus e of children and neglect are reviewed in S ection 49.3. F oster care is discuss ed in S ection 49.2.

R E F E R E NC E S Ainsworth MD, B lehar MS , W aters E , W all S . Attachment: A P s ychological S tudy of the S trange S ituation. Hills dale, NJ : E rlbaum; 1985. B oris NW , F ueyo MA, Zeanah C H: T he clinical as sess ment of attachment in children less than five. Am Acad C hild Adole s c P s ychiatry. 1997;36:295. *B oris NW, Hinshaw-F us elier S S , S myke AT , MS , Heller S S , Zeanah C H: C omparing criteria for attachment disorders : E s tablis hing reliability and validity in high-ris k samples. J Am Acad C hild P s ychiatry. 2004;43:568. B oris NW , Zeanah C H: C linical disturbances and 4318 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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disorders of attachment in infancy and early C urr O pin P ediatr. 1998;10:365. B oris NW , Zeanah C H: Disorders and dis turbances attachment in infancy: An overview. Infant Me nt J . 1999;20:1. B oris NW , Zeanah C H, Larrieu J A, S cheeringa MS , S S : R eactive attachment dis order of infancy and childhood: A preliminary investigation of diagnostic criteria. Am J P s ychiatry. 1998;155:295. B owlby J . Maternal C are and C hild He alth. G eneva: Health Organization; 1951. B owlby J . Attachment and L os s . 2nd ed. V ols 13. Y ork: B as ic B ooks; 1982. C arls on E A: A prospective longitudinal s tudy of attachment disorganization/dis orientation. C hild 1998;69:1107. C hapin HD: Are institutions for infants necess ary? 1915;64:1. C his holm K : A three-year follow-up of attachment indis criminate friendlines s in children adopted from R omanian orphanages. C hild De v. 1998;69:1092. *G reen J , G oldwyn R : Annotation: Attachment disorganization and psychopathology: New findings attachment res earch and their potential implications 4319 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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developmental psychopathology in childhood. J P s ychol P s ychiatry. 2002;43:835. Hins haw-F us ilier S , B oris NW, Zeanah C H: R eactive attachment disorder in maltreated twins. Infant Me nt Health J . 1999;20:42. Hodges J , T izard B : S ocial and family relationships institutional adoles cents . J C hild P s ychol P s ychiatry. 1989;30:77. K aren R . B ecoming Attache d. New Y ork: W arner; Lieberman AF , P awl J H. Infant-parent Zeanah C H, ed. Handbook of Infant Mental He alth. ed. New Y ork: G uilford; 2000. Main M, K aplan N, C as sidy J : S ecurity in infancy, childhood, and adulthood: A move to the level of representation. Monogr S oc R e s C hild De v. O'C onnor T G . Attachment dis orders of infancy and childhood. In: R utter M, T aylor E , eds. C hild and Adoles ce nt P s ychiatry: Mode rn Approache s . 4th ed. London: B lackwell S cience; 2002. O'C onnor T G , B redenkamp D, R utter M: T he R omanian Adoptees (E R A) S tudy T eam. disturbances and disorders in children expos ed to severe deprivation. Infant Me nt H ealth J . O'C onnor T G , Marvin R S , R utter M, Olrick J , B ritner 4320 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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T he E R A S tudy T eam. C hild-parent attachment following early institutional deprivation. Dev P s ychopathol. 2003;15:1938. *O'C onnor T G , Zeanah C H: Attachment disorders : Ass es sment strategies and treatment approaches. Attach Hum Dev. 2003;5:223244. R ichters MM, V olkmar F R : R eactive attachment of infancy or early childhood. J Am Acad C hild P s ychiatry. 1994;33:328. R obertson J , R obertson J . S eparation and the V e ry London: F ree Ass ociation B ooks; 1989. S keels HM: Adult status of children with contras ting early life experiences. Monogr S oc R e s C hild De v. 1966;31:1. S myke AT , Dumitrescu A, Zeanah C H: Disturbances attachment in young children: I. T he continuum of taking casualty. J Am Acad C hild Adole s c 2002;41:972982. S pitz R : Anaclitic depress ion. P s ychoanal S tud 1946;2:313. T as k F orce on R esearch Diagnos tic C riteria: Infancy P res chool: R esearch diagnostic criteria for infants preschool children. J Am Acad C hild Adole s c 2003;42:1504.

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T izard B , Hodges J : T he effect of early ins titutional rearing on the development of eight-year-old J C hild P s ychol P s ychiatry. 1978;19:99. P.3254 *T izard B , R ees J : T he effect of early ins titutional on the behaviour problems and affectional relations hips of four-year-old children. J C hild P s ychiatry. 1975;16:61. *Zeanah C H: B eyond ins ecurity: A of attachment dis orders in infancy. J C ons ult C lin P s ychol. 1996;64:42. Zeanah C H: Disturbances of attachment in young children adopted from ins titutions. J De v B e hav 2000;21:230236. Zeanah C H, B oris NW. Disturbances and disorders attachment in early childhood. In: Zeanah C H, ed. Handbook of Infant Mental H ealth. 2nd ed. New G uilford P ress ; 2000: 353368. Zeanah C H, S cheeringa MS , B oris NW , Heller S S , AT , T rapani J : R eactive attachment dis order in maltreated toddlers . C hild Abus e Ne gl. (in pre s s ). Zeanah C H, S myke AT , Dumitrescu A: Disturbances attachment in young children: II. Indis criminate behavior and ins titutional care. J Am Acad C hild 4322 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/44.1.htm

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P s ychiatry. 2002;41:983989.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 45 - Mood Dis orders in C hildren and Adoles cents > 45.1: Dis orders a nd S uicide in C hildren and Adoles cents

45.1: Depres s ive Dis orders and S uic ide in C hildren and Adoles c ents David S haffer M.D., F.R .C .P. P art of "45 - Mood Dis orders in C hildren and

DE P R E S S IVE DIS OR DE R S Depress ive disorders , rare before puberty but common adoles cence, account for a significant proportion of all child and adoles cent referrals and admiss ions for treatment. T heir importance for the practicing clinician cannot be overstated. T his can be a devas tating Depress ed children and adoles cents, often irritable or withdrawn, can be difficult or remote, and their friends family might res pond with hostility or increas ed T he preoccupations of depres sed teenagers interfere their s choolwork, and their search for s olitude deprives them of much needed support. T he illness can last or years, is prone to recurrence, can have lasting career and social potential, and, in rare ins tances , can in s uicidal death. Although depres sion and s uicide are often cons idered together, only a minority of depres sed children and teenagers become suicidal, and a s ubs tantial number young people who think about, attempt, or commit 4324 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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suicide are not depres sed. T he biology and the demography of suicidal youth are distinct from thos e of nonsuicidal depres sed children and teens , and there is yet no evidence that the optimal treatments for depres sion influence s uicidal behavior. In a s mall proportion of cases, there is a s uggestion that antidepres sant medication treatment might actually increase suicidal tendency. F or thes e reasons, the two conditions are dealt with separately in this chapter.

Definitions and Nomenc lature Depres s ion T he tenth edition of the Inte rnational S tatis tical C las s ification of Dis e as e s and R e late d He alth 10) and revised fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV -T R ) clas sifications differ in several respects . DS M-IV -T R the following categories: major depres sion, minor depres sion, dys thymia, and depres sion not otherwise specified (NOS ). IC D-10 adopts a cons iderably more complex approach to the class ification of depress ion. broad equivalent to major depress ive disorder is epis ode, which is , in turn, broken down into s ubtypes according to severity, with psychotic depres sion being subtype of the most severe category. T here are, in addition, a s eries of codes for recurrent depres sive disorders , which preclude intervening mania or hypomania s tates, and for pers is tent mood disorders , which carry cyclothymia and dys thymia. T here are no specific instructions for coding child or adolescent depres sion, but the accompanying diagnos tic notes indicate that dysthymia rarely has its onset until early 4325 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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adulthood. IC D-10 offers the following types: Depres sive episode broadly comparable to major depress ive disorder; recurrent depres sive dis order and persistent mood disorder are broadly comparable to dysthymia; and are codes provided for recurrent and atypical mood disorders . Numerous s ubtypes are offered, most somatization s ubtype. A depres sive episode requires that four criteria be met (compared to five criteria for DS M-IV -T R ), and they include at leas t two of the following: depress ion, anhedonia, and decreased energy or fatigability. T he remaining one or two criteria are drawn from a list of criteria. IC D-10 allows for the s ubtype s omatic depres sion, for which four of eight criteria mus t be met, three of which are unique to IC D-10. T hese are los s of libido, morning worsening, and lack of emotional reactivity. T he DS M-IV -T R criteria for a depress ive episode in and adoles cents differ in two respects from the criteria applied to adults . C riterion 1 can be met not only by a depres sed mood, but als o by persistent irritability. C riterion 3 (weight los s in the absence of dieting) can be met in the young by failure to make expected weight gain. T here are no s pecial coding instructions for or adolescents in this system in IC D-10. Irritability is a criterion for depress ion and for four DS MT R disorders , including oppos itional defiant disorder, attention-deficit/hyperactivity dis order (ADHD), posttraumatic stress disorder (P T S D), and generalized anxiety dis order. T his might contribute to the high rates 4326 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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comorbidity with depress ion that are found in the DS MT R meeting.

Dys thymia T he DS M-IV -T R criteria for dysthymia are depres sed poor appetite or overeating, insomnia or hypersomnia, energy or fatigue, low s elf-es teem, poor concentration difficulty making decis ions , and feelings of Dys thymia is chronic but is s ubject to periodic exacerbation. T o differentiate thes e from discrete of depress ion, this diagnos is is only to be used if there been a sustained period of euthymia between children, this can be 1 year ins tead of the 2 years of adults. As with major depress ion, irritability is an acceptable alternative to depres sed mood for children.

His tory It has long been noted that depres sion is rare before puberty but common thereafter. T he ps ychoanalytic school postulated that this was becaus e depres sion requires adequate superego development, P.3263 which is incomplete in the younger child. P henomenologically oriented ps ychiatris ts explained age-related prevalence differences with the position depres sion in the young child was not less common, rather that it took a different formso-called mas ked depres sion. T extbooks in the 1960s and 1970s that a wide variety of childhood s ymptoms, from nail biting and enures is to fighting and fire setting, be regarded as features of underlying depres sion. 4327 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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With the advent of DS M-III, it was apparent that s ome prepubertal children could meet full criteria for depres sion, challenging the notion that children were incapable of major depres sion and the pres s to extend diagnosis to those who did not meet full criteria. E arly models of depres sion placed most emphas is on effects of loss . T hese models failed to explain why, in a family with children exposed to s imilar stress es, some would emerge without evidence of later T his led to the s tres s -diathesis model, in which experiences have negative consequences only for with a vulnerable diathesis. T wo candidates for a vulnerable diathesis that are currently being s tudied are the MAOA gene, which is res ponsible for the effective functioning of monoamine oxidase, and the serotonin trans porter gene (5HT T ).

E pidemiology Depres s ion T he point prevalence of major depres sion (DS M-IV -T R ) less than 1 percent in prepubertal children and and 6 percent for adolescents . During adolescence, the incidence rises in a linear fashion, reaching as ymptote the early 20s . T eenagers are mos t likely to present for treatment in their 16th and 17th years of life. B efore puberty, male and female rates are broadly s imilar. However, in adolescence, depress ion is nearly twice as common in girls as in boys. E stimates of the cumulative prevalence by the end of teens runs between 14 and 25 percent. T he methods to evaluate depres sion have a big effect on prevalence, 4328 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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with interviews generally producing more cons ervative es timates than s elf-report s cales . As an example of the latter, the national Y outh R isk B ehavior S urvey that almost one-third of high-school s tudents had felt sad or hopeles s almos t every day for at leas t two a row that they s topped doing s ome us ual activities. feeling is reported by approximately one-third of all girls but by only one-fifth of boys. Hispanic s tudents were likely than black or white s tudents to report depress ed mood, but the femalemale predominance was s imilar acros s ethnic groups .

Dys thymia Dys thymia is less common than major depres sion in children and teenagers . It is especially uncommon puberty, with rates of approximately 5 in 100,000, rising approximately 5 in 1,000 in adolescence.

C linic al Features A careful analysis of the clinical features of depress ion children and teens s hows a s imilar profile, regardless age. In 90 percent of cases, the epis ode can be dated precipitating stress . In addition to depres sion, which is present in nearly all ins tances , s ymptoms occurring in more than two-thirds of cas es include tearfulnes s, brooding about a past experience, being irritable, pess imistic, having difficulty concentrating, feeling worthles s, and fatigue. W eight and appetite changes three-fourths , with anorexia and weight loss being cons iderably more common than overeating and gain. Insomnia affects four-fifths and is most commonly experienced when trying to fall as leep. E arly morning 4329 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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wakening is less common. R epeat epis odes are similar to the first. C hildren and teenagers rarely present to a parent or practitioner complaining of depress ion. P arents , those who have a history of depres sion themselves, suspect a mood problem, but, more often than not, if young pers on is brought to clinical attention at all, it is because of s ome signal event, such as unusually poor grades , a s uicide attempt, or a change of behavior to some psychosocial disturbance, such as divorce, separation, or the illnes s or death of a loved one or a friend. T eenagers' natural reticence, ready sense of and concern about letting down the family (or being criticized by them) can cons pire to hold back any disclos ure of dysphoric feelings or thoughts . Depress ion in adoles cence is often found with other disorders , most commonly an anxiety or conduct In some cas es, this is because the other conditions predis pos e to depres sion, particularly those ass ociated with s ocial isolation, academic failure, or entanglement with the law. In other cases, both conditions probably from a similar root, s uch as early deprivation and los s genetic predispositions and their impact on the child's environment. C omorbidity with an anxiety dis order is es pecially interes ting. It is es timated that between 20 50 percent of major depres sive dis order children have anxiety dis order. Longitudinal studies s uggest that not only is adolescent depress ion often preceded by a of anxiety, but also that anxiety might return after depres sive features abate. C omorbidity with one of the externalizing dis orders is common, with between one-fifth and one-third of teens 4330 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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with a conduct dis order and a s imilar proportion among those with ADHD experiencing depres sion. T here is evidence to support the s peculation that conduct is a manifes tation of an underlying depress ion. Y oung people with a conduct dis order frequently become depres sed after getting into trouble or being arrested or incarcerated. T here is no evidence that the antisocial behavior of patients with a comorbid mood dis order improves when the depress ion is treated. Indeed, their prognos is for later criminality and for s uicide more res embles youngsters with a prior conduct disorder those with comorbid depres sion and conduct dis order. Antisocial youth predictably experience numerous setbacks and as saults on their feelings of well-being confidence. T heir behavior leads to unpopularity and rejection by peers and parents, poor performance at school, and punis hments meted out by parents, school, and, ultimately, the law. R elationships are uns table, loss es are frequent. It is reasonable to ass ume that the depres sion s een in youth with a conduct or oppos itional disorder is s econdary rather than primary. Mood dis orders are often found to be comorbid with subs tance use. Des pite the prevailing belief about s elfmedication, there is little evidence that s ubs tance res ponds to treatment for depres sion. E arlier s tudies suggested that depres sion in the early teens predicts subs tance abus e, but more detailed longitudinal examination of this proces s s ugges ts that anxiety is likely to predict s ubs tance abus e than depress ion. It be that the common cooccurrence of anxiety is the mediator for the link between depres sion and abuse. Alcohol and other drugs readily induce 4331 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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states , and, when the two conditions cooccur, it is sens ible to ass ume that depres sion is a consequence subs tance abus e, rather than the reverse. Although comorbidity does not s eem to influence history, little is known about how the treatment of depres sion affects the comorbid condition. It is important that comorbid conditions be viewed in their own right.

Natural His tory More than 90 percent of depres sed children and seen clinically recover within 2 years , regardless of treatment. As many as two-thirds of thes e relaps e the following P.3264 3 to 8 years. T his relaps e rate is higher than that reported among adults . As much as 40 percent of dys thymic youth experience epis odes of major disorder, s o-called double depres sion. T here are no consistent demographic predictors of outcome or res ponse to treatment during childhood or adoles cence. However, there is some evidence that placebo respons e is more common in the young and in low s ocioeconomic s tatus (S E S ) patients . R es earch has als o shown a relationship between poor outcome and adverse family factors . However, a child's teenager's psychiatric s ymptoms might have impact on family functioning, and, in individual cas es, persis tence of the child's depres sive symptoms might impact negatively on family functioning. 4332 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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Pathology and E tiology Neuroanatomy T he areas of the brain that appear to be mos t important mood recognition and control are the prefrontal cortex and related areas of the s triatum, the thalamus, and amygdala. T he most consistent findings in depres sed adults have been decreased frontal and prefrontal volume and increased metabolic activity in the ventral medial prefrontal cortex and the anterior cingulate. have been few s tudies of brain structures and in depress ed children and adolescents , but the few available are broadly compatible with thos e indicated previous ly.

F amiliality P arents with a history of mental illnes s are more likely seek treatment for their children. W hen a depress ed is seen in the clinic, depres sion is frequently found in another family member. B ecause of the confounds with the factors that promote s eeking help, mos t of the of familial influences, whether they be on the offs pring depres sed adults (top-down studies) or the relatives of depres sed youth (bottom-up studies), have found a degree of familiality. S ome of these studies have found familiality to be les s marked for children with comorbid depres sion and conduct disorder. Other strategies for looking at familial factors include and adopted-away s tudies. S everal twin s tudies have done, and thes e have the advantage of uns elected samples . T hese studies have shown a greater degree heritability for information derived from parents than 4333 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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self-reports by the children or youth, and this finding raised concerns about how bes t to overcome important meas urement problems. T here are no cons is tent data whether familiality is more or les s common before or puberty. Another approach us ed in s tudies of familiality are adopted-away s tudies that compare concordance rates among biological s iblings reared apart to those among nonbiological s iblings reared with the index child and biological s iblings or parents living apart. T he few with this design have failed to demons trate a heritable element. T he discrepancy between findings for the family and the twin and adopted-away s tudies has been interpreted as supporting a pas s ive ge ne e nvironment correlate , that is, that a depres sed parent, as a cons equence of his or her genetic makeup, es tablis hes environment that is depress ion causing for his or her children with that genetic makeup.

Molec ular G enetic S tudies T he serotonin trans porter gene (5HT T ) plays a key role the availability of serotonin. P olymorphism commonly affects this gene, s o that only one-third of the is homozygous for a (full) long allele of the gene. T he remainder have one long and one s hort allele (approximately 50 percent) or two short alleles (17 percent). An elegant longitudinal s tudy of more than New Zealand children, during which data on external stress es were collected, has s hown that early s tres s is strongly ass ociated with later depres sion, but only in individuals who have one or two s hort alleles of the 4334 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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T he short form of the allele is known to be as sociated less efficient trans criptions, and, hence, the availability the transporter gene is a good example of a marker.

Medic ation His tory C ertain medications, such as β-blockers , s teroid antihypertens ives, and some analges ics, can cause or exacerbate depres sive s ymptoms. Isotretinoin has been thought to be as sociated with depres sive symptoms, but there is a well-recognized ass ociation between acne and depres sion, and there have been no systematic studies that sugges t a causal relations hip between isotretinoin and depres sion.

E valuation In addition to documenting improvement or the lack thereof, it is us eful for clinicians to code their initial impres sions on a s tandardized measure, s uch as the C hildren's Depress ion R ating S cale-R evised (C DR S which is an adaptation of the Hamilton R ating S cale for Depress ion adapted for children and adolescents and, the Hamilton R ating S cale for Depress ion, is completed clinicians . T he us e of standardized forms can elicit information. It adds weight to a clinical opinion and provides a valuable way for charting progress . It is appropriate to complete a C DR S -R monthly for the first several months of treatment and les s frequently to monitor progress . C hange can also be revealed on B eck Depres sion Index, which is a 21-item s elfform that can be completed by mos t older children and adoles cents . S elf-completion forms often reveal 4335 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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information about levels of depres sion that might be difficult to obtain by conventional interview methods .

Treatment When to Treat T he remarkable lability of the depres sed child and teenager can be a challenge to the clinician. E ven the saddest child is cheered from time to time, and, in therapeutic trials , placebo respons e rates are high. Although this might be a bless ing for the patient, poses a problem for the investigator, who requires numbers of subjects to demons trate a s ignificant treatment effect, and for the clinician, who may be excused for thinking that their original impress ion of depres sion was mistaken. It is not known whether a youngster who appears better shortly after an (a rapid responder) has a good prognos is or whether her short-term clinical progres s is deceptive. T here is evidence that the initial s tate might be the best index, because long-term follow-up studies s uggest a poor prognos is for youngsters who were found to be on at leas t one previous occas ion, with as many as thirds having at leas t one further episode of major depres sive dis order. Would it have been different if the clinician had ignored that early res ponse and had treatment anyway? Des pite this uncertainty, it is s ensible to defer treating adoles cents for at leas t 2 weeks and then to reevaluate child. T he decis ion to treat should then be made on the basis of dis tres s or interference in the child's s ocial or academic life, rather than on whether full diagnos tic 4336 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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criteria for a major depres sive epis ode or dys thymia been met.

C hoos ing among Treatments A limited number of randomized, controlled trials have shown that s elective serotonin reuptake inhibitors and variants of S S R Is , cognitive-behavioral therapy and interpersonal therapy for adolescents (IP T -A) are effective in depress ed children and teenagers . At the of writing, most P.3265 studies of adult depress ion have s hown that a combination of medication and one of thes e types of ps ychotherapy is more effective than either alone, and same as sumption could be made for teenagers . F urthermore, many of the ps ychotherapy s tudies in teenagers have us ed a treatment-as -us ual or a waitingcontrol design, which do not control for the therapeutic effects of contact time or nons pecific therapist effects . T here have been no studies of treatment moderators , is , who is best suited for which type of psychotherapy whether mental or chronological age or specific comorbidities limit treatment respons e.

P s yc hotherapy T wo forms of somewhat s imilar and overlapping ps ychotherapy have been tested in children and teenagersC B T and interpers onal therapy (IP T ).

C OG NITIVE -B E HAVIOR AL THE R APY C B T is based on the principle that thoughts , feelings , 4337 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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behavior affect each other. S pecifically, negative such as pes simis m and s elf-criticis m, have the capacity increase the negative emotions that are characteristic depres sion. As currently practiced, C B T sets out (1) to modify negative thoughts through the proces s of re s tructuring, which us es a questioning approach to challenge the negative thoughts (e.g., everything goes wrong with me, it's all my fault), dichotomous thinking (e.g., when one thing goes wrong, everything always will be wrong), and jumping to conclus ions making a negative conclus ion without any evidence) are characteris tic of depress ion; and (2) to reduce the social withdrawal that is characteris tic of depres sion that res tricts opportunities for exposure to reinforcing social s ituations . T his is done by be havioral activation, which encourages participation in social activities . B ehavioral activation can be an es pecially important component of C B T in children and teenagers who lack ability to participate in cognitive re s tructuring. C B T als o provides (3) ps ychoe ducation to educate the youth and family about the condition and its ramifications into areas of s ocial and phys ical functioning; and (4) mood monitoring, that is, becoming aware of the (chain analys is ) of mood changes and, through that, to better understand and to avoid or to cope with depres sion-initiated experiences. C B T requires the and family to monitor the patient's mood and to s tudy contingencies of mood change. It is not known whether each of these elements is for the treatment to be effective, nor which element has the greates t impact on which children. B ecaus e C B T manuals differ in their emphasis, there is no certainty 4338 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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res earch that indicates the efficacy or inefficacy of one manualized version of C B T can be generalized to all A typical course of C B T for depres sion las ts from 8 to sess ions, and the patient is then s een for s everal sess ions, which might prevent recurrence. S ome of depress ion (e.g., the B eck Depres sion Index) is regularly. C B T is started before medication, and, if, to 6 weeks of C B T , there has been no change in depres sion, medication treatment s hould be s tarted continuing C B T . If, after an initial response, the recurs , a further course of C B T can be started. S ome cognitive-behavioral s trategies , s uch as res tructuring, are unique to the treatment, whereas have long been us ed as part of the general of dis turbed children, such as encouraging or social contacts and chain analyses to allow the be more accurate in identifying precipitants of a deterioration or change in mood. T he evidence is not available to determine whether the benefits of C B T flow from its unique, or from its more generic, components. F urthermore, it is not known whether tas ks , s uch as identification and examination of s elfstatements, can be accomplished by children younger than a certain mental or chronological age.

INTE R PE R S ONAL THE R APY (IPT) IP T s hares many characteris tics with C B T but places emphasis on the interpersonal problems that might be contributing to or resulting from a patient's depress ion than on the automatic thoughts of the depress ed individual. V ers ions of IP T have been developed for a number of dis orders, and one vers ion (IP T -A) has been 4339 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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developed for adoles cents. Like C B T , IP T includes a ps ychoe ducational component that s tres ses a medical model of depres sion, on the ass umption that this is stigmatizing and best prepares the patient for S pecial features of the treatment include preparation of interpe rs onal inve ntory that lists interpe rs onal problems important relationships and their relations hip to the or exacerbation of depress ion. E mphasis is also put on helping the adolescent communicate feelings appropriately. T he therapis t can then ass ist the patient identify mis perceptions and ass umptions about others' thoughts and feelings . P arents are actively involved in treatment and are trained to practice communication problem-solving skills that are directly related to the youth's interpersonal problems . A course of IP T usually lasts for 12 months , and monthly booster sess ions are given for as long as 1 year.

P s yc hopharmac ologic al Treatment S S R I ANTIDE PR E S S ANTS At the time of writing, double-blind, randomized control trials have demons trated the efficacy of fluoxetine (P rozac), citalopram (C elexa), and s ertraline (Zoloft) in depres sed adoles cents . In the abs ence of comparative studies, the choice of S S R I can be made on the bas is effects, half-life (if the teenager frequently forgets to his or her medication, fluoxetine, with its long half-life, might be indicated), interactions with other and, if available, family his tory of s ucces sful medication treatments . If there is coexisting anxiety, the starting doses s hould 4340 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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lower. If there is active s uicidal ideation, medication be administered by the family, and mental state s hould monitored to be alert for any increas e in suicidal agitation, or irritability. T reatment with S S R I antidepress ants is when there has been recent exposure to monoamine oxidase inhibitors (MAOIs ), terfenadine (S eldane), as temizole (Hismanal), and pimozide (Orap). T he syndrome (motor restles sness , tremor of the fever, confus ion or hallucination, tachycardia, and nausea) has been reported with accidental in children who have recently been treated with certain antips ychotics , s uch as pimozide, which is often for T ourette's s yndrome, or when given with P 450 inhibitors , s uch as erythromycin (E -Mycin). S tarting and maximum dos es for firs t-line S S R Is are provided in T able 45.1-1.

Table 45.1-1 Firs t-Line Antidepre E ffic ac y Data  

Younger Than 12 Yrs of Age

  Medic ation

S tarting Dos e

Inc rements

Maximum Daily Dos e

S ta Do

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C italopram (C elexa)

10 mg b.i.d.

10 mg per dose

50 mg

20 b.i

F luoxetine (P rozac)

10 mg q.d.

10 mg per dose

60 mg

20 q.d

F luvoxamine (Luvox)

25 mg q.d., then b.i.d.

25 mg per dose

250 mg

25 q.d the b.i

S ertraline (Zoloft)

12.5 mg b.i.d.

25 mg per dose

250 mg

25 b.i

Note: T here have been other unpublis hed indus try-back studies are not known. b.i.d., twice a day; q.d., every day.

S IDE E FFE C TS When treatment with antidepress ants is being it is important to first ask about symptoms that could be misattributed to s ide effects (gastrointes tinal [G I] complaints , drows iness , irritability, s uicidal ideation, headaches, and rashes). S uicide ideation and attempts common in depres sed teenagers. In clinical trials of suicide attempts have been found to be more common 4342 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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those treated with antidepres sants than in placebo controls. It is not known if this is a cons equence of medication-induced akathis ia or activation; whether it is similar to the increase in s uicidality often seen in recovering depres sed patients during a mixed affective state; or whether it is due to dis inhibition and a greater propens ity to dis close suicidal thoughts and behaviors that would otherwis e have been kept secret. S ide effects can emerge during the early days of and clos e contact should be maintained with the or parent during this time. If emergent side effects are and tolerable, pers is t P.3266 with treatment for 2 to 5 days on the original starting If the s ide effects are intolerable, discontinue there are no unwanted side effects, but therapeutic res ponse is poor, gradually increase the dos e in the increments indicated in T able 45.1-1. If, after 4 to 6 of treatment, the dose has been increas ed to the level above the maximum recommended, and side effects only slight, but the therapeutic res pons e is s uboptimal, reasonable to augment with another medication, such lithium (E s kalith), divalproex (Depakote), bus pirone (B uS par), or a s timulant. If this cours e of action fails to produce an improvement, consider a second-line medication, such as venlafaxine (E ffexor) or bupropion (W ellbutrin). Although most teenagers treated with antidepres sants show improvement, only a minorityjus t over one-thirdof these teenagers who show a positive res ponse do s o completely. B as ed on experience with adults , treatment 4343 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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should be continued for 6 to 12 months to reduce the chance of relaps e. T reatment should be dis continued gradually, and the clinician s hould alert parents and to the pos sible ons et of a discontinuation s yndrome (dizziness , drows iness , nausea, lethargy, and A common quandary facing the clinician is what to offer the child or teenager if neither of the so-called based ps ychotherapies is available or affordable. no evidence that active support and couns eling and environmental manipulation, among other therapies , detrimental or without value, and they s hould not be withheld. It is important to regularly review progress , if there has been no change, treatments s hould be In the event that the youth and family can take of evidence-based ps ychotherapy and that s uch is conveniently available and affordable, the following guidelines might be us eful. E vide nce -bas e d alone is indicated if the youth has mild to moderate symptoms (e.g., C DR S -R raw s core of les s than 58). E vide nce -bas e d the rapy plus medication s hould be cons idered if the youth has moderate to severe (e.g., C DR S -R raw s core between 58 and 75) and functional impairment. Me dication plus s upportive is recommended if the youth is ps ychotic or if based ps ychotherapy is not available in the area or if youth is unable or unwilling to cooperate. T here is no evidence that s upportive therapy alone is helpful.

S UIC IDE C ompleted s uicide is a rare but terrible occurrence. poss ibility of suicide lies like a s hadow over other much more common and not always s erious manifes tations 4344 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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suicidal tendencythoughts and s uicide attempts. In developed nations, s uicide is the s econd leading cause adoles cent death (after accidents ). In the United high incidence of homicide places suicide in the third position, a true blight on this otherwis e healthy time of S uicide attempts , threats , and ideation account for a proportion of all teenage referrals to ps ychiatric clinics . any one year, as many as one in five U.S . high school students will have thought about suicide, and one in will have initiated a behavior with at leas t s ome degree intent to die. T he different manifestations of s uicidal tendency are related to one another in a complex fashion that differs childhood and adolescence from other times of life. T hinking about s uicide is , of course, a necess ary for making a s uicide attempt or for committing suicide, and it is extremely common. Approximately one-half of large number of teenagers who ideate s uicide make an attempt, and one-fourth of these attempts lead to treatment. T he proportion of s uicide attempts that presage an eventual s uicide is s mall. S uicide attempts 400 times more common than s uicides in adolescent and 4,000 times more common than suicide in girls. Having made an attempt increases the likelihood completed s uicide more than 30-fold among boys . However, clinical concerns about a child or adoles cent who is thinking about s uicide are not dictated s olely by fear that he or s he might commit suicide. T houghts of suicide are often as sociated with s ignificant distress are an indication that any accompanying mental such as anxiety, depres sion, alcohol abuse, or behavior, is serious ly disabling to the patient. 4345 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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Definitions and C las s ific ation A s uicide attempt is a DS M-IV -T R criterion for major depres sive disorder (296.2x: recurrent thoughts of [not just fear of dying], recurrent s uicidal ideation a s pecific plan, or a suicide attempt or a s pecific plan committing suicide) and borderline personality dis order (301.83, C riterion 5: recurrent s uicidal behavior, or threats, or s elf-mutilating behavior). However, attempts are made, and s uicide is thought about by teenagers without either of thes e diagnoses. T he World Health Organization has defined a s uicide atte mpt as an act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behavior that, without intervention from others, will cause selfharm, or deliberately ingests a s ubs tance in excess of prescribed or generally recognized therapeutic dosage, and which is aimed at realizing changes which the desired via the actual or expected phys ical T his definition omits any mention of a wis h to die or the us e of the broader concept of s e lf-harm and thus the reluctance of many to accept that all attempts are accompanied by some degree of lethal intent. It is reminiscent of the term paras uicide developed by P.3267 Norman K reitman to describe ingestions or s kin cutting, most often in girls and usually with a benign outcome. us e conveys the view that s ome types of suicidal are benign in nature. T he term s uicide ges ture has different implications. It is frequently, and probably erroneous ly, us ed to imply 4346 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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suicidal behavior was initiated without lethal intent, as a cry for help or to attract attention. Us e of the term that motivation and intent are known. In truth, both are often hard to as sess , and res earch gives little help in direction. E ven though many teenagers take no action prevent being dis covered or to use methods that are unlikely to result in death, approximately one-half of teenagers seen in an emergency department after a supposed attempt say that, at the time of their action, wanted to die. T erms such as de libe rate s e lf-pois oning de libe rate s e lf-harm, in common use in E urope, might preferable, for they at leas t avoid as sumptions about motivation and intent. F inally, the C enters for Disease C ontrol clas sify suicide attempts according to whether they elicited medical attention. Although this provides us eful information service burdens , it is not necess arily a good indication severity or prognosis. Medical attention is determined the availability and affordability of treatment and by attitudes toward obtaining treatment for mental phenomena, as well as by the severity of intent, and it best reserved for the purpos e of recording service rather than s uicidal tendency.

His tory T he current view of s uicide is a medicalized one, that that it is a fatal complication of an underlying condition. T his view prevailed for a while during the century, and s uicide was considered a s uitable subject epidemiological res earch. T hat early research demonstrated the greater incidence among men, the rate in elderly men, and the s trong relations hip to 4347 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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alcoholism, observations that still apply more than a century after they were first made. Most psychiatric symptoms have, at s ome time, been explained in s piritual or moral terms, and suicidal has retained a nonmedical connotation longer than T hose who argue for medically as sis ted suicide are applying an argument us ed in early R ome, where was considered a matter of choice with some social material value. S uicide by a s lave or a s oldierwhich in a loss of the owner's or the state's wealthwas by confiscation of the deceas ed's pos sess ions . for other class es , it was a matter of choice. In the days the early C hristian church, suicide in anticipation of a glorious life after death was allegedly common among C hris tians . T his was argued agains t by S t. Augus tine various church councils, which, in the sixth century, initiated a tradition of s anction and intolerance that until the early 1970s , when the United K ingdom and of the United S tates cons idered suicide and attempted suicide illegal. In 1938, K arl Menninger sugges ted that a wide variety behaviors that caus e harm to the patient, s uch as subs tance and alcohol us e, compuls ive gambling, and promis cuous sex, could be grouped on a s pectrum of de s tructive behavior. Although thes e behaviors whether this is becaus e they share a common as implied by Menninger; because they are of a common psychological trait, such as impulsivity, or some common prior experience, such as early or abus e; or becaus e they are manifes tations of a sequential events, for example, a youth with conduct disorder who becomes depress ed and suicidal 4348 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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repeated s chool failure and haras sment, is not known. In summary, a s uicide attempt should be seen as a symptom or behavior with varying etiologies . Motivation and s everity are difficult to as sess , and, in most the patient's mental s tate is a better predictor of later outcome than the features and circumstances of the method.

E pidemiology S uic ide AG E In all countries, suicide rates are extremely low before puberty. In boys, the rate increas es in a linear fas hion through the teens, until reaching a peak in the mid-20s that is s ix to eight times greater than it was 10 years (F ig. 45.1-1). T he rate among girls shows little change during the period.

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FIGUR E 45.1-1 S uicide rates during adolescence S tates, 10 to 24 years of age, 2000) T he reasons for the low rates of s uicide before puberty not known. Y oung children threaten s uicide and even make attempts, s o P.3268 it is likely that they are aware of the concept. However, two mos t potent ris k factors for suicide are depress ion subs tance abus e, and both are unus ual before puberty.

GE NDE R In 2000, in the United S tates , the suicide rate among 14-year-old boys and girls was 2.3 and 0.6 per 4350 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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res pectively. T he rates increase sharply through the teenage years to 13.2 and 2.8 per 100,000 among 1519-year-old boys and girls, respectively. Attempted and s uicidal ideation are more common in girls , and completed s uicide rates in girls are generally lower boys in all countries except C hina. T he lower female suicide rate probably reflects s ome combination of the lower lethality of the preferred method of ingestion, coupled with the great importance impulsive and aggress ive behavior as a determinant of suicide and the exces s of these attributes among boys .

E THNIC ITY AND C UL TUR E S uicide rates vary cons iderably among different defined culturally or geographically. In the United suicide has long been more common in whites than nonwhites. In the mid-1980s , suicide rates s tarted to increase among African American adoles cents, while declining or remaining s tatic among whites. Differences male rates are now clos e for boys 15 through 24 years age. T he s uicide rate varies geographically, even adjoining countries and regions. In the United S tates , youth suicide rates are lowes t in the Northeas t and in Alas ka, New Mexico, and Arizona. S imilar have existed for many years and are not attributable to differences in ethnicity or firearm availability. T here is evidence that the differences reflect different rates of factors , s uch as types of psychiatric disorder, familial suicidal tendency, precipitating stress es, or differences cultural or national group.

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S uicide is most common during the spring months in northern and s outhern hemispheres, with a secondary peak occurring in the fall. S easonal variation has diminis hed since the 1980s. If s eas onal differences the s eas onality of mood disorders , a flattening could reflect broader recognition of, and treatment for, mood disorders .

C HANG E S IN THE S UIC IDE R ATE TIME Male suicide rates increas ed threefold between 1964 1988 (F ig. 45.1-2). T hey then went through a period, 1993, with no increases accruing and then started to going from approximately 19 in 100,000 in 1994 to approximately 14 in 100,000 in 2000.

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FIGUR E 45.1-2 T eenage s uicide rates by race, 1964 to (United S tates , 15 to 19 years of age, and all male adoles cents ). *C rude rates; before 1979, African data are not broken out. T he earlier increas e coincided with a period of greatly increased exposure to drugs and alcohol, which are ris k factors for male suicide. However, the recent does not appear to have been due to any reversal of factor. E xposure to drugs or alcohol has been stable this period. Although firearm us age has declined during this period, and although, in Aus tralia, the impos ition of radical changes in gun owners hip rules coincided with abrupt decline in the youth s uicide rate in that country, this might not be the mechanis m in the United S tates . Declining firearm owners hip long predates the decline youth suicide rates , and, most importantly, the of youth suicides committed by firearm has not On the other hand, the reduction has coincided with a sharp increase in the pres cription of antidepress ants disturbed youth behaviors. E pidemiological s tudies indicate that, across s mall areas in the United S tates, increase in S S R I pres criptions for teenagers has with declines in the teenage s uicide rate.

A ttempted S uic ide Large, frequently repeated benchmark surveys of adoles cent s uicide ideation and behavior indicate that approximately 20 percent of U.S . high s chool s tudents thought about s uicide, whereas approximately 10 had made one or more suicide attempts. B etween 2 4353 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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percent of teenagers receive medical attention for their attempt. T he peak incidence is among 15- to 16-yearT he rates are broadly compatible with other studies.

AG E S uicide attempts are relatively rare among prepubertal children and increase in frequency through peaking between 16 and 18 years of age. P.3269

GE NDE R G irls are significantly more likely to have s eriously cons idered attempting s uicide (23.6 percent), to have made a s pecific plan (17.7 percent), and to have suicide (11.2 percent) than boys (14.2 percent, 11.8 percent, and 6.2 percent, respectively); however, the gender difference narrows when cons idering attempts requiring medical attention (3.1 percent of females, 2.1 percent of males ). T he femalemale ratio of attempted suicide differs in clinical populations (greater differences) and in community studies (s maller differences).

E THNIC ITY Higher rates of s uicide ideation are found in white (19.7 percent) and Latino teenagers (19.4 percent) than in African American teenagers (13.3 percent). Latino are more likely (12.1 percent) to attempt s uicide than African American (8.8 percent) or white (7.9 percent) students. R eas ons for the higher rate of s uicidal 4354 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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and attempt behavior in His panic youth are not known.

S E C UL AR TR E NDS As with s uicide-completion rates , s uicidal-ideation rates have dropped cons iderably, from 21 percent in boys 29 percent in girls in 1991 to 14 and 19 percent, res pectively, in 2001. R eports that attempt rates have increased in E urope are bas ed on the number of attempters who have attended clinics a rate that is influenced by the availability of s ervices.

Methods , Prec ipitants , and Methods S UIC IDE In 1999, in the United S tates , 64 percent of boys and percent of girls who committed suicide did s o with firearms, usually legally owned, but often inadequately secured. Mos t deaths are from rifle or shotgun wounds , with only 18 percent of firearm suicides being with handguns. Other methods us ed by U.S . teenagers include hanging (26 percent of boys and 33 percent of girls) and jumping from a height (2 percent of boys and percent of girls). Inges tion accounts for only 2 percent male, but 16 percent of female, s uicides. T he suicides attributable to self-as phyxiation is only 2 for both genders . T his represents a decline from 7 before the introduction of catalytic converters in 1975, which, by reducing the amount of available carbon monoxide, also reduced the lethality of the method. T here is no evidence linking s uicide method to the type underlying ps ychopathology. Mos t res earch sugges ts 4355 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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method is determined in part by availability and in part local custom. In countries in which female s uicide that of boys, such as India and C hina, inges tants are most common method but are of a type, for example, paraquat or organophosphates, that lead to disorders cannot readily be treated.

ATTE MPTE D S UIC IDE In general-population s amples , the methods used most commonly by girls and by boys differ quite markedly. Among girls, 55 percent us e an inges tant, and 31 us e s kin cutting. T he percentages of thes e methods among boys are 20 percent and 25 percent, 15 percent of male attempts involve firearms , and 11 percent involve attempted hanging. Most attempters seen in a clinic after an inges tion, most often of a nonnarcotic analgesic or ps ychotropic drug.

P rec ipitants S UIC IDE Most suicides are committed shortly after a stress ful (posts tres sor suicide) or just before an event that has anticipated with fear (prestress or s uicide). T he timing the nature of the stress or often reflect the victim's underlying ps ychopathology. T he interval between the stress or and the s uicide is often briefhours or, minutes. S tres sors that mos t commonly precede a are us ually of a dis ciplinary or forens ic nature or terminating a relationship with a boyfriend or girlfriend. T his type of s tres sor is es pecially common in with an ass ociated conduct or s ubs tance abus e S uicides that occur in anticipation of a feared event 4356 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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commonly affect anxious teenagers. T he feared event might be as banal as a test or examination or might involve more important changes , s uch as s tarting at a school or moving to a new neighborhood. A relatively small number of suicides occur without any preceding anticipatory stress or and are most likely to afflict a teenager experiencing a major depres sion. A small of suicides occur on the annivers ary of a friend's death, whereas a disproportionate number occurs within a time of (before or after) the s uicidal person's own

ATTE MPTE D S UIC IDE T he most common precipitants of s uicide attempts are relations hip cris is with a boyfriend or girlfriend, an argument with parents over limits , or recent financial or legal difficulties. As many as one-third of adoles cent attempters are unable or unwilling to identify a clear precipitant, and this group should be evaluated for evidence of an underlying depres sion.

E xplic it Threats and Warning Approximately one-half of all suicidal persons discus s threaten s uicide within 24 hours of their deaths, mos t commonly with their friends. More complex, explicit behaviors , s uch as writing a will or giving away poss ess ions, are much les s common. Des pite this, suicide awarenes s programs emphas ize the detecting these infrequent behaviors . However, their rarity, this is unlikely to be a useful s trategy.

Natural His tory S uic ide 4357 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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As much as 40 percent of suicidal pers ons have made previous known suicide attempt. P revious attempts are most common in girls and among persons experiencing mood dis order at the time of their death.

A ttempted S uic ide In community s amples , approximately 10 percent of teenagers who have attempted s uicide make a s econd subs equent attempt within 2 years . More repeat are seen in clinics , where 12 to 30 percent will have prior attempt. Mos t repetitions take place within 3 of the initial attempt. R epeat attempts are more in boys and teenagers with a his tory of s ubs tance ps ychos is , or depress ion and in thos e who pres ent with hopeless nes s. T hey are les s common among those home and in thos e with good peer relationships.

E tiology T he large number of res earch s tudies of s uicide and attempted s uicide have indicated many contributing factors . Many of thes e are correlated with one another, their independent contributions might be small. T hey grouped as being individual differences (e.g., ps ychological traits, psychiatric illness es , or biological abnormalities ) or environmental influences . An diagram of how thes e factors might be linked to one another on the path to suicide is pres ented in F igure 3.

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FIGUR E 45.1-3 How do s uicides occur, and how can be prevented?

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POVE R TY AND S E S Adults who commit suicide and adoles cents who suicide are more likely to be of low S E S . However, this relations hip has not been found in teenage s uicides. In adoles cent attempters, the relations hip holds even controlling for other s ocial and psychiatric risk factors . discrepant findings from studies of teenaged could be a function of the s mall number of studies that have been done, or it could be that the economic disadvantages found in older s uicides result from the social drift that occurs once eventual s uicides with a chronic psychiatric disorder leave home. P.3270

S OC IAL E NVIR ONME NT A large proportion of older teenaged s uicide were drifters neither attending s chool nor employed. proces s probably s tarted in the mid-teens , and there is strong relationship between high s chool dropout and suicide attempts.

IMITATION R eading about, s eeing, or hearing about suicidal seems to induce imitative behavior in some Increased suicidal behavior after exposure to s uiciderelated material on television, in newspapers, in and in books has been widely and regularly reported. would be expected from imitative learning, the effect is proportional to the amount, duration, and s alience of expos ure. T he individual characteristics of adoles cents who are s usceptible to imitation are currently unknown. 4360 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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S uicide clus ters are striking manifes tations of the phenomenon and account for as much as 4 percent of teenage s uicides in the United S tates . T he American F oundation for S uicide P revention has prepared guidelines for journalis ts on how to minimize when reporting on a youth s uicide, which include minimizing the graphic display of s tories on s uicide, avoiding romanticization and precis e description of methods, and dis seminating treatment resources. Imitation might als o play an important role in suicide attempts. T here are cons is tent reports that teenagers attempt s uicide are s ignificantly more likely to have a friend who attempted suicide or to have a family who attempted s uicide.

PAR E NTC HIL D R E LATIONS HIPS AND AB US E S uicide victims are more likely than teenagers in the general population to live with only one parent, to have parents with ps ychiatric illness , and to live in homes much parentparent dis cord. P arental ps ychiatric illness accounts for a s ignificant part of the high rates of and s exual abus e found in attempted and completed suicides. However, there als o seems to be a s pecific relations hip between abus e and s uicidal tendency, because it is found even after accounting for characteristics and parental ps ychopathology. P arentyouth conflict often precedes an attempt but less often before a death. C onflicts before an attempt us ually concern unresolved differences over limit T eenagers frequently view the relations hip with their 4361 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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parents as more dys functional than the parents acknowledge. It is highly likely that thes e s tres sors with as -yet unknown individual vulnerability factors to lead to the behavioral res ponse style that makes a attempt more likely.

Individual Differenc es PS YC HOPATHOLOG Y Although few adoles cents (or adults ) commit s uicide in absence of a psychiatric disorder, few individuals P.3271 with a psychiatric disorder commit suicide. P sychopathology is therefore a necess ary but not caus e of s uicide. Information about prior psychopathologies is usually obtained through the ps ychological-autops y method, which obtains accounts of s ymptomatic behavior and of the suicides from those who had a chance to the victims frequently during a period before their T hey s how that approximately 90 percent of children teenagers who commit suicide were experiencing a ps ychiatric disorder at the time of death. T he disorder us ually well established and, in approximately one-half suicides, has been present for 2 or more years . Major depress ion is the most s ignificant ris k factor for suicide in girls , increasing the risk of s uicide 20-fold. A previous suicide attempt increases the risk for s uicide girls threefold. A prior s uicide attempt is the s trongest predictor of completed s uicide in boys, increas ing ris k fold. 4362 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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Many young pers ons who commit suicide with a mood dis order also have a comorbid conduct disorder or s ubs tance and alcohol abus e , or both, which, alone or comorbid, is pres ent in as much as two-thirds of older who commit s uicide. C onduct or oppos itional dis orde r present in between one-third and one-half of suicides , somewhat more frequently among boys and older teenagers. Although the s uicide rate is greatly s chizophre nia and bipolar illne s s , because of their rarity, they account for fewer than 5 percent of suicides each. Many severely depress ed patients are not suicidal, others with only mild or trans ient depres sion or, indeed, no depress ion at all can make s erious suicide attempts succes sfully commit s uicide. T his has led s ome to that s uicidal tendency should be regarded as an independent condition. In support of this , the biological determinants of s uicide appear to be different from of depress ion and are found in suicidal patients of their as sociated diagnos es . T he ps ychiatric profile of s uicide attempters is , in many ways, s imilar to that of suicides. Almos t all teenage attempters have a ps ychiatric illness or have previously experienced one. Most commonly, this is a mood often comorbid with a conduct or anxiety dis order or, much les s commonly, with an eating disorder. disorders are als o common. S ubthres hold s ymptoms might increas e rapidly in respons e to a s tres s but normal shortly after the attempt. S uicide attempts are significantly more common in heavy smokers. Heavy drinking increas es the likelihood of a s uicide attempt nearly tenfold. Alcoholis m is three times more powerful 4363 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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a risk factor for attempts than is physical or s exual

PS YC HOL OG IC AL FAC TOR S Most emphas is has been put on the ps ychological cons tructs of hopeless ness , impulsivity, and imitation. F ew pers ons who commit s uicide have studied in this regard before their deaths , so much of information has been obtained from s tudies of s uicide attempters , and its generalizability to suicide uncertain.

Hopeles s nes s T he relationship between s uicidal tendency and hopeless nes s remains an area of controversy. Large longitudinal studies have failed to find a relations hip between the two afte r controlling for depres sion. T hos e that have found a relationship have noted it to be strongest among girls, who cons titute a majority of attempters and a minority of completers. T he evidence for impuls ivity owes more to the study of suicidal decisions and to the nature of the biological abnormalities in suicides than to s tandard laboratory meas ures . In one series of cons ecutive emergency department admiss ions, only 10 to 15 percent reported thinking about their attempt for more than a day, and percent of suicide attempters reported no prior However, this might not reflect a trait-like cognitive set, but rather extreme mood volatility.

A ggres s ivenes s T he relationship between s uicidal tendency and aggres siveness has been reported frequently and is in 4364 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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with the biological findings . T he aggres sivenes s of the suicidal youth might be more than a manifes tation of current depress ion. Aggres sive 8-year-olds have been shown to have twice the rate of later ideation and behavior than matched nonaggres sive controls .

S exual Orientation Large community studies have shown that gay, and bisexual (G LB ) youth are between two and six more likely than heteros exual adolescents to think and to attempt suicide. In a nationally repres entative sample, 9 percent of U.S . G LB adolescents had made attempt in the last year. In a Mass achus etts S tate as many as 35 percent had made an attempt. T he mechanisms of this relations hip remain largely G LB youth are more likely to be victimized at s chool, they als o have higher rates of drug and alcohol us e higher rates of ps ychiatric dis orders, including major depres sion, generalized anxiety disorder, and conduct disorder. All or any of thes e factors might account for or all of the s trikingly increased rates of s uicidal among G LB teenagers.

B IOLOG Y Family His tory and G enetic s C ompleted teenage suicides and suicide attempters between two and four times more likely than matched controls to have a first-degree relative who committed suicide. T win studies demonstrate that this is not cons equence of being reared by a ps ychiatrically ill T he increased ris k of committing s uicide among cotwins of suicides is approximately 11 to 1, compared 4365 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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twice the risk in nonidentical twins.

S E R OTONE R G IC AB NOR MALITIE S A great many s tudies have pointed to abnormalities of serotonin function in s uicidal individuals and in aggres sive individuals. T he original investigators to low levels of s erotonin metabolites in urine and cerebrospinal fluid (C S F ). S ubs equent and neuroanatomical s tudies have s hown a reduction the overall density of s erotonin type 1A receptors and serotonin trans porter receptors (which regulate uptake) in the prefrontal cortex and in the dors al raphe nucle us , the s ource of serotonin innervation of the prefrontal cortex. S everal genetic mechanisms have been propos ed to explain the s erotoninergic abnormalities ass ociated suicidal tendency. T hese include polymorphis ms in the serotonin trans port gene and the s erotonin type 1A receptor gene and polymorphisms on intron 7 of the for tryptophan hydroxylas e (T P H) (the rate-limiting enzyme for the bios ynthes is of s erotonin). T he suicide phenotype is probably heterogeneous and complex, genetic effects are probably small, and it is likely that a single genetic variant is les s important than patterns of variance. B ecaus e this relationship is independent of diagnosis, thought to be a marker of an underlying trait. A mechanism would be that these abnormalities or differences modify the respons e of a mentally ill person stress , resulting directly in s uicidal behavior or in a res ponse that generates advers e cons equences and es calating cas cade of stress es and aggres sion, 4366 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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in suicidal behavior. T he proportion of s uicides that fall into this category is not known. T here has been a s ingle promising report indicating attempters who have low levels of serotonin in the C S F are significantly more likely to make a future attempt or to commit suicide, P.3272 or both, but, before thes e findings can be us ed for prediction or prevention, replication is needed, along collection of information on the bas e rate of thes e abnormalities in the general nons uicidal population.

PE R INATAL MOR B IDITY A relations hip between perinatal morbidity and subs equent s uicide has been reported in s everal, but all, s tudies that have examined this . T he mechanism of relations hip is unknown.

Treatment of S uic idal Tendenc y P as t and C urrent Treatment Lifetime contact with mental health profess ionals from 25 to 60 percent. A s mall minorityapproximately percentof s uicides occurs during the cours e (within a month) of active psychiatric treatment. Approximately one-third of suicide attempts res ult in a clinical evaluation and later treatment. F emale are more likely to be treated than male attempters , and His panics are more likely to be treated than blacks or whites. 4367 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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Initial Management S uicide attempters are commonly s een in an department, where, after medical s tabilization, a needs to be made about whether they need continued observation or can return home.

AS S E S S ME NT T he prognos tic s ignificance of a s uicide attempt ranges from benign, with few, if any, negative s equelae, to malignant, with later s uicide. T hese various outcomes probably dependent on the mental context in which suicidal behavior occurs , and they s hould be the focus the clinical evaluation. S uicidal tendency is not, in its elf, adequate diagnos is. Approximately one-fourth of attempters have no of s ustained psychopathology. A number of s uicide attempters have what can best be described as an adjus tment disorder. B etween stress ors , they might subthreshold symptoms , but their mental state changes abruptly in res ponse to a s tres s and then recovers to former mildly abnormal level s hortly after the attempt. T he clinician's greatest concern when evaluating is to differentiate between those with a benign and those with a malignant prognosis . B ecause of the frequency of ideation and attempts and the rarity of completed s uicide, it is statis tically reasonable to attempts as benign. However, few clinicians as sume actuarial pos ition. T he problem facing clinicians is that teenager's intent is difficult to gauge before or after the event. T eenagers are poorly informed about the ris ks they take. B etween 30 and 50 percent of teenagers 4368 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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an emergency department after an attempt s ay that wanted to die, even though few took active precautions agains t being discovered. T he teenager and the clinician frequently differ on how dangerous the behavior was. In one s tudy of who said that they wanted to die, ps ychiatris ts drew the same conclusion in only one-third. T his raises the of if and when it is reas onable to challenge a patient's statement about intent. Intent cannot be eas ily inferred from the s ize of an overdose. Normal and dis turbed adoles cents frequently misjudge the potential lethality inges tions, in s ome instances overestimating lethality in others, underestimating lethality. In a study that compared attempter and pediatrician es timates of the seriousness of an ingestion, teenagers rated 26 attempts as having lethal potential, but only 2 percent were considered potentially lethal by the pediatricians. P rior planning is often us ed to as ses s intent, but attempts and suicides commonly occur shortly after a stress ful event, and it is unlikely that they were planned. T he Y outh R is k B ehavior S urvey regularly that three-fourths of teenagers who ideated s uicide had made a plan about how to commit suicide. Mos t of teenagers do not go on to attempt or commit s uicide, a s tudy of nonplanners s hows that they have a similar attempt rate and also show other problems . C ontinued observation is indicated for attempters with abnormal mental s tate, es pecially those who are depres sed, irritable, or ps ychotic, and for the s mall proportion who declare a pers is tent wish to die. T he features that increase ris k for later s uicide are lis ted in T able 45.1-2, and the decision to admit a patient is 4369 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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made by an imprecis e juggling of thes e ris ks . T he s hort medium risk of suicide is s mall in prepubertal children, suicidal ideation or behavior s hould not, by itself, be as an indication for hos pitalization in that age group.

Table 45.1-2 As s es s ing C hild Adoles c ent S uic ide Attempters (E mergenc y) Attempters at greates t ris k for s uic ide Do not dis c harge without a ps yc hiatric evaluation Mental s tate    Depres sed, manic, hypomanic, s everely a mixture of thes e s tates    S ubs tance abus e alone or in as sociation with a mood dis order    Irritable, agitated, threatening violence to delus ional, or hallucinating S uicidal his tory    S till thinking of s uicide

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   Has made a prior s uicide attempt

T here are no studies that demons trate the pos itive or negative impact of hospitalization, although it has been shown that, within an adoles cent ward, attempters tend seek one another's company, jus t as they do in other settings , such as college. Deciding whether to admit a currently euthymic recent attempter often depends on es sentially nonclinical cons iderations, such as coverage and bed availability. W hen an admis sion can be brief and can only be to a dis tant hospital that does provide wraparound care, it likely has les s value than admis sion to a site that offers more significant intervention. R egardless of mental s tate, no teenager s hould be discharged from the emergency department without an interview with a respons ible adult, ideally, the T he youth should be dis charged to the care of the who s hould be told to secure or to remove dangerous medications and firearms. P arents accept and comply these ins tructions when they are given clearly but not think to do so otherwis e. It is reas onable to hold the young patient in the emergency department until weapons and medications have been s ecured or 4371 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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discarded. P atients are often required to sign a contract for s afety condition for dis charge. T his contract requires the to contact a clinician before engaging in any further suicidal behavior. T he impact of these contracts is not known, and, in one study of 135 repeat attempters , 31 percent had previous ly signed a contract for s afety. T he emergency department offers an opportunity to obtain a detailed account of the events and feelings preceded the attempt and its cons equences at the first visit. T his information can be helpful for planning and is best obtained while memory of the event is

Outpatient C are Only a minority of attempters s een in an emergency department s ubs equently engage in s ubs tantive ps ychiatric treatment. Unfortunately, noncompliance offers of further P.3273 treatment is mos t common in attempters who are symptomatic and who continue to think about s uicide. F actors that might improve adherence to planned treatment include (1) teaching the family about the condition and its treatment; (2) dealing with factors that are not directly related to the patient's suicide attempt, such as family s trife; (3) offering follow-up from the emergency department before dis charge; and es tablis hing procedures to remind the patient of future appointments and proactive follow-up after miss ed appointments . 4372 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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P s yc hotherapy Only a s mall number of ps ychotherapy s tudies have conducted among teenage s uicide attempters. that have failed to reduce the attempt-repetition rate include problem solving, enhanced access to clinical service, and home-based family therapy. C B T , widely tested for depress ed adolescents, has not as sess ed in suicidal children, but studies of its effect in suicidal adults have not been promising. Dialectical behavior therapy (DB T ) has been shown to reduce repeat attempts in adults, but its effect on teenagers is not known. DB T is a complex and lengthy behavioral intervention given in individual and group contexts . DB T builds on a well-es tablis hed model of suicidal tendency, s o that its components are worth considering. T hes e include (1) mindfulnes s to improve self-acceptance, (2) ass ertiveness training reduce interpersonal conflicts, (3) training the patient to avoid situations that trigger negative moods, and (4) increasing tolerance for psychological dis tres s. C B T been us ed success fully in adolescent patients with depres sion, but no s tudies of individualized C B T with adoles cent s uicide attempters have been published.

P harmac otherapy S ome s uicide attempters are extremely volatile and frequent s uicidal attempts . In such cas es, small dos es antips ychotic medication have been s hown to be es pecially us eful. S S R I antide pre s s ants have been s hown to reduce ideation in depres sed and nondepres sed adults with 4373 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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clus ter B personality dis orders and in individuals who made a limited number of previous suicide attempts . T here is s ome ecological evidence that links the rate of use of S S R Is by teenagers to the decline in the teenage s uicide rate. T here are anecdotal reports suggesting that at least some antidepres sants might precis ely the oppos ite effect in teenagers . However, have been shown to be more effective than placebo in treating depres sed teenagers , and they reduce the frequency of impuls ive and aggres sive behaviors, are common in s uicidal teenagers . T hey are less dangerous in overdose than tricyclic L ithium has been shown to exert a powerful antisuicide effect in bipolar adults. However, when a bipolar withdrawn from lithium s uddenly, the ris k of s uicide increases, even if manic s ymptoms do not appear. C lozapine (C lozaril) has been found to be effective in reducing s uicidal tendency in s chizophrenic adults , when there is no apparent effect or impact on other symptoms of s chizophrenia. T he antis uicidal effects of lithium and clozapine have not been ass es sed in or adolescents. W hen lithium is being us ed to treat an adoles cent, caution s hould be us ed when the drug is withdrawn, and sudden withdrawal should be avoided.

Iatrogenic S uic idal Tendenc y Uncontrolled reports on the induction of s uicidal by S S R I antidepres sants appeared s hortly after their introduction. In s ome, but not all, cases, suicidal was reversed after treatment was dis continued. metaanalyses of many thousands of children and suggest that the overwhelming effect of S S R Is is to 4374 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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suicidal ideation. Although it s eems likely that suicidal tendency during treatment reflect the fact that suicidal tendency is closely linked to suicide, this might always be the case. C linicians s hould s ys tematically about s uicidal ideation before and after treatment is started and should be alert to the pos sibility of s uicidal tendency. C linicians s hould generally be cautious about medications that can reduce s elf-control, s uch as the benzodiazepines, in patients who have made a suicide attempt. P henobarbital (B arbita) also has a high lethal potential if taken in overdos e. B enzodiazepines might disinhibit s ome individuals , who then exhibit aggres sion and make suicide attempts . T here are indications of effects from the antidepress ants maprotiline (Ludiomil) and amitriptyline (E lavil), the amphetamines, and phenobarbital.

S UG G E S TE D C R OS S C hapter 13 provides an exhaus tive discus sion of mood disorders , and suicide is dis cuss ed further in S ection

R E F E R E NC E S Anderson R N. Deaths: Leading caus es for 2000. In: National V ital S tatis tics R e ports . V ol 50. Hyattsville, National C enter for Health S tatistics ; 2002. Arango V , Huang Y , Underwood MD, Mann J J : of the s erotonergic system in suicidal behavior. J P s ychiatr R es . 2003;37:375. B irmaher B , B rent D. P harmacological treatment of 4375 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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children and adolescents with major depress ive disorder. In: S haffer D, W as lick B , eds . T he Many Depre s s ion. W ashington, DC : American P s ychiatric P ublis hing; 2002. B rent DA, B augher M, B ridge J , C hen T , C hiappetta Age- and s ex-related ris k factors for adolescent J Am Acad C hild Adole s c P s ychiatry. 1999;38:1497. *C aspi A, S ugden K , Moffitt T E , T aylor A, C raig IW , Harrington H, McC lay J , Mill J , Martin J , B raithwaite P oulton R : Influence of life s tres s on depress ion: Moderation by a polymorphism in the 5-HT T gene. S cience. 2003;301:386. *C olumbia T reatment G uidelines. Depre s s ive (V ers ion 2). New Y ork: C olumbia Univers ity, of C hild and Adoles cent P s ychiatry; 2002. *C ostello E J , Mustillo S , E rkanli A, K eeler G , Angold P revalence and development of psychiatric childhood and adolescence. Arch G e n P s ychiatry. 2003;60:837. E ms lie G J , Mayes T L, Laptook R S , B att M: res ponse to treatment in children and adoles cents mood dis orders. P s ychiatr C lin North Am. F arberow NL. T he his tory of suicide. In: E vans G , F arberow NL, eds . T he E ncyclope dia of S uicide . F acts on F ile; 1988.

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F awcett J : T argeting treatment in patients with symptoms of anxiety and depress ion. J C lin 1990;51[S uppl]:40. F ergus son DM, Horwood LJ , B eautrais AL: Is s exual orientation related to mental health problems and suicidality in young people? Arch G e n P s ychiatry. 1999;56:876. F ombonne E , Wos tear G , C ooper V , Harrington R , M: T he Mauds ley long-term follow-up of child and adoles cent depress ion. 1. P s ychiatric outcomes in adulthood. B r J P s ychiatry. 2001;179:210. G ould MS , G reenberg T , V elting DM, S haffer D: suicide ris k and preventive interventions: A review of the pas t ten years . J Am Acad C hild Adole s c 2003;42:386. G runbaum J A, K ann L, K inchen S A, W illiams B , Lowry R , K olbe L: Y outh R isk B ehavior S urveillanceUnited S tates, 2001. MMW R S urve ill 2002;51:1. *Hawton K , T ownsend E , Arensman E , G unnell D, P , House A, van Heeringen K : P sychosocial versus pharmacological treatments for deliberate s elf harm. C ochrane Databas e S ys t R e v. 2002;C D001764(2). K es sler R C , Avenevoli S , R ies MK : Mood dis orders children and adoles cents: An epidemiologic 4377 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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perspective. B iol P s ychiatry. 2001;49:1002. K ing R A, R iddle MA, C happell P B , Hardin MT , G M, Lombros o P , S cahill L: E mergence of selfdestructive phenomena in children and adolescents during fluoxetine treatment. J Am Acad C hild P s ychiatry. 1991;30:179. K ovacs M, Obros ky DS , G ats onis C , R ichards C : episode major depres sive and dys thymic disorder in childhood: C linical and s ociodemographic factors in recovery. J Am Acad C hild Adole s c P s ychiatry. 1997;36:777. Lewins ohn P M, C larke G N: P sychosocial treatments adoles cent depress ion. C lin P s ychol R e v. Lewins ohn P M, C larke G N, S eeley J R , R ohde P : depres sion in community adoles cents: Age at onset, episode duration, and time to recurrence. J Am C hild Adole s c P s ychiatry. 1994;33:809. *Mann J J : A current pers pective of suicide and attempted suicide. Ann Inte rn Me d. 2002;136:302. Mufson L, V elting DM. P s ychotherapy for and s uicidal behavior in children and adoles cents . S haffer D, W as lick B , eds . T he Many F ace s of Was hington, DC : American P s ychiatric Ass ociation; 2002. Murray C J , Lopez AD. T he G lobal B urden of 4378 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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C omprehe ns ive As s es s me nt of Mortality and from Dis eas es , Injurie s , and R is k F actors in 1990 P roje cte d to 2020. B os ton: Harvard Univers ity 1996. P.3274 Olfs on M, S haffer D, Marcus S C , G reenberg T : R elationship between antidepres sant medication treatment and s uicide in adolescents . Arch G e n P s ychiatry. 2003;60:978. Oquendo MA, Mann J J : T he biology of impuls ivity suicidality. P s ychiatr C lin North Am. 2000;23:11. R ice F , Harold G , T hapar A: T he genetic aetiology of childhood depres sion: A review. J C hild P s ychol P s ychiatry. 2002;43:65. R oy A, Nielsen D, R ylander G , S archiapone M. T he genetics of s uicidal behavior. In: Hawton K , V an Heeringen C , eds. T he International Handbook of and Atte mpte d S uicide . London: J ohn W iley & S ons, 2000. R us sell S T , J oyner K : Adoles cent s exual orientation suicide ris k: E vidence from a national s tudy. 2001;91:1276. R yan ND: C hild and adolescent depress ion: S horttreatment effectiveness and long-term opportunities . Int J Me thod P s ychiatr R es . 2003;12:44. 4379 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/45.1.htm

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S haffer D, G ould MS , F isher P , T rautman P , Moreau K leinman M, F lory M: P sychiatric diagnos is in child adoles cent s uicide. Arch G e n P s ychiatry. T odd R D, B otteron K N: E tiology and genetics of onset mood disorders . C hild Adole s c P s ychiatr C lin Am. 2002;11:499. Wagner K D, Ambrosini P , R ynn M, W ohlberg C , G reenbaum MS , C hildres s A, Donnelly C , Deas D: E fficacy of s ertraline in the treatment of children and adoles cents with major depres sive dis order: T wo randomized controlled trials . J AMA. 2003;290:1033. Whittington C J , K endall T , F onagy P , C otrell D, A, B oddington E : S elective s erotonin reuptake in childhood depres sion: S ys tematic review of published versus unpublis hed data. L ance t. 2004;363:1341. World Health Organization. W HO Mortality S uicide R ate s and Abs olute Numbe rs of S uicide by Available at: http://www.who.int/mental_health/prevention/suicide/s uici Acces sed May 6, 2004.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 46 - Anxiety Dis orders in C hildren > 46.1: Obs es s ive-C ompuls i Dis order in C hildren

46.1: Obs es s iveDis order in C hildren J ames T. Mc C racken M.D. P art of "46 - Anxiety Dis orders in C hildren" T he appreciation that the majority of all cases of compuls ive disorder (OC D) have their ons et in or adolescence has made awarenes s of identification treatment approaches for younger patients of cons iderable importance. Although there is s ubstantial similarity between the features of OC D encountered in children and thos e encountered in adults, differences do exis t. K nowledge of these differences been gaining rapidly over the past decade. Increas ed unders tanding of the extent and s ource of these differences has aided efforts to refine the notions of the etiology of the disorder and have advanced treatment approaches to better as sist the younger patients by the condition. Although OC D in children is often chronic and can be s evere, the outlook for patients receiving prompt diagnosis and appropriate treatment quite pos itive. F urther refinements in treatment approaches for youth with OC D are a priority to the suffering and developmental cos t due to the condition.

DE F INITIONS 4381 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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Obsess ions are defined as recurrent, intrus ive, and generally persistent thoughts that are experienced by individual as dis tres sing and a product of one's own T hese thoughts or images are us ually des cribed as generating or as sociated with feelings of anxiety, disgust, or avers ion. C ommon obs es sional fears and concerns are included in T able 46.1-1. Although recognized in most children as s ens eless or obses sions lead to efforts to neutralize the worry by res ponses that form compulsions . C ompuls ions are defined as repetitive purpos eful mental or physical that have the purpose of reducing anxiety or tens ion caus ed by obsess ions. C ompulsions us ually embody magical and exaggerated reactions to the triggering stimulus . T ypical compuls ive behaviors are also lis ted T able 46.1-1. F or the most part, s ymptoms of children OC D are quite similar to those seen in adults.

Table 46.1-1 Mos t Frequent S ymptoms of Pediatric C ompuls ive Dis order Obsess ions    C oncerns with dirt, germ expos ure, fears of    F ears of harm befalling self or others    Need for symmetry, exactness 4382 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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   Need to save or hoard    E xcess ive moral or religious concerns C ompulsions    C leaning rituals    C hecking    R epeating behaviors    Ordering or arranging

HIS TOR Y E xamples of childhood-onset OC D can be found in literature from as far back as the late 1800s. In 1895, S igmund F reud included mention of an 11-year-old with obs es sions . In 1902, description of a cas e s eries individuals with obs es sional illnes s noted child or adoles cent onset in almos t half. T he F rench phys ician P ierre J anet provided a detailed description of a 5child with class ic symptoms of OC D and s ugges ted tics may be due to a related ps ychic process . In 1942, B erman extracted clinical information on 62 children poss ible obses sive-compuls ive neuros is out of a cas e registry of 3,050 cas es; six were unequivocally affected displayed prominent symptoms revolving around 4383 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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aggres sive themes . Leo K anner's 1962 textbook of ps ychiatry contained des criptions of childhood OC D the consequences of s ocial isolation and family accommodation. A description by Louise Despert of than 60 cases of children with obses sive-compuls ive neuros is highlighted the insight of children as to the irrationality of s ymptoms and their ability to conceal suffering from others. As early as 1965, Lewis J udd put forth descriptive criteria for the diagnos is of OC D in children that closely resembles current diagnostic including the requirement of significant impairment in functioning. A book on obses sional children by Adams 1973 reviewed 49 cases and, although noting familial histories of OC D, concluded that parental withdrawal of affection was a critical causative factor. A follow-up published in 1980 of 14 cas es of childhood-onset OC D gleaned from a large hospital registry documented the frequent persis tence of s ymptoms even after a decade, cons istent with evolving notions of OC D as a neurobiological dis order with poss ible childhood onset. Last, the common emergence of OC D during childhood and adolescence was es tablis hed by surveys of samples at the National Institute of Mental Health fundamentally dismis sing any notion of child or adoles cent onset as unusual or unexpected.

C OMP A R A TIVE NOS OL OG Y T he diagnostic criteria for OC D have changed little the pas t three editions of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M). T he revised fourth edition of the DS M (DS M-IV -T R ) defines the following features of OC D: (1) recurrent obses sions or (2) s ymptoms recognized as a product of one's own 4384 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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(3) s ymptoms take more than 1 hour per day, (4) obses sions and compuls ions not due to the pres ence another mental dis order. T he tenth revis ion of the Inte rnational S tatis tical C las s ification of Dis e as e s and R e late d He alth 10) includes a general description of features for OC D overlaps cons iderably with fourth edition of the DS M (DS M-IV ) but lacks some of the s pecifiers included in IV -T R for duration of symptoms , degree of impairment, exclusion criteria for other diagnos es , and for children. IC D-10 includes descriptions of five characterized by predominating symptoms. T hese differences may be expected to yield higher rates of diagnosis, although direct comparis ons are

E P IDE MIOL OG Y Although rigorous epidemiological s urveys clearly document that OC D in childhood and adolescence is rare as once believed, P.3281 prevalence estimates do vary considerably. T he source of variation in observed prevalence appears to due to the age of the sample s tudied, with older adoles cent s amples yielding lifetime rates for the between .53 and 4.0 percent, whereas rates in s choolto midadolescence s amples have fallen between .17 percent. One of the larges t prevalence s tudies 10,438 children in the United K ingdom and calculated a rate of .25 percent for DS M-IV OC D. C los er ins pection the relations hip between age and prevalence of OC D the United K ingdom s tudy s howed an exponential ris e 4385 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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rates across the 5 to 7, 8 to 10, 11 to 12, and 13 to 15 ranges (.026, .14, .21, and .63 percent, respectively). data s uggest the interaction between phys ical development and the expres sion of vulnerability to the disorder. T he prevalence rates of late adoles cents are line with available estimates for adult samples of 1 to 4 percent. B y comparis on, these rates of OC D frequency teenagers place the disorder as more common than disorder, s chizophrenia, or bipolar dis order. F or the part, the epidemiology of pediatric OC D reflects a slight male predominance for younger affected individuals; however, this diminis hes with increasing age. In s pite increased awarenes s of OC D in young people, the of individuals receiving res earch diagnos es of OC D in community survey studies have never received treatment for the disorder. E xamination of age-of-onset reports from a variety of samples of individuals has been interpreted to show main peaks of onset: an early-onset s ubgroup during the prepubertal and early adoles cent period and the other during late adolescence or after puberty. Of is the consistent observation that the prepubertal onset group is more highly familial and is more commonly as sociated with tic dis order comorbidity. Indeed, many studies were unable to demons trate excess OC D in relatives of OC D probands who had illness older than 18 years of age versus relatives of control probands.

E TIOL OG Y C urrent models of the etiology of OC D emphas ize the neurops ychiatric foundation of the dis order. Ongoing 4386 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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etiological research focus es on familygenetic, neuroanatomical, hormonal, immunological, neurochemical, and cognitive correlates of the C linical des criptions of OC D ass ociated with traumatic brain injury, encephalitis, S ydenham's chorea, tic and Huntington's chorea have helped to solidify the concept of the dis order as brain-based and pres umably reflecting impaired s triatal functioning. Although the neural circuitry involved in OC D symptomatology has been better clarified through the us e of in vivo brain imaging techniques , there continues to be a need to further refine etiological models of the condition. of children and adolescents with OC D have contributed progres s in the s earch for the etiology of the disorder.

Neuroimaging V olumetric analyses us ing both computed tomography (C T ) and magnetic res onance imaging (MR I) have revealed that treatment-nave children and adults with OC D have smaller basal ganglia s egments as compared with normal controls. However, treatmentchildren appear also to have larger thalamic volumes. It has been hypothesized that children with OC D dis play abnormality in the normal developmental remodeling of key brain areas s ubs erving affect integration, respons e inhibition, and process ing. T hese frontal corticalthalamo-cortical networks have been well ass es sed in studies of adults and appear to be dysfunctional in reflected by hypermetabolis m at res t or in response to symptom provocation. Orbitofrontal and caudate metabolic rates are highly correlated, s ugges ting that interconnecting loops are freed from us ual inhibitory influences and reverberate. T he observations that both 4387 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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medication and behavioral therapies reduce and caudate blood flow seem to validate these regions critical to the neuroanatomy of OC D. S omewhat paradoxically, lower bas eline orbitofrontal metabolism predicts better res ponse to pharmacotherapy. Imaging during symptom provocation als o activates paralimbic regions as well as insular, anterior temporal, and amygdalar regions, demons trating the wider interaction cognitive and emotional circuits in relation to symptom mediation. Imaging s tudies of child OC D patients before and after treatment have provided additional insights into OC D pathophys iology. Us ing magnetic res onance evidence for altered concentrations of N marker of neuronal integrity, was observed in pediatric OC D patients versus controls . Although the of res earch from imaging s tudies indicating dysfunction orbitofrontal cortex, caudate, anterior cingulate, and thalamus is impres sive, what is les s clear is if dis ease pathology typically results from single or multiple s ites dysfunction.

FamilyG enetic s T he familial nature of most cas es of OC D has been recognized for decades . A metaanalys is of s tudies exploring familial patterns of ps ychopathology in of subjects with OC D has documented the fourfold increased frequency of OC D in firs t-degree relatives of OC D probands (8.2 vs . 2.0 percent from control Quite consistently, s maller family s tudies of early-onset cases of OC D find even higher rates of OC D in parents other first-degree relatives. In addition, subclinical 4388 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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of OC D also appear to breed true in families of with OC D. S ubclinical features are us ually defined as typical symptom constellations without the level of interference required for formal diagnos is . Analys is of family patterns of OC D finds s upport for subclinical an intermediate phenotype that s hares s imilar genetic factors with OC D per s e. An important relationship between OC D and tic including T ourette's s yndrome, has als o emerged from family s tudies . T ic disorders and s ome cases of OC D to share common susceptibility factors , leading s ome argue that OC D may be an alternative expres sion of ris k factors underlying tic disorders . Additional strength a tic-related subtype of OC D has been found in s tudies symptom patterns . B esides tic dis orders, the notion of exis tence of a broader obses sive-compuls ive s pectrum related dis orders has been advanced, bas ed primarily the similarity of repetitive and stereotyped nature of behaviors as sociated with impuls e-control disorders , P.3282 somatoform disorders , and eating disorders, many of which have onset in childhood or adoles cence. initial evidence s upporting an OC D s pectrum concept spotty, more recent family study analys es have the familial connection between OC D and body dysmorphic dis order, hypochondriasis, eating and abnormal grooming behaviors , but not impulsecontrol problems . S uch findings may be us eful in alternative phenotypes for genetic s tudies as well as suggesting common treatment approaches. Initial molecular genetic s tudies have been reported for 4389 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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OC D. Although preliminary, sugges tive linkage to of chromosomes 2 and 9 has been reported from a of extended pedigrees as certained from probands with early-onset OC D. C andidate gene studies including younger s ubjects with OC D have been inconclus ive, variable findings from analys es of polymorphis ms of serotonin trans porter, the 5HT 1Dβ, and C OMT genes.

Neuroendoc rine T he repeated observations of the ons et of OC D during puberty, pregnancy, and the postpartum period have fueled s peculation that hormones may play a role the emergence or s everity of OC D s ymptoms. Antiandrogen treatment appeared to s how benefits for some refractory individuals , but improvement was transitory. Nevertheles s, the effects of adrenarche and menarche on the relevant brain circuits believed to underlie OC D s ymptoms needs further study and could yield clues to new treatment approaches . Other systems have been inves tigated in OC D s ubgroups . Differences in oxytocin concentrations in cerebros pinal fluid (C S F ) between tic-related and pure OC D are intriguing, given the role of oxytocin in affiliative in animals . One report als o s uggested differences in arginine vas opres sin (AV P ) concentrations in adults OC D, but studies of younger patients have not been pursued.

Neuroimmunology A redis covery of the triggering of OC D symptoms after infection, es pecially expos ure to group A β-hemolytic streptococcus, has kindled s tudies of immune 4390 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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OC D. S uch infection-triggered cases of OC D have coined pe diatric autoimmune ne urops ychiatric as s ociated with s tre ptococcus (P ANDAS ) and are represent an autoimmune process related to, if not identical to, that as sociated with rheumatic fever and S ydenham's chorea. P atients with rheumatic fever and S ydenham's chorea both display higher frequencies of obses sive and compulsive symptoms versus groups , and up to one-third of individuals with S ydenham's chorea meet research criteria for the of OC D. According to the autoimmune hypothes is , autoimmune activation leads to the inflammation of ganglia and disruption of cortical-striatal-thalamofunction. C orrelation between s ize of bas al ganglia and s ymptom severity has been observed us ing MR I. S imilarly, small s tudies of immune-modulating (intravenous immunoglobulin G [IgG ] and have provocatively been ass ociated with improvement OC D in patients with sus pected P ANDAS . However, treatments remain experimental, and efforts to clinical or laboratory markers of P ANDAS have been inconclusive. Initial studies of the D8/17 lymphocyte antigen as a biomarker of P ANDAS have not been satis factorily replicated. Although additional research autoimmune mechanisms in s us pected P ANDAS warranted, the as sociation between infection and OC D remains unclear and probably represents an unus ual etiological influence.

Neuroc hemis try Abnormal neurotrans mitter regulation, including dysfunction of central s erotoninergic s ys tems, has continued to be s us pected in OC D. Obs ervations of the 4391 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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efficacy of selective serotonin reuptake inhibitors altered sensitivity to the acute adminis tration of 5hydroxytryptamine (5-HT ) agonists , and res ults from preliminary s tudies of 5-HT s ynthes is sugges t that the system is altered in OC D. P latelet [3H]imipramine has been obs erved to be reduced in young patients OC D; conversely, thos e OC D patients with higher [3 H] imipramine binding at baseline differentiated versus nonres ponders to S S R I treatment. In addition to serotonin dys function, the s uggested involvement of the dopamine system may be especially relevant to early-onset OC D, given the increased rate comorbid tic dis orders in young persons with OC D. C linically, obsess ions and compuls ions may wors en in res ponse to the adminis tration of ps ychostimulants . C onvers ely, the coadministration of dopamine with S S R Is may augment the beneficial effects of thes e agents . However, direct as sess ment of the dopamine system in children with OC D has not been attempted. An interesting animal model of T ourette's s yndrome shed some light on the interaction of these neurotransmitter s ys tems, particularly in comorbid such as tic-related OC D. T rans genic potentiation of cortical-limbic D1 neurons has been ass ociated with tic movements and repetitive behaviors in mice. T he suggests that excess ive glutamatergic output from the cortex to the s triatum is as sociated with repetitive movements. T his finding is cons is tent with typical res ponses to dopamine antagonists . Human studies in children with OC D have reported the correlation of glutamate with OC D s ymptoms, and the fall in striatal glutamate as sociated with S S R I treatment. T aken 4392 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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available neurochemical models suggest the poss ibility several neurotrans mitter abnormalities ass ociated with OC D.

DIA G NOS IS A ND C L INIC A L T he caus e for referral and presenting problems of and adolescents with OC D bears res emblance to the presentation in adults. Not infrequently, though, deny impairment due to obsess ions and compulsions more readily acknowledge dis tres s from conflict with family due to the burden of their rituals or their disappointment caused by interference with s choolwork and res ulting drops in grades . However, many children quite open in describing their symptoms and seek as sistance in better managing the illnes s. According to DS M-IV criteria, the diagnos is is bas ed on the s ame requirements necess ary for diagnosis in adults; one modification for children is that the requirement for children to recognize their s ymptoms as exces sive or irrational is waived. Although comorbidity is the rule than the exception in pediatric OC D, the content of the obses sions and compuls ions cannot be better by a cooccurring Axis I dis order (e.g., s elf-deprecating ruminations as sociated with depress ion). S imilarly, the symptoms als o are required not to be s ubs tance or due to the influence of a medical condition. T he most commonly reported obs es sions in children adoles cence include concerns with dirt, exposure to germs , or fears of contracting an illness , followed by of harm befalling self or others (aggress ive), need for symmetry or exactness , hoarding or s aving concerns, excess ive religious or moral concerns . Mos t common 4393 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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compuls ions in children and adoles cents involve rituals , checking, repeating behaviors , and ordering or arranging behaviors . Other as sociated behaviors to pediatric OC D include avoidance, s lowness , and doubt. P ure obsess ional illnes s is rare in children adoles cents , and almost all cas es of pediatric P.3283 OC D involve multiple obses sions and compuls ions number of four current obsess ions and four in one report). T he content and type of symptoms change over time. Although cross -national s urveys of have found s imilar prevalence rates for the disorder, and cultural influences may partially s hape the content individual obs ess ions and compulsions in children as in adults . Onset patterns have been noted to vary in relation to and gender. Abrupt and fulminant onset of s ymptoms be more likely s een in males with early ons et, whereas majority of children and adoles cents are noted to have more insidious ons et. C ompared with adults, children adoles cents may experience a more rapid unfolding of multiple symptoms, with progres sion to most s evere symptom pictures occurring over weeks or months than a more protracted ons et. Often in the early stages the condition, children are able to suppres s symptoms extended periods and may escape detection by schoolteachers or other observers as a result. C omorbidity with other ps ychiatric disorders has been described in up to 84 percent of children with OC D, fully half of clinically referred s amples of children with have been found to carry two or more additional 4394 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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diagnoses (T able 46.1-2). Among the most common of cooccurring diagnos es are other anxiety dis orders 42 percent), mood disorders (11 to 32 percent), tic disorders (11 to 26 percent), attentiondisorder (ADHD) (16 to 20 percent), and other behavior dis orders (9 to 19 percent). C omorbidity of pediatric OC D with tic disorders is as sociated with a likelihood of cleaning and was hing compuls ions and a greater tendency to experience repeating and arranging/ordering compuls ions. Awareness of comorbidity is important in optimizing treatment and in differential diagnosis.

Table 46.1-2 C omorbid in Pediatric Obs es s iveDis order Diagnos is

Frequenc y (%)

Anxiety disorders (generalized anxiety, separation anxiety)

2642

Mood dis orders

1162

T ic disorders

1126

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Attention-deficit/hyperactivity disorder

1620

Dis ruptive behavior disorders (conduct dis order, oppos itional defiant disorder)

919

DIF FE R E NTIA L DIA G NOS IS S uperstitious and ritualized behaviors are not in certain phas es of early childhood as an attempt to replay or manage s ituations in the s ervice of achieving sens e of mas tery, s uch as the child who requires a particular bedtime ritual to s moothly manage the transition or the child who demands to wear an article clothing. T hese normative rituals usually fade by the of entry into formal s chooling and rarely are as sociated with dis tres s, s ignificant interference with activities, or overlap in content with typical obsess ions or C hildren and adoles cents with generalized anxiety disorder present with heightened anxiety relating to own performance, their future, or their evaluation by others . T he content of thes e s ymptoms , although exaggerated, is grounded in everyday matters , as to the unus ual or even bizarre content of obs es sive worries. F urthermore, children with generalized anxiety display few, if any, behaviors analogous to besides requests for reass urance from others, which to reduce anxiety. S imilarly, the content of fears 4396 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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by children with s eparation anxiety dis order is confined the themes of separation or fears of harm to s elf or ones. B esides avoidance of s eparation, other features or rituals are abs ent from the presentation. C hildren and adoles cents with pervasive disorders are often des cribed as dis playing repetitive behaviors that appear similar to obsess ions or compuls ions. S uch behaviors on closer ins pection are better clas sified as examples of pers everations or stereotypies . In contras t to OC D, perseverations lack as sociation with anxiety; indeed, thes e may contain sought-after or pleasurable topics. S imilarly, movements may be elicited by excitement or may manage s timulation and generally are not as sociated a preceding thought or impuls e. Likewis e, children with disorders dis play frequent repetitive movements , and these can overlap in form with some compulsive behaviors . However, tics lack an ass ociated thought and are les s often under volitional control than compuls ions. T he content of tics is unlikely to be as purpos eful as common compulsions e.g., was hing or arranging. T he differential diagnosis of OC D from incipient in an adolescent is sometimes challenging. Although related obs es sions and compuls ions may appear insight is usually preserved, and common themes are evident. T hat the s ymptom is the product of one's mind generally preserved in adoles cents with OC D. J ohn, a 9-year-old boy in the third grade, was brought evaluation by his parents, who express ed concerns his repeated ques tioning and anxious and sad moods. 4397 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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parents described J ohn as a previously happy and adjus ted boy who abruptly developed unusual approximately 2 to 3 months before the evaluation. behaviors included J ohn's concern about contracting illness , was hing rituals , uncertainty over his own needing reass urance, repeating rituals, and avoidance. S pecifically, J ohn had begun to expres s the worry that may have been exposed to human immunodeficiency virus (HIV ) whenever he would obs erve another person public who he believed may be suffering with acquired immune deficiency syndrome (AIDS ). F or example, riding in the car, if J ohn saw s omeone who appeared to him to be poor or ill-kempt, he would begin asking his parents if they thought it pos sible that he may have expos ed to germs even from quite a distance. Although parents ' reas surances had some effect, J ohn us ually insis ted on vigorously was hing hims elf once home. also had begun to express doubts over his control of own behavior. He would often as k his parents, Did I s___ word? Did I use the f___ word? R eas surance was temporarily calming. Of much concern to J ohn was his new-found difficulty with s choolwork. R eading from as signed materials , J ohn would frequently get to end of a s entence, only to ques tion whether he might miss ed a word or content of the s entence and need to reread the material. C ompleting a page could take up to 30 minutes . Over several weeks , he was less and capable of completing ass ignments, and as a result he very dis tres sed over his dropping grades. E xamination of the family history sugges ted that J ohn's older s ister may have had s imilar traits but with less interference in functioning, and s he had never received 4398 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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any treatment for those behaviors . P.3284 At the intake interview, J ohn appeared as a quiet and boy who was cooperative with ques tioning. He did not volunteer as much information as his parents regarding the nature and extent of his s ymptoms but did not deny what his parents reported. He acknowledged that he his mind was tricking him and that it led to his need to for reas surance from his parents. J ohn met full criteria OC D. S ome symptoms of depres sion were pres ent but sufficient for major depress ive disorder. An initial attempt at cognitive-behavioral therapy (C B T ) was attempted, but J ohn continued to feel and discouraged by thes e behaviors . He began to try refuse school, apparently due to his increasing distress as sociated with reading. G iven limited progres s during first 2 months of cognitive-behavioral therapy, (P rozac) was added and increased up to 40 mg per with good improvement. After three more months of and S S R I treatment, J ohn was able to stop cognitivebehavioral therapy and maintain substantial F ollow-up over the next year showed J ohn to be able retain all of his gains from initial treatment and to show minimal interference from occas ional OC D symptoms .

C OUR S E A ND P R OG NOS IS T he cours e of OC D with ons et in childhood or is typically cited as chronic and characterized by subs tantial morbidity; however, the exis ting follow-up literature is complicated to interpret, given the 4399 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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between ascertainment of s amples, availability and to treatments , and the potential of multiple confounding effects on cours e. In the absence of a large, long-term controlled treatment s tudy, it is difficult to es timate the optimal cours e and outcome for children and with OC D. In fact, a review of existing follow-up studies suggests cons iderable variability in outcome. Less appreciated is the observation that as many as 11 to percent of follow-up samples (in s ome instances reass ess ing up to 14 years later) experience recovery OC D with minimal s ymptoms. At the oppos ite end, continued OC D s ymptoms sufficient for the diagnos is been s een in 26 to 60 percent. S ubclinical OC D, or intermediate s ymptomatology, is a common outcome in the remainder. A rate of 47 percent remis sion and remis sion in another 25 percent in a sample of children and adolescents with OC D participating in a clinical with sertraline (Zoloft) for up to a year of treatment are encouraging. Likewis e, the follow-up of a severely sample at the NIMH found a discouraging persis tence of OC D diagnosis at 60 percent; however, from the time of initial ass ess ment was reported by 80 percent of the total sample at follow-up. F ew cons is tent predictors of outcome have been reported; poorer outcome may be as sociated with comorbid tic and limited respons e to initial S S R I treatment, family strain, parental ps ychopathology. Overall, the prognosis for onset OC D is encouraging, especially in light of treatment options . One cautionary note: A repeated although uncommon obs ervation in most follow-up reports was the emergence of a ps ychotic dis order in 10 percent of s ome s amples . 4400 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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T he prognos is of children and adolescents with forms of OC D des erves mention. S ubclinical OC D is a common finding among relatives of individuals with F ollow-up periods of jus t 2 years document the high conversion of s ubclinical OC D to OC D in young C linically, relatives of patients with s ubclinical OC D should be monitored closely and cons idered for even in the absence of more severe or impairing symptoms.

TR E A TME NT C ons iderable progres s has been made in the testing refinement of both pharmacological (T able 46.1-3) and ps ychos ocial treatments for children and adolescents OC D. As in adult OC D, both forms of treatment are effective in symptom relief and producing in functioning, and clinical consensus s ugges ts that combined treatment has added benefits. T he goals of treatment are now conceptualized as including impairment due to OC D s ymptoms in all domains and striving to achieve remis sion. As treatment res earch expands, more information on the optimal s election sequencing of treatments for children and adolescents become clearer.

Table 46.1-3 Indic ated and Dos e R anges for Pediatric Obs es s ive-C ompuls ive Dis order

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Medic ation

Dos age

F luoxetine (P rozac)

2060

S ertraline (Zoloft)

50200

F luvoxamine (Luvox)

50200

P aroxetine (P axil)

2060

C italopram (C elexa)

2060

E scitalopram (Lexapro)

520

C lomipramine

50200

Note: S ee text regarding paroxetine (P axil).

S erotonergic Antidepres s ants T he evidence bas e s upporting the efficacy and s afety the S S R Is has s trengthened considerably over the past several years . S even randomized, controlled clinical have demons trated the superiority of the S S R Is over placebo. F luvoxamine (Luvox), sertraline, and have been granted U.S . F ood and Drug Administration (F DA) approval for their use for pediatric OC D. S imilar benefits have been reported in two controlled trials with 4402 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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paroxetine (P axil), and one open trial with citalopram (C elexa) has also sugges ted efficacy. In controlled reduction in baseline s ymptom ratings with treatment of up to 16 weeks has been relatively consis tent, although modes t, ranging from 18 to 44 percent. More important perhaps , thos e studies that included longer-term treatment observations have witness ed continued symptom reduction during total treatment periods of up to 1 year. F or example, an acute remis sion rate of only percent with sertraline was noted after the initial 12treatment trial; by the end of 52 weeks, the proportion remitters had doubled to 47 percent. An additional 25 percent were des cribed as having achieved partial remis sion. T hes e data s uggest that treatment benefits from S S R Is are stable and can be expected to many with continued treatment. However, almost half children and adoles cents treated with an S S R I have interfering s ymptoms of OC D; these individuals require trials of alternative S S R Is, addition of therapies, or combined pharmacotherapy in the cas e of significant comorbid disorders . Overall, the S S R Is are well tolerated by child and adoles cent patients with OC D. Most frequent side reported with S S R Is in the treatment of pediatric OC D been naus ea, ins omnia, headache, and asthenia. to tolerate treatment due to side effects is s een in 15 percent or less . However, on J une 19, 2003, the F DA the following advisory regarding the us e of paroxetine children and adoles cents from studies of depress ion: is recommending that P axil not be used in children and adoles cents for the P.3285 4403 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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treatment of major depress ive disorder (MDD). T he added that paroxetine had not demons trated efficacy major depres sive dis order in the pediatric age range. warning closely followed the U.K . Department of similar announcement rais ing concerns about the and s afety of paroxetine and other S S R Is as depres sion in children and adolescents. S ubs equent reviews by nongovernmental groups have not link between any S S R I and safety concerns above linked to the pres ence of the mental disorder itself. T he F DA did not comment on the us e of P axil for OC D in pediatric patients ; however, the comorbidity of with OC D is s een in one out of five children and adoles cents with OC D. Activation, disinhibition, and poss ible wors ening of suicidal thoughts as sociated with S S R I expos ure may be a s pecial concern in depres sed children and adolescents receiving these medications certainly demand caution and careful monitoring. A thorough discuss ion of the benefits of treatment the ris ks is required, although firm conclus ions are not always available. S uch adverse effects may reflect developmental differences in pharmacokinetics and pharmacodynamics .

C lomipramine B as ed on a total of five controlled trials , clomipramine (Anafranil) was the firs t agent to receive F DA approval pediatric OC D. R ecent metaanalyses have sugges ted clomipramine poss es ses greater efficacy for pediatric than the S S R Is ; the largest controlled trial was with symptom reductions from baseline up to 37 with an estimated effect s ize approaching 1.0. 4404 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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a tricyclic, clomipramine is as sociated with a greater risk of side effects, including additional side of cardiac conduction changes, anticholinergic effects, seizures , s edation, and urinary retention. T herefore, clomipramine is relegated to a second- or third-line treatment choice for children and adoles cents with

C ognitive-B ehavioral Therapy Developmentally modified forms of C B T that key ingredients of expos ure to feared stimuli with res ponse prevention are often recommended as a treatment for pediatric OC D. Older children and adoles cents appear to res pond well to C B T clos ely patterned after effective approaches for adults ; children require a greater number of modifications. include additional efforts to educate about the nature of excess ive anxiety and the role of treatment, sensitizing child to the impact of OC D on his or her life and motivation for change through his or her cooperation perseverance in treatment, building a s hared language better communicate the nature of ass ociated feelings cognitions, and including behavioral rewards for maintaining engagement in treatment. Uncontrolled of C B T appear highly promis ing, with excellent up to three-fourths of patients treated. F ull results from initial controlled trials will be available s oon; preliminary res ults of these studies appear to confirm efficacy over varying control conditions . Manuals for modified C B T OC D s uitable for children are available. W hether C B T greater and more durable symptom control than medication for children with OC D is of considerable interes t. 4405 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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Treatment Planning Many experts and cons ens us guidelines recommend as the first-line approach for the majority of children adoles cents with OC D. However, more severe comorbid depress ion, or limited motivation or may prompt the clinician to cons ider medication alone in combination with C B T . One-half or more of young patients with OC D may require combined therapy at point to achieve the goal of remiss ion of symptoms . However, the mos t effective sequencing of drug with behavioral approaches is a matter of opinion. the high degree of psychiatric comorbidity, additional treatments may be needed outside of treatment for the anxiety dis order. Address ing as sociated s chool and is sues is often critical to treatment success . F amilies have accommodated to the demands or rituals of the child, and firm guidance to resist participation in rituals not allowing avoidance of feared s timuli is neces sary to fully expunge the interference of the dis order. As a disorder, long-term medication treatment is often to maintain s ymptom control, and s imilarly, periodic res umption of C B T may be necess ary to combat exacerbations in res ponse to stress or developmental transitions.

Other Treatments Adjunctive treatments may be indicated for children adoles cents with OC D. T he comorbidity of tic disorders may require the addition of α-agonis ts or neuroleptics ; combination of neuroleptics with an S S R I has also noted to benefit OC D symptoms in refractory OC D in adults . Other anxiety symptoms may improve with the 4406 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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addition of benzodiazepines or bus pirone (B uS par). Depress ive s ymptoms may be improved by lithium (E skalith) addition. E xperimental intravenous S S R I or clomipramine adminis tration has been noted to yield res ponses in patients refractory to oral medications. In general, OC D in children and adoles cents is very res ponsive to treatment. T he vas t majority of patients should expect s ignificant symptom relief and return of functioning. Aggres sive treatment, often with combined approaches, is indicated to minimize impact on development. R educing delays in diagnosis and of indicated treatments are important goals .

S UG G E S TE D C R OS S C hapter 42 reviews tic disorders . Other anxiety children are found in C hapter 46. P harmacotherapy antianxiety agents is des cribed in S ection 48.6.

R E F E R E NC E S Abramowitz J , S chwartz S , Moore K , Luenzmann K : Obsess ive-compuls ive s ymptoms in pregnancy and puerperium: A review of literature. J Anxiety Dis ord. 2003;17:461. Anderluh M, T chanturia K , R abe-Hes keth S , C hildhood obsess ive-compuls ive personality traits in adult women with eating disorders : Defining a eating dis order phenotype. Am J P s ychiatry. 2003;160:242. Arnold P , B anejee S , B handari R , Lorch E , Ivey J , R os enberg D: C hildhood anxiety disorders and 4407 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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developmental iss ues in anxiety. C urr P s ychiatry 2003;5:252. B anazon N, Moore G , R osenberg D: Neurochemical analyses in pediatric obs ess ive-compuls ive disorder patients treated with cognitive behavioral therapy. J Acad C hild Adole s c P s ychiatry. 2003;42:1279. *B arrett P , Healy L: An examination of the cognitive proces ses involved in childhood obsess ivedisorder. B ehav R e s T her. 2003;41:285. B arrett P , Healy-F arrell L, March J : C ognitivefamily treatment of childhood obsess ive-compuls ive disorder: A controlled trial. J Am Acad C hild Adole s c P s ychiatry. 2004;43:46. B ienvenu O, S amuels J , R iddle M, Hoehn-S aric R , K , C ullen B , G rados M, Nes tadt G : T he relationship obses sive-compuls ive disorder to poss ible spectrum disorders : R esults from a family study. B iol 2000;48:287. B lack D, G anney G , S cholos ser S , G abel J : C hildren parents with obs es sive-compuls ive disordera 2-year follow-up study. Acta P s ychiatr S cand. C ath D, S pinhoven P , van W oerkom T , van de B , Hoogduin C , Landman A, R oos R , R ooijmans H: de la T ourette's syndrome with and without compuls ive disorder compared with obsess ivecompuls ive disorder without tics: W hich s ymptoms 4408 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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discriminate? J Ne rv Ment Dis . 2001;189:219. F itzgerald K , Moore G , P aulson L, S tewart C , D: P roton s pectros copic imaging of the thalamus in treatment-nave pediatric obsess ive compuls ive disorder. B iol P s ychiatry. 2000;47:174. F reeman J , G arcia A, F ucci C , K aritani M, Miller L, Leonard H: F amily-based treatment of early-onset obses sive compulsive dis order. J Am Acad C hild P s ychiatry. 2003;13:S 71. P.3286 G eller D, B iederman J , S tewart S , Mullin B , F arrell Wagner K , E ms lie G , C arpenter D: Impact of on treatment res ponse to paroxetine in pediatric obses sive- compuls ive disorder: Is the use of criteria empirically s upported in randomized clinical trials . J C hild Adoles c P s ychopharmacol. G eller D, B iederman J , S tewart S , Mullin B , Martin S pencer T , F araone S : W hich S S R I? A metapharmacotherapy trials in pediatric obs es sivecompuls ive disorder. Am J P s ychiatry. 2003;160:11. *G eller D, C offey B , F araone S , Hagermos er L, F arrell C , Mullin B , B iederman J : Does morbid deficit/hyperactivity disorder impact the clinical expres sion of pediatric obs es sive-compuls ive C NS S pe ctr. 2003;8:259.

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G eller D, Hoog S , Heiligens tein J , R icardi R , T amura K luszyns ki S , J acobs on J , F luoxetine P ediatric OC D S tudy T eam: F luoxetine treatment for obsess ivecompuls ive disorder in children and adoles cents: A placebo-controlled clinical trial. J Am Acad C hild P s ychiatry. 2002;41:363. G rabe H, Meyer C , Hapke U, R umpf H, F reyberger Dilling H, J ohn U: Lifetime-comorbidity of obsess ivecompuls ive disorder and s ubclinical obsess ivecompuls ive disorder in Northern G ermany. E ur Arch P s ychiatry C lin Ne uros ci. 2001;251:130. G rachev I, B reiter H, R auch S , S avage C , B aer L, K ennefy D, Makris N, C avines s V , J enike M: abnormalities of frontal neocortex in obs ess ivecompuls ive disorder. Arch G e n P s ychiatry. G rados M, R iddle M, S amuels J , K ung-Y ee L, R , B ienvenu O, W alkup J , S ong D, Nestadt G : T he phenotype of obsess ive-compuls ive disorder in to tic dis orders: T he Hopkins OC D family s tudy. B iol P s ychiatry. 2001;50:559. G uerrero A, Hishinuma E , Andrade N, B ell C , Lee T , T urner H, Andrus, J , Y uen N, S tokes A: Demographic and clinical characteristics of in Hawaii with obs es sive-compuls ive disorder. Arch P ediatr Adole s c Me d. 2003;157:665. Hanna G : Demographic and clinical features of obses sive-compuls ive disorder in children and 4410 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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adoles cents . J Am Acad C hild Adole s c P s ychiatry. 1995;34:19. Hanna G , P iacentini J , C antwell D, F is cher D, Himle V an E tten M: Obses sive-compuls ive disorder with without tics in a clinical s ample of children and adoles cents . Depre s s Anxiety. 2002;16:59. Hettema J , Neale M, K endler K : A review of metaanalysis of the genetic epidemiology of anxiety disorders . Am J P s ychiatry. 2001;158:1568. Heyman I, F ombonne E , S immons H, F ord T , G oodman R : P revalence of obs ess ive-compuls ive disorder in the B ritish nationwide s urvey of child health. B r J P s ychiatry. 2001;179:324. J ais oorya T , J anardhan Y , S rinath S : T he obses sive-compuls ive disorder to putative s pectrum disorders : R esults from an Indian study. C ompr P s ychiatry. 2003;44:317. J anardhan Y , S rinath S , P rakash H, G irimaji S , S , K hanna S , S ubbakris hna D: A follow-up study of juvenile obs es sive compuls ive disorder from India. P s ychiatr S cand. 2003;107:457. J udd L: Obs ess ive compuls ive neuros is in children. G e n P s ychiatry. 1965;12:136. Liebowitz M, T urner S , P iacentini J , B eidel D, C larvit Davies S , G raae F , J affer M, Lin S , S allee F , 4411 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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S imps on B : F luoxetine in children and adoles cents OC D: A placebo-controlled trial. J Am Acad C hild P s ychiatry. 2002;41: 1431. Loisella C , Wendlandt J , R ohde C , S inger H: Antistreptococcal, neuronal, and nuclear antibodies T ourette syndrome. P ediatr Ne urol. 2003;28:119. Mayerovitch J , G albaud du F ort G , K akuma R , Newman S , P inard G : T reatment s eeking for compuls ive disorder: R ole of obsess ive-compuls ive disorder s ymptoms and comorbid psychiatric C ompr P s ychiatry. 2003;44:162. McMahon W, C arter A, F redine N, P auls D: C hildren familial ris k for T ourette's disorder: C hild and parent diagnosis. Am J Med G e net. 2003;121B :105. Mercadante M, B us atta G , Lombros o P , P rado L, C ampos M, Marques -Dias M, K is s M, Leckman J , E uripedes C : T he ps ychiatric s ymptoms of fever. Am J P s ychiatry. 2000;15:2036. Mukaddes N, Abali O, K aynak N: C italopram of children and adoles cents with obsess ivedisorder: A preliminary report. P s ychiatry C lin 2003;57:405. *Nestadt G , Addington A, S amuels J , Liang K , O, R iddle M, G rados M, Hoehn-S aric R , C ullen B : identification of OC D-related subgroups bas ed on morbidity. B iol P s ychiatry. 2003;53:914. 4412 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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Nes tadt G , Lan T , S amuels J , R iddle M, B einvenu K , Hoehn-S aric R , C ullen B , G rados M, B eaty T , C omplex s egregation analys is provides compelling evidence for major gene underlying obsess ivecompuls ive disorder and for heterogeneity by s ex. Hum G e ne t. 2000;67:1611. Nes tadt G , S amuels J , R iddle M, Liang K , B einvenu Hoehn-S aric R , G rados M, C ullen B : T he between obs ess ive-compuls ive disorders and and affective disorders: R esult from the J ohn OC D F amily S tudy. P s ychol Me d. 2001;31:481. Nords trom E , B urton F : A trans genic model of T ourette's s yndrome and obses sive-compuls ive disorder circuitry. Mol P s ychiatry. 2002;7:617. *P eterson B , P ine B , C ohen P , B rook J : P ros pective, longitudinal study of tic, obs ess ive-compuls ive and attention-deficit/hyperactivity dis orders in an epidemiological s ample. J Am Acad C hild Adole s c P s ychiatry. 2001;40:685. P iacentini J , B ergman R , J acobs C , McC racken J , K retchman J : Open trial of cognitive behavior for childhood obs es sive compuls ive disorder. J Dis ord. 2002;16:207. R apoport J , Inoff-G ermain G , W eis sman M, Narrow W , J ens en P , Lahey B , C anino G : C hildhood obses sive-compuls ive disorder in the NIMH ME C A study: P arent vers us child identification of cas es. 4413 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/46.1.htm

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Methods for the epidemiology of child and mental disorders . J Anxie ty Dis ord. 2000;14:535. R iddle M, R eeve E , Y aryura-T obias J , Y ang H, G affney G , Holland D, McC onville B , P igott T , F luvoxamine for children and adoles cents with obses sive-compuls ive disorder: A randomized, controlled, multicenter trial. J Am Acad C hild P s ychiatry. 2001;40:222. R os enberg D, B enazon N, G ilbert A, S ullivan A, T halamic volume in pediatric obs es sive compulsive disorder patients before and after cognitive therapy. B iol P s ychiatry. 2000;48:194. *R ous sos A, F rancis K , K oumoula A, R ichards on C , K abakos C , K irikidou: T he Leyton obses sional child version in G reek adolescents . E ur C hild P s ychiatry. 2003;12:58. S nider L, S wedo S : P ediatric obs ess ive-compuls ive disorder. J AMA. 2000;284:3104.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > 47 - E arly-Ons et

47 E arly-Ons et S c hizophrenia J on M. Mc C lellan M.D. Although typically considered an adult disorder, the incidence of s chizophrenia increas es steadily after the onset of puberty, with onset before age 12 occurring rarely. S chizophrenia with ons et during childhood and adoles cence may have a particularly deleterious effect cognitive and s ocial functioning, as the illnes s disrupts normal neurodevelopmental process es . T herefore, clinicians working with youth need to be familiar with phenomenology, clinical course, and treatment of this disorder. 

DE F INIT ION

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HIS T OR Y

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C OMP AR AT IV E NOS OLOG Y

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E P IDE MIOLOG Y

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E T IOLOG Y

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DIAG NOS IS AND C LINIC AL F E AT UR E S

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P AT HOLOG Y AND LAB OR AT OR Y

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DIF F E R E NT IAL DIAG NOS IS

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C OUR S E AND P R OG NOS IS 4415

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T R E AT ME NT

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F UT UR E DIR E C T IONS

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S UG G E S T E D C R OS S -R E F E R E NC E S E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > DE F INIT IO

DE FINITION P art of "47 - E arly-Onset S chizophrenia" T he diagnosis of schizophrenia in children and is made us ing the same criteria as for adults. T he is defined by the presence of pos itive and negative symptoms. P ositive s ymptoms consist of delus ions, or bizarre or disorganized thinking and behavior. Negative symptoms cons is t of paucity of paucity of thought content, apathy, avolition, and flat affect. T hese symptoms are coupled with a significant deterioration in functioning, including the failure to achieve expected levels of s ocial development. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > HIS T OR

HIS TOR Y P art of "47 - E arly-Onset S chizophrenia" R eports of s chizophrenia occurring in children have noted s ince the time of E mil K raepelin. However, as concept of childhood ps ychoses evolved, autis m and 4416 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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pervas ive developmental dis orders became grouped under a broader rubric of “childhood s chizophrenia.” much of the early literature describing childhood schizophrenia relates more to modern day constructs autis m and pervasive developmental dis orders. Israel K olvin and others challenged this nosology by demonstrating that autis m was a dis crete disorder from s chizophrenia. B eginning with the ninth revision of the Inte rnational S tatis tical C las s ification of Dis e as e s R elated H ealth P roble ms (IC D-9) and the third edition Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs III), childhood schizophrenia was differentiated from pervas ive developmental dis orders and diagnos ed the same criteria as for adults. S ubsequent res earch generally validated this decision. T here is a paucity of res earch examining schizophrenia youth. T reatment studies are generally lacking. the incidence of the dis order increases after the onset puberty, much of the existing literature focuses on childhood onset. Other methodological problems retrospective des igns; lack of standardized ass ess ment tools , such as diagnos tic interviews ; small s ubject and lack of comparison groups . However, the exis ting studies are s ufficient to draw some reasonable regarding the early-onset form of the disorder. At this the evidence supports that s chizophrenia in youth is continuous with the adult-onset form, and, therefore, adult literature can generally be extrapolated to and adolescents as long as developmental is sues are into cons ideration. Although, historically, researchers referred to children under age 13 as pre pube rtal, this definition, for the 4417 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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part, was based solely on age and not on physical maturation. F or this chapter, the authors have adopted commonly used conventions of early-onset defined as onset before 18 years of age, and very onset schizophrenia, defined as onset before age 13. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > C OMP AR AT IVE NOS O L

C OMPAR ATIVE P art of "47 - E arly-Onset S chizophrenia" T he basic cons truct of s chizophrenia, including its characteristic s ymptoms and course of illness , remains unchanged. B ecaus e the research demonstrating that childhood s chizophrenia and autism are dis tinct conditions, there have been no separate distinguis hing criteria for making the diagnosis in youth. T he modifications incorporated into DS M-IV and maintained with DS M-IV -T R , which specified that active psychotic symptoms mus t persist for at leas t 1 month and that negative symptoms are one of the characteris tic symptoms of the active phase of the disorder, appear justified. T he diagnostic criteria defined by the IC D-10 are those of DS M-IV -T R . T he only difference is that IC D-10 requires a total duration criterion of 1 month, compared the 6 months' duration s pecified by DS M-IV -T R . J orge Armenteros and colleagues found a high rate of agreement between DS M-III-R , DS M-IV -T R , and IC Dhospitalized ps ychotic adolescents . E ditors : S adock, B e njamin J .; S adock, V irginia A

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T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > E P IDE MIO LOG

E PIDE MIOL OGY P art of "47 - E arly-Onset S chizophrenia" T he prevalence of early-onset schizophrenia has not adequately es tablis hed. C linical experience sugges ts schizophrenia with onset before age 12 years is rare. It been estimated that 0.1 to 1.0 percent of all disorders pres ent before age 10, with 4 percent before age 15. T he rate of ons et increases s harply adoles cence, with the peak ages of onset generally ranging from 15 to 30. In a s tudy of all youth for schizophrenia in Denmark over a 13-year period (N 312), P er Hove T homsen noted that only 4 were under age of 13, and only 28 were younger than age 15. Although there are case reports of onset before age 6, diagnosis of schizophrenia in young children mus t be carefully s crutinized. Although that pattern of ons et s uggests s ome to puberty, the National Institute of Mental Health study of childhood-onset s chizophrenia did not find an as sociation between the timing of onset and pubertal status . E arly-onset schizophrenia, P.3308 es pecially very early–onset schizophrenia, occurs predominantly in boys. As age increas es, this ratio even out. B ecause the adult literature s uggests that the age of ons et in men is s ignificantly younger than that in 4419 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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women, the male predominance in early-onset schizophrenia may be a cross -sectional effect. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > E T IOLO G

E TIOL OGY P art of "47 - E arly-Onset S chizophrenia" S chizophrenia is a heterogeneous disorder of unknown etiology. E tiological mechanisms are undoubtedly complex and remain to be elucidated. However, certain ris k factors have been identified. G e ne tics : T here is substantial evidence that plays an important role in the development of schizophrenia, including data from both twin and adoption s tudies . T he lifetime risk of developing schizophrenia is 5 to 20 times higher in firs t-degree relatives of affected probands , when compared to general population. In early-onset s chizophrenia, familial ris k appears to be at leas t as high as for onset. Moreover, s ome s tudies have found that an earlier age of onset is as sociated with an increas ed heritable risk. Des pite this evidence, no s ingle model of genetic inheritance has been identified. Although some studies have identified potential sites on the that were linked to s chizophrenia, these have not been cons is tently found or replicated. B ecaus e s chizophrenia is a heterogeneous 4420 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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is likely that multiple genes are involved. Moreover, the ris k conferred by any one gene is likely s mall or may not be always expres sed as s chizophrenia rather, as related traits such as a schizoid F inally, some cas es are ass umed to be sporadic due to environmental causes rather than genes. current evidence sugges ts that the development of schizophrenia is best explained by a multifactorial polygenic model. Neurode velopme ntal trauma: S chizophrenia is to be a neurodevelopmental disorder with early central nervous s ys tem (C NS ) lesions affecting maturational process es . T hus, premorbid abnormalities and developmental delays may represent the early neuropathological of the dis order. P erinatal complications , alterations brain s tructure and size, minor phys ical anomalies , disruption of fetal neural development, especially during the second trimes ter of pregnancy, have correlated with the illness . An earlier age of onset (before age 22) has been as sociated with an rate of obs tetrical complications . It has been hypothes ized that early neurological trauma may interact with genetic risk factors to produce schizophrenia in at-ris k individuals . V iral e xpos ure : V iral exposure has been implicated ris k factor for schizophrenia. Individuals with schizophrenia have a higher-than-expected rate of being born during winter months , which s uggests involvement of an infectious agent. F urthermore, several s tudies have found an increase in viral and immunological markers in s chizophrenic 4421 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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F inally, birth cohorts who were in the second of pregnancy during an influenza epidemic have shown to have an increased ris k for s chizophrenia. However, efforts to directly link s chizophrenia to maternal influenza infections have produced mixed findings. F urther research is needed to clarify what role, if any, exposure to viral infections has in the development of s chizophrenia. One propos ed mechanism is that viral expos ure produces the in some at-ris k individuals by an autoimmune P s ychological factors : T here is no evidence that ps ychological factors alone cause schizophrenia. R ather, ps ychological factors interact with ris k factors, primarily influencing the course of the disorder. P s ychos ocial stress ors , including emotion within the family setting, influence the or exacerbation of acute epis odes and relaps e However, thes e interactions are complex and bidirectional. T he presence of difficult family interactions may not be caus al, but, rather, a to the collection of difficulties the patient brings to family s etting. In summary, the existing data sugges t that the etiology schizophrenia is heterogeneous and multifactorial. A neurodevelopmental model is propos ed, whereby a variety of ris k factors, genetic and environmental, in an additive fashion to produce vulnerability towards disorder. If a threshold is reached, the individual will develop the illness . S ubthreshold cases may pres ent related conditions, s uch as s chizotypal personality disorder. T he relative ris k of different etiological 4422 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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mechanisms, and how these factors interact, remains important area of ongoing res earch. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > DIAG NOS IS AND C LINIC AL

DIAGNOS IS AND C L INIC AL FE ATUR E S P art of "47 - E arly-Onset S chizophrenia" T he diagnostic criteria for s chizophrenia are outlined in DS M-IV -T R . Diagnostic tools , s uch as structured symptom scales, and diagnostic algorithms , help the reliability and veracity of diagnos is . B ecause schizophrenia portends an ominous prognosis and stigma, it is important that the criteria be adequately as sess ed before a diagnos is is made. However, in settings , there is s ometimes a hesitancy to diagnose onset schizophrenia, despite clear evidence of the disorder. T his generally reflects clinicians' lack of with the illnes s and juveniles, and concerns over Although these concerns are valid, the failure to schizophrenia when unmistakably pres ent potentially denies the child and family access to appropriate treatment and psychoeducational res ources . S ome have found a 1- to 2-year lag between the ons et of ps ychotic symptoms in youth and the making of the diagnosis (T able 47-1).

Table 47-1 DS M-IV-TR Diagnos tic 4423 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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C riteria for S c hizophrenia A. C haracteris tic s ymptoms: At least two of the following are needed for a period of at least 1 month: delus ions , hallucinations , disorganized speech, gros sly disorganized or catatonic or negative s ymptoms. T he duration of thes e symptoms may be les s than 1 month if they have been alleviated by treatment. B . S ocial/occupational dysfunction: T he level of social, occupational, and self-care functioning markedly deteriorated below the highest obtained level. In children and adoles cents, this includes the failure to achieve expected levels of social development. C . Duration: T he disturbances must be present period of at least 6 months. T his includes an phase of overt ps ychotic symptoms (C riterion A) with or without a prodromal or res idual phase. A prodromal phas e involves the deterioration in functioning before the ons et of ps ychotic whereas the res idual phase follows the active S ymptoms characteristic of both prodromal and res idual phas es include marked s ocial is olation, deterioration in occupational functioning, peculiar behavior s uch as food hoarding, poor hygiene, blunted or inappropriate affect, disordered 4424 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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proces ses (tangentiality, circumferentiality, of speech or s peech content), odd beliefs or perceptions, and anergia. D. E xclusion of mood dis order: S chizoaffective disorder and mood dis order with ps ychotic must be ruled out. If mood epis odes are present, their duration mus t be brief relative to the cours e the schizophrenic s ymptoms . T his exclus ion is es pecially pertinent for adoles cents with bipolar disorder, as manic epis odes in this age group frequently include s chizophrenic-like symptoms at onset. T his needs to be s ys tematically patients, as continued follow-up may be the only accurate method for distinguishing the two disorders . E . S ubstance/general medical condition T he s ymptoms are not due to either the direct effects of a s ubs tance or a medical condition. F . R elations hip to a pervas ive developmental disorder: If there is a his tory of autis m, or another pervas ive developmental dis order, prominent delus ions or hallucinations (for at least 1 month unles s s ucces sfully treated) are required to make diagnosis of schizophrenia.

F rom American P sychiatric As sociation. 4425 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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and S tatis tical Manual of Me ntal Dis orde rs . 4th T ext rev. W ashington, DC : American P sychiatric Ass ociation; 2000, with permiss ion.

Although early-onset schizophrenia is diagnosed us ing same criteria that are us ed for adults, s ome s pecific developmental characteris tics have been noted. T hes e include: P remorbid functioning: E arly-onset s chizophrenia generally has an ins idious onset, with a longhistory of developmental and personality abnormalities . An age of onset before age 12 is as sociated with highest rates of premorbid T he abnormalities most frequently described (1) being s ocially withdrawn, odd, and isolated; (2) behavioral disorders ; and (3) multiple delays, including lags in cognitive, motor, s ensory, social functioning. P remorbid autis m and pervasive developmental disorders have been reported. T hese premorbid features are not equivalent to a diagnosis of s chizophrenia. Many children are cons idered odd or have multiple developmental problems . However, mos t will not have the prerequisite psychotic symptoms inherent to schizophrenia, nor do they necess arily ever go on 4426 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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develop the disorder. S ymptomatology in e arly-ons e t s chizophre nia: In of early-onset schizophrenia, hallucinations , disorder, and flat affect are cons istently found, whereas systematic delus ions and catatonic are les s common. Developmental differences in language and cognition potentially influence the spectrum and quality of s ymptom presentation. C hildren tend to have less complex delus ions , with content reflecting childhood themes. C onvers ely, many children without ps ychotic report phenomena s uggestive of hallucinations . hallucinations reported by children lack the persis tence and ass ociated s ymptomatology P.3309 for schizophrenia. T hese diagnostic is sues have high rates of mis diagnosis , es pecially in children. A child's report of hallucinations may repres ent imagination, misinterpretation of normal experiences , misunders tanding of the clinician's question, developmental phenomena, diss ociative posttraumatic phenomena, factitious s ymptoms , or symptoms of another ps ychotic illness (i.e., a mood disorder). On structured diagnostic interviews, rates of false positives are noted for ques tions inquiring about phenomena for which children have no experience or understanding, including symptoms. T hes e is sues must be examined before diagnosing a child with schizophrenia, given its lasting treatment and prognos tic ramifications . 4427 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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S ignificant rates of formal thought disorder, loose as sociations and illogical thinking, have been found in children with s chizophrenia. It is important, however, to differentiate the thought dis order of ps ychos is from that of either developmental delays language disorders . R apidity of ons et: V ery early–onset s chizophrenia generally has an ins idious onset. C onvers ely, vary in adolescents , with s ome studies noting high rates of acute or s ubacute onset (defined as less year's duration) and others describing a of ins idious onset. Acute onset (i.e., days ) with a completely normal his tory of premorbid functioning does not appear to be very common in juveniles. S chizophre nic s ubtype s : In early-onset reports vary as to whether the paranoid s ubtype or undifferentiated s ubtypes are more common. It is not clear how s table these subtypes are over time. regard to categorizing early-onset s chizophrenia as separate diagnos tic group, current evidence it is continuous with the adult-onset form and not be treated as a separate entity. C ognitive and language dys function: On average, with early-onset schizophrenia have intelligence quotients (IQs ) in the lower normal range, with 10 20 percent having significant cognitive Language and communication deficits are C hildren with schizophrenia have deficits in their information process ing capacities , a finding als o in adults . C aution mus t be us ed in making the diagnos is of 4428 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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schizophrenia in children with s evere language impairments . B ecaus e the s tandard presentations hallucinations and delusions involve language, as sess ing a child with s everely impaired language ps ychotic symptoms can be a challenge. In these cases, the clinician is dependent on observations of behavior. P sychotic s ymptoms may be identified their emergence is as sociated with deterioration in mental s tatus and global functioning. Mortality: In follow-up studies, the risk of s uicide or accidental death directly due to ps ychosis appears be approximately 5 percent. However, this es timate needs to be further studied given the small number subjects examined and the limited length of followperiods. A 12-year-old boy developed concerns that his parents might be pois oning his food. Over the next year, his symptoms progress ed with increased fearfulnes s, preoccupation with food, and beliefs that S atan and from the radio and televis ion were sending him bad thoughts. During this time, his parents also obs erved bizarre behaviors , including talking and yelling to perseverating about devils and demons , as saulting members because he thought they were evil, and attempting to hurt himself because he believed it would pleas e G od. T here were no predominant mood or any history of s ubs tance abus e. Developmentally, he was the product of a full-term pregnancy complicated by a difficult labor and forceps delivery. His early motor and s peech milestones were normal. As a younger child, he tended to be quiet and 4429 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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socially awkward. His intelligence was felt to be in the normal range, but academic testing was cons is tently below grade level. He has had no s ignificant medical problems. An work-up included normal serum chemistries, thyroid functions , toxicology screen, ceruloplasmin, and brain magnetic res onance imaging (MR I). His family history was s ignificant for depress ion in a maternal and completed s uicide in a maternal greatUnfortunately, his symptoms have not s ignificantly improved in the 5 years s ubs equent to the onset of his illness . He has been hos pitalized nine times , including placement in a long-term res idential program. He has been on numerous antips ychotic medications, both traditional neuroleptics and atypical agents , and other agents, including s elective serotonin reuptake inhibitors (S S R Is) and mood s tabilizers . His mental examination continued to dis play tangential and disorganized thinking, paranoid delus ions, loos e as sociations, pers everative speech patterns , and a flat, times inappropriate, affect. His time has generally been spent P.3310 pacing and muttering to hims elf, with no s ocial with others unless initiated by adults. S ome was finally noted with clozapine (C lozaril) therapy, although he remained s ymptomatic. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > P AT HOL OG Y AND E X AMINAT IO NS

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PATHOL OGY AND LAB OR ATOR Y E XAMINATIONS P art of "47 - E arly-Onset S chizophrenia" T here are few s tudies examining biological markers of early-onset s chizophrenia. In an ongoing s tudy of youth with very early–onset schizophrenia at the NIMH, neurobiological abnormalities have been noted. T hes e include deficits in smooth pursuit eye movements and autonomic res ponsivity, which are s imilar to thos e reported in the adult literature. Us ing MR I, subjects very early–onset schizophrenia had larger left frontal ventricular horns , larger left caudate regions, and a normal caudate as ymmetry when compared to normal controls. S maller total cerebral volumes were with negative s ymptoms . A progress ive increase in ventricular s ize was seen in these subjects over a 2period, sugges ting a pos sible neurodegenerative T his finding has not been noted in adults or in one study of adoles cents with s chizophrenia. S o far, imaging studies s uggest frontal lobe dysfunction similar findings in adults. In the University of C alifornia, Los Angeles (UC LA) S tudy, family members of individuals with childhoodschizophrenia have higher rates of both s chizophrenia schizotypal personality dis order. Although there are not yet s tudies definitely identifying a gene as sociated with 4431 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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the illnes s, youth with velocardiofacial syndrome, which involves a deletion in chromosome 22, are at higher the disorder. T hese neurobiological findings are important research efforts to unders tand the underlying etiological mechanisms of the dis order. However, none are diagnostic. T he primary role for laboratory evaluations neuroimaging techniques in the s tandard ass es sment early-onset schizophrenia is for ruling out other medical disorders . E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > DIF F E R E NT IAL DIAG NO

DIFFE R E NTIAL DIAGNOS IS P art of "47 - E arly-Onset S chizophrenia" Misdiagnos is has been a major concern with earlyschizophrenia. Mos t children who report psychotic-like symptoms do not actually have a ps ychotic dis order. In suspected cas es referred nationwide to the NIMH childhood-onset schizophrenia, the vast majority did have the disorder. F ollow-up studies of early-onset schizophrenia have found s ome youth who have disorder or pers onality disorders at outcome. W hen as sess ing a child or adoles cent with symptoms of schizophrenia, a comprehens ive diagnostic needed to rule out other conditions that present with similar symptomatology. A thorough review of symptoms, course and premorbid functioning, to DS M-IV -T R criteria, familiarity with how ps ychotic 4432 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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symptoms pres ent in this age group, and determination family ps ychiatric history all help improve the accuracy diagnosis. However, discriminating between thes e disorders still may be difficult, es pecially at the initial presentation. T herefore, the diagnos is needs to be periodically reass ess ed.

Mood Dis orders B oth schizophrenia and psychotic mood disorders (es pecially bipolar disorder) present with a variety of affective and ps ychotic s ymptoms . T his overlap in symptomatology increases the likelihood of at the time of ons et. Negative symptoms appear to be more s pecific to schizophrenia and may be a more marker of the illness . His torically, approximately oneof adoles cents with bipolar disorder were originally misdiagnos ed as having s chizophrenia. Longitudinal reass ess ment is therefore needed to ens ure accuracy diagnosis. F amily ps ychiatric his tory may als o be a differentiating factor, although it is important to note studies have also found an increased family his tory of depres sion in s chizophrenic youth. T hus , the presence depres sion in relatives does not ensure that the child's presentation is due to a mood disorder.

S c hizoaffec tive Dis order E arly-onset schizoaffective disorder has not been well defined in this age group. C hristian E ggers found that percent of his early-onset s chizophrenia sample, at up, had schizoaffective ps ychoses , which is an IC D-9 diagnosis that overlaps with DS M-III-R diagnoses of disorder and s chizoaffective dis order. Other follow-up 4433 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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studies of ps ychotic youth have also found this disorder but at lower rates .

Nonps yc hotic B ehavioral or E motional Dis orders (Inc luding Dis s oc iative and P ers onality Dis orders ) Y outh with conduct and other nonpsychotic emotional disorders may report psychotic-like symptoms and, be misdiagnosed as having a primary ps ychotic When compared to psychotic children, thes e children lower rates of delus ions and thought disorder. At up, an increas e in personality dys function, including personality dis orders, but not ps ychotic disorders , has been found. When there is a his tory of abuse or the ps ychotic-like symptoms may repres ent phenomena. It is important that these children be accurately characterized, as a misdiagnosis of schizophrenia may unnecess arily expose them to the term s ide effects of neuroleptics .

A utis m and P ervas ive Dis orders Autism and pervas ive developmental dis orders are distinguished by the absence or transitory nature of the required positive ps ychotic s ymptomatology (i.e., hallucinations and delusions ), as well as by the predominance of the characteris tic deviant language patterns, aberrant s ocial relatednes s, and other key symptoms that characterize these dis orders. T he age of ons et and the absence of a normal period of development are als o indicative, although s ome 4434 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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schizophrenic children do have a lifelong history of developmental delays . However, compared to developmental disorders , the premorbid abnormalities early-onset schizophrenia tend to be les s pervasive severe. C hildhood dis integrative dis order res embles autis m, the ons et occurs after 2 or more years of normal development. C hildren with As perger's s yndrome lack marked language dis turbances ass ociated with autism present with deficits in s ocial relatedness , contextual communication (es pecially with social cues ), and a res tricted (and pos sibly bizarre) range of interests . T he of overt hallucinations and delusions distinguishes both these conditions from s chizophrenia.

Developmental L anguage C hildren with developmental speech and language disorders may be mis takenly diagnosed as having a thought disorder. S uch children do not, however, have other prerequis ite s chizophrenic s ymptoms, such as hallucinations , delus ions, and odd social relatednes s.

Other Dis orders Other dis orders that need to be differentiated from schizophrenia include schizotypal and schizoid disorders and other ps ychotic disorders (e.g., disorders P.3311 and s chizophreniform disorder). F inally, there are with multiple developmental lags, including in affect modulation, s ocial relatedness , and thinking, 4435 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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whos e s ymptoms do not fit well within the current for schizophrenia.

Organic Dis orders It is important that all ps ychotic children and receive a thorough pediatric and neurological T he poss ibility of an organic ps ychosis needs to be cons idered when obtaining the his tory, completing the phys ical examination, and s electing initial laboratory inves tigations . T he lis t of potential organic etiological agents is exhaustive; however, some of the entities must be cons idered include (1) delirium, (2) seizure disorders , (3) central nervous s ys tem les ions (e.g., tumors , congenital malformations, head trauma), (4) neurodegenerative dis orders (e.g., Huntington's lipid storage dis orders), (5) metabolic disorders (e.g., endocrinopathies , W ilson's dis eas e), (6) toxic encephalopathies (e.g., s ubs tances of abus e s uch as amphetamines, cocaine, hallucinogens , phencyclidine, solvents ; medications s uch as stimulants, and anticholinergic agents ; and other toxins such as metals), and (7) infectious dis eas es (e.g., encephalitis , meningitis, or human immunodeficiency virus [HIV ]– related syndromes). Also, it is important to examine for comorbid medical or developmental dis orders. F or example, there is an increased ris k for ps ychotic as sociated with the genetic condition velocardiofacial syndrome. G iven the s ignificant rates of comorbid substance with s chizophrenia and psychotic mood dis orders in adoles cents (as high as 50 percent comorbidity in studies), it is not uncommon for a his tory of drug abus e 4436 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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be obtained at the firs t onset of the ps ychotic dis order. the ps ychotic s ymptoms pers is t for longer than a few despite documented detoxification from the abus ed subs tance(s ), a primary psychotic disorder s hould be cons idered, with subs tance abus e as a comorbid and exacerbating factor. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > C OUR S E AND P R O G N

C OUR S E AND PR OGNOS IS P art of "47 - E arly-Onset S chizophrenia" T here are few s tudies examining the cours e of earlyschizophrenia. Mos t are retrospective, and none factor the influence of treatment. T he adult literature s ugges ts that s chizophrenia is a phasic disorder, although there great deal of individual variability. Diagnostic and therapeutic decis ions depend on the recognition of stages. T he phas es include the following.

P rodrome B efore the overt development of ps ychotic s ymptoms , most patients experience s ome degree of functional deterioration. T his may include social withdrawal, odd schizotypal preoccupations, deteriorating academic performance, wors ening hygiene and s elf-care s kills , dysphoria, or idiosyncratic or bizarre behaviors. S ome youth will pres ent with an increase in aggress ive or other conduct problems , including s ubs tance abus e. T hese symptoms may confus e the diagnostic picture. 4437 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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T he prodromal phas e varies greatly in time, from an change (days to weeks ) to chronic impairment (months years ). T he symptoms may repres ent a marked from baseline functioning, or, alternatively, a wors ening premorbid pers onality or behavioral characteris tics. youth, es pecially those with very early–onset schizophrenia, have an ins idious onset. In such cas es , may be difficult to dis tinguis h between the premorbid personality and cognitive abnormalities and the ons et the disorder.

A c ute P has e During the acute phase, pos itive symptoms (i.e., hallucinations , delus ions, thought dis order, and disorganized behavior) and are as sociated with a significant deterioration in functioning. T his phase generally lasts 1 to 6 months , although it may pers ist over 1 year. S ymptoms may shift from positive to over the cours e of treatment, and the length of this is , in part, determined by treatment response.

R ec uperative/R ec overy P has e As the acute psychosis remits , there is generally a lasting s everal months in which the patient continues to experience a significant degree of impairment. T his is often due to negative symptoms (flat affect, anergia, withdrawal), although it is common for s ome positive symptoms to persist. In addition, some patients posts chizophrenic depres sion (IC D-10) characterized dysphoria and flat affect.

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As they recover, youth with early-onset schizophrenia have prolonged periods (several months or more) active positive s ymptoms. However, mos t patients continue to experience s ome degree of impairment due negative symptoms .

C hronic ally Ill P atients S ome patients remain chronically s ymptomatic, des pite adequate treatment, over a period of many years. patients are among the most s everely impaired and require the mos t intensive treatment res ources. T he percentage of patients within this chronically impaired group hopefully will less en as advancements in continue to be made.

L ongitudinal C ours e S chizophrenia generally follows a pattern characterized increasing deterioration after each cycle until, after approximately 10 years , the disorder tends to wane, leaving a res idual s tate of varying disability typified predominantly by negative symptoms . T here are insufficient data to determine whether this long-term pattern holds for early-onset schizophrenia. S ome with schizophrenia may only have one cycle, although is not common. R ecovery is incomplete in 80 percent of cas es in which youth have had more than one episode.

L ong-Term Outc ome T here are few s tudies examining long-term outcome in early-onset s chizophrenia. Most are retrospective. In addition, there are potential problems in interpreting the 4439 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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exis ting literature. Outcome s tudies may be influenced diagnostic errors , given that, historically, bipolar was frequently mis diagnos ed as s chizophrenia. Als o, because schizophrenia is a phas ic dis order, ratings of outcome vary depending on the phas e during which as sess ment occurs. S hort-term outcome is invariably predicted by characteristics , treatment respons e, and adequacy of therapeutic res ources . F ollow-up studies looking at outcome over 1 to 2 years have found that the majority youth continue to display symptoms of their illness . Although youth with schizophrenia may return to near their level of premorbid functioning, their premorbid functioning is often in the moderately impaired range. Negative s ymptoms, cognitive abilities , and premorbid functioning best predict outcome. In studies that have examined outcome over an approximate 5-year period, high rates of moderate to severe impairment at outcome are described, although there are some cases in which remis sion occurs . was bes t predicted by better premorbid and intellectual functioning. C omprehensive treatment interventions been hypothes ized to improve outcomes, including in those cas es in which the disorder remitted, but this has been s tudied s ys tematically. P.3312 T here are two s ets of studies that have examined longterm outcome. Michel Maziade and colleagues up on 40 s ubjects with early-onset s chizophrenia follow-up, 14.8 years ; mean age of onset, 14.0 years ). 4440 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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two s ubjects had a complete recovery. T he majority (74 percent) were moderately to severely impaired. functioning and the s everity of pos itive and negative symptoms during acute episodes bes t predicted C hris tian E ggers followed 57 patients with childhood schizophrenia (onset between ages 7 and 13) over a follow-up period of 16 years. Overall, 50 percent of the subjects were significantly impaired at outcome, 30 percent had good social adaptation, and 20 percent complete remis sion. T wenty-eight percent had schizoaffective disorder. T hes e youth had a more cours e and less premorbid difficulties. Ons et before (N = 11) was uniformly as sociated with a poor Within this s ame s ample, 44 s ubjects were reass ess ed a mean follow-up period of 42 years. T he outcome were similar: 25 percent had complete remis sion, 25 percent partial remis sion, and 50 percent had chronic impairment. An ins idious onset (over more than a 4period) and an age of onset before age 12 were both as sociated with greater disability at outcome. In general, the available follow-up studies are with the adult literature. T here are few studies that compared early-onset to adult-onset schizophrenia. onset appears to be as sociated with higher rates of negative symptoms and greater social impairment. findings sugges t that that early-onset schizophrenia have a more insidious and chronic cours e, with less favorable outcome. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > T R E AT ME N

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TR E ATME NT P art of "47 - E arly-Onset S chizophrenia" T here is little res earch address ing the treatment of onset s chizophrenia. T herefore, treatment recommendations must be extrapolated from the adult literature. T herapeutic strategies are tailored to the developmental characteristics of the patient, the needs their family, and the different s tages of the dis order. C omprehens ive multimodal interventions are needed incorporate both ps ychopharmacological and ps ychos ocial therapies. An array of therapeutic are needed, including inpatient/partial hos pitalization programs, medication management, services , intensive cas e management, family vocational and rehabilitative ass is tance, s pecial programs, and, in some cas es, res idential programs.

P s yc hopharmac ology T he efficacy of antipsychotic agents for the treatment schizophrenia has been firmly es tablis hed. However, are few s tudies examining their us e in youth. T here are only three controlled trials examining the effectivenes s traditional neuroleptics for early-onset schizophrenia. Haloperidol (Haldol) (0.02 to 0.12 mg/kg) was found to superior to placebo in reducing symptoms of thought disorder, hallucinations , and persecutory ideation in children with s chizophrenia. Loxapine (Loxitane) was superior to placebo in a s tudy of adoles cents with schizophrenia. B oth thiothixene (Navane) and 4442 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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(Mellaril) improved psychotic symptoms in 50 percent of youth diagnos ed with chronic In thes e trials and other cas e reports , youth the same side effects noted in adults (e.g., symptoms, sedation, tardive dys kines ia, and malignant s yndrome). T he long-term us e of early-onset schizophrenia has not been s tudied. T he atypical antips ychotic agents repres ent a major advance in the pharmacopoeia for schizophrenia and largely replaced traditional neuroleptics , due to their favorable side-effect profile, greater effectivenes s for negative symptoms , and mood-stabilizing effects . However, although they are widely used in youth, there only one publis hed controlled trial examining an agent for youth with schizophrenia. In the NIMH s tudy, clozapine (mean dos e, 176 mg ± 149 mg per day) was superior to haloperidol (16 ± 8 mg per day) for treating both positive and negative symptoms in 21 youth age, 14.0 ± 2.3 years ) with childhood-onset However, while on clozapine, five youth developed significant neutropenia (this res olved spontaneously in three of the patients), and two had seizures . T herefore, although potentially more efficacious , clozapine's apparent increased risk for adverse reactions in youth raises concerns . T here are case series and open-label trials des cribing effectivenes s and s afety of olanzapine (Zyprexa), ris peridone (R is perdal), and quetiapine (S eroquel), with few reports for zipras idone. C linically s ignificant improvements are generally noted for both positive and negative s ymptoms. Y outh generally experience the spectrum of s ide effects described in adults , although 4443 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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magnitude of weight gain appears to be greater. In one open-label comparative trial, olanzapine caus ed the greates t degree of weight gain. It is not uncommon for youth to gain 1 lb or more per week during the initial phases of therapy, with some gaining cons iderably T here are controlled trials under way examining the and effectivenes s of these agents for early-onset schizophrenia. Other adjunctive medications with some reported for s chizophrenia in adults include lithium (E s kalith), benzodiazepines, and anticonvuls ants. However, the evidence supporting the antips ychotic activity of these agents is limited, and their us e in youth with has not been s tudied. T reatment varies depending on the phase of the illness and the patient's history of medication respons e and effects. Despite the lack of s tudies , most clinicians the atypical agents , with the exception of clozapine, as first-line agents. C lozapine is recommended for res is tant cases . G eneral guidelines for the ps ychopharmacological management of s chizophrenia include the following.

B as eline As s es s ment B efore initiating a medication trial, the targeted symptoms s hould be adequately documented. T he and his or her family s hould be provided with adequate information regarding diagnos is , medication options, side effects . A thorough medical as sess ment is also needed. of neurological dysfunction warrants further evaluation, 4444 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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including cons ideration of an electroencephalogram neuroimaging studies, or a neurology cons ultation. Any preexisting abnormal movements s hould be to avoid later mis labeling them as medication s ide R outine laboratory s creening tests to be cons idered include blood counts, s erum chemis tries, thyroid functions , urinalys is , and toxicology screens . If the ris k factors are pres ent, testing for HIV s hould be done. C hromos omal analys is may be indicated for patients clinical presentations or features sugges tive of a developmental s yndrome.

Ac ute Phas e Antips ychotic therapy s hould be implemented for a of no less than 4 to 6 weeks, using adequate dos ages, before efficacy of the medication choice is determined. Dos ages in children are usually less than those for However, as youth tend to metabolize psychotropic more rapidly than adults, older children and often require the same dos age ranges recommended the adult literature. Ins tituting large dos ages during the early part of treatment generally does not hasten and P.3313 more often results in unnecess arily excess ive dosages side effects . If no results are apparent after 4 to 6 if side effects are not manageable, a trial of a different antips ychotic should then be undertaken.

R ec uperative Phas e T he recuperative phas e generally occurs after 4 to 12 4445 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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weeks, provided the acute-phase symptoms can be controlled. As pos itive symptoms improve, the patient may have persis tent confusion, disorganization, and dysphoria. During this period, antips ychotic medication should be maintained. Attempts to gradually lower the dosage may be indicated to decrease side effects, including exacerbation of negative s ymptoms. T his is es pecially true if high dos ages were needed to control acute psychotic phas e. However, any lowering of the antips ychotic dos e must be carefully monitored to relaps e.

R ec overy/R es idual Phas e In the recovery/res idual phas e, antipsychotic therapy well-documented efficacy in preventing relaps e. Approximately 65 percent of adult patients on placebo have a relaps e within 1 year of their acute ps ychotic compared to 30 percent on neuroleptics. However, in newly diagnosed patients who have been s tabilized for least 6 months, a medication-free trial may be a s mall percentage of patients will not relaps e and, therefore, s hould not be expos ed to the ris k of longneuroleptic s ide effects . In patients with relaps es or chronic illness , or in newly diagnos ed patients with persis tent ps ychotic symptoms , the maintenance medication s hould be maintained indefinitely at the lowest effective dos e. Longitudinal monitoring is

Nonres ponders to Antips yc hotic s A s ignificant minority of patients with s chizophrenia will not res pond adequately to the first-line antipsychotic agents . T he atypical agents may be more effective for 4446 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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treatment-res is tant cases , although, at this time, is the only antipsychotic with clearly documented superiority in efficacy. G iven clozapine's potential side effects, it is only used in cases in which patients have to respond (or have had significant s ide effects) to at two adequate trials of different antipsychotic at least one of which s hould be an atypical agent.

P s yc hos oc ial Therapies In the adult literature, traditional ins ight-oriented ps ychotherapies have not been effective for treating schizophrenia. F ortunately, ps ychoeducational interventions directed at family functioning, problemsolving and communication skills, and relaps e have been shown to decrease relaps e rates . T he interventions stem, in part, from res earch regarding expres sed emotion. E xpress ed emotion refers to of overprotectivenes s or criticism expres sed towards patient. T he relaps e rates for patients with are higher when living in families characterized as high express ed emotion. F amily intervention programs , conjunction with medication therapy, have been s hown significantly decreas e s chizophrenia relapse rates. Another important ps ychoeducational modality is social skills training. T hes e programs focus on improving the patient's s trategies for dealing with conflict and identifying the correct meaning, content, and context of verbal mess ages within his or her family; and his or her s ocialization and vocational s kills . T he combination of family treatment, s ocial s kills training, medication therapy als o has been shown to decreas e relaps e rates. 4447 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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T o date, there is only one study examining interventions in early-onset schizophrenia. B jorn R und colleagues compared the effectivenes s of a ps ychoeducational treatment program to the standard community treatment in a s ample of adolescents with schizophrenia (12 patients per group). T he ps ychoeducational treatment program included parent seminars , problem-solving ses sions , milieu therapy the subjects were hos pitalized), and networks (reintegrating the s ubjects back into their s chools and communities). T hes e interventions were used in conjunction with medication therapy. T he s tandard treatment group received a mixture of individual ps ychotherapy, milieu therapy, and medications . was as ses sed after 2 years . T he ps ychoeducational treatment program had lower rates of rehos pitalization and was more cost-effective. S ubjects with poor premorbid ps ychosocial functioning benefited the most from the ps ychoeducational interventions . C linical improvement was ass ociated with the families ' emotion ratings changing from high to low. Although more research is needed in this area, family treatment social s kills training s hould be cons idered helpful to medication treatment for children and adoles cents schizophrenia. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > F UT UR E DIR E C T IO

FUTUR E DIR E C TIONS P art of "47 - E arly-Onset S chizophrenia" 4448 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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F urther research is needed to delineate the cours e, phenomenology, res ponse to treatment, and outcome early-onset schizophrenia. B ecause s chizophrenia in appears to be the s ame disorder as in adults , s tudying progres sion of the neurops ychiatric manifestations of early-onset s chizophrenia agains t the backdrop of developmental maturation may potentially provide to underlying etiological mechanisms. Moreover, early-onset schizophrenia may be a more form of the illnes s, res earch examining this population may be more likely to identify potential biological and genetic markers. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > S UG G E S T E D C R O S S -

S UGGE S TE D C R OS S R E FE R E NC E S P art of "47 - E arly-Onset S chizophrenia" C hapter 12 reviews the adult literature on antips ychotic medications are discus sed in more detail S ections 31.16 and 31.25. Other pertinent s ections those on the psychiatric treatment of children (C hapter 48), mood disorders (C hapter 13), and pervasive developmental disorders (C hapter 38). E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 47 - E arly-Ons et S chizophrenia > R E F E R E NC

R E FE R E NC E S Alaghband-R ad J , Hamburger S D, G iedd J N, 4449 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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R apoport J L: C hildhood-onset schizophrenia: markers in relation to clinical characteristics . Am J P s ychiatry. 1997;154:64–68. Alaghband-R ad J , McK enna K , G ordon C T , Albus Hamburger S D, R umsey J M, F razier J A, Lenane R apoport J L: C hildhood-onset schizophrenia: the severity of premorbid course. J Am Acad C hild P s ychiatry. 1995;34(10):1273–1283. *American Academy of C hild and Adolescent P sychiatry: P ractice parameters for the as sess ment treatment of children and adoles cents with schizophrenia. J Am Acad C hild Adole s c P s ychiatry. 2001;40(7 S uppl):4S –23S . *American P s ychiatric Ass ociation: P ractice for the treatment of patients with s chizophrenia. Am P s ychiatry. 1997;154(4 S uppl):1–63. Armenteros J L, F ennelly B W , Hallin A, Adams P B , P omerantz P , Michell M, S anchez LE , C ampbell M: S chizophrenia in hos pitalized adoles cents: clinical diagnosis, DS M-III-R , DS M-IV , and IC D-10 criteria. P s ychopharmacol B ull. 1995;31(2):383–387. Asarnow J R , T omps on MC , G oldstein MJ : onset schizophrenia: a follow-up study. S chizophr 1994;20(4):647–670. Asarnow R , Asamen J , G ranholm E , S herman T , J M, W illiams ME : C ognitive/neurops ychological 4450 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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of children with a s chizophrenic disorder. S chizophr 1994;20(4):647–670. Asarnow R F , Nuechterlein K H, F ogels on D, P ayne DA, R us sell AT , Asamen J , K uppinger H, K S : S chizophrenia and s chizophrenia-spectrum personality dis orders in the firs t-degree relatives of children with s chizophrenia: the UC LA family s tudy. Arch G e n P s ychiatry. 2001;58(6):581–588. C aplan R , G uthrie D, G is h B , T anguay P , DavidT he K iddie F ormal T hought Dis order S cale: clinical as sess ment, reliability, and validity. J Am Acad C hild Adoles c P s ychiatry. 1989;28(3):408–416. C arls on G A, F ennig S , B romet E J : T he confusion between bipolar disorder and s chizophrenia in where does it s tand in the 1990s? J Am Acad C hild Adoles c P s ychiatry. 1994;33(4):453–460. P.3314 E ggers C : C ours e and prognosis in childhood schizophrenia. J Autis m C hild S chizophr. E ggers C : S chizo-affective ps ychos is in childhood: a follow-up study. J Autis m De v Dis ord. 1989;19:327– E ggers C , B unk D: T he long-term cours e of earlyschizophrenia. S chizophr B ull. 1997;23:105–118. G ordon C T , F razier J A, Mckenna K , G iedd J , 4451 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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Zahn T , Hommer D, Hong W , K ays en D, Albus K E , R apoport J L: C hildhood-onset schizophrenia: an study in progress . S chizophr B ull. 1994;20:697–712. Hafner H, Nowotny B : E pidemiology of early-onset schizophrenia. E ur Arch P s ychiatry C lin Ne uros ci. 1995;245:80–92. J ames AC , J avaloyes A, J ames S , S mith DM: non-progres sive changes in adoles cent-onset schizophrenia: follow-up magnetic resonance study. B r J P s ychiatry. 2002;180:339–344. *K eller A, C astellanos F X, V aituzis AC , J effries NO, J N, R apoport J L: P rogress ive loss of cerebellar childhood-onset s chizophrenia. Am J P s ychiatry. 2003;160:128–133. K olvin I: S tudies in the childhood ps ychoses . B r J P s ychiatry. 1971;6:209–234. Maziade M, B ouchard S , G ingras N, C harron L, A, R oy M, G authier B , T remblay G , C ote S , F ournier B outin P , Hamel M, Merette C , Martinez M: Longstability of diagnos is and symptom dimensions in a systematic sample of patients with onset of schizophrenia in childhood and early adolescence. P os itive/negative distinction and childhood of adult outcome. B r J P s ychiatry. 1996;169: 371– Maziade M, G ingras N, R odrigue C , B ouchard S , A, G authier B , T remblay G , C ote S , F ournier C , 4452 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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Hamel M, R oy M, Martinez M, Merette C : Long-term stability of diagnos is and symptom dimensions in a systematic sample of patients with onset of schizophrenia in childhood and early adoles cence. I: Nos ology, sex and age of ons et. B r J P s ychiatry. 1996;169:361–370. McC lellan J , McC urry C : Neurocognitive pathways in development of s chizophrenia. S emin C lin Neurops ychiatry. 1998;3:320–332. McC lellan J , McC urry C , S nell J , DuB os e A: E arly ps ychotic disorders : cours e and outcome over a two year period. J Am Acad C hild Adole s c P s ychiatry. 1999;38:1380–1389. McC lellan J M, W erry J S , Ham M: A follow-up study early ons et ps ychosis : comparis on between diagnoses of schizophrenia, mood disorders and personality dis orders. J Autis m De v Dis ord. 262. *McK enna K , G ordon C T , Lenane M, K ays en D, R apoport J : Looking for childhood onset the firs t 71 cases s creened. J Am Acad C hild P s ychiatry. 1994;33(5):636–644. P ool D, B loom W, Mielke DH, R oniger J J J r, G allant controlled evaluation of Loxitane in s eventy-five adoles cent s chizophrenia patients. C urr T her R e s E xp. 1976;19:99–104.

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R apoport J L, G iedd J , K umra S , J acobs en L, S mith P , Nelson J , Hamburger S : C hildhood-onset schizophrenia: progress ive ventricular change adoles cence. Arch G e n P s ychiatry. 1997:54:897– R atzoni G , G othelf D, B rand-G othelf A, R eidman J , K ikinzon L, G al G , P hillip M, Apter A, W eizman R : gain ass ociated with olanzapine and risperidone in adoles cent patients : a comparative prospective Am Acad C hild Adole s c P s ychiatry. 2002;41(3):337– R os s R G , Novins D, F arley G K , Adler LE : A 1-year label trial of olanzapine in s chool-age children with schizophrenia. J C hild Adole s c P s ychopharmacol. 2003;13:301–309. R und B R , Moe L, S ollien T , F jell A, B orchgrevink T , M, Naes s P O: T he ps ychos is project: outcome and effectivenes s of a psychoeducational treatment programme for s chizophrenic adoles cents . Acta P s ychiatr S cand. 1994;89:211–218. R us sell AT : T he clinical pres entation of childhoodschizophrenia. S chizophr B ull. 1994;20(4):631–647. S pencer E K , K afantaris V , P adron-G ayol MV , C , C ampbell M: Haloperidol in schizophrenic early findings from a study in progress . S chizophr 1992;28(2):183–186. S porn AL, Addington AM, G ogtay N, Ordonez AE , G ornick M, C las en L, G reenstein D, T os sell J W , 4454 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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P , Lenane M, S harp W S , S traub R E , R apoport J L: P ervas ive developmental disorder and childhoodschizophrenia: comorbid disorder or a phenotypic variant of a very early onset illnes s? B iol P s ychiatry. 2004;55:989–994. S porn A, Addington A, R eis s AL, Dean M, G ogtay N, P otocnik U, G reenstein D, Hallmayer J , G ochman P , Lenane M, B aker N, T oss ell J , R apoport J L: 22q11 deletion s yndrome in childhood onset schizophrenia: an update. Mol P s ychiatry. 2004;9:225–226. T homs on P H: S chizophrenia with childhood and adoles cent onset—a nationwide register-based Acta P s ychiatr S cand. 1996;94:187–193. *T suang MT , F araone S V : T he case for the etiology of s chizophrenia. S chizophr R e s . 1995;17:161–175. Werry J S , McC lellan J : P redicting outcome in child adoles cent (early-onset) schizophrenia and bipolar disorder. J Acad C hild Adole s c P s ychiatry. 1992;31 147–150. Werry J S , McC lellan J , C hard L: E arly-onset schizophrenia, bipolar and s chizoaffective dis orders : clinical and follow-up study. J Am Acad C hild P s ychiatry. 1991;30(3):457–465. World Health Organization. Inte rnational of Dis e as e s (IC D-9). G eneva: World Health 4455 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/47.htm

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1978. World Health Organization. T he IC D-10 Me ntal H ealth and B e havioural Dis orde rs : C linical Des criptions and Diagnos tic G uide line s . G eneva: Health Organization; 1992. Zahn T P , J acobsen LK , G ordon C T , McK enna K , J A, R apoport J L: Autonomic nervous s ys tem ps ychopathology in childhood-onset s chizophrenia. Arch G e n P s ychiatry. 1997;54:904–912.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 48 - C hild P s ychiatry: P s ychiatric T reatment > 48.1: Individu P s ychodyna mic P s ychotherapy

48.1: Individual Ps yc hodynamic Ps yc hotherapy David L. K aye M.D. P art of "48 - C hild P s ychiatry: P sychiatric T reatment"

DE F INITION P sychodynamic ps ychotherapy, used interchangeably ps ychoanalytic psychotherapy by mos t practitioners , long and s toried tradition in child and adolescent ps ychiatry, both in the United S tates and Although, for many years, it had been the backbone of child ps ychiatric theory and practice, psychodynamic ps ychotherapy has been under s iege from different quarters s ince the 1980s . T he as cendancy of neurobiological approaches and understanding, third party payers' demands for briefer and less expensive treatments , and the public's demand for empirical have all contributed to the diminished influence of ps ychoanalys is. Despite this , ps ychoanalys is remains vibrant, and s till the most comprehens ive, framework unders tanding ps ychotherapy and the human mind. A current Medline s earch reveals that the number of articles on the s ubject of child ps ychoanalys is or ps ychoanalytic psychotherapy has increased modes tly 4457 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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since the late 1960s (833 articles publis hed from 1966 1978 and 965 published from 1990 to 2002). F urther, a perusal of recent book titles reveals a broad pluralis m thought about psychoanalytic theory and method, reflecting the vitality of the field. Although the place of psychoanalytic psychotherapy within child and adolescent psychiatry is in flux, it a primary framework for many practitioners . In the pas t, was often s een as a s tand-alone treatment of child ps ychiatric disorders. In current practice, all but the orthodox practitioners us e the approaches flexibly, and in concert with other approaches, including family therapy, behavior therapy, ps ychopharmacology, school interventions, and s o forth. P sychoanalytic concepts also continue to be applied to broad clinical in res idential and other intensive treatment milieus, services , police and juvenile justice s ettings , and As psychoanalysis has evolved, even recently res earch agenda, it has been poised to move back the ps ychiatric mainstream. Leon E is enberg, a longcritic of psychoanalysis, recently observed that Where I erred was in failing to appreciate the powerful and lasting contribution ps ychoanalys is made to by teaching trainees to lis ten to patients and to try to understand their distress , rather than merely to class ify them by some diagnostic algorithm, or snow them with drugs , or lock them 4458 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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away, or release them to homeles sness . B as ing care on what is unique to the individual patient is central to clinical competence, whether in or s urgery or ps ychiatry. Looking to find its place in contemporary ps ychiatry given the pluralis m already mentioned, psychoanalysis must make clear what it is that makes an approach ps ychoanalytic. In fact, far from a single and monolithic of ideas, psychoanalysis encompass es a wide Dis agreement exis ts about the nature of the mind, development, ps ychopathology, and treatment. Despite this, mos t psychoanalytically oriented practitioners share the following precepts : T he primacy of individual e xpe rie nce and s e lfunders tanding. A primary goal in treatment is s elfacceptance and unders tanding the subjective emotional experience of the patient through the instrument of a relations hip. T he primary tool of ps ychoanalytically informed therapy is, in fact, the relations hip between the doctor and the patient. T he importance of uncons cious me ntation. affects, motivations, and process (including mechanisms) are accepted as critical determinants normal and abnormal human behavior. T he reality of ps ychic de te rminis m. Human happens for ps ychological reasons and is unders tandable through following a link of multiple impulses, affects, and their as sociated relational 4459 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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experiences . Often thes e links are unconscious. T he child is father to the man. E arly experience in a child's life is critical in initiating important and enduring patterns in perceiving, thinking, feeling, behaving. A focus on trans fe re nce . Individuals relate to others the present bas ed on expectations, emotions, and beliefs about relationships generated in the pas t by interactions with early important figures (e.g., T hese interactional patterns are not just external events but are als o internalized by the child. T re atme nt goals are broad. T his type of aims to promote psychological growth broadly, not just s ymptom amelioration. R es is tance is an expectable phenome non. barriers (res is tance) to ps ychological growth or res olution of s ymptoms can be expected in the of treatment.

HIS TOR Y T he firs t psychoanalytic reference to child cas es was S igmund F reud's cas e of Little Hans in 1909. Although F reud was s keptical that children could be analyzed, in case, he provided s upervis ion to Hans' phys ician who success fully analyzed the 5-year-old boy's phobia horses . A few years later, S andor F erenczi reported his attempt to directly treat a child but found that the child quickly became bored with the analytic process and wanted to return to his toys to play. It was not until a of women ps ychoanalys ts entered the scene that it 4460 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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became appreciated that play was the central medium expres sion for children and should be incorporated into work with thos e with emotional disturbance. Hermine Hug-Hellmuth, a teacher by prior training, in 1921, the firs t psychoanalys t P.3316 to report the us e of play in the treatment of children. believed that the treatment of children was primarily educational and limited in its goals . B y far, the major figures in the early development of ps ychoanalytic treatment of children were Anna F reud Melanie K lein. In some res pects , their influences , and differences, continue to dominate much of the field. began to develop a technique for working with children while in B erlin in the early 1920s and, in 1926, moved London, where she continued her work. S he saw as a cauldron of pas sionate drives (both aggres sive sexual) with rigid, hars h s uperegos. Her technique on equally powerful and direct interpretations of unconscious impuls es. S he appraised play as the equivalent of adult free ass ociation and eschewed any for parents in the treatment. Anna F reud, also a training, began her psychoanalytic training in the early 1920s and shortly thereafter formed a child study group in V ienna. S he viewed children as and undeveloped, necess itating a gentler approach was careful not to interpret too deeply for fear of overwhelming the child. S he recognized work with the parents as difficult but neces sary to further the development of the child and also to s upport treatment the child. S he saw the goals of treatment as being to 4461 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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the child to his or her developmental path without neces sarily effectuating a definitive or complete cure. 1927, Anna F reud wrote the first book on child Introduction to the T echnique of C hild Analys is . T he differences between K lein and F reud led to a confrontational S ymposium on C hild Analysis in May T hese controvers ial discus sions brought points of disagreement into sharp focus, and this s chism has persis ted to the present day, albeit les sening in the past. T he K leinian s chool became dominant in the K ingdom and S outh America, while the F reudian held s way in North America. In the 1940s, the analys ts of the independent s chool in G reat B ritain, including Donald W innicott, W ilfred B ion, and others as sociated with the object relations perspective, entered into this fray. S tarting in the camp, they attempted to bridge the divide with the F reudians. Winnicott contributed enormous ly to the analytic unders tanding of child development and treatment. His rich body of work included an emphasis the importance of the early motherchild relations hip; role of play, mirroring, and the es tablis hment of the holding environment in healthy development and in analysis; the meaning of the transitional object; and the true versus false self. In North America, a s econd pers pective was emerging, beginning with Heinz K ohut's work in the 1970s on the development of the s elf. T his evolution has continued the present, with major contributions from relational, and inters ubjective pers pectives . Harry S ullivan, R obert S tolorow, S tephen Mitchell, J os eph Lichtenberg, J ames F os shage, and Irwin Hoffman, 4462 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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others , have been major figures repres enting thes e perspectives . All of thes e authors have written primarily about clinical work with adults, and, in general, little that applies the relational perspective directly to work children. T hes e theorists have als o been informed by convergences with infant and attachment res earchers such as Daniel S tern, J ohn B owlby, Mary Main, and Ainsworth. R ather than emphasizing the role of drives , defens es , res is tance, conflict, and other traditional concepts , these authors as sert that the basic building blocks of mental life are relations with others. T his a s hift in the foreground from an intraps ychic focus to a relational field model, from objectivism to C ons equently, there is a s hift in emphasis in treatment from interpretation to the co-creation of needed relational experiences. Although the relational view converges with much of the traditional literature, fundamental differences exist and are recently being recognized as legitimate by clas sic analys ts. T his is embodied by the work of P eter F onagy and Mary who have written about the central importance of mentalization, or the self-reflective function. T his ability read the feelings, thoughts, and impuls es ass ociated human behaviors is fundamentally dependent on the es tablis hment of s ecure attachments . T raditionally, ps ychoanalys is has supported its claims us efulnes s by the use of cas e descriptions and has oppos ed efforts to document its effectiveness through empirical res earch. R ecently, F onagy, T arget, and have initiated a major effort to es tablis h child ps ychoanalys is and ps ychoanalytic therapy as supported treatments. Although thes e initial efforts are 4463 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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promis ing, more work needs to be done. It s hould als o be noted that the term ps ychodynamic originally us ed to describe the ever-changing balance mental and neurophys iological energy intrins ic to the inner life of humans. T his was contrasted with an that emphasized behavior, des criptive phenomenology, anatomic structure. In this s ense, ps ychodynamic and ps ychoanalytic are not synonymous . In the United there have been a number of influential writers who be considered within this broad ps ychodynamic even though they were not as sociated with the ps ychoanalytic tradition. T hes e psychodynamic play therapists (for example, F rederick Allen, C lark Ann J ernberg, and V irginia Axline) have als o had a place in the his tory of child psychotherapy and influence current practice.

THE OR E TIC A L IS S UE S S ome of the overarching theoretical iss ues in ps ychodynamic ps ychotherapy have been reviewed in previous section. P articular is sues in work with children as follows .

Differenc es between C hild and Adult Patients C hild patients differ in significant ways from adults . differences are crucial in informing practice. F irs t, children's limitations in language, cognition, and experience mus t be taken into account to engage and sustain children in treatment. B ecause of cognitive and emotional limitations , their understanding of the or the need for treatment is likely to be incomplete or 4464 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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inaccurate. C hildren tend to externalize problematic and have little ability to understand how therapy might help them now, let alone in the future. F urther, they limited capacity for tolerating pain and anxiety, creating another barrier for keeping child patients in treatment. Meeting with a s tranger who will meet and talk with the child is certainly extraordinary and may be confusing and threatening. F or all of thes e reasons, the child therapist mus t actively woo, educate, and work the child to create the secure space needed to therapeutic alliance. Another major difference is that children do not come treatment at their own request. T hey are brought by parents . T he reasons for treatment mus t be explored explained in a way that is unders tandable and to the child. T he rationale that engages the child may different from the reasons the parents bring the child in. A 7-year-old boy was brought in for treatment by his parents , who were concerned about his depress ive irritability and argumentativeness , which had created great tension in the family. W hen seen individually, the therapist as ked the child if he understood why they meeting. T he boy responded, I dont know. T he then as ked why he thought his parents had brought and he again avoided the question. Later in the the therapist returned to the iss ue, while the child out a puppet s cene of different animals fighting. T he therapist explored how the animals felt, and the child sad. T his then opened the door for considering whether the child might also be s ad. T he child acceded, head yes and went back to playing with the puppets . 4465 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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therapist then said, W ell, maybe if we meet together, can unders tand these sad feelings and help you feel better. P.3317 T he therapist mus t also be able to s us tain enough of a relations hip with the parent(s ) or caretakers to s upport treatment of the child. T he parents must be engaged sufficiently to bring the child to treatment, pay for the treatment, and withs tand the emotional reactions they may experience as the child changes . F urther, a alliance with the parents can sustain a child patient through the usual feelings of reluctance to coming to treatment. T his all requires the psychodynamic child therapist to develop a s olid working relations hip with parents , while pres erving a sense of confidentiality and trus t with the child. A 10-year-old girl was s een in twice-weekly ps ychodynamic ps ychotherapy. As the child left her sess ions, her mother would ask each time How is s he doing? T he therapist made a s eparate appointment the parents to discus s these concerns further, while exploring how the child felt about this meeting. T he girl had concerns about what they are going to say about but acceded with s upport and understanding from the therapist. After dis cus sion with the parents , it was that the therapist would meet with the parents once month to discus s the child's progress and current functioning, provide s upport and guidance to the and monitor the parents ' anxiety. Once this plan was initiated, the mother's anxiety s eemed to less en, and 4466 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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no longer waited expectantly after the sess ions with daughter. T he child patient is als o dependent on the parents materially, phys ically, and emotionally. T his has implications and has led to the conviction, even among the most traditional child psychoanalys ts , that work with the parents is ess ential and neces sary in working ps ychodynamically with children. F urthermore, the ongoing interactions with caretakers have a continuing effect on the growth and progress of in therapy. B ecause a child's personality is unfolding shaped s trongly by continuing developmental experiences , the ongoing parentchild interactions have double-barreled effect. T hey not only affect the child's developing internal world of expectations , as sumptions , and beliefs about self and others , but also influence the child's expos ure to future developmental experiences . inhibiting or encouraging expos ure to growth-promoting developmental experiences , the ongoing parentchild interaction exerts a multiplier effect on the child. T his observation s trongly influences the overall aim of ps ychodynamic ps ychotherapy with children, which, as initially articulated by Anna F reud, is to res tore the child the path of normal development. Once back on track, normal development can then take over and provide experiences needed for internal growth. Lastly, children evoke strong feelings in the therapists work with them. T his often results in desires to protect res cue the child, es pecially when therapists obs erve and-now pathogenic interactions and traumatic experiences enacted by parents . At other times, the behaviors can be exas perating, infuriating, and 4467 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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frightening. All of this res ults in feelings within the therapist that are generally much higher in intensity those generated in adult work. T his places a premium the therapist's recognition and containment of his or own emotional respons es . Although these reactions be helpful clues in understanding the child's world, they can make for challenging work that often dis courages clinicians from becoming child therapists .

C entral R ole of Play S ince its initial recognition by early ps ychoanalysts, has been recognized as the central vehicle for communicating with children in ps ychodynamic ps ychotherapy. T his is es pecially true for younger whos e language skills have developed to a limited Older children are increasingly comfortable talking their own inner s tates and, by age 9 or 10, may find baby-is h. W hether or not to us e play materials with an individual child mus t be determined on a case-by-case basis . Nevertheless , play is the most comfortable and natural medium of expres sion for most children. P sychodynamic ps ychotherapists encourage play by having a number of toys visible and access ible to the T his helps to engage the child and conveys that the therapist is willing to meet him or her on their turf. Most therapists recommend a limited number of toys that for the symbolic expres sion of a wide array of affects themes (e.g., doll house, dolls , puppets, animals , Art materials (e.g., drawing, painting, clay) and (e.g., W innicott's s quiggle game), storytelling (e.g., G ardner's mutual s torytelling technique), and role are often incorporated into dynamic therapy. T herapis ts also may use structured games (e.g., checkers , ches s) 4468 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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therapeutic games (e.g., the T alking, F eeling, Doing in some circumstances. As W innicott has pointed out, play exis ts in the space between the inner world and external life, between and analyst. P lay requires active participation from the patient and the analyst. It is aimless and nonproductive; there are no social cons equences . As play allows for the s afe exploration of affects, conflicts , ideals, roles , wis hes , and s o forth. T his accords play a healing effect in and of itself. P lay is a forum for solving and experimentation. P lay als o offers a window into the inner life of the child, perhaps even a royal the unconscious for children. T his allows for a of the understanding of the child and may be the basis targeted interventions . W hen play is not pos sible, the of the therapy is to help the child to be able to play. A 6-year-old boy was brought for treatment because of long-standing s evere aggres sion and des tructivenes s. addition to an evaluation for medication, the child was seen in twice-weekly ps ychoanalytically oriented ps ychotherapy. T he beginning s es sions were marked the repeated need to set limits and contain the child's aggres sive behaviors. T wo months into treatment, he began to pump himself up, roar, and announce that he was the Incredible Hulk. He would then proceed to around the play therapy room, attempting to destroy toys. T he therapis t then s aid, Y ou know you cant really the Hulk. Y ou can pre tend that you are the Hulk, and maybe we can play this together. After a number of exchanges the child gradually and increasingly became able to play the part without becoming it. 4469 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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Trans ferenc e Much controvers y has surrounded the concept of transference in work with children. C hildren's internal representational world is s till being actively formed and altered by ongoing current interactions with parents others . As such, trans ference reactions are s till in flux. B ecaus e children are s till dependent on their parents, child patient does not develop the dependency that occurs in adult psychoanalytic ps ychotherapy. Instead, child patients have a primary need to work out iss ues parents directly. Nevertheles s, broadly speaking, transference reactions occur ubiquitous ly in ps ychodynamic psychotherapy as children enact the beliefs, ass umptions, and expectations they are developing. T hes e reactions are here-and-now of the prototypical interactions that are interfering with their happines s and development. Interpretations of transference phenomena primarily addres s this herenow aspect (perhaps the nervous feeling you have is because of s ome anger you are feeling) and, much genetic roots (i.e., the analyst does not often make interpretations about the child's reaction being to previous experiences with parents). P sychodynamic ps ychotherapy focuses its greatest attention on thes e transference reactions , s eeing this as the most arena to help children gain flexibility and greater in their unders tanding of themselves P.3318 and their interactions with others. C ountertrans ference reactions are seen as invaluable clues to the transference reactions and warded-off self4470 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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of the child.

R es is tanc e R es is tance is a concept that originated in clas sical describe the inevitable intraps ychic barriers to growth. T raditionally, this is thought to derive from conflicts between the patient's ego, id, and s uperego. theoris ts have conceptualized this differently. S ome unders tood these barriers as attempts to mas ter experience. Others have s een the terror and dread of changing and giving up familiar ways of seeing oneself and others as central. S till other contemporary theorists discard the term entirely as implying an adversarial and pass ive attitude that resides within the patient. Instead, they account for thes e impass es as the child's unders tandable emotional res ponse to the absence of needed relational experiences and empathic failures by the therapist. Although res is tance is typically seen as intrapsychic, are also systemic barriers to change. As the child less symptomatic and grows psychologically, the self-concept, parentchild, or marital relations hip may become challenged. T his, in turn, can create an impediment to the child's progres s and requires the therapist to attend and res pond to the parents ' anxiety about change. An 8-year-old boy was s een in individual ps ychotherapy for s eparation anxiety dis order. As the child's s ymptoms les sened and he developed greater confidence, he began to experiment with des ires to out from the orbit of his family and into the world 4471 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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the family. T his , in turn, s timulated the mother's worries about the child's physical and emotional s afety. S he to her husband for increas ing support and empathetic unders tanding, a long-standing iss ue in the marriage. Unless the parents are able to negotiate this in a more satis factory way, these systemic implications can on the child, creating a check on the child's progres s.

Oedipal vers us P reoedipal Foc us C las sic theorists have highlighted the central of oedipal iss ues in understanding both and treatment. E arly case descriptions appear to clinical phenomena almost entirely through this is , as a manifes tation of oedipal iss ues . Likewise, appears to hinge on adequately address ing thes e is sues consis tently; triadic relations hip patterns and of competition, s haring, sexuality, and rivalry are paramount. In contrast, contemporary theorists have instead emphasized preoedipal is sues. As s uch, the primary focus of understanding psychopathology and treatment has shifted to early parentinfant interaction, basic trust, attachment, s eparationindividuation and s o forth. T his has prompted a major shift in from triadic to dyadic iss ues . An 8-year-old boy was brought for treatment because his multiple fears and poor academic performance. the end of the analys is, after the child had made much progres s, his father attempted suicide. Although the original s ymptoms can be understood as a reflection of oedipal iss ues (e.g., castration fear and guilt over with the father leading to academic inhibition and 4472 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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fearfulnes s), contemporary theoris ts unders tand this in terms of his anxiety over separation and los s, that he recognized, at s ome level, his father's tenuous commitment to living. Als o central is cons ideration of security of the boy's attachment with his mother, his base.

Therapeutic Ac tion C las sical analysts have emphas ized the central role of interpretation and making the uncons cious cons cious the treatment of children. Interpretations proceed from that clos est to cons cious nes s to thos e mental contents furthes t away (i.e., uncons cious). T his is especially important with children. T hes e interpretations may be directed toward defenses , wis hes or intentions, or transference phenomena. Interpretations are made in a specified order: affect, defens e, impuls e. In words , the analyst firs t interprets the affect (Y ou be feeling angry right now), followed by the defens e (P erhaps you are angry becaus e you were that I did not remember your birthday), and, las t, the underlying impulse (P erhaps you were really hoping someone would remember your birthday). T heoris ts in what they s ee as the primary impuls es or motivators. C lass ically oriented analysts follow F reud's original drive theories and s ee sexuality and primary; contemporary analysts might emphas ize s elfcohes ion, s elf-regulation, attachment, mas tery, and as sertion as the most powerful organizers of Hence, contemporary theorists see therapeutic action stemming from the provision of needed relationship experiences that allow for the development of a 4473 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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and vital self. F onagy, E phraim B leiberg, and others attempted to bridge these views, attachment theory, cognitive neuros cience by highlighting the goal of mentalization. Mentalization, or the s elf-reflective enables the child to perceive and process mental the self and others . T his allows the child to develop a model of the inner thoughts and feelings that underlie human behavior. Optimally, this capacity develops out the child's early attachment with parents who relate to child as an intentional being with underlying thoughts , feelings, and intentions. As a result of these the child is then able to unders tand other's behaviors inner s tates. T hes e theorists posit that this is the centerpiece of ps ychoanalytic work with children (and adults ) and s ucces s depends on the degree to which develops .

P R A C TIC A L MA TTE R S Forms and Frequenc y of C hild Ps yc hodynamic Ps yc hotherapy P sychoanalytically informed ps ychotherapy can take numerous forms. C lass ically, child ps ychoanalys is seeing the child four or more times per week, lasting a period of years. In this form, ps ychoanalys is is rarely currently, although there is s ome res earch to s uggest it may have a place with particularly dis turbed children. P sychodynamic ps ychotherapy occurring one to two per week over a period of months to years is much common in both private practice and public clinic although it is increasingly difficult because of managed care restrictions . T he nationalized health systems in United K ingdom and C anada continue to s upport s uch 4474 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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treatments widely. Although typically open-ended in length, there have recent adaptations of brief, time-limited psychodynamic ps ychotherapy principles to work with children. Interpersonal therapy has been applied with and likely will be adapted to work with children. P sychoanalytic principles have also been widely group and family therapies. As noted previous ly, ps ychoanalytically informed is most commonly integrated into other approaches . Owen Lewis has delineated a model of s uch integrated treatment, in which ps ychodynamic principles fundamentally inform the gamut of treatment interventions (e.g., behavior therapy, ps ychopharmacology, family therapy, and s o forth).

Therapeutic Frame and S etting C hild therapy requires a dedicated office that can s erve a concrete reminder of safety, security, P.3319 and predictability for the child. Using the s ame office every sess ion fos ters thes e goals. S ome analys ts special cubbyholes or boxes for children to keep their particular toys, drawings, and so forth. T his also s erves personalize the s pace for the child. T he office s hould neither so small that the child feels closed in, nor so that the child is overwhelmed and overs timulated. An explicit therapeutic contract s hould be discuss ed with child and parents . C hildren should not be forced to therapy, although reluctance is not uncommon. Ass ent cons ent) is a more appropriate goal. It is generally 4475 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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recommended that therapy occur at the s ame time, on same day of the week. T his also strengthens the predictable frame necess ary for s ucces sful work. All ingredients contribute to establishing what Winnicott referred to as the holding e nvironme nt.

C onfidentiality C onfidentiality is a particularly thorny is sue with On the one hand, there is a clear need to maintain a of safety and security for the child to reveal his or her deepes t worries , hopes , thoughts, and desires, but, on other hand, therapis ts have a legal and ethical to safeguard the child's welfare. W hen is sues of s afety suicidality) arise, parents must be informed. At other the involvement of child protective authorities may be needed, which, in s ome s ituations, may end the In any event, the limits and extent of confidentiality be carefully explained to both the child and parents at beginning of treatment.

Working with Parents As already noted, parents are decisive players in ps ychodynamic ps ychotherapy with children. Although there are times when the parents need to honor the neces sary boundaries of treatment with the child, it is seldom appropriate that the parents are excluded from treatment. T ypically, parents are included from the beginning to obtain the history and to begin to establish working relationship that can sus tain the treatment of child. At the conclus ion of the evaluation period, it is helpful to explicitly review the as sess ment and treatment plan with the parents. T he analys t must 4476 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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concordance with the parents on the nature of this treatment contract from the beginning and may need to revis it this throughout the cours e of treatment. R egular meetings with the parents (with or without the child) are routine parts of ps ychodynamic ps ychotherapy. T hes e ongoing meetings s erve to maintain the working relations hip, provide further information about the child, and create a forum for parent guidance or exploration parental ps ychological is sues that impede the child's growth. W hen it becomes apparent that the parents are need of their own treatment, then referral is generally made to another therapist. P roviding psychodynamic ps ychotherapy to two members of the same family contemporaneous ly is dis couraged, due to the inherent conflict of interest and encroachment on confidentiality that may undercut the alliance with one or both individuals .

C L INIC A L IS S UE S A ND Aims P sychoanalytic ps ychotherapy has always been an ambitious therapy. It aims to go well beyond the relief symptoms and greater coping or adaptation. W ith the goals have been to s eek a cure, broadly improving quality of life and inoculating the patient from future stress ors . In contrast, Anna F reud firs t articulated the of child psychoanalysis as a return to the path of development. S ubs equent analys ts have emphasized aims of increas ed mentalization, self-unders tanding, regulation, personality integration, self-expres sivenes s, self-es teem, flexibility, increased frustration tolerance, capacity to play. It is as sumed that reaching thes e 4477 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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a good enough fas hion res ults in a diminution of symptoms, as well as improved functioning in s chool, peers, and with family members .

Indic ations Indications for psychodynamic psychotherapy have historically focus ed on the presence of certain loose categories of problems generally seen as due to intraps ychic conflict. T ypically, indications have those children with neurotic level disorders and good internal and external res ources such that the will be sustainable after termination of treatment. T his situation rarely exists in clinical practice. F urther, has indicated that this group of children may derive as much or more benefit from less intens ive treatment involving the s chool, family, or community res ources. the same time, children with more severe disturbances , often s ubs umed under the category of borderline conditions, may require an intensive effort, s uch as ps ychoanalys is, for effective results to be achieved. work has s upported the use of psychoanalytic for children with internalizing dis orders , regardles s of whether externalizing disorders exist. Another way to at indications is to cons ider what the goals of the treatment are. F or example, if the goal is to understand one's feelings , thoughts, and the connections between inner world and the outer world of behavior or s elf-reflective function), then ps ychodynamic ps ychotherapy is likely to be helpful. B ecause ps ychodynamic ps ychotherapy is now generally integrated with other treatment approaches , it is not neces sary for this treatment to be all encompass ing rather, to aid in forwarding critical developmental 4478 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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proces ses.

C ontraindic ations C ontraindications include children with externalizing problems , es pecially when there are features or when there is no comorbid internalizing disorder. T here is als o little to jus tify this treatment for children with more than mild mental retardation, autis m and many autis tic-spectrum dis orders, traumatic brain injury, and others whos e receptive language abilities subs tantially compromis ed. T hes e may be relative contraindications, as there can be focal psychodynamic goals even in s ome of these cases . Again, treatment these individuals will be multimodal, and other modalities may be more critical. More intens ive ps ychoanalytic treatments also should not be unles s the family is able to support the child in the treatment.

B eginning Treatment T he initial goal in treatment is to establish a working relations hip with the child. T his requires not only a therapeutic ambiance for the child, but als o a s upportive, working relations hip with the parents . T he initial goal with the child is to create a playful, environment in which he or she and the therapist can explore the world of the child's thoughts , feelings , and behaviors . In the beginning, some exploration and unders tanding of why the child is meeting with the therapist is us eful, as well as an explicit clarification of treatment contract (W e will be meeting for 45 minutes every T uesday at 4:00. T his time will just be for us . 4479 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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really hard to meet every week.). It is als o helpful for therapist to explain to the child that he or she is who meets with kids to help them with their feelings, to see if we can understand you, to help you feel better, help you understand how you feel and why you do of the things that caus e you trouble, and so forth. T he of thes e comments is to explain the role of the therapis t and to convey a steadfastly hopeful attitude to the child (and parents ) through what will be inevitable ups and downs. F or the P.3320 playroom to acquire a specialnes s to the child, these mess ages mus t be communicated repeatedly. T he rules should also be explained (W e will talk and play together during the time we are together. Anything is as long as no one gets hurt and nothing gets broken.). cours e, once the child begins to express him- or or s he will s ee what the therapist is made of. T his is the true acid test for the child. Only over time can the child the sense that the therapy is not a punis hment, that the therapist has hope for the child, that the child can feel unders tood, and that problems can be solved. F or the most part, in the initial phas e, the therapist keeps his or comments and interpretations focus ed on the displacement of the play rather than on making direct comments about the child's real-life s ituation. It takes a few weeks (in the healthies t children) to a of months to achieve a secure working relations hip.

Midphas e Treatment Midphas e treatment begins when the child has 4480 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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es tablis hed a clear working alliance. T he child has a familiarity with the frame of treatment, even though emotional upheavals may continue in the sess ions. this phas e, the primary emphasis is on the work of therapythat is , the slow and repetitive recognition of feelings, defens es, and their relations hip to behaviors. Over this time, the s ame theme in a play s es sion may for months at a time. T he therapist continues to create with the child a s ens e of hope and comfort as recognition and unders tanding of the child's inner world accrues. It is in this phas e that interpretation of problematic patterns and transference reactions T he focus on the here-and-now reactions of the child the therapist is especially fruitful, although much work continues to be done in the play dis placement. in this phas e, the child becomes more able to connect displacement with his or her own life. R econstructive statements linking current emotional or behavioral patterns with previous life experiences are generally emphasized in work with children. A 10-year-old was in psychodynamic ps ychotherapy times per week because of s evere obs ess ivedisorder (OC D). In mos t s ess ions, beginning from the fourth month of treatment and lasting until the eighth month, the child would crawl under a table, conducting conversation from this womb-like s pace they had T he analyst commented to the child, who had been months prematurely, It feels like a really good place to to when you want, and to be able to come out when want. T his interpretation emphas ized the current emotional experience of the child, rather than linking in some direct way to the child's real-life experience 4481 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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example, Y ou want to climb back in your mother's and are angry that you cant.). C onnecting the herenow with the past mus t be timed carefully so as not to experienced as confus ing and overwhelming to the

E nding Treatment Optimally, treatment ends when the child is free from symptoms, has made sufficient progres s in growth and maturity, and is back on track developmentally. In the real world, termination comes about for other reasons . F requently, termination occurs when partial improvement has been made and practical considerations (ins urance, finances, transportation, moves , graduation) become paramount. T ermination provides an opportunity for the child to on is sues of separation, loss , and mourning. P aulina K ernberg has elegantly s tated: As the child approaches the end her treatment, the s ame is sues that brought her to therapy once again come to the fore: (1) Do (the parents) care? (2) Does the therapist care? (3) Do I care for (the therapist)? (4) Do I care for them (the parents)? (5) C an I for myself? (6) W ill you me? (7) W ill I remember you? In the process of ending, it is important to include the actively in setting a final date. G enerally, 6 weeks to 3 months is s ufficient time to allow the child and family to 4482 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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meaningfully concentrate on these is sues. S etting the so that it does not coincide with other real-life endings (e.g., graduation, moving dates) permits the child and family to experience the fullest impact of the During the ending phase, children frequently regres s, a recurrence of symptoms and defenses in the face of stress or. Denial of the importance of the relations hip by the child, parent, and therapist is not uncommon and should be unders tood as reactions to the impending separation and loss . In the course of ending, the child should have an opportunity to explore the gamut of feelings that inevitably ariseanxiety, guilt, anger, satis faction, ambivalence, and s o forth. T his frees the from developing defensive patterns to face the future los ses of life. After 8 months of weekly ps ychotherapy, an 11-yeargirl's s ymptoms of perfectionis m and s evere recurrent abdominal pain had improved s ufficiently that the child came in and stated that I dont have pain! I dont need to come here anymore. T hen she added, although maybe need help with boys. T his led to a series of dis cus sions about termination, which resulted in the s etting of a date 6 weeks hence. In the firs t meeting after the termination date was s et, s he revealed that s he was comfortably talk with the therapist, unlike with her with whom she felt s he could not be open. T he next she became irritated by a comment of the therapist and said, If I had known you would s ay that I would have weeks ago! S he continued to talk about other in her life, es pecially the death of her grandmother. In final ses sions , s he alternated between denial and recognition of her emotional reactions about the 4483 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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upcoming termination. S he continued to dis cuss other endings, moves , and friends leaving. In the last said, Okay. I have something to say. I think Ill mis s helped me. T o which the therapist responded, W ell, we have worked well together. And I will mis s you, too. left the s ess ion knowing that she could make future appointments if the need aros e.

R E S E A R C H A ND E VA L UA TION Although there has been a s urge of interest recently, res earch into the efficacy of psychoanalytic with children has been limited to a handful of studies. B ecaus e of its handcrafted and highly individualized nature, s ingle cas e descriptions have been traditionally. T hese have typically been reported as detailed narratives without the systematic or objectified approach typically taken in reports of behavioral treatments . W ith the as cendancy of the randomized, controlled treatment s tudy, this traditional approach has been widely seen as lacking. As a res ult, there is increasing interest within ps ychoanalytic circles addres s this . Although this interest is present, it mus t recognized that the randomized, controlled treatment is fraught with practical and ethical difficulties when to ps ychoanalytic psychotherapy. Its typical length, ambitious goals and the difficulties operationalizing and the difficulty in manualizing the approach have serious barriers to applying the randomized, controlled treatment model to ps ychoanalytic ps ychotherapy. Nevertheles s, progress has been made, and at leas t prospective, randomized, controlled treatment is under way. 4484 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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P.3321 T here have been a number of retrospective chart review studies of ps ychoanalytic psychotherapy with children, almos t all done since the 1990s. Although all s upport effectivenes s of ps ychoanalytic psychotherapy with children, there are significant limitations to thes e None of them approach the level necess ary to meet an empirically supported standard. Most of these studies come out of the Anna F reud C entre in London. T hey with a series of s tudies on the psychoanalytic treatment children with brittle diabetes . In the largest of these, G eorge Moran and his colleagues offered treatment (three to five times per week) to 11 children (mean age, 14) for 15 weeks , while the children were hospitalized for stabilization of their diabetes . T hese children als o received some degree of parent guidance multidis ciplinary consultation and collaboration. T hey compared to 11 children who received standard medical treatment, including an average of 3 weeks of inpatient medical care. T he children were above average in intelligence and came from higher socioeconomic backgrounds . At 1-year follow-up, the treated group was functioning better and their diabetes was in s ubs tantially better control (6 of 11 of the treated group had hemoglobin A1c levels ; 0 of 11 in the control group). res earch group later retrospectively reviewed 763 terminated cases s een over 40 years at the Anna F reud C entre. In a s eries of reports , F onagy and T arget have published their review of thes e extensive and case records . In the firs t report, they reviewed the for 135 children (mean age, 9) with dis ruptive behavior 4485 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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disorders and compared that with 135 children with emotional disorders . T wo-thirds of the children in each group received ps ychoanalysis (four to five times per week), and one-third received ps ychoanalytic ps ychotherapy (one to two times per week). In both groups , parent contact was included to provide and s upport. Average length of treatment was 2 years. children in both groups had above-average IQs and tended to come from families of higher socioeconomic status . As is typical with a dis ruptive dis order group, was a higher dropout rate (31 percent) as compared to those with emotional dis orders . C hildren in less treatment were much more likely to drop out than were those in psychoanalysis . At termination, the children remained in treatment had improved but less s o than control group. Almost one-third had no diagnosis and were functioning well. Nearly half made significant and reliable improvement in adaptation. T hose with a diagnosis of oppos itional defiant dis order improved more s o than those with conduct disorder (only 23 improved). C hildren younger than age 9 improved than older children, as did thos e who received the intens ive ps ychoanalys is . In another s tudy, the s ame res earchers reviewed the 353 cases of children (mean 10) with internalizing dis orders. T hree-fourths of these children were s een in psychoanalysis (four to five times week), and one-fourth were in ps ychotherapy (one to three times per week). T hey were s een for a median of years . At termination, les s than 25 percent continued to have a psychiatric dis order, 40 percent had no and were functioning well, and 61 percent showed subs tantial global improvement. Y ounger children, showed greater improvement. T he more disturbed 4486 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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children fared much better with ps ychoanalys is (56 percent who received psychotherapy made no improvement or wors ened; only 15 percent in ps ychoanalys is showed no improvement or wors ened). difference in outcomes between ps ychoanalys is and ps ychotherapy was noted for the less dis turbed both groups did equally well. In a third report, this same cohort was analyzed by age and developmental Again, younger children (i.e., ages 6 to 11) responded better to treatment, although this effect was mitigated when treatment dropouts were excluded. In short, adoles cents tended to s tay in treatment for shorter periods. F urther, younger children responded more positively to higher-frequency ps ychoanalysis, whereas adoles cents res ponded equally regardless of T here have als o been a s mall number of studies the outcome for broader ps ychodynamic Although these studies often fail to find a significant treatment effect, they als o have substantial design limitations , tempering the conclusions . Metaanalytic reviews by J ohn W eis z and colleagues and P eter K im Hoagwood, and T heodore P etti both concluded traditional child therapy had little demons trable effect. Although traditional therapy is not well defined, there suggestions that these treatments were strongly influenced by ps ychodynamic principles . B ahr W eiss colleagues subsequently des cribed a prospective randomized controlled treatment involving traditional child therapy versus academic tutoring for a group of latency-aged boys with a mixed variety of problems (although mos t were externalizing). T he children (mean age, 10) in traditional treatment received a mean of 60 4487 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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sess ions of individual psychotherapy (favoring ps ychodynamic and cognitive, but not behavioral, approaches), 18 parent/family intervention s ess ions, periodic school consultation over a 22-month period. At the end of treatment and at the 1-year and 2-year ups, there were no significant differences on any for the treated group. T his s tudy, while not s upporting efficacy of this treatment, is consis tent with F onagy's suggesting that children require a high frequency of sess ions, especially for externalizing problems , to res ults. Other inves tigators have also examined the effects of intens ity, time-limited psychodynamic psychotherapy children and have found modes tly pos itive results . T wo these studies (K osmas S myrnios and R obert K irkby, Muratori and colleagues ) specifically examined the of time-limited, brief ps ychodynamic ps ychotherapy children. B oth (one of which was a small, randomized, controlled treatment) s upported the effectivenes s of the focus ed, brief ps ychodynamic ps ychotherapy. T aken altogether, the conclusions of research can be summarized as follows : 



T here is limited evidence on either side regarding efficacy of ps ychoanalytically informed with children. T he evidence that does exist s ugges ts that younger children res pond more favorably to this treatment than older children and adolescents , but that frequency of s es sions must be achieved to produce positive outcomes. F or adoles cents , length of time treatment appears relevant, although there seems 4488

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be little benefit from increas ed frequency of 







C hildren with internalizing dis orders tend to more favorably than those with externalizing disorders ; further, externalizing disorders require greater intensity of treatment to be effective. C hildren with conduct disorders appear leas t likely res pond; children with autistic-spectrum dis orders, ps ychotic dis orders, receptive language dis orders, mental retardation are als o unlikely to respond to form of treatment. T he typical good patient (i.e., neurotic, higher functioning, less disturbed child) responds as well low-intens ity treatment as to high-intens ity ps ychoanalys is. As s uch, from a cost-effectivenes s perspective, it is hard to jus tify ps ychoanalys is for population. C onvers ely, the more disturbed child (for example, borderline, multiple complex developmental multidimens ionally impaired) may require highfrequency treatment to produce any positive less er forms of treatment appear to offer little and may even wors en the outcome.

FUTUR E DIR E C TIONS P sychoanalytically informed ps ychotherapy is at a cross roads. Although it has remained vital without further empirical s upport for its efficacy, it may become marginalized outs ide the psychiatric treatment mains tream. Much has been accomplished to lay the groundwork for these needed s tudies , but res ources 4489 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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be allocated to carry them out. C ritically, there are now ps ychoanalytically informed outcome measures, as treatment manuals (T he Hamps te ad Manual of P s ychodynamic Deve lopme ntal T he rapy for C hildren F onagy and colleagues, and C hildre n with C onduct Dis orde rs : A P s ychothe rapy Manual by P aulina S aralea C hazan). B y furthering this res earch base, the may maximize its unders tanding of the indications and contraindications for this approach (especially unders tanding those patients or clinical problems for which this technique is es pecially or uniquely relevant), mechanism of action, and critical areas of technique. P.3322

S UG G E S TE D C R OS S T he reader is encouraged to refer to the related on ps ychoanalys is and ps ychoanalytic ps ychotherapy (S ections 6.1 and 30.1), E rik E riks on (S ection 6.2), ps ychodynamic s chools (S ection 6.3), and brief ps ychotherapy (S ection 30.9). F amily therapy is in S ections 30.5 and 48.5. Adoles cent treatment is reviewed in S ection 48.10. Other types of treatment of children are discus sed in S ections

R E F E R E NC E S Ablon S L: T he therapeutic action of play. J Am Acad C hild Adole s c P s ychiatry. 1996; 35(4):545549. Allen F . P s ychothe rapy with C hildren. New Y ork: Norton; 1942. 4490 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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Altman N, B riggs R , F rankel J , G ensler D, P antone R elational C hild P s ychothe rapy. New Y ork: Other 2002. B leiberg E . T re ating P e rs onality Dis orde rs in Adoles ce nts : A R elational Approach. New Y ork: P res s; 2001. *B leiberg E , F onagy P , T arget M: C hild critical overview and a proposed recons ideration. Adoles c P s ychiatr C lin N orth Am. 1997;6(1):138. C hethik M. T e chnique s of C hild T herapy: S trate gie s . New Y ork: G uilford P res s; 2000. E is enberg L: T he past 50 years of child and ps ychiatry: a personal memoir. J Am Acad C hild P s ychiatry. 2001;40(7):744. F onagy P : E valuating the effectivenes s of in child psychiatry. C an J P s ychiatry. F onagy P , et al. T he Hamps te ad Manual of P s ychodynamic Deve lopme ntal T he rapy for Y ork: G uilford P res s; (in pre s s ). F onagy P , T arget M: P redictors of outcome in child ps ychoanalys is: a retrospective study of 763 cas es Anna F reud C entre. J Am P s ychoanal As s oc. 1996;44:2777. *F onagy P , T arget M: Mentalization and the 4491 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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aims of child psychoanalys is . P s ychoanal 1998;8(1):87114. F reud A. T he P s ychoanalytic T re atme nt of C hildre n. London: Imago P ublishing; 1946. G abbard G O, G underson J G , F onagy P : T he place ps ychoanalytic treatments within psychiatry. Arch P s ychiatry. 2002;59(6):505510. G reenberg J R , Mitchell S A. O bje ct R e lations in P s ychoanalytic T he ory. C ambridge, MA: Harvard Univers ity P res s; 1983. Hug-Hellmuth H: On the technique of child analysis . J P s ychoanal. 1921;2:287305. J ens on P S , Hoagwood K , P etti T : Outcomes of health care for children and adolescents : II. review and application of a comprehens ive model. J Acad C hild Adole s c P s ychiatry. 1996;35 K ernberg P F , C hazan S E . C hildre n with C onduct Dis orde rs : A P s ychothe rapy Manual. New Y ork: B ooks ; 1991. K lein M. T he P s ychoanalys is of C hildren. London: P res s; 1932. Lanyado M, Horne A. T he Handbook of C hild and Adoles ce nt P s ychothe rapy: P s ychoanalytic London: R outledge; 1999. 4492 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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Lewis O: Integrated ps ychodynamic ps ychotherapy with children. C hild Adole s c P s ychiatr C lin North 1997;6(1):5368. Muratori F , P icchi L, B runi G , P atarnello M, A two-year follow-up of psychodynamic for internalizing disorders in children. J Am Acad Adoles c P s ychiatry. 2003;42:331339. O'B rien J , P ilows ky D, Lewis O. P s ychothe rapies C hildre n and Adoles ce nts : Adapting the P roces s . W ashington, DC : American P sychiatric 1992. *S andler J , K ennedy H, T ys on R . T he T e chnique of Analys is : Dis cus s ions with Anna F re ud. London: P res s; 1980. S myrnios K X, K irkby R J : Long-term comparis on of versus unlimited psychodynamic treatments with children and their parents . J C ons ult C lin 1993;61(6):10201027. S roufe J . T he application of attachment theory to the treatment of latency-aged children. In: C ortina M, Marrone M, eds . Attachment T he ory and the P s ychoanalytic P roce s s . London: W hurr 2003. S zapocznik J , R io A, Murray E , C ohen R , S copetta R ivas-V azquez A, Hervis O, P os ada V , K urtines W : S tructural family vers us ps ychodynamic child 4493 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/48.1.htm

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for problematic His panic boys. J C ons ult C lin 1989;57:571578. *T arget M. T he problem of outcome in child ps ychoanalys is: contributions from the Anna F reud C entre. In: Leuzinger-B ohleber M, T arget M. P s ychoanalytic T re atme nt: P e rs pe ctive s for R es e arche rs . London: W hurr P ublishers; Weiss B , C atron T , Harris V : A 2-year follow-up of effectivenes s of traditional child ps ychotherapy. J C ons ult C lin P s ychol. 2000;68:10941101. Weiss S . V icis situdes of termination: trans ferences countertransferences. In: S chmukler AG , ed. S aying G oodbye : A C as ebook of T e rmination in C hild and Adoles ce nt Analys is and T he rapy. Hills dale, NJ : T he Analytic P ress ; 1991:265284. Weisz J , J ensen AL: C hild and adolescent in res earch and practice contexts: review of the evidence and suggestions for improving the field. C hild Adole s c P s ychiatry. 2001;10(1):1218. *Winnicott DW . P laying and R e ality. London: P ublications ; 1971:54.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 49 - C hild P s ychiatry: S pecial Areas of Interes t > 49.1: of Day C are

49.1: Ps yc hiatric As pec ts of Day C are K laus Minde M.D., F.R .C .P.(C ) P art of "49 - C hild P s ychiatry: S pecial Areas of Women with small children repres ent the fastestsector of employed mothers in the labor market. In 37 percent of married women with children younger age 6 years were employed. In 1998, this rate had 64 percent. T he employment rate of married mothers of infants younger than age 2 years increased even more, from 31 percent in 1975 to 62 percent in 1998. Of children, only approximately 5 percent were cared for their mothers at work; the remainder were looked after other people. In fact, a significant percentage of nonworking mothers als o s pent time in nonparental F or example, in 1997, 79 percent of children younger age 3 years regularly spent time in nonparental care, 39 percent of them for 35 or more hours per week. In addition, 81 percent of the children in the kindergarten clas s of 19981999 had child care experience before entry. B ecause mothers want to ens ure that their are well cared for during their abs ence from home, concerns , as well as the challenges child care pres ents deeply held beliefs and scientific theories about child development, have triggered a number of studies that 4495 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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examine the effects of maternal employment on Mothers s pending less time at home is not the only that maternal employment affects children. In many worker families , both parents and children experience increased stress because women generally have their traditional role in child rearing and family life. T his has led to role conflicts and guilt in more than 40 of both employed men and women. Hence, children do not only have les s time with their parents , but also may be affected by the s tres s their parents experience from trying to do too much.

E FF E C TS OF NONP A R E NTA L C A R E ON C HIL D DE VE L OP ME NT C hildAdult R elations hips S ome highly publicized s tudies in the late 1980s that early initiated nonparental care (i.e., before 12 of age) affects the s ecurity of infantparent attachment. S pecifically, these authors reported that, in five homogeneous samples of 491 maritally intact middleworking-clas s families , 43 percent of the infants were clas sified as ins ecurely attached if they experienced 20 more hours a week of routine child care during the firs t year of life. Infants with less -extensive routine child showed an ins ecure attachment rate of only 26 T his pattern was confirmed by Michael Lamb and S ternberg. However, more recent work s uggests that a number of family and maternal pers onality affect both the timing and the extent of maternal employment and, consequently, the duration and type nonparental care of children. F or example, E dward 4496 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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Melhuis h and colleagues showed that, of 18-month-old children who had either stayed home with their mothers or were cared for by relatives , by caregivers , or in a only thos e in the last two categories s howed a number of affectionate acts toward the caregiving less overall res ponsiveness , and less -engaged However, the characteristics of the mothers who chose different nonparental s ettings als o varied, explaining much of the overall variability in their children's T his highlights the need to ass es s children both before after they enter day care to control for thes e factors. In such a s tudy, J aipaul R oopnarine and Michael Lamb that 3-year-old children whos e parents had decided to enroll them in day care were initially more anxious and distress ed by a brief s eparation than those in a group who would remain at home. After 3 months of care, however, group differences had disappeared, suggesting that differences obs erved between home day care children cannot automatically be interpreted effects of nonparental care. Other, more recent inves tigations found no significant relationship between child care experience and attachment s ecurity. One poss ible explanation for the differences between studies from the 1980s and 2000s could be that today's mothers who place their infants in child care are more informed about the pos sible effects this may have on attachment patterns. T his , in turn, may make them sens itive and respons ive toward their babies when they are with them after work, which compensates for deleterious child care effects. E mployed mothers may receive more s ocial support today than in the past, allows them to spend more quality time with their 4497 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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when they are with them. T o clarify these and other important ques tions, the National Institute of C hild Health and Human Development (NIC HD) in 1991 funded a major ten-site study, initially involving 1,364 children and their T his s tudy has various advantages . It is pros pective infants were identified at birth and will be followed until 2004, when they reach middle primary school) and as sess es children and their mothers on cognitive, emotional, and phys ical growth and health meas ures at intervals of between 3 and 6 months by telephone or direct interview. T he inves tigators also as ses s both proximal (e.g., parenting skills and quality of interactions) as well as distal variables (e.g., maternal education and caretaker's exposure to ongoing us ing both questionnaires and direct observations . It here that P.3402 they documented for the first time in the day care literature that s ome distal variables s uch as a ongoing education in child development directly led to higher-quality care, which in turn res ults in higher of the child's social and cognitive competence. T he study therefore allows an examination of developmental outcomes and trajectories in the social-emotional, and growth and health domains over time that can be related to normative (e.g., s chool and individual (e.g., parental divorce or changes in care arrangements ) contextual influences . F inally, by working with a large number of children, the 4498 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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authors can examine the effects of child care in context (i.e., as it relates to the age at entry and the quality, amount, and s tability over time). T hey can als o differentiate between the effects of different types of care (e.g., care by the father, grandmother, or other relatives ; in-home care from a nonrelative; or day care centers). Last, they can ass es s to what degree selection of types of day care is a significant variable cons ider whether any day care effects are large be of practical relevance' that is , have a s ignificant size. E arly results of this study showed no significant in attachment s ecurity related to child care participation per se. E ven enrollment in extens ive, uns table, poorquality day care was not related to a higher rate of insecure attachment. However, childhood attachment affected by a combination of child care and maternal factors . F or example, children who received les s care both at home and from their child care providers were at dual risk) s howed the highes t rate of ins ecure attachment (up to 56 percent). T he attachment rating of less sensitively mothered children was also affected by more extensive or unstable care arrangements. F urthermore, only high-quality, brief day care s erved a compens atory function for children with unres pons ive insensitive mothers, decreas ing the rate of insecure attachment to 23 percent. T his s uggests that extensive care, regardles s of its quality, did not compens ate for insensitive mothering. T he authors sugges t that this is to a dosage effect for maternal sensitivity and involvement. C hildren with less involved or s ens itive mothers may need more time with her to develop a 4499 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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of her being available; hence, they show the highes t secure attachment if they are expos ed to only brief but high-quality day care. R es ults at 54 months confirm some of the early Using maternal reports of social s kills and behavior problems , as ses sed with Achenbach's C hild B ehavior C hecklis t (C B C L), s howed that neither the quality nor quantity or type of day care s ignificantly predicts behavioral difficulties . On the other hand, ratings by the children's caretakers indicate that the quantity of day is significantly correlated with an increas e in problem behaviors in the children (F [2, 505] = 5.78; P =.003). Although both the quality of care and quality of moderated thes e res ults s omewhat, the quantity of remained the only significant predictor of behavior all covariates were cons idered. S pecifically, children had experienced high-quantity day care, on average, scored 4.2 points higher on the C B C L than children less than 10 hours of day care per week. T his even when the length of contact between a caregiver and the child was taken into account and when various parental s election factors (e.g., mother's separation anxiety, psychological adjustment, and about the benefit of maternal employment) were taken into cons ideration. An explanation of the differences between caregiver maternal reports about the children's behavior may the fact that mothers and caregivers observe the in different contexts . B ehavior at home is us ually to a few well-known individuals, and many other document that mothers and caregivers offer different perspectives on child functioning. 4500 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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F urthermore, the overall effect size of high-quantity day care was 0.38 (moderate). T his compares with an of 0.25 or 2.4 points on the C B C L when cons idering differences in children exposed to low vers us high parenting quality and 0.47 or 4.5 points on the C B C L the poores t and least poor families were compared. Nevertheles s, this s tudy confirms , at leas t up to 54 of age, that children who spend more than 30 hours week in day care for 4 or more years on average score higher on a well-validated problem checklist. S imilar incremental effects were not observed in the areas of care quality, where one could have expected a longer more intensive high-quality experience to lead to an increasingly beneficial effect on the children's behavior. A very recent update on the children's s ocial the end of firs t grade s howed that maternal sensitivity remained an important predictor for s ocial skills and externalizing disorders , whereas type of child care was a s ignificant factor. T eachers als o rated children who more hours of day care in the pas t as showing more externalizing behaviors and less s ocial skills. Mothers had reported more depres sive symptoms also their children as showing an increas e in anxiety and depres sion during firs t grade, sugges ting that mothers may begin to recognize specific family behavior their children at that time. F inally, class room factors overall clas sroom management and a pos itive climate) as well as the s ens itivity of the firs t-grade and their degree of involvement were s ignificantly as sociated with les s anxiety and sadnes s in the

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Authors who have inves tigated relationships with peers have reported res ults s imilar to thos e examining the childadult relations hip after nonparental care T hus, papers published in the 1980s report that infant care was as sociated with later aggress ion or other problematic behaviors toward peers . However, more recent work emphas izes the relation between the of nonparental care and later behaviors with peers. F or example, C arrollee Howes found that children who had experienced low-quality care in infancy dis played poor peer relations in kindergarten. In contras t, the more the caregiverchild relations hip had been in day care, more gregarious , complex, and empathic the play was between thes e children and their peers at age 4 years. Long-term follow-up studies confirm the benefit of highquality care. F or example, T iffany F ield and her found that 7-year-olds with a long day care his tory more popular, more mature, and les s aggress ive than children who had entered day care only after the age of B enet-E vis Anders on, in a longitudinal s tudy of children, confirmed the s uperior social competence of year-old youngsters who had received other than home care s ince infancy. T his s upports the notion that the of early nonparental care is as sociated with later relations hip skills toward both adults and peers . T he more recent data from the NIC HD study do not directly with peer relations hips, although the inferior behavior ratings of the high-quantity day care children their caretakers s uggest that these children were als o behaving more problematically toward their peers . In general, however, the study confirms that children who rated by mothers and caregivers to be more s ociable 4502 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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have better peer skills. T his was also confirmed by observations . In addition, children with better cognitive and language skills do well with their peers .

B ehavior Problems According to attachment theory, children who are insecurely attached to their parents are less compliant toddlers than thos e who have es tablis hed a s ecure relations hip. B ecaus e in early s tudies an increas ed rate insecure attachment had been reported in children who experienced early nonmaternal care, it is not to find studies that s ugges t an as sociation between day care in infancy and later inappropriate noncompliance with P.3403 parental reques ts. C arrollee Howes and Michael studied toddlers at home, in their day care centers , and a laboratory situation and found that compliance with adult requests at home and in a laboratory were not correlated. T his s uggests that thes e early findings must regarded with caution because compliance or noncompliance is not a trait related to child care Overall, then, the earlier literature s uggests that nonparental care is s ometimes as sociated with problems . T hese tend to involve externalizing such as aggress ion and as sertivenes s and may be the behaviors these children s how toward their peers . NIC HD study confirms this earlier work and documents previous ly cited direct as sociation between quantity of care and a moderate increase in mos tly externalizing behavior in children up to 54 months on ratings by their 4503 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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caretakers . Although this increas e from a total group of 50.4 to 54.6 for the high-quantity s ubgroup on the item C B C L is statis tically s ignificant, it has to be that C B C L s cores can range from 0 to 200 and the point for poss ible clinical s ignificance is 60. T hus , the reported increment in the long child care s ubgroup is approximately 2 percent and leaves the s ubgroup well below clinical s ignificance. T he increment was also res tricted to ratings by the caretakers. F inally, the study does not provide any additional data that would that this 2 percent ris e has any clinical implications, requiring a cautious res ponse from the informed

C ognitive C ompetenc e T he literature dealing with cognitive competence can divided into s tudies that describe infants who were enrolled in intervention programs because of s pecific biological (e.g., prematurity) or s ocial ris k factors (e.g., poverty) and thos e that explore the overall effects of day care on cognitive development in general. R es ults show that s pecific intervention programs are invariably as sociated with increas ed cognitive competence, very s mall premature infants benefit less from than heavier ones , poss ibly becaus e of neurological cons traints. F urthermore, evidence s uggests that the effects of cognitive stimulation, even in the bigger premature infants, do not pers is t after the enrichment program terminates . F or example, in the multisite of 986 premature infants s tudied by J eanne B rooks and colleagues , the special programs for the treatment group continued for 3 years . T he cognitive advantages the children who had attended the child care program were highly significant at 3 years of age (14 intelligence 4504 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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quotient [IQ] points) but far les s s o at age 5 years, and, years later, all treatment effects had disappeared. are als o variable in nonhigh-ris k populations , although children from dis advantaged families seem to benefit most, es pecially thos e enrolled in high-quality Interes tingly, in some S candinavian prospective longstudies, 6-year-old children with more center-based before age 3.5 years s cored higher than those with care, irres pective of family background. T he NIC HD study provides additional data here. S pecifically, the authors s how that all tested cognitive functions (i.e., preacademic s kills , language abilities , short-term memory) are ass ociated with child care. S pecifically, children who attended higher-quality child care s core higher on preacademic skills and language abilities (effect size, 0.24). In this domain, the type of care is also important in that children with more centertype day care experience do better than those with types of day care experience. Maternal education size, 0.85), income, and parenting competence are good predictors of cognitive outcome, with an effect of 0.83 for income and 0.87 for parenting quality. V ery recent data indicate that academic achievement at the of grade one is also related to the extracurricular these children participated in before and after kindergarten and s chool (effect s ize, approximately Here again, children who attended day care centers child care homes also were more likely to attend while those who were cared for by fathers did not. T his s ugges ts that day care has the most general effects on cognitive as pects of development and that of the potentially negative behavioral cons equences of 4505 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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high-quantity care seen in the socioemotional domain observed within the cognitive area. Nevertheless , even this mos t s ucces sful domain of developmental overall child care accounts for only a small portion (between 1.3 and 3.6 percent) of children's cognitive language skills.

QUA L ITY OF C A R E Quality of care has been defined and meas ured by structural and dynamic meas ures in the NIC HD s tudy. S tructural meas ures as sess as pects of the care s etting facilitate s ens itive adultchild interaction. T hey include staff-to-child ratios (e.g., there s hould be no more than three infants younger than age 2 years per caregiver in good-quality day care situation), quality of phys ical settings (e.g., furnis hings and toys , phys ical s afety features), experience and training of s taff and management, group size, and the type of nutrition the children receive. Dynamic measures are designed to the quality of the experience provided to the children. E xamples here are the developmental appropriateness the children's experiences and s timulation (e.g., fine gross motor activities , language and reas oning experiences , creative experiences), the sensitivity of caregivers' res ponses to the children, staffparent interactions, and staff s upervis ion and evaluation. T he NIC HD results document the effects day care has es pecially on cognitive competence. In fact, even children who had experienced increasing-quality child care during the pas t year or two had better skills than those whose child care quality was high but had decreased over time. 4506 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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However, only a minority of children receive highchild care s ervices in North America at pres ent. F or example, only approximately 2 percent (1,800 of eligible child care facilities in the United S tates and 10 percent in C anada had achieved accreditation by their res pective organizations in 1990. In the 15 months ' up of the NIC HD study, only 20 percent of child care facilities met recommended guidelines for childs taff 25 percent for observed group s ize, and 60 and 69 for caretaker training and education, respectively.

R OL E OF THE P S YC HIA TR IC C ONS UL TA NT C hild psychiatris ts can be helpful in various ways. T hey help s taff understand especially challenging youngsters and provide direct case cons ultations, including T hey can als o be us ed on a more systemic level. F or example, they may provide regular in-service training staff and adminis trators, speak at parent meetings on specific developmental topics, or be available in times crisis (e.g., documented child abuse). S ome child ps ychiatris ts may engage in a mix of thes e activities. As with any consultative role, the ps ychiatris t and the care agency mus t clearly state their respective and roles toward the children, their families , and each other. T his engenders mutual respect and trust and the work of the psychiatris t more effective. C hildren in nonparental care s ituations need multifaceted P.3404 care, and the psychiatrist can have a well-defined role within this multidis ciplinary group of caregivers . 4507 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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P eter was 11 months old when he was referred to a ps ychiatris t by his pediatrician and the director of his care program because he did not want to go to s leep at night unless his mother laid down with him and entertained him for up to an hour. He would wake up at least twice at night and cry until his mother picked him He usually fell asleep again in her arms after 30 day care, he was unhappy and did not mix with the children. P eter's mother was a 38-year-old fashion designer who worked from 9 AM to 6 P M. His father, age 43, was an accountant. T he couple had been married for 8 years had tried to have children for 3 years before P eter's B oth had been delighted when P eter was born and had taken 6 months off work to be with P eter at home. One week before her return to work, she had enrolled in a day nurs ery to ease the trans ition. S he had s pent time at the nursery with him during his first week there now only delivered him there in the morning. T he s taff claimed that P eter slept well at the nursery but did not readily mix with the other children and s eemed vis ibly relieved when he was picked up by his father around P M. T his had not changed since he had entered the nursery 5 months ago. Mrs. A. had als o weaned P eter during the month her return to work. T his had been quite difficult. P eter initially refused to take the bottle for 3 days and had for many hours . In fact, his s leep had become at this time, and his mother believed that he mis sed his midnight breas t-feed. However, she had not dared to continue breas t-feeding him in the evening and at as she feared he would then refuse the bottle during 4508 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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day. Mr. A. believed that P eter was spoiled and needed discipline. He never got up at night to care for P eter but did enjoy playing s ome s pecial boys ' games with him bringing him home from the nursery. Mr. A. als o P eter should be allowed to take a bottle into bed at and was convinced that P eter could and would take the bottle on his own and, as a cons equence, s leep much better. Mrs. A. was the oldest of three children. Her parents emigrated from northern Africa, and she had grown up family in which her mother's traditional family values clas hed with her father's demands on his children to North American expectations of high profes sional achievements. Mrs . A. s aw her artistic profes sion as a compromise between thes e two cultures , but s he had welcomed the opportunity to join her husband in a city away from her hometown. T he only direct family in was Mrs . A.'s 75-year-old father, who had lost his wife years earlier and lived with another woman in a for seniors . He vis ited the A. family three to four times year. Mrs. A. brought P eter to the initial interview. S he cried great deal, expres sing both exas peration and anger P eter because he kept her up every night and s eemed be so needy. S he talked about her work and the she was under with res pect to the upcoming season. also talked about her mother, whom s he remembered aloof and lacking unders tanding when s he was a youngster. Above all, she tried to make clear how she wanted to be a good mother to P eter. T he therapist mentioned how much P eter loved and mis sed her 4509 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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she went back to work and how hard it was for him to unders tand the s udden changes in his life. T hey P eter's inability to judge time and how that might make his days in the nurs ery seem indeterminably long. After play ses sion with P eter and his parents during which was keen to set up games that involved both his father and mother, the following treatment plan was 1. Mother would accept the offer of her trusted woman to have her s is ter look after P eter during afternoon in his own home. 2. Mother would continue to bring P eter to his day at 9 AM but alternate with her husband in picking up at noon and bringing him back home to his new babys itter. 3. Mother would put P eter to bed each night and develop a special ritual to facilitate his falling (e.g., two songs and one story before leaving the room). 4. F ather would attend to P eter if he woke up during night by s imply putting him down when he cried remaining in the room without engaging in conversations or games until the boy had calmed down. T his new plan was discus sed with P eter and his the therapist's office. P eter obviously did not the details of the discus sion, but he clearly knew that something important was taking place. T he therapist promis ed to call the family every second evening the following week and arranged another interview 4510 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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approximately 2 weeks later.

FOL LOW-UP P eter accepted his new babysitter readily, es pecially because she initially came with her sis ter, the cleaning woman, and enjoyed taking him out for a walk and let sit on her shoulder while s he prepared his supper. Although P eter initially s eemed unhappy that his father came to his room at night, he ceased to wake up within week, improving the level of contentment of all family members. He also seemed delighted to welcome his mother home in the evening, showing her what he had done with the babys itter during the day. T he nursery reported improvement, and the staff commented specifically on P eter's s ens itivity toward other children's feelings.

DIS C US S ION T his cas e s hows that the sudden transition from being single child at home to being one of 20 children in a nursery can be extremely s tres sful for a toddler. T he as sociated sudden weaning obvious ly added to the of los s this little boy felt, all of which may explain his sleep and behavior at night. Although his father be somewhat aloof and dis tant, he did res pond to his role as the night caregiver and quickly managed to reass ure his son of his parents ' faithfulnes s. In turn, could sleep better and enjoy his mother in a less controlling and anxious way. S emantha had just turned 4 when she was referred by parents on the advice of her day care center. had been attending a university-based center for years but had failed to make any friends and s till 4511 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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as if she had just joined the group. S he s till would not participate in most group activities, des pite her verbal social competence, and appeared s ad and often tearful when her mother dropped her off in the morning. Mother, 36, worked as a half-time s ecretary at the university. S he was born in C hina as the youngest of girls. Her family had immigrated to S outh America she was 12 months old, moving on to North America 5 years later. B oth parents worked long hours in lowjobs, leaving the children to rais e themselves. Mother married at 18 but left this hus band 8 years later, their only child, a boy, now 15, who had severe difficulties . T wo of mother's s is ters were described as highly anxious , and one was treated for depress ion. Mother had remarried and was 5 months' pregnant at time of referral. F ather was a 35-year-old s ales man who came from a Italian family. He had two younger siblings, had always enjoyed life, and knew of no ps ychiatric family P.3405 S emantha was born after a normal pregnancy and Mother took 9 months off work and spent all of her time with the baby, as s he seemed to need much attention. example, from 6 to 9 months , she would cry if her did not look at her at all times and could not be from her mother for even s hort periods . S he als o the bed with her parents until last year. However, even the time of referral, she woke up every night at around AM and demanded to come into her parents ' bed. T hey always gave in. Mother, who des cribed hers elf as a s hy 4512 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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cautious woman, did not let S emantha play in the yard did not introduce her to other children until s he placed in the day care center when she had to return to work. S emantha found this placement very hard. S he cried to 2 hours whenever her mother left her there, for 12 to weeks. At the time of referral, S emantha was able to with only one child at a time but spent s ignificant on the laps of two favorite caretakers, seemingly afraid join the others in their play. S emantha came with both her parents to the initial interview. During the first 90 minutes , s he s at on her mother's lap facing her body, burrowing her face into mother's breasts and placing both of her hands and into her s leeves . S he never looked at the interviewers any of the toys that had been provided for her. Her seemed calm and relaxed about S emantha's behavior, whereas her father indicated by ges tures that this was way she was and that he saw this as a problem. he never tried to pick up his daughter or attempted to help her feel more comfortable with the interviewers. Mother als o s tres sed that s hyness was part of her as well as her own pers onality and that it was primarily concern about the arrival of the new baby that caused to seek help at this time. Nevertheless , when the interviewer asked mother to turn S emantha around and gently offered her some wooden animal domino pieces , the girl, after s ome hesitation, picked up a few pieces matched them correctly, showing an ever-so-small After a discus sion that emphasized that the little girl seemed to have a highly anxious disposition and help to develop s trategies to counteract these vulnerabilities , the following was agreed: 4513 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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1. Mother and child would come for weekly play s ess ions, where both would sit on the floor mother would follow any of the girl's leads and pride in any autonomous behavior. 2. B oth parents would have four ses sions to dis cus s relations hip and the needs of S emantha and the baby. 3. T he primary interviewer would arrange a visit to the day care center to meet with S emantha's primary teachers and encourage them to facilitate her autonomy and individuation.

DIS C US S ION T his cas e demonstrates that anxiety-like behavior can identified early in life and als o be addres sed therapeutically. Although one has to keep in mind that some of the behaviors of S emantha could also be prodromal signs of a pervasive developmental her readiness to play a bit of domino s uggests that a change in mother's behavior and the expectations of day care providers would be helpful for her overall development.

FOL LOW-UP S emantha made good us e of the chance to play with mother by engaging her in increasingly complex Mother was able to express her pleas ure in thes e es pecially when the girl mothered a baby doll and was able to tell her about her coming baby brother. Although S emantha remained a child who needed time embrace new challenges, 1 year later, her brother was clearly in awe of her, and s he was a very proud big who wanted to learn how to read. 4514 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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T his s ection s hows that regular exposure to caregivers need not have harmful effects on children's development and their relations hips with others . T he relations hips children develop with their caregivers influence their later behavior and may compensate for, magnify, the effects of the original parentchild T he chapter also emphas izes that the quality of interaction with their family members and the quality of care they receive at home exert the most influence on later development and behavior. Nonparental care, therefore, is most beneficial if it complements the of family care. P s ychiatris ts can play an important role sens itizing both caretakers and family members to the developmental and emotional needs of groups or individual children. T hey can als o use their knowledge about child development to influence lawmakers to provide high-quality nonparental care to all thos e who need it.

S UG G E S TE D C R OS S Normal child development is described in S ection 32.2. S ection 25.12 provides an overview of ps ychiatry. P ublic community ps ychiatry is dis cuss ed in S ection 52.1.

R E F E R E NC E S Ablow J C , Measelle J R , K raemer HC , Harrington R , J , S mider N, Dierker L, C lark V , Dubick B , E ss ex MJ , K upfer DJ : T he MacArthur T hree-C ity Outcome S tudy: evaluating multi-informant of young children's symptomatology. J Am Acad 4515 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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Adoles c P s ychiatry. 1999;38:1580. B ates J E , Marvinney D, K elly T , Dodge K A, B ennett P ettit G S : C hild-care history and kindergarten adjus tment. Dev P s ychol. 1994;30:690. B eaujot R , G ee E M, R ajulton F , R avanera ZR . the L ife C ours e . C urrent De mographic Analys is . C anada: S tatis tics C anada; 1995. B elsky J : Infant daycare: a cause for concern? Ze ro 1986;6:1. *B els ky J : E manuel Miller lecture developmental (s till) as sociated with early child care. J C hild P s ychiatry. 2001;42:845. B elsky J , R ovine MJ : Nonmaternal care in the firs t life and the s ecurity of infant-parent attachment. Dev. 1988;59:929. B orge AIH, Melhuis h E C : A longitudinal s tudy of childhood behavior problems, maternal employment and day care in a rural Norwegian community. Int J B ehav De v. 1995;18:23. B redekamp S , ed. Accreditation C riteria and P rocedure s 'P os ition S tate ment of the National E arly C hildhood P rograms 'A Divis ion of the N ational As s ociation for the E ducation of Y oung C hildre n. Was hington, DC : National As sociation for the of Y oung C hildren; 1987. 4516 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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*B roberg AG , W ess els H, Lamb ME , Hwang C P : effects of day care on the development of cognitive abilities in eight-year olds : a longitudinal study. Dev P s ychol. 1997;33:62. B rooks -G unn J , K lebanov P K , Liaw F , S piker D: E nhancing the development of low-birthweight, premature infants: changes in cognition and over the first three years. C hild Dev. 1993;64:736. C appizano J , Adams G . T he Hours that C hildre n F ive S pend in C hild C are: V ariation acros s S tate s . A As s es s ing the Ne w F e deralis m. W ashington, DC : Urban Ins titute; 2000. C aughy MO, DiP ietro J A, S trobino DM: Day care participation as a protective factor in the cognitive development of low-income children. C hild De v. 1994;65:457. *G ross D, S ambrook A, F ogg L: B ehavior problems among young children in low-income urban day care centers. R es Nurs H ealth. 1999;22:15. Hoffman LW : E ffects of maternal employment in the two-parent family. Am P s ychol. 1989;44:283. Howes C , Hamilton C E , Matheson C C : C hildren's relations hips with peers: differential as sociations as pects of the teacher-child relationship. C hild De v. 1994;65:253. 4517 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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Howes C , Olenick M: F amily and child care toddler compliance. C hild De v. 1986;57:202. Lamb M, S ternberg K : Do we really know how dayaffects children? J Appl De v P s ychol. 1990;11:351. Melhuis h E C , Mooney A, Martin C , Lloyd E : T ype of care at 18 months 'I. Differences in interactional experience. J C hild P s ychol P s ychiatry. *NIC HD E arly C hild C are R esearch Network: T he of infant child care on infant-mother attachment security: res ults of the NIC HD S tudy of E arly C hild C hild De v. 1997;68:860. NIC HD E arly C hild C are R esearch Network: F amilial factors as sociated with the characteris tics of nonmaternal care for infants. J Marriage F am. 1997;59:389. NIC HD E arly C hild C are R esearch Network: E arly care and s elf control, compliance, and problem behavior at twenty-four and thirty-six months . C hild Dev. 1998;69:1145. NIC HD E arly C hild C are R esearch Network: T he relations hip of child care to cognitive and language development. C hild De v. 2000;71:958. *NIC HD E arly C hild C are R esearch Network: Nonmaternal care and family factors in early development: an overview of the NIC HD S tudy of 4518 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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C hild C are. Appl Dev P s ychol. 2001;22:457. P.3406 NIC HD E arly C hild C are R esearch Network: C hildstructure → proces s → outcome: direct and indirect effects of child-care quality on young children's development. P s ychol S ci. 2002;13:199. *NIC HD E arly C hild C are R esearch Network: E arly care and children's development prior to s chool res ults from the NIC HD S tudy of E arly C hild C are. E duc R e c J . 2002;39:133. NIC HD E arly C hild C are R esearch Network: S ocial functioning in first grade: as sociations with earlier home and child care predictors and with current clas sroom experiences. C hild Dev. 2003;74:1639. NIC HD E arly C hild C are R esearch Network: Are developmental outcomes related to before and afterschool care arrangements ? R es ults from the NIC HD study of early child care. C hild Dev. 2004;75:280. R amey C T : High-ris k children and IQ: altering intergenerational patterns. Inte llige nce . R oggman L, Langlois J , Huggs-T ait L, R ies erInfant day-care, attachment, and the file drawer problem. C hild De v. 1994;65:1429. R oopnarine J L, Lamb ME : P eer and parent-child 4519 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/49.1.htm

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interaction before and after enrollment in nurs ery school. J Appl De v P s ychol. 1980;1:77. U.S . B ureau of the C ensus . S tatis tical Abs tract of Unite d S tates . 119th ed. W as hington, DC : U.S . G overnment P rinting Office; 1999. *V an Horn ML, Newell W : C os ts and benefits of child care. Am P s ychol. 1999;54:142.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > 50 - Adulthood

50 Adulthood C alvin A. C olarus s o M.D. Deve lopme nt has been defined as the emergence of mental s tructure and functions and resulting behavior are the res ult of exchanges among the organis m, the as it exists at any point in the life cycle, and the environment. T he ess ence of this definition is that development in adulthood, as in childhood, is always res ult of the interaction among body, mind, and environment, never exclus ively the result of any one of three variables. F or mos t of the his tory of developmental ps ychology, predominant theory held that development ended with childhood and adolescence. Adults were considered to finis hed products in whom the ultimate developmental states had been reached. B eyond adolescence, the developmental point of view was relevant only insofar succes s or failure to reach adult levels or to maintain determined the maturity or immaturity of the adult personality. In contradistinction were the long-recognized ideas that adult experiences , s uch as pregnancy, marriage, parenthood, and aging, had an obvious and s ignificant impact on mental proces ses and experience in the years . T his view of adulthood s uggests that the patient, 4521 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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any age, is s till in the process of ongoing development, oppos ed to merely being in pos ses sion of a past that influences current mental process es and largely determines behavior. Although the debate continues , idea that development continues throughout life is increasingly accepted and is the theoretical basis of chapter. 

B IOLOG Y AND AG ING IN T HE DE V E LOP ME NT

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C ONC E P T UALIZING DE V E LOP ME NT IN

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P IONE E R ADULT DE V E LOP ME NT ALIS T S

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C ONT E MP OR AR Y ADULT

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Y OUNG ADULT HOOD (20 T O 40 Y E AR S OF

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MIDDLE ADULT HOOD (40 T O 60 Y E AR S OF

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MIDLIF E T R ANS IT ION AND C R IS IS

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LAT E ADULT HOOD (60 Y E AR S OF AG E AND

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T HE F IF T H INDIV IDUAT ION

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ADULT DE V E LOP ME NT AL DIAG NOS T IC

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WIS DOM, MAT UR IT Y , AND F ULF ILLME NT

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S UG G E S T E D C R OS S -R E F E R E NC E S

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > B IOL OG Y AND AG ING IN T HE

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P art of "50 - Adulthood" If the view is accepted that s ignificant intraps ychic does occur in adulthood, including late adulthood, two prominent iss ues of controversy, the relative influence biological vers us ps ychological factors in the adult and the place of biological aging and los s as s timuli to development, must still be addres sed. T he ris e of biological psychiatry has led s ome to an unsophis ticated adherence to biological or variables as caus ative agents in normal development ps ychopathology. Increasingly, scholars of both are attempting an integration, evolving a new dis cipline that attempts to develop an effective interaction the behavioral and biological sciences , with cognitive ps ychology, developmental theory, and ps ychological approaches to treatment on the one hand and cell and molecular neurobiology and ps ychopharmacology on other. S igmund F reud would have relis hed this effort. As early 1912, he recognized the importance of both s ets of etiological factors and as sumed that they regularly together in affecting human thought and behavior. He looked forward to the day when res earch would unders tanding of the biological influences on mental What of the effect of aging, that is , phys ical regress ion'clearly, the dominant biological factor in adulthood'on the mind and intrapsychic proces ses? adult developmental school of thought sugges ts that aging process is as powerful an influence on the adult mind as growth is on the mind of the child and T he oppos ing view holds that the maturational pull is 4523 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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present in adult life in the s ame way that it is in and that the s tructural changes that do occur in are mostly related to adaptation and reorganization of exis ting mental structures , but not the formation of new ones. C ommon ground between the two viewpoints may be found in the idea that the awarenes s of the adult experience of aging and the preoccupation with time limitation and personal death that accompanies it are increasingly powerful cons cious and uncons cious intraps ychic preoccupations that grow in intens ity as adulthood progress es . T hey s timulate the psyche to levels of complexity and produce great change in ps ychic s tructure. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > C ONC E P T U AL IZING DE V E LOP ME NT IN

C ONC E PTUAL IZING DE VE L OPME NT IN ADUL THOOD P art of "50 - Adulthood" C hild development is organized around the familiar development s tages: oral, anal, oedipal, latency, and adoles cence. However, the use of s tages to describe development in adulthood presents some conceptual problems . F or ins tance, in E rik E riks on's divis ion of adulthood into 20-year blocks , each adult phase is as as all five childhood phas es together. F urthermore, in 4524 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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adulthood, most developmental themes do not appear with the chronological precision or the phas e s pecificity that they do in childhood. F or example, the experience biological fatherhood can occur at any age from 13 to years of age, and the intrapsychic effects vary depending on the phas e of development in which parenthood occurs . In attempts to encompas s thes e differences, new theoretical models are beginning to appear. S ome theoreticians have taken E rikson's divisions and them into subphases defined by false as sumptions or alternating intervals of stability and transition. Others abandoned stage theory altogether, replacing it with a theory of developmental proces s based on human relations hips . T here, developmental interactions throughout the life cycle are conceived as resulting in formation of s ucces sively higher levels of mental organization. At present, the mos t effective way to present adult developmental theory may be to use the concept of de ve lopmental tas ks ' the ps ychological respons e to life experiences (s uch as work, parenthood, grandparenthood, death of loved ones, and retirement) that produce intrapsychic change as the result of actual occurrence or psychological cons ideration by all in a particular age group. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > P IONE E R ADULT DE V E LOP ME NT AL

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DE VE L OPME NTAL IS TS P art of "50 - Adulthood" T he scientific study of adulthood is ess entially a phenomenon of the 20th century, stimulated by the writings of four men (T able 50-1). In P.3566 1908, Arnold V an G ennep (1873 to 1957), a cultural anthropologis t, described the importance and meaning the universal rituals that s urround events such as pregnancy, childbirth, menarche, betrothal, and death. rituals are ceremonies whose es sential purpos e is to enable individuals to pas s from one stage in life to

Table 50-1 Developmental Theoretic ians Pioneers

C ontemporaries

E rik E rikson (1902–1994)

C alvin C olaruss o

S igmund F reud (1856–1957)

Daniel Levins on

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C arl J ung (1875–1961)

R obert Nemiroff

Arnold V an G ennep (1873– 1957)

B ernice Neugarten

 

G eorge V aillant

F reud (1856 to 1937) formulated the first modern child development. Intrins ic to the predictable developmental progress ions were bas ic regress ions, and advances . E ss ential to F reud's theory development is the idea that the mind changes as a result of the ongoing interaction among mind, and environment. T he pioneer who focused primarily on the adult years C arl G us tav J ung (1875 to 1961). He described a proces s of phys ical and ps ychological s eparation from parents during the 20s and 30s and viewed 40 years of as a time of s ignificant ps ychological change, growth, transition. J ung saw the archetypes pue r (young) and (old) as fundamental polarities that stimulated modern adult developmentalis ts. T he fourth major pioneer, E rikson (1902 to 1994), the first integrated ps ychos ocial view of individual development through eight s tages from birth to death. him, development lies not in s tability per s e, but in the changes necess ary to trans cend s ucces sive conflicts, and s tates of dis equilibrium. C urrent-day 4527 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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developmentalists owe a profound debt to E rikson. E rikson's theory has recently been us ed to examine the developmental and s exual is sues facing s eropos itive men with particular reference to the polarities of identity versus role confusion and intimacy versus isolation. inves tigators , s tudying the adult development of have found that women do not conform to the as pect of E rikson's s tage model, because, in W es tern society, they tend to be more relations hip oriented. intimacy may occur as a dominant theme earlier in development. In addition, identity and intimacy are conceptualized as concurrent process es for men and women. T he unfolding of one leads to the further delineation of the other and affects the related self and other, masculine and feminine, and agency communion. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > C ONT E MP OR AR Y ADULT

C ONTE MPOR AR Y ADUL T DE VE L OPME NTAL IS TS P art of "50 - Adulthood" A comprehensive understanding of adult development beginning to emerge from s tudies conducted since the 1970s . T he study of childhood preceded the s tudy of adulthood becaus e of social and psychological factors such as the s pread of compulsory education and discovery of the influence of childhood experiences on adult psychopathology. T he recent shift of interes t to 4528 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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adult years builds on this knowledge and may be owing the increased life s pan and the need to understand and accommodate the rapidly growing number of middleaged and elderly individuals. Among the most current theoreticians are the following. Daniel Levins on and his as sociates devis ed a theory of male development that proposes a life cycle cons isting of distinctive, identifiable eras of 20 years extending from birth to death. W ithin these are alternating periods of 6 to 7 years of s tability by 4- to 5-year intervals of transition, each with its own tas ks to be mas tered. T hese concepts are clinically because many patients , particularly the healthier ones , tend to pres ent thems elves during periods of transition when internal and external conflicts are increas ed. Levinson's theory is currently being us ed as a for the s tudy of various groups . Application of his of developmental periods to the exis ting data on older men indicates that the s tereotype of lonely, depres sed, sexually frustrated, aging gay men may not be a valid picture of the cohort. G ender-oriented res earch has begun to question adult transitions are the s ame for men and women. Levinson's alternating intervals of s table s tructure and transition have been used to delineate the and transitional periods experienced by Army officers preadulthood to midlife. T he study examined the of living and working within a highly ordered, organizational s tructure, such as the military, on the which thes e adult lives unfold. Levins on's outline of phases was found to be useful in understanding intellectual and emotional life within a career military 4529 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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setting. T he impact of regimentation and a clearly delineated future for young adulthood and midlife to mute the distinctions between periods of transition stable s tructure. T he effect of a military career on and late adulthood postmilitary life remains a fertile for investigation. T he Harvard G rant S tudy has followed longitudinally life cours e of 268 undergraduate s tudents from 1939 to the present. T he current director, G eorge V aillant, has these data to s tudy adaptation in adulthood, particularly ego mechanisms of defens e. Illus trating the developmental nature of intrapsychic process es in the adult, V aillant demonstrated that the ps ychologically healthier members of the research sample used defens es , s uch as suppress ion, altruis m, sublimation, anticipation, and humor, more frequently in midlife than late adolescence and young adulthood, thus illus trating the effect of ongoing, dynamic developmental In agreement with all other major dynamic theories , V aillant found conflict to be an integral, ines capable of normal development. More recently, because the subjects of the G rant S tudy now in the developmental phas e of late adulthood, V aillant has used a modified version of E rikson's s tage model to organize the proces s of ps ychos ocial in the latter third of life, focus ing on the E riks onian generativity and integrity by rating longitudinal case histories of the G rant S tudy s ubjects. S uccess or engage and to mas ter thes e developmental themes clos ely correlated with patterns established earlier in development in this s elect group of men who were originally chos en for their emotional and phys ical 4530 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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and who have now been followed for more than half a century (18 to 65 years of age). T hrough the study of adults in nonclinical s ettings , Neugarten and her colleagues have emphas ized the ps ychological importance of an increased awarenes s aging and the pers onalization of death, as express ed in body monitoring and a tendency to view time in terms time left to live, rather than time s ince birth. Middleadults develop a sense of competence that was earlier in life and have a unique pers pective on the younger and older generations . As middle age people become more intros pective and develop an increased sens e of interiority. On the basis of their experience as clinicians and ps ychoanalys ts, C alvin C olaruss o and R obert Nemiroff propos e a broad theoretical foundation for adult development (T able 50-2) by s uggesting that the developmental process is bas ically the s ame in the in the child, because, like the child, the adult is always the mids t of an ongoing dynamic process , continually influenced by a constantly changing environment, and mind. Whereas child development focuses on the formation of ps ychic s tructure, adult P.3567 development is concerned with the continuing evolution of existing psychic structure and with its us e. Although fundamental iss ues of childhood continue in altered as central as pects of adult life, attempts to explain all behavior and pathology in terms of the experiences of childhood are considered reductionistic. T he adult past must be taken into account in unders tanding adult 4531 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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behavior in the s ame way that the childhood past is cons idered. T he aging body is understood to have a profound influence on ps ychological development in adulthood, as is the growing midlife recognition and acceptance of the finitenes s of time and the inevitability personal death.

Table 50-2 Hypothes es about Development in Adulthood Development is a lifelong, dynamic process that basically the s ame in childhood and adulthood. themes from childhood continue to affect ps ychic development in adulthood, but adult functioning and s ymptomatology are an amalgam of and adult experiences. R ecognition and of the finiteness of time and the inevitability of personal death are major psychic organizers in adulthood, in the promotion of normal and the formation of s ymptomatology.

E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > Y O UNG ADULT HOO D (20 T O 40 Y E AR S O F

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P art of "50 - Adulthood"

S hift from B iologic al G rowth to T he shift from physical progres sion to retrogres sion, growth to aging, occurs in young adulthood. T his obvious and developmentally s ignificant event has scarcely been address ed in the literature on adulthood. T he effect of biological maturation on mental evolution has been extens ively described in the developmental theory of childhood. F or instance, F reud described the libidinal progres sion from erogenous zone to zone and built his conceptualization of oral, anal, latency, and adoles cent s tates on this biologically determined sequence. T here is no interval between the end of maturational progres sion and the beginning of aging. T he two during the young adult years , but aging gradually growth as the dominant biological influence. E vidence this s hift includes s lowing of reflexes, los s of skin tone, early signs of balding (in s ome during the 20s ), and the more dramatic los s of the procreative function in in the late 30s and 40s.

Trans ition from A doles c enc e to A dulthood T he transition from adoles cence to young adulthood is characterized by real and intrapsychic s eparation from family of origin and the engagement of new, phas especific tasks (T able 50-3). V arious authors have this process as the shedding of family dependencies to become a member of society at large, the shift from 4533 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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preadoles cent idealized parental images to idealized ethics and values , and the gradual shift from family of origin to the family of procreation.

Table 50-3 Development Tas ks of Young Adulthood T o develop a young-adult sense of s elf and other: the third individuation T o develop adult friendships T o develop the capacity for intimacy; to become a spous e T o become a biological and ps ychological parent T o develop a relationship of mutuality and with parents while facilitating their midlife development T o establish an adult work identity T o develop adult forms of play T o integrate new attitudes toward time

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T he B erkeley G uidance and the Oakland G rowth are long-term investigations of normal development were begun in 1929 and 1932, res pectively. T hey that ps ychological adjus tment in adulthood is not easily predicted from adjustment during adoles cence. T his important obs ervation s upports the idea that conflicts in adulthood can lead to the reworking of pas t is sues with better resolutions or to the ons et of new forms of pathology. T he same idea is incorporated in Levinson's characterization of transitions, intervals of change and turmoil that occur between periods of relative stability. T he transition from late adolescence to young occurs between 17 and 22 years of age. During these the individual res olves the is sue of childhood enough to establish self-reliance and begins to new, young-adult goals that eventually res ult in new life structures that promote stability and continuity. Another important intraps ychic as pect of the transition redefinition of the childhood and adoles cent past. F or first time, an entire phas e of life is consigned to the T his gradual, painful proces s brings clos ure to an life and forces redefinition of as pects of psychic particularly the s uperego and ego ideal.

Developmental Tas ks of Young A dulthood Developing a Young-Adult S ens e of S elf and Other: The Third E stablishing a s elf that is separate from parents is a tas k of young adulthood. F or most individuals , the 4535 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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emotional detachment from parents that takes place in adoles cence and young adulthood is followed by a new inner definition of themselves as comfortably alone and competent, able to care for thems elves in the real and intraps ychic worlds. T his s hift away from the parents continues long after marriage, and parenthood results the formation of new relations hips that replace the progenitors as the most important individuals in the young adult's life. P sychological separation from the parents is followed synthes is of mental representations from the childhood past and the young-adult pres ent. F or ins tance, as their children grow, young parents reengage memories of own childhoods and fuse their experiences as parents memories of their own progenitors from a generation T he separation-individuation process in infancy is res ponsible for establis hing a stable sense of s elf and capacity to relate to others. T he ps ychological from parents in adoles cence has been called the individuation, and the continued elaboration of thes e themes in young adulthood has been called the third individuation. T he continuous proces s of elaboration of and differentiation from other that occurs in the developmental phas es of young (20 to 40 years of age) and middle (40 to 60 years of age) adulthood is by all important adult relations hips. At its core are ties children, spous e, and parents (i.e., the family), the ps ychological constellation that s haped the first and second individuations . Adult developmental theory postulates a growing complexity in relations hips as the individual moves developmental phas e to developmental phas e. T he 4536 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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individuation is a rather exclusive affair among infant, mother, and father. During the second individuation, relations hips expand to include important nonfamilial relations hips , s uch as friends and mentors. T he from the s econd to the third individuation is a youngexperience, s timulated by growing intrapsychic from the parents and the loneliness that follows in its wake. S ooner or later, mos t young adults attempt to fill real and intrapsychic voids left by s eparation from the parents of childhood by establishing a family of procreation. Other aspects of the P.3568 third individuation deal with the developmental tasks of intimacy and parenthood.

Developing Adult Friends hips F reud described friendship as an expres sion of libido, stemming from the s ame source as sexual love that sexual union as its aim. In the relations hip between the sexes, the impuls es force their way toward s exual but, in other circums tances , they are diverted from this or are prevented from reaching it, although always preserving enough of their original nature to keep their identity recognizable. However, human relationships , including friendships, are als o based on aggress ion. character of friendship is determined by the aimexpres sion of the aggres sion, not by its absence. Using a ps ychodynamic framework, friendship may be defined as an extrafamilial object relations hip bas ed on mutuality, equality, and freedom of choice, in which the expres sion of s exual and aggress ive impulses is 4537 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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predominantly aim inhibited. However, becaus e of the power of emotion, friends can be transformed into or enemies and s ometimes back again into friends. tendency toward fluidity is common in childhood, the maintenance of a stable state of friends hip over an extended period of time is more characteristic of adulthood. F rom the latency period onward, friends hips are an integral part of human experience, a vital form of relations hips . At each s ubs equent developmental including adolescence and young adulthood, the character and s ubs tance of healthy friendships are determined in part by the mutual need to engage and res olve major phase-specific developmental tasks. At times, developmental pres sures strain the capacity friends hip to the limit. In early adoles cence, in the strength of the drives vis -á-vis the ego often breaks down aim inhibition, as observed in homosexual and heteros exual experimentation between peers. generally s peaking, at no other time in life do play such a prominent role in the developmental In adoles cence, they facilitate the engagement and res olution of developmental tas ks , s uch as separation parents and beginning integration of adult s exual and work identities . In late adoles cence and young adulthood, before and parenthood, friends hips are often the primary of emotional sus tenance. In the years between the of origin and the family of procreation, the young adult little opportunity to gratify impuls es within a committed relations hip and experiences the lonelines s of young adulthood. R oommates , apartment mates, s orority 4538 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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and fraternity brothers, as indicated by the names used describe them, are s ubs titutes for parents and s iblings, temporary stand-ins until more permanent are found. T he emotional needs for clos eness and confidentiality largely met by friendships . All major developmental are dis cuss ed with friends, particularly thos e in s imilar circums tances . As marriages occur and children are the central emotional importance of friends hips diminis hes . S ome friendships are abandoned at this because the spouse objects to the friend, recognizing some level that they are competitors. G radually, there movement toward a new form of friends hip, couples friends hips. T hey reflect the newly committed status are more difficult to form and to maintain, because four individuals must be compatible, not jus t two. As children begin to move out of the family into the community, parents follow. Dance clas ses and Little League games provide the progenitors with a new and the opportunity to make friends with others who at the s ame point developmentally and who are to the formation of relations hips that help explain, and cushion, the pres sures of young-adult life.

Developing the C apac ity for B ec oming a S pous e E rikson defined the major developmental dichotomy of young adulthood as intimacy versus s tagnation. includes the capacity to experience others ' needs and concerns as being as important as one's own. T he be intimate has its origins in the early parent–child relations hips , the s ucces sful res olution of the oedipal 4539 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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complex, and adolescent s exual experimentation. However, it does not become a s us tainable capacity young adulthood, apparent in the highes t-functioning individuals by the fourth post–high s chool year. T he developmental s hift from s exual experimentation the des ire for intimacy is experienced in young as an intens e lonelines s, res ulting from the awarenes s an abs ence of committed love similar to that in childhood with the parents. B rief sexual encounters short-lived relationships no longer s ignificantly boost es teem. Having mastered the mechanics of capable performance, mere repetition no longer provides emotional satis faction. Increasingly, the desire is for emotional involvement in a s exual context. T he young adult who fails to develop the capacity for intimate relations hips runs the risk of living in isolation and s elfabsorption in midlife. S ignificant intrapsychic change occurs when intimacy achieved. T hrough the repeated fus ion of sex and love, self is increas ingly linked to the partner. As s exual thoughts, feelings, and practices are repeated in the loved one, the superego becomes more tolerant flexible. S exual identity is refined as feminine or as pects of the s elf are projected onto, and accepted loved in, the partner. T he ego ideal is altered by of the partner's goals for the couple's future, regard to such young-adult iss ues as the desire for and career ambitions. T he development of the capacity for intimacy the acceptance of the equal status and complementary nature of the male and female genitals . R epeated experiences with foreplay, intercours e, conception, 4540 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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pregnancy, childbirth, and psychological parenthood provide the optimal environment in which to abandon infantile notions of phallic s uperiority and to replace with the recognition that female and male genitalia are equal and interdependent for sexual pleas ure, and reproduction. F or mos t individuals in W estern culture, the experience intimacy increases the desire for marriage. Longitudinal developmental s tudies indicate that no single variable predicts mental health as clearly as the capacity to happily married over time.

B ec oming a B iologic al and Ps yc hologic al Parent Although biological parenthood is not limited to young adulthood, it is experienced by mos t individuals for the first time during this phase of development. of the developmental line of sexual identity during childhood places parenthood in a developmental During the first 18 months of life, a bas ic sens e of or femaleness called the core ge nde r ide ntity is B y 3 years of age, children become aware that there two s exes ; then, during the oedipal phase, s exuality is explored within relationships . During latency, s ubjective family, community, and cultural attitudes about masculinity and femininity are integrated. During adoles cence, the maturational changes of puberty stimulate interest in the us e of the adult body as a instrument, first with the s elf, then with others. T hen, in young adulthood, the developmental experiences of intimacy and parenthood are added. B iological parenthood initiates the process of 4541 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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ps ychological parenthood, the mental state in which healthy young adults become increas ingly attached to involved with their children. F or both parents-to-be, pregnancy adds a new dimens ion to sexual identity by confirming that their sexual apparatus can perform the primary function for which they were intended. After each interaction with the P.3569 infant enhances the heightened s ense of s exual completenes s and s timulates the des ire to lovingly the baby who is s o s trongly identified with the s elf. young couple becomes parents for the first time, a created. Its s tructure is identical to the family of origin except for the reversal of roles. As the former children, the parents, minister to their creation, they undergo profound intraps ychic change as a result of the simultaneous reexamination of their own experiences children and the growing sens e of themselves as P arenthood intensifies the relationship between the parents . T hrough their phys ical and emotional union, couple has produced a fragile, dependent being who needs them in the interlocking roles of father and T his recognition expands their internal images of each other to include thoughts and feelings emanating from the role of parent. T he s uperego and ego ideal are expanded, and, as they live together as a family, the relations hip to each other changes. T hey become relating to one another and to their children. B ecoming a parent als o s timulates further individuation from the members of the family of origin. As suming the roles that were formerly the exclus ive prerogative of 4542 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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progenitors , the new parents develop parity. cons tant conscious and unconscious comparisons of rearing practices heighten an internal sense of while paradoxically reinforcing connectedness and continuity between the generations . F inally, the ability to be instrumental in the midlife development of one's parents by providing them with experience of grandparenthood is s triking evidence of shift in the power balance between the generations, foreshadowing the not-too-distant future when the parents may become dependent on their children for phys ical and psychological well-being.

S eparating Ps yc hologic ally from Parents and Developing a with Them of Mutuality and E quality While Fac ilitating Their Midlife Development R eal and intraps ychic relations hips with parents dramatic changes during young adulthood. T his experience may be divided into three phas es that build one another.

P HA S E I P sychological separation from parents continues . Not as pects of the first and s econd individuations are by the end of adolescence. B oth, but particularly the recent second individuation, continue to be engaged during young adulthood. T he ability to function independently of parents , without using them as a source of comfort, security, and direction, comes to during the young-adult years. 4543 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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B uilding on the developmental achievements of adoles cence, this process is greatly facilitated by and parenthood. As the s pouse is internalized as a significant partner, and children as sume roles of intraps ychic importance, the power of earlier parental introjects is gradually diminis hed. T hese childhood memories and images are further trans formed by their fus ion with current repres entations of the s pouse and self in conjunction with the functions of both as lover parent. E very young adult brings from childhood a detailed plan (largely unconscious, but firmly institutionalized in the s uperego and ego ideal) of how husband or wife and parent s hould act. T hese idealized expectations must be modified by current reality if they are to be adaptive.

P HA S E II Once the roles of s pous e, parent, and provider have as sumed, the s tage is set for the establishment of an sens e of equality and mutuality with parents . T his as young adults marry, become parents , work, develop adult friendships , and become part of a community. As these adult experiences become the s ubs tance of everyday life, they trans form the intrapsychic with parents of childhood from one of dependency and need to one of mutuality and equality. However, parents remain important as long as they because only parents and children place one in the of a genetic continuity that s pans three generations. As middle age approaches, with its preoccupation with limitation and personal death, the intrapsychic of this genetic immortality increases . 4544 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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P HA S E III E quality and mutuality with parents may continue for many years or may be s hort lived, depending on the mental and phys ical health of the parents. At s ome the adult child is confronted with the ps ychological and, poss ibly, phys ical tas k of caring for vulnerable, parents who no longer function independently. W hen occurs, the memories from childhood of the dependent, immature self and the aging parent of the pres ent stimulate the child to reenter the parent–child dyad, revers ed, and ass ume the role of caretaker. S imultaneous ly, through their interactions, living and grandparents provide examples of how the developmental tasks of middle and late adulthood may engaged. As the young adult parents and their children internalize thes e examples, the foundation is laid for interactions in the years to come when their roles will revers ed. Longitudinal studies that have traced pers onality development through childhood and into adulthood indicate that the adult personalities of children closely res emble thos e of one or both parents . T his s imilarity be attributed not only to the earlier adult–child interaction, but also to their continuing relations hips as adult to adult. B oth parents have an effect, not just the parent of the same sex. In fact, identification with the parent of the oppos ite sex tends to increas e in young adulthood, because heterosexual identity is more s ecure, strengthened by marriage and psychological T he young adult is then freer to incorporate valued 4545 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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of the character of the opposite-sex parent, particularly regard to the engagement of the developmental tas ks middle and late adulthood.

E s tablis hing an Adult Work Identity E stablishing a work identity is a critical developmental of young adulthood. When this developmental line is relatively conflict free, there is a smooth progres sion high s chool to on-the-job training or from high s chool to college and graduate school. In most advanced opportunities to change jobs or to acquire further to enhance career advancement remain open the young-adult years. In more clos ed or clas s -oriented societies, such as C hina or the United K ingdom, about career choice are made in adolescence on the of intellectual potential and academic achievement. excluded from the educational track, the individual has little s ubs equent opportunity for formal academic advancement. T he transition from learning and play to work may be gradual or abrupt, but, at some point, us ually in the late teens or 20s, work becomes a central intrapsychic and activity. T hen, the pleasures of play or learning must be subordinated to the temporal and emotional demands job or career. Depending on choice of career and opportunity, work may become a s ource of ongoing frus tration or an activity that enhances self-es teem and gradually leads to a s hift in identity from child to adult from player to worker. A young-adult female patient had greatly enjoyed her 5 years in college and only reluctantly accepted a job 4546 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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large real estate firm. During college, s he had had interes t in her appearance, and she began work in borrowed from family and friends . S he scoffed when boss began to criticize her dress and gave her an to buy an ups cale wardrobe, but s he began to enjoy fine clothing and the res pect engendered by her appearance and position. As her income began to ris e, P.3570 work became a source of pleas ure and s elf-es teem way to acquire some of the trappings of adulthood. Y oung adults, regardles s of career choice, mus t role of mentee and mus t work with mentors to acquire information and s kills necess ary to forge a work T he relationship with the mentor is based on infantile identifications , but this adult proces s is not a the parent–child experience. T he relations hip with the mentor normally goes through three phas es . T he firs t phase, a psychological fusion with the mentor, is by an internalization of aspects of the mentor's ideas attitudes. E ventually, psychological and phys ical separation from the mentor lead to further C linicians who recognize the importance of this critical developmental process are extremely sensitive to the presence (or absence) of material about work and relations hips . In some patients , problems with work be a major symptom, rooted in s ignificant internal in others, work may be the unrecognized source of interference with other developmental themes. A 28-year-old lawyer who worked 80 hours a week did recognize that his social is olation was of his own 4547 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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C hronic fatigue and lack of time were the he us ed to avoid considering more deeply seated avoid sex and intimacy.

Developing Adult Forms of Play In young adulthood, the ability required to perform most of the phys ical games learned in childhood and adoles cence reaches a peak and then declines . Mos t individuals do not realize their childhood fantas ies athletic fame and fortune and mus t realistically their capability and mourn what was not achieved. Aspirations for athletic fame are not easily relinquis hed, however. S ome are maintained through identification sport figures who are now chronological T hese identifications may continue into middle and late adulthood'these are the true fans . F or others, however, new interests and acceptance of the aging proces s the credibility of comparisons between youthful heroes and the middle-aged s elf, until such identifications become imposs ible, which leads to a diminished spectator sports and a s earch for new forms of play. S ome patterns of childhood play continue into the adult years , exis ting s ide by side with new forms of play that reflect the growing importance of spous e and children. T hese range from tennis or jogging with one's partner mental games , s uch as bridge, with friends. the play activities of children is a powerful s ource of narcis sistic gratification for some parents, providing a second chance to realize childhood goals through identification with the s ucces s of sons or daughters . In ps ychotherapeutic s etting, material about childhood is a rich source of information, whos e exploration may 4548 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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to unexpected revelations and ins ight. T he exploration adult play activities may have s imilar benefits . F or example, the failure to moderate physical activity in keeping with the aging proces s in the body may res ult phys ical injury that precipitates anxiety or depress ion expos es conflicts about aging and other young-adult is sues.

Integrating New Attitudes Toward Time TIME S E NS E IN Y OUNG T ime s ense in the 20s rests on ps ychic structures built childhood and adolescence. In the early 20s, of childhood to the past can produce a brief, latencytemporal calm that is built on the res onance between cons cious aspirations and unconscious expectations the realization that the future is long enough to some decis ions, to undo mis takes in career or object choice, and to s tart again, if neces sary. However, by mid-20s, time sense is increasingly influenced by the search for adult s tructure and new objects 'career definitions, friends, lovers , and s pous e and children'to replace the temporal organizers of childhood, mother father. S ubjective time sense in the 30s differs qualitatively that in the 20s, becaus e midlife iss ues emerge and gradually become dominant. F or example, as signs of phys ical aging become more apparent, the of los s is translated into a growing awarenes s of time limitation. T his is particularly true for women, who must confront the approaching loss of procreative 4549 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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function, which affects s ubjective time s ens e in as dramatic a manner as the ons et of puberty did in early adoles cence. T he s o-called 30-something individual also ass es s relations hips and work achievement S ignificant progres s toward establishing the family of procreation to replace the family of origin is expected, work and financial achievement.

R E L A TIONS HIP S R elationships significantly influence s ubjective time in young adulthood. T he relationship to the spous e is of the mos t important intrapsychic organizers of time sens e in adulthood. T his temporal commitment is made the most demanding terms, and, like no other mutually cons ens ual relations hip in life, marriage defines the expectation of how time will be us ed, as well as how it conceptualized consciously and unconsciously. Over a long-lasting, mature love relationship becomes as significant an organizer of time sense in adulthood as relations hip between parent and child was in childhood. However, becoming a biological parent is the quintess ential temporal experience of young adulthood. T he ability to reproduce provides humans with their immortality; through genetic transmis sion, a part of the self will live on after death. B iological parenthood, with the capacity to love and to remain invested in offspring, leads to major ps ychological and more specifically temporal reorganization. F uture s ens e is expanded, and the past is extens ively reworked as the parent conscious ly and unconsciously relives each developmental s tage with the child.

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NOR MA L TE MP OR A L F UNC TIONING THE E ND OF Y OUNG A DUL THOOD In temporal terms, normal functioning implies that, as individuals approach 40 years of age, they have the aging process in the body, have integrated the use time with productivity, have separated psychologically from Mother and F ather T ime, have begun to deal with notion of pers onal death, and have forged new ties with contemporaries and children who give new meaning to the present and future. S o equipped, the young adult approaches middle age ready to engage, to mas ter, integrate the monumental temporal challenges that lie just ahead. One of the most profound influences on development adulthood is the increasingly conflictual awarenes s that personal time is limited and that one will die. T his realization is a source of conflict and ps ychopathology a developmental stimulus that forces a new of the precious nes s of time and a reordering of C oming to terms with time limitations is a central ps ychological task of middle age. Implicit in this is the conviction that temporal awarenes s and management in midlife has a greater impact on development, healthy and pathological, than at any point in the life cycle. P.3571

Female Development A radical change in the theory of female development crys tallized in 1976 when the J ournal of the Ame rican 4551 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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P s ychoanalytic As s ociation devoted an entire to female ps ychology. F emale development was conceptualized as following its own line from birth onward, which differed from F reud's proposal that male and female ps ychic development was identical until the oedipal phas e. F urthermore, penis envy was no longer recognized as a major component of female during the oedipal phas e. T he s upplement was als o noteworthy in extending the consideration of female development into adulthood. Aspirations for a career and motherhood are press ing is sues for women in young adulthood. T he absence of a single, s ocially prescribed role for them provides opportunities for growth and cons iderable turmoil. T herapists are treating increased numbers of disillus ioned young-adult women'and men'who concentrated on their careers and did not marry and children. Accomplis hed in the workplace, they complain lonelines s, depres sion, and isolation. T he loss of women's ability to have children in their 30s and 40s is the most striking developmental difference between the sexes in young adulthood, and it affects almos t every other developmental line. A childless , 38-year-old, divorced lawyer s ought for herself and her live-in boyfriend of 2 years. S he was anxious to marry and to have children, but he was S he had become increasingly depres sed over the past several years , as her awarenes s that the pas sage of was diminis hing her chances to have children After several months of therapy, the boyfriend decided leave the relationship. 4552 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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Developmental theory sugges ts that psychopathology res ults from the failure to engage and to mas ter major developmental tasks during the phase in which they central themes. T his remains true throughout the life An awarenes s of the basic biological and psychological forces that underlie normal young-adult development provide individuals and clinicians with the knowledge needed to prevent such young-adult psychopathology.

Trans itional C onflic ts Y oung adulthood spans a generation. W ithin these boys become men as they struggle with the powerful is sues of intimacy, autonomy, work, and parenthood. following clinical material from the childhood and adult treatment of one young man illus trates many of the developmental themes and conflicts of young J im was 9 years of age when his parents brought him evaluation because of temper tantrums, difficulty friends , and a dis gruntled attitude at home and in E valuation revealed a bright, intact youngs ter, and a recommendation for treatment was made. During 3 of therapy, analys t and patient were able to work inon J im's infantile s exual iss ues , his difficulty with peers , and his aggres sive feelings and fantasies about his whom J im experienced as distant, demanding, and ungiving. J im terminated his treatment just before his 12th Although his analys t had thought of him many times in intervening years , there was no direct contact until he called the analyst, 13 years later, when he was 25 age. G reeting him in the waiting room was s omewhat 4553 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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shock, because the analys t half expected to see the preadoles cent boy that he had come to know so well. his place was a s lightly built young man more than 6 tall. T he analyst was s truck by the s ens e of warmth and familiarity that was instantly present. J im seemed comforted and reas sured by the familiar s etting and to tell the analyst, without delay, about his concerns. wanted to be a profes sional golfer but was concerned about the financial uncertainty of s uch a venture. He graduated from college 2 years before and was living home, working at odd jobs, and dealing with his diss atis faction with the lack of direction in his life. J im informed the analys t that adolescence had been a good time. He went through puberty eas ily, had many friends , was active in s ports , and did well academically. always difficult relationship with his father improved during adoles cence becaus e of his academic and succes s, but they were never close becaus e of the continued emotional dis tance. J im dated regularly throughout high school and college and had for the firs t time at the end of tenth grade. He did not a girlfriend at pres ent and was bitter about women. Occasional casual contacts s atisfied his sexual needs , for reas ons that were not clear, he doubted that he ever find a wife. T oward the end of the firs t sess ion, J im volunteered he smoked “a lot” of pot. “It makes me happy with the status quo,” he said. If he were the analyst, he he would tell him to s top smoking pot and to give up alcohol, which he us ed s everal times per week. After a diagnostic s es sions , the analyst conveyed his concern 4554 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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about the s ignificance of J im's drug us e and offered various ways to addres s it, including a return to J im decided to stop on his own and as ked if the analys t would agree to s ee him two or three times per month. didn't want to rely on his father financially, and all he needed was a chance to s ort a few things out in and he would be on his way. As their work together began, J im complained about a boring job as a clerk that he had taken as a last res ort. G radually, he began to abandon his plans for a career golf pro and began to mention becoming an elementary school teacher. W hen the analys t s upported this he found a volunteer position as an aide in an school. As he began to enjoy this activity, he decided seek a teaching credential. During these months , he not drinking or s moking, s till coexisting at home with diss atis fied and concerned parents , and, although openly about his sexual interests , dating little. Once J im decided to take the year of full-time s tudy required to obtain the teaching credential, his selfimproved noticeably. He used his own money from his to pay for the tuition but s till needed help from his parents . W hen s chool went well, he asked a woman at work for a date. T hey dated briefly but then he s aid, dumped me.” J im's eyes lit up as he talked about s chool. He was well academically and had cut back on his work week allow more time for study. He was apprehensive about prospects for finding a teaching job when he finished school. He noted that his sales job was more tolerable now, becaus e he had a goal and could s ee the finish As J im made obvious progress toward a career goal, 4555 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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friends hip with his father improved noticeably. G radually, J im turned the attention of therapy to He complained that, although he was dating and sex, there was no emotional satis faction in the relations hips . B uilding a relations hip should not be s o difficult. He complained that hones ty was a tough thing find in a woman. W hen the therapist inquired what he meant by honesty, he replied, “S omeone who lets me know how she feels about me. W ho does n't make S ometimes I feel like I'm the only person out there my who tries to be respons ible.” Here was the emergence the young-adult need for a loving and caring with a woman. T his desire s tood in sharp contrast with J im's opening statement when he returned to treatment that he never expected to marry. J im received his teaching credential but could not find permanent job, s o he began to teach as a s ubs titute. moved into a condo that his P.3572 parents owned, paid a reasonable rent, and enjoyed newly found freedom. After several months, he took a short vacation and proudly announced that it was the one that he had taken and paid for as a working man. mid-sentence he switched topics and s aid, “I've got my on this girl. S he's perfect, aged 23.” When I asked word perfect, he laughed. “Well, great for s ex, but I what you were getting at. F or getting married, too.” He could see hims elf getting married, but not before he steady job and money in the bank. Work on J im's relationship with his father continued. He stated, “I think the only s olution to that problem is time 4556 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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and s ucces s. Once I've made it, and I'm completely independent, he won't have any control over me. He'll probably relax when I don't need anything from him anymore, but I don't think we'll ever be real clos e.” C hanging the subject, he mentioned that he had just obtained car insurance. “I gues s that's another s ign of growing up, isn't it? ” He ended the sess ion with a statement on his current situation: “I'm as happy as I've ever been. I'm moving forward.” E ventually, J im got a permanent teaching job and to serious ly date a teacher in his school. He decided he no longer needed to see his analyst but asked that analyst keep the door open for the day when he was to get married and have a family. He thought that a up” might be a good idea at that time. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > MIDDLE ADULT HO OD (40 T O 60 Y E AR S OF

MIDDL E ADUL THOOD (40 60 YE AR S OF AGE ) P art of "50 - Adulthood" C oncepts of time, aging, and death are the currency of midlife development. C ons equently, therapeutic can no longer focus entirely on the past. It must als o include current reality and the s truggle to adapt to everchanging time, becaus e these is sues are at the core of unders tanding and treating individuals between 40 and years of age. Despite growing awarenes s of aging and death, the middle years are the best time in life for 4557 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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Middle adulthood is the golden age of adulthood, to the latency years in childhood, but much longer. P hysical health, emotional maturity, competence and power in the work s ituation, and gratifying relations hips with spous e, children, parents, friends, and colleagues contribute to a normative sense of s atis faction and being.

Trans ition from Y oung to Middle A dulthood T he transition from young adulthood to middle is slow and gradual, with no sharp phys ical or ps ychological demarcation. T he aging proces s picks up speed and becomes a powerful organizing influence on intraps ychic life, but the change is gradual, unlike adoles cence. Mental change is experienced in a similar fas hion, s low and imperceptible, without a sense of disruption. Development in young adulthood is embedded in clos e relations hips . Intimacy, love, and commitment are to the mas tery of the relations hips most immediate to personal experience. T he transition from young to middle age includes widening concern for the larger social s ys tem and differentiation of one's own s ocial, political, and historical s ys tem from others . Authors described middle adulthood in terms of generativity, actualization, and wisdom.

Developmental Tas ks Integrating the Potential for Attac hment and L os s : The Fourth 4558 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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Individuation T he fourth individuation refers to the elaboration of separation-individuation process es in middle adulthood (40 to 60 years of age). One of the mos t powerful influences on these proces ses in midlife is the ironic awarenes s that one will die and will be deprived of involvement with loved ones at the very time that a mature understanding of the importance of others for one's health, happines s, and security is at its peak. paradox is particularly poignant in middle adulthood, because fulfillment is based, in no small meas ure, on incredible richness of involvements that grow by leaps bounds between 40 and 60 years of age. Unlike the and s ome of the 30s, when, in the mids t of the third individuation, individuals have left their family of origin and have not yet created a family of procreation, men and women are immers ed in relations hips with spous e, children, elderly parents, in-laws , friends, and colleagues and are forging new ties with new of great pers onal importance, grandchildren. At no point in life is the potential for attachment'and loss 's o great. Accepting this juxtaposition of interdependence with others and the inevitability of total separation and loss is a central developmental tas k of middle that must be engaged and mastered if developmental progres sion is to continue (T able 50-4).

Table 50-4 Development Tas ks of Middle Adulthood 4559 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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T o integrate the potential for attachment and loss : the fourth individuation T o accept the aging body T o accept time limitation and pers onal death: sens e in middle adulthood T o reapprais e relations hips; to let children go, to achieve a relations hip of equality with them, and integrate new members into the family T o accept the reversal of roles with elderly T o develop midlife friendships T o become a generative mentor and to plan for retirement T o give play new meanings and purposes T o become a grandparent

Ac c epting the Aging B ody P hysical decline begins to affect ps ychological development in the 20s and begins to have a effect in the 30s. B y midlife, however, because of the 4560 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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universal awarenes s of aging and the marked increas e major illness es and peer group death that occur then, thoughts and feelings about the aging body become a major, sometimes dominant, influence on mental life. appearance of the midlife body takes on a different significance. E fforts to remain trim and fit are no longer made to develop a s ens e of identity or to s eparate and individuate as they were in young adulthood. T he in midlife is to maintain body integrity in the face of anxieties about aging, failing health, and the potential of independence. Awareness of change in phys ical appearance and function is constant. In addition to in public presentation, such as vis ion, hair color, and tone, more private aspects of phys ical functioning such as ces sation of menstruation, altered s exual functioning, increas ed urinary frequency, and force of the urinary s tream, also occur. T he reaction to these dramatic biological changes cons iderably from individual to individual, as evidenced the res ponses to the menopaus e. F ormerly thought to direct res ult of decreased production of es trogen, more recent studies indicate that emotional lability, irritability, and other somatic and psychological complaints are individual res ponses that are present to varying degrees in a minority of women. Only cess ation mens truation and hot flas hes occur universally, they are the direct res ult of diminis hed es trogen production. T he phys ical changes jus t described are experienced mentally in the form of body monitoring'a continual, cons cious and uncons cious , comparis on of the midlife body with the body of youth. T his painful proces s leads 4561 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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a conflict between wishes to deny the effects P.3573 of aging and the need to accept the loss of a youthful body. T he normative result is mourning for the lost adoles cence and young adulthood. Attempts to deny aging include the inappropriate use of plas tic surgery, fus ion with younger bodies , and exaggerated phys ical competition with younger individuals. T he acquis ition of poss ess ions, such as rare art, expensive automobiles , fine clothing, is also us ed as substitutes for the body. B ecaus e the aging proces s continues for the res t of there is no res olution of this conflict, but, in the healthy individual, the gradual acceptance of aging produces a major change in the body image and increases the pleas ure that the midlife body can provide, particularly is cared for properly.

Ac c epting Time L imitation and Pers onal Death: Time S ens e in Adulthood B ecaus e of the aging process in the body, the death of parents and contemporaries, the growth of children into adulthood, grandparenthood, and the approach of retirement, midlife individuals come face to face with mortality and with the painful, but unavoidable, that the future is limited and that they will die. An extremely powerful ps ychic organizer, acceptance of inevitability of personal death, precipitates of all aspects of pas t and present life and how the time left to live will be used.

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Death Awarenes s F reud observed that humans s how an unmistakable tendency to put death aside and to eliminate it from life. Human ins tincts do not respond to a belief in death, in the timeless nes s of the unconscious , humans are convinced of their immortality. An understanding of a developmental line of time s ens e from childhood and young adulthood helps explain how experience this uncons cious (and conscious) wish and fals e belief immortality and culminates in midlife in a poignant, painful, monumental conflict between irrationality and reason that, more than any other, defines the mature and the es sence of the human condition. C hildhood is characterized by a tendency to deny the inevitability of pers onal death becaus e of the of the psychic apparatus, the forward thrus t of and the limited understanding of the concept of time. Little in the anabolic thrust of the developmental indicates a personal end. T hen, in late adolescence, the loos ening of ties to the parents elicits a s ens e of his tory that the realization that a part of the self and an entire life (childhood) is in the past and irretrievably los t. However, this dawning recognition is quickly defended agains t by the optimis m and idealization of youth, a succes sful attempt to deny the two fundamental of human life'the inevitability of death and the exis tence hate and destructive impuls es inside each pers on. G radually, a more contemplative pes simism replaces youthful belief that the power of s tas is, the status quo, catabolis m can be overcome. W ith youth behind them, 4563 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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normal midlife adults mus t confront their finiteness as defens es agains t the acceptance of time limitation and personal death crumble before the power of new ps ychological, and environmental experiences . T hen, too, parents, friends, and contemporaries die. death of a parent, in particular, undercuts the childhood sens e of unending continuance and s afety that was provided by the good-enough parent. One is left alone, unprotected by the infantile notion of parental omnipotence, with the staggering realization that the must die, just as the parent did. As the older generation disappears from the s cene, the younger generation approaches adulthood. T he transformation of children phys ically and s exually mature adults also shatters the parent's sense of perpetual youth, becaus e with young, immature children is no longer poss ible as they become bigger and s tronger than their T hrough genetic extension and through the proces s of identification of parent, child, and grandchild, middleaged grandparents, for the s econd time in their lives, participate in the creation of new life'the creation of T hrough genetic continuity, children and grandchildren provide the only form of phys ical immortality that exis ts. T he dynamic relationship between grandparents and grandchildren cannot be fully unders tood without comprehending the temporal bonds that define this relations hip. G randchildren draw grandparents toward beginning of life, toward tender years when time its elf seemed to exis t in unlimited s upply, and away from the painful awarenes s of old age, time limitation, and T he realization that time is running out is als o painfully thrust into cons cious nes s by the growing awarenes s 4564 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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many cheris hed ambitions and goals will never be and that there is not enough time left to achieve new of equal importance. F urthermore, a pers onal end is forcefully brought into focus by the loss of power and prestige in the workplace or the realization that the highes t level of achievement pos sible has been P ower belongs to the young, who have the time to new ventures and to bring them to fruition in the distant future. As one patient, a highly s ucces sful profes sional, it: “I've become redundant. T he heirs apparent can do everything I can and a lot that I can't. My time in the spotlight is jus t about over. S oon it will be lights out!”

Time S ens e in Middle-Aged Women P uberty focuses and defines gender differences in temporal attitudes , which continue to expand during the remainder of adolescence and adulthood. W ith the beginning of menstruation, a woman's s ens e of time is influenced by her mens trual period, commonly referred as her monthly or her cycle . Later, in s exual relations, woman is les s cons tricted temporally; s he has no period after climax. P regnancy produces another s exually defined cycle for woman. T his quintes sential ps ychobiological event that spans 9 calendar months is divided into temporal phases'early, middle, and late'and has a clear (intercours e) and end (labor and delivery). In young and middle adulthood, gender differences continue to manifes t thems elves , most notably through the loss of the procreative function in the late 30s and T he running down of the biological clock leads to the of this interval and produces two paradoxical effects on 4565 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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middle-aged time s ens e. T he ces sation of temporal watershed, forcing a mourning reaction to the los s of procreative capacity and its power to time with a s ens e of youthful purpose and productivity and the awes ome ability to create time through the creation of new life. T he inability to engage and to this mourning proces s is a significant dynamic factor in problematic and pathological res ponses to the menopaus e that are s een in s ome women. However, after the mourning proces s related to the menopaus e is s ucces sfully worked through, a major developmental trans formation in subjective time sense occurs. No longer dominated by the time-tables of the monthly mens trual cycle or the pos sibility of pregnancy, women are free to use time in new, egocentric ways. sens e of liberation is one of the dynamic factors supporting the contention that a problematic reaction to menopaus e and the empty nest is not a us ual A s ignificant developmental task of middle adulthood both s exes is the ability, free of s ignificant conflict and guilt, to use increas ing amounts of time for egocentric purpos es. F or women, this task is thrust into the of the developmental proces s and is driven by the menopaus e. However, in men and women, the newly found temporal freedom and sense of exhilaration that accompanies it become quickly fused with generative activities. In other words, the s elf is aggrandized by to and caring for younger generations and identifying their abundant future and temporal riches. W hen this fus ion occurs, the focus on giving to and caring for the young continues a pattern that was begun with parenthood but that is 4566 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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P.3574 now driven by a different dynamic force, namely, the to react to the midlife confrontation with awareness of limitation and personal death.

Maintaining Intimac y in the Fac e of S ignific ant Phys ic al, Intraps yc hic , E nvironmental Interferenc es Whereas the young adult is preoccupied with the capacity for intimacy, the midlife individual is on maintaining intimacy in the face of deterring phys ical, ps ychological, and environmental press ures . In a longstanding relationship, thes e press ures include real and imaginary concerns about diminished s exual capability, emotional withdrawal due to preoccupation with developmental tasks, and the realistic pres sures related work and providing for dependent children and, sometimes, elderly parents as well. In relations hips that begin in midlife, all of the previously mentioned factors may operate, but, in addition, the maintenance of may be compromised by the absence of a common age and generational differences in interests and and the difficulties involved in forming a s tepfamily. F or sexual intimacy to continue, the participants must accept the appearance of the partner's middle-aged must continue to find it sexually s timulating, and must accept the normative changes that occur in s exual functioning. F or those who mas ter thes e developmental is sues, the partner's body remains sexually stimulating. Diminished s exual ability is compens ated for by feelings love and tenderness generated over the years by a 4567 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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satis fying relations hip. T hose who cannot accept the changes in the partner's body or their own stop having sex, begin affairs, or leave the relationship, usually in search of a younger partner. Normative changes in midlife s exual functioning diminis hed s exual drive and an increase in mechanical problems . Men have greater difficult getting and sustaining erections and experience a longer refractory period after ejaculation. B ecaus e of diminished production, women experience a thinning of the vaginal mucosa, a decrease in secretions , and fewer at the time of orgas m. T hese physical changes are powerful psychological stimuli that produce normative and pathological res ponses in every patient in this age group. B ecause the subject matter is embarrass ing and difficult, many patients avoid this area entirely and attempts by the therapis t to introduce the s ubject. T he demands of raising children interfere with the and emotional equilibrium required for intimacy, as do press ures and res ponsibilities of work. F atigue and diminis hed interes t are common denominators in thes e circums tances . P atients with deeply rooted problems sexuality or relationships may use aging, work, and relations hips with children or elderly parents as a rationalizing their conflicts and refus ing to analyze

R eapprais ing R elations hips Midlife is a time of serious reapprais al of marriage and committed relations hips. In the proces s, individuals struggle with the question of whether to settle for what they have or to s earch for greater perfection with a new partner. F or s ome, the conflict rages internally and is 4568 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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from others ; others express it through actions that take form of affairs , trial s eparations, and divorce. R ecent research on happy marriage indicates that couples, despite internal and real conflict, have found achieved a s pecial goodness -of-it between their needs , wis hes , and expectations . T hey regard this fit unique and probably irreplaceable. In the eyes of these couples, marital succes s is based on the ongoing, succes sful engagement of a number of psychological tas ks . Among the most important are providing a safe place for conflict and difference, holding a double the other, and maintaining a s atis fying sexual life. T he decis ion to leave a long-standing, committed relations hip has great cons equences , not only for the individuals involved, but also for their friends and loved ones. T he effect on children, in particular, is es pecially profound, extending far beyond childhood. T he effects the abandoned spous e, parents, and close relatives nearly as severe. V arious forms of therapeutic intervention, such as couns eling, individual ps ychotherapy, and can be extremely effective in helping uncertain decide what to do or in helping those who leave deal the consequences of their decision on the abandoned partner, children, and other loved ones. P roblems to intimacy, love, and sex can occupy a prominent in an outpatient practice. A 55-year-old patient, Mrs. A. sought treatment “in leave my marriage. W e've been married for 35 years, haven't loved my hus band for the last 20. I've been so dependent on him all of my adult life that I don't know if 4569 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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have the courage to leave.” T wice-weekly that lasted 15 months helped her leave her hus band, a bus ines s, and begin a new relations hip. “I have les s money and I'm scared about the future, but I feel alive in control of my life. I think B ill is happier, too.” A 43-year-old patient, Mr. S . was continually with his marriage during this 4-year psychoanalys is . S exually inhibited during adolescence, he “married the only girl in the world who knew less about s ex than I E xploration of his sexual inhibitions led to a decis ion to stay in the marriage. “I've learned in this analysis that not the rare, extraordinary thing I thought it was as a billions of people do it every day. I know I could go out sleep with a lot of different women, but how different, or better would it actually be? J ane and I have built a good life together. S he's changed a lot and so have I. I think we can make the next 20 years better than the 20.” Mr. V . was distraught when his wife of 21 years left him another man. During the first 2 years of psychotherapy, worked through his feelings of abandonment. T hen, at years of age, in a compuls ive attempt to reass ure about his deeply damaged s ens e of masculine competence, he began sleeping with many different partners . R epeated interpretation diminished the but 4 years after the divorce, he was s till unable “to chance on getting clos e to a woman again.” S ix years the divorce, after detailed consideration in therapy, he remarried.

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F ifty-year-old Mrs. T . left her “wonderful” husband, because “I've mis sed something. I jus t have to get out my own.” Married at 18 years of age, “after going from parent's home to his home,” she recognized that her at her husband for “not being all the other men I could have married, for clos ing off all the living I could have done,” was irrational but uncontrollable. “I have to live my own for awhile, to see if I can do it, before it's too F ully intending to return to her hus band, s he continued exploring the infantile and adult is sues that precipitated the separation, leaving the future of the marriage in P.3575

L etting C hildren Go, Ac hieving E quality, and Integrating New Members into the Family During middle adulthood, children grow into and young adults. T heir inevitable progres sion through the developmental phas es from childhood to adulthood affects every as pect of the parents ' life. How parents facilitate their children's individuation and relate to them as young adults s ets the stage for a new relations hip on equality and mutuality. T he integration of in-laws grandchildren into their lives can make the difference between a rich, full, late adulthood or one rancor and emptines s.

L E TTING G O Y oung-adult parental vigor and the control of young children go hand in hand, but so do middle-age of physical decline and time limitation and the 4571 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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loss of control of adolescent and young-adult offspring. T he shift in the balance of power between them is taking place over many years as both engage their separate, but interlocking, developmental tasks. F acilitating the developing sexuality of adoles cent is difficult for the midlife parents because of the juxtapos ition between their waning sexuality and the adoles cent's sexual promis e. T he liberalization of mores and attitudes s ince the parent's adolescence also add to the discomfort by making the contras t between the parent's experience and the adolescent's opportunities quite distinct, particularly for women. Healthy parents s truggle with their conscious and unconscious envy and concerns but gradually accept fact that s ons and daughters are likely to begin dating to become sexually active in mid- or late adoles cence. C ons cious concerns about their children's s exual and the reactivation of unres olved sexual conflicts from the childhood and adult pas t are frequent pres enting themes in the treatment of middle-aged patients . find this area a s ource of great res is tance becaus e of excess ive interes t in or undue res triction of their sexual development and the arousal of unconscious inces tuous feelings. A fundamental knowledge of child and adult development helps the clinician unders tand interplay of the infantile, adolescent, and adult s exual is sues that determine the patient's s ymptomatology interaction with sons and daughters. E ach developmental trans ition brings with it the of s ignificant intraps ychic change and a shifting relations hips . In middle adulthood, that trans ition is characterized by physical aging and disappearance of 4572 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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parental function. C ross -cultural s tudies of older men women indicate that normal midlife development and late-onset pathology are driven by the same forces, energies released in men and women in the cours e of postparental trans ition toward androgyny. As the distinctions between middle-aged parents blur, postparental men become more nurturing and tender, their wives adopt s ome of the ascendant, competitive qualities that their husbands have relinquished. As postparental s pouse becomes as the other us ed to be, couple moves toward the normal androgyny of later B ecaus e of its linkage to the genetic requirements of parenthood, this contrasexual transition is , like and maternity thems elves, a quas i-universal event. As such, it usually precedes a developmental advance. some period of ps ychic dislocation, most men and accommodate to the changes in thems elves and in spous es . T hey s hape the energies liberated by the postparental revers al into new executive capacities of personality without losing their identities as men or women. However, the relations hip between grown children and their parents does not end here. T he potential for transformation remains, as the young-adult child and middle-aged parent work together to s tructure a new relations hip that is in s ome ways more complex than one that exis ted when they were younger.

A C HIE VING E QUA L ITY As parent and child move toward the latter s tages of middle and young adulthood, res pectively, all ves tiges the child dis appear. T he youthful appearance of 4573 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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adoles cent and the early 20s is gone, replaced by the mature young adult who s hows signs of aging. T he dependent child has been replaced by the independent adult who lives away from home, is s elf-supporting, significantly involved with others , s exually and emotionally. T hese adult relations hips and capabilities push the healthy parent–child relationship toward equality, but they are not in and of thems elves that equality has been achieved. R on, a 25-year-old man, complained bitterly in his that his 57-year-old mother continued to treat him like a child. On a recent vis it home, his mother insisted that change his s lacks and s port coat, cons idering them inappropriate for the occas ion planned. W hen an argument ensued, R on's father intervened (as he did) and encouraged his s on to change his clothes, he did. R on readily recognized his parent's need to infantalize him but was unaware of his own struggle between the wish to appease his mother and so remain emotionally involved and dependent on her and the to be independent. Over the cours e of 2 years of ps ychotherapy, as he came to recognize his own contribution to the continuation of an unequal relations hip, he began to make more independent decis ions. At firs t, the changes in R on's behavior were treated as provocations and intensified his mother's attempts to control him. G radually, s he worked through her feelings of rage, impotence, and loss of control and begrudgingly moved toward a more equal relations hip. In the more normative situation, healthy parents not accept their child's des ire for independence and 4574 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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autonomy, but als o actively encourage moves in that direction whenever pos sible. T he rationale for such behavior is not entirely altruistic, becaus e it is based, in part, on the recognition of how involvement with this special adult and his or her loved ones enhances the parent's mid- and late-life development.

INTE G R A TING NE W ME MB E R S F A MIL Y Mother-in-law jokes are more than the sarcas tic of some comic's humor. T hey als o illustrate a univers al tension between the newly married and their in-laws . tas k for the in-laws is clear enough, if difficult to give up the claim to the pos ition of primary love object the child's life, then accept the new partner, initially experienced to s ome degree as an interloper, and work cultivate his or her friendship. Once again, the for such behavior is not selfless . It is bas ed on a des ire continue to occupy a central, although les s important, position in the life of their child and to form a with someone who may add a new dimension to life but who will als o exercis e s ome control over future involvement with one's child and grandchildren. B ecaus e s pouse and parent of the same s ex love the person, a triangle is created that is s imilar to the oedipal one. C onsequently, all three individuals are to reengage and to rework their infantile experience in new adult context. Like the infantile version, this rendition is only res olved gradually and partially, with outcome determined by the emotional capabilities of participants. T he solution for midlife parents may lie in birth of grandchildren, thos e marvelous creatures who 4575 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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provide s uch a s ignificant boost to midlife and late-life development by serving as partial replacements for los t children, connecting midlife development to childhood themes, and providing the only mastery of death that is available, the opportunity to continue living through genetic continuity. F or many midlife parents , particularly mothers , the attraction to grandchildren is not all consuming, nor it replace in importance or preference for other, extrafamilial, interests . T he failure of young adults to recognize that their parents have other interes ts than them and their children can be a source of conflict between the generations .

Ac c epting the R evers al of R oles E lderly Parents At s ome point, as elderly parents become less able to for thems elves , a role reversal occurs. T he child the P.3576 parent of the parent, increas ingly fulfilling the functions phys ical and mental caregiver. A middle-aged patient described the change in her relations hip with her 83-year-old mother. “It's sad. S he us ed to be so vital. I remember her being s o s trong. was a child, s he worked from morning till night. Now I have to help her when s he walks . Y es terday, I had to her meat. I felt like I was taking care of a 2-year-old. every once in awhile, she gets that s park back in her and I remember what she was like for so many years. 4576 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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daughter was there at the time. Neither one of us said anything, but I knew we were seeing ourselves in the situation, 20 or 30 years in the future.” F or this woman, relations hip with her mother was a central as pect of her ps ychotherapy, s timulating a reengagement of iss ues the childhood and adoles cent past and the of phas e-specific midlife themes . T he acute reversal of roles that occurs when elderly parents cannot care for thems elves forces the middlechild to anticipate the parent's demise, thus s timulating the ongoing process of psychological s eparation from them. C aring for aging parents is one of the mos t and most frequently avoided developmental tas ks of middle adulthood. In addition to pres enting difficult financial and management problems , it forces a of childhood themes, focuses attention on time and personal death, and anticipates the inevitable role revers al that will occur with one's own children. Avoidance of this developmental task has cons iderable ps ychological cons equences, including the occurrence late-onset depress ion. C linicians who are aware of the enormous psychological power of this developmental proces s pay clos e attention to their patients ' this area and address the res is tances to such material when it is abs ent. When an elderly parent dies, no matter how expected anticipated, a mourning proces s ens ues . Long after the acute phase of this process is over, intrapsychic relations hips with dead parents remain dynamic, emotionally charged, and an important subject for ps ychotherapeutic exploration. 4577 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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Developing Midlife Friends hips Unlike friends hips in latency and adoles cence and, to extent, in young adulthood, midlife friends hips do not us ually have the s ens e of urgency or the need for or nearly cons tant phys ical presence of the friend. individuals have neither the need to build new psychic structure (as do latency-age children and adoles cents) the press ing need to find new relations hips (as do adults ). T hey may have many s ources of gratification available through relationships with spous e, children, colleagues. As their firs tborn s ons progres sed through high school, two women in their mid-40s became fas t friends . In addition to raising money for the s chool activities in their s ons were involved, thus maintaining a clos e involvement with the boys, they spent many hours about the boys ' activities , girlfriends , and plans for T heir husbands, who liked each other, became acquaintances, not friends. T hey directed their own feelings about their s ons into other relationships . After boys left for college, the intensity of the friends hip diminis hed, tending to peak again during vacation periods. B ecaus e of their unique position in the life cycle, these individuals are eas ily able to initiate and to s ustain friends hips with individuals of different ages, as well as chronological peers . It need not be as sumed that the unconscious motivation underlying thes e relations hips different from any other. However, the capacity for sublimation, particularly of aggres sive impuls es , may 4578 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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cons iderable. F riends hips with adolescents may be in part, on an identification with their youth and an envy their abundant future in an attempt to bolster a sagging sexuality and painful feelings about aging. F riendship young adults may s erve the same ps ychic aims , as provide an outlet for s exual and aggress ive impulses related to parenthood and work. F riends hips with older individuals may have multiple determinants , including longing for preoedipal parenting, oedipal sexual and aggres sive gratification, or the pas sive gratification of a mentee relating to an older mentor. However, as at all other points in the life cycle, F reud's recognition that friends can rapidly become lovers or enemies remains completely valid. In the face of a disrupted marriage or intimacy or the pres sure of other midlife developmental themes , friendships may quickly become vehicles for the direct expres sion of impulses. In the face of his wife's aging, a man in his early 50s to a younger woman. In a spirit of locker room camaraderie, he s poke openly to his clos es t friends of sexual details of the affair, bragging about sexual and adventure. As it appeared to his therapist (and to the patient as well), the woman seemed more interes ted in the gifts and money that he lavis hed on than his s exual prowess . He did not tell his friends of occasional impotence with the girlfriend and with his At first, the friends lis tened to his war stories and vicariously enjoyed the affair. However, their feelings turned to concern when he expres sed a des ire to leave wife and bus iness and move away with his girlfriend. C oncurrent therapeutic efforts to understand and to 4579 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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temper the des ire for abrupt action were stymied by the excitement of the affair and an urgent wish for a new Dynamically, the behavior was unders tood as a flight fears of aging, loss of sexual prowess , impotence, and multiple difficulties in the marriage. T hese midlife also had many, readily apparent, infantile determinants that were being presented concurrently in the transference. T he therapist watched as the patient's best friend confronted the patient, telling him that his behavior was stupid and inappropriate and that his girlfriend did not really love him and was taking him for a ride. He was that he was acting like “an old fool” and had better s top before he threw away his life. After initial and rage, the patient analyzed his res ponse and came to admire his friend's courage and to appreciate depth of his concern. T he confrontation produced a postponement of the move and greater willingnes s to the therapeutic proces s. E ventually, after a minithe patient broke off the affair and began to approach complicated and painful is sues in his marriage and in hims elf.

Pres s ures on Therapis ts ' T he relationship between friends and between and patient are alike in that both are primarily aim inhibited. Neither friend nor therapis t is expected to use the relationship as an avenue for sexual or aggress ive actions. S ometimes , the aim-inhibited nature of the relations hip breaks down, and therapist and patient become lovers or enemies. Much more frequently, the feelings generated in therapis ts by their work are 4580 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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displaced onto nontherapeutic relations hips, s uch as with spous e and children or friends. Although the family is a constant repos itory of such displacement, friendships may be uncons cious ly out even more, because they do not have the central importance of relationships within the family and therefore can be disrupted with les s realistic cons equences. In P.3577 many ins tances , disruption of a friendship caus es les s intraps ychic pain, becaus e it can be more easily rationalized and more eas ily replaced than a with a family member or a patient. In addition, like all other human beings in the second of life, therapis ts are s ubject to the normative conflicts engendered by the incess ant pres sures of the adult developmental process . If thes e conflicts become particularly severe, or if therapists become s ubject to unusual number of traumatic acts of fate, such as personal illnes s or the premature loss of loved ones through death, their work and their friends hips may even more.

B ec oming a Generative Mentor and Planning for R etirement Work is a psychic organizer of major importance: organizing the us e of time, providing meaning and purpos e, enhancing relations hips, and ens uring well-being. Midlife is the time of achievement and of power, the res ult of years of effort during young and middle adulthood when skills were mastered and 4581 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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acquired. T he narcis sistic gratifications related to work may be cons iderable, compens ating for the painful realities of everyday life. S ometimes, the imbalance is such that becomes the main s ource of emotional gratification, res ulting in a relative failure to engage more difficult developmental iss ues of midlife and neglect of relations hips with spous e and children. As a res ult, the eventual los s of work as a central organizing function source of gratification may be ignored. T he recognition the juxtapos ition of maximum achievement and power the workplace and the acceptance of eventual displacement by the next generation are at the core of midlife worker's intraps ychic experience. R ecognition of the conflict may be facilitated by plateauing (lateral movement in the workplace instead promotion), indicating that the highest level of achievement pos sible has been attained, or by relations hips with subordinates. As one company pres ident put it, “My toughest job is running the company and making tough decis ions, it's finding and training s omebody to s ucceed me. I know whomever I choose will be grateful and appreciative, they'll als o be anxious to get me the hell out of there.” T he conflict of the midlife mentor is to pass on and power to the next generation while recognizing that this behavior will lead to eventual dis placement. T he healthy individual does not act to any s ignificant degree on the anger and envy generated by s uch and instead s ublimates these feelings into generativity. Others , however, may dis play cruel, s adistic verbal 4582 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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or actions intended to impede the development and progres sion of the mentee. Midlife attitudes toward money are clos ely related to succes s or failure in the workplace. F or almost all individuals , except the wealthy, the is sue is the s ame: to earn enough money to meet the simultaneous demands to cover daily expens es , to provide children the opportunity for higher education or the trans ition to independent s tatus, to care for aging parents, and to life in the present while providing for a s ecure old age. In the treatment proces s, money may be a therapeutic preoccupation or may be defens ively ignored. In either circums tance, the developmentally oriented therapist helps the middle-aged patient deal with the powerful thoughts and feelings about finances and develop plans regarding money management.

Giving Play New Meanings and Purpos es P lay is a life-long human activity, an amalgam of abilities and limitations and mental capabilities and preoccupations. T hus , the unique features of midlife not surpris ingly, reflect the phase-specific with the acceptance of time limitation and pers onal T he s tructure of play changes little beyond T he games that most adults and children prefer are learned before adulthood begins. B y midlife, aging forces the abandonment of most sports and the modification of other physically ones. Individuals who refuse to modify their physical expectations of themselves often pres ent thems elves 4583 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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therapy with pathological respons es to phys ical injuries an exaggerated preoccupation with phys ical activity. T he ps ychological meaning of play als o changes . of being a joyous express ion of mental and physical capability, as it was in childhood and young adulthood, phys ical play is increasingly as sociated with the maintenance of physical integrity and the enhancement the aging body. All forms of play are increas ingly used (cons cious ly unconsciously) to master the developmental tas ks of accepting time limitation and personal death. G olf and rummy are examples . G olf is a game full of brief with numerous beginnings and endings; in other words, opportunities to conquer time and imperfection by beginning over and over. T here is always another shot, approaching hole, tomorrow's match, unlike one's life, which has one beginning and, more to the midlife point, an approaching end. G in rummy and similar mental eliminate the neces sity to us e the increasingly body at all and offer the s ame concept of inexhaus tible rhythmic beginnings . T he musing of an avid golfer patient who was his game with great s eriousness eventually led to the following insight. “I got s o upset on the course cons idered quitting for good. T hen, I thought to mys elf: T his is ridiculous . T his isn't life or death, it's jus t a month from now I won't even remember what I shot today. I don't want to s top; I love the game. All I have to is accept a higher handicap as I get older. On second thought, no I don't, when I'm eighty, I want to s hoot my age.” 4584 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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B ec oming a Grandparent In the mid-twilight of their lives , and because of their position in the life cycle, grandparents tend to idealize their grandchildren. T he grandparental tendency to engage their grandchildren with intens e love and devotion is similar to the toddler's undeterrable need mother during the rapprochement crisis. T he s imilarity exis ts becaus e toddler and grandparent have an developmental need for fusion with those they love as they face an immens e developmental challenge. T he toddler needs to be refueled before venturing out into ever-expanding world beckoning beyond the s ymbiotic membrane, and the grandparent faces the collaps e of world and the great unknown void beyond the end of mortal existence. T hus , the intens e inves tment in and idealization of grandchildren s erves s everal defens ive developmental purpos es : (1) a narcis sistic buffer the stings of old age and the inevitability of death, (2) a chance for magical repair of one's own life through immortality, and (3) a denial of unalterable in the s elf through s elective identification with particular qualities in the grandchild. T he healthy grandparent the falsenes s in this idealization but deeply enjoys the intens ity of the rapprochement that accompanies it. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > MIDLIF E T R ANS IT ION AND C R

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P art of "50 - Adulthood" Although the terms midlife trans ition and midlife cris is become part of the popular culture, they are definable syndromes that have cons iderable clinical relevance 50-5). T he midlife trans ition is a quasi-universal, developmental phenomenon. T he P.3578 midlife cris is , on the other hand, is a pathological s tate experienced by only a few.

Table 50-5 Definitions Midlife trans ition—a s earing intraps ychic all as pects of life Midlife cris is —a major press ured upheaval in long-standing relationships and achievements are abandoned impulsively, without insight

T he midlife trans ition has been defined as an intense reappraisal of all as pects of life precipitated by the growing recognition that life is finite and approaching end. It is characterized by mental turmoil, not action. 80 percent of thos e s tudied, the examination of relations hips , achievements, failures , and future plans 4586 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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preoccupying, painful, and searing. F or the others, this midlife critique was les s cons cious and much les s T he common denominator was the need to reapprais e as pects of life and to make decis ions about them'while there was s till time to change. F or most people, the reappraisal res ults in decisions to keep most life such as marriages and careers , which have been pains takingly built over time. W hen major changes are made, they are thoughtful and considered, even when they include major shifts , s uch as divorce or a job T he developmentally aware clinician recognizes that patient in this age group is engaged in a midlife (whether the patient is talking about it or not) and facilitates the process by making it cons cious and A true midlife cris is is a major, revolutionary turning in life, involving changes in commitments to career or spous e, or both, and accompanied by s ignificant, emotional turmoil for the individual and others . It is an upheaval of major proportions . A period of internal agitation is followed by a flurry of impuls ive actions; for example, leaving s pouse and children, becoming with a new sexual partner, and quitting a job, all within days or weeks of each other. Although there may have been unrecognized warning signs , those who are left behind are often s hocked by the suddennes s and abruptness of the change. E fforts by family members or therapis ts to get the individual to s top and to reconsider us ually fall on deaf ears. T he overwhelming need is to avoid anyone who couns els res traint and to ignore therapis ts who recommend examining motivations and feelings before making s uch major decis ions. Us ually, in the mids t of 4587 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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crisis, the therapis t is left with the painful job of helping those who have been left to deal with their s hock and grief. T om was a 42-year-old man who walked into an ps ychiatric clinic after experiencing days of anxiety as sociated with memories of childhood and intense In his words , “T he rats are running,” a reference to disturbing thoughts about his parents. F or example, he visualized his father's death and his mother's anger at for wishing his father dead. T he fantasies about his were highly dis turbing and intens ely painful. V ague suicidal ideation and the intensity of his dis comfort led desperate cry for help.

ME NTAL S TATUS E XAMINATION At this firs t visit, T om was a bit dis heveled, and his was press ured, but his thoughts were logical, and there was no evidence of delus ions or hallucinations. His varied from pleas antnes s to depres sion and He was oriented as to time, pers on, and place. T om had a need to talk about his family. His father from a middle-clas s family that contained accomplished individuals and alcoholics . His father was described as bright but withholding. He rarely express ed loving thoughts and communicated with a s eries of grunts. mother “had married up” and was domineering and controlling. S he ruled the family like a field mars hal. His father and mother rarely talked to each other in front of the children. T om thought that might be due to the fact that his mother had insisted on sleeping alone for the 10 years. 4588 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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DE VE L OPME NTAL HIGHLIGHTS T om felt that he was unplanned but had early maternal attention. S ome of the interest was pos itive, he als o remembered verbal abus e and “whippings that bordered on child abus e.” T om related his emergence practical joker to these beatings, feeling that he had no other way to expres s his anger. T om's mother was highly prejudiced, a fact that s he hid public. Although he never confronted her, his mother's attitudes dis turbed him, and he chos e to retaliate. In school, he became the firs t non-J ewish member of a J ewish fraternity. Later, he married a woman from an ethnic group disparaged by his mother. After high s chool, T om spent 4 years in the s ervice. His father took him to s ee a recruiter after T om could not up his mind about going to college. While he was in the service, T om married a woman whom he des cribed as volatile and vicious. After this enlis tment was up, he earned a master's degree and s tarted a bus iness . He that his 20s and 30s were good ones, des pite diss atis faction with his marriage. He loved his three children very much.

C R IS IS When T om was 37 years of age, he found himself toward religious and philosophical ques tions . He preoccupied with the lyrics of a popular song that that if a man didn't like what he had achieved in the he should change it. Like a bolt from the blue, T om felt that he was an example of the man in the s ong, who had never realized his potential or express ed fully. T om began to talk openly to his wife and children about 4589 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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his inner feelings and doubts about his future with Although he tried to stay involved with his family, T om began to believe that his “new self” and new values not survive his wife's criticisms and his own doubts. At point, he decided to leave. T om des cribed how his wife literally tore the shirt off his back as he walked away home. W ithout much prior planning, T om ran to the mountains and holed up in a cabin. No one knew was , and, during the following months, he avoided contact and s pent his time deep in thought. As “the rats were running,” T om tried to focus his on his childhood and on the future. He began reading about theology and philosophy. T houghts about death were prominent as he wres tled with the concept of his own mortality. He felt close to G od but als o arrived at intellectual conclusion that s uicide was a viable option man. After s everal months , T om became panicky and lonely and walked into the outpatient clinic and began therapy. T om eventually returned home and tried to rees tablis h marriage, busines s, and social life. W hen the attempt reconciliation with this wife was unrewarding to him, got a divorce and left all of his material poss es sions , including their bank accounts , to his wife. He continued ps ychotherapy and began to come to grips with his “demons ” from the childhood past, the cons equences his midlife crisis , and the decision to end his marriage. gradually began to build a new life and a new relations hip'increasingly aware that his midlife crisis led to a rebirth and des tructive cons equences. P.3579 4590 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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DIS C US S ION T om's midlife crisis was a true revolutionary turning in his life, which was accompanied by profound turmoil and upheaval in relation to family and career. self-impos ed retreat from others was , in part, an self-definition. In the midst of this narcis sis tic he ignored the needs of his family and bus iness while attempted to understand himself and the meaning of Once recons tituted, like Mos es , a changed pers on, he attempted to reengage his pas t life but could not. Over number of years, he continued to work on the tasks of forging new relations hips and a new career in an to cas t off as pects of the old or false self and to make hims elf into a new man.

Trans ition to L ate A dulthood T he transition to late adulthood is characterized by two contradictory trends: the shift from being left to leaving one contemplates and accepts the nearnes s of death the loss of all human relatedness and the s imultaneous desire, s timulated by the acceptance of a pers onal end, fus e with loved ones, community, culture, and the expanse of humanity by giving, without res traint or expectation of return, of one's wisdom and E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > LAT E ADUL T HO OD (60 Y E AR S O F AG E AND

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P art of "50 - Adulthood"

Developmental Tas ks Maintaining the B ody Image and Phys ic al Integrity F or many individuals, the pas sage from youth to old mirrored by a shift from the pursuit of wealth to the maintenance of health. In late adulthood, the aging increasingly becomes a central concern, replacing the midlife preoccupations with career and relations hips. is so because of normal diminution in function, altered phys ical appearance, and the increas ed incidence of phys ical illness . Des pite these occurrences, the body in adulthood can still be a source of considerable and can convey a s ens e of competence, particularly if attention is paid to regular exercis e, healthy diet, res t, and preventive maintenance medical care. T he normal state in late adulthood is physical and mental health, not illnes s and debilitation (T able 50-6).

Table 50-6 Developmental Tas ks Late Adulthood T o maintain the body image and physical integrity T o conduct the life review

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T o maintain s exual interes ts and activities T o deal with the death of significant loved ones T o accept the implications of retirement T o accept the genetically programmed failure of organ s ys tems T o dives t oneself of the attachment to T o accept changes in the relations hip with grandchildren

T he aging process precipitates significant change in body image, that emotionally charged mental representation of the phys ical body, which is constantly altered throughout life by actual physical change and evolving demands and expectations . F or the mos t part, body image closely res embles actual phys ical is a s ource of pleas ure, or pain, depending on how well maintained and functions; and is experienced as an integral part of the psychological sense of s elf. However, in late adulthood, a normal dis sonance between the body image and the s ens e of s elf. As one year-old put it on looking in the mirror, “Who is that impos tor staring back at me? ” T his dis sonance is not expres sion of a body image disturbance, becaus e the mental representation of the body res embles its actual 4593 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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appearance and functional ability. R ather, it is evidence a dis crepancy between the body image and the self, the latter being experienced as younger and more vigorous , impris oned, in a sense, in a s hell of a body no longer compatible with the mind or able to carry out commands. T he healthy older pers on faces the developmental tas k recognizing that, eventually, his or her body will impaired. T hen, in the face of s erious physical or incapacitation, the elderly individual, and his or her therapist, faces the daunting tas k of maintaining mental and phys ical functioning at the highest level poss ible while mourning los t functions and altering the body and s ens e of self.

C onduc ting the L ife R eview T he aging process , the awareness of the finitenes s of personal time, and the death of contemporaries are among the influences that s timulate individuals in late to conduct an intens e examination of their lives . R es earchers cons ider the life review to be a universal proces s brought about by the clos eness of diss olution and death. It marks the lives of thos e in late adulthood as their myths of invulnerability and immortality diminish and as death begins to be viewed an imminent reality. T he res ult of this critical ass ess ment may be a s ens e integrity or des pair, as E rikson noted. Integrity s tems a realization of having lived life with meaning, fully and well. Des pair is the res ult if the life review categorizes a series of miss ed opportunities , bungled relations hips, personal mis fortune. T hen, death is to be feared, for it 4594 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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symbolizes a life of pers onal emptines s.

Maintaining S exual Interes ts and Ac tivities T he frequency of orgas m, from coitus or mas turbation, decreases with age in men and women. T he mos t important factors in determining the level of sexual with age are the health and s urvival of the spous e, own health, and the level of pas t s exual activity. some degree of declining s exual interest and function inevitable with age, s ocial and cultural factors appear more responsible for the s exual changes observed the ps ychological changes of aging per se. Although satis fying sexual activity is poss ible for the reas onably healthy elderly, many do not actualize this potential. widely held notion that the elderly are es sentially is often a self-fulfilling prophecy. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > T HE F IF T H INDIVIDUAT IO

THE FIFTH INDIVIDUATION P art of "50 - Adulthood" T he fifth individuation in late adulthood is primarily focus ed on the ps ychological effects of the anticipation personal death and the reaction to this idea. Death leads to no further individuation, unles s one makes the leap from developmental theory to religious faith. It is nearnes s of death while one is still alive that is the preeminent intraps ychic influence on s eparation4595 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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individuation process es during the fifth individuation. When s eparation occurs through the death of others , the impact on individuation is profound, and a occurs in representations of s elf and others. In the awarenes s of loss and the pain of the mourning proces s, the self is redefined as more alone, singular, is olated from irreplaceable objects. However, and paradoxically, the intrapsychic attachment to and fus ion with the mental images of a lost loved one may intens ified as the mourning proces s enriches memories with powerful affects. P.3580 In late adulthood, emotional sus tenance is engendered reconnecting with affects and memories of mother and father and their adult replacements , s pouse, children, from all phas es of development. Older adults s ustain thems elves by dipping into emotionally charged memories of connectedness with the youthful parents infancy and childhood, with the invigorating connectednes s to and emancipation from the parents adoles cence, with the tender intimacy and s trength generated by caring for aging and dying parents, and the multitude of memories of clos enes s to s pouse, children, grandchildren, and friends that are fueled by affects as intense and as gratifying as those connected the parents of childhood. In the real world, the intact elderly compensate for the of s ignificant others by intensifying existing with children, grandchildren, great-grandchildren, and friends and by s eeking out new friendships and, 4596 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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sometimes, new s pouses . T he healthy, creative cycle loss , mourning, and reattachment continues in intact elderly individuals until death itself arrests the proces s. ability to engage this process is a major indicator of health and developmental progres sion during the fifth individuation. S ometime in middle adulthood, but always by late adulthood'whether voluntarily, by force, or through sicknes s or death'comes a separation from work and workplace. F or mos t individuals , work and its expertise, relations hips , and temporal rhythms define the self and a major as pect of identity throughout the adult years . some, the intraps ychic and real s eparation from work is liberating and wonderful, and, for others, it is s ad and depres sing, but all s eparation from the workplace significant individuation. One becomes a retired nonworker, outside the mainstream of the economic creative forces that energize s ociety and drive it toward the future. T he retiree must s truggle with the realization that he or s he is separate from the younger on the other side of an ever-widening chas m of time, knowledge, energy, and technology. Unique to the fifth individuation is the genetically programmed failure of organ s ys tems , which forces a separation from the sens e of pos ses sion of a fully competent, functioning body. T he loss of function and capability forces a separation from thos e interactions others that require particular phys ical s kills ; s ignificant of hearing or diminis hed vision, for example, may result loss of the ability to drive an automobile. S uch loss es , many others like them, diminis h the s ens e of and limit the scope of gratifying interactions with 4597 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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In late adulthood, the shedding of poss ess ions by giving them to others is a s ignificant form of purposeful separation and an integral as pect of the fifth E ach act of giving s harpens late-life identity and res ults a s impler, more s harply delineated sense of s elf as the of the human life cycle nears. W illing worldly for dis tribution after death, is a s imilar proces s but is devoid of the narcis sis tic gratification and meaning that come when there is interaction with the beneficiary of gift during life. T he desire to be remembered by the after death and to live on through them perfectly complements the desire of the young for pos ses sions enrich their lives. T his fifth individuation s hift away from poss ess ions and toward generative connections to who will live on is a hallmark of late-life wis dom. B ecoming a grandparent in middle adulthood, although ambivalent, is us ually filled with joy and awe becaus e the intens e cons cious love and idealization of the new extension of the self. However, during the fifth individuation, feelings often veer toward and detachment. T his s hift is due to developmental changes in the grandchild that impact the relations hip between the generations . As grandchildren advance latency and adolescence, they increas ingly inves t their time and affect in peers and new activities and pay less attention to and have les s need for their grandparents . F urthermore, as latency and adolescent egos and superegos develop, and as experience with other increases, grandchildren observe their elders more critically and los e the pure, naïve idealization of their grandparents that was so gratifying to the older generation. 4598 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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R etirement and R edundanc y R etirement produces a growing awarenes s of of no longer being in the mainstream of a world that rapidly, even frantically, rushes pas t the retiree, and integrating new knowledge and technologies that no longer be fully unders tood by nonworkers. S ome individuals welcome their position on the s idelines , whereas others s truggle with the realization that he or is separate from the younger generations . As did earlier s eparations , retirement may act as a to further individuation and a new definition of s elf. this occurs without undue conflict, the result is a sense relief, freedom, and pleas ure, which is referred to as golde n ye ars . W hen retirement is unwelcomed and unprepared for, the result may be boredom, phys ical debilitation, and even premature death. When the transition goes well, the los s is made narcis sistically tolerable, even enjoyable, through a combination of generative activities , identification with the young, and an acceptance and unders tanding of human cycle that is only poss ible in one who has embraced life through all of its phas es and has become wis e in the proces s. W hether retired or not, even individuals in late adulthood mus t mourn for unrealized ambitions and goals . If life was lived to its fulles t, with of the major developmental experiences at each developmental phas e having been engaged and mastered, the end result is, as E rik E rikson described integrity rather than despair.

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A dulthood T he following is a summation of a case history by G ary Levinson, M.D.

PR E S E NT IL LNE S S Mrs. A. pres ented for treatment at 63 years of age as obese, white, twice-divorced woman. T he mother of she lived alone, supporting herself on social s ecurity disability payments. T he patient des cribed hers elf as experiencing “neurotic fears ” about her health, s uch as blurred vision, dizziness , and unsteady gait. T he reason for referral from the patient's internis t, who that the somatic complaints were not organic in nature, was marked obesity. Mrs . A. began to gain weight in 50s, reaching her current weight of 220 pounds during that decade, probably partially due to her role of for a debilitated, s enile mother. E arlier in her life, s he been interested in her appearance and had highly her slimnes s. At present, s he was not concerned about weight, becaus e s he was “old and hopeless ly ugly.” Mrs. A. weathered the death of her mother and a years before beginning treatment without s erious difficulty. However, a myocardial infarction 9 months before the treatment began caus ed her to confront her own mortality and to experience recurrent feelings of depres sion, alienation, and is olation. S he feared an invalid living in a “sleazy nurs ing home.” Mrs. A. was als o preoccupied with guilty feelings about past. S he lamented the fact that her son from her firs t marriage had totally rejected her after s he left him with father at the time of the divorce. S he had not s een him 30 years and was crus hed when he emphatically rapprochement. E ven more upsetting were recurrent 4600 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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memories of two daughters from a second marriage, in their 30s, who lived in a foreign P.3581 country with their father. S he had not s een them since they were latency-aged children. Whereas most of her had been s pent in a freewheeling, adventuresome without a thought about tomorrow, s he now found confronted by a bleak, limited future and a cruel past.

DE VE L OPME NTAL HIS TOR Y T he patient was the firs t of four children. Of three male siblings , two became profes sionals, and the third was a chronic s chizophrenic. T he oldes t brother, her favorite, died a year before treatment began. T he patient's was des cribed as a hypochondriacal, domineering who always had the patient's best interes ts in mind. the time that the patient was 8 years of age until her teens , her mother was hospitalized s everal times for depres sion. Her father was des cribed as a “wonderful tyrant” who favored the patient. After a severe financial revers al during Mrs. A.'s teens, she became s everely depres sed and was hos pitalized. When the patient was her mid-30s, her father died in a fire that was set in a drunken s tate with a lit cigarette. Mrs. A. had few memories of her early years . S he did remember that her mother told her that she was an baby who developed normally. Her mother was the primary caretaker, although maids were heavily her daily care, and there were no s ignificant from either parent. At 8 years of age, during her recurrent hospitalizations, Mrs . A. found hers elf in conflict with the nuns at the parochial boarding school 4601 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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which s he had been sent. An excellent student, she outgoing and popular, particularly with boys . Her relations hips with women were always fraught with conflict, because Mrs . A. felt that they might be jealous , turn on her, and be untrus tworthy. T he patient remembered herself as quite irritable and withdrawn before the onset of her menses at 14 years of age. Afterward, s he began to date and was more outgoing comfortable. After her father's financial reverses and hospitalization, the patient returned home. T he conflicts intens ified until, at 17 years of age, s he impuls ively ran away with a boyfriend.

ADUL T DE VE L OPME NTAL HIS TOR Y Mrs. A.'s firs t husband was an itinerant mus ician who traveled the country during the big band era. T he enjoyed the lifes tyle and s oon was epis odically drinking excess . When her parents began having serious problems , Mrs . A. invited her mother to travel with her, husband, and infant s on, a pattern that continued for almos t 7 years. T oward the end of her 20s, Mrs. A. for a more adventuresome life, without the restraints of marriage and parenthood, and impulsively left her and went to a foreign country. T here, Mrs . A. described herself as attractive and outgoing, a woman who made friends easily and who attracted interesting men. S he slim, outgoing, and the center of attention. At 33 years of age, she married her second hus band, a foreign busines sman. After s everal years and two she began to experience him as overbearing and dominating. F urthermore, s he was torn between her and her mother, who was having recurrent periods of depres sion and who as ked the patient to come home 4602 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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to take care of her. After frequent trips to her mother's side, one las ting s everal months , Mrs . A.'s hus band initiated divorce proceedings and won cus tody of the couple's two children. Mrs . A.'s first s erious bout of depres sion followed. When the patient was in her early 40s, s he firs t hypochondriacal symptoms of dizziness , nausea, and unsteady gait. S he refused the recommendation of a ps ychiatris t that ps ychotherapy was indicated. occurred at 46 years of age. Until her mother died, she was 58 years of age, Mrs. A. worked and took occasional trips out of the country, s eeking the and feelings of her former life. Her involvement with which had been one of recurrent “flings ,” became less frequent. W ith advancing age and rapid weight gain, patient was no longer the attractive, s eductive woman that s he once was. S he found herself “not caring” her appearance, because “it didn't matter anymore.” body was now experienced as “a convenience that had its us efulness .” After the death of her mother, and s oon after her brother, Mrs . A. took her las t trip abroad. It that point that she had the myocardial infarction.

ME NTAL S TATUS E XAMINATION Mrs. A. pres ented as a tall, obese woman who was neatly in out-of-fas hion floral print dress es and who walked with effort. Her face, when not hidden by sunglass es , was that of a younger woman. S he had an attractive vitality about her, despite her weight. A mildly depres sed affective state was evident behind the exterior. As sociations were always intact, and there evidence of a thinking dis order. T he patient suicidal ideation in the past but none in the pres ent. 4603 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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was oriented as to time, person, and place, and had an intact memory. J udgment was good, and intelligence appeared to be in the s uperior range.

DIAGNOS TIC FOR MULATIONS Mrs. A. appeared to be experiencing dysthymia with hypochondriacal features and alcoholis m, which had in remiss ion for 2 years before s tarting therapy. T here cons iderable evidence of arres t along thos e youngdevelopmental lines related to intimacy, marriage, and parenthood. When the patient entered midlife, she symptomatically to the aging proces s in herself and to mother's death, becoming hypochondriacal and, later, obese. S he was a woman who, as s he conducted her review, recognized that her itinerant lifestyle had her to “race through life” without experiencing many of most significant pleas ures'particularly, a lasting and sustained relations hip with children and grandchildren. How could that have happened, s he as ked? W as it too to do anything about it? Here was an introspective bud that might bloss om in a conducive therapeutic s etting. C ould change happen in one s o old and with s uch a life history?

THE R APY F or the firs t 3 years of treatment, Mrs. A. was seen twice per week. T hereafter, treatment continued every other week. B ecause the patient had no financial of her own, the treatment was paid for by Medicare and Medi-C al.

OPE NING PHAS E T he initial s ess ions were dominated by the patient's concerns about her symptoms and anxiety. T his soon to consideration of the major change that had occurred 4604 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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her life after the myocardial infarction. Never having experienced any physical limitations , Mrs . A. now tired easily and found herself occasionally short of breath. lamented, “I haven't adapted to old age … old age is … I'm on my way down and out; this is jus t an to an interesting life, and there is nothing left for me anymore.” During the s econd half of the first year of therapy, her intros pective curiosity grew by leaps and bounds . “I've always wanted to find out more about myself, but I was afraid that no one would ever be able to figure me out. I never could before this.” As the trans ference Mrs. A. express ed fear that the therapist would tire of and get rid of her like the other men in the recent past.

MIDDLE PHAS E S lowly, she began to idealize the therapis t as a caring, stable, knowledgeable father who could be trusted with her innermost thoughts . T he patient began bringing baked goods for the therapist, who commented, “I felt surpris ed that this older woman would s ee me in a paternal role, becaus e I was 30 years her junior; was much more than I P.3582 expected. I had to be continually aware of my own countertransference wis hes to be taken care of by a mother or grandmother.” Much of the therapeutic effort during thes e years on Mrs . A.'s ambivalence toward her mother and As she cared for her remaining brother and watched downhill cours e, Mrs. A. continually dealt with to, acceptance of, and working through feelings about 4605 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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growing old. S he also experienced survivor guilt, that “fate must have mis sed me. I s hould have died. I such a bad life.” T he focus on her family led to an in genealogy. As she dis covered unknown ancestors, sens e gaining new loved ones and conquering time death, her attitude toward her known relatives As time pass ed, she became increasingly aware of complication of aging, arthritis of the hands, knees, and hip joints , described by an internist as degenerative.

ON TUR NING 65 YE AR S OF AGE Her 65th birthday occurred during the third year of treatment. Now, s he was “officially designated as old certified old lady.” R eaching this milestone prompted intens ified life review and heightened feelings of insignificance and inadequacy, becaus e her grand plan life had not produced any money, friends , or material poss es sions . T herapeutic efforts centered on helping Mrs. A. recognize the magical thinking surrounding turning 65 years of age. G radually, she to expres s positive feelings about her knowledge. After she noted, she “knew a thing or two about life” and advis e the young and foolish, as she now s aw her about the pitfalls ahead. B eing younger, the therapis t, could benefit from her wisdom, particularly about life in foreign countries . Within the trans ference, the therapist became her lost child, young, naïve, and learning about the world from a wise, loving mother or grandmother.

B E C OMING A MOTHE R AND GR ANDMOTHE R As therapis t and patient continued to work on Mrs. A.'s feelings about the abandonment of her children, s he expres sed a des ire to s ee them but was fearful of 4606 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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up old wounds. E ventually, she wrote to a friend in country who had contact with her children, inquiring about their well-being. T o her s urprise, the reply that her daughters wished to s ee her. An anxiety-filled joyous reunion followed. Mrs . A. brought her daughters meet Dr. Levins on. Mrs . A.'s older daughter was a interes ting woman who was supportive of her mother. Unfortunately, the younger daughter had paranoid schizophrenia and needed treatment that the therapis t facilitated. P ractically overnight, Mrs. A.'s life had changed significantly. S uddenly, she was a mother with one succes sful child and another with major problems . Ongoing contact between mother and daughters was continuous. W hen the grandchildren came to s ee her, A. experienced one of the joys of later life for the firs t T hey were active, inquisitive children, who enjoyed pampered by their grandmother.

TUR NING 70 YE AR S OF AGE Mrs. A. approached her 70th birthday with a more positive attitude than s he had earlier ones . feeling “old and on my last lap,” she energetically her daughters and grandchildren on their frequent Her role as mother and grandmother “I feel needed have a purpose in life” was clearly energizing and to put the psychosomatic preoccupations into a more manageable perspective.

S UMMAR Y T his cas e illustrates the interaction of the normative of aging with earlier developmental psychopathology demonstrates how dynamically oriented even once weekly, can be effectively us ed to treat 4607 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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T he clinical material clearly demonstrates the capacity an elderly patient to us e dreams, free ass ociation, and transference to effect s ignificant emotional and change. W orking with s uch patients requires an unders tanding of the developmental proces ses of late adulthood and a therapeutic flexibility that the patient's phys ical condition, real life relations hips, intraps ychic world. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > ADULT DE V E L OP ME NT AL DIAG NO S T IC

ADUL T DE VE L OPME NTAL DIAGNOS TIC E VAL UATION P art of "50 - Adulthood" T he purpos e of doing an adult developmental evaluation is to collect relevant data about the patient allow the clinician to formulate a clear understanding of the normal and deviant developmental influences from childhood and adulthood that underlie the patient's healthy growth and s ymptomatology and to formulate a treatment plan (T able 50-7).

Table 50-7 Adult Dvelopmental His tory

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T races the patient's life experience from birth to adult pres ent P rovides the information necess ary to understand the meaning of presenting s ymptoms Des cribes the influence of important figures such parents , s iblings, and grandparents in adulthood

T he components of the evaluation are the same as any s tandard psychiatric evaluation; however, added emphasis is placed on obtaining a developmental that extends beyond childhood and adoles cence to the chronological present. T he child and adult histories provide the information necess ary to the meaning of the pres enting symptoms and their effect. W ithout detailed knowledge of the patient's life experiences , the diagnostician is reduced to making educated gues ses in an impersonal context. R elying on knowledge of child and adult development, the clinician traces the individual's life experience from conception the present, relating the findings to the information obtained in the history of the present illness . T he influence of important figures , s uch as parents , siblings , and grandparents, does not end with adoles cence. C onsequently, the course of thes e interactions may be traced throughout life, focusing on critical iss ues, s uch as the interactions between newly married children and their middle-aged parents. E ven 4609 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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death, parents remain important intraps ychic objects may be the s ubject of meaningful therapeutic dialogue when the clinician recognizes their importance to the older patient and inquires about them. In gathering information about adult developmental proces ses, the historian inquires s ys tematically about major areas of adult development. T hinking in terms of adult development tasks described earlier in the one way to organize the proces s. F or example, in the young-adult years, the clinician would inquire about how patients feel about the aging proces s in their body. the body being cared for or neglected? In another area, questions would be as ked to determine whether increasing s exual experience had led to a sens e of with the body as a sexual instrument and P.3583 to the emergence of the capacity for intimacy. Other developmental tasks of young adulthood would be addres sed in s imilar ways . If patients are in middle adulthood, 40 to 60 years of examples of the questions to be as ked are as follows : an adult-to-adult relations hip been forged with grown children and their spous es? Have grandchildren been recognized and enjoyed? Has generativity become a central as pect of relationships with young individuals, particularly in the workplace? Have intimacy and an sexual life been maintained in the face of diminis hed sexual drive, menopaus e, and the environmental of midlife?

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Treatment of A dults P es simis m about the dynamic treatment of older began with F reud and continues to the present, despite large body of contradictory literature. F reud said that, approximately 50 years of age, individuals became and were not amenable to ps ychotherapeutic intervention. F urthermore, the patient's long past would present the therapist with an amount of material too to analyze. F inally, he was concerned that the patient might die in the near future, choos ing cost over quality of life. Des pite an extens ive literature to contrary, including detailed case histories of individuals all s tages of the life cycle, including late adulthood, have benefited from dynamic approaches, many continue to shy away from the treatment of older individuals . T he reasons are owing, at leas t in part, to attitudes about the s econd half of life on the part of therapists . Y oung-adult and middle-aged therapists wis h to avoid thinking about aging and personal death, are uncomfortable with the s exuality of older adults, as sume that organic impairment is a given. T he implications of adult developmental theory for work s tem from the view that human development is a continuous, life-long process . W ithin such a framework, mental illness is conceptualized as functional which not only interferes with the current functioning of the individual, but als o impedes the development of evolving functions along one or more lines of development. B y placing mental illness within this the goal of treatment becomes the progres sion of development in all of its dimensions rather than s imply symptom relief. T he key to success ful treatment lies in 4611 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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ability of the clinician to focus on the current, phas especific adult developmental is sues and the effect of earlier experiences and conflicts , eventually leading to redefinition and s ynthes is of the relations hip between earlier experience and the reengagement of phaseappropriate developmental tasks.

Trans ferenc e T ransference phenomena in the second half of life are complex and, in some ways , qualitatively different from those pres ented by children and younger adults. T his is because, in middle and late adulthood, transference phenomena, in addition to being recapitulations of infantile experience, are also expres sions of iss ues and conflicts from all developmental stages beyond F urthermore, memories from early in life are continually transformed and modified by subsequent experience. very real sense, memories in adulthood are developmentally determined and as sociated with experiences from each of the phas es from birth to the chronological present. S uch an unders tanding the therapist's tas k of understanding and interpreting transference by s uggesting that it is not enough to help the patient recognize the relations hip between the childhood past and current s ymptomatology; the contributions of the intervening developmental s tages the s ymptom complex must als o be delineated and analyzed. S everal forms of transference, some of them unique to adulthood, are present in middle-aged and older adults . F irst is the well-recognized pare ntal trans fe rence , in the patient reacts to the therapist as a child to a parent. 4612 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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P ee r or s ibling trans fere nce , express ions of from a variety of nonparental relations hips , is also common. In this form of transference, the patient looks the therapist to s hare experiences with s iblings, friends , and ass ociates . At firs t, therapists may be by older patients ' ability to ignore their age in creating such transferences . In s on or daughte r trans fe rence, quite common in aged individuals and the elderly, the therapist is cas t in role of the patient's child, grandchild, or s on-in-law or daughter-in-law. T he themes expres sed in this form of transference are multiple and often center around defens es agains t dependency feelings, activity and dominance vers us pas sivity and s ubmis sion, and to rework unsatis fying aspects of relationships with children before time runs out. Las t, but by no means s e xual trans fere nce s in older individuals are frequent, intens e, and extremely useful to the therapist who can accept them and who can manage his or her countertransference res ponses.

C ountertrans ferenc e In addition to the typical forms of countertrans ference observed in the treatment of younger patients, some related to the adult patient's position in the life cycle. Older individuals are dealing with illnes s and s igns of aging, the los s of s pous es and friends , and the awarenes s of time limitation and the nearness of death. T hese are painful iss ues that are just beginning to into focus for younger therapists who would prefer not confront them with great intensity on a daily bas is . A s econd s ource of countertransference responses 4613 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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around the older patient's sexuality. T he presence of a vivid fantas y life, masturbation, and intercours e are disconcerting in and of themselves if the therapist has had much experience in working with individuals who the same age as their parents and grandparents. the experience of this 31-year-old female therapist who was treating a 62-year-old man. E arly in the treatment process , Mr. E .'s s exual feelings emerged. His well-groomed appearance and like nervous nes s caused the therapis t to recognize her discomfort. Her concern was how to engender respect to develop a therapeutic alliance with a patient who approached each ses sion as a date, particularly was old enough to be her grandfather. At firs t s hocked his open express ion of sexual interes t in her, with the of s upervis ion and her own therapy, she was able to recognize that s he and the patient had s imilar conflicts res olve, in s pite of the 30-year age difference between them. S he had hoped that Mr. E . would be “all grown devoid of is sues that she was grappling with also. S he came to recognize that failure to help him unders tand relations hip between his pas t and still vibrant s exuality would do the patient a great dis service and would from her lack of understanding of late-life s exual development and her countertrans ference reaction to based on her conflicted attitudes toward the s exuality her parents and grandparents.

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development concepts are integrated into a diagnostic evaluation.

IDE NTIFYING INFOR MATION R obert was a 43-year-old profes sional. A hands ome with graying hair and a trim figure, he had the air of a gracefully aging middle-aged man of emotional His 40-year-old wife of 20 years was des cribed as overweight, anxious, and preoccupied. A college she had been at loos e ends since their s on recently left college. T heir son was described as a bright, capable year-old who was ambitious and happy. Although no else lived in the home, R obert and his wife were in the care of their parents, who lived nearby. P.3584

R E FE R R AL S OUR C E T he patient was self-referred. Despite his wife's encouragement and a brief pos itive experience with ps ychotherapy in his late 20s , R obert came for with considerable reluctance.

C HIE F C OMPL AINT With cons iderable embarrass ment, R obert revealed came to s ee the therapist becaus e he had s tarted to interes t in his wife s exually. He was depres sed and to change this as pect of his life. B y the end of the evaluation, it was clear that R obert's sexual problems not as acute as he presented them and that they had antecedents at s everal earlier s tages of development.

HIS TOR Y OF PR E S E NT IL LNE S S R obert's lack of interes t in his wife began years ago, when s he s tarted to gain weight. As s he did, 4615 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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lost interest sexually and occasionally became On occasion, R obert was able to overcome his s exual reluctance by fantas izing about centerfolds. S umming the state of affairs , he said: “I'm all right as long as I think about her. My G od, I'm in bed with a 40-year-old woman.”

DE VE L OPME NTAL HIS TOR Y P regnancy, delivery, and early development occurred uneventfully. His mother was the primary caretaker, there were no lengthy separations from either parent. S oon, R obert was identified as the “shining light” of the family, overs hadowing his older brother. T oilet training commenced in the s econd year of life was conducted with authority and firmnes s. T he family enema bag was a fixture, and both parents s poke of virtue of “being regular.” R obert vividly recalled the bathroom ritual, which continued until he was 8 years age, in which he would s it on the toilet and bend his face in his mother's dres s, as she inserted the nozzle in his rectum. R obert clearly remembered his tonsillectomy at 5 years age. He awoke to find his penis bandaged'he had been circumcis ed at the same time without being told. His father was s itting by the beds ide when he awoke, like C ount Dracula.” When his father was away on trips, R obert s lept with his mother, serving as her companion. He knew he was “her favorite; the s un rose and s et on me.” One day, when he was approximately 8 years old, his father invited R obert in the bathroom to talk while his father lay in the bathtub. T he memory of his father's floating on the water, seemingly dis connected, was still 4616 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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vivid in his mind. Although, outwardly, R obert seemed happy and was succes sful academically, elementary s chool was a time becaus e of his “tremendous s exual curiosity.” He sure that no one else was as curious as he was. During third grade, he lived in cons tant fear that his would follow through on a threat to tell his father that had caught him involved in s exual play with a neighborhood girl. However, his intelligence and inclination to learn were attractive to adults, and, thus , R obert was able to attach himself to teachers and who were willing to pay attention to him. B y early adolescence, R obert's mind was flooded by thoughts about class mates . Later, in treatment, he revealed that he had mas turbated while thinking of girls and of the back and leg rubs that his mother gave him when he was a little boy. B y mid-adoles cence, he was is olated and lonely, s eparated from his peers by his intelligence and anxieties . He began dating at 18 years age and had intercours e for the firs t time 2 years later. pattern developed of impotence on the initial attempt at penetration, followed by succes sful coitus. R obert felt “absolutely liberated” when he left home for college and found himself engaged in activities that he knew would displease his strict parents. R eading new books , eating different foods , and relating to new were highly enjoyable, as was his s exual freedom. T he 20s were a period of academic achievement. His acceptance to graduate s chool and plans for a career res earch filled him with confidence. “Once I got to graduate school, I looked back on my life, at all that during childhood, and I knew things were going to get 4617 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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better.” At 23 years of age, he married, and a child was born 2 later. Des pite the press ures of graduate s chool, the years of the marriage were es sentially happy ones. practice, the young couple's sex life improved, and the anxiety about s ex, which was prominent during the first year of marriage, diminis hed. B y 30 years of age, was happier than he had even been. He was becoming prominent leader in his field, enjoyed his child and life, and began to make s ome money. He remained from his parents. An occasional letter and rare vis its the only forms of contact that he permitted, des pite a nearly constant preoccupation with thoughts about S uddenly, at 32 years of age, his life was dramatically changed when a rapidly growing malignant testicular cancer was dis covered. In the mids t of a nightmarish weeks, he was operated on and s ubjected to radiation therapy that res ulted in s terilization. He and his wife been attempting to have another child at the time. T he growing sense of s exual and emotional clos eness them was s hattered and, for s everal years, was distance and cautiousnes s. When R obert was 37 years of age, his father died. the illness , he managed, at great emotional cost, a rapprochement with his parents . T he anger and anxiety that he experienced s eemed inappropriate to the reality the situation, as he watched his father decline. After death, he encouraged his mother to move nearby, s o he could take care of her.

FAMILY HIS TOR Y R obert's father was rais ed in a large farm family. His parents were loving, strict fundamentalists who actively 4618 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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preached thes e values to their children. His father was unable to purs ue formal learning beyond high school was an avid reader of religion and philos ophy. R obert had little contact with his father after he left he felt that the progenitor had lived a happy, if life, although he always s eemed puzzled by the between himself and his younger son. His mother was described as a sad worrier. R obert felt she had been emotionally neglected by her hus band had thus centered her life on her children, particularly R obert. His mother was rais ed in an intact, happy Her parents were emotionally available and financially succes sful. S he was attending college when s he met married R obert's father. Named after his father, R obert's older brother was described as a plodder who did okay but never fully realized his potential. As a young child, R obert admired sibling but s oon learned that he was brighter and more capable than his brother. T hey “coexisted” through of childhood. At the time of the evaluation, R obert felt res ponsible for his mother and his brother and provided advice and money when it was needed.

DIS C US S ION During childhood, maternal and paternal seductiveness the form of frequent enemas , exaggerated interest, and cosleeping stimulated R obert's s exual impulses curios ity. However, at the s ame time, the paradoxical parental preaching agains t s exual curios ity and the punitive circumcis ion produced a major intrapsychic conflict over s exuality and the emergence of a punitive superego. T his neurotic conflict was manifest during latency by undiminis hed sexual curiosity, cons iderable 4619 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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anxiety, and es trangement from peers . In adoles cence, normal ups urge of sexual impulses P.3585 became problematic becaus e of a conscious preoccupation with inces tuous wishes toward his and concerns about homosexuality fantas ies . T he experienced intense guilt and constant anxiety throughout thes e years . During young adulthood, R obert was well on his way to es tablis hing a satisfying emotional and s exual with his wife when their relations hip and the couple's plans for more children were devas tated by the cancer. T he res ulting surgery and radiation were experienced unconsciously as punis hment for s exual fantas ies and enjoyment. During midlife, the aging in his and his wife's body led to sexual insecurity and impotence, which res ulted in the des ire for treatment.

DIAGNOS IS Using the fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs (DS M-IV ), the following diagnoses were made: Axis I: generalized anxiety dis order and male disorder. Axis II: personality dis orders; none was pres ent. Axis III: T he testicular cancer, radiation, and were ins trumental in the development of the generalized anxiety disorder and male erectile disorder. Axis IV : P roblems with the primary s upport 4620 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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group'emotional and s exual estrangement from spous e. Axis V : 51 to 60 on the G lobal Ass es sment S cale of F unctioning, moderate.

TR E ATME NT R E C OMME NDATION AND T he patient was thought to be an excellent candidate intens ive ps ychotherapy or ps ychoanalys is. S uch treatment was indicated because of the intensity of the multiple childhood and adult determinants of the generalized anxiety dis order and male erectile addition, R obert was bright, verbal, and well motivated change. B ecause of these factors , the prognos is was be good to excellent. A major theme in the therapy was the patient's failure pursue regular medical checkups after his cancer T his failure had a direct bearing on his current sexual functioning, becaus e replacement dos es of s exual hormones were required because of the loss of hormone production. F or 11 years , the patient had immobilized by his unres olved feelings about the Only after dealing in treatment with his rage over being castrated, his inability to father another child, and the multitude of connections between this adult experience and his childhood s exual conflicts was he able to and cooperate with an endocrinologis t. T he res ultant ability to work closely with an endocrinologis t to normal hormonal levels and the therapeutic work led to disappearance of the impotence, diminis hed anxiety, increased intimacy with his wife, and a comfortable to care for his aging mother and befriend his brother. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di

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C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > W IS DOM, MAT UR IT Y , AND F ULF ILL M

WIS DOM, MATUR ITY, AND FULFIL L ME NT P art of "50 - Adulthood" S uccess and happiness in adulthood are made achieving a modicum of maturity'a mental s tate, not an age. However, the capacity for maturity is a direct outgrowth of the engagement and mas tery of the developmental tasks of young and middle adulthood. F rom a developmental perspective, maturity may be defined as a mental state found in healthy adults that is characterized by a detailed knowledge of the of human existence, a s ophis ticated level of s elfbased on an hones t apprais al of one's own experience within thos e basic parameters , and the ability to us e intellectual and emotional knowledge and insight in relation to one's self and others . T he achievement of maturity in midlife leads to the emergence of the capacity for wisdom. T hose who wis dom have learned from the pas t and are fully in life in the pres ent. J ust as important, they anticipate future and make the neces sary decisions to enhance prospects for health and happines s. In other words, a philosophy of life has been developed that includes an unders tanding and acceptance of the pers on's place in order of human exis tence. T hat world view, which widely from individual to individual, produces fulfillment when the following as pects of the human condition are 4622 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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accepted and integrated. 1. T he body mus t be cared for'in health, through checkups, exercis e, and a proper diet, and in through prompt treatment and proper care. C aring the body is not an end in its elf, but it is critically important, becaus e s entience, the ess ence of experience, s prings from a healthy brain and body. 2. Human beings are individuals who are alone with thems elves , s eparated and individuated from all others . 3. P aradoxically, human beings cannot s urvive or develop on their own. Helples s at birth and dependent throughout childhood, even the most sufficient individuals require the sustaining of others. Humans exis t in a framework of interdependence, a basic characteristic of all relations hips , be it the parental view of the child as confirmation of his or her sexuality, the need of the child for the parents' loving care and protection, or revers al of these roles between child and aging progenitor. T he mature adult (unlike the child who takes , us es , controls, and dominates ) mutes the grandiose expectations of childhood and propels self toward interactions characterized by caring and mutuality, thus striking a balance between pers onal needs and those of others . 4. C hange is a constant in life. A bas ic as pect of this change is the s hifting nature of significant relations hips . Adult involvement with loved ones , as children, parents, colleagues, and friends, is in cons tant realignment. Healthy marriages deepen in 4623 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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significance, whereas others break up on the midlife development. P arents die. C hildren grow, leave, and return with new family members . As oppos ed to old age and, in s ome res pects, as well, the tas k for the mature pers on is to s ort categorize, and to set priorities among the proces s balancing emotional needs and demands and respons ibilities . T he s hifting nature of relations hips s timulates the achievement of greater maturity by forcing a constant redefinition of who is in relationship to others . Mature individuals lost relations hips but can remain focused on and future ones . 5. All human beings 'regardles s of wealth, pos ition, power, achievement, appearance, or cultural background'are on the s ame developmental All are born and will die. All have a body with the functions . All have the s ame emotional needs for clos enes s and love and the s ame vulnerability to and deprivation. 6. F ew individuals have an exaggerated importance. wis h for such grandiose prominence is universal, res ult of the untempered narciss ism of infancy and childhood. In reality, most individuals are important thems elves and a relatively limited number of who know and love them. T he mature individual accepts this fact without despair and us es the knowledge to set realis tic goals and priorities that increase the chances for personal happiness and fulfillment. 7. P ers onal time is limited. E veryone will die. Y oung children do not have the cognitive capacity to 4624 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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unders tand the notion of personal death. S purred by the thrust of phys ical growth and a seemingly endles s future, adolescents and young adults think and act as though they are immortal. T he true acceptance of time limitation and personal death occurs in midlife. T hen, the mature individual, P.3586 or not, stimulated by an awareness of the aging proces s in the body, the maturation of children, the death of parents and friends, and the arrival of grandchildren, accepts the inevitability of a end. As with the realization of the limited of each individual, this painful recognition, which precipitates midlife crises in s ome, s timulates the mature individual to seek fulfillment in each to define what is truly important, and to plan the future to actualize those priorities . 8. Money and poss ess ions have limited intrinsic T hey are a means to an end, tools for enriching life improving the human condition of loved ones and broader community. Owners hip of tangible objects temporary; sooner or later they will be los t, left or given to others . 9. Work occupies a central pos ition in adult life. C ons idered a drudgery by s ome, the wis e person recognizes its extraordinary value. In addition to the obvious function of earning a living, work is organizing, an activity that provides purpos e and direction, a meaningful way to manage time, and environment in which to form s us taining S atisfied midlife workers, at the peak of power and 4625 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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position in the workplace, facilitate the development of the skills and capabilities of younger colleagues while fully realizing that these individuals will, or later, replace them and as sume control of the of power. W is hes to hold down and to attack workers are s ublimated into ge nerativity, E riks on's for enhancing the development of the next generation. 10. Midlife is the phas e of life in which the experience being human can be realized and enjoyed most T hen, the combination of phys ical health and vigor, power and prestige in the workplace, accumulation wealth and poss es sions , and meaningful from within the midst of three or four generations provide the potential for a life overflowing with richness and complexity. T he mature life is one in which the triumvirate of human experience'love, and play'are success fully balanced to bring true fulfillment. 11. Unfortunately, the joys of midlife do not las t forever. Old age lies ahead. Although the hope and expectation is for many years of mental and independence, phys ical and mental decline, increased dependence, and, eventually, death anticipated. Late adulthood has its own great when there is a focus on continued mental and phys ical activity, a dominant preoccupation with the present and the future, and involvement with and facilitation of the young. T hen, death can be met feelings of s atisfaction and acceptance, the natural point of human exis tence that follows a life lived well loved. 4626 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > S U G G E S T E D C R O S S -R E F E R E

S UGGE S TE D C R OS S R E FE R E NC E S P art of "50 - Adulthood" Anthropology is discus sed in S ection 4.1, discuss ed in S ection 6.1, and E rik E rikson is discus sed S ection 6.2. Other theories of personality may be found C hapter 6, and child development and are covered in C hapter 32. S exual functioning, normal pathological, is discuss ed in C hapter 18. G eriatrics and normal aging are discus sed in C hapter 51. E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 Lippincott W illiams & W ilkins > T able of C ontents > V olume II > 50 - Adulthood > R E F E R E NC E

R E FE R E NC E S B lock J . L ive s through T ime . B erkeley, C A: B ancroft; C olarus so C A. C hild and Adult De ve lopment: A P s ychoanalytic Introduction for C linicians . New P lenum; 1992. C olarus so C A: S eparation-individuation process es middle adulthood: T he fourth individuation. In: S , K ramer S , eds . T he S eas ons of L ife. Northvale, Aronson; 1997. C olarus so C A: A developmental line of time sense: 4627 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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adulthood and throughout the life cycle. P s ychoanal S tudy C hild. 1998;53:113. C olarus so C A: T he development of time s ens e in adulthood. P s ychoanal Q . 1999;68:52–83. C olarus so C A. A child-analytic case report: A 17follow-up. In: C ohen J , C ohler B , eds. T he S tudy of L ive s over T ime . S an Diego, C A: Academic 2000. *C olaruss o C A: S eparation-individuation adulthood. Am J P s ychoanal. 2000;48:1467–1491. Dederick J G , Miller HL. T rans itions into adulthood: they the s ame for women and for men? In: Wainrib ed. G e nde r Is s ue s acros s the L ife C ycle . New Y ork: S pringer; 1992. E rikson E H. C hildhood and S ocie ty. 2nd ed. New Norton; 1963. G ould R . T ransformational tas ks in adulthood. In: P ollock G , G reenspan S , eds . T he C ours e of L ife. L ate Adulthood. Madison, W I: International P res s; 1993. *G uttmann DL. T he country of old men: C ultural in the psychology of later life. In: O ccas ional P ape rs G e rontology. 5th ed. Ann Arbor, MI: Institute of G erontology, Univers ity of Michigan; 1969.

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J acques E . T he midlife cris is . In: P ollock G , eds. T he C ours e of L ife. V ol 5. E arly Adulthood. WI: International Univers ities P ress ; 1993. K immel DC . Adult development and aging: A gay perspective. In: G arnets L, K immel D, eds . P ers pe ctives on L es bian and G ay Male E xperie nce . Y ork: C olumbia University P ress ; 1993. *Levinson DJ , Darrow C N, K lein E B . T he S eas ons Man's L ife . New Y ork: K nopf; 1978. Levinson G A. New beginnings at s eventy: A decade ps ychotherapy in late adulthood. In: T he R ace T ime : P s ychothe rapy and P s ychoanalys is in the Half of L ife . New Y ork: P lenum P ublis hing; 1985. Lyketsos C G , C hen L, Anthony J C : C ognitive adulthood: An 11.5-year follow-up of the B altimore E pidemiologic C atchment Area S tudy. Am J 1999;156: 58. McNally J A. T he Adult Developme nt of C are e r Army O fficers . New Y ork: P raeger; 1991. Nemiroff R A, C olarus so C A. T he R ace agains t P s ychothe rapy and P s ychoanalys is in the S e cond L ife. New Y ork: P lenum; 1985. Neugarten B L, B erkowitz H, C rotty W J , G ruen W , G uttman DL, Lubin MI, Miller DL, P eck R F , R os en S hukin A, T obin S S . P ers onality in Middle and L ate 4629 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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New Y ork: Atherton; 1964. P ers on E P . T he “cons truction” of femininity: Its throughout the life cycle. In: P ollock G , G reens pan eds. C ours e of L ife. V ol 5. E arly Adulthood. International Univers ities P res s; 1993. P lotkin F P : T reatment of the older adult. Am J P s ychoanal. 2000;48:1591–1616. *P ollock G H, G reenspan S I, eds . T he C ours e of C omple ting the J ourne y. Madison, W I: International Univers ities P ress ; 1998. S tevens -Long J . Adult development: T heories pas t present. In: Nemiroff R A, C olaruss o C A, eds. New Dime ns ions in Adult De velopme nt. New Y ork: B as ic B ooks ; 1990. V aillant G . Adaptation to L ife . B oston: Little, B rown; V aillant G : Natural his tory of male ps ychological 17. A forty-five year study of predictors of success ful aging at age 65. Am J P s ychiatry. 1990;147:31. V alens tein AF : T he older patient in psychoanalysis . P s ychoanal. 2000;48:1563–1589. V an G ennep A. T he R ite s of P as s age . C hicago: of C hicago P res s; 1960. V rdang E . Human B e havior in the S ocial 4630 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/50.htm

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New Y ork: T he Haworth S ocial Work P ractice P ress ; 2002. Wallers tein J : T he ps ychological tas ks of marriage: J O rthops ychiatry. 1996;66:217.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 51 - G eriatric P s ychiatry > 51.1 Overview

51.1 Overview P art of "51 - G eriatric P s ychiatry"

51.1a G eriatric P s yc hiatry: Introduc tion Lis s y F. J arvik M.D., Ph.D. Gary W. S mall M.D. Advances in medical technology have contributed to has been described as an age revolution, es sentially, a rapid growth in the proportion of the population in the upper age groups. T his older s egment of the U.S . population will continue to grow in the future (T able 51.1a-1). Although their expans ion slowed slightly the 1990s , because relatively fewer babies were born during the G reat Depress ion of the 1930s , the of so-called baby boomers is now rapidly approaching middle age and beyond, leading to an ever increas ing number of people 65 years of age and older. In the 2000, nearly 35 million people comprised this age and this figure will double to approximately 70 million 2030 and will reach 82 million by 2050. B y that time, projected proportion of older minority adults will be 35.7 percent, compared to 16.5 percent in 2000.

Table 51.1a-1 Aging Population of United S tates : 1900-2050 4632 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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Year

Median Age

Mean Age

Population, in Millions and Perc entage of Total

All Ages

65 and Older

85 and Older

(N)

(N)

(%)

(N)

(%

1900

76.0

3.1

4.1

0.1

0

1950

150.1

12.3

8.2

0.6

0

1990

248.7

31.1

12.5

3.0

1

2000

35.8

36.5

275.3

34.8

12.6

4.3

1

2010

37.4

37.9

299.9

39.7

13.2

5.8

1

2030

38.9

40.2

351.1

70.3

20.0

8.9

2

2050

38.8

40.7

403.7

82.0

20.3

19.4

4

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Adapted from P opulation: U.S . B ureau of the C ensus : P opulation R eports, S pecial S tudies, P 23190, 65+ in the United S tates . W ashington, DC : U.S . G overnment Office; 1996; and P rojections of the T otal R esident by 5-Y ear Age G roups and S ex with S pecial Age Middle S eries , 1999 to 2100 (NP -T 3). U.S . C ensus P opulation Division, P opulation P rojections B ranch; 2002. T he most rapidly growing s egment of the population is age group 85 years and older, the group with the morbidity and the highes t rate of ps ychiatric and comorbidities. T his age group grew 40-fold, from in 1900 to more than 4 million in 2000, and is projected reach 19.4 million by 2050 (T able 51.1a-1). T he accuracy of the previously mentioned projections depends on the accuracy of predictions concerning rates, immigration, and emigration, as well as death and life expectancies . P rojections concerning life expectancy, for example, can change substantially single decade. T hus , on the bas is of the 1980 census, life expectancy for women at birth was projected to continue to exceed that for men by 6.9 years until the 2050. After the 1990 cens us , however, new projections show the gap in life expectancy gradually diminis hing 4.6 years by 2050 (T able 51.1a-2). Indeed, the had already dropped to 5.4 years by the time of the cens us. In addition, the difference in life expectancy already declined at 65 years of age by 2.9 years as of 4634 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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1990 cens us (T able 51.1a-2). B y 2050, therefore, the composition of the U.S . population by age and s ex is es timated to differ markedly from that of 1990. S uch changes are bound to influence income and marital statis tics, the percent of elderly living alone or in longterm-care facilities , and other as pects of the s ocial network. T he social s tructure of ethnic groups is likely be affected by the different changes in the percentage elderly people experienced by various ethnic groups 51.1a-1).

Table 51.1a-2 L ife E xpec tanc y at B

 

At B irth

  Y ear

Men

Women

Difference

1900

46.3

48.3

2.0

1950

65.6

71.1

5.5

 

Men

1980 C ens us

Women

1990 C en

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1990

72.1

79.0

6.9

1990 a 2000

73.5

80.4

6.9

2000 a

71.8

78.8

71.8

78.8

73.0

79.7

74.1

79.5

2010

74.4

81.3

6.9

74.1

80.6

2030

75.4

82.3

6.9

76.9

82.4

2050

76.4

83.3

6.9

79.7

84.3

aUpdate

to 1990 cens us from NP -T 7 S ummary of F ertilit Middle, and Highes t S eries, 1999 to 2100. National P roj 2000. Actual life expectancies 19001990. Data from U.S . B ure United S tates . W ashington, DC : U.S . G overnment P rinti P rojected life expectancies for 20002050 (1990 census ) race and His panic origin: 1995 to 2050. U.S . B ureau of t P rinting Office; 1996:251130. Middle mortality as sumption: P rojected life expectancies of the United S tates, by age, sex and race: 1988 to 2080 1989:43.

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1990 actual data (under 1990 cens us ) from National C e Health S ervice, 1996.

FIGUR E 51.1a-1 P ercentages of persons 65 years of and older in different racial and ethnic groups: 1995 to 2050. (F rom Day J C : P opulation projections of the S tates by age, s ex, race, and Hispanic origin: 19954637 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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U.S . B ureau of the C ensus . C urre nt P opulation Was hington, DC : U.S . G overnment P rinting Office; with permiss ion.) P revalence data for mental dis orders in the elderly vary widely, but a conservatively estimated 25 percent of population has s ignificant ps ychiatric s ymptoms. T hus , number of elderly mentally ill totaled nearly 9 million in 2000 and will reach nearly 18 million by 2030, barring major advances in the prevention and treatment of geriatric psychopathology. In recognition of this trend, April 1991, the initial examination was offered for qualifications in geriatric ps ychiatry, the first area of specialization recognized within ps ychiatry in three decades. In 1988, it was estimated that the geropsychiatrist of 21st century will have, at bes t, approximately 20 to spend with each patient each year. T hat prediction as sumed that 34 geriatric ps ychiatris ts would complete training annually. Although the Department of V eterans Affairs funded additional positions, and some hospitals funding their own positions , that is s till not enough to fulfill the prediction of even the inadequate 20 minutes each patient each year. When cons idering how variations in the geographic distribution of the older population (F ig. 51.1a-2) the availability of geriatric psychiatrists , one must remember that s tates in which the elderly cons titute a higher percentage of the population are not neces sarily the states with the largest numbers of pers ons older 4638 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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65 years of age. F or example, C alifornia, with the number of individuals older than 65 years of age (3.6 million in 2000) ranked only 45th among the 50 U.S . in terms of the percentage of the population that is (10.6 percent). T he leader, F lorida (17.6 percent), had 2.8 million individuals older than 65 years of age in Nonetheles s, clearly, there will be so few geriatric ps ychiatris ts that mos t will be needed as clinical cons ultants and academic teachers, leaving the major burden of providing mental health care for elderly to their profes sional colleagues. C ons equently, every ps ychiatris t needs to know the basics of geriatric ps ychiatry.

FIGUR E 51.1a-2 P ercentage of the population that is years of age and older, by state: 1993. (F rom U.S . the C ens us . C urre nt P opulation R e ports , S pe cial 4639 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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190, 65+ in the Unite d S tates . W ashington, DC : U.S . G overnment P rinting Office; 1996, with permiss ion.) Why is s pecialized training in geriatric psychiatry emphasized? After all, is not geriatric psychiatry just general adult psychiatry applied to people who are elderly? T rue, many patients grow old with their and neuros es . Others remain well until their years and circums tances eventually exceed their ability to cope. It perhaps , the frequency and s everity of the s tres sors as sociated with aging that make geriatric psychiatry unique.

S TR E S S OR S High-ranking s tres ses of aging include acute and medical illness es (T able 51.1a-3), the concomitant us e therapeutic drugs, and the complicating drugdrug and drugdisease interactions. T hus, geriatric ps ychiatris ts be able to recognize the physical and mental ills of patients, as well as have s kills in the s ocial sciences, knowledge of the health care delivery s ys tem, and information about the availability of financial and s ocial supports, especially nurs ing homes (T able 51.1a-4). Medical illnes s connotes phys ical los s and changes in image. Moreover, self-as sess ment of health is with income (F ig. 51.1a-3). T he loss of one's job, P.3588 including voluntary and involuntary retirement, carries with it the loss of financial res ources, social s tatus, and much of the s ocial network (F ig. 51.1a-4 and F ig. 4640 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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the loss of contemporaries through death, illnes s, and migration brings not only ps ychological deprivation of intimate love object, but also a void that us ually unfilled; forming new relationships that res ult in is difficult in old age. In part, because of their greater expectancy, older women are more likely to live alone older men. P hysical limitations and the loss of friends frequently as sociated with res tricted mobility, which to further s ocial is olation and increased difficulty in pursuing the tasks of daily living, s uch as procuring and clothing and maintaining one's shelter. Often, are lost becaus e of financial strains and the inability to perform home upkeep. Many middle class widows , for example, have had to move from the five- to ten-room family homes, which they occupied for most of their to one-half of a room in a residential extended-care for the elderly. In addition to los ing most of their worldly poss ess ions and s ocial support, they als o lose their and their s ens e of self-worth.

Table 51.1a-3 Top Ten C hronic for Pers ons 65 Years of Age and O Age and R ac e: 1996 (Number per Pers ons )  

Age (Yrs )

R ac e (65 of Age a Older)

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  C ondition

4564

65+

6574

75+

White

Arthritis

240.1

482.7

453.1

523.6

477.6

Hypertension 214.1

363.5

356.0

373.8

348.1

Hearing impairment

131.5

303.4

255.2

369.8

320.3

Heart

116.4

268.7

238.2

310.7

278.2

C ataracts

23.3

171.5

151.9

198.6

174.8

Deformity or orthopedic impairment

177.8

157.6

175.1

133.5

161.9

C hronic sinus itis

174.1

117.1

127.0

103.5

118.3

Diabetes

58.2

100.0

98.4

102.3

87.5

T innitus a

59.6

87.7

95.0

76.2

90.7

V is ual impairment

48.3

84.2

69.6

104.3

86.1

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aT he

1989 s urvey order was the s ame except for tinnitus replaced vis ual impairment as number nine, and varicos was dropped from the list. F rom National C enter for Health S tatis tics: C urrent National Health Interview S urvey, 1996. (P HS ) 991528. G overnment P rinting Office stock number 017-01471-8, permis sion.

Table 51.1a-4 Nurs ing Homes : S el  

1985

Nurs ing homes (N)

19,100

B eds

 

   N 1,000

1,624

   N per nursing home

85

C urrent res idents

 

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   N 1,000

1,491

   Occupancy rate a (% )

91.8

F ull-time equivalent employment

 

   Adminis trative, medical, and

 

      N 1,000

N/A

      R ate per 100 beds

N/A

   Nursing

 

      N 1,000

N/A

      R ate per 100 beds

N/A

N/A, not available. aNumber

of res idents divided by the number of available

Adapted from the U.S . National C enter for Health S tatis t J anuary 23, 1997 and the C DC Web site: National Nurs at: ftp://ftp.cdc.gov/pub/Health_S tatis tics/NC HS /Datas ets /N

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FIGUR E 51.1a-3 S elf-as sess ment of health by income people 65 years of age and older: 1989. (F rom National C enter for Health S tatistics : C urrent estimates from the National Health Interview S urvey, 1989. In: V ital and S tatis tics . W ashington, DC : U.S . G overnment P rinting 1990, with permis sion.)

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FIGUR E 51.1a-4 Median income of elderly men and women by marital s tatus: 1989. (F rom the R es earch S ervice. C urre nt P opulation S urve y. DC : U.S . G overnment P rinting Office; 1990, with permis sion.)

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FIGUR E 51.1a-5 Income s ources of people 65 years of and older: 2000. (F rom F acts from E B R I: Income of the E lderly 2000, available at http://www.ebri.org/facts /0602fact.pdf. Access ed May 2004.) A technological development that may militate against such is olation is greater acces s to computers and the Internet, which provide older persons an opportunity to remain socially connected to family and friends. Older adults trail all other age groups with respect to 4647 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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ownership (25.8 percent) and Internet access (14.6 percent). B y contras t, hous eholds in the middle-age groups (35 to 55 years of age) lead all other age personal computer penetration (nearly 55 percent) and Internet acces s (>34 percent). Although data s how levels of access for older pers ons than for the general P.3589 population, it is encouraging that many older adults are beginning to maintain s ocial connections through the Internet.

HE TE R OG E NE ITY G eneralizations concerning the s tres ses of aging mus t viewed in light of the heterogeneity of the aged as a group, as well as the uniqueness of each older person. Individual variability characterizes the geriatric age not only in terms of chronological age, phys ical and mental vigor, socioeconomic res ources , educational background, ethnocultural heritage, s pirituality, and life experience, but also in terms of phys iological, genetic, and ps ychodynamic elements. At one end of spectrum is the healthy, active, involved person, younger than 85 years of age, whos e lifes tyle differs imperceptibly from that of the middle-aged adult, changed res ponsibilities (e.g., grandchildren, of increas ed ass ets , and es tate planning). Many in this group are retirees who are bus ier now than they were before retirement. At the other end of the s pectrum is frail octogenarian, nonagenarian, or centenarian by chronic illness , s ens ory loss , and debility, P.3590 4648 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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who has difficulty in proces sing information and performing the ess ential activities of daily living. Age is not the sole determining factor, as illustrated by J ohn G lenn's flight into s pace while in his mid-70s. T he geriatric psychiatrist mus t be aware of the vast individual variability in this age group and mus t be sens itive to the pos sibility that medical comorbidity, as well as atypical pres entation of ps ychiatric illnes s, may complicate diagnos is and treatment of frail elderly persons. S ubtle cues many have to be purs ued in detecting divers e disorders , s uch as major depres sion, subdural hematoma, cardiovascular disease, and or hematological dis eas e. Attention to ps ychiatric symptoms among the medically has become a focus for geriatric ps ychiatris ts. these patients were excluded not only from clinical but also from other res earch targeting uncomplicated patients with a single disorder (i.e., the disorder under study). P s ychiatric comorbidities are emerging as important factors in increas ing lengths of acute stays and frequency of medical complications , as well mortality. T herefore, geriatric psychiatrists are participating much more in the care of these patients . addition, psychogeriatric intervention can s ignificantly reduce inpatient cos ts. F urthermore, the geriatric ps ychiatris t must recognize that the impairment of functioning produced by ps ychiatric or medical illnes s be only temporary or may pers is t for prolonged either cas e, the goal is to maintain the individual in the least res trictive environment. Many older individuals embedded in a system: F amily members , friends, or 4649 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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neighbors are closely involved in activities of daily T he ps ychiatris t mus t be skilled in as sess ing the caregiver at risk for medical or ps ychiatric illnes s or subs tance abus e? Do caregivers need res pite, or are unable to continue caring for the older individual for reasons? Are there appropriate res ources in the community, such as day programs, as sis tance in the or group living s ituations? Does the community have access ible and affordable options for trans portation for older individuals? Is elder abus e present, whether abuse, neglect by s elf or others , or fiduciary abuse? and legal dilemmas that arise as people age mandate additional expertise in ass es sment and the ability to appropriate referrals. T he ps ychiatris t who treats older adults mus t be comfortable when collaborating with primary care phys icians and various s ubs pecialty physicians . T he to work with a multidisciplinary team is es sential. E ducation of phys icians , nonphys icians, older and their families is an important role for the geriatric ps ychiatris t. T he older adult must be able to access ps ychiatric care. B arriers to care include beliefs on the of health providers and individuals in the community, as I'd feel depress ed too, if I were old and sick, won't do any good, they'll only make her sicker, and person is too old for therapy. Older individuals may fear being labeled crazy if they s eek ps ychiatric K nowledge of beliefs of different cultures regarding and ps ychiatric illness contributes to improved acces s evaluation and treatment. Advocacy for the older adult by the psychiatrist and members of other dis ciplines will become increasingly 4650 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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important as guidelines for care, reimbursement and meas urement of outcomes are developed in the public and the private s ectors. Organizations s uch as National Alliance for the Mentally Ill (NAMI), the Ass ociation of R etired P ersons (AAR P ), the American Ass ociation for G eriatric P s ychiatry, and the Ass ociation will have input in many areas, including the aging chronically mentally ill. As managed care organizations enroll increas ing numbers of older adults, the need for adequate access to psychiatric care will emerge, as will the need for collaboration between ps ychiatris ts, other phys icians , and other health care profes sionals in the diagnosis and treatment of disorders . P.3591 T he quiet, apathetic 86-year-old brought to the office relatives convinced that something is wrong is readily dismiss ed as demented, probably experiencing disease, and bes t left undisturbed. In collaboration with the geriatric psychiatrist who makes the diagnosis of coexisting myocardial infarction and depres sed mood, type of patient can receive appropriate treatment for conditions. All psychiatrists , all phys icians, all mental health specialists , and all health care profes sionals bear in mind that most elderly patients are neither demented nor experiencing any other ps ychiatric and they mus t carry out their profess ional mandate to as sess carefully each patient, regardles s of age, before arriving at a diagnosis. T his means giving thoughtful cons ideration to the differential diagnosis, including the diagnos is of no me ntal dis order. 4651 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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B UR DE N OF C AR E As the cos t for extended-care facilities continues to skyrocket, fewer and fewer pers ons will be able to them; therefore, the burden of care is likely to increas e the adult children of mentally ill and physically frail parents . S ociety and psychiatry are ill prepared. As the sandwich generation'the adult children s andwiched between the needs of their parents and the needs of children'becomes more prominent and more s queezed, more facilities at affordable rates will be needed to treat the major mental disorders of old age, such as disease (called de me ntia of the Alzhe ime r's type in the revis ed fourth edition of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs [DS M-IV -T R ]), depress ion, anxiety. T hos e dis orders are frequently reasons for the dependence of elderly persons. Most dependence needs of elderly parents are being fulfilled by adult children, especially daughters . 1982 and 1994, there has been a s ubs tantial increas e percent) in the percentage of s ons and a marked (>40 percent) in the percentage of wives providing care (F ig. 51.1a-6). C aring for elderly parents rais es ps ychological is sues for the adult children. G eriatric ps ychiatris ts P.3592 may often be the mos t appropriate profes sionals to with those caregivers 'directly or in conjunction with mental health profess ionals 'becaus e their expertis e encompas ses the ps ychological, medical, and knowledge required for truly informed decision making. 4652 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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FIGUR E 51.1a-6 C aregivers and their relations hip to care recipient: 1982 and 1994. (C aregiver population includes primary and s econdary caregivers.) (F rom C ommittee on Aging, U.S . House of R epresentatives. E xploding the Myths : C are giving in America. U.S . G overnment P rinting Office; 1987, with

TR E ATME NT P sychiatrists are familiar with diverse treatment approaches and can use pharmacotherapy or ps ychotherapy, or both, as well as other s omatic E lderly persons require special techniques in all forms therapy. T he ps ychiatris t of an 87-year-old patient experiencing heart disease, arthritis, and depress ion as k a number of ques tions: W hat is the bes t treatment? P harmacotherapy? P s ychotherapy? E lectroconvulsive therapy (E C T )? If pharmacotherapy, what are the mos t appropriate drugs? B alancing adverse effects and what is the bes t dosage? W hat is the impact of genetic factors , as well as lifetime habits , on the optimal daily 4653 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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for individual patients? How s oon will the patient's symptoms decreas e? If the drug is effective, how long the improvement las t? If the drug is ineffective, how should the ps ychiatris t wait before changing the treatment? W ill the ps ychiatris t and patient have to for improvement without remis sion? C urrently, ps ychopharmacology is the mainstay of treatment in geriatric psychiatry. Advantages include acceptability to this cohort of patients accus tomed to medication treatment of other dis orders, ability of nonps ychiatris ts to prescribe thes e drugs , and ability to obtain reimbursement. Dis advantages include advers e effects (even with newer medications), drugdrug interaction, and interaction of medication with exis ting disease process es. P sychos ocial treatments have not yet gained for several reasons: R esults become evident later than pharmacotherapy; it may be more difficult to quantify evaluations of treatment effectiveness , because such res earch usually fails to qualify for financial s upport the pharmaceutical indus try or comparable private deep pockets ; exis ting data s pecifically addres sing adults are limited; treatments tend to be more than pharmacotherapy, even if adminis tered in group settings ; and reimbursement is often problematic. A metaanalysis of s tudies reported between 1974 and indicates that s ome of thes e treatments , s pecifically, cognitive-behavioral, behavioral, and psychodynamic treatments , are significantly better than placebo (F ig. 51.1a-7).

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FIGUR E 51.1a-7 Metaanalys is: pharmacological and ps ychological treatment for depres sed older persons. Initial and final Hamilton Depress ion (HAMD) S cale by type of treatment. Minimum and 25th percentiles coincide for nondrug groups. All HAMD scores unweighted values (see reference for weighted T otal percent dropout by type of treatment. Minimum coincides with 25th percentile, and maximum coincides with 75th percentile for other nondrug group. behavioral, behavioral, and psychodynamic therapies. **C enter line repres ents the median, bottom edge represents the 25th percentile and top edge repres ents 75th percentile, and extreme points are at the minimum and maximum. S S R I, s elective serotonin reuptake T C A, tricyclic antidepres sant. (F rom G erson S A, B elin K aufman A, et al.: P harmacological and ps ychological treatments for depress ed older patients: A metaand overview of recent findings. Harvard R e v 1999:7:128, with permiss ion.) E C T is an effective treatment for depress ion in elderly 4655 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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patients. However, its effectiveness and s afety have been widely recognized because of politically charged is sues. E C T should be considered es pecially in frail individuals whos e nutritional s tatus and activity level deteriorated s ignificantly, becaus e it may result in rapid improvement. T he ris k of memory loss must be agains t the adverse effects and drug interactions of ps ychotropic medication. P.3593

E AR L Y DE TE C TION AND S TR ATE GIE S Many age-related illnes ses develop ins idious ly and gradually progres s over the years. T he mos t common caus e of late-life cognitive impairment, Alzheimer's disease, is characterized neuropathologically by a accumulation of neuritic plaques and neurofibrillary tangles in the brain. C linically, one s ees a progress ion cognitive decline that begins with mild memory loss ends with s evere cognitive and behavioral B ecaus e it will likely be easier to prevent neural than to repair it once it occurs , inves tigators are developing s trategies for early detection and age-related illnes ses, such as Alzheimer's disease. C ons iderable progres s has been made in the detection component of this s trategy, us ing brain imaging technologies , s uch as pos itron emis sion tomography functional magnetic res onance imaging (MR I), in combination with genetic ris k meas ures . W ith thes e approaches, s ubtle brain changes can now be detected that progres s and can be followed over time. S uch 4656 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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surrogate markers allow clinical s cientists to track progres sion and to tes t novel treatments des igned to decelerate brain aging. C linical trials of cholines terase inhibitor drugs , anticholesterol drugs, antiinflammatory drugs, and others (e.g., vitamin E ) are in progres s to determine if s uch treatments delay the ons et of Alzheimer's disease or the progres sion of brain or cognitive decline. Novel approaches to meas uring the phys ical evidence Alzheimer's disease, the plaques and tangles in the cerebral cortex, have been s ucces sful in initial s tudies will likely facilitate the testing of innovative treatments designed to rid the brain of these pathognomonic S cientists may not be able to cure Alzheimer's diseas e advanced stages , but they may be able to delay its effectively, thus helping patients live longer without the debilitating manifes tations of the dis eas e, including cognitive decline.

FUTUR E DIR E C TIONS Little is known about the needs of elderly patients in 21st century. W hat will happen to the V ietnam-era and G ulf W ar veterans who experience posttraumatic disorder (P T S D) and to s imilarly afflicted victims of and s urvivors of genocide in Africa, Asia, the Middle and E as tern E urope? S ubs tance abus e and its longeffects will undoubtedly as sume increas ed importance the youths of the 1960s enter the geriatric age groups . the trend toward decreasing alcohol and nicotine abus e continue among elderly persons (F ig. 51.1a-8)? ps ychiatris ts of the 21st century will have to be alert to acquired immune deficiency syndrome (AIDS ) 4657 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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among elderly persons (F ig. 51.1a-9), as improved treatments prolong the lives of thos e testing positive for human immunodeficiency virus. F urthermore, genetic factors will probably ass ume increasing importance in elucidating sus ceptibility and res is tance not only to but also to C reutzfeldt-J akob disease, bovine encephalopathy (mad cow dis eas e), and other transmis sible dis eas es . E xpertise in molecular genetics help geriatric ps ychiatris ts participate actively in the causes and cures of other dementing (e.g., disease) and nondementing (e.g., mood disorders and anxiety dis orders) illness es afflicting the elderly population.

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FIGUR E 51.1a-8 Alcohol use and cigarette smoking in elderly. P ercentages of people s urveyed reporting that were current s mokers or drinkers . (Data adapted from B ureau of the C ens us. C urre nt P opulation R e ports , S tudie s , P 23-190, 65+ in the Unite d S tates . U.S . G overnment P rinting Office; 1996.)

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FIGUR E 51.1a-9 Acquired immune deficiency deaths in patients under 20 years of age and 60 years age and over: 1987 to 1992. (Data adapted from U.S . of the C ensus . C urre nt P opulation R e ports , S pecial P 23-190, 65+ in the Unite d S tates . W ashington, DC : G overnment P rinting Office; 1996.) Although ps ychiatris ts delight in the advances made in neuroimaging, brain mapping, and other technological approaches to the neurocognitive aspects of disease and look forward to the dis covery of additional genes for the major ps ychiatric illnes ses, progress has slow when it comes to converting knowledge gained in these areas into effective treatments or prevention. G eriatric ps ychiatris ts of the 21s t century will not only increase their collaboration with primary care increasing numbers of frail elderly pers ons are in the community, but they will also find thems elves in 4660 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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new settings as aged individuals increas ingly become of the penal P.3594 system. R egardles s of how divers e the area of geriatric ps ychiatry, when it comes to treating the individual patient, it will s till be the psychiatrist's clinical skills 'grounded in s cientific knowledge'that will ensure that the patient receives the bes t care that medicine offer, and it is likely that the psychiatrist will s till the roles of family doctor, friend, parent, and child to geriatric patient. It is an awesome respons ibility for ps ychiatris ts need to be prepared.

S UG G E S TE D C R OS S -R E FE R E NC E S Normal aging is discus sed in S ections 51.2b and neuroimaging is dis cuss ed in S ections 51.2e and 51.3f, Alzheimer's disease and other dementing disorders are discuss ed in S ection 51.3e, psychiatric problems in medically ill geriatric patients are discus sed in S ection 51.3a, s ociocultural and minority is sues are dis cus sed S ection 51.6d, and financial is sues are dis cus sed in 51.5a. AIDS is dis cus sed in S ections 2.8 and 49.5.

R E FE R E NC E S American G eriatric S ociety, American Ass ociation G eriatric P sychiatry: C onsensus s tatement on the quality of mental health care in U.S . nursing Management of depres sion and behavioral as sociated with dementia. J Am G eriatr S oc. 2003;51:12871298. 4661 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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B aldwin R C , Anders on D, B lack S , E vans S , J ones Wilson K , Iliffe S ; F aculty of Old Age P sychiatry G roup, R oyal C ollege of P sychiatrists : G uideline for management of late-life depres sion in primary care. G e riatr P s ychiatry. 2003;18:829838. C ens us 2000 P HC -T -13. P opulation and R anking of the Older P opulation for the United S tates, S tates , P uerto R ico, S ource: U.S . C ensus B ureau, C ens us S ummary F ile 1; 1990 C ensus of P opulation, P opulation C haracteristics , United S tates (1990 C P Available at: http://www.cens us.gov/population/cen2000/phct13/tab03.pdf. *C harney DS , R eynolds C F 3rd, Lewis L, Lebowitz S underland T , Alexopoulos G S , B lazer DG , K atz IR , Meyers B S , Arean P A, B ors on S , B rown C , B ruce C allahan C M, C harlson ME , C onwell Y , C uthbert Devanand DP , G ibson MJ , G ottlieb G L, K ris hnan Laden S K , Lyketsos C G , Muls ant B H, Niederehe G , J T , Oslin DW , P ears on J , P ersky T , P ollock B G , S , R eynolds M, S alzman C , S chulz R , S chwenk T L, S colnick E , Unutzer J , W eis sman MM, Y oung R C ; Depress ion and B ipolar S upport Alliance: and B ipolar S upport Alliance cons ens us statement the unmet needs in diagnos is and treatment of disorders in late life. Arch G e n P s ychiatry. 2003;60:664672. Devanand DP : T he interrelations between behavioral disturbance, and depress ion in Alzheimer 4662 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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disease. Alzhe ime r Dis As s oc Dis ord. 1999;13 2]:S 3S 8. F alling through the Net: Defining the Digital Divide (1999). National T elecommunications and Administration (NT IA) U.S . Department of Web site. Available at: http://www.ntia.doc.gov/ntiahome/fttn99/introduction.html G erson S , B elin T R , K aufman A, Mintz J , J arvik L: P harmacological and ps ychological treatments for depres sed older patients : A meta-analysis and of recent findings . Harvard R e v P s ychiatry. Iqbal K , S is odia S S , W inblad B , eds . Alzhe ime r's Advances in E tiology, P athoge nes is and P rocee dings of the 7th Inte rnational C onfere nce on Alzhe ime r's Dis e as e and R elate d Dis orde rs . Wiley & S ons; 2001. P.3595 J arvik L, S mall G . P are ntcare . New Y ork: B antam; K nopman DS , DeK osky S T , C ummings J L, C hui H, B loom J , R elkin N, S mall G W , Miller B , S tevens J C : P ractice parameter: Diagnos is of dementia (an evidence-based review): R eport of the Quality S tandards S ubcommittee of the American Academy Neurology. Neurology. 2001;56:11431153. K omins ki G , Andersen R , B as tani R , G ould R , 4663 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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Huang D, J arvik L, Maxwell A, Moye J , Ols en E , R ohrbaugh R , R os ans ky J , T aylor S , V an S tone W : UP B E AT : T he impact of a psychogeriatric V A medical centers . Unified P sychogeriatric B iopsychosocial E valuation and T reatment. Me d 2001;39:500512. Oslin DW , Datto C J , K allan MJ , K atz IR , E dell W S , T enHave T : As sociation between medical and treatment outcomes in late-life depres sion. J G e riatr S oc. 2002;50:969970. R as gon N, J arvik LF : Ins ulin resis tance, affective disorders and Alzheimer's disease: R eview and hypothes is. J G e rontol A B iol S ci Me d S ci. discuss ion, 184192. S adavoy J , J arvik LF , G ros sberg G T , Meyers B , C omprehe ns ive T e xtbook of G eriatric P s ychiatry-III. Y ork: Norton, Inc.; 2004. *S alzman C , ed. C linical G e riatric 3rd ed. B altimore: W illiams & W ilkins ; 2003. *S chneider LS , R eynolds C F , Lebowitz B D, eds. Diagnos is and T re atme nt of De pre s s ion in L ate R es ults of the N IH C ons e ns us Developme nt Was hington, DC : American P s ychiatric P res s; 1994. S eeman T E , B erkman LF , C harpentier P A: ps ychos ocial predictors of phys ical performance: MacArthur s tudies of s ucces sful aging. J G e rontol 4664 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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S ci. 1995;50:M177M183. S hoghi-J adid K , S mall G W , Agdeppa E D, K epe V , LM, S iddarth P , R ead S , S atyamurthy N, P etric A, S C , B arrio J R : Localization of neurofibrillary tangles (NF T s ) and beta-amyloid plaques (AP s ) in the living patients with Alzheimer's dis eas e. Am J P s ychiatry. 2002;10:2435. S mall G W : G eriatric psychiatry fellows hip C ris is or opportunity? Am J G eriatr P s ychiatry. 1993;1:6773. S mall G W : Inves tigations into geriatric ps ychiatry challenges: AAG P S enior Inves tigator Award 2000. G e riatr P s ychiatry. 2000;8:276283. S mall G W . T he Me mory B ible . New Y ork: Hyperion; S mall G W : What we need to know about age related memory loss . B MJ . 2002; 324:15021505. S mall G W . T he Me mory P re s cription. New Y ork: 2004. *S mall G W , R abins P V , B arry P P , B uckholtz NS , S T , F erris S H, F inkel S I, G wyther LP , K hachaturian Lebowitz B D, McR ae T D, Morris J C , Oakley F , LS , S treim J E , S underland T , T eri LA, T une LE : and treatment of Alzheimer dis eas e and related disorders : C ons ens us s tatement of the American Ass ociation for G eriatric P s ychiatry, the Alzheimer's 4665 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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Ass ociation, and the American G eriatrics S ociety. 1997;278:13631371. T abbarah M, C rimmins E M, S eeman T E : T he between cognitive and physical performance: MacArthur S tudies of S ucces sful Aging. J G e rontol S ci Me d S ci. 2002;57:M228M235. T ariot P N, R yan J M, P ors teinss on AP , Loy R , LS : P harmacologic therapy for behavioral s ymptoms Alzheimer's disease. C lin G e riatr Me d. *U.S . C ensus B ureau. F acts and F igures: S tatis tics Minority Aging in the U.S . P rojected Distribution of P opulation Age 65 and Older, by R ace and His panic Origin, 2000 and 2050; access ed on J une 23, 2004. Available at: http://www.aoa.gov/prof/s tatistics /census2000/minoritys u

51.1b E pidemiology of P s yc hiatric Dis orders C elia F. Hybels Ph.D. Dan G. B lazer II M.D., Ph.D. E pidemiology is the study of the frequency, distribution, and determinants of dis eas e in populations. As a epidemiology has much to offer geriatric psychiatry through studying the frequency and distribution of ps ychiatric disorders in late life, as well as their ris k factors, and outcomes in this population. Inherent epidemiology is cas e definition, as well as the identification of cases in populations. In examining the 4666 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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epidemiology of ps ychiatric dis orders in older adults, epidemiologists meas ure the prevalence of the disorders 'the number of cas es pres ent in the a particular point in time'as well as the incidence of the disorders 'the number of new cas es that develop in this older population within a s pecified time period. T he incidence and the duration of a dis order affect its prevalence. F or example, disorders that have a slow progres sive course, such as Alzheimer's disease, are to increas e in prevalence if the incidence increases no treatment is found. T o meas ure determinants of the frequency of psychiatric disorders , epidemiologists ris k factors for the onset of the disorders and correlates the disorders as they affect the course of the illness . C as e identification of ps ychiatric dis orders in late life presents s pecial challenges. Not only can these occur for the first time in late life, but their presentation older adults may also be different from that s een in younger adults . In addition, through their comorbidity with phys ical illness and other mental dis orders , ps ychiatric disorders in older adults present diagnostic, prevention, and treatment challenges to health care profes sionals. T his chapter provides a des cription of the aging and an overview of the prevalence of psychiatric disorders in older adults . Is sues such as cas e definition detection are address ed, as well as factors that affect prevalence reported in the res ults of research s tudies, as the type of s tudy sample, potential bias , and cohort effects. E pidemiological data for several psychiatric disorders and their as sociated subclinical forms are provided in preparation for the more specific material 4667 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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each dis order presented in later chapters. F inally, the chapter concludes with the potential impact of these disorders on health care services in the future.

DE MOG R APHIC S OF AGING According to data from the 2000 C ens us , 13 percent of population in the United S tates is 65 years of age or A total of 1.6 percent of the population is 85 years of or older. T hese oldest old are projected to reach 20 by the year 2050 and to make up 5 percent of the U.S . population. E ven within the next 30 years, the of pers ons 65 years of age or older in the United S tates expected to double and is expected to be 70 million persons by the year 2030. S imilar increas es the proportion of older adults are also expected outs ide the United S tates , as better treatments for chronic and other phys ical illnes s become available. T hes e projections s ugges t that, even if the proportion of older adults with a current ps ychiatric disorder remains unchanged, the number of older pers ons with a will likely increas e over the next several decades . In addition, the proportion of younger adults with a ps ychiatric disorder (excluding the dementias ) is much higher than the proportion among older adults, suggesting that, as current younger cohorts age, the proportion of older adults with a ps ychiatric dis order increase as well. F inally, as better treatments for illness are developed, the proportion of adults with a mental disorder s urviving to old age may increas e. S ome forecasters have es timated the prevalence of mentally ill adults in the United S tates will increase by least 10 percent in the next 30 years and that the 4668 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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of older adults with a psychiatric disorder will be 15 by the year 2030. T hes e numbers emphas ize the importance of unders tanding the epidemiology of ps ychiatric disorders in older adults.

PR E VAL E NC E OF PS YC HIATR IC DIS OR DE R S IN OL DE R ADUL TS Although conducted in the late 1970s and early 1980s, E pidemiological C atchment Area (E C A) s urvey landmark study of the prevalence of ps ychiatric among older adults in the United S tates . T he E C A was es tablished to determine the prevalence and incidence of ps ychiatric disorders and the use of health services acros s all age groups of adults 18 years of older. T he E C A s urveys were conducted in five U.S . communities' New Haven, C onnecticut; B altimore, Maryland; S t. Louis, Mis souri; Durham, North C arolina; Los Angeles, C alifornia. A total of 18,571 persons participated, including 5,702 persons 65 years of age older. P.3596 P sychiatric dis orders were measured using the Interview S chedule (DIS ), a s tructured interview from which Diagnos tic and S tatis tical Manual of Me ntal (DS M) diagnoses can be established, which was adminis tered by trained lay interviewers. Across all five E C A s ites, the 1-month prevalence of disorder in adults 65 years of age or older was 12.3 percent, compared to 16.9 percent in adults 18 to 24 of age, 17.3 percent in those 25 to 44 years of age, percent in those 45 to 64 years of age. W ith the 4669 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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of s evere cognitive impairment, the prevalence of each disorder was lower in those 65 years of age or older compared to other adults. T he mos t prevalent disorder among those in the older age group, excluding the dementias , which were not as sess ed in the E C A was any anxiety dis order with a prevalence of 5.5 T his was lower than the 7.7 percent in adults 18 to 24 of age, 8.3 percent in those 25 to 44 years of age, and percent in those 45 to 64 years of age. T he prevalence any mood dis order was 2.5 percent in thos e 65 years age or older, compared to 4.4 percent in adults 18 to years of age, 6.4 percent in those 25 to 44 years of 5.2 percent in thos e 45 to 64 years of age. T he of severe cognitive impairment in those 65 years of age older was 4.9 percent. T he prevalence of s elected ps ychiatric disorders in adults 65 years of age or older the E C A survey by gender is shown in F ig. 51.1b-1. disorders , with the exception of s ubs tance us e, alcohol abuse and dependence, and s evere cognitive the prevalence was higher in older women than in older men. T he prevalence of any DIS disorder, excluding dementias , was 10.5 percent in men 65 years of age or older and 13.6 percent in older women.

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FIGUR E 51.1b-1 One-month prevalence of ps ychiatric disorders in adults 65 years of age or older by gender. Diagnos tic Interview S chedule. T he findings from the E dmonton study, which followed the E C A and us ed similar methods , were consis tent. month prevalence of any DIS disorder in communitydwelling adults 65 years of age or older, also excluding dementias , was 10.9 percent, with 11.7 percent in compared to 9.9 percent in men. Although the E C A surveys were s cientifically rigorous, some geriatric psychiatrists have sugges ted that the studies underestimated the prevalence of ps ychiatric disorders in older adults and that the true prevalence of older adults with s ignificant ps ychopathological 4671 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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symptoms may be closer to 19.6 percent. Data from recent studies conducted in the United S tates , as well other countries , among persons 60 years of age or have added much information concerning the of and ris k factors for various ps ychiatric disorders and their ass ociated subclinical forms in late life. Although have publis hed varying prevalence estimates of the disorders , these studies have concluded that the mental illness in older adults is a significant public problem. T he reported prevalence (and incidence) of ps ychiatric disorders in late life can be influenced by a variety of factors , including cas e definition, s ampling iss ues , potential bias, and cohort effects. E ach of thes e factors discuss ed in the following sections .

C as e Definition If s trict diagnos tic criteria are applied, the prevalence of ps ychiatric disorder is generally lower than if the for a case are more relaxed. F or example, the fourth of the DS M (DS M-IV ), the revised fourth edition of the (DS M-IV -T R ), the earlier versions of the third edition of DS M (DS M-III), and the revised third edition of the (DS M-III-R ) define cases by the presentation of specific symptoms, often within a specific time period. W ithin DS M, certain hierarchical s tructures are in place, such if individuals meet criteria for one disorder, they may be eligible for a s econd dis order. T herefore, individuals with current major depres sion, for example, may not be eligible for a diagnosis of primary anxiety disorder, all anxiety criteria are met. T hese differences can affect reported prevalence. In s ome studies, hierarchical 4672 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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exclusion criteria have been applied, which can res ult lower reported prevalence of some dis orders than if hierarchical exclusion criteria are not applied. T he E C A prevalence data reported in this chapter do not take account hierarchical exclus ion criteria. T here are s everal ins truments that can be us ed to persons with a s pecific dis order that corresponds to the DS M nomenclature. S pecifically, the DIS was the National Ins titute of Mental Health in the 1980s for E C A program and was bas ed on the nomenclature in at the time at which the E C A s tudies were conducted (DS M-III). S imilarly, the C omposite International Interview (C IDI) corres ponds to DS M-III-R criteria and, the DIS , can be adminis tered by trained lay T he S tructured C linical Interview for DS M-IV -T R another structured ins trument to make clinical Ins truments have also been developed that correspond the tenth edition of the Inte rnational S tatis tical C las s ification P .3597 of Dis e as e s and R e late d Health P roble ms (IC D-10) T he G eriatric Mental S tateAutomated G eriatric E xamination for C omputer Ass is ted T axonomy (G MS AG E C AT ) has been used in many s tudies in E urope to identify clinically s ignificant s ymptoms of depres sion, dementia, and other disorders that allow clinicians to identify cas es . Other ins truments us ed widely in clinical and epidemiological res earch identify s pecific s ymptoms than diagnostic criteria for selected dis orders. F or the C enter for E pidemiologic S tudiesDepress ion (C E S 4673 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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S cale and the G eriatric Depress ion S cale (G DS ) depres sive s ymptomatology, whereas the Mini-Mental S tate E xamination (MMS E ) meas ures cognitive impairment. It is important to note that many epidemiological s tudies of mental illness in older adults include individuals as cas es who do not neces sarily the diagnostic criteria for a particular psychiatric (s uch as clinically significant depres sive symptoms that not meet criteria for depres sion). P revalence and es timates can vary, therefore, depending on the instrument us ed to define the cases and whether symptoms or disorders are being reported. Many older adults have clinically significant s ymptoms that, in number or duration, do not meet the DS M-IV (or DS M-IV -T R ) or IC D-10 criteria yet are as sociated with decreased physical and s ocial functioning and overall quality of life, particularly subs yndromal depres sion mild cognitive impairment. S ince the 1990s , there has been much focus on thes e s ubs yndromal disorders general, whether the diagnos tic nomenclature is les s applicable to older adults. As described later in this chapter, the prevalence of these s ubclinical forms of disorders is high and, for some dis orders, may be more representative of the dis order in older adults . Other factors affect cas e identification. P revalence es timates may be bas ed on occurrence of s ymptoms within the past month, 6 months, 1 year, or lifetime, so, example, the 1-month prevalence is us ually much than the lifetime prevalence, except for disorders that not remit. Age of ons et may affect the lifetime of a disorder. Older adults may not recall the age at symptoms were first experienced or even if they have 4674 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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experienced a prior epis ode. T he reported prevalence be affected if the dis order had to appear before a age to satisfy the diagnostic criteria. F or example, res trictions of the diagnosis of schizophrenia to an age onset before 45 years of age reduced the prevalence es timates of schizophrenia among the elderly. C ase detection in late life is also complicated by the fact that many ps ychiatric dis orders appear for the firs t time at a younger age and then reappear in late life. F inally, it is difficult to distinguis h ps ychiatric s ymptoms in older adults that have a ps ychogenic origin from those that res ult from medication us e or a phys ical illness . Older adults may experience symptoms of depress ion or cognitive impairment that are the res ults of medication us e and may be mis class ified as having a ps ychiatric disorder. S imilarly, the older adults may experience virtually all of the symptoms of major depres sion; yet symptoms may be attributed to a phys ical illness .

S ampling Is s ues and S ourc es of P revalence and incidence estimates can be affected by source of s ubjects s tudied and other sampling is sues. example, the prevalence of clinically s ignificant symptomatology among older adults is generally higher patient samples than in community s tudies . T he prevalence of dementia in older adults is higher in from long-term-care facilities compared to s amples of community-dwelling older adults. P sychiatric disorders which adults may be les s likely to s eek treatment may quite prevalent in community s amples , yet rarely in clinical samples . F or example, one of the most findings from the E C A surveys was the high prevalence phobic disorder in the community population of elders . 4675 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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B ecaus e individuals may be unlikely to seek treatment, prevalence was not known until a large-scale sample was undertaken. Older adults may be more likely than younger adults to experience a phys ical illness or to be in a long-termfacility, which can complicate or preclude their participation in a study that us es a repres entative res ulting in an underestimate of the true prevalence of ps ychiatric disorders among older adults. S imilarly, epidemiological s tudies do not include persons older 65 years of age in the study des ign. Additionally, some older adults may not be cognitively able to give consent and to participate in res earch studies . If individuals with dementia are more likely to have depres sive symptoms than those without dementia, and demented subjects excluded, the prevalence of depres sive underes timated. F inally, older adults may refus e to consent to res earch s tudies , or their family may refus e to allow to participate. If these pers ons are more likely to have clinically significant symptoms of mental illness , differential patterns of nonres pons e can result. In particular, studies in which elderly volunteers are may be more likely to enroll healthier s ubjects than one would get in a random s ample. T here are s everal types of biases that can affect the prevalence of ps ychiatric disorders in older adults from res earch studies . Mis class ification bias is an is sue. S pecifically, if the current nomenclature is less applicable to older adults, elderly subjects may be misclas sified as not meeting criteria for the disorder. bias is important in studies of older adults. S election 4676 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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should be considered, in that prevalence estimates can affected by s elective survival, that is , only the adults s urvive to old age. As is discus sed later in this chapter, s uicide rates increas e in late life, which can the prevalence of disorders such as major depres sion.

C ohort E ffec ts C ohort effects can als o affect the prevalence of disorders in older adults . It is important to determine if observed prevalence of a psychiatric disorder in a particular age group is likely to remain s table over time (that is , age is a major determinant of the disorder) or whether the prevalence is likely to be ass ociated with a particular cohort. F or example, individuals born 75 ago may carry less burden of ps ychiatric disorders drug or alcohol abuse compared to adults born in more recent years . In addition, elders today may have fewer ps ychiatric disorders, becaus e they have always been healthier, having survived such occurrences as the flu epidemic of 1918, the G reat Depres sion, and W orld In comparing the prevalence of ps ychiatric disorders acros s s tudies , it is important to note in what time the particular research was conducted and whether a particular characteristic of a cohort could affect the reported prevalence.

E PIDE MIOL OGY OF S E L E C TE D PS YC HIATR IC DIS OR DE R S IN ADUL TS A lzheimer's Dis eas e and Other Dementias S ince the 1980s, many epidemiological s tudies have 4677 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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conducted to determine the prevalence and incidence dementia in older pers ons in community and populations. T he overall prevalence es timates of in pers ons 65 years of age or older range from approximately 1 to 20 percent, depending on how dementia was defined in the research study, as well as population s ampled. In the recent C anadian S tudy of Health and Aging, a large repres entative s ample of 65 years of age or older res iding in the community (N = 9,008) and in institutions (N = 1,255), the prevalence of dementia was estimated to be 8 percent. T he of severe dementia reported from epidemiological is somewhat lower than when mild and s evere forms of dementia are combined and ranges from les s than 1 percent to 7 percent. In the E C A surveys, the severe cognitive impairment in noninstitutionalized 65 years of age or older was 4.9 percent. T he prevalence of dementia in institutional s amples is generally higher than that reported in community samples . T he E dmonton s tudy reported that more than two-thirds of the institutional population (69 percent) mild or s evere cognitive impairment, whereas the prevalence of mild impairment in the hous ehold s ample was 3.5 P.3598 percent, and s evere impairment was not found outs ide institutional sample. Alzheimer's disease is the mos t common subtype of dementia among older adults, although other forms of dementia, including vascular dementia (dementia res ulting from cerebrovas cular dis eas e), are not 4678 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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uncommon. In the C anadian S tudy of Health and the prevalence of Alzheimer's dis eas e was 5.1 percent, whereas the prevalence of vas cular dementia was 1.5 percent. Although less prevalent, other s ubtypes , including dementia with Lewy bodies , frontal lobe dementia, mixed dementia, P arkins on's dementia, and unspecified dementia, have all been noted in samples of older adults . S ome geographic or ethnic differences in prevalence subtype have been noted. T he prevalence of disease is higher among African Americans compared whites. Among whites , the vast majority of the is of the Alzheimer's type, whereas , in Asian approximately 60 percent of the dementias are of the vascular type. T he prevalence of dementia and cognitive impairment higher in older age groups. In the E C A s tudy, the prevalence of severe cognitive impairment was 2.9 in adults 65 to 74 years of age, 6.8 percent in those 75 years of age, and 15.8 percent in thos e adults 85 years age or older. T he proportion of adults with dementia is es timated to double every 5.1 years after 65 years of S pecifically, the es timated prevalence of dementia is percent in those 60 to 64 years of age, increasing to percent in those 80 to 84 years of age, 20.8 percent in those 85 to 89 years of age, and 38.6 percent in those 95 years of age. T he prevalence of Alzheimer's doubles exponentially, from roughly 0.5 percent at 65 69 years of age, to 8 percent at 80 to 85 years of age, 20 percent at 90 years of age and older. Difficulties sampling prevent inves tigators from accurately determining if the prevalence of dementia continues to 4679 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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increase or levels off after 90 years of age. In the E C A s tudies , the prevalence of severe cognitive impairment in those 65 to 74 years of age was higher men (4.2 percent) than in women (1.9 percent), but the prevalence was higher in females in the older age Among thos e 85 years of age or older in the E C A, the prevalence of severe cognitive impairment was 8.2 in men and 19.5 percent in women. Alzheimer's has been found more often in older women in s ome studies, yet a true difference in prevalence by gender remains to be determined. Incidence s tudies do not a gender difference. V as cular dementias are more common in men, probably owing to a higher hypertens ion in men compared to women. T he incidence of dementia and Alzheimer's dis eas e ris es exponentially with age at least to as old as 85 or years of age. It is not clear if the incidence of vas cular dementia follows a similar exponential increase with T he es timated incidence of dementia among persons 69 years of age is 2 to 7 per 1,000 person-years at risk, ris ing to 40 to 100 or more per 1,000 pers on-years at after 90 years of age. T he incidence of mild cas es of dementia is twice that of the incidence of moderate or s evere dementia. A recent study in Australia reported a 10 percent increase in the incidence of mild plus (mild, moderate, or severe) dementia with each year of age, a s imilar pattern for Alzheimer's disease. T he incidence mode rate plus (moderate or severe) dementia was T he incidence of vascular depres sion was not affected age. Although there do not appear to be gender differences in the incidence of dementia, women tend 4680 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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have a higher incidence of Alzheimer's disease in old whereas men tend to have a higher incidence of dementia at younger ages . R is k and protective factors for Alzheimer's disease, dementia, and cognitive decline continue to be inves tigated extens ively in epidemiological s tudies . A family history of dementia, Down s yndrome, or disease is a risk factor for dementia. In one genetic the relative risk of developing Alzheimer's dis eas e in with one firs t-degree relative affected was 2.6 those with no relative. T he relative ris k was 7.5 in those with two first-degree relatives with Alzheimer's disease. R ecent studies over the last decade have found the E 4 allele of apolipoprotein E (apoE ) on chromos ome 19 to a s us ceptibility gene for the development of disease. Head trauma and exposure to aluminum have been s uggested as risk factors for Alzheimer's dis ease, the res ults of epidemiological studies have been mixed. R is k factors for vascular dementia have been les s but include hypertension, diabetes mellitus , and cardiovascular dis eas e. W hether mild cognitive impairment leads to later Alzheimer's disease is not known. S everal pos sible protective factors have been Higher education is as sociated with a decreased ris k of Alzheimer's disease, perhaps owing to increased res erves. T aking nonsteroidal antiinflammatory drugs also been shown to be a protective factor agains t onset Alzheimer's disease. S ome factors, s uch as es trogen, been s tudied as protective factors for the ons et of Alzheimer's disease, but results have been T he relations hip between s moking history and 4681 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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not clear, but some s tudies have shown a decreas ed Alzheimer's disease in s mokers . A history of depres sion has been identified as a risk for dementia, but it is difficult to es tablis h caus ality. Depress ion may be the res ult of an awareness of early cognitive decline. Depress ion and dementia may also share common ris k factors . Older adults with dementia at increas ed risk of mortality, and survival may be patients with vas cular dementia than in patients with Alzheimer's disease. Although depress ion has been to be a risk factor for cognitive decline, cognitive has been shown to be a ris k factor for onset of thus leading some to s uggest unique diagnos tic criteria depres sion in dementia (especially Alzheimer's T he differential diagnos is between depres sion and dementia in older adults can therefore be challenging, patients with depres sion can experience s ymptoms of cognitive impairment.

Mood Dis orders Depress ive s ymptoms are common among older T he prevalence of DS M major depres sion, however, is when compared to younger adults. T he 1-month prevalence of any mood dis order in communityadults 65 years of age or older in the E C A surveys was percent. T he most common DS M dis order in this age group was dysthymia (1.8 percent), whereas the prevalence of major depres sion was 0.7 percent. T he res ults from E dmonton were s lightly higher when 6rates were us ed. T he 6-month prevalence of any mood disorder in those 65 years of age or older was 3.8 with a (lifetime) prevalence of dysthymia of 3.3 percent 4682 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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and a 6-month prevalence of major depres sive episode 1.2 percent. In both of thes e community s tudies, manic disorder was rare in older adults. T he prevalence of depres sion in community studies of older adults has ranged from 1 to 5 percent. T he E uropean Depres sion (E UR ODE P ) S tudy investigators recently reviewed the prevalence of depres sion as reported from 34 s tudies community-dwelling elderly and concluded that major depres sion in older adults had a prevalence of approximately 1.8 percent. Minor depres sion, as later in this chapter, was more common, with a of 9.8 percent. T he prevalence of clinically relevant depres sive s ymptoms was estimated to be 13.5 older adults. T he E UR ODE P P rogramme, conducted in E uropean countries with a sample of 13,808 older reported an overall prevalence of cases and s ubcas es depres sion of 12.3 percent, 14.1 percent for older and 8.6 percent for older men. Most elderly adults with depress ive s ymptoms in the community do not meet criteria for major depres sion or dysthymia. Much P.3599 res earch in recent years has focus ed on the clinically significant depress ive s ymptoms in older who do not meet DS M criteria. T hes e es timates are from depres sion s creening s cales , such as the C E S -D described previously. In the recent Longitudinal Aging S tudies Amsterdam (LAS A), a longitudinal s tudy of community-dwelling older adults 55 to 85 years of age, prevalence of minor de pre s s ion, defined as positive for depres sion by the C E S -D but not meeting DS M-III-R 4683 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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for major depres sion, was 12.9 percent. Across various epidemiological s tudies , the es timated prevalence of minor depress ion or depres sive symptomatology community-dwelling older adults is approximately 15 percent, with a range from 10 to 25 percent. T he reported prevalence of major depres sion is higher in clinical s amples than reported from the community samples. T he prevalence of major in older adults in medical care facilities is to 10 percent. In long-term care facilities , the major depress ion is es timated in some studies to be than 25 percent. Older pers ons with depres sive generally do not s eek medical help, s o the prevalence depres sive s ymptoms in primary care may the true prevalence of clinically s ignificant depress ive symptoms not meeting criteria among older adults. T here are few s tudies examining the incidence of major depres sion in older adults. W hen the B altimore E C A was followed for 10 years , the annual incidence was 3 1,000, with a peak for adults in their 30s, a smaller adults in their 50s, and the lowes t incidence in older adults . Depress ive s ymptoms are often pres ent in the preceding the ons et of major depres sion. T he first onset of major depres sion declines with age, es pecially for men. E pidemiological studies have confirmed that, although major depres sion is les s common among older adults among younger adults , depres sive symptoms with impairments in functioning may be common in late life and increas e with advancing age. T his high of symptoms s uggests that the current nomenclature be les s applicable for older adults . C linically s ignificant 4684 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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depres sive s ymptoms in older adults , although also can be serious and chronic. In the LAS A s tudy, depres sed elderly were followed for 6 years . A total of percent of the sample had a s evere, chronic cours e of depres sion, whereas 44 percent had an unfavorable fluctuating cours e. T hos e with subthreshold or minor depres sion had the best outcome, followed by those major depress ive disorder, dys thymia, and, last, those double depres sion or depress ion and dysthymia T hose with s ubthres hold depres sion were at a high risk developing DS M mood disorders . Major depress ion and dysthymia, as well as depress ive symptoms, are more common in older women to men. R acial and ethnic differences in the prevalence depres sive s ymptoms and major depress ion have not cons istently observed in older adults res iding in the community. R isk factors and correlates of major in late life include factors , s uch as being widowed or otherwis e unmarried, impaired functional status, social s upport, perceived loneliness , perceived poorer health, and low internal locus of control. Older adults major depress ion are more likely to have a family or personal his tory of major depres sion. In addition, los s partner in the previous year was as sociated with risk. factors for depress ive s ymptoms or minor depress ion include, in addition, fewer years of education, living in urban area, having one or more chronic physical having mild cognitive impairment, and experiencing recent stress ful life events . Major depress ion and depres sive s ymptomatology are comorbid with anxiety dis orders and anxiety symptoms older adults. S ome studies have found alcohol 4685 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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and depres sion to be comorbid. T herefore, major depres sion and depres sive symptoms in late life may ris k for other psychiatric disorders , or thes e disorders place the older adults at a greater ris k for depres sion. Although disability is a ris k factor for late-life depres sive s ymptoms are als o a ris k factor for decline and disability. S ome longitudinal res earch has found depress ion to be predictive of cognitive decline, other s tudies are les s conclus ive. Depres sive as sociated with an increased ris k of mortality in older adults , although this risk is confounded by factors s uch phys ical health and health behaviors , es pecially and tobacco use. F inally, major depres sion is a ris k for suicide in older adults as dis cus sed later in this

A nxiety Dis orders E pidemiological studies cons is tently show that anxiety disorders are less prevalent in older adults compared younger adults . Y et the prevalence of anxiety dis orders this older age group is high when compared to that of other disorders . In the E C A surveys, anxiety disorders the most prevalent ps ychiatric dis order (excluding the dementias ) in persons 65 years of age or older. T he 1month prevalence of any anxiety disorder among nonins titutionalized older adults in the E C A was 5.5 percent, more than two times the prevalence of any disorder in this age group. T he prevalence was lower in older men, 3.6 percent, compared to 6.8 percent in women. T hes e prevalence estimates only include disorder, panic disorder, and obsess ive-compuls ive disorder (OC D), suggesting that the true prevalence all age groups may be higher than reported, because 4686 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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generalized anxiety disorder and posttraumatic s tres s disorder (P T S D) were not as ses sed at all E C A sites therefore not included in thes e es timates. In these E C A es timates, however, DS M hierarchical rules were not applied. In the E dmonton s urvey, which, like s ome of E C A sites , did not include generalized anxiety dis order, 6-month prevalence of any anxiety or s omatoform disorder was 3.8 percent among noninstitutionalized adults 65 years of age or older. Among community of older adults, the overall prevalence of any anxiety disorder ranges from 0.7 to 18.6 percent, depending on how cas e nes s is defined. T he prevalence of anxiety disorders in ins titutionalized adults is higher than observed among communitydwelling elders . In the E dmonton s urvey, the any anxiety dis order in older institutionalized women 7.1 percent, compared to 1.4 percent in the community, and 4.1 percent in institutionalized men, compared to percent in older men in the community. T he prevalence of anxiety disorders appears to with increasing age. T his is true for phobic dis order, disorder, and OC D. T he prevalence of generalized disorder may remain stable with increas ing age or may even increas e. T he prevalence of anxiety s ymptoms in older adults is higher than the prevalence of anxiety dis orders. Approximately 17 percent of older men and 21 percent older women report clinically significant anxiety that do not meet DS M criteria for any anxiety dis order.

Phobic Dis orders 4687 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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In the E C A s urveys, the mos t prevalent anxiety among older adults was phobic disorder, with a 1prevalence of 4.8 percent. T he prevalence was twice high in older women (6.1 percent) compared to men percent). Among older women, the prevalence of disorder was higher than that of cognitive impairment. community studies of older adults , the prevalence of phobic disorder ranges from 0 to 12 percent, with the prevalence cons is tently higher in women. T his wide is again due primarily to case definition and whether hierarchical rules are applied, as was done in s urveys reporting a prevalence of phobic dis order of 0 percent older adults. Among those 65 years of age or older in E dmonton, phobic dis order was the mos t prevalent anxiety dis order among community-dwelling elders , but OC D was the mos t prevalent among older adults in institutions . F inally, some prevalence studies have phobic disorder to be les s prevalent among older than generalized anxiety disorder. P.3600 T he prevalence of any phobic disorder is affected by prevalence of the subtypes in the population s tudied. In the E C A data, the most common phobia type was phobia, but other s tudies have s hown agoraphobia to the most common type in this age group. Overall, es timates of agoraphobia range from 1.4 to 7.9 whereas the prevalence of s ocial phobia is es timated approximately 1 percent. T he prevalence of specific or simple phobia in older adults is approximately 4 T herefore, much of the variation in prevalence is the variation in the prevalence of agoraphobia. 4688 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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T he 1-year prevalence of any phobic dis order in the was twice as high in older African American men as in white and His panic men. T he prevalence was also among African American women compared to older and His panic women. T he incidence of phobic disorder in older adults is es timated to be 4.29 cas es per 100 person-years of which is s imilar to the incidence in younger age groups . Incidence was more common in older women (5.52 per 100 person-years ) than in men (2.66 per 100 personS ome s tudies have s uggested that, although simple phobia us ually has an ons et in younger children or agoraphobia can often have its onset in late life. P hobic disorder overall appears to have an earlier age of ons et women. Mos t cases of phobic disorder among older are new cas es and are not in individuals with a lifetime diagnosis of phobic disorder.

Panic Dis order P anic dis order was the leas t common anxiety disorder among adults 65 years of age or older in the E C A, with prevalence of les s than 1 percent in men and women. E pidemiological studies of community-dwelling older adults have found that panic dis order is rare, and most the few cas es identified are in older women. T he prevalence of panic dis order is slightly higher among those in institutions (1 percent) than among dwelling elders . T he 1-year prevalence of panic the E C A was higher among older white (0.3 percent) His panic (3.4 percent) women than in African-American women (0 percent). T here were no racial or ethnic differences among men. T he incidence of panic 4689 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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older adults has been es timated to be 0.04 percent, suggesting that the few cas es of panic disorder pres ent late life had an earlier onset.

Generalized Anxiety Dis order G eneralized anxiety disorder was not meas ured at all of the E C A s ites , but, in the Durham, North C arolina, the 1-year prevalence among adults 65 years of age or older was es timated to be 2.2 percent, with a higher prevalence in women (2.6 percent) compared to men percent). T he prevalence was higher in older white (1.5 percent) than in African American men (0.9 whereas there were no differences for women. In epidemiological s tudies of older adults , the prevalence generalized anxiety disorder ranges from less than 1 percent to 17 percent. In s ome studies, generalized disorder accounts for the majority of the cases of disorder in older adults, whereas , in other s tudies , disorder is much more common. In the Durham E C A, approximately 3 percent of thos e with generalized disorder had an onset of the disorder at 65 years of older.

Obs es s ive-C ompuls ive Dis order T he prevalence of OC D in older adults in the E C A was percent, with a prevalence of 0.7 percent in older men compared to 0.9 percent in older women. T he overall es timated prevalence of OC D from epidemiological is es timated to be 0.1 to 0.8 percent. Among institutionalized older adults , the prevalence of OC D is es timated to be as high as 4.7 percent in women and percent in men. T he annual incidence in those 65 4690 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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age or older is less than 1 case per 100 person-years es timated to be lower in late life in men than at earlier ages, whereas, in women, the incidence is s lightly those 65 years of age or older.

R is k Fac tors for Anxiety Dis orders Across all age groups , anxiety dis orders are more in women than men, but these gender differences are apparent in the older age groups . R is k factors for the of anxiety disorders or anxiety symptoms in late life include having another anxiety disorder or other ps ychiatric disorder, neuroticism, being female, experiencing a traumatic life event, and having an impaired social network. Anxiety symptoms, anxiety dis order, and agoraphobia can be ass ociated decreased quality of life in older adults. S ocial phobia specific (s imple) phobia in older adults are unlikely to as sociated with s evere anxiety symptoms, and thes e phobic s ubtypes are therefore less likely to lead to decreased functioning. Although anxiety and depress ion are often comorbid in younger adults, less is known about their comorbidity in older adults. Data from epidemiological s tudies however, that comorbidity between depres sive and anxiety dis orders is prevalent in late life. Depres sion been observed in patients with phobic dis order and generalized anxiety disorder and among res idents of term care facilities with anxiety s ymptoms. Anxiety disorders are also frequent among patients with diagnosed depres sion and depres sive s ymptoms. symptoms are also prevalent in persons with dementia, suggesting that one reas on for the decline in 4691 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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anxiety dis orders with age is the inability of older cognitively impaired subjects to participate in studies. T here is less comorbidity of anxiety and medical illnes s anxiety and alcohol abuse in older adults than is seen those who are younger.

S c hizophrenia In the E C A s urveys, the 1-month prevalence of schizophrenia in noninstitutionalized adults 65 years of age or older was 0.1 percent, compared to 0.7 percent those 18 to 24 years of age, 0.9 percent in those 25 to years of age, and 0.4 percent in thos e 45 to 64 years of T he prevalence was the s ame in women and men older adults. T he prevalence was slightly higher in African Americans (0.3 percent) compared to whites percent). In the E dmonton community sample, the prevalence was 0 percent, whereas the prevalence in institutionalized older adults was 0 percent in men and percent among women. T he overall lower prevalence reported by those 65 years of age or older may be due part to fewer persons with the disorder surviving to age. T he E C A and E dmonton prevalence reports were based on DS M-III criteria, which specified the illness begin before 45 years of age. S ince the 1980s , there been a growing body of evidence that s ome individuals with s chizophrenia become ill in middle age or late life. DS M-III-R included a s eparate category for pers ons met the s ymptom criteria but the age of ons et was 45 years or later. DS M-IV -T R does not differentiate age of ons et but notes differences among those individuals with a later ons et compared to earlier ons et. T he proportion of schizophrenia patients with a disease 4692 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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onset after 40 years of age is estimated to be approximately 23.5 percent. In the E C A s urveys , 5.2 percent of the total cases of schizophrenia identified an age of ons et after 40 years of age (but before 45 age to meet DS M-III criteria). T he prevalence of schizophrenia in community samples in thos e 65 years age or older can range from 0.1 to 0.5 percent. T he prevalence of s ymptoms of s us picion or paranoid symptoms in older adults is much higher, between 4 percent and 6 percent. Incidence of the dis order tends to peak in early adult mid-life, and in older age. T he incidence of late-onset schizophrenia has been es timated at 12.6 per 100,000 persons per year. Incidence differs by gender, with P.3601 women more at risk than older men. A very-late-onset schizophrenia-like psychosis has als o been obs erved adults 60 years of age or older. Multiple studies have found a later age of ons et of schizophrenia among women and an of women in the late-onset group, with an even higher frequency of late-life paranoid symptoms compared to men. In addition, late-onset patients are more likely early-onset patients to have s hown good premorbid educational, occupational, and social functioning. with a later ons et tend to have a greater frequency of paranoid s ymptoms but fewer negative symptoms , less thought disorder, and better neurops ychological performance compared to thos e with an earlier onset of schizophrenia. R isk factors for late-onset schizophrenia may include ps ychos ocial factors , such as retirement, 4693 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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bereavement, and decline in physical functioning. R elatives of late-onset schizophrenia patients have reported to have a lower risk of s chizophrenia than relatives of patients with an earlier onset of dis eas e, whereas other studies have not found differences in history between the two groups. S ome studies have reported that patients with very-late-life onset of the disease may have a high prevalence of s ens ory S chizophrenia in late life may be comorbid with other ps ychiatric illness , s uch as depress ion. P aranoid are als o not uncommon in persons with dementia. outcomes of schizophrenia symptoms have also been noted. F or example, in a recent longitudinal s tudy of 85-year-old community-dwelling S wedish elders , the prevalence of any ps ychotic symptom was 10 percent, prevalence of hallucinations was 7 percent, and the prevalence of delusions was 6 percent. Hallucinations as sociated with major depres sion, dis ability, and vis ual deficits . Delusions were ass ociated with disability, and paranoid ideation was ass ociated with visual deficits . Hallucinations, delusions , and paranoid ideation were as sociated with incident dementia. In addition, hallucinations and paranoid ideation were as sociated increased mortality in older women but not in older

Alc ohol Us e Dis orders In the E C A s urveys, the 1-month prevalence of alcohol abuse and dependence was 0.9 percent in adults 65 of age or older, which was lower than that in those 18 24 years of age (4.1 percent), 25 to 44 years of age percent), and 45 to 64 years of age (2.1 percent). T he prevalence was higher in older men (1.8 percent) 4694 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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compared to older women (0.3 percent). T here are poss ible reasons for this low prevalence in older adults. F irst, many persons with a lifetime his tory of alcohol and dependence may not survive to older age. In there may be a cohort effect. T hat is , s ocial norms changed over the years. T oday's older adults have cons umed less alcohol throughout their lives, whereas us e of alcohol has become more acceptable to those adults growing up s ince the 1960s . Als o, as with s ome of the other dis orders, the criteria may be les s applicable for older adults, an underes timate of the burden of alcohol-related problems in this population. Older adults have an increased sens itivity to the effects of alcohol due to decreases in lean body mass , which res ults in higher alcohol concentration per level of alcohol cons umed. R ecent research has s uggested that the recommended limits of alcohol us e for older adults s hould be s et lower than those for younger adults . T herefore, the quantity alcohol reported cons umed may not be a good of alcohol problems in late life. It is als o difficult to measure alcohol-related changes in social functioning and social decline in older adults . F or example, those who no longer drive are not s topped for driving while impaired, those who are retired do not experience work problems , and those who are do not experience marital conflicts related to alcohol. In older adults, therefore, attention must be focus ed on alcohol-related problems and drinking in exces s of standardized limits for older adults. E ven changing the case definition is still somewhat problematic for older drinkers, becaus e the diagnosis relies on s elf-report. 4695 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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older adults may not reliably report their us e of alcohol. Although the prevalence of alcohol problems in older adults is generally higher in hospital emergency department samples and among hos pital admiss ions, relying on case identification in clinical s ettings is also problematic. P hys icians are less likely to diagnos e alcoholism in an older patient than a younger patient, even when cas es are diagnos ed, elderly patients are likely than younger patients to be referred for R ecognizing thes e limitations , res earch s tudies have shown that the prevalence of alcohol abus e and dependence in older adults is low, and alcohol cons umption decreases with age. However, alcohol not uncommon in late life. T en to 20 percent of older adults report daily us e of alcohol, and an average of 40 percent of elders are nondrinkers. T he prevalence of alcohol problems is es timated to be between 1 and 20 percent in community s amples and 20 and 50 percent hospital samples. T he prevalence of heavy drinking according to how s tringent the criteria are. W hen he avy drinking is defined as cons uming five to seven drinks week, the prevalence among older adults is 11 to 25 percent, whereas the prevalence is 7 to 8 percent heavy drinking is defined as 12 to 21 drinks per week. R es earchers have identified two groups of older adults who drink in excess : an early-ons e t alcoholism, which includes long-term alcoholics who survive into old age, and a late -ons e t alcoholism, which includes thos e older adults with a recent onset of problem drinking. T hos e begin to drink heavily in old age appear to have social and medical characteristics compared to those an early onset of heavy drinking. P ersons with a late 4696 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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of alcohol problems may increase their drinking in res ponse to s tres sful life events, such as retirement grief. Other identified ris k factors for late-onset include a history of alcohol use, more opportunities to drink, lonelines s and boredom, depress ion, lack of support, and phys ical illness causing pain. one-third of older individuals with drinking problems a later ons et. T he incidence of late-onset problem may be as high as 4 percent in the general population. prognos is for late-onset problem drinkers , however, is generally more favorable than for early-onset problem drinkers. Over the 1-year follow-up period in the E C A acros s all age groups , the incidence of alcohol abus e declined with age until 60 years of age and then particularly for men 75 years of age or older. Alcohol-related problems are more prevalent in older compared to women, as are the quantity and frequency alcohol use. R acial or ethnic differences in alcohol us e less known, although white older adults may be more likely to us e alcohol than older African Americans . adults with lower income consume les s alcohol than with higher income. P hysical health problems are as sociated with past or current alcohol use in older P sychiatric comorbidity is more likely in pers ons who cons ume alcohol than in general populations. is correlated with anxiety and affective disorders and tobacco or drug dependence, and a history of alcohol has been as sociated with cognitive impairment. In the C anadian S tudy of Health and Aging, the occurrence of types of dementias, except Alzheimer's disease, was in those with definite or questionable alcohol abus e. Other adverse outcomes of alcohol us e include 4697 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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hospitalization, increased incidence of ps ychiatric disorders , and increased medical disorders. T he of physical illnes s is higher in older alcoholics than nondrinking older adults . F or example, cirrhosis of the is one of the leading causes of death in late life. some studies have reported increas ed mortality due to alcoholism in older adults , it is important to note there be a protective effect of moderate alcohol use in late res ulting in decreas ed likelihood of mortality. P.3602

S uic ide S uicide rates increas e with age, with the highes t rates those 75 years of age or older. In the United S tates in the death rate for suicide was 17.5 per 100,000 those 85 years of age or older and 17.4 for those 75 to years of age. F or those 25 to 74 years of age, rates of suicide ranged from 13.1 among those 55 to 64 years age to 14.7 among thos e 35 to 44 years of age. T he suicide in 1950 for adults 45 years of age or older were higher than those in more recent years for the corres ponding age group. As s hown in F ig. 51.1b-2, was a decline in suicides in older adults from 1950 to Data since the 1980s sugges t that the future trends are clear at the present. S pecifically, the s uicide rates in the 1980s and then leveled off in the 1990s. T he decade will help identify future patterns. T hes e however, were almost totally explained by declines and increases in suicide deaths by older men. T he highest of s uicide in the United S tates are observed among men, and particularly white men. 4698 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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FIGUR E 51.1b-2 S uicide rates by age in the United from 1950 to 2001. B ecaus e many elderly may commit s uicide us ing les s noticeable methods , such as medication overdose or cess ation of eating, which can be difficult to detect, es pecially in older adults who live alone, it is likely that suicide rates in older adults are underestimated. Older adults tend to give fewer warnings of suicidal T he prevalence of s uicidal ideation among older adults approximately 1 percent. Older adults , however, inves t more planning and preparing for the act than younger adults and may als o us e more violent methods. Older adults are als o more s ucces sful in their s uicide Among younger adults , suicide attempts occur 200 as frequently as completed suicides , whereas , in older adults , one out of every four attempts is succes sful. Among older adults , s uicide is as sociated with s everal ps ychiatric disorders , including major and minor 4699 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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depres sion, s ubs tance use disorder, ps ychotic and anxiety dis order. C ompleted s uicides are with more depress ive illness , physical illness , limitations , and us e of prescribed medications , antidepres sants, anxiolytic agents, and narcotic S tudies of risk factors for suicide are difficult to because the suicide rate, although higher in older than in younger adults, is s till low. In a recent analys is the E stablished P opulations for E pidemiologic S tudies the E lderly (E P E S E ) data, there were 12 suicides sample of 14,456 adults 65 years of age or older for 10 years . S uicide was predicted by depress ion, perceived heath s tatus, poor sleep quality, and a confidant.

US E OF HE AL TH S E R VIC E S P sychiatric dis orders and their subclinical forms are prevalent in older adults. Older adults are less likely younger adults to seek help from a mental health profes sional for psychiatric disorders or emotional problems . If help from a health profes sional is sought, it generally from the individual's primary care provider. Overall, many older adults with ps ychiatric dis orders or clinically significant symptoms remain untreated. Older adults may not bring problems to the attention of providers . P roviders may not recognize the s ignificance clinical s ymptoms that do not meet criteria for a ps ychiatric disorder. Disorders or clinically s ignificant symptoms may be more difficult to recognize in older adults with comorbid physical illnes s. Additionally, older adults may attribute their symptoms to a physical Overall, comorbidity of physical illness and ps ychiatric 4700 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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disorders is a s ignificant problem in geriatric psychiatry. F inally, thes e psychiatric disorders and their s ymptoms have adverse consequences, such as mortality, functioning, and disability. With the projected increas e in the number of adults surviving into old age and the projected increase in the prevalence of ps ychiatric dis orders in this age group, planning for increased us e of health services will be important. T raining primary care providers to recognize and to treat or to refer adults with disorders will be an important part of medical education. T he public heath focus should include interventions to treat these symptoms and dis orders in older adults to reduce the likelihood of negative outcomes .

S UG G E S TE D C R OS S -R E FE R E NC E S F or similar related material, please refer to the previous section on an introduction to geriatric ps ychiatry 51.1a), detailed information on selected psychiatric disorders in older adults (S ection 51.3), and the epidemiology s ection in the quantitative and methods in psychiatry chapter (S ection 5.1).

R E FE R E NC E S Adams W L, C ox NS : E pidemiology of problem among elderly people. Int J Addict. 1995;30:1693. *B eekman AT , B remmer MA, Deeg DJ , V an B alkom S mit J H, De B eurs E , V an Dyck R , V an T ilberg W : disorders in later life: A report from the Longitudinal Aging S tudy Ams terdam. Int J G eriatr P s ychiatry. 4701 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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1998;13:717. B eekman AT , C opeland J R , P rince MJ : R eview of community prevalence of depress ion in late life. B r J P s ychiatry. 1999;174:307. P.3603 B eekman AT , Deeg DJ , van T ilberg T , S mit J H, van T ilberg W : Major and minor depres sion in later A s tudy of prevalence and risk factors . J Affect 1995;36:65. B eekman AT , G eerlings S W, Deeg DJ , S mit J H, R S , De B eurs E , B raam AW , P enninx B W, V an T he natural his tory of late-life depres sion. Arch G e n P s ychiatry. 2002;59:605. B land R C , Newman S C , Orn H: P revalence of disorders in the elderly in E dmonton. Acta P s ychiatr S cand. 1988;338[S uppl]:57. *B lazer DG : Depress ion in late life: R eview and commentary. J G e rontol Me d S ci. 2003;58A:249. C anadian S tudy of Health and Aging Working C anadian S tudy of Health and Aging: S tudy and prevalence of dementia. C an Me d As s oc J . 1994;150:899. C onwell Y , Dubers tein P R , C ox C , Herrmann J , C aine E D: Age differences in behaviors leading to 4702 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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completed s uicide. Am J G eriatr P s ychiatry. C onwell Y , Lynes s J M, Dubers tein P , C ox C , S eidlitz DiG iorgio A, C aine E : C ompleted suicide among patients in primary care practices: A controlled Am G e riatr S oc. 2000;48:23. *C opeland J R , B eekman AT , Dewey ME , Hooijer C , J ordan A, Lawlor B A, Lobo A, Magnus son H, Mann Meller I, P rince MJ , R eischies F , T urrina C , deV ries Wilson K C : Depress ion in E urope: G eographic distribution among older people. B r J P s ychiatry. 1999;174:312. C opeland J R , Dewey ME , S cott A, G ilmore C , Larkin C leave N, McC racken C F , McK ibbin P E : and delus ional dis order in older age: C ommunity prevalence, incidence, comorbidity, and outcome. S chizophr B ull. 1998;24:153. Davis HS , R ockwood K : C onceptualization of mild cognitive impairment: A review. Int J G e riatr 2004;19:313. DeB eurs E , B eekman AT , Deeg DJ , V an Dyck R , T ilberg W: P redictors of change in anxiety older persons : R es ults from the Longitudinal Aging S tudy Amsterdam. P s ychol Me d. 2000;30:515. F ederal Interagency F orum on Aging R elated Older Americans 2000. K ey Indicators of W ellWas hington, DC : U. S . G overnment P rinting Office; 4703 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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F lint AJ : E pidemiology and comorbidity of anxiety disorders in the elderly. Am J P s ychiatry. *G allo J J , Liebowitz B D: T he epidemiology of late-life mental disorders in the community: T hemes the new century. P s ychiatr S erv. 1999;50:1158. Howard R , R abins P V , S eeman MV , J es te DV : T he International Late-Onset S chizophrenia G roup: Lateonset schizophrenia and very-late-onset like psychosis: An international consensus. Am J P s ychiatry. 2000;157:172. Hybels C F , B lazer DG : E pidemiology of late-life disorders . C lin G e riatr Me d. 2003;19:663. J este DV , Alexopoulos G S , B artels S J , C ummings G allo J J , G ottlieb G L, Halpain MC , P almer B W , T L, R eynolds C F , Lebowitz B D: C onsensus the upcoming crisis in geriatric mental health. Arch P s ychiatry. 1999;56:848. J ohns on I: Alcohol problems in old age: A review of recent epidemiologic research. Int J G e riatr 2000;15:575. J orm AF , J olley D: T he incidence of dementia: A analysis. Neurology. 1998;51:728. J orm AF , K orten AE , Henders on AS : T he dementia: A quantitative integration of the literature. 4704 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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Acta P s ychiatr S cand. 1987;76:465. K es sler R C , B erglund P , Demler O, J in R , K oretz D, Merikangas K R , R ush AJ , W alters E E , W ang P S : epidemiology of major depres sive dis order. R es ults from the National C omorbidity S tudy. J AMA. 2003;289:3095. K ras ucki C , Howard R , Mann A: T he relations hip between anxiety dis orders and age. Int J G e riatr P s ychiatry. 1998;13:79. Liberto J G , Oslin DW , R us kin P E : Alcoholism in persons: A review of the literature. Hos p C ommun P s ychiatry. 1992;43:975. McDowell I: Alzheimer's dis eas e: Insights from epidemiology. Aging (Milano). 2001;13:143. National C enter for Health S tatistics . C enter for C ontrol and P revention. Death rates for s uicide, 2001 (2003). Available at: http://www.cdc.gov/nchs/data/hus /tables /2003/03hus 046. Ostling S , S koog I: P s ychotic s ymptoms and ideation in a nondemented population-based sample of the very old. Arch G e n P s ychiatry. 2002;59:53. P almer B W , McC lure F S , J es te DV : S chizophrenia life: F indings challenge traditional concepts . Harvard R ev P s ychiatry. 2001;9:51.

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R egier DA, B oyd J H, B urke J D, R ae DS , Myers J K , M, R obins LN, G eorge LK , K arno M, Locke B Z: month prevalence of mental disorders in the United S tates. Arch G e n P s ychiatry. 1988;45:977. R itchie K , Artero S , B eluche I, Ancelin M-L, Mann A, Dupuy A-M, Malafoss e A, B oulenger J P : P revalence DS M-IV psychiatric disorder in the F rench elderly population. B r J P s ychiatry. 2004;184:147. *R obins L, R egier D. P s ychiatric Dis orders in New Y ork: T he F ree P res s; 1991. S tevens T , Livingston G , K itchen G , Manela M, K atona C : Islington s tudy of dementia subtypes in community. B r J P s ychiatry. 2002;180:270. T homas V S , R ockwood K J : Alcohol abus e, cognitive impairment, and mortality among older people. J Am G e riatr S oc. 2001;49:415. T urvey C L, C onwell Y , J ones MP , P hillips C , P earson J L, Wallace R : R isk factors for late-life prospective, community-based study. Am J G eriatr P s ychiatry. 2002;10:398. van Duijn C M: E pidemiology of the dementias : developments and new approaches . J Ne urol P s ychiatry. 1996;60:478. Waern M, R uneson B S , Allebeck P , B eskow J , R ubenowitz E , S kong I, W ilhelmss on K : Mental 4706 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/51.1.htm

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in elderly s uicides: A cas e-control s tudy. Am J 2002;159:450. Waite LM, B roe G A, G rayson DA, C reasey H: T he incidence of dementia in an Aus tralian community population: T he S ydney Older P ers ons S tudy. Int J G e riatr P s ychiatry. 2001;16:680.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 52 - Hos pital and C ommunity P s ychiatry > 52.1 P ublic and P s ychiatry

52.1 Public and C ommunity Ps yc hiatry Leighton Y. Huey M.D. J ulian D. Ford Ph.D. R obert F. C ole Ph.D. P art of "52 - Hos pital and C ommunity P s ychiatry" E ach term in the phrase public and community burdened by a complex pas t and needs interpretation clarify its contemporary meaning. T he term public can to psychiatric programs , treatment, or institutions paid by public funds or as objects of public policy, whether for or not. T he traditional concept of public psychiatry been expanded to include medical and ps ychosocial initiatives directed for the public good, whether funded public or private funds, and directed in particular to who are economically disadvantaged. As is s een in this section, American ps ychiatry started out as a public endeavor through an act of the C olonial V irginia Legis lature and, for more than a century, found its principal domain in the public state hos pitals. P ublic ps ychiatry stands in stark contrast to personal or ps ychiatry, which is the entrepreneurial practice of delivering s ervices to individuals having s ome means purchasing them. P ublic ps ychiatry is generally to be the care and treatment of adults with s erious 4708 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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illness or s erious and persistent mental illness or of children with s erious emotional dis orders who cannot access private mental health services . T hese identify target or priority populations that us ually of the pres ence of at leas t one qualifying major mental illness , an ass es sment of its impact on ability to multiple areas, and an evaluation of the individual's personal res ources to obtain private mental health (T able 52.1-1).

Table 52.1-1 E ligibility for Mental Health S ervic e G rants T he following definitions are in the F e deral and are currently used to determine eligibility for services provided by the federal C enter for Health S ervices block grant funds : Adults with s e rious mental illnes s are persons:    18 Y rs of age and older,    W ho currently or at any time during the past    Have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DS M-IV -T R ,

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   W hich has resulted in functional impairment subs equently interferes with or limits one or more major life activities and    Las ts les s than 6 mos of the pas t year. Adults with s e rious and pe rs is te nt mental persons who are recently s everely impaired, and duration of the impairment totals 6 mos or longer the pas t year. C hildren with a s e rious e motional dis turbance are persons    F rom birth to as old as 18 yrs of age,    W ho currently or at any time during the past    Have had a diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within DS M-IV -T R    T hat resulted in functional impairment that subs tantially interfered with or limited the child's role or functioning in family, s chool, or community activities.

T he care and treatment offered under public ps ychiatry delivered in a variegated mosaic of inpatient and 4710 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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community-based services that are more or les s into a coherent network sponsored by public agencies . T he term community, as his torically applied to connotes the mental health status of a s pecific, geographically defined population. It is s ynonymous in res pects with not the s tate hos pital and is contras ted to institutional care, especially in the move to community mental health in the second half of the 20th century. C ommunity ps ychiatry in this context refers to practice in the community as part of the community to care for individuals afflicted with major mental illnes s a s pecific geographic catchment area. C ommunity ps ychiatry initially was an attempt to break with public ps ychiatry. At the end of the 20th century, it obtained s till broader connotation in terms of the health the community: C ommunity ps ychiatry activities involve the impact of ps ychiatric disorders in individuals on the health of the community and formulate treatment strategies to improve community he alth. T he term ps ychiatry originally described the medical specialty focused on the care of persons with mental illness in the s tate hos pital s etting. Its domain was strengthened by the dominant role of the medical superintendents of the state hos pitals and their medical colleagues in the latter half of the 19th century and firs t half of the 20th century. However, in the era of mental health in the latter half of the 20th century, the term exploded to cover a hos t of dis ciplines and new personnel recruited to s taff the community-based supportive treatment s ys tems that were s upposed to the place of the institutions . Nurs ing, s ocial work, ps ychology, various therapeutic specialties, and 4711 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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paraprofess ional direct care functions all became as part of psychiatry. T he traditional concept of public and community has had a narrow focus on the ps ychiatris t in his or her as the medical specialis t, trained in the dis cipline of medical science (which is increasingly important) and exercising medical and legal authority to take defined actions on behalf of individual patients . In this the public ps ychiatris t practices psychiatry in publicly funded services and carries out programs that are mandated by public policy. As a public and community ps ychiatris t, he or she is engaged with a s pecific geographically defined population in terms of programs for the care of its individuals with mental and in terms of concern and action to improve the of the community as broadly defined. T wo contemporary cons iderations augment this basic rather narrow) conceptualization of public and ps ychiatry. T he first is the realization that the impact pervas iveness of psychiatric disorders impos es a burden on s ociety. In the mid-1990s , a landmark s tudy called T he G lobal B urden of Dis eas e appeared. T his funded by the W orld Health Organization, the W orld and s everal foundations , cons idered the leading disability and premature death worldwide as a result of various health and s ituational problems. Of the ten caus es of disability worldwide, five are with the leading caus e of dis ability being depress ion. When cons idering the leading caus es of healthy years life lost us ing a concept of dis ability-adjus ted life ye ars (DALY s ), which reflects premature death and dis ability, depres sion was s econd in the United S tates and was 4712 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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expected to rank second in the world by the year 2020. Although it has been known for s ome time that disorders by thems elves and in comparis on to other phys ical disorders are highly prevalent and have significant impact on populations of people (e.g., C ounty S tudy, Midtown Manhattan S tudy, C atchment Area S tudy, National C omorbidity S tudy, Medical Outcomes S tudy), the G lobal B urden of report clearly cas t the enormity of the problem in a straightforward, unambiguous manner. T he and the importance of properly addres sing primary and comorbid psychiatric dis orders acros s a s pectrum as of enlightened health policy are compelling. T he P.3846 prevalence of ps ychiatric dis orders warrants a based approach, which is the conceptual s trength of public and community ps ychiatry. A systems -based of psychiatry involves unders tanding and drawing on wide range of biops ychos ocial factors that underlie illness to develop ps ychiatric treatment and interventions to reduce the disease burden ass ociated with severe and pers is tent mental illness . T he second cons ideration is a critical evaluation of American medical practice by the Institute of Medicine its report entitled C ros s ing the Q uality C has m: A Ne w S ys te m for the 21s t C entury. T his is a call to American medicine to reform inadequate s ervice delivery and to apply effective practices s ys tematically. It documents the need for a fundamental overhaul of the entire American health care s ys tem, addres ses the problems caused by insufficient quality in the health 4713 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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system, and offers a road map for creating a new system. Accountability for health care outcomes as the primary public policy concern facing American medicine. P ublic and community psychiatry compris es percent of health care expenditures for all behavioral health services in America and thus plays a critical role health care's reconfiguration. S imply maintaining the status quo and the historical manner in which health has been conducted is not s ufficient. A reform to how ps ychiatric s ervices s hould be provided, the public or private sectors , is in keeping with the of the Institute of Medicine. His torically, the connotation as sociated with public and community ps ychiatry has been s ynonymous with care the poor and underprivileged, care for special normally not attended to by the private s ector, overwhelmed s ys tems, low reimbursement, inferior and unrespons ive care, and a final common pathway for individuals no longer able to afford private care. In these individuals as a group lack the most bas ic to sus tain thems elves in society (food, clothing, financial support, s ocial s upport, etc.), and they are arguably the group least likely to have the capacity to recover from this default pos ition. As noted at the of this s ection, a more encompas sing cons truct could cons idered in which, regardles s of funding (i.e., public private), as long as the effort is directed at the public with an eye toward the economically disadvantaged, could become a new definition of what constitutes and community psychiatry. In addition, the arbitrary segregation of public and community psychiatry from res t of ps ychiatry is more a reflection of the his torical 4714 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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that the field has had on the individual to the relative exclusion of the family, the s chool, the workplace, and community, representative of an insulation from an population-based pers pective and approach. Ironically, more information becomes available about the mos t effective treatments (i.e., those with the bes t outcomes delivered in the mos t appropriate and most cos tmanner), the importance, indeed, the necess ity, of a systems approach to focus ed ass es sment and that cons iders individuals along a continuum is evident. A community paradigm in which public health concepts education, prevention, and early identification are integrated with acute and chronic illness care management with outcomes as sess ment mus t res ult in healthier communities and, therefore, healthier individuals . S uch a paradigm encompass es a broad of necess ary services from institution to community, on the individualized as sess ment of need. T his then becomes the new s tandard of what cons titutes contemporary success ful care, whether in the private public s ectors. In s hort, the most effective approach to public ps ychiatry involves the development of a system of care for each individual within the context of or her family, community, and culture. It is in this that this s ection is written. It begins with a brief review of public and community ps ychiatry in America a dis cus sion of contemporary themes and movements public and community ps ychiatry. T he dis cus sion identifies , but does not dwell on, the difficulties and frus trations that have aris en in the last quarter-century the movement from institutions to community mental health and the radical changes brought about with 4715 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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managed care. T his is a period of some degree of that is , chaos, in American health care'a time to build anew, based on the les sons of the pas t.

HIS TOR IC A L P E R S P E C TIVE Mental health policy and treatment has been a public in America from the beginning. A broad brus h overview this complex history can distinguish four stages . times and the early years of the republic were the era the poorhous e during which the great majority of with mental illnes s found refuge or were confined for own and others' protection as part of local community management. C are and custody were the operative functions , and treatment was nonexis tent. In the midcentury, the pioneering work of Dorothea Dix us hered the age of the as ylum, during which public inpatient facilities, generically called s tate hos pitals , were cons tructed in every state. A century later, advances in medicine, ps ychodynamic psychiatry, and biological ps ychiatry along with a remarkable policy consens us moved federal legis lation to s hift from institutionally based care to an era of community me ntal health. health care costs began to soar at the end of the 20th century, and as employer purchasers and government moved to create market-driven health care, mental policy has moved to tightly organized s ys te ms of care focus on prevention, early intervention, community support, and recovery for children with severe disturbances and adults with serious acute and mental illness es. P.3847 4716 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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T he movement of his tory is bes t unders tood at its transition points. T o get a s ens e of this his tory, the following quick review of public and community ps ychiatry in America focuses on three vignettes at the transition points that s eparate thes e s tages.

From the Poorhous e to the As ylum Now for near five years I have indulged by the gracious in my long holiday in this goodly house of mine entertaining and entertained by s o many worthy and gifted friends and all this poor Nancy B arron the madwoman has been s creaming herself hoarse at the poorhous e acros s the brook and I s till hear whenever I open my window. --R alph W aldo E merson, 1840 In the American colonies and in the early days of the republic, the care of the mentally ill was modeled on practices of 18th century E ngland, where the E nclos ure Laws disrupted the rural social order and s et the road to seek s helter and employment in the cities . P eople with mental disabilities were at a particular disadvantage. T hey were s aved from vagrancy by confinement in poorhous es, pris ons , and jails, along criminals, debtors, and other people with disabilities. In American colonies, mos t towns would es tablis h a poorhouse, and pers ons with mental illness , es pecially 4717 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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those who were found to be dis ruptive, would be committed by the actions of local government to extended stays in them. It is not that there were no hospitals . T he cons truction of a public hospital was firs t propos ed in V irginia in 1766. T he money was in 1770, and the P ublic Hos pital at Williams burg 1773, which was the firs t public mental hospital in the C olonies. In Mass achus etts , McLean Asylum opened C harles town in 1818. T his was a community effort endowed by more than 50 philanthropis ts led by a S cottis h busines sman to s upport the work of a young minis ter caring for persons who had gone mad at s ea had found themselves delivered to the B oston docks. though this was private ly financed, it was a public Only a few years before his journal entry, E mers on had to commit his brother, who experienced bipolar illnes s, the McLean As ylum in C harles town. T his may have heightened his s ympathy for poor Nancy B arron. thereafter, the first large state hospital opened in Worces ter, Mas sachusetts in 1833. T he phys ician s uperintendents of thes e early hos pitals were the reformers of the era, following the ideas of manage me nt put forth by the F rench reformer, P hilippe P inel. He believed that, if people were removed from urban environments, were relocated to an as ylum in a beautiful pas toral setting, were engaged in agriculture the trades , lived in close proximity with staff, and were treated with kindnes s, then s oon they would fully from the behavioral changes that they manifes ted as a res ult of having lived in a stress ful, demanding environment. T he E nglis h Quaker, W illiam T uke, built a private as ylum near Y ork, E ngland, called the R etre at 4718 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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pursued s imilar approaches to the humane care of with mental illnes s. B enjamin R us h, a signer of the Declaration of Independence, cons idered the founder American psychiatry, applied many of these theories methods of his own in the treatment of the insane in years after 1783 in the P hiladelphia Hos pital. T he great majority of thos e who experienced mental illness , however, were kept in poorhouses or jails deplorable conditions and became a cause for reform. the year of E merson's journal entry, the Unitarian Dorothea Dix, had begun a 2-year s urvey of the in which these people lived. In 1843, she compiled her findings in a Me morial to the L e gis lature of tell what I have seen, to present the state of the insane persons confined within the C ommonwealth in cages , clos ets , cellars, stalls , pens! C hained, naked, beaten rods, and las hed into obedience! T he long lists of the from her findings began with the following entry: A woman from the [W orces ter] hospital in a cage in the alms house'likely the s ame Nancy B arron over whos e agonies E mers on had reflected. After the Mas sachusetts Legislature appropriated funds a s ubs tantial expans ion of the W orcester Hos pital, Dix proceeded to write me morials for states up and down eastern s eaboard and the wes tern states as far as Wiscons in. In the 10 years between 1844 and 1854, traveled more than 30,000 miles , visiting hundreds of prisons, almshous es, jails , and hospitals, collecting and arousing public opinion to her caus e. In 1848, federal support similar to that given to education, she sought federal s upport for national hospitals. T he 12,225,000 Acre B ill finally pas sed both houses of 4719 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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in 1854. It was vetoed by P res ident F ranklin P ierce, stated: I cannot find any authority in the C onstitution makes the F ederal G overnment the great almoner of public charity throughout the United S tates . P ublic health was, for the next century, exclus ively in the the states and the state hos pitals that continued to be built only to be quickly filled and hopeles sly

C ommunity Mental Health I am propos ing a new approach mental illness and to mental retardation. T his approach is designed, in large meas ure, to F ederal res ources to stimulate state, local, and private action. When carried out, reliance on cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability. E mphas is on prevention, treatment, and rehabilitation will be substituted for des ultory interest in confining patients in an institution to wither away. --J ohn F . K ennedy, Me s s age the P res ide nt of the Unite d R elative to Me ntal Illnes s and Me ntal R etardation, F ebruary 5, 1963 In a little more than a century after P res ident P ierce 4720 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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blocked the federal government from involvement in problem of mental illnes s, another P res ident reversed direction and committed the federal government to the caus e of pers ons with mental dis abilities and their P res ident J ohn F . K ennedy s igned the Mental F acilities and C ommunity Mental Health C enters C ons truction Act (P L 88-164) in October 1963. He did perched on a wave of reform that defined a new era of community mental health. T he reform was founded on century of steady progres s in which asylums were built and their weakness es dis covered. T he advances of medicine offered new hope to ps ychiatry, and that optimism gathered the momentum of public opinion. C ons umers and advocates for the mentally ill found voice in the mental hygiene movement. A s eries of res earch-oriented institutions were established. therapeutic improvements were dis covered. F inally, a coalition of skillful bureaucrats, advocates , and set the s cene for the public policy s hift that P res ident K ennedy declared would supplant the cold mercy of custodial is olation with the open warmth of community concern and capability. It is a fascinating story, and a review of its high points . It has been s aid that American medicine reached a juncture at the turn of the 20th century. S cience and medicine had es tablis hed a s trong alliance in the major university medical s chools , and the profes sion a powerful public credibility as breakthrough P.3848 after breakthrough trans formed medicine. P s ychiatris ts were not in the forefront of this transformation, but they 4721 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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were profoundly affected by it. One of the most ps ychiatris ts of the period, from 1890 until his at the eve of W orld W ar II, was Adolf Meyer, and his career may be thought of as repres entative of what happening to psychiatry. Meyer was born in (1866) and was trained as a neurologis t. He came to America in 1892 and worked for 8 years in s tate in Illinois and Mas sachusetts. In this sense, he came the ranks of the asylum psychiatrists who were the bulwark of the s tate hos pital s ys tem that had, by that point, spread throughout the country. T he firs t public psychiatrists were state hospital superintendents, res ponsible for all ins titutional clinical and adminis trative functions. W ithin a few s hort years, populations of s tate hos pitals grew, so that their function was eclips ed by care and cus tody concerns . superintendent became more of a manager and adminis trator than a treatment provider. T he ability to organize and to bring order to the institution became a neces sary s kill. Although thes e early ps ychiatris ts reluctantly accepted care and cus tody functions as part their responsibilities, succeeding generations found thems elves struggling with that iss ue, as well as new problems . T he New Y ork S tate Hos pital s ys tem had es tablis hed, 1895, the P athological Ins titute, which had two the study of mental dis eas es from the s tandpoint of cellular biology and the offer of ins truction in brain pathology to state hospital physicians . T he Ins titute sought to become the cutting edge of reform, not oppos ition from the asylum ps ychiatris ts who were oriented toward managerial and adminis trative 4722 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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and clear demarcation of the diseased s tate of inmates from the normality of functioning people in the community. Meyer became its director in 1901. W hen Henry P hipps endowed a ps ychiatric clinic at J ohns Hopkins, Meyer was chos en as its first head. F rom Hopkins, he played a leading role in American for more than three decades . In the beginning of the 20th century, the concept of dynamic ps ychiatry opened the poss ibility of psychiatry practiced in the community. Dynamic psychiatry blurred the distinction between health and disease and saw mental illness on a continuum. T his allowed the center attention for ps ychiatric practice to move beyond the institutions and to include troubled individuals in the stages of illnes s. T his approach elevated the the life history and prior experience of each person. It a s hort leap of faith to suggest that early community treatment might prevent the ons et of s evere mental illness es that, up to then, had required T he once s trong bond between the as ylum and was unraveling. Dynamic psychiatry expanded the jurisdictional boundaries to include psychologically troubled individuals , as well as allegedly dysfunctional social s tructures and relations hips. F rom 1880 to 1940, ps ychiatris ts identified new careers outside of P sychiatrists articulated novel theories and therapies ; expanded jurisdictional boundaries to include not only mental disorders , but als o the problems of everyday propos ed s olutions for s ociety's ills ; and defined a preventive role. Despite its good intentions , it was, in retrospect, gros s overstatement bas ed more on and opinion than a scientific bas is. 4723 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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Meyer was a leading figure in advocating a fresh and courageous pragmatis m and held a biological of human beings. W e mus t accept the s tatement that mental activity must have its phys iological s ide and its anatomical s ubstratum. He developed a geneticor developmental approach to mental illnes s, which he named ps ychobiology. He s tres sed the interaction of organism to its environment and defined mental in behavioral terms, tracing their origins to defective habits . He recognized the importance of cons umer advocacy and s upported C lifford B eers , a former patient, who wrote a celebrated work, A Mind T hat Its elf, and who founded the mental hygiene movement. Meyer was an empiricist, urging his colleagues to and to catalogue facts . He was not a theoretician or a systematizer. P erhaps he realized that biology did not have the s cientific tools to cons truct adequate theories about human mental process es . In this regard, he did favor S igmund F reud and what he viewed as the tendencies to dogmatic pronouncement. T he eminent social his torian of American mental health policy, G rob, observes that ps ychoanalytic concepts had far greater influence on culture and thought than on medicine in general or psychiatry in particular. T his to overs tate the case, given the great enthusias m for ps ychoanalys is that came after W orld W ar II and that dominated popular perceptions of ps ychiatry. However, G rob appears to place figures like Meyer more at the center of ps ychiatry in the period, especially as it medicine in medical s cience. On the eve of World W ar II, as Meyer retired, public ps ychiatry had advanced on three fronts. On the firs t, 4724 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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res earch institutes and psychopathic hospitals were developed alongside the state asylums in which and training would benefit the care of persons with illness . In addition to the New Y ork P athological and the P hipps C linic, where Meyer had worked, a P sychopathic Hos pital was developed at the University Michigan Medical S chool in Ann Arbor, the B os ton P sychopathic Hos pital (later known as Mass Mental) developed at Harvard Medical S chool, and similar institutes were developed in a number of states. T hes e hospitals and institutes had limited s ucces s in that their res earch efforts to es tablish the efficacy of treatment progress ed s lowly, and they suffered a of mis sion drift away from the s erious ly and pers is tently mentally ill in the as ylums and toward less s evere health problems in the community. S econd, an active cons umer advocacy movement began in the founding the National C ommittee for Mental Hygiene in 1909, developed into a national movement focus ing first on plight of individuals in the as ylums and then on mental health is sues in the community. F inally, the ideas of dynamic ps ychiatry made it pos sible to think of the stages of mental illnes s and the pos sibility of the prevention and amelioration of mental disease. B efore W orld W ar II, there were fewer than 3,000 ps ychiatris ts in the United S tates , with more than oneof them working in the public sector. At war's end, the American P s ychiatric Ass ociation (AP A) still hospital psychiatry. However, a bitter and divis ive struggle ensued. B y 1950, the AP A had been into a visible and active organization that repres ented ps ychodynamic and psychoanalytic viewpoints. 4725 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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to thes e perspectives controlled virtually all univers ity departments, ens uring that ps ychiatris ts trained in the 1950s and 1960s shared thes e concepts. B y 1957, 1,700 of the 10,000 AP A members worked in state hospitals . W ithin less than 20 years , the overwhelming majority of psychiatris ts in America went from working state hos pitals to working in other s ettings that had little or no interface with the populations having s erious illness or s erious and persistent mental illness , or with children with s erious emotional disorders . As W orld War II ended, two factors entered the public ps ychiatry arena that would have a catalytic T he firs t was the corps of 2,400 physicians ass igned to ps ychiatry along with prominent leaders in American ps ychiatry who had s creened recruits and s ucces sfully treated neurops ychiatric s ymptoms in noninstitutional settings . Many psychiatrists left military life convinced the need for change in the ways in which the needs of persons with s evere P.3849 mental illness and individuals with mental health were address ed. T hey entered the nonmilitary world confirmed in the ideas that dynamic ps ychiatry had articulated. T he s econd factor was the appearance of so-called F rench drug, chlorpromazine (T horazine). C hlorpromazine was tes ted in a P aris ian mental after encouraging findings of its effect on trauma in the war. T he positive findings of these trials led to its marketing under the name T horazine in the United in the early 1950s . T he new drug was cautiously and ambivalently received by ps ychiatris ts committed to 4726 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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ps ychodynamic concepts, but it opened a new world of poss ibilities for the academics and res earchers who to represent biological ps ychiatry. T he 1950s were a time of great therapeutic optimis m. B iological ps ychiatris ts pointed to the efficacy of drug therapy; their psychodynamic colleagues could point to ps ychological, ps ychos ocial, and environmental that would reach the most s everely disabled institutionalized patients. Milieu therapy (the community) arose in this period and had much in with moral therapy. P ioneered by Maxwell J ones, therapy recognized the impact of the hospital environment on patients and the poss ibility of it as an active component of treatment. It appeared that medications were going to allow patients to engage in therapeutic community, and then other innovations , as unlocked wards and partial or day hos pitals , were to help some chronic patients trans fer to the F inally, an extensive network of community s ervices help these individuals reintegrate into society by for their ps ychiatric, s ocial, and financial support. T he Milbank Memorial F und celebrated all of thes e caus es optimism in a s eries of conferences and monographs modeled a new approach to public psychiatry and a social policy. As all of this momentum for change was building, a remarkable partnership for political action was between R obert F elix, the head of the newly formed National Ins titute for Mental Health, S enator Lister Hill, R epresentative J . P ercy P riest. In a carefully proces s, hearings were held, aimed at focusing public attention on mental health problems and thus 4727 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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strengthening the cas e for an enhanced federal role. Mental Health S tudy Act was pass ed in J uly 1955, the J oint C ommis sion on Mental Illness and Mental (J C MIMH). T he J C MIMH final report, Action for Mental Health, did not make a clear-cut distinction between individuals with serious and persistent mental illness ps ychologically troubled individuals. T he report favored shift of funding s upport to accommodate the needs of latter without addres sing the implications of s uch a T he report criticized the mental hygiene movement for diverting attention from the core problem of major illness (i.e., s erious and persistent mental illness ) by emphasizing primary prevention, but it also the need to provide treatment to ps ychologically individuals . It supported community-based and based services , propos ing that regional psychiatric inpatient treatment centers limited to no more than acutely ill patients be es tablis hed. It s aid that exis ting institutions of more than 1,000 beds should be converted to long-term-care facilities for all chronic It als o insisted that aftercare and rehabilitation be integrated with all other services to limit the need for hospitalization or rehos pitalization. Although the J C MIMH report was obviously a among the 26 participating constituency organizations, there was s trong support for fundamental change. the effectivenes s of treatment in community programs was bas ed on belief in the efficacy of early intervention, ps ychodynamic theories, epidemiological efforts to elucidate the prevalence of mental illness in the community, and the putative identification of environmental variables . Altogether, it was believed 4728 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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one could predict who was at risk of developing mental illness by identifying environmental factors that or retarded the onset of s ymptoms , thus allowing for opportunity to intervene early. At the end of the decade, with a new administration an aggres sive domes tic agenda, the National Ins titute Mental Health (NIMH) convened the Interagency T ask F orce on Mental Health, which developed the B lue print Action and, more importantly, activated the political coalition that made P resident K ennedy's initiative T he final policy side-stepped the provisions by the J C MIMH for the refurbishment of the s tate and providing acute ins titutional care for the most disabled and devoted its attention to community mental health clinics , which it recommended to be enhanced comprehensive community mental health treatment centers'the community mental health centers (C MHC s ). T he C ons truction Act for the C ommunity Mental Health C enters was followed by the S taffing Law, which was signed by P res ident J ohnson in 1965 after P resident K ennedy's tragic death. T he national program for compre he ns ive C MHC s was in place. F or the next 15 grants flowed to the localities and then through the to the localities to the new centers , and s tates to build community systems while beginning the of phas ing out the old state hos pitals. T he immediate discovery was that the C MHC s were able to expand health services for the communities but were not at all prepared to care for pers ons with serious and mental illness who had s pent most of their lives in state institutions . T he discharge of 90 percent of the s tate hospital population (the deins titutionalization proces s) 4729 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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without adequate community resources available was chaotic and often precipitous. It led to a clas s of and generally untreated or trans ins titutionalized individuals (put into nurs ing homes, pris ons, s qualid rooming hous es and hotels, etc.) who deteriorated the state hos pitals. T here also aros e a peripatetic subpopulation (the young adult chronic population) with serious mental illnes s and s erious and pers is tent illness , who often had comorbid substance abus e and generally avoided any beneficial involvement in for a s ignificant portion of the early phase of their However, the s tates, to varying degrees , were s et on a cours e of dis mantling s tate hospitals that were increasingly expensive. As federal s taffing grants to the C MHC s were phas ed out, and s tate contract dollars replaced them, the states gradually narrowed the focus the community programs to its priority clients, the res idents of the s tate hos pitals . S pecial programming models were developed to provide s upportive programming for them that focused on community support and rehabilitative approaches rather than ones. As community mental health programs developed, it became clear that ps ychiatris ts were, for the most part, playing limited roles: R eimburs ement could not support them full time, and they gravitated to private practice models that were appropriate for individuals with less severe mental health is sues. T he ps ychiatris ts who involved in the early C MHC s were quickly the other disciplines and often sidelined thems elves in private practice models in which they could treat and functional people with relatively mild disorders . 4730 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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practice models limited their ability to treat pers ons with severe mental health disabilities without appropriate outreach and s upportive care. T he Hill-B urton Act, had provided s ubstantial funding for general hospital cons truction, had led to the development of acute ps ychiatry units in most hos pitals . T he es tablis hment of ps ychiatric services in these hos pitals was encouraged the movement of psychiatrists into private practice, need for some type of hos pital facility, and the P.3850 growth of third-party health insurance. T he who moved to this kind of model effectively left the care the most severely dis abled to the public agencies and C MHC s . It was a chaotic period in American mental health. T he different s tates advanced unevenly in the development community programs , while, uniformly, political built to reduce the cens us in the expensive state In some cas es, appropriate community-based programming was ready to receive the newly individuals , but in many cas es it was not. T here are who have come to look back in dis may at the mass ive changes that the federal community mental health programs put in motion. T he durable and revered of the asylum was to be abandoned in this process . the picture of many deins titutionalized former s tate hospital residents, homeless or living marginally, in the nation's cities , the optimism and faith in the effectivenes s of the new treatment modalities that these policy decisions might be judged (in hindsight) to unwarranted. T he process had been driven by rhetoric 4731 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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enthus ias m, and, strangely, NIMH had ignored the balanced recommendations of the J C MIMH report that supported improvement meas ures for the hospital facilities and the community programs. Many mistakes were made, but many valuable les sons were learned. In 1977, P resident C arter signed an order creating the P resident's C ommiss ion on Mental Health to review the progress and needs of the national programs and to make recommendations . His wife, R os alynn C arter, s erved as honorary chairpers on and played a critical role in its deliberations. T he reports monographs prepared by the C ommiss ion documented and catalogued the learnings that had been gleaned the development of community programs and the of deinstitutionalization that had ens ued. Overall, they represented a more balanced and informed conceptualization of the agenda and the problems that needed to be addres sed. T he C ommiss ion's findings the pas sage of the Mental Health S ys tems Act (P L 96which P resident C arter signed in October 1980. It a National P lan for the C hronically Mentally Ill, which releas ed a month after his defeat for reelection. Under succes sor, P res ident R onald R egan, the Omnibus R econciliation Act, 1981, repealed most of the Mental Health S ystems Act in favor of block grants to s tates . role of federal leadership and national policy was subs tantially diminished, and the s tates were largely on their own.

Organized S ys tems of C are T he ps ychiatric hos pital is a 4732 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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target of health care Its profit margins are large, inves tment cos ts are low, ps ychiatric care is now widely insured, and the complexity (and perhaps ambiguity) of diagnosis and treatment makes cost control efforts by insurers the government difficult. In 1968, for-profit hos pital chains were nonexistent in psychiatric care. 1980, investor chains owned 25 percent of private psychiatric hospitals and, just two years these corporations owned a full percent market share. B etween 1982 and 1983, the number of inves tor-owned ps ychiatric hospitals ros e 42.5 percent, 106 to 151. T he increase was attributable to inves tor groups ' acquisition of existing facilities, but new construction of ps ychiatric hos pitals , which grew 53.3 percent, accounted for of the growth. Ad-P sych (Adoles cent P s ychiatry) units so lucrative that corporations clos ed units providing other of services in order to es tablis h more profitable adoles cent units . Admis sion data reflect the domination of the private sector 4733 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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the provision of adoles cent inpatient psychiatric s ervices. In 1980, for example, private admitted 61 percent of all adoles cents who underwent ps ychiatric hos pitalization; since that time, juvenile admiss ions to these facilities have increased subs tantially. --Lois A. Weithorn, S tanford L aw R eview, 1988 American health care cos ts began to increase in the 1970s . B y the end of the 1980s , they were T he article by Lois W eithorn in the S tanford L aw addres sed the poss ible violation of children's rights by their involuntary hospitalization in commercially operated ps ychiatric hospitals . It documented a trend which American employers 'and the ins urance that they hired to adminis ter their health benefits 'were too aware. While employee health care costs overall climbing, behavioral health expenditures were by 50 percent each year. V enture capital had chink in the armor of health care finance. E ven though there were lifetime limits for mental health benefits, a subs tantial amount of money lay in thos e coffers . P sychiatric hospitals were relatively cheap to build and could be des igned to be converted to elderly housing facilities once the gap was closed. T he criteria for illness were s ufficiently permeable and s tandards of were sufficiently undefined that decis ions for hospitalizations were made on behalf of many patients 4734 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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where more cons idered judgments would have found other alternatives . In fact, many hospitals launched deliberate marketing campaigns to fill their beds , and many practitioners followed. T he trend was an abus e. most cynical aspect was that benefit dollars that could have been devoted to the care of pers ons with severe mental illness were quickly extracted'a $50,000 lifetime limit could be spent in 60 days of private hos pital that s ick patients were discharged to the care of public sector agencies . Although s everal examples of he alth mainte nance organizations had demonstrated their effectivenes s in improving the health status of enrolled populations for several decades , American employers were reluctant require their employees to s ign up for a plan instead of traditional indemnity (or fee-for-service) health However, the growth of behavioral health expenditures was so dramatic that they overcame their reluctance this s ector. W ithin a few years , an industry of manage d be havioral he alth organizations was created by the contracting activities of human res ource executives of major American corporations. T he new companies staffed by a corps of seasoned mental health most of whom had been prepared in the ranks of the community mental health movement. T hey introduced, a bus ines s-like fas hion, utilization review techniques reinforced by elaborate information and communication technology. T hey selected panels of providers who be trus ted to care for enrolled members without inappropriate or extended use of hospital or other expensive care. T heir impact was dramatic: W ithin a years , behavioral health expenditures s tabilized. 4735 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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T he succes s of the carve out of behavioral health care inspired employers to apply their contracting to the rest of health care. B y 1990, 95 percent of employees were enrolled in s ome form of managed S imultaneous ly, in the early 1990s , P res ident C linton undertook a health care reform that attempted to universal health care as a highly regulated public entitlement. T he C linton health plan was labeled compe tition as a nod to the rapid move to competitive health care markets. However, the originators of that an as sembly of bus iness and health care experts the J acks on H ole G roup, were much clearer about an approach in which government and government regulation would play a minimal role. P.3851 Nonetheles s, a health care marketplace was created in cours e of the failed C linton health care reform. A wide variety of health care entrepreneurs would organize providers to bring their products to the markets, and cons umers were encouraged to make choices that ensure the value of the care that they would receive. employers, through their contracting practices, s ought apply the principles of industrial organization to health care delivery to advance the ideal of organize d he alth care that were accountable and attractive to driven cons umers. Although, certainly, some excellent health care delivery systems have developed, mos t fallen far short of thes e ideals in a full array of organizational s tructures . All of thes e s tructures and models fell under the term manage d care . In their early years , these approaches were dramatically s ucces sful 4736 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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stabilizing health care costs . However, soon cost meas ures and the pres sure of competition among care s ys tems began to cut into the bone by denying appropriate services in some instances. Quality and accountability began to dominate the health care by the end of the 1990s, and cons umers were to look to quality ratings by major accreditation organizations in making their choices. Although it has been opined that, as it enters the new century, care is faltering, as patient rights legislation hovers in C ongres s, reports of its demise may be exaggerated. It certainly had an indelible impact on the American care s ys tem, and is sues of quality and accountability, reinforced by the Institute of Medicine's report, the Q uality C has m: A Ne w He alth S ys te m for the 21s tand the growing population of uninsured Americans will continue to goad the reform impulse. What has happened to public and community in this turbulent period for American health care? It is a story of s trengths and weakness es. T he repeal in 1981 the Mental Health S ystems Act, which was a national for the chronically mentally ill, forced NIMH (apart from res earch agenda) to narrow its focus to two areas of initiative: community s upport s ys tems for adults with serious and pers istent mental illnes s and the child and adoles cent s ervice system program (C AS S P ). In both the agency provided the states with modest grants to them purs ue the reforms and improvements to the community mental health s ys tems that had been laid in the blueprint of the P resident's C ommiss ion on Health. T he s tates, on the other hand, proceeded on a track to wind down the state hos pitals and, in most 4737 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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to build community support programs. T his too was uneven. In many large cities, pers ons discharged from hospitals with serious mental illness joined the ranks of homeles s or lived in s ubs tandard conditions in welfare hotels or board-and-care facilities .

C urrent S tatus At the level of service delivery, public and community ps ychiatry is currently driven by the complex interplay three factors: the ne e d for focus , the impact of care , and the interplay of s cie nce and delivery first is the need for public agencies to focus the ir on their mandated target populations. Departments of mental health are narrowing their res pons ibilities to the needs of pers ons with s evere and persistent mental providing, through their contract agencies , a broad of community s upport s ervices to help them function in the community. P revention activities or s ervices to the general population are left to the health care system to managed care plans that adminis ter it. C hildren's agencies are much more complex, involving child primary health care, education, juvenile justice, and subs tance abus e. Mental health public agencies divert relatively s mall part of their attention to child and adoles cent mental health. T hes e agencies are jus t beginning to focus their attention, in a more or les s fragmented way, on children with serious emotional disturbances . T he S ubstance Abus e and Mental Health S ervices Adminis tration (S AMHS A), an agency service delivery programs , formed in the early 1990s to parallel the NIMH, offers, along with other federal categorical agencies , generous funding to encourage agencies to integrate their efforts to create coherent 4738 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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service delivery s ys tems for children and their families . T hese efforts have grown out of the C AS S P grants in 1980s . In addition to NIMH, two other agencies within the National Institutes of Health (NIH) have been created advance scientific knowledge concerning s ubs tance disorders : the National Ins titute on Alcohol Abuse and Alcoholis m (NIAAA; founded in 1970 as a component NIMH, established as an independent agency in 1974, subs equently incorporated within NIH as a distinct institute) and the National Ins titute on Drug Abus e founded to overs ee federally funded drug abuse and res earch programs in 1974 and incorporated within NIH as a dis tinct institute in 1992). W hile NIMH, NIDA historically have taken the lead in federal s upport and overs ight of ps ychiatric res earch, a s eparate S AMHS A, was established within the federal P ublic S ervice as the counterpart of the NIH institutes, with miss ion of advancing the delivery and real-world evaluation of mental health and s ubs tance abus e for adults and children. S AMHS A has three primary component divisions, the C enter for Mental Health S ervices (C MHS ), the C enter for S ubs tance Abus e P revention (C S AP ), and the C enter for S ubstance T reatment (C S AT ). T he second factor is the de libe rate move toward care on the part of the Medicaid program in almos t state. S tate Medicaid programs have adopted s ome of managed care, often contracting with managed care companies. T he impact on public and community ps ychiatry has been complicated. T he problem is that managed care products are generally designed to 4739 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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health care for large populations with general health needs . T his is appropriate for the 75 percent of the Medicaid population that is compos ed of generally mothers and their children: It is very awkward for the percent of the Medicaid program that consis ts of who are elderly and frail or who have s evere T he standard managed care products are generally not suitable for them, whereas specialized disease management models (sophisticated chronic illnes s management, such as community support programs ) appropriate. However, there is a further complication, that s tates are transferring categorical programs (i.e., programs funded in categorical public agencies, such mental health or mental retardation) and the ir budge ts the manage d care Medicaid program to capture federal financial participation in the state expenditures . T his entails replacing the adminis trative and programmatic infras tructure of s ophisticated chronic illnes s care management programs with the managed care that are suitable for health care delivery for general populations. T hes e trends are obviously at cross and threaten to weaken delivery systems for pers ons serious and persistent mental illness and to neglect the needs of poor people with less s erious mental health needs . F inally, the third factor is the interplay of science-based ps ychiatry and the development of coherent and delivery systems . In the year 2000, the Nobel P rize in Medicine was awarded to Arvid C arlss on, P aul and E ric K andel for their dis coveries concerning signal transduction in the nervous s ys tem'work that explained the level of molecular biology the effect of the s o-called 4740 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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F rench drug (chlorpromazine) and the ps ychotropic medications that followed it. In J une of that same year, Human G enome P roject of the U.S . Department of announced the completion of a working P.3852 draft of the entire human genome s equence. B iological ps ychiatry has made remarkable s trides in the last half the 20th century and promises s till more in the 21st century. Nonetheles s, P res ident G eorge W . B ush's F reedom C ommiss ion on Mental Health reported in 2003 that there are hopeless fragmentation and gaps care for children and adults, that people disabled with serious mental illnes s are unemployed, that older with mental illnes s are neglected, and that prevention not yet a national priority. T he challenge for public and community psychiatry is to match the progres s of based ps ychiatry with the development of effective delivery systems and structures that will bring care into the mainstream of American medicine.

R epris e It may appear that, in two centuries , American mental health has come full circle, that individuals severely disabled by mental illnes s are back in communities and wander through cities without appropriate care. T here certainly much truth in this . However, on the very spot where Nancy B arron was res trained in the poor hous e screamed through the day in E mers on's C oncord, there now stands a community res idential program for adoles cent girls with s erious emotional dis turbances is part of a community system of care. T hey are treated 4741 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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doctors who understand the brain chemistry that their illness es and who have pharmaceuticals that can alleviate them. T here are many s hortfalls in current health policies and practices . However, progress has made, and the stage is s et for even greater progres s.

C ONTE MP OR A R Y P UB L IC A ND C OMMUNITY P S YC HIA TR Y T here are five themes around which the dis cuss ion of contemporary public and community ps ychiatry is structured: public health, public agencies, evidenceps ychiatry, roles for ps ychiatris ts, and delivery

Public Health P ublic health is not simply publicly funded health care rather a specific dis cipline and tradition. It is a field that his torically has been defined negatively by the dominance of pe rs onal he alth, that is, the health care delivery systems that take care of individual patients . the advent of managed care in the 1990s , American care was an industry organized largely as individual doctor-entrepreneurs. E ach jurisdiction uniquely and organizes its public health programs, but, as a discipline and tradition, public health's mis sion is to the conditions in which people can be healthy. P ublic health consists of organized community efforts aimed the prevention of disease and the promotion of health. involves many disciplines , but rests on the s cientific epidemiology. Mental illness and substance abuse problems certainly public health concerns . Mental illness affects the lives many as one in four individuals acros s all walks of life, 4742 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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as many as 6 percent of all adults (i.e., more than ten million adults in the United S tates alone) experiencing mental illness that is so severe and persis tent as to cons titute a major impairment to the ability to live and work safely, independently, happily, and productively. Mental illness and substance abuse constitute an enormous financial burden on communities and states , well as the federal government. As community mental health efforts developed in the past 50 years, mental health profes sionals increas ingly have as sumed the res ponsibilities called for by the Institute of Medicine's C ommittee for the S tudy of the F uture of P ublic Health, which include fos tering the development of competent people, effective leadership, a scientifically sound knowledge bas e, the tools to monitor health problems meas ure progress , a productive organizational adequate financial res ources , and a legal foundation supports effective action, all motivated by a vis ion of public's health that is unders tood and s upported by that public. T he 2000 S urgeon G eneral's report on mental health unders cored the necess ity of a public health approach care and rehabilitation for people experiencing mental illness that is broader in focus than medical models concentrate on diagnosis and treatment. Although diagnosis and treatment is a core expertis e for all ps ychiatris ts, the S urgeon G eneral recommended that'even when ps ychiatric diagnosis or treatment is the primary focus for practitioners, res earchers, or educators 'they should ground their profess ional in a vision and knowledge base that is populationencompas s[ing] a focus on epidemiologic surveillance, 4743 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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health promotion, dis eas e prevention, and access to services . T hes e fundamental public health functions the public health perspective in public and community ps ychiatry.

E pidemiology More than one-half of people experiencing a mental actually have more than one distinct ps ychiatric and, often, as many as three or four comorbid that complicate diagnosis and treatment. It is important for psychiatrists to be prepared to identify not jus t the most obvious ps ychiatric disorder, but also other comorbid dis orders, and to recognize the potential of culture and socioeconomic status on the ways in people describe and understand the illnes s and their expectations for care. An immediate implication of population-based epidemiological s tudies is the need for timely identification of people with or at high ris k for disorders . When s ys tematic res earch diagnos tic done in the most acces sible arena for ris k factor surveillance'primary and specialty medical care settings 'the findings consistently demonstrate that mos t ps ychiatric disorders are underdiagnos ed (by 25 to 75 percent). S ubthre s hold ps ychiatric disorders (i.e., symptoms and impairment but not sufficient to meet full diagnostic criteria), although potentially more to treatment and often ass ociated with s ubs tantial ps ychos ocial impairment, are even les s well identified. Des pite the exis tence of s trong evidence from ris k factor s tudies, surveillance of the principal risk for psychiatric dis orders (e.g., family his tory, life 4744 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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and prodromal signs and symptoms ) is not done by most ps ychiatris ts nor by the public mental treatment s ys tem in most s tates and local

Health Promotion P eople experiencing mental illnes s or addiction can benefit from enhanced physical and mental health, as as from the alleviation or management of ps ychiatric symptoms. Achieving or regaining physical or mental health (i.e., recovery) depends on not only genetic and biological factors, but also a person's or family's access social and psychological resources and integration in supportive s ocial networks. Illnes s management (als o known as dis e as e manage me nt or chronic illne s s care manage me nt) is a framework that has been adapted medicine to guide mental health profes sionals in delivering s ervices that go beyond traditional diagnos tic treatment to promote the health and recovery of people with mental illnes s or addiction. Illne s s manageme nt been defined as profes sional-based interventions designed to help people collaborate with profes sionals the treatment of their mental illness , reduce their susceptibility to relapses, and cope more effectively their s ymptoms [to] improve s elf-efficacy and selfand to fos ter s kills that help people purs ue their P.3853 goals . A number of approaches to illnes s management have been scientifically and clinically evaluated and been found to enhance s tandard psychiatric treatment. P roviding patients and families with education about mental illness and the proces s of treatment and 4745 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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has been shown to increas e their knowledge and potentially to enhance adherence to treatment. An more effective approach to promoting adherence to medication treatment is called be havioral tailoring' the careful design of practical reminders , routines, and incentives that adapt medication regimens to the preferences , lifes tyle, and limitations of each individual patient. T eaching patients skills for recognizing and with stress ors , symptoms, or potential relapses of symptoms in a timely and effective manner has been shown to reduce the severity of ps ychotic, anxiety, or addictive s ymptoms and to prevent rehos pitalization the res umption of potentially harmful (e.g., s uicide or subs tance use) behaviors. E ncouraging active, social activities or, for lower functioning patients , setting up structured opportunities (e.g., social or milieus (e.g., s ocial clubs or partial hospital that foster safe and rewarding social interaction and membership in an ongoing s ocial support system has found to reduce s ymptoms of affective, anxiety, and ps ychotic dis orders, as well as to enhance overall s ocial adjustment, s elf-es teem, and quality of Illnes s management thus offers an added s et of tools the ps ychiatris t's toolkit that promote the health and being of patients and that do not replace, but rather complement, the more traditional approaches to ps ychiatric diagnosis and treatment.

Prevention P sychiatric dis orders mos t often follow a cours e over that begins with an often lengthy period in which prodromal or subthreshold symptoms or functional problems precede the full onset of a dis order with 4746 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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impairment. Intervention with adults, adoles cents, or children who are not clinically impaired but who are at high risk (e.g., owing to a family his tory of ps ychiatric or addictive disorders or exposure to extreme stress ors , as violence, neglect, or the modeling of antisocial behavior) or who are manifes ting preclinical s ymptoms functional problems (e.g., periodic or pervasive problems with s eparation from caregivers , or with deviant peers) is an approach to prevention that been found to be cost effective, because it targets a relatively s mall group of individuals in a timely manner. Application of the traditional public health concepts of primary, s econdary, and te rtiary ps ychiatry has been confusing in ps ychiatry. P rimary pre ve ntion involves addres sing the root caus es of illness with healthy individuals , with a goal of preventing illness before it occurs. S econdary preve ntion involves the early identification and early treatment of individuals with or s ubclinical dis orders or high-ris k persons to reduce morbidity. T e rtiary pre ve ntion attempts to reduce the effects of a disorder on an individual through rehabilitation and chronic illness care management. Ins titute of Medicine, in an effort to clarify different of prevention, developed a clas sification s ys tem with categories . Univers al interventions are those intended the general public, such as immunizations or media campaigns providing information about illness es , early warning signs, and res ources for health promotion and timely treatment. S ele ctive interventions focus on individuals at higher than average risk (e.g., persons prodromal symptoms or a family his tory of psychiatric disorders ) to reduce morbidity by enhancing res ilience preventing the ons et of illness . Indicate d interventions 4747 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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target individuals who are experiencing impairment as res ult of illness as early as pos sible in the cours e of the illness , to reduce the burden of the illness on the individual, family, community, and treatment s ys tem. P sychiatric services mos t often take the form of interventions , but the smaller number of ps ychiatric practitioners and res earchers who conduct and selective or universal interventions in public and community settings is making a s ubs tantial contribution the larger health of society. P revention interventions have been found effective with adults with a variety of risk factors or preclinical F or example, women who have been raped are les s to develop posttraumatic s tres s disorder (P T S D) if they receive a five-sess ion cognitive-behavioral treatment if their recovery is left to chance. Men and women identified with subthreshold s ymptoms of depress ion by primary care medical providers are more likely to free from the full syndrome of depres sion or to be able recover rapidly with treatment if they do become depres sed, if their s tandard medical treatment is by education about depress ion and learning skills for coping actively with depres sive s ymptoms or s tres sors. P revention with adults must be judicious ly des igned to addres s the s pecific factors that place a pers on at ris k illness or enhance the pers on's ability to cope F or example, brief s upportive meetings with people have experienced a traumatic s tres sor (e.g., a mas s or life-threatening accident) tend to have little benefit may inadvertently intensify posttraumatic s tres s, a focus ed cognitive-behavioral approach to teaching for coping with traumatic memories and stress 4748 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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has been shown to be effective in preventing posttraumatic stress and depres sive dis orders with and child disaster or accident s urvivors . A number of prevention programs have been and evaluated to address phys ical and mental health in childhood and adoles cence, incorporating several elements that influence intervention effectiveness . bas e d interventions involving teachers and the peer tend to be more effective than programs exclus ively relying on intervening only with parents or children S uch interventions in middle childhood have been succes sful in influencing peer group norms regarding alcohol and substance us e, thus achieving the dual outcome of reducing immediate initiation of alcohol and subs tance use and increas ing the long-term s upport within the peer group for s ustained abstinence into adoles cence. T hus, systems -based multimodal interventions simultaneously targeting and developing enhanced relationships among the child, peer group, school personnel, parents, and the wider community to be mos t effective as universal or s elected early prevention of what otherwis e may become behavioral, legal, academic, and addictive problems.

Ac c es s to E ffec tive Mental Health As noted in the P reface to the S urgeon G eneral's 2000 report, even more than other areas of health and the mental health field is plagued by disparities in the availability of and acces s to its s ervices. R ace (i.e., color), age (i.e., children and older adults ), gender (i.e., female), s exual preference (i.e., gay or lesbian), (i.e., monolingual non-E nglis h s peaking or E nglish as a 4749 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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second language), national background (i.e., s elf or from nations in C entral or S outh America, Africa, or education (i.e., less than college), and financial status low income) are ass ociated with barriers to access , not only to mental health care, but also to health care and health ins urance of any kind'as well as to health that s pecifically covers ps ychiatric dis orders. P eople primary access to mental health or addiction recovery services comes through publicly funded programs or agencies tend to have s ome, if not many, of thes e characteristics . P ublic sector mental health providers to provide services to people of varied backgrounds P.3854 but primarily to people who have been marginalized to thes e characteris tics. Acces s is a serious problem for most people with mental illness or addictions . In the United S tates, the National C omorbidity S tudy found that fewer than 40 percent of people with s evere psychiatric disorders had received any mental health treatment in the pas t year, fewer than one in six (15 percent) had received adequate mental health s ervices. Y oung adults, African American individuals, people residing in certain geographic areas , people with psychotic disorders , and patients treated by medical but not mental health providers were at highes t risk for inadequate treatment. Although income was not a predictor of inadequate treatment, it is likely that many of the who did not receive adequate mental health s ervices unins ured or had insufficient insurance coverage for mental health conditions and had no viable source of 4750 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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mental health care other than through a medical or clinic or in the public mental health s ys tem. T he was not a critique of the quality of s ervices actually provided by mental health profes sionals but rather was demonstration of a larger s ys tem-level problem, the inadequacy of treatment was due to poor acces s to specialized mental health care. E ven when mental illness is identified, people with socioeconomic adversities often do not, or cannot, get adequate mental health s ervices in their communities. example, although it is es timated that more than incarcerated adults in the United S tates have disorders , few were detected or received treatment they reached jail or pris on. F ederal and s tate systems have ins tituted mental health screening and treatment programs to addres s psychiatric dis orders as health problem for incarcerated adults and to manage problematic behavior that can occur in controlled as a result of mental illnes s. On returning to the community, the vas t majority of pris oners with disorders cease to receive more than minimal mental health services : A recent study found that fewer than in six (16 percent's trikingly similar to the National C omorbidity S tudy finding) received steady mental services , and only 1 in 20 with addictions received subs tance abus e recovery services . T hus, acces s to health and addiction treatment s ervices is far better in prison than in the community! T his has caus ed great concern because of the poss ibility that correctional facilities may be a de facto s ys tem of care for lowpeople (often of minority backgrounds) with s erious mental illness . 4751 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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E vidence of s erious and pervas ive barriers to mental health care can be found in s everal social P oor children and adults increasingly are deferring phys ical and mental health care until illness es become chronic and s evere and then often do not know or cannot gain entry into any s etting for services except public hospital emergency departments. C hildren with severe ps ychiatric or behavioral dis orders are being emergency department facilities for days and even because the s taff cannot locate any treatment facilities with an appropriate level of care that have an opening are willing to take the child as a patient (or accept the or family's insurance coverage or lack thereof). P eople cannot afford private services thus face daunting when seeking appropriate mental health care as a a s erious underfunding of practitioners and programs. economic forces and public policy dilemmas driven by ever-increasing cos t of health care bear directly on the field of public ps ychiatry, as well as the lives of tens or hundreds of thous ands of people who do not receive adequate care. Des pite the stated intent to provide community-based mental health care to people who cannot acces s ps ychiatric care, contemporary state and local mental health services increasingly place adults with chronic persis tent mental illness in minimally s upervis ed res idential placements , homeles s s helters or or jail or pris on. All of these restrictive s ettings are mandated to provide mental health and s ocial services , but most have limited res ources to do s o (or fail to use res ources except to provide cris is management). T he that people of color and people of all races who have 4752 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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lives (often generations ) of s ocioeconomic deprivation stigma are disproportionately repres ented in these las tchance and highly restrictive s ettings has led s ome to to the criminal justice system and public domiciliaries the homeless or the chronically mentally ill as a de warehous ing program for marginalized people in lieu of adequate public mental health system.

Ps yc hiatry and Public S ec tor P sychiatry's relations hip to public sector agencies has , some s pecific exceptions , been one of detachment'becaus e of the dominance of the private practice models before the advent of managed care also largely because of the nature and structure of American s ocial welfare programs. In contrast to most indus trial nations in which comprehens ive s ocial reforms have been initiated, American s ocial welfare programs grew incrementally and categorically, that is , one category of s ervice at a time. Large-scale such as P resident J ohns on's War on P overty, have implemented in piecemeal fashion by fragmented state, and local government bureaucracies and have vastly reduced through s ubs equent initiatives, such as recent changes in federal regulations to end welfare as know it. V arious s ocial s ervice agencies have been through a process and set of alliances that has been the iron triangle . Advocates form an organization to champion a particular caus e, s uch as blindnes s, developmental disabilities, primary care, or mental among others . T hey find key legis lative spons ors who advance the cause through legis lation and T his creates a bureaucracy and bureaucrats that join alliance. T hrough success ive legis lative s ess ions, the 4753 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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alliance of advocates, lawmakers, and bureaucrats stronger and s tronger categorical agency, for example, adults and families with dependent children or people with biologically bas ed, s evere mental illnes s. F rom the 1930s through the end of the century, American social welfare agencies were created on this pattern: T he has resulted in generous funding and hopeless fragmentation of s ervices at local service delivery which each agency depends on s eparate funding s ilos also deliver conflicting rules and regulations. It has been s aid that mental health is not a place. P sychiatrists have a role at the receiving end of every categorical s ilo, because the clients of each categorical agency experience mental illnes s or various addictions . S ervices for children with severe emotional, mental, or behavioral disturbances are a dramatic case. F ive categorical agencies'child welfare, education, primary health, subs tance abus e, and juvenile justice'all have a res ponsibility to care for these children (and indirectly, their caregivers, including parents and families ). for the children with the most s evere dis abilities, the protective s ervice worker taking a child into court, the special education teacher working day to day with the child, the juvenile probation officer, the s ubs tance couns elor, and the child's pediatrician all need the cons ultation and support of a skilled ps ychiatrist. T he situation is similar for adults with severe mental illness , whom case managers, vocational rehabilitation couns elors, bas ic needs benefits s pecialists, s ocial ps ychotherapis ts, substance abuse counselors , parole probation officers , legal conservators , visiting nurs es , phys icians all may be mandated to deliver s ervices. 4754 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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T he need for ps ychiatric consultation and support is equally important for thos e who care for pers ons with mental retardation or developmental dis abilities, for the elderly, for persons in vocational rehabilitation and for pers ons in correctional programs . V irtually all public resources come through this complex of agencies . It will be imposs ible to achieve the ideals of public P.3855 health pers pective on public and community ps ychiatry unles s ways are deliberately devis ed to engage and proficient ps ychiatris ts in meaningful roles in the operations of thes e agencies .

C ontemporary E videnc e B as e for E ffec tive Public and C ommunity Ps yc hiatry Interventions A dults with S evere and P ers is tent Illnes s Although ps ychiatris ts working in public and community settings encounter patients with mild impairment or disorders , the preponderance of the work involves with severe ps ychiatric dis orders and chronic impairment. Adults who have been faced with socioeconomic deprivation for most or all of their lives (often over several generations) are at ris k for chronic ps ychiatric disorders that often are complicated by medical illness , violence, s ocial stigma, and cultural or political marginalization. T hese advers ities, as well as cognitive, emotional, biological, and interpersonal impairments often experienced by adults with s evere 4755 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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persis tent mental illness , may obs cure their personal strengths and res ilience and the res ources potentially available to support them in their families and communities. A major challenge to ps ychiatris ts adults who have the dual burden of mental illnes s and socioeconomic disadvantage is the identification of and enhancement of the ps ychological and s ociocultural res ources that can promote illness management and reintegration in a s upport s ys tem. T he traditional foci ps ychiatric practice'evaluation and diagnos is of ps ychopathology, and pharmacotherapy'are an component in the larger program of ass is ting adults severe and persistent mental illness to make the best poss ible adjus tment in the least res trictive public and community s ettings . However, thes e traditional functions must be coordinated with several other recovery-oriented interventions within the context of multidis ciplinary ps ychiatric rehabilitation teams.

E videnc e-B as ed Manualized Interventions for A dult P s yc hiatric R ehabilitation S ince the 1980s, s everal structured interventions have been developed to address the gap between what historically has been taught in most ps ychiatry training programs'typically, an office, clinic, or hospital-based approach focusing on Axes I and II diagnos es and pharmacotherapy s upplemented by ps ychotherapy'and the competencies required to deliver or to s upport the delivery of the full array of psychiatric rehabilitation services . P s ychiatric rehabilitation involves not only pharmacotherapy, but als o an array of complementary services that must be coordinated to ass ist people with 4756 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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severe mental illness to manage symptoms , to access to use res ources effectively, and to gain the greates t degree of autonomy in the least restrictive setting poss ible. T he competences required to effect thes e interventions go beyond the s cope of ps ychiatry, thus requiring that psychiatrists effectively collaborate with other rehabilitation and mental health specialists. Although ps ychiatris ts rarely implement the res ource linkage, and ps ychotherapy interventions involved in these protocols, it is es sential that the ps ychiatris t become aware of and be able to reinforce these interventions. Hence, familiarity with the manuals that describe how to execute thes e interventions is strongly advised'and increas ingly incorporated into ps ychiatry training. An illustrative but not exhaustive sample of these interventions is detailed in T able 52.1-

Table 52.1-2 E videnc e-B as ed Manualized Interventions for Adult Ps yc hiatric R ehabilitation Modality

Goals and Targeted

R es ults of E valuation

S ocial and independent living s kills

T eaches skills managing symptoms and

S ocial and independent living s kills

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preventing relaps e (mental illness and addictions).

evaluated in randomized, clinical trials ; show positive outcome with increased succes sful community living and reduced rehospitalization.

 

Improved communication with providers, peers, and family.

 

 

C hoosing and engaging in activities and jobs that match with an individual's abilities , limitations , and interes ts .

 

Dialectical behavior

T eaches skills regulating

E valuated in randomized,

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therapy

intens e emotions , tolerating extreme emotional distress , achieving interpersonal effectivenes s, and developing mindfulness .

clinical trials parasuicidal borderline personality disorder adult patients, res ulting in reduced behavioral and ps ychiatric crises. Open studies show positive ps ychos ocial outcomes with adults with severe and persis tent mental illness and chronic addictions and with adolescent subs tance abusers.

 

Originally developed for adults with borderline personality

 

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disorder, but been adapted for use with a wide range of Axis I dis orders in which dysregulation and poor impulse control are problematic. AC T

T eaches skills identifying and managing (rather than avoidance and feeling controlled by) the symptoms ps ychos is .

One randomized, clinical trial showed that increased patients' reporting of ps ychiatric symptoms but reduced the of the hospitalization by 50 percent when us ed with chronic ps ychiatric inpatients . A diss emination study showed

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that AC T led to enhanced outcomes in a large mental health program compared to year before training.  

Acceptance of symptoms facilitated by explanation that ps ychotic symptoms are extreme of normal perception and cognitive phenomena (private experiences ).

 

 

P romotes reflective observation as an alternative to struggling with symptoms.

 

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R elaps e prevention therapy

T eaches skills identifying the warning signs potential or actual res umption of subs tance use ps ychiatric symptoms.

T es ted in randomized, clinical trails found to delay, reduce the severity of, or prevent subs tance use relaps e with adults with chronic addictions.

 

Uses cognitivebehavioral s kills for modifying patterns of thought and behavior that likely to into a full relaps e.

 

 

Ass is ts patients in proactively recognizing and managing symptoms in a timely manner.

 

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Interpersonal T eaches skills ps ychotherapy interacting and communicating effectively in clos e relations hips with a particular focus on overcoming four core interpersonal problems : unresolved role conflict diss atis faction with parenting), role transition (e.g., marital separation), interpersonal deficits (e.g., is olation and anger management).

T es ted in randomized, clinical trials found to reduce the severity and the ris k of relaps e of moderate to severe depres sion. shown efficacy with anxiety and binge-eating disorders . Has not been scientifically tes ted with adults who experience severe and persis tent mental illness addictions.

T rauma recovery therapy

Open trials and quasiexperimental trials show and efficacy for

T eaches skills recognizing and managing symptoms, as intrus ive

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memories or flashbacks , problems with sleep, anger, or concentration problems due to hyperarous al or hypervigilance.

adults with severe and persis tent mental illness (cognitivebehavioral therapy for severe mental illness , trauma recovery and empowerment, and trauma adaptive recovery group education and therapy) or chronic addiction (s eeking safety, subs tance dependence, P T S D therapy, and trauma adaptive recovery group education and therapy); randomized clinical trials are in process .

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Unlike behavioral therapy expos ure treatments , which have shown efficacy for P T S D but have not been tes ted with adults with serious and persis tent mental illness chronic addictions, it does not intens ive memory recons truction.  

Developed for adults in community or res idential mental health treatment who have severe persis tent mental illness

 

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addictions.  

  P rovides ps ychoeducation about the effect of extreme on the body and the brain's normal stress res ponse proces ses.

AC T , acceptance and commitment therapy; P T S D, posttraumatic stress disorder.

C hildren with S evere E motional Dis turbanc e C hildren from all walks of life experience severe illness es (such as developmental, affective, and disorders ) and behavioral problems (such as attentiondeficit, oppositional defiant, or conduct disorders ). However, when these children als o live in communities that are affected by poverty (including the working and therefore rely on public s ector s ocial and health services , they and their families also often experience additional burden of s ocial marginalization (s uch as language barriers, or limited acces s to high quality education or employment). P ublic and community 4766 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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ps ychiatry treatment for children with severe emotional disturbance therefore mus t be viewed as a proces s of delivering a coordinated combination of psychiatric and ps ychos ocial services that wrap around the child and family like a protective membrane. As with adults , the services must include traditional ps ychiatric evaluation, diagnosis, and pharmacotherapy where indicated, but they mus t also link the child and family to a larger supportive s ys tem of care that address es the full range socioeconomic, as well as ps ychiatric, impairments and needs .

E videnc e-B as ed Manualized Interventions for C hild P s yc hiatric R ehabilitation C hildren with severe emotional dis turbance and adoles cents with s evere behavioral disorders have been removed from their families and placed in res trictive psychiatric or juvenile jus tice s ettings (e.g., ps ychiatric inpatient wards, res idential group homes, juvenile detention centers). T hes e placements child from the natural family, s chool, peer group, and community environment, which may provide s ome by reducing the child's exposure to addiction, conflict, violence, or deviant behavior. However, the also deprive the child and family of the opportunity to build better relations hips with one another and with children, families, teachers, and community groups . Moreover, psychiatric or juvenile justice placements to increas e each child's expos ure to the environmental problems that are intended to be reduced, becaus e the placement creates an artificial concentrated peer group that is extremely impaired or delinquent. T he s econd 4767 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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ingredient to effective public and community child ps ychiatry is interventions that complement pharmacotherapy. S ince the 1970s , s everal approaches for children with s evere disorders (and families ) have been developed, tes ted, and in replicable manuals and training programs , and these presented in T able 52.1-3.

Table 52.1-3 E videnc e-B as ed Manualized Intervention for C hild Ps yc hiattric R ehabilitation Modality

Goals and Targeted Areas

R es ults of E valuation

P roblem-solving skills training

T each children skills and parents in helping children with selfmonitoring, prosocial goal setting, developing peer positive environments , setting limits

A randomized, clinical trial with children 1014 of age who at high ris k es tranged from parents , in emotional distress , academically disengaged, found that

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with friends , and developing problem-solving and communication skills .

 

P roblem-solving skills training teaches the directly.

P arent management training

P arent management training how parents tangible incentives and cons equences

families who received thos e modalities showed better parentchild cooperation, reduced conflict and reduced externalizing behaviors . One year follow-up showed wors ening of externalizing behaviors as rated by teachers.

 

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change and how they model behavior and interact with their children. F amily therapy

E nhance communication patterns in children's family systems .

In a clinical trial with inner city whos e children had a variety of behavior problems and varying degrees of juvenile involvement, brief s trategic family therapy was superior to us ual care s ervices.

 

Improve parenting s kills and children's ability to s elfregulate.

 

 

V iew children's problem

 

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behaviors as serving s pecific purpos es within the family.    F unctional therapy

F unctional therapy teaches skills for solving and behavior management and delivers to parents and children together.

   Multidimensional Multidimens ional family therapy family therapy identifies family interaction patterns and res tructures them to trus t and cooperation.

One and two quas iexperimental studies s how reduced juvenile recidivism for youths receiving functional family therapy.

One effectivenes s study showed multidimens iona family therapy res ult in greater overall improvement than group therapy or education for subs tanceabusing adoles cents .

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   B rief s trategic family therapy

B rief strategic family therapy is a problemfocus ed family therapy that focus es on improving family relations hips by addres sing family leadership, alliances, behavioral control, and parental res ponsibilities; was developed and us ed extensively with inner city children and families of color.

 

F amily, s chool, community treatment

Developed for children who cannot be maintained safely in their families of dangerous or

 

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disruptive behaviors . Multisystemic therapy

Multisystemic therapy involves up to 6 mos of individualized, communitybased contact a therapis t, supported by a 24-hr back-up team; multisystemic therapy addres ses all relevant environments empowering parents with the skills and res ources needed to independently addres s whatever difficulties arise.

In randomized, clinical trials , multisystemic therapy reduces juvenile delinquent recidivism and crime severity, ps ychiatric symptoms, outof-home placements, drug us e, while improving family functioning and school attendance. Large-scale diss emination studies in the United S tates , C anada, and S candinavia show that multisystemic therapy is superior to

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services on but not all, ps ychos ocial outcomes . Oregon treatment fos ter care

Oregon treatment foster care provides training and ongoing s upport and s upervis ion to enable fos ter parents to maintain a structured therapeutic environment for teaching skills , s etting limits, and modeling communication and problemsolving strategies .

T hree randomized, controlled trials have found that Oregon treatment foster care reduced adoles cents ' ps ychiatric rehospitalization arrests and incarceration, running away, and drug us e, while improving vocational and educational outcome.

R oles of Ps yc hiatris ts in Public and C ommunity Ps yc hiatry 4774 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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Multidis c iplinary Team P sychiatrists in the public s ector rarely work in Most often, psychiatrists work within a team that profes sionals from s everal disciplines (e.g., social work, nursing, occupational therapy, or addiction counseling, s ocial services , housing, and employment s pecialis ts) and paraprofes sionals (e.g., bachelor's degree-level couns elors or case managers, school graduate indigenous outreach workers , and advocates), each of whom brings unique skills and experience to addres s the varied needs of people with severe and persistent mental illness es . T he team, than any s ingle provider, as sumes res ponsibility for the ongoing care of each patient across the many levels of services and often for many years. Its s ucces s is based effective communication. E very communication s hould explicitly focused on the clie nt's (i.e., patient and s tate d goals as well as on the team's technical and is sues, to maximize the client's motivation to participate actively and productively in all services by ensuring the s ervices truly are patient centered and P sychiatrists play three primary roles on ps ychiatric rehabilitation teams , including conducting ps ychiatric P.3856 evaluations , providing pharmacotherapy, and s erving the team's medical director (and, at times , as the adminis trative s upervis or or team leader).

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In public and community s ettings and populations no than in any other practice s etting or patient population, the sine qua non is a thorough evaluation of all relevant history and s ys tems and an accurate diagnos is . T he evaluation and diagnos is is to develop the mos t effective individualized approach to treatment and rehabilitation for each individual patient. P s ychiatric evaluations in public and community s ettings must include a careful review of the individual's ps ychos ocial strengths and res ources. T he focus on strengths and res ources often is lost or obscured when systemic (e.g., eligibility regulations for governmentally funded services or benefits ) emphasize dis ability or limit the individual or family's acces s to services or benefits welfare-to-work regulations that place time or other eligibility res trictions on types of temporary aid, such as food s tamps or vouchers for hous ehold s upplies or housing). A full multiaxial psychiatric evaluation is in public and community settings to addres s not only primary s ymptomatic dimens ions of ps ychiatric but also, equally or perhaps even more importantly, the final two of the five diagnostic axes in the revis ed fourth edition P.3857 of the Diagnos tic and S tatis tical Manual of Me ntal (DS M-IV -T R ).

P harmac otherapy T he ps ychiatris t's most visible role usually is providing pharmacotherapy. T he mos t difficult challenge in public sector mental health s ettings often is not the technical 4776 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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formulation of an effective medication regimen but instead the arranging of conditions so that the patient reliably follows the prescribed regimen (i.e., adhere nce compliance ). A recent review of interventions designed enhance adherence to ps ychotropic medication by patients with s chizophrenia found that education often was the only strategy us ed'despite being less effective than approaches that focus on concrete solving, motivational techniques, and reminders , s elfmonitoring tools , cues, and reinforcements or that an array of supportive and rehabilitative communityservices . T hus , although the ps ychiatris t mus t addres s technical medical is sues to formulate accurately and to establish an effective ps ychotropic regimen, effective pharmacotherapy depends heavily on providing'directly, in encounters with patients, or indirectly, by working clos ely with nonps ychiatric health profess ionals and paraprofes sionals'practical as sistance to patients to enable them to anticipate and manage the ps ychos ocial stress ors or problems that render even the most technically sound medication regimen completely ineffective as a res ult of nonadherence by the patient.

Team L eaders hip T he ps ychiatris t also often plays a leadership role as project or program medical director'with the attendant res ponsibilities of monitoring the medical safety and being of all patients and es tablis hing or s upporting management and clinical procedures that support of care and a cohesive treatment team. As the team or s imply as a team member, the ps ychiatris t s erves as role model for compass ionate and profes sional 4777 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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relation not only to patients , but als o to all other team members. F ormal or informal leadership is especially important when psychiatry res idents and medical work on a team as a training experience. T he team ps ychiatris t s erves as a mentor and a role model not for the core as pects of ps ychiatric practice, but als o to demonstrate the values and skills necess ary to ps ychiatry P.3858 within the framework of multimodal community-based longitudinal psychos ocial interventions. F or example, psychiatric rehabilitation adapts and the traditional ps ychiatric s ervices and roles by them within the context of a s et of ps ychos ocial interventions des igned not only to alleviate ps ychiatric symptoms, but moreover to promote optimal readjustment in the community: A recent review of the requirements for multidis ciplinary teamwork in rehabilitation summarized the challenge facing public community ps ychiatris ts : P sychiatrists who work with persons with s evere mental and who wish to contribute as members or leaders of their must go beyond their pads to acquire knowledge, attitudes, and skills congruent with contemporary practice guidelines for ps ychiatric rehabilitation; giving res pect and 4778 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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support to multidisciplinary team members and gaining their res pect and s upport in return; coping with large cas eloads ; collaborating with agencies and programs to ensure continuity, cons istency, and coordination of care; and valuing the roles and expertise of s taff who provide management, supported employment, skills training, and family and hous ing supports. If ps ychiatris ts can incorporate attitudes and skills, they can expect reciprocity and cohesion from other team members, and clients will benefit. T he paradigm s hift from a narrow focus on treatment to broader ps ychiatric rehabilitation model requires s olid training (and continuing education) and hard work, as as a combination of pers onal qualities and expertis e have been summarized as: pers is tence, realistic a collaborative s tyle, teaching ability, and networking system coordination s kills . S urveys of ps ychiatris ts in public s ector indicate that those who embrace the rehabilitation pers pective by expanding their roles to be cons ultants and teachers for patients, families, and colleagues from other mental health disciplines are more s atisfied profes sionally than those who focus on diagnosis and treatment alone.

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NE W P A R A DIG MS V irtually all health care should be integrated and coordinated to deliver effective, rational, and costcare. T he broader, contemporary definition of care include public health. In fact, linking public health with acute care management, which, in turn, is coupled with chronic illness care management, rehabilitation or recovery models , is the continuum for an integrated system (F ig. 52.1-1).

FIGUR E 52.1-1 A model clinical and training s ys tem. academic community health system for quality practice integrating public health, acute care, and rehabilitation recovery models with s cience and advocacy. However, this continuum is insufficient without four components: (1) the application of new res earch to improve care and the application of bench-to-bedside models to translational res earch. (2) meaningful involvement of patients and families in a s hared 4780 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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making paradigm; (3) integration with primary and specialty care systems ; and (4) the development of the clinical s ys tem as a s ys tem of advocacy. T raining preprofess ionals in such a model is one approach to introduce meaningful and sustained change to health and its delivery and is already operational in some

NE W MODE L S FOR S E R VIC E A ND TR E A TME NT Organized S ys tems of C are T he focus of reform has moved increasingly to efficient, and accountable delivery systems . T here are number of factors contributing to this trend. As noted previous ly, large employers in the early 1990s, by the effectivenes s of mental health carve-out moved to full-scope managed care contracting us ing purchasing power to encourage the application of the principles of indus trial organization on health care and the ideal of organized s ys tems of care. T he that influenced them were, on the one hand, the (at experimental and now established s taff model health maintenance organizations , and, on the other hand, the efforts in community mental health to develop balanced s ys te ms ' intensive care service delivery systems that res pond cons tantly to s upport the changing needs of persons with s erious and pers istent mental illnes s. NIMH set the process toward organized systems of motion in the 1980s with grants to states to develop s ys te ms of care for children with s erious emotional disturbances and their families and community s upport s ys te ms for adults with serious and persistent mental 4781 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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illness . T he bas ic idea of the system of care for with serious emotional disturbances can be described two ways : in terms of interagency s tructures and in of clinical proces ses . F ive categorical agencies in a community need to form a s trong cons ortium that specific population of children (and their families ) for whos e needs none of the agencies can adequately res pond on their own. T he consortium agencies need commit themselves to treat the child and family with a common plan of care and to find ways to pool their res ources to do s o appropriately. T his P.3859 often requires that, in the central bureaucracies at the state level, a parallel interagency commitment be in that s upports the local s ys tem of care initiative, any regulatory conflicts that may arise, and gives permis sion to innovative aspects of the delivery T he collaborative interagency s tructure provides the res ources and the flexibility for effective clinical work. F rom the viewpoint of clinical proce s s e s , the s ys tem of provides a full enactment of the traditional clinical that meets the requirements of medical quality What is different is that it is carried out in home and community settings, and it involves participants from different disciplines'child welfare, s pecial education, juvenile jus tice'in one standardized treatment methodology. T he center of the s ys tem of care is the and family te am that is made up the child and family, clinicians and agency repres entatives involved in the and s ignificant supportive individuals identified by the child and family. C urrent iss ues are reviewed's trengths , 4782 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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problems , and needs 'diagnos tic is sues are cons idered, clinical goals are articulated, and appropriate treatment strategies are identified. T he expected outcome of intervention is s pecified, and progress toward it is systematically charted. T he s ys tem of care requires a array of flexible s ervices. T he ess ential s tarte rs include clinical diagnostic services , care coordination or case management, cris is intervention s ervices, and a flexible es sential s upportive s ervice'child care specialis ts who be as signed to s upport the child and family in any situation. S ys tems of care that have been particularly effective have relied on substantial community organization and collaboration or innovative funding models, or both, that blend or braid funding s treams to focus on clear ass ignment of respons ibility for a child and family, as well as adequate resources. T he basic model for community s upport for adults was called as s e rtive community treatme nt (AC T ). AC T was implemented with multidis ciplinary teams with ps ychiatris ts, nurs es , ps ychologists , s ocial workers , ps ychiatric aides , and paraprofess ionals . T he AC T would as sume the care of a des ignated number of patients with s erious and pers is tent mental illness and would be available around the clock, 7 days a week. team would help find housing, manage money, household routines, find social contacts , find work, and support the individual's adjustment to workplace at the same time that medications would be managed help provided to facilitate an individual adjusting to community living. At the heart of the program was the basic clinical process that developed and maintained individualized treatment plan, which was cons tantly 4783 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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adjus ted to the changing needs of each client. T he model has been modified in various ways as it has implemented in different states . Innovative funding models have been developed in several s tates by bundled rates and cas e rates , which make it easier to implement and to sustain than traditional fee-forpayment s ys tems. In contemporary managed care AC T teams are dis e as e and dis ability management that as sign accountability to provider systems that may not as sume risk in managing community support of persons with disabling conditions . T he National for the Mentally Ill (NAMI) has developed program and protocols for the P rogram for As sertive C ommunity T reatment (P AC T ) to encourage public agencies to contract for AC T s ervices.

E ffec tive Treatment Models T he previous dis cuss ions have outlined the various treatment models that have been introduced since the 1980s in the effort to establish an evidence base for effectivenes s of s pecific interventions and approaches care. T he attention to evide nce -bas e d treatment has been a respons e to the call for quality and accountability for s ervice outcomes demanded from health care s ervices in general by purchasers and makers and part of an effort to cope with the difficulties evaluating s ervice delivery models or systems of care. the field of health services res earch has matured, and economic cons traints of managed care have developed since the 1990s , adminis trative data about s ervice increasingly have become available to scientis ts, policy makers, and program managers . T his made it poss ible focus on the ques tions of quality and service 4784 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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in a much sharper way than before. T he different approaches to organized systems of care do not lend themselves to rigorous evaluation of because they require substantial reorganization of community resources, involving s everal categorical agencies , reconfiguration of traditional private and different levels of government even before the expansion of flexible service capability begins . T he movement to evidence-based services is break down components of the s ervice delivery system determine the relative effectivenes s of s pecific s ervice interventions us ing the evaluative tools and methods are available. E ventually, the cas e will be made to the larger policy questions concerning the value of coherent and rationally organized service delivery in mitigating the effects of mental disability on the development of the child and enabling the recovery proces s for adults with s erious and pers is tent mental illness .

C hronic Illnes s C are Model: in the C ontext of Primary C are F inally, the care of persons with long-term mental problems is included in innovative developments in the provis ion of primary health care for pers ons with illness es (http://www.improvingchroniccare.org/). T he Health R es ources S ervices Adminis tration (HR S A), the federal agency res ponsible for the community health centers, has adopted the chronic illness care model in training and technical ass istance efforts for community health centers . T he model grows out of the current concern for quality of care and accountability for health 4785 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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care delivery systems for effective outcomes. It entails revis ion of practice management techniques in primary care s etting that focuses on effective decis ion making involves the active participation of patients with chronic health conditions, enlis ting them to be active and res ponsible for their care. Depress ion management is of the four chronic health conditions that HR S A has selected for its training collaboratives. T he model begins with the ass umption that the health care delivery s ys tem is part of a community context must be respons ive in its interactions with the T here are four areas of focus that are es sential in implementing the model in the health care delivery system: self-management s upport, delivery s ys tem decis ion support, and clinical tracking system. S elfmanage me nt s upport gives patients a central role in determining their care, fos tering a sens e of for their own health. P atients collaborate with the care team to establish goals, to create treatment plans , to solve problems along the way. Delive ry s ys tem requires a reorganization of the way in which the health system operates , s o that up-to-date information about given patient is centralized, and follow-up res pons ibility as signed as a s tandard procedure, etc. Decis ion requires that treatment decisions are bas ed on explicit, proven practice guidelines s upported by at leas t one defining s tudy. G uidelines are discuss ed with patients providers , and treatment team members are cons tantly trained in the latest proven methods. F inally, clinical tracking s ys te ms track individual patients and of patients with similar problems . T hese systems must practical and operational'able to check an individual's 4786 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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treatment at any point to confirm that the treatment conforms to recommended guidelines. In the chronic illness care model, P.3860 the system aims at productive interaction between informed and activated patients and prepared and proactive practice teams to produce improved health outcomes . It embodies ideals that are not new to community mental health efforts but are all the more promis ing because the model opens the door to incorporation of ps ychiatric care into the realm of care.

THE FUTUR E : A B A K E R 'S DOZE N INITIA TIVE S A ND C ONC E P TS F inally, this review of public and community ps ychiatry concludes with a s election of initiatives and key that hopefully pulls together a s trategic overview of the current situation for ps ychiatry as a profes sion. F ig. provides a conceptual map that attempts to s chematize the connection of these ideas.

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FIGUR E 52.1-2 C onceptual map for initiatives and concepts for public and community ps ychiatry. F rom a strategic point of view, two cardinal concepts the advance of psychiatry in the contemporary turmoil that engulfs American health care: the validation of interventions demonstrating that they really work and produce appropriate outcomes and, therefore, value the accountability of health care delivery systems to implement valid interventions s o as to provide quality health care. T he former is the challenge for academic ps ychiatry, which trains and retrains the workforce and spons ors bas ic, clinical, and s ervices research that to the validity of s tandard practice, and the latter is the challenge for the organization of health care delivery its relations hip with public and private purchas ers and health care cons umers and their communities . W ith in mind, here is a baker's dozen of progres sive ideas. 4788 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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Ps yc hiatry Needs Health C are R eform T he American health care s ys tem is in terrible shape. Influential s tudies and groups have concluded that care and the overall health s ys tem are dysfunctional that s weeping changes are needed. V ariability of patterns for the same clinical problem, poor diagnostic accuracy, inefficient us e of res ources , inadequate care models, overwhelmed and fragmented s ys tems, insufficient attention to the proces s and coordination of care, and other critical factors all contribute to the observation that, in routine clinical practice settings, individuals with chronic ps ychiatric disorders are highly unlikely to receive effective services on a regular bas is , all. W ith incentives and dis incentives not yet aligned to bring about true reform, the provision of generally marginal services unfortunately is s till the unintended community standard. T he public s ector is es pecially vulnerable, with its dependence on the s ociopolitical proces s for its well-being with an electorate that is generally uninformed and ignorant about psychiatric disorders and their impact. Although the C linton health care reform initiative of the early 1990s failed, the managed care revolution forged ahead, driven by private sector payers. E fforts at incremental reform have failed. Nonetheless , as health costs s piral, and as the demand for quality increases, American health care s ys tem will, in time, be reformed, and, in the meantime, the reform agenda must the ground level of day-to-day practice. P sychiatry and behavioral health care have suffered as an acces sory these changes. T hey have everything to gain by 4789 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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leadership in the pus h for health care reform.

What Pric e Integration and the of Multi-dis c iplinary Prac tic e? T o be effective, care mus t be integrated, and it s hould integrated in various ways . Integration should mean improved proces s, efficiency, and elimination of redundancy and was te, having each point along the continuum of care be a natural and logical extens ion of preceding point, s o that care flows smoothly to a reasonable conclus ion or thoughtful extension. P roper health delivery is complex, requiring at the outs et a multidis ciplinary perspective, because no one single s ys tem is capable of providing the neces sary spectrum of care that, in the mos t complete s ens e, encompas ses public health and prevention, acute care management, and chronic illness care. C ollaborative multidis ciplinary care transcends profes sional guild and s hould be configured according to the needs of patients and their families . T he concept of primary care been enhanced to mean a team effort'multidis ciplinary its core, with ready access and guidance from s pecialty expertise. C urrently, one of the stronges t models for enhancement of primary care is in the federally health centers (F QHC s) or community health centers . T hese organizations are particularly important for and community psychiatry, because they are among few organizations that are financed to care for the poor and indigent, and becaus e they are able to provide needed general medical care for pers ons with major mental illness , as well as ps ychiatric care. Integrating ps ychiatry into the framework of the F QHC s medical home for poor people with psychiatric 4790 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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and offers a new model for effective delivery of health services . T he effectivenes s of collaborative, multidisciplinary demands that, to be effective from a larger pers pective, ps ychiatric care must be integrated under the primary umbrella.

Adminis trative S ys tems : C ritic al Ingredient of Health C are R eform Although s eldom articulated, a major obs tacle to achieving effective and high-quality delivery s ys tems is antiquated and badly des igned adminis trative systems . Administrative procedures , reporting, and record bend the s hape of clinical services and the way in they are delivered. T he elus ive automated clinical the firs t necess ity for building advanced practice health delivery systems . On this bas e, order-entry s ys tems, management, and financial systems can be built. S ophis ticated administrative s ys tems are es pecially important to s tate mental health authorities that are res ponsible for quality management, us e management, and ris k management. T he automated administrative systems developed by managed behavioral health organizations might be considered prototypes of the of administrative s ys tems that are demanded. Many clinicians have grave res ervations about P.3861 these, a fact that demons trates the importance of attending to the development of more appropriate systems . P s ychiatris ts s hould demand the sophisticated adminis trative s ys tems and s hould fully 4791 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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participate in their design and implementation.

R ole of Training R eforming the s ys tem and how its workforce functions clearly are complex challenges that will take decades achieve. S hort of having an inborn s ens e of what would comprise a contemporary approach to health care delivery, the majority of practitioners function as they trained, and training determines clinical pers pective. If practitioners are trained poorly, they practice poorly, so training determines a lot about the level of health care is achieved or achievable. T he variability of practice patterns is appropriate, and the validation of practice patterns and s pecific interventions is es sential. In behavioral health care, clinical perspectives can be diffus e, influenced more by theoretical orientation, to conjecture and opinion, poorly validated concepts , limited exposure to evidence-based concepts , and cons iderable lack of rigor. F or example, a cros sapproach to diagnosis historically has been It is not unus ual in tertiary care centers to s ee patients referred in who have been diagnosed as schizophrenic, simply because they were having auditory or paranoia, when, in fact, a broad differential approach based on cours e of symptoms , family, and s ocial his tory should be the accepted s tandard of adequate contemporary as ses sment. It is not to expect that practitioners s hould have a s tandardized approach to the diagnostic process . S uch a approach mus t come from how one is trained (or retrained). E ffective care in reformed systems requires profes sional training that incorporates the advances in 4792 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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science-based ps ychiatry and retraining of many practitioners in validated and s tandardized as sess ment and practice patterns.

Models for Funding Innovations T he way in which funding res ources are delivered determines what happens in health care and health delivery. P eople do what they are paid to do. If the system needs to be redesigned, then how funding and where it goes must be redesigned as well. All streams s hould support a fully integrated local delivery system rather than prescribing parallel functions for prevention, early identification, early intervention, evidence-based practice, and chronic illnes s Likewise, they s hould provide flexibility and s upport to introducing innovation and experimentation in the local delivery s ys tem. Integrated delivery s ys tems will integration of the funding mechanisms that will s upport them.

Des ired Impac t of Federal S tates , and C ities on S ys tems P ublic policy in the context of American federalis m is certainly complex. F ederal initiatives can be powerful stimuli to change and reform, but they are never T he most powerful factor in mental health policy is the state mental health authority, because the states have been primary funders of mental health programs s ince they s tarted to build asylums in the 19th century. On other hand, effective service delivery is as local as If psychiatrists are to have an effective voice in mental health policy, they must operate at multiple levels 4793 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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simultaneously and be seen as cons tructive agents of reform, willing to take on the responsibilities of care to those individuals seen in public and community systems . In short, psychiatrists must become identified cons tructive agents of reform to trans form the exis ting health care s ys tem. T o bring about health care reform advances behavioral health is sues to their appropriate place, ps ychiatry as a profes sion must have a voice must play an active role at local, state, and federal

R ole of L arge E mployers and Although all employers have interes t in the health and productivity of their workforce, large employers , private or public, have recognized the importance of cons tructive health policy and the need for reform. have also demons trated with their purchas ing power neces sity of cons tructive change to improve the health the work force that they sponsor through their health plans . T hey have insis ted that their health systems are accountable for quality health care and improved outcomes . Large employers are the mos t s ophisticated purchasers of health care for the populations that they spons or. T hey have a key role to play in any health reform that incorporates market forces and the that they bring to achieving quality care and effective outcomes .

R ole of the C ommunity Health care, and es pecially behavioral health care, done in the context of communities. T he s ymbols, and traditions alive in the community become grist for ps ychiatris t's mill in working with patients and families . 4794 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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be effective, the health care system mus t be in conversation with the community (or communities ) that serves, responding to its needs and enabling it to its members ' health. T o res pond, the health care needs to be able to marshal a full range of therapeutic supportive s ervices, especially for children with s evere emotional, mental, and behavioral disturbances and families and for adults with s erious and persistent illness . T he system mus t be able to res pond flexibly to support them in every area of their lives and in difficult periods in which they might decompensate. T he and the community mus t have the full range of s ervices available and access ible, from practical s upports for living to genuine intensive care services , including inpatient and subacute facilities , when these are Advanced practice delivery systems are rooted in communities; they are respons ive to community needs and incorporate in their mis sion the advance and maintenance of the health of the community.

R ole of C ons umer Advoc ac y E ffective psychiatrists need to lead multidisciplinary of caregivers to enable and to empower patients and cons umers to take res ponsibility for their own health. should encourage and support consumers and families to organize and to reach out to others whom can help and to reach out to their communities. T he increasing influence of the NAMI, the Depress ion and B ipolar S upport Alliance (DB S A), the Academic C ons ortium, the National Mental Health Ass ociation, the F ederation of F amilies for C hildren's Mental Health examples of how the advocacy process can benefit influence the field. Individual consumers have a critical 4795 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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to play in managing their own health, es pecially if they have chronic health conditions. C onsumer advocacy groups have demons trated their effectivenes s in policy that s upports good clinical care and in mobilizing community resources for adults and children with health problems.

R ole of the Media If one accepts the fact that the health s ys tem of the century begins with a public health pers pective toward community education, then, conceivably, one of the firs t initiatives will be educating the media about ps ychiatry and behavioral health affect the health of communities. T he media s hould be cons idered by ps ychiatry to be a fundamental ins trument for public P.3862 education and social marketing; ps ychiatris ts should develop communications skills and s hould work with communication specialists .

R ole of E duc ational S ys tems A community's educational s ys tem offers an framework to educate itself. E arly educational efforts in grade s chool at an appropriate developmental phas e could begin to inculcate important concepts that could cons titute a public health initiative in bas ic behavioral health that could not only inform, but als o reduce S imilar efforts could occur in s econdary s chools , and universities . P s ychiatry s hould undertake a initiative to develop curricula appropriate for the secondary, and college and univers ity levels that will 4796 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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systematically introduce information about mental and behavioral illness es and mental dis abilities to deepen students' understanding of thes e areas , s o that they recognize these problems in themselves and others, if exis t, and s eek appropriate help.

R ole of Public Health P ublic health functions are useful for ps ychiatry and its agenda for reform. P ublic health epidemiological perspectives provide a window to access and to shape health policy. Licens ing and regulatory functions and systematic meas urement of the health status of communities make it pos sible to enforce the accountability of health delivery systems . T he public health miss ion for health promotion and prevention as a vehicle for community education and public awarenes s. P sychiatry should deliberately partner with public health officials and agencies to as ses s the the community, to promote cons tructive policy development, and to improve public awarenes s of ps ychiatric illness and the benefits of effective

R ole of Ac ademia T he es tablis hment of ps ychiatry's science and its relations hip to neuros cience, genetics, pharmacology, clinical ps ychology, s ociology, the law, and other important areas has come from academia. P utting important clinical findings that improve care into the in a timely way will be part of what will change the field over time. R obust s ervices research that determines best ways to deliver care will be part of the effort to enhance quality. Use of algorithm approaches as part 4797 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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evidence-based practice for chronic psychiatric will mean that treatment will be more focus ed. T he of academic s ys tems to public s ector s ys tems in a true, nonexploitative partners hip will improve the level of in the public sector and in the community. Academic ps ychiatry is the engine for validation of effective health and substance abus e treatment through its in services res earch and the translation and application basic res earch findings . It provides profes sional to a s ophisticated workforce and should provide an aggres sive program of continuing education for practitioners to keep them abreas t of current developments in science and practice. F inally, medical centers are positioned to take the lead in the development of models of advanced practice s ervice delivery that are accountable and based on current standards .

G E TTING TO A FUNC TIONA L C A R E S YS TE M A critical question to as k if change is to be made in the present health care s ys tem is If the health care s ys tem must be reconfigured, in what guis e s hould it be? T o answer this question, one mus t begin with what is desirable and what makes sense (F ig. 52.1-2). Mos t probably agree that what is des irable is a system that functional, in which res ources are us ed only where needed, and in which there is evidence of improvement the system level and in the health of individuals served. this to occur, financing reform is necess ary to s top to integrate funding into s ingle streams delivered to the care of individuals and their encompass ing health from s imple to complex, that are neces sary to 4798 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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the overall health goal (i.e., to improve overall health status in as efficient and cost-effective a manner as poss ible). T his, in turn, depends on enlightened health policy that mus t incorporate the key principles of accountability and validity. Accountability refers to a system and its components (i.e., practitioners , patients cons umers, families, and health plan and payers ) res ponsibility for what is done or not done. implies cons equences that can be pos itive or negative. V alidity refers to ensuring that whatever steps taken by health system and its components are based on the available evidence s upported by the field through cons ens us founded on research evidence to the extent that is poss ible. T he quality of the res earch evidence into the province of academic psychiatry (and other academic disciplines), which then has a respons ibility diss eminating the evidence into a format that can be readily introduced to the field (i.e., trans lational to create effective practice. T his then ties into the and education miss ion of academic psychiatry, for preprofess ionals and the existing workforce. J ust as policy mus t drive changes in financing, it should also create organizational reform, so that payers and purchasers create, through enlightened financing (i.e., reward) mechanis ms , organized s ys tems of care that encompas s public health interventions (e.g., early identification, and early intervention), evidencebased acute care management, and chronic illnes s management in which consumers and their advocates incorporated into the overall decision-making process what transpires.

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T he other s ections in this chapter on economics 51.5a), the role of the ps ychiatric hos pital (S ection and ps ychiatric rehabilitation (S ection 52.4) are of importance to pers ons interes ted in public psychiatry. addition, all of C hapter 12 on s chizophrenia is of interes t, especially S ection 12.9 on its ps ychos ocial treatment. C hapters 12, 13, and 23, dealing with other ps ychotic dis orders, mood disorders, and pers onality disorders , res pectively, are also important, because disorders provide many of the public s ector's patients. S ection 5.1 discus ses epidemiology. F inally, anyone involved in public ps ychiatry should be interested in the comprehensive coverage of managed care in S ection

R E F E R E NC E S B artels S J , Dumas AR , Oxman T E , S chneider LS , P A, Alexopoulos G S , J este DV : E vidence-based in geriatric mental health care: An overview of systematic reviews and meta-analyses . P s ychiatr North Am. 2003;26:971-990. *B odenheimer T , G rumbach K . Unde rs tanding P olicy: A C linical Approach. New Y ork: Lange; 2002. B us h G W. New F reedom C ommis sion on Mental Available at: http://www.mentalhealthcommiss ion.gov/reports /Interim_ Acces sed October, 2002. C ohen C I, F einer J S , Huffine C , Moffic HS , T he future of community psychiatry. C ommunity 4800 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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Health J . 2003;39:459471. C ruz M, P incus HA: R esearch on the influence that communication in psychiatric encounters has on treatment. P s ychiatr S erv. 2002;53:12531265. Dix DL. Me morial. T o the Mas s achus e tts B os ton: Munroe & F rancis ; 1843. E ngland MJ , C ole R : P reparing for communities of for child and family mental health for the twenty-first century. C hild Adole s c P s ychiatr C lin North Am. 1998;7:469482. E nthoven AC : T he history and principles of competition. Health Affair S uppl. 1993;12:24. F oley HA, S harfstein S . Madne s s in G ove rnme nt: C are s for the Me ntally Ill? W ashington, DC : P sychiatric P ress ; 1983. F ord J D: T raumatic victimization in childhood and persis tent problems with oppositional-defiance. J T rauma Maltre at Aggres s . 2002;11:2558. G ollaher D. V oice for the Mad. T he L ife of Dorothe a New Y ork: F ree P res s; 1995:538. P.3863 G rob G N. T he Mad Among Us . A His tory of the C are 4801 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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Ame rica's Mentally Ill. New Y ork: T he F ree P ress ; Huey S J r, Henggeler S . E ffective community-based interventions for antis ocial and delinquent In: Hughes J , La G reca A, eds. Handbook of S ervice s for C hildre n and Adole s ce nts . New Y ork: Univers ity P res s; 2001:301322. *Ins titute of Medicine. C ros s ing the Q uality C has m: New H ealth S ys te m for the 21s t-C entury. National Academy P ress ; 2001. Ins titute of Medicine. T he F uture of P ublic H ealth. Was hington, DC : National Academy P res s; 1988. *Iss ac R J , Armat V C . Madne s s in the S tre ets : How P s ychiatry and the L aw Abandone d the Me ntally Ill. Y ork: T he F ree P res s; 1990. K azdin AE . P s ychothe rapy for C hildren and Dire ctions for R e s earch and P ractice . New Y ork: 2000. K azdin AE : T he s tate of child and adolescent ps ychotherapy research. C hild Adole s c Me nt H ealth. 2002;7. Lawlor T : P ublic sector risk management: A specific model. Admin P olicy Me nt H ealth. 2002;29:461. Lehman AF , B uchanan R W, Dickerson F B , Dixon G oldberg R , G reen-P aden L, K reyenbuhl J : 4802 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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based treatment for s chizophrenia. P s ychiatr C lin Am. 2003;26:939954. Liberman R P , Hilty DM, Drake R E , T s ang HW : R equirements for multidis ciplinary teamwork in ps ychiatric rehabilitation P s ychiatr S erv. 2001;52:13311342. Lovell D, G agliarid G J , P eterson P : R ecidivism and services among persons with mental illness after from prison. P s ychiatr S erv. 2002;53:12901296. McC lellan J M, W erry J S : E vidence-based child and adoles cent psychiatry: An inventory. J Am Acad C hild Adole s c P s ychiatr. 2003;42:13881400. Moris sey J P , G oldman HH, K lerman LV . T he As ylum: C ycle s of Ins titutional R eform at W orces ter Hos pital. New Y ork: G rune & S tratton; 1980. Mues er K T , C orrigan P W , Hilton DW, T anzman B , A, G ingerich S , E ss ock S M, T arrier N, Morey B , S cibilia S , Herz M: Illness management and P s ychiatr S erv. 2002;53:12721284. *Murray C J , Lopez AD. T he G lobal B urden of C ambridge, MA: Harvard Univers ity P ress ; 1996. New F reedom C ommiss ion on Mental Health. the P romis e : T rans forming Me ntal He alth C are in F inal R e port. R ockville, MD: DHHS P ub. No. S MA3832; 2003. 4803 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/52.1.htm

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Newman S J . Hous ing attributes and serious mental illness : Implications for res earch and practice. S erv. 2001;52:1309. R os enheck R , Lam J , Morris sey J P , C alloway M, R andolph F : AC C E S S National E valuation T eam. systems integration and outcomes for mentally ill homeles s persons in the AC C E S S program. S erv. 2002;53:958. T yler AF . F re e doms F erme nt. P has e s of American His tory from the C olonial P e riod to the O utbre ak of C ivil W ar. New Y ork: Harper; 1962:304. Wang P S , Demler O, K es sler R C : Adequacy of for serious mental illness in the United S tates. Am J Health. 2002;92:92. Weithorn LA: Mental hos pitalization of troublesome youth: An analysis of s kyrocketing admiss ion rates. S tanford L aw R e v. 1988;40:773838. Zwelling S S . Q ues t for a C ure . T he P ublic Hos pital W illiams burg, V irginia, 17731885. W illiamsburg, V A: C olonial W illiamsburg F oundation; 1985:30. Zygmunt A, Olfson M, B oyer C A, Mechanic D: Interventions to improve medication adherence in schizophrenia. Am J P s ychiatry. 2002;159:1653.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 53 - P s ychiatric E ducation > 53.1 G ra duate P s ychiatric

53.1 Graduate Ps yc hiatric E duc ation S tephen C . S c heiber M.D. P art of "53 - P sychiatric E ducation" T he American B oard of P sychiatry and Neurology certifies phys icians in the specialties of psychiatry, neurology, and child neurology and certifies diplomates nine s ubs pecialties. T he certification process , which is voluntary, protects the public by enhancing the quality ps ychiatric and neurological care. T he P sychiatry R es idency R eview C ommittee (R R C ) accredits programs in ps ychiatry and its six and the Neurology R R C does the s ame for adult and neurology, clinical neurophys iology (C NP ), pain (along with psychiatry), neurodevelopmental and vascular neurology. T he AB P N works clos ely with P sychiatry R R C , particularly with regard to training requirements, but it is the res idency programs that the principal sources of learning for their trainees, mos t whom eventually apply for board certification. T he is suance of 10-year, time-limited certificates led to development of recertification programs . R ecertification requirements include maintaining profess ional standing evidenced by having an unrestricted licens e in one of states or provinces of C anada and pas sing a clinically oriented multiple-choice examination. T hes e two 4805 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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components'licensure and cognitive examinations'are part of the evolving maintenance of certification (MOC ) programs mandated by the American B oard of Medical S pecialties (AB MS ). T wo additional elements of MOC the demonstration of s elf-as sess ment and lifelong and practice ass es sment. S pecialty and subspecialty s ocieties are prepared to diplomates with their continuing education programs to keep them abreas t of the rapid advances occurring in field of ps ychiatry and its subs pecialties . Learning res ources include textbooks, journal articles, courses annual meetings , audiotapes, and review articles on the latest clinical advances in the field and others.

HIS TOR Y T he growth and development of psychiatry are the AB P N's history. T he need to establish standards of competence in the field of ps ychiatry was firs t by Adolf Meyer during his presidential address at the annual meeting of the American P s ychiatric (AP A). He urged establishing a s ys tem of education similar to the B ritish system. T he AP A, its C ommittee on Medical S ervices , took a leadership in 1929 by urging that the field establis h formal requirements for the practice of ps ychiatry. T he supported the initiation of a plan to sanction competent ps ychiatris ts. E dward S trecker pres ented the report at the 1929 AP A annual meeting. T he G raduate E ducation was formed and given to inves tigate s uch a plan. Meyer chaired the and S trecker and G eorge K irby were appointed as members. In s pite of numerous reports along with a 4806 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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change to the C ommittee on P sychiatry and G raduate E ducation, no action was taken. In 1931, the American Medical As sociation (AMA), its s ection on nervous and mental dis eases , also called attention to the need for a certification proces s for ps ychiatris ts and sugges ted involving the National of Medical E xaminers (NB ME ) in establishing such a proces s. At the 1933 annual meeting of the AP A, the National C ommittee on Mental Hygiene held a conference, at time the 28 participants urged the formation of an examining board of the AP A. T he council of the AP A adopted this s uggestion and appointed a board of examiners. T he appointees were Meyer, W illiam W hite, Macfie C ampbell, and F ranklin E baugh. T hey were with preparing a plan for certification of ps ychiatris ts . In 1933, the AMA als o adopted a plan for the of neuropsychiatrists . T he AMA appointed W alter as chairman and Lloyd H. Ziegler, E dwin G . Zabris kie, Allen J acks on, and G eorge W . Hall as members of its committee. T o avoid duplication of effort, a third group, the Neurological As sociation (ANA), was invited to join the AMA and the AP A to participate in the formation of an examining body. T he ANA committee cons is ted of J . R amsey Hunt, I. S . Wechs ler, and A. H. R iley. At a 1933 meeting, the following was established: (1) of the two specialties would choos e four members, and the AMA would choos e two from each specialty; (2) discipline would es tablis h s eparate qualifications ; (3) a separate examination would be adminis tered for each 4807 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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discipline; and (4) to achieve certification in both disciplines, a candidate would need to pas s both examinations. In 1934, the following requirements for psychiatry were es tablis hed: (1) degree from an approved medical and a medical license; (2) bas ic training in psychiatry included 3 years of study in psychiatry after the with at leas t 18 months in a clinical s etting in an hospital, clinic, or laboratory; and (3) 2 years of hospital or 1 year largely limited to ps ychiatry. In October 1934, the first organizational meeting of the board was held with Meyer as chairman. He, C larence C heney, C ampbell, and E baugh were AP A appointees; Louis C asamajor, Lewis J . P ollock, H. Douglas S inger, Zabris kie were ANA appointees; and Hall, J ackson, F reeman, and Ziegler were AMA appointees. T hey the firs t directors of the board. T he board was incorporated P.3932 under a Delaware charter, and bylaws were adopted. elected officers were S inger, pres ident, C ampbell, vice president, and F reeman s ecretary-treasurer. S tanding committees were established, and directors were to them. At the December 1934 meeting, iss ues of fees , clas ses applicants, a grandfather claus e, and the name of the board were decided. A great deal of s plitting occurred whether neurology or psychiatry s hould appear firs t in name. P sychiatry, with a larger constituency, prevailed over the alphabet. 4808 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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T he firs t certifying meeting was held in F ebruary 1935, the board iss ued its first certificates on J une 7, 1935: ps ychiatry and neurology and 12 solely in ps ychiatry. first 11 went to the founding directors , although P ollock refused to apply for or accept a diploma. In 1974, the number of directors increased from 12 to with the addition of two representatives from each discipline. S eventeen directors currently serve the 16 of them with votes (F ig. 53.1-1). T he American of Neurology (AAN) became the fourth s ponsoring in 1974. After 1981, the board voted to no longer recognize the AMA as a s pons oring s ociety for directors. In 2001, the AB P N added the American of P sychiatrists (AC P ) as a third nominating society for ps ychiatry directors . T he AB P N also decided to request nominees from all three ps ychiatric nominating each time there was a vacancy for a psychiatry director both neurological societies each time there was a for a neurology director. T he directors of the board conduct their own election of new directors . S ervice is 4-year term, and a director cannot s erve more than two terms. T he autonomous functioning of the board was articulated by Henry W . B ros in in 1962, when he wrote following:

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FIGUR E 53.1-1 American B oard of P s ychiatry and Neurology directors for 2003. F irst row from left: P atricia C oylee, M.D.; Michael H. E bert, M.D.; E dgar J . K enton M.D., E lizabeth B . W eller, M.D.; S tephen C . S cheiber, (executive vice president); Naleen N. Andrade, M.D.; Mancall, M.D. (consultant); Alan K . P ercy, M.D. S econd from left: B urton V . R eifler, M.D.; David A. Mrazek, Danieel K . W instead, M.D.; G lenn C . Davis, M.D.; Larry F aulkner, M.D.; Michael V . J ohnston, M.D.; R obert M. P as cuzzi, M.D. T hird row from left: H. R oydeen J ones M.D.; S teven T . DeK osky, M.D.; J ames S cully J r., M.D.; P . Adams J r., M.D.

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five] constituent s ocieties to whom they report and are res ponsible, it is a working principle that the Directors vote solely in the best interest of the board. In the final analys is , they are res pons ible only to thems elves .

A ME R IC A N B OA R D OF ME DIC A L S P E C IA L TIE S T he AB P N is one of 24 s pecialty boards. T he other are allergy and immunology, anes thesiology, colon and rectal surgery, dermatology, emergency medicine, practice, internal medicine, medical genetics, surgery, nuclear medicine, obs tetrics and gynecology, ophthalmology, orthopedic s urgery, otolaryngology, pathology, pediatrics, phys ical medicine and rehabilitation, plastic surgery, preventive medicine, radiology, surgery, thoracic surgery, and urology. In 1970, the AB MS was founded as the umbrella organization for all of the boards. It is res ponsible for reviewing and approving applications for any new and for any new s pecialty and subspecialty certificates . 2002, the AB MS voted to review MOC programs from of the boards. It also maintains s tandards of and operation for all s pecialty boards. S tephen H. Miller, M.D., M.P .H., became the executive president of the AB MS effective J anuary 1, 1998. His predecess ors included J . Lee Dockery, M.D., and Langs ley, 4811 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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P.3933 M.D. Langs ley, a psychiatrist who s erved as a director AB P N and as president of the AP A, functioned as the executive officer of the AB MS for 10 years. He is the archivis t for the AB MS and an alternate AB P N to AB MS . T he late M. J . Martin, M.D., a former vice and director of the AB P N, served as AB MS P resident 1994 to 1996. B arbara S chneidman, M.D., a psychiatrist S eattle, was appointed the first deputy executive vice president of the AB MS in 1993 after serving as the F ederation of S tate Medical B oards (F S MB ). On completing her s ervice to the AB MS , she joined the staff in 1998, where she is now the vice president for medical education. T he Advis ory B oard for Medical S pecialties, founded in 1933, was the predeces sor of the AB MS . otolaryngology, obs tetrics and gynecology, and dermatology and s yphilology were the four exis ting specialty boards at that time. Along with thes e four the American Hos pital As sociation (AHA), the American Medical C olleges (AAMC ), the F S MB , and the NB ME were the founding s ponsoring organizations of advis ory board. T hes e four organizations continue to as as sociate members of the AB MS , along with the the C ouncil of Medical S pecialty S ocieties (C MS S ), the Accreditation C ouncil for G raduate Medical E ducation (AC G ME ), and the E ducational C ommiss ion for F oreign Medical G raduates (E C F MG ). E ach ass ociate member one vote in the as sembly of the AB MS . T here are als o public members with votes who are appointed by the executive committee of the AB MS . 4812 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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AB MS is a nonprofit corporation s upported by dues each of the 24 boards . Dues and the number of voting representatives allotted to each board are determined the number of general certificates is sued by a board. T hrough 1992 biannually, the AB MS publis hed the C ompendium of C ertifie d Me dical S pe cialis ts , which only official biographical directory authorized by all 24 medical specialty boards . In 1993, the AB MS merged with the Marquis W ho's W ho Dire ctory in S pe cialtie s and became the O fficial AB MS Directory of C ertifie d Me dical S pe cialis ts , published by W . B . T he directory can als o be access ed on the Internet. Information regarding s pecialty certification, certification, or recertification is provided by the boards . Other information, s uch as medical education specialty training, is provided by the diplomate. Information about each of the 24 boards is included in directory. T he AB MS maintains a very active telephone service to respond to inquiries as to whether a certified by one of the AB MS boards. T he AB MS als o individual boards by providing as sistance in conducting res earch projects . Information about the AB MS is als o available on the Internet. In addition to the AB MS , the C MS S , the AAMC , the and the AHA were the founders in 1972 of the Liaison C ommittee on G raduate Medical E ducation (LC G ME ) the C oordinating C ouncil on Medical E ducation. T he LC G ME was given ultimate res pons ibility for approving graduate medical education programs . T he AB MS was one of the founders of the Liaison C ommittee on C ontinuing Medical E ducation (LC C ME ), which programs in continuing medical education. T his 4813 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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subs equently became the Accreditation C ouncil for C ontinuing Medical E ducation (AC C ME ). In 1997, T anguay, M.D., a former psychiatry director, chaired committee and s erved as vice president of the AB P N. 2003, E lliott Mancall, M.D., s erved as the chair of the AC C ME , and Mark Dyken J r., M.D., s erved as vice the AC G ME . T hey are former neurology directors .

A ME R IC A N ME DIC A L T he AMA has his torically provided leadership in accreditation of American medical education that with voluntary accreditation of medical s chools and interns hips in 1914. T o prepare for accreditation of res idency programs, the AMA's C ouncil on Medical E ducation formed committees to establish procedures 1920.

Ac c reditation C ounc il for G raduate Medic al E duc ation R R C s for each of the specialties are respons ible for accreditation of res idency programs. Until 1975, each committee had final authority for accreditation. in 1975, each of the review committees reported to the LC G ME , which, in turn, had final authority. In addition the five founding organizations noted previously, the LC G ME had repres entatives from the public and from federal government. In 1981, the AC G ME replaced the LC G ME as the final authority. W hereas each of the five founding organizations had veto power over actions of AC G ME in the pas t, the AC G ME now is an body. Under the leaders hip of David Leach, M.D., teaching 4814 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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as sess ing core competencies during residency has one of the AC G ME 's major initiatives . Indeed, the ps ychiatry R R C adopted five core competencies in the teaching of psychotherapy as one of the first initiatives this area. T hey were brief therapy, cognitive-behavioral therapy, combined ps ychotherapy and ps ychopharmacology, psychodynamic therapy, and supportive therapy. T he AC G ME has also been very involved in res idency work hours, an iss ue that has quite controversial, particularly in the surgical and s ubs pecialties . T he AC G ME has joined with AB MS adopting s ix areas of competence that must be during residency training. T hese areas are patient care, medical knowledge, interpersonal and communications skills , practice-based learning and improvement, profes sionalism, and s ys tems-based practice. All requirements now refer to the need for goals and objectives and the need to as sess their attainment.

R es idenc y R eview C ommittees for Ps yc hiatry and Neurology Until 1983, there was a s ingle R R C for psychiatry and neurology. S ince then, each of the disciplines has had own committee. T he ps ychiatry R R C has 15 voting members: five from the AB P N, five representing the and five representing the AMA who are recommended the C ouncil on Medical E ducation. E ach of the three spons oring organizations s elects three general ps ychiatris ts and two child and adoles cent psychiatrists serve. T he executive vice president of the AB P N, the president for medical education of the AMA, and the deputy medical director for education of the AP A serve an ex officio capacity, as does a resident 4815 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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the AP A. T here are currently 180 ps ychiatry training programs. J ames S cully J r., M.D., an AB P N director, chaired the ps ychiatry R R C in 2002. He became the medical the AP A on J anuary 1, 2003. S heldon Miller, M.D., director and vice pres ident of the AB P N, was appointed the AC G ME by the C MS S , and Dyken, former director and president of the board, served as a representative from the AB MS . J ames S hore, M.D., president in 1994, was chair of the ps ychiatry R R C in and was elected chair of the C ouncil of C hairmen of all R R C s in 1992. T he neurology R R C has six members 'two each from AB P N, the AMA, and the AAN'and four of these are four P.3934 adult neurologists and two child neurologists . T he AAN became a third parent of the neurology R R C in 1992, J anuary 1998, the firs t neurology res ident jointed the committee. T he ps ychiatry R R C is res ponsible for reviewing programs in general ps ychiatry, child and adoles cent ps ychiatry, geriatric ps ychiatry, addiction ps ychiatry, forens ic psychiatry, pain medicine (formerly pain management), and psychosomatic medicine. T he R R C reviewed and approved the requirements for ps ychos omatic medicine and has s ubmitted them to AC G ME for approval. T he neurology R R C reviews programs for adult child neurology, C NP , pain medicine, 4816 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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disabilities, and vas cular neurology. E ach program is reviewed to determine whether it the requirements that are lis ted in the annual G raduate Me dical E ducation Directory. F or new s ubs pecialties, the R R C es tablis hes the requirements that mus t then be approved by the T he AC G ME approved the training guidelines for ps ychiatry in 1993; C NP and addiction ps ychiatry in forens ic psychiatry in 1996; pain medicine in 2000, and neurodevelopmental dis abilities and vas cular 2002.

OR G A NIZA TION OF THE A B P N E xec utive Vic e Pres ident T he AB P N has had five executive directors s ince its inception in 1934. T he name of the office was changed from s ecretary of the board to executive s ecretarytreasurer to executive director to executive secretary, finally, to its current designation of executive vice president. T he firs t four executives 'F reeman (1934 to 1946), F rancis B raceland (1947 to 1951), David A. (1951 to 1971), and Les ter H. R udy (1972 to board directors before s erving in a part-time adminis trative capacity. In 1985, the board selected S tephen C . S cheiber, M.D., profes sor of psychiatry and director of ps ychiatric residency training and profes sor ps ychiatry at the Univers ity of Arizona, to s erve as its full-time executive secretary. He as sumed his duties on J anuary 1, 1986, and, in 1989, his title was changed to executive vice president. T he executive vice president is respons ible for the 4817 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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supervis ion and adminis tration of the affairs of the He is charged with es tablis hing an effective s taff organization to carry out the respons ibilities of the He coordinates all approved projects , programs, and activities of the office s taff. He s ees that there is appropriate administrative and adequate staff s upport all activities of the board and its components, including scheduling busines s, policy, and committee meetings preparing and distributing agendas and all background materials before s uch meetings . He s upervises and the board records and keeps and dis tributes minutes of the board meetings and other official meetings under direction of the s ecretary. He responds to inquiries regarding credentials of individual candidates; examination procedures by s etting up and arranging for sites for the written, computerized, and oral informs candidates of their performance in accordance with the policies of the board; is sues certificates to succes sful candidates; and s ubmits names of certified neurologis ts and ps ychiatris ts to the appropriate bodies for publication. He maintains an administrative relations hip with the AB MS , the R R C s , the nominating societies, and other relevant organizations . He the policies of the board and articulates the board's position on a variety of is sues. He also oversees and legal matters related to the board.

B oard S taff T o accommodate all the new initiatives , including examination committees at the board offices , the AB P N has grown to 38 s taff members from as few as eight in 1986. T he AB P N has ass umed a leaders hip role ps ychiatric and neurological organizations in promoting 4818 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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the highes t s tandards for both fields .

C ons ultant to the E xec utive Vic e Pres ident Mancall, a former neurology director and former of the department of neurology at Hahnemann Medical C ollege and interim chairman of J efferson Medical agreed to s erve the board once more in the capacity as cons ultant. He has been involved in a number of AB MS activities over the years , including his current as chair of the AC C ME . He will represent the board in number of s ettings where the board is working clos ely with the field of neurology.

R es earc h and Development In 1989, the AB P N approved a new full-time pos ition of res earch coordinator for the board, and Dorthea J uul, P h.D., from the Univers ity of Illinois , joined the staff in 1990. S he works closely with the res earch and development committees of the board in s tudying the reliability and validity of board examinations . R ecent projects have focus ed on exploration of alternatives to current P art II examination formats . Her current title is president, res earch and development. In addition, for many years, she contributed abstracts on articles pertaining to medical education and evaluation to Acade mic P s ychiatry.

Public ations T he AB P N publis hed the his tory of its firs t 50 years , was edited by Dr. Marc Hollender, former president director. Drs . S hore and S cheiber edited a book on 4819 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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certification, recertification, and continuing medical education that was publis hed by American P s ychiatric P res s. P roceedings from the J une 2001 invitational conference on core competencies were edited by Drs. S cheiber, T homas K ramer, and S us an Adamowski. conference proceedings for ps ychiatry was publis hed the American P s ychiatric P res s and the conference proceedings for neurology by B utterworth-Heinemann, both in 2003. In addition, many articles have been published by the board, often in conjunction with others. T hes e have included correlations of performance on the in-service training examinations in both neurology and ps ychiatry with s ubs equent performance on the P art I T hese have reported high correlations, particularly for ps ychiatry for ps ychiatris ts portion of the examination.

S trategic Plan In F ebruary 2000, the AB P N adopted a s trategic plan, the challenges were to continue to s trive for excellence and to continuous ly review the reliability, validity, and fairnes s of its certification procedures . In this regard, board has explored alternatives to the current oral examination. A three-phase pilot project that address ed the utility of standardized patients for as ses sing the skills of psychiatrists was conducted. T he executive president and several board members attended the C ollege of P hysicians and S urgeons of C anada's examinations in ps ychiatry and in neurology to obs erve the us e of Objective S tructured C linical E xamination stations as well as vignettes for ps ychiatry Directors have als o observed the oral examinations 4820 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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conducted by the American B oard of E mergency and the American B oard of S urgery. In 2000, the board built a 53-station computer tes t at its headquarters in Deerfield, Illinois , in collaboration with the American P.3935 B oard of R adiology (T ucs on, AZ) and the American of P athology (T ampa, F L). T he AB P N administers subs pecialty and recertification examinations in its and, when justified by the number of examinees, als o the facilities of the other two boards. In turn, the AB P N hosts examinations for other boards . In J une 2001, the AB P N s ponsored an invitational conference on core competencies in T oronto, with of American ps ychiatry and American neurology and representatives from its supporting organizations . T wo books have been publis hed: C ore C ompe tencie s for P s ychiatric P ractice : W hat C linicians Ne e d to K now C ompete ncies for N eurologis ts : W hat C linicians Nee d K now. T o carry out the work in thes e new areas, the board es tablis hed an Informatics C ommittee, a C ore C ommittee, a Maintenance of C ertification C ommittee, and a P art II T as k F orce. T he Informatics C ommittee completed its work in 2003.

Dis s emination of B oard Information T he board continuously reviews, updates , and changes policies and procedures . T o keep its constituency informed, it s eeks to communicate changes through a 4821 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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variety of mechanis ms . One method is by an annual which is circulated to its nominating bodies . T he report sent to the AP A is , in turn, s ent to the Ame rican P s ychiatry, where it appears under O fficial Actions of AP A with the subtitle Annual R eport of the AB P N, Inc. T he AB P N has also offered a works hop (AB P N the annual meeting of the AP A, chaired by the vice pres ident and including the ps ychiatry directors. In addition, the executive vice pres ident and psychiatry directors have participated in plenary s es sions and workshops of the AP A and the AADP R T , s uch as a workshop on core competencies at the 2003 annual meeting. T hes e meetings s erve to minimize misunderstandings and to publicize policy changes and is sues under review by the board.

C redentials Over the years, the board has reviewed and revis ed its training requirements, weighing factors such as training program requirements, bas ic s cience instruction, knowledge of the s pecialty, and clinical education and training. One major change in policy occurred in 1976, when the board no longer required that candidates complete 2 years of experience in their specialty before admis sion to the examination. B eginning in 1993, candidates could s ubmit applications during the las t 6 months of their final year of training provided that all training requirements were fulfilled no later than J une of the year in which the candidate s ubmitted his or her application. R equirements to sit for the certification examination included the s ubmis sion of an application and the 4822 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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application fee by the application deadline along with documentation of satis factory completion of the board's specialized training requirements and a copy of a unrestricted licens e to practice medicine in a s tate, commonwealth, or territory of the United S tates or a province of C anada. If a copy of the license was not submitted before the written examination, it had to be submitted before scheduling for the oral examination. B efore fall 1994, all P art I examinations were held in spring. T he change to a fall administration was in to a reques t from the field to move the examination to the completion of residency training. An applicant who sought admis sion to examination for certification in ps ychiatry mus t have satisfactorily completed an approved first pos tgraduate year of (P G Y -1) and 3 full years of pos tgraduate specialized training in a program accredited by the AC G ME . In J uly 1997, the board ins tituted a policy that only AC G ME approved training in the s pecialty in which the applicant sought certification would be accepted. No res idency training credit is given for time s pent in a residency program in another s pecialty. T raining programs by the R R C and accredited by the AC G ME can be the G raduate Medical E ducation Directory, published AMA and on the AC G ME 's W eb s ite. T raining may be completed on a part-time bas is, that it is no less than half-time, and credit is not given less than 1-year blocks of training except under special circums tances , which mus t be approved by the AB P N C redentials C ommittee for P sychiatry. T o ensure of training, the board requires that 2 of the 3 years of res idency after the P G Y -1 be s pent in a s ingle 4823 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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T he board has given much thought to the minimum requirements for the P G Y -1. T he current requirements include a minimum of 4 months of primary care experience, and it is recommended that the required 2 months of neurology be taken in the P G Y -1. T he care requirement can be met by experience in internal medicine, family practice, and/or pediatrics . E mergency medicine rotations mus t emphasize medical rather than surgical experiences and cannot exceed 1 month of the required primary care training.

Four-Year Training Programs A 4-year program in ps ychiatry is acceptable, with the provis ion that no fewer than 4 months during the first be spent in an approved program providing supervis ed, direct res pons ibility for the general medical care of children, adults , or both. B eginning J uly 1, 1988, all osteopathic phys icians a P G Y -2 in ps ychiatry mus t have success fully AC G ME -approved P G Y -1 as described previous ly. T he ps ychiatry R R C , in its s pecial requirements for res idency training, has worked arduously to allow for flexibility and originality in programs while at the s ame time s etting minimum standards. T o accomplis h this , ps ychiatry R R C requires that training programs provide educational experiences in which res idents are for the diagnos is and treatment of an appropriate and variety of ps ychiatric inpatients for a period of not than 9 months but no more than 18 months (or its fulltime equivalent if done on a part-time bas is) in 4 years training. T he 4-year programs mus t also provide at year (or its full-time equivalent if done on a part-time 4824 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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in an organized and well-supervis ed outpatient that includes experience with (1) a wide variety of disorders and patients and treatment modalities and (2) brief and long-term care of patients using both ps ychodynamic and biological approaches to treatment. T he s pecial requirements als o include a minimum of 2 months of child and adoles cent 2 months of cons ultation ps ychiatry, 1 month of ps ychiatry, and 1 month of geriatric psychiatry plus 2 months for the diagnosis and treatment of neurological patients as well as experience in emergency services forens ic ps ychiatry.

C ombined Training Programs with Ps yc hiatry Applicants s eeking certification in both psychiatry and neurology who began postgraduate training after 1, 1988, must complete a P G Y -1 that meets the requirements for entry into a neurology program. In addition, applicants (1) must complete 6 full years of postgraduate training in approved programs, including full years in ps ychiatry and 3 full years in neurology, or at the dis cretion and approval of both training directors and in accordance with R R C requirements , may full years of pos tgraduate training in approved including 2 full years in psychiatry, 2 full years P.3936 in neurology, and a fifth full year of training designed to eligible for s imultaneous credit in ps ychiatry and neurology. All training must be done in the United P roposals for combined training in psychiatry and 4825 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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neurology are reviewed by the C redentials C ommittee P sychiatry and the C redentials C ommittee for Approved programs are published in the G raduate E ducation Directory. C urrently, eight are approved. T he AB P N and the American B oard of Internal have agreed to a 5-year combined training program in internal medicine and psychiatry as well as a 5-year combined training program in internal medicine and neurology. Interes ted program directors in the disciplines must propose a combined program to each the two boards. Once approved by the two boards , the programs are listed in the G raduate Medical E ducation Dire ctory. C urrently, there are 20 approved programs internal medicine/ps ychiatry and 11 in internal medicine/neurology. T he AB P N and the American B oard of F amily P ractice agreed to a 5-year combined training program for practice and psychiatry. Interested program directors in the res pective disciplines mus t propos e a combined training program to each of the two boards . Once approved by the two boards, the programs are listed in G raduate Medical E ducation Dire ctory. C urrently, there 11 approved programs. C ombined training programs are als o available in neurology and phys ical medicine and rehabilitation (6 years ) and in neurology, diagnos tic radiology, and neuroradiology (7 years). T hree programs have been approved with radiology. G uidelines have been set up combined training in neurology and nuclear medicine. T here also have been negotiations to have combined training in ps ychiatry and medical genetics and 4826 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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and medical genetics.

Non-U.S . Training E ffective for res idents entering res idency training as of 1, 1997, the board accepts only AC G ME -accredited training. In 2000, the AB P N and the R C P S C negotiated a agreement based on certification in the respective countries and not on a particular training track. T here is reciprocity of training. G raduates of American res idency training programs in ps ychiatry who have an unres tricted licens e to practice medicine in one of the s tates, have been certified by AB P N in ps ychiatry, and have a year of practice or an additional year of training may apply and s it for the R C P S C 's ps ychiatry examination. G raduates of programs who are licens ed in one of the provinces of C anada and are certified by the R C P S C may apply and for the AB P N examinations.

Interns hip One of the most controversial decisions the board the last 35 years was to eliminate the interns hip requirement in 1970. T his move was a product of a recommendation by the AMA's Millis C ommis sion, a citizen's commis sion on graduate medical education, the interns hip be abolis hed. T he policy to eliminate the interns hip in ps ychiatry was adopted in October 1969, implementation effective J uly 1970. P art of the furor followed res ulted from the board's failure to cons ult adequately with cons tituent organizations and with educational organizations and to allow s ufficient time 4827 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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the field to debate the merits of s uch a decis ion before implementing this policy. In 1974, the board revers ed its decis ion and enacted a policy that was to become effective in J uly 1976, that the interns hip year be reins tated. Again, the board faced opposition to its decis ion. T his time, the AP A reques ted delay of implementation until 1977 to allow programs s ufficient time to arrange for the necess ary medical experiences and to arrange for appropriate financing of the P G Y -1. T he board solicited and the input from s ponsoring societies and other relevant profes sional organizations . As a res ult, the interns hip not reinstated until 1977, although programs were to do s o as s oon as pos sible. T he AB P N collaborates with a number of cons tituent organizations to prevent a recurrence of the turmoil occurred in res ponse to the internship decision. T he works clos ely with the AP A through its C ouncil on E ducation and C areer Development and through meetings of the leadership of the two organizations. has led to fruitful dis cuss ions, particularly about res ponsibilities for maintenance of certification and for defining and meas uring core competencies . T he executive vice president served as a cons ultant to council through 1993 and in 1994 was appointed as a corres ponding member of the G raduate Medical E ducation C ommittee. T he AB P N directors serve on AP A councils and committees . F or example, S hore the C ouncil on G raduate Medical E ducation and Development of the AP A from 1992 to 1997 and president of the AC P in 2003. W hen the G raduate E ducation C ommittee was diss olved, the executive 4828 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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president was appointed as a corresponding member the C ouncil on Medical E ducation and C areer Development. In addition, AB P N directors and staff communicate regularly with the American As sociation of Directors of P sychiatric R esidency T raining (AADP R T ). T hey als o the annual meetings and pres ent updated information the training directors and participate in works hops. In a similar fashion, the ps ychiatry R R C has repres entation this meeting and conducts workshops . T he AC P , which has administrative res ponsibility for P sychiatric R esidency In-T raining E xamination collaborated with the board on a project correlating the res ults of the P R IT E with subsequent performance on board examinations. T he results of the s tudy revealed good correlation. T hat s tudy is now being replicated. national meetings in which repres entatives of the board have participated include thos e of the American of C hild and Adoles cent P sychiatry (AAC AP ), the Ass ociation for G eriatric P s ychiatry (AAG P ), the Academy of Addiction P s ychiatry, the American of P sychiatry and the Law, and the As sociation for Academic P sychiatry (AAP ). T he AB P N als o works closely with residency training directors. Approximately every 5 years , the AB P N the outline of the P art I examination to residency directors to receive feedback to help update it.

E xamination Polic ies and S urpass ing its humble beginnings in J une 1935, when 31 candidates sat for the first examination at the 4829 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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P hiladelphia G eneral Hospital, in 2002, the board examined 1,881 psychiatrists , 621 adult neurologis ts, 75 child neurologists at three P art II oral examinations . S ince 1990, the board examined between 1,800 and ps ychiatry candidates per year for the P art I written examination (T able 53.1-1). As of December 2002, the board had iss ued 39,930 certificates in ps ychiatry, neurops ychiatry, 10,570 in adult neurology, and 1,355 child neurology. T he board added a fourth examination the P art II examination cycle in 1992, 1993, 1994, 2000, and 2002 to accommodate increas ed numbers of candidates.

Table 53.1-1 Pas s R ates -Part I Ps yc hiatry(1990-2003) Year

Number E xamined

Number Pas s ed

% Pas s ed

1990

2,108

1,244

59

1991

2,422

1,406

58

1992

2,974

1,788

60

1993

2,982

1,681

56

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1994 (s pring)

2,181

1,225

56

1994 (fall) a

742

604

81

1995

2,424

1,341

55

1996

2,462

1,321

54

1997

2,429

1,255

52

1998

2,330

1,248

54

1999

2,192

1,227

56

2000

2,105

1,260

60

2001

1,960

1,176

60

2002

1,812

1,203

66

2003

1,815

1,282

71

a C andidates

were limited to those who graduated from res idency training in J une 1994. T o administer the 2002 P art I written examinations, 55 examination centers in the United S tates , P uerto R ico, 4831 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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C anada were us ed. Due to security cons iderations , the military sites that formerly participated were clos ed to civilians, and previously s cheduled P.3937 examinations in G ermany had to be canceled. In spite the large numbers, every effort is made to s chedule candidates for the P art I examination at their preferred sites . Having acknowledged differences between neurology ps ychiatry, the board has remained firm over the years the strong alliance of the two s pecialties . In fact, when strategic plan was being developed in 1999, the first principle that was adopted was to maintain the two disciplines under one board. T here have been periodic reviews by the directors regarding splitting into two separate boards , with the last s erious dis cuss ion in 1982. In the first 10 years of the board's history, candidate was administered the s ame oral and evaluation of performance was bas ed on the certificate the candidate was seeking. In 1946, the introduced separate examinations for each of the specialties , and this policy has been retained up to the present time.

Written E xaminations With the increasing numbers of applicants in the the board voted to administer a written examination to screen candidates for the oral examination. In 1964, board contracted with the NB ME to develop the written examination. T he written examination replaced the oral examination over a 5-year period to test for basic 4832 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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knowledge in the two dis ciplines . T he board undertook res earch project to determine whether the written examination could be used as a s creening device to predict how well candidates would perform on the oral examination. B as ed on the res ults of the 1965 and written examinations, the board was convinced of the validity of the written examination as a screening instrument. T he board als o found that the s imultaneous adminis tration of the written and oral examinations was too time-cons uming and cos tly. Hence, beginning in 1967, a separate written examination was introduced P art I of a two-step process . T he board elected to development of the P art I from the NB ME in to the board offices in Deerfield beginning with the examination. After success ful completion of P art I, which was adminis tered once a year, candidates were s cheduled the oral P art II examination. Uns ucces sful candidates the P art I examination may reapply to sit for the written examination on an annual basis with no limit on the number of times a candidate can take the examination. T he P art I E xamination C ommittee reviews and refines examination on an annual basis (T able 53.1-2).

Table 53.1-2 Part I E xamination C ommittee, 2002-2003 Daniel K . Winstead, M.D.,

Donna M. Mancuso,

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chair

M.D.

Michael H. E bert, M.D., chair

K athleen McK enna, M.D.

B urton V . R eifler, M.D., M.P .H.,

S us an McLeer, M.D.

vice chair

David Mrazek, M.D.

Naleen N. Andrade, M.D.

J effrey Nicholl, M.D.

Linda B . Andrews, M.D.

J ohn W . Norton,

S heldon B enjamin, M.D.

P hillip L. P earl, M.D.

Martin F arlow, M.D.

David W . P reven,

R obert G olden, M.D.

R onald E . P rier,

K arl G oodkin, M.D.,

V ictor I. R eus , M.D.

P atrick G riffith, M.D.

C ynthia W. S antos , M.D.

R obert G uynn, M.D.

Michael S ateia, M.D.

Deborah Hales , M.D.

Michael J . S ernyak M.D.

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J ack Hirs chowicz, M.D.

Deborah S pitz, M.D.

Marilyn K raus , M.D.

T he overall pass rate for P art I candidates since 1990 percent. T his represents an overabundance of who delay taking their initial examinations after graduating from res idencies and als o individuals who repeatedly failed the P art I examination. T he fall 1994 examination was res tricted to thos e who completed res idency training in J une 1994. R es tricting the examination to recent graduates resulted in an 81 pass rate (T able 53.1-1). B ecause this was a group, it lent itself to further s tudy. T he AB P N followed these 1994 examinees for 8 years and es tablis hed that percent of the cohort was certified. T his s hould give encouragement to graduates of AC G ME -approved res idencies to s it as soon as poss ible after graduation to pers is t in the process . In April 1972, a new 4-hour written examination was introduced. All basic psychiatry and bas ic neurology included, thereby eliminating the need to as ses s bas ic science material in the oral examination. In 1975, the content for ps ychiatris ts and neurologists was With the 1976 examination, the board decided to honor pass ing grade on P art I from the date of pass ing for a 4835 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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period not to exceed 7 years provided it was dated April 1 1969. T hose who pass ed P art I could apply or reapply for the P art II examination any time during the year period. E ffective March 1987, a pas sing grade on P art I examination dated March 1987, or thereafter was valid for a period of 6 years or three attempts to the P art II examination s ucces sfully, whichever came T hose who were unsuccess ful after three attempts or failed to pas s P art II within the 6 years were requested retake the P art I examination. T he purpose of these policies is to ens ure that candidates have a current knowledge at the time of certification. In 2001, the board voted to change its policy s o that for those who pass ed the P art I examination in November 2002 or thereafter, the pass ing grade is valid for a 6 years or three opportunities (invitations) to complete P art II examination success fully, whichever comes firs t. In 1981, both clinical as well as basic neurology for ps ychiatry candidates was incorporated into the P art I examination, and neurology was eliminated from the II examination for ps ychiatry candidates who s at for the written examination in 1981 or subsequently. A comparable change for neurologists was ins tituted in 1982. When candidates apply for the P art I examination, they receive comprehensive information about the examination. T his includes the P.3938 length of the examination, how the time is divided between the two disciplines , the approximate number 4836 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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questions devoted to each discipline, and the of items ass igned to s pecific s ubject matter areas. In addition, candidates receive general information about format of the examination questions and how to their test performance. Information about the is available on the AB P N's Web site. T he P sychiatry P art I E xamination C ommittee s olicits from ps ychiatric educators about the content and uses input to review the test blueprint. T he board also distributes the content outlines for the subspecialty examinations to subspecialty educators to obtain their input.

Oral E xaminations T he P art II examination has s parked more criticism the written examination. T he AB P N is the only one of 24 AB MS boards that continues to us e patients as part the oral examination. All patients used for examining ps ychiatris ts are thos e with ps ychiatric dis orders and, neurologis ts , those with neurological dis orders. the difficulties in recruiting patients and the ris ing costs adminis tering the oral examination, the board is alternative methods for its oral examination. T he board introduced the audiovis ual section of the examination in 1976. T his format led to a more standardized examination. S tudies were conducted on new format to evaluate the relations hip between the patient and audiovis ual sections during a 1-year trial period. T he concordance rate in both s pecialties was high: 84 percent for ps ychiatry and 86 percent for neurology candidates . 4837 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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T he acceptance of the audiovis ual section as an to a patient interview led to the current examination procedure for ps ychiatris ts. After succes sful completion the P art I examination, the psychiatry candidates are invited to sit for the two s ections of the oral one with a patient and one audiovisual. T he tape is that of a psychiatrist interviewing a patient with ps ychiatric disorder. No simulated patients are us ed. taped interview is used as a stimulus for ques tions that as ked by the examiners. T he neurologis ts have s ince replaced the audiovisual section with patient vignette sections, one with six 10minute adult neurology vignettes and one with six 10minute child neurology vignettes . T he las t 15 minutes the patient s ection includes three additional 5-minute vignettes .

E xaminers T he board devotes considerable effort to the s election orientation of P art II examiners . E ach of the directors selects the members of his or her examining team from recommended lis t of board-certified ps ychiatris ts , including those from the region where the examination being adminis tered. E xaminers work in a wide academic, institutional, and private practice settings. E ach examiner is mailed information about the examination, including guidelines for evaluating candidates. B eginning in 1979, a special 5-hour (s ince changed to a 4-hour format) orientation ses sion was instituted for new examiners . In 1984, the board that all new examiners must attend this orientation. T he next year, this policy was extended to include all 4838 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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examiners who had not examined in the previous 4 In 1994, this was further modified to include all who had not examined in the last 2 years . T he orientation sess ion focuses on the examination proces s from the perspective of an examiner. Demons trations of appropriate and inappropriate examination behaviors are given. New examiners then meet in s mall groups with s enior examiners to role play examining, and their questioning techniques are With the advent of the mandatory orientation s es sions new or returning examiners, a plenary s es sion for all examiners with the board of directors was eliminated. examiners continue to attend mandatory team chaired by the team leaders. F or thos e examinations there are more than eight ps ychiatry teams, directors emeriti are invited to serve as team leaders. T he board has continued its efforts to standardize the examination. Depending on the number of candidates , examination teams now include four to five senior examiners and 22 to 32 primary examiners . one-half of the team members are chosen from a pool and examine at all sites during an examination T he additional examiners are selected from the local region. F or each examination, two primary examiners scheduled with a s ingle candidate throughout the examination hour, and a s enior examiner s upervis es pairs of primary examiners. Alternatives to this arrangement are being explored.

G rading T he grading of candidates is bas ed on a composite of 4839 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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performance on both s ections of the P art II candidates perform marginally in 1 hour, they can compens ate for this in the s econd hour with an aboveaverage or exceptional performance. T he previously numerical grading was replaced in 1978 with grades of High P as s, P ass , C ondition, and F ail. In 1981, the further refined the grading to P ass , C ondition, and F ail. ps ychiatris ts have eliminated the C ondition grade for patient interview portion of the examination. In May High and Low C onditions for subtes ts were eliminated replaced with C ondition. All candidate grades are reviewed by the ps ychiatry directors in a grading s ess ion, and a final grade is T he pass ing rates have remained fairly stable over the years . T he overall pass rate for P art II candidates s ince is 58 percent (T able 53.1-3).

Table 53.1-3 Pas s R ates -Part II Ps yc hiatry (1990-2003) Year

Number E xamined

Number Pas s ed

% Pas s ed

1990

1,629

967

59

1991

1,881

1,132

60

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1992

2,051

1,256

61

1993

2,671

1,641

61

1994

2,396

1,467

61

1995

1,793

1,066

59

1996

1,562

940

60

1997

1,709

973

57

1998

1,830

1,058

58

1999

1,901

1,106

58

2000

1,921

1,097

57

2001

1,867

998

53

2002

1,881

967

51

2003

1,996

1,041

52

C hild and Adoles c ent Ps yc hiatry In 1959, the AB P N, with the concurrence of the AB MS , instituted a certification proces s for its first child ps ychiatry. T he C ommittee on C ertification in 4841 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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P sychiatry recommends policy to the board and adminis ters the examination process . T he name of the committee was changed in 1987 to the C ommittee on C ertification in C hild and Adoles cent P s ychiatry (T able 53.1-4 and 53.1-5).

Table 53.1-4 C ommittee on C ertific ation in C hild and Adoles c ent Ps yc hiatry, 2003 E lizabeth B . Weller, M.D., chair

Andrew R uss ell, M.D.

K ailie R . S haw, M.D., vice chair

S andra S exs on,

Donald W . B echtold, M.D.

Harry H. Wright, M.D.

B arbara J . C offey, M.D.,

 

Table 53.1-5 C hild and Ps yc hiatry Written E xamination S ubc ommitte, 2003 4842 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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E lizabeth B . Weller, M.D., chair

Daniel S . P ine,

B arbara C offey, M.D., M.S ., vice chair

Andrew R uss ell, M.D.

Donald W . B echtold, M.D.

S andra S exs on,

J ohn F . B ober, M.D.

K ailie R . S haw,

J udith Dogin, M.D.

Marcia S lomowitz, M.D.

C arl F einstein, M.D.

Harry H. Wright, M.D.

J ohn D. O'B rien, M.D.

 

T his committee is under the supervis ion of the board follows general board policies and guidelines . T he committee is compris ed P.3939 of six board-certified child and adolescent ps ychiatris ts, one AB P N director, and one board-certified E ach member s erves a 4-year term, with one renewal, the exception of the director. C ommittee nominations 4843 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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solicited from the AAC AP and the AP A. T he for the pediatrician are sought from the American P ediatrics . T he director is appointed by the board president. T he committee nominates its members and submits its recommendations to the board for final approval. T he committee is res ponsible for the adminis tration of annual examination. B eginning with the S eptember examination in Minneapolis, the examination has been conducted on weekends. S ince 1990, more than 200 candidates have taken the child and adolescent examination each year. As of the fall of 2002, 5,327 candidates have been certified in child and adoles cent ps ychiatry. T here are currently 114 AC G ME -accredited child and adoles cent ps ychiatry training programs. T he pass ing rate has been fairly cons tant for the last the child and adoles cent psychiatry examination (T able 53.1-6). T he overall pas s rate s ince 1990 is 61 percent.

Table 53.1-6 Pas s R ates -C hild Adoles c ent Ps yc hiatry (1990Year

Number E xamined

Number Pas s ed

% Pas s ed

1990

284

190

67

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1991

342

205

60

1992

435

269

62

1993

359

220

61

1994 (s pring)

367

233

64

1994 (fall)

407

246

60

1995

287

184

64

1996 (s pring)

154

90

58

1996 (fall)

239

151

63

1997

284

159

56

1998

270

140

52

1999

309

190

61

2000

317

189

60

2001

283

174

61

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2002

308

185

60

2003

320

201

63

T he certifying examination in child and adolescent ps ychiatry has undergone periodic review and revision res ulting in major changes since its inception. In 1973, year s tudy was funded by T he Ittleson F oundation, the G rant F oundation, and the Maurice F alk Medical F und. purpos e was to ass es s s ys tematically and broadly the competencies required by a child ps ychiatris t. T he for E ducational Development at the University of Illinois C ollege of Medicine was contracted to as sis t in the In 1976, the res ults were publis hed as a manuscript R ole s and F unctions of C hild P s ychiatris ts . As a res ult of this study, several major changes were instituted in the examination. T he six s ections of the examination were reviewed, and the two bas ic science sections 'his tory and literature and growth and development'were eliminated from the oral examination and incorporated into a 2-hour written examination. C andidates who failed only one section of the needed only to repeat that section and not the entire examination. Numerical grades were abandoned in of grades of High P as s, P ass , Marginal F ail, and F ail. 4846 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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Written clinical vignettes had been us ed to as sess cons ultation s kills . C andidates were given a onedescription of a situation in which a child and ps ychiatris t was called on to s erve as a consultant in a school, hos pital, or courtroom s etting. T he candidate been asked to describe orally how he or she would conduct the cons ultation. T he monograph describes criteria for evaluation of this s ection. In 1981, this which had been previously designated as the interprofes sional and community relations s ection, was renamed the child ps ychiatry cons ultation (not cons ultation/liais on) s e ction. B eginning in 1999, cons ultation was integrated into the other three namely, the written examination, the preschool/grade school, and the adolescence s ections, and hence was longer a s eparate s ection of the examination. B eginning with the F ebruary 1978 examination, a grade on the written examination was valid for a maximum of 7 years . In 1980, the committee voted that pass ing grade on all sections of the oral examination valid for a maximum of 4 years . In 1997, the committee voted that a pass ing grade on the written and oral was valid for 5 years. In 1978, the committee initiated a project to as sess the validity of the child psychiatry examination. W ith the permis sion of candidates, training directors were asked res pond to a ques tionnaire to predict how graduates of their programs would perform on the certification examination. T hey were also as ked to grade the performance of candidates during their 2 years of T he data from this study sugges ted that training were very accurate in predicting the performance of 4847 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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graduates on the certifying examination. In 1986, the committee approved combining the format the preschool and grade s chool sections of the examination. B oth clinical vignettes and audiovisual are us ed for the oral examination. T he committee continues to evaluate its examination, with recent attention paid to the s ections us ing videotaped

C ombined Training In 1984, the C ommittee established the Articles of Agreement for the P ilot P roject on T raining in P sychiatry, and C hild P sychiatry. Approval of the was received from the American B oard of P ediatrics, AP A, the AAC AP , the AADP R T , the American C hairs of Departments of P s ychiatry (AAC DP ), the of P rofes sors of C hild and Adoles cent P s ychiatry and the ps ychiatry R R C . All members of the P ediatrics P sychiatry P.3940 J oint T raining C ommittee (P P J T C ) were s elected by organizations involved in the project, the AB P N, the C ommittee on C ertification in C hild and Adoles cent P sychiatry, the American B oard of P ediatrics , and the National Ins titute of Mental Health (NIMH). T he vice pres ident of the AB P N and the deputy medical director for education of the AP A s erved in an ex officio capacity. T he NIMH and the University of Illinois funded the first meeting of the P P J T C in November of 1984. E ight were site-visited by members of the P P J T C for of their propos ed programs . S ix training programs were 4848 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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selected: Albert E instein C ollege of Medicine, B rown Univers ity, Mount S inai S chool of Medicine, T ufts Univers ity, the Univers ity of K entucky Medical C enter, the Univers ity of Utah. T he first residents accepted for triple-board project began their P G Y -1 in J uly 1986. programs are 5 years in length, and graduates can sit the certifying examinations in pediatrics, general ps ychiatry, and child and adoles cent ps ychiatry on succes sful completion of training. T he first class in J une 1991. S everal have chos en academic careers, there is a trend toward working in consultation-liais on child and adolescent psychiatry. T he AB P N, in conjunction with the American B oard of P ediatrics and the NIMH, funded a 10-year evaluation the triple-board project in 1985, and the res ults were published in Acade mic P s ychiatry. B oth boards agreed give permanent s tatus to the triple-board program and have distributed guidelines for thos e programs wishing submit propos als to both boards . C urrently, there are approved programs in the G raduate Medical E ducation Dire ctory.

R ec ertific ation T he board has studied the is sue of recertification. In the following principles were accepted: (1) T he board is res ponsible for the adminis tration of a recertification examination, (2) the board is not res ponsible for educational activities related to the preparation for recertification, and (3) the board is res ponsible for specialty organizations about the specific educational deficiencies that are identified by examination res ults. In 1976, the board established a S teering C ommittee 4849 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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R ecertification, with representation from the board and cons tituent organizations. S eparate s ubcommittees es tablis hed for the two dis ciplines . C onstituent organizations included the AP A, the C ommittee on C ertification in C hild and Adoles cent P s ychiatry, and AAC AP . C ons tituent neurology organizations included ANA, the AAN, and the C hild Neurology S ociety. R epresentatives from the private s ector also served on committee. T he board s ubmitted recertification plans ps ychiatry, child psychiatry, and neurology to the 1979. T he proposal included the following principles: C andidates must hold a valid certificate from the AB P N and a current medical license; (2) recertification is voluntary; (3) plans for ps ychiatry, child and adolescent ps ychiatry, and neurology will be s imilar but not and (4) the proces s is not a repetition of the original certification proces s. In respons e, the AB MS C ommittee on C ertification, S ubcertification and R ecertification (C OC E R T ) propos al and s ugges ted some modifications. T he continued to review the is sues of recertification but did not res ubmit a propos al until 1988 after working clos ely with the AP A's T as k F orce on R ecertification. In 1989, AB P N es tablis hed a new policy that, beginning in 1994, all certificates would be 10-year, time-limited certificates and that a recertification mechanism would put in place no later than the year 2000. As a minimum, recertification would include a test of cognitive knowledge. In F ebruary 1994, the AB P N created a C ommiss ion on R ecertification, cons is ting of three psychiatry directors , two AP A appointees , and an AAC AP appointee from 4850 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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board's child and adolescent ps ychiatry committee. commis sion reported to the P sychiatry C ouncil of the AB P N. T he commis sion endors ed using the AP A guidelines as an educational resource for also voted that the examinations s hould be written, book, take-home examinations . T his goal turned out to in violation of the AB MS 's subsequent requirement that each board would give the public as surance that the person seeking recertification had actually taken the examination. It was clear that a take-home examination could not meet this requirement (T able 53.1-7).

Table 53.1-7 C ommittee on R ec ertific ation in Ps yc hiatry, Naleen N. Andrade, chair

J oseph P enn, M.D.

Daniel B . Auerbach,

Iliss e P erlmutter,

David B ienenfeld, M.D.

Laura W eis s R oberts , M.D.

Lesley M. B lake, M.D.

Aaron S atloff, M.D.

Murray A. B rown, M.D.

R ege S tewart, M.D.

V ivien K . B urt, M.D.

J oyce A. T ins ley,

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J acqueline E temad,

S us an T urkel, M.D.

David G . F olks, M.D.

J ohn Urbach, M.D.

William M. G reenberg, M.D.

G eorge M. Wohlreich, M.D.

C arl G reiner, M.D.

J oel Y ager, M.D.

V alorie Haves, M.D.

Alayne Y ates, M.D.

P hilip Margolis, M.D.

S tephen Y oung, M.D.

T imothy Mueller, M.D.

 

In the meantime, all of the 24 specialty boards have approved recertification for their s pecialties. In addition, several boards had begun is suing time-limited whereby a certificate is valid only for a s pecific time after pass ing a board examination. At that point, the diplomate must success fully complete a recertification examination to remain board-certified. All new is sued by the AB P N are 10-year, time-limited Hence, certificates iss ued in the last decade in geriatric ps ychiatry, C NP , addiction psychiatry, forens ic pain medicine, and neurodevelopmental disabilities time-limited, as will be the certificates for medicine and vascular neurology. T he AB P N administered two geriatric psychiatry take4852 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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home examinations in 2000 and 2001, and, these, as well as thos e for general ps ychiatry, C NP , addiction ps ychiatry, and forensic psychiatry, have computerized, proctored examinations . C urrently, examinations are adminis tered at the AB P N test center at the American B oard of R adiology and the American B oard of P athology centers as needed.

S ubs pec ialty C ertific ation T he only psychiatric s ubs pecialty certification offered the AB P N for three decades was in child and ps ychiatry. T he AB P N als o is sues a certificate in with special qualification in child neurology. S pecial training requirements mus t be met by candidates to s it the child neurology examination. Over the las t three decades , the AB P N has , at various reviewed reques ts for s ubs pecialty certification from ps ychiatry groups, s uch as ps ychoanalysis, ps ychiatry, forensic psychiatry, and cons ultation-liais on ps ychiatry. S imilar requests for neurology have been forthcoming for subs pecialty certification in electrophysiology and electrodiagnosis. T hes e were either withdrawn or turned down by the board. In J uly 1986, the board hosted a conference on subs pecialty certification. S ix groups were invited to attend to initiate or renew a dialogue with the board subs pecialty certification. T hey included the American B oard of F orensic P s ychiatry, which adminis tered its P.3941 own certifying examination; the American S ociety for Adoles cent P s ychiatry; the AAG P ; the American 4853 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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of P s ychiatris ts in Alcoholism and Addictions (AAP AA); AP A C ommittee on Administrative P s ychiatry, which adminis tered its own certifying examination; and the American P s ychoanalytic As sociation, which had its certifying process . C ons tituent organizations , along with the AB P N, to debate the wis dom of offering additional certificates in psychiatry. T hese organizations include AP A, the AADP R T , the AAC DP , and the AAP , among T he AP A recommended that the board is sue a added qualifications in geriatric ps ychiatry in 1987. T he board appointed a task force on geriatric psychiatry cons isting of repres entatives from the board, the AP A, AAG P , and the AADP R T and an internis t to advis e the directors about this propos al. T he tas k force held its meeting in April 1988. T his date corres ponded with the adminis tration by the American B oard of Internal and the American B oard of F amily P ractice of the first added qualifications examination in geriatric medicine. 1988, the AB P N approved geriatric ps ychiatry as a subs pecialty. T he AB MS mus t approve any certificates for subs pecialization by its member boards , and, hence, reques t was then submitted to the AB MS . In addition to general certificates , the AB MS at that time had for two types of subspecialty certificates : a certificate in special qualifications and recognition of added qualifications. In 1996, the AB MS voted to simplify the names of certificates and dis continued using the qualifying terms added qualifications and special qualifications. S ubs equently, the AB MS approved certificates for s ubs pecialization. T he AB P N voted to 4854 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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the AB MS designations and no longer uses the terms added and special qualifications . A certificate of added qualifications , s ubs equently renamed s ubs pecialization, reflected that a candidate completed full-time accredited training of at leas t 1 year length and had satis factorily completed an additional examination in that field adminis tered by an AB MS member board. T he training program cannot be freestanding but mus t be ass ociated with an AC G ME accredited res idency. T he AB P N no longer recognizes C anadian training as equivalent. T he training program must incorporate a s pecific and identifiable body of knowledge. T he purpose, however, cannot be to train principally for additional technical s kills . Also, a board mus t give the AB MS as surance that it has the impact and effect of a modified certificate before receiving AB MS approval. Intent to s ubmit a propos al mus t be announced to all member boards at least 1 year before the meeting at which the formal propos al is submitted for a vote. Ultimately, a two-thirds majority of voting members of AB MS mus t approve any proposal before it can be effected. T he proposal must be distributed 180 days in advance of a vote. T he increased emphasis on subspecialty training and practice has led to the 24 AB MS boards is suing 90 certificates beyond their general certificates as of May 2003. P ediatrics and internal medicine had the mos t and 19, res pectively) by that date. T he American B oard Internal Medicine has s ubmitted a letter of intent to reques t recognition of a 20th subspecialty in transplant 4855 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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hepatology in the future.

GE R IATR IC PS YC HIATR Y T he AB MS approved added qualifications in geriatric ps ychiatry (now a subspecialty) in S eptember 1989. first C ommittee on C ertification for Added G eriatric P sychiatry was appointed in the fall of 1989. R ecommendations for members hip on the committee were submitted by the AP A and the AAG P . T he original committee cons is ted of five psychiatrists and one neurologis t. T he number of geriatric psychiatris ts on the committee has s ince increased (T able 53.1-8). B eginning in 1998, an internist with added geriatric medicine was added to the committee.

Table 53.1-8 C ommittee on S ubs pec ialty C ertific ation and R ec ertific ation in G eriatric Ps yc hiatry, 2003 B urton R eifler, M.D., chair

Larry Lawhorne,

C hris topher C olenda, M.P .H.,

Maria D. Llorente, M.D.

vice chair

B enoit H. Mulsant, M.D.

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P eter Aupperle, M.D.

Marcella P as cualy, M.D.

G iovanni C aracci, M.D.

S us an S chultz, M.D.

R ita Hargrave, M.D.

J oel E . S treim, M.D.

G ary J . K ennedy, M.D.

Deborah B . D.O.

Mark K unik, M.D., M.P .H.

 

T he firs t examination was administered in the s pring of 1991, and s even more were adminis tered through the 3,730 candidates , 2,595 (70 percent) were certified (T able 53.1-9).

Table 53.1-9 Pas s R ates -Geriatric Ps yc hiatry C andidates (1991Year

Number E xamined

Number Pas s ed

% Pas s ed

1991

661

490

74

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1992

578

359

62

1994

641

422

66

1995

559

376

67

1996

1,026

713

69

1998

72

65

90

2000

90

83

92

2002

103

87

84

T otal

3,730

2,595

70

T he criteria for sitting for the geriatric ps ychiatry examination include being board-certified in psychiatry, having an unrestricted license to practice medicine, completion of AC G ME -accredited res idency training. T hrough 1996, thos e diplomates devoting 25 percent more of their profes sional time to geriatric psychiatry could sit for the examination in lieu of res idency (T he same was true for addiction ps ychiatry through for forensic ps ychiatry through 1999, and for pain medicine through 2003.) T he AB P N reques ted that the R R C es tablis h guidelines res idency training in geriatric psychiatry at the P G Y -5 or higher. T hes e guidelines were approved by the 4858 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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and there are currently 61 accredited programs.

C LINIC AL NE UR OPHYS IOL OGY In 1989, the neurologis ts received AB P N approval and subs equent AB MS approval in 1990 to is sue a added qualifications in C NP . T he original test-writing committee included 12 board-certified neurologists and one board-certified psychiatrist. T he firs t examination was administered in March 1992. C andidates who had not completed res idency training C NP had to have the equivalent of 3 years in C NP after completion of a residency training program. S ix tes ts were adminis tered through 2003, and of the 1,912 candidates, 1,451 (76 percent) were certified. T he Neurology R R C es tablis hed requirements for training in C NP , and beginning in 2000, only thos e who graduated from AC G ME -accredited programs have able to sit for the examination. T here are currently 86 accredited programs. P.3942

ADDIC TION PS YC HIATR Y In 1990, the AP A recommended addiction ps ychiatry added qualifications . T he AB P N accepted the recommendation, and its propos al was approved in S eptember 1991, by the AB MS . Nominations were for membership on the tes t-writing committee from the AP A and the AAP AA, s ince renamed the American Academy of Addiction P sychiatry. T he C ommittee on C ertification for Added Qualifications in Addiction P sychiatry (T able 53.1-10) held its firs t meeting in 4859 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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December 1991, the firs t written, multiple-choice examination was administered in March 1993, and s ix more were adminis tered through 2002. Of the 2,341 candidates, 1,854 (79 percent) were certified (T able 11). B eginning in 2001, only thos e who graduate from AC G ME -accredited programs have been able to s it for examination. T here are currently 43 accredited

Table 53.1-10 C ommittee on S ubs pec ialty C ertific ation and R ec ertific ation in Addic tion Ps yc hiatry, 2003 Michael H. E bert, chair

E linore McC ance-K atz, M.D., P h.D.

S tephen Dilts , M.D., chair

K evin Olden, M.D.

for recertification

Is mene P etrakis, M.D.

J oseph Westermeyer, M.D., vice

J onathan R itvo, M.D.

chair for certification

Wes ley S owers, M.D.

K aren Drexler, M.D.

S heila S pecker, M.D.

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William F . Haning III, M.D.

E ric S train, M.D.

F rances Levin, M.D.

R ichard S uchins ky,

J oseph Liberto, M.D.

Mark W illenbring, M.D.

P eter Martin, M.D.

 

Table 53.1-11 Pas s R ates Ps yc hiatry C anditates (1993Year

Number E xamined

Number Pas s ed

% Pas s ed

1993

642

475

74

1994

402

302

75

1996

347

290

84

1997

347

278

80

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1998

525

431

82

2000

41

41

100

2002

37

37

100

T otal

2,341

1,854

79

FOR E NS IC PS YC HIATR Y T he AP A recommended that the AB P N is sue a added qualifications in forensic ps ychiatry. T he AB P N accepted the recommendation and s ubmitted a to the AB MS that was approved in S eptember 1992. first F orens ic P sychiatry C ommittee met in December (T able 53.1-12). T he first examination was October 1994, and five more were administered 2003. Of the 1,893 candidates, 1,467 (77 percent) certified (T able 53.1-13). T here are currently 40 programs.

Table 53.1-12 C ommittee on C ertific ation and R ec ertific ation Forens ic Ps yc hiatry, 2003

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Larry F aulkner, M.D.,

G regory Leong, M.D.

Howard Zonana, M.D., vice chair

Daryl Matthews, P h.D.

K enneth Appelbaum,

J effrey Metzner, M.D.

P eter Ash, M.D.

Michael Norko, M.D.

R en B inder, M.D.

Donna S chwartzM.D.

J . R ichard C iccone,

R obert S imon, M.D.

R ichard F rierson, M.D.

R obert W ettstein,

S tephen Herman, M.D.

R ichard Y arvis, M.D., M.P .H.

J effrey J anofsky, M.D.

 

Table 53.1-13 Pas s R ates Ps yc hiatry C anditates (1994-

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Year

Number E xamined

Number Pas s ed

% Pas s ed

1994

326

266

82

1996

292

236

81

1998

452

322

71

1999

656

486

74

2001

84

74

88

2003

83

83

100

T otal

1,893

1,467

77

PAIN ME DIC INE T he AB P N joined with the American B oard of Anesthesiology and the American B oard of P hysical Medicine and R ehabilitation in iss uing s ubs pecialty certificates in pain medicine beginning in 2000. T his examination is adminis tered by the American B oard of Anesthesiology, which has iss ued certificates for this subs pecialty over the las t decade. A board-certified ps ychiatris t, a board-certified neurologist, and a boardcertified physiatris t s erve on the tes t-writing committee, 4864 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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which is dominated by anes thes iologists . Of the 240 certified candidates in 2000 through 2003, 153 (64 percent) pass ed. Of these, 106 were neurologis ts, four were child neurologists, 31 were ps ychiatris ts , and were double-boarded in psychiatry and neurology. Nine held primary certification from other boards medicine, family practice, and internal medicine). In addition to thos e s ubs pecialties that are open to ps ychiatris ts, the AB P N has joined with the American B oard of P ediatrics in iss uing a certificate in neurodevelopmental dis abilities , a s ubs pecialty of child neurology. T he American Academy of P s ychosomatic Medicine submitted an application to the AB P N for recognition of ps ychos omatic medicine as a s ubs pecialty in decade before this , the academy had reques ted recognition for consultation-liais on psychiatry. T he AP A each time s upported this initiative. In 1993, the board rejected the application primarily becaus e, at that time, new subspecialties were being discouraged by the and, in turn, by the AB MS due to a national emphasis training primary care phys icians . In October 2001, the AB P N approved submitting an application to the AB MS for psychosomatic medicine, the review process began in 2002. S imilarly, the AAN submitted an application for vascular neurology as a subs pecialty of neurology. B oth applications were approved by the AB MS in March 2003. AB P N is a voluntary organization whos e major has been to es tablis h examination procedures to competent clinicians in psychiatry, neurology, and its 4865 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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subs pecialties . T he examining bodies have increased public res ponsibility and accountability, as manifested the increased support for continuing competence MOC programs. T he AB P N is a s pecialty board that input into the accreditation of training programs in both its disciplines P.3943 and works clos ely with its s pecialty s ocieties regarding MOC programs.

S UG G E S TE D C R OS S R elated information can be found in S ection 53.2 on examining psychiatrists and in S ection 55.1 on the of psychiatry.

R E F E R E NC E S American B oard of Medical S pecialties. Annual and R efe re nce H andbook'2002. E vans ton, IL: B oard of Medical S pecialties; 2002. American B oard of Medical S pecialties. T he O fficial Dire ctory of B oard C e rtified Me dical S pe cialis ts . E vans ton, IL: W. B . S aunders ; 2003. *American B oard of P sychiatry and Neurology Inc. Information for Applicants . 1939, 1944, 1946, 1957, 1978, 1981, 1982, 1983, 1986, 1987, 1988, 1991, 1993/1994, 1995, 1996, 1997, 1998, 1999, 2000, 2002, 2003 editions. American B oard of P s ychiatry and Neurology. 4866 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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Information for Applicants for C e rtification in C hild Adoles ce nt P s ychiatry. 2003 ed. American B oard of P s ychiatry and Neurology. Information for Applicants for C e rtification in the S ubs pe cialtie s of Addiction P s ychiatry, C linical Neurophys iology, F ore ns ic P s ychiatry, G eriatric and N eurode velopme ntal Dis abilities . 2003 ed. *American Medical Ass ociation. 20032004 G raduate Me dical E ducation Dire ctory. C hicago: American Ass ociation; 2003. B raceland F J , B oyd DA: S ecretary of the board: pro vita s ua. J AMA. 1952;148:708. B ros in HW . Working agreements (19531962). In: HW, ed. AB P N W orkbook. R ochester, MN: B oard of P sychiatry and Neurology; 1962:1. C armichael HT , S mall S M, R egan P F . P ros pe cts P ropos als : L ife time L e arning for P s ychiatris ts . Was hington, DC : American P s ychiatric Ass ociation; 1972. E ps tein R M, Hundert E M: Defining and as ses sing profes sional competence. J AMA. 2002;287:226. F reeman W , E baugh F G , B oyd DA: T he founding of American B oard of P s ychiatry and Neurology. Am J P s ychiatry. 1959;115:769.

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*Hollender M, ed. T he Ame rican B oard of P s ychiatry Neurology: T he F irs t F ifty Y e ars . Deerfield, IL: B oard of P s ychiatry and Neurology; 1991. J uul D, Martin MJ , S cheiber S C : T he examination added qualifications in geriatric psychiatry. Am J P s ychiatry. 1996;4:24. J uul D, S cheiber S C : S ubspecialty certification in geriatric psychiatry. Am J G eriatr P s ychiatry. J uul D, S cully, J , S cheiber S C : Achieving board certification in psychiatry: A cohort s tudy. Am J P s ychiatry. 2003;160:563. Langs ley DG : C hanging patterns of psychiatry certification in the E nglish-speaking countries . Am J P s ychiatry. 1981;138:493. Langs ley DG , Darragh J H, eds . T re nds in T omorrow's Me dicine . E vans ton, IL: American Medical S pecialties; 1985. Langs ley DG , Y ager J : T he definition of a E ight years later. Am J P s ychiatry. 1988;145:469. Mancall E L, B ashook P G , eds . R ece rtification: N ew E valuation Me thods and S trate gies . E vans ton, IL: American B oard of Medical S pecialties; 1994. McDermott J F , McG uire C , B erner E S . R ole s and F unctions of C hild P s ychiatris ts . E vans ton, IL: 4868 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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on C ertification in C hild P s ychiatry of the American B oard of P sychiatry and Neurology; 1976. *McDermott J F J r, T anguay P E , S cheiber S C , J uul S hore J H, T ucker G J , McC urdy L, T err LC : the P art II board certification examination in Interexaminer consistency. Am J P s ychiatry. 1991;148:1672. McDermott J F J r, T anguay P E , S cheiber S C , J uul D, J H, T ucker G J , McC urdy L, T err LC : R eliability of II board certification examination in psychiatry: E xamination s tability. Am J P s ychiatry. Nadels on C C , R obinowitz C B , eds . T raining for the '90s : Is s ue s and R ecomme ndations . DC : American P sychiatric P res s; 1987. R udy LH: R easons given for s ucces s after initial on the American B oard of P sychiatry and Neurology P art II examination. Am J P s ychiatry. S cheiber S C : C ertification and recertification. Q . 1991;62:2. S cheiber S C : F requently as ked ques tions about the American B oard of P s ychiatry and Neurology. Acad P s ychiatry. 1993;17:43. S cheiber S C . R ecertification: Implementation In: Mancall E L, B as hook P G , eds. R ece rtification: E valuation Me thods and S trategies . E vans ton, IL: 4869 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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American B oard of Medical S pecialties, 1994:127. *S cheiber S C . S pecialty board ass ess ment iss ues opportunities . In: Mancall E L, B ashook P G , eds . R ece rtification: N ew E valuation Me thods and E vans ton, IL: American B oard of Medical 1994:101. S cheiber S C , K ramer T M, Adamowski S , eds . C ore C ompete ncies for Ne urological P ractice : W hat Nee d to K now (A R e port of the Ame rican B oard of P s ychiatry and Ne urology). B oston: B utterworthHeinemann; 2003. S cheiber S C , K ramer T M, Adamowski S , eds . C ore C ompete ncies for P s ychiatric P ractice: W hat Nee d to K now (A R e port of the Ame rican B oard of P s ychiatry and Ne urology). W ashington, DC : P sychiatric P ress , Inc.; 2003. S cheiber S C , K ramer T AK , Adamows ki S : core competencies for psychiatric education and practice in the US . C an J P s ychiatry. 2003;48:215. S chowalter J E , F riedman C P , S cheiber S C , J uul D: experiment in graduate medical education: res idency training in pediatrics, psychiatry, and child and adolescent psychiatry. Acad P s ychiatry. S hapiro T , J uul D, S cheiber S C : E xploration of the subspecialty examination for child and ps ychiatry. Am J P s ychiatry. 1996;153:693. 4870 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/53.1.htm

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S hore J H, S cheiber S C , eds. C ertification, and L ifetime L earning in P s ychiatry. W ashington, American P s ychiatric P res s, Inc.; 1994. S mall S M: C ontinuing certification in psychiatry. P s ychiatr O pin. 1977;14:19. T albott J A: Oppos ition to coercive continuing and mandatory recertification. Am J P s ychiatry. 1979;136:923. T albott J A: Is the live patient interview on the boards neces sary? Am J P s ychiatry. 1983;140:890. T ucker G J , Martin MJ , S cheiber S C : ps ychiatry. Am J P s ychiatry. 1991;148:11. Webb LC , J uul D, R eynolds C F , R uiz B , R uiz P , S C , S cully, J : How well does the psychiatry training examination predict performance on the American B oard of P s ychiatry and Neurology P art I examination? Am J P s ychiatry. 1996;153:831.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 54 - E thics and F orensic P s ychiatry > 54.1: C linical-Legal Iss ue P s ychiatry

54.1: C linic al-Legal Is s ues Ps yc hiatry R obert I. S imon M.D. P art of "54 - E thics and F orens ic P sychiatry" P sychiatrists mus t be able to manage the clinical-legal is sues and tensions that frequently aris e in clinical or types of practice. K nowledge of the legal regulations of ps ychiatric practice is a neces sity for the ps ychiatric clinician to practice effectively. P sychiatric practice is influenced by (1) the profes sional, ethical, and legal duties to provide competent care to patients; (2) the patients rights of determination to receive or refuse treatment; (3) court decis ions, legislative directives , governmental agencies , and licensure boards ; and (4) the ethical and practice guidelines of profes sional organizations . Legal regulations that govern clinical practice do not neces sarily conflict with the provis ion of good care. T he ps ychiatris t us ually is able to incorporate legal requirements into clinical interventions . F or example, ps ychiatris t may be able to engage the patient in and protecting a third party whom the patient has seriously threatened to harm. C linical risk management combines the ps ychiatris t's profes sional expertise, knowledge of the patient, and an unders tanding of 4872 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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pertinent legal is sues to provide competent care and, secondarily, to reduce liability exposure. A lack of knowledge about the legal requirements governing ps ychiatric practice may constrict treatment options promoting unduly defens ive practices . Defe ns ive ps ychiatry refers to acts or omis sions by the clinician aimed at avoiding malpractice liability or providing a legal defense agains t a potential claim. E xamples include unneces sary hospitalization of patients at low to moderate ris k of suicide or failure to prescribe indicated, effective medication at therapeutic levels that have rare, but potentially serious, side F ear of legal liability can trump the bes t interes t of the patient when unduly defens ive practices influence the ps ychiatris t's clinical decision making. Defensive may paradoxically result in the provis ion of patient care that increas es the ris k of a malpractice C ompetency determinations by psychiatrists are health care decision making. Informed cons ent, the to refus e treatment, s ubs titute decision making, guardians hip, and tes tamentary capacity are just a few areas in which determinations of competency are important. In criminal cases, the competency to stand is an es sential determination. P sychiatry and the law intersect in many ways. T he forens ically informed clinician is in the bes t position to manage ps ychiatriclegal interactions .

P S YC HIA TR IC MA L P R A C TIC E P sychiatric malpractice is medical malpractice. Medical malpractice is a tort or civil wrong. It is a noncriminal, 4873 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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noncontract wrong res ulting from a physician which caus es injury to a patient under his or her care. S imply put, ne gligence means doing something that a phys ician with a duty to care for the patient should not have done or failing to do something that s hould have been done as defined by current medical practice. T he standard of care is the legal measure by which is es tablis hed. T he legal definition in each s tate is variation of the following: T he ps ychiatris t mus t the care and s kill cus tomarily exercis ed by an average qualified (or prudent) ps ychiatris t. E xperts from both tes tify whether the defendant ps ychiatris t breached the standard of care. R eference to journal articles , textbooks and treatis es , practice guidelines , and ethical principles promulgated by profess ional organizations may be admitted regarding whether the defendant deviated from the standard of care. T o prove malpractice, the plaintiff (e.g., patient, family, es tate) must establish by a preponderance of the that (1) a doctorpatient relationship exis ted that created duty of care, (2) there was a de viation from the care, (3) the patient was damage d, and (4) the dire ctly caus ed the damage. T hese elements of a malpractice claim are s ometimes referred to as the four Ds (duty, deviation, damage, direct causation). P roof by a pre ponderance of the as required in a malpractice suit s imply means more than not. Although the law does not ass ign a preponderance of the evidence is akin to 49 to 51 or jus t enough evidence to tip the scale one way or the other. E ach of the four elements of a malpractice claim mus t 4874 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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present, or there can be no finding of liability. F or a psychiatrist whose negligence is the direct caus e of to an individual (physical or ps ychological, or both) is liable for malpractice if no doctorpatient relations hip exis ted to create a duty of care. P sychiatrists are not to be success fully sued if they give negligent advice on radio program that is harmful to a caller, particularly if a caveat was given to the caller that no doctorpatient relations hip was being created. No malpractice claim is sustained against a ps ychiatris t if a patient's wors ening condition is unrelated to negligent care. F inally, if a ps ychiatris t treats a patient who is then harmed, no malpractice exists if the ps ychiatrist did not deviate the standard of care. F or example, if a ps ychiatris t prescribes clozapine (C lozaril) after proper patient selection, appropriate drug adminis tration, and careful monitoring of the white blood count, there would be no basis for a claim of negligence if the patient develops agranulocytosis and dies. Not every bad outcome is the result of negligence. P sychiatrists cannot guarantee correct diagnos es and treatments . W hen the ps ychiatris t provides due care, mistakes may be made without necess arily incurring liability. Many ps ychiatric cases are complicated. P sychiatrists make judgment calls when s electing a particular treatment P.3970 cours e among a variety of options that may exis t. In hinds ight, the decis ion may prove to be wrong, but it not a deviation in the standard of care at the time treatment was initiated. J uries are instructed by trial 4875 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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that a physician is not liable for a mistake in judgment if she or he, after careful examination, decides what is for the patient and if it is a judgment that a reasonably prudent doctor could have made under similar circums tances . T his knowledge creates a powerful risk management the riskbenefit note. R ecording riskbenefit notes in the patient's chart for treatments and procedures that were explained to the patient limits liability exposure. C linical judgments that may prove to be wrong later cannot be shown to be negligent when the psychiatrist used reasonable care and carefully documented his or her treatment rationale. T he law is not interested in errors in judgment per se. In addition to negligence s uits , ps ychiatris ts can be for the intentional torts of ass ault, battery, false imprisonment, defamation, fraud or mis repres entation, invas ion of privacy, and intentional infliction of distress . In an intentional tort, wrongdoers are by the intent to harm another person or s hould have realized that such harm is likely to follow from their actions. F or example, telling a patient that sex with the therapist is therapeutic perpetrates a fraud. Most malpractice policies do not provide coverage of intentional torts. Other legal theories of liability include breach of contract and civil rights violations of the U.S . C ons titution, s tate cons titutions, or federal civil rights statutes.

Malprac tic e C laims Malpractice claims usually arise when bad outcomes combined with bad feelings. A good doctorpatient 4876 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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relations hip is the bes t protection against a laws uit. Managed care has transformed the relationship ps ychiatris t and patient. P s ychiatris ts are treating more patients for s horter periods of time. Much les s time is available to develop a therapeutic alliance with the patient. S plit treatments are common, in which the ps ychiatris t provides medication and sees the patient infrequently, and a nonmedical therapis t conducts the ps ychotherapy. T he psychiatrist may bear the liability burden in a s plit treatment s ituation, if a lawsuit arises. P sychiatrists are treating chronic, severely ill patients , frequently as outpatients . Under managed care, the res trictive criteria for ps ychiatric hospitalization or exceed the substantive s tandards for involuntary commitments of severe mental illness and P sychiatrists with large practices and psychiatrists who practice at a number of locations are at higher risk of S upervision of nonmedical mental health profes sionals also increas es the ris k of being s ued. P s ychiatris ts are specializing in geriatric psychopharmacology, disorders , adoles cent addiction medicine, pain management, and adult children of alcoholics , resulting areas of risk not usually present in a general practice. S ome ps ychiatris ts are taking on primary care roles, such as managing patient's hypertens ion and diabetes, as well as a variety of acute medical T he changing health care marketplace als o leaves ps ychiatris ts more vulnerable to s uits as their with patients are undermined. Many opportunities for feelings and bad outcomes exist, including poor communication, a perceived lack of caring or interes t, unavailability during critical events, and perceived 4877 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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unrespons ivenes s to a patient's particular treatment needs . Malpractice claims experienced by the P sychiatrist's P urchas ing G roup, the liability insurer of members of American P s ychiatric Ass ociation (AP A), reveal the following approximate frequencies of alleged claims by percentage: 1. Incorrect treatment: 33 percent 2. Attempted or completed suicide: 20 percent 3. Incorrect diagnos is : 11 percent 4. Improper s upervis ion: 7 percent 5. Medication error or drug reaction: 7 percent 6. Improper commitment: 5 percent 7. B reach of confidentiality: 4 percent 8. Unneces sary hos pitalization: 4 percent 9. Undue familiarity: 3 percent 10. Libel or s lander: 2 percent 11. Other (e.g., abandonment, electroconvulsive [E C T ], or third-party injury): 4 percent B orderline patients pos e great clinical challenges and as sociated liability risks. F or instance, s uicide, violence toward others , the capacity to induce therapist violations, alcohol and drug abus e, impulsive actions, comorbidity, and uns table trans ferences combined with tenuous therapeutic alliance all contribute to the ris k of a bad outcome when treating the borderline 4878 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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patient. P urs uing a success ful claim agains t a psychiatrist is difficult. T he plaintiff mus t prove by a preponderance of the evidence that all four elements neces sary to bring a malpractice suit are present. A draw means that the plaintiff los es in court. Approximately 70 to 80 percent laws uits brought agains t psychiatris ts are not

National Prac titioner Data B ank On S eptember 1, 1990, the Health C are Quality Improvement Act of 1986 established the National P ractitioner Data B ank. T he data bank tracks actions, malpractice judgments, and settlements phys icians , dentists , and other health care Hos pitals , health maintenance organizations (HMOs ), managed care organizations (MC Os ), profes sional societies, state medical boards, and other health care organizations are required to report any disciplinary taken against health care profess ionals that lasts more than 30 days . MC Os do not report phys icians to the bank becaus e they did not follow treatment protocols . Dis ciplinary actions include limitation, s uspens ion, or revocation of privileges or profes sional society membership. Medical malpractice payments account roughly three-fourths of reports to the data bank. Under the Health C are Quality Improvement Act, health care entities and health care profess ionals are granted immunity from liability when making good-faith peer review reports. If a phys ician is des elected for qualitycare iss ues , the MC O must report it. Hos pitals must request information from the data bank 4879 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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regarding all phys icians applying for staff privileges. 2 years, a check of the data bank is required for each phys ician or other practitioner on the hospital staff. Hos pitals that do not comply with these requirements loss of immunity for profes sional peer-review activities . P laintiffs attorneys can have access to the data bank when they can prove that the hospital failed to check data bank regarding the phys ician in ques tion. T he information obtained can be used only to s ue the for negligent credentialing. P hys icians can request information from the data bank about their own file at a nominal cos t. Hos pital reporting of actions taken clinicians privileges between 1991 and 1995 declined, raising concerns about underreporting.

S ome Therapies : S tandard of C are S omatic therapies , including E C T , are evaluated no differently than any other medical or ps ychiatric in malpractice litigation. T he same general s tandard of ordinary and reasonable care governs whether a P sychiatrist's us e or failure to us e a somatic deviated from the accepted standard of care. Within the psychiatric profess ion, no abs olute s tandard protocol exis ts for the adminis tration of ps ychotropic medication or E C T . C li P.3971 nicians should give careful consideration to the of procedures, clinical res ources , and practice regularly accepted or us ed by a number of F or example, the AP A has published comprehens ive findings as tas k force reports concerning E C T (2000) 4880 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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tardive dyskinesia (1992). Less profess ional autonomy and flexibility are with the us e of E C T , which is more rigidly regulated most other ps ychiatric treatments . T he J oint on Accreditation of Health C are Organizations cons iders E C T a s pecial treatme nt procedure, which requires hospitals to have written, informed cons ent policies concerning its use. In addition, state statutory regulatory standards, coupled with the s pecific of a ps ychiatric facility regarding E C T , could establis h a basis for liability, if violated. No official or practice guidelines, however, s hould be interpreted as a for sound clinical judgment. T he standard for judging the us e and adminis tration of medication is cons is tent with the more flexible and general re as onable care requirement. Us e of the Des k R efe rence (P DR ) to establish or to dispute a P sychiatrist's pharmacotherapy procedures is a case in point. T he P DR is a commercially distributed, privately published reference of drug products used in the S tates. T he U.S . F ood and Drug Administration (F DA) requires that drug manufacturers report their official package ins erts in the P DR . Although a number of have cited the P DR as a credible source of information about medication usage by the medical profes sion, it not, by itself, es tablis h the s tandard of care. Instead, P DR can be us ed as one piece of evidence to es tablis h standard of care in a particular s ituation. Most courts now follow the ruling in R amon v. F arr holding that drug ins erts alone do not set the standard care. Drug inserts are only one factor to be considered, addition to previous personal experience, the scientific 4881 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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literature, expert testimony, approvals in other and other pertinent factors. T he F DA, the P DR , or any reference s ource cannot s ubs titute for the P s ychiatrist's clinical judgment. A s ubs tantial body of scientific that justifies the clinician's treatment is much more persuasive. S imilarly, in managed care s ettings , ps ychiatris ts mus t vigorous ly res ist efforts to res trict choice of drugs by predetermined, limited formularies, should the choice of generic or proprietary drugs or dosages be dictated by others. T he treating ps ychiatris t determines the s pecific drug to be pres cribed the clinical needs of the patient. C ourts recognize the importance of profess ional and allow ps ychiatris ts and other medical specialists latitude in explaining any s pecial diagnostic or cons iderations that guided their decis ion making. F or example, res earch in the pharmacological treatment of aggres sion s hows a variety of potentially useful drug therapies, some considered experimental or cutting However, no drug is s pecifically approved by the F DA the treatment of aggres sion. T he courts consider the fact that only rarely does one treatment choice exist. Moreover, evidence that a treatment or procedure is used by at leas t a minority of profes sionals in the field could help as a reas onable profes sional practice. P ractice recommend a variety of treatment approaches but to the clinical judgment of the practitioner about the treatment decisions . T he standard of care as sociated with the use of a therapy to treat a psychiatric patient, at a minimum, 4882 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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should include some variation of the following: A. B efore treatment 1. C omplete clinical history (medical, psychiatric) 2. C urrent phys ical examination, when indicated (performed by the patient's phys ician or the ps ychiatris t) 3. Ordering of neces sary laboratory tes ts and of all tes t res ults 4. Dis closure of sufficient information to obtain competent informed consent 5. T horough documentation of clinical and decis ions, informed consent, procedures , treatments B . During treatment 1. C areful monitoring of the patient's res ponse to treatment, including appropriate follow-up and laboratory tes ting 2. P rompt adjustments in medications or strategies , as needed 3. Obtaining a renewed informed cons ent when treatment is s ubs tantially altered or a new treatment is initiated F inal treatment decis ions rest on the clinician's medical judgment and a working knowledge of legal iss ues governing informed cons ent and patients rights to treatment.

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S omatic Therapies : L egal L iabilities Although no thoroughly reliable data on malpractice claims have been publis hed, laws uits involving medications appear to cons titute a s ignificant share of litigation filed agains t ps ychiatris ts. T he previously cited malpractice claims experience of the AP A reveals that medication error and drug reactions accounted for 7 percent of all claims. Incorrect treatment was the malpractice claim category (33 percent). Mos t cases fall into one of four categories : s uicide, sex, and what s ome defens e attorneys cynically call flavor of the month. A variety of omis sions and poor drug treatment commonly res ult in malpractice actions agains t ps ychiatris ts. T he dis cuss ion below identifies problem areas ass ociated with medication treatment.

F ailure to E valuate S ound clinical practice requires that the patient be adequately evaluated before any somatic treatment is started. At a minimum, the ps ychiatris t s hould obtain a clinical history and perform a mental status recent medical examination or continuing medical up by the patient's phys ician may s uffice in lieu of the phys ical examination, or the patient may be referred for medical evaluation, when indicated. A number of laws uits have resulted from the failure to adequately evaluate a patient before pres cribing ps ychotropic medication. As a res ult of this omiss ion, a patient's condition may be mis diagnos ed, may remain untreated, or may wors en. Also, the patient may be 4884 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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expos ed to unneces sary drug s ide effects and risks. In managed care settings, psychiatrists must be careful to spend enough time to conduct an adequate evaluation, es pecially in split treatment arrangements.

F ailure to Monitor or S urpris e P robably the most common act of negligence with pharmacotherapy is the failure to s upervis e the patient's cours e while taking the medication, including monitoring the patient for adverse effects . Monitoring require laboratory testing, physical examination, and medical referral. S erum drug concentrations can be determined for a number of drugs . T he primary for obtaining drug concentrations include ass ess ing therapeutic and toxic levels of medication and patient compliance with treatment. T he us e of carbamazepine (T egretol), valproic acid (Depakene), and clozapine requires careful monitoring of the hematopoietic and the liver. F ailure to properly s upervise patients ps ychotropic medications may result in mis sing harmful advers e effects and can delay a change to more treatment. A malpractice action may res ult if a patient harmed by these omis sions . P.3972 T he question is often as ked: How frequently should patients be s een for medication follow-up? T he answer that patients should be s een as frequently as their needs dictate. No s tock ans wer about the frequency of visits can be given. T he longer the time interval visits, the greater the likelihood of undetected adverse drug reactions and clinical developments. Managed 4885 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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policies that do not reimburse for frequent follow-up appointments may result in ps ychiatris ts pres cribing amounts of medications inappropriately. T he duty bound to provide appropriate treatment to the patient quite independently of managed care or other payment policies, if the patient's clinical needs s o

Negligent P res c ription P rac tic es T he selection of a medication, initial dosage, form of adminis tration, and other related procedures are all decis ions left to the clinical discretion of the treating ps ychiatris t. T he law recognizes that the treating ps ychiatris t is in the bes t position to know the patient to determine the bes t cours e of treatment under the circums tances . Accordingly, a P s ychiatris t's practices are evaluated by a reasonable practice In pres cribing ps ychotropic medication, psychiatrists required to conform their procedures and decis ion with those ordinarily practiced by other psychiatrists similar circumstances. Negligent prescription practices us ually include recommended dos ages and then failing to adjust the medication level to therapeutic levels, unreasonable mixing of drugs, pres cribing medication that is not indicated, prescribing too many drugs at one time, and failing to dis clos e medication effects . E lderly patients frequently take a variety of drugs prescribed by phys icians . Multiple ps ychotropic medications should prescribed with special care becaus e of poss ible interactions and adverse effects . P sychiatrists who pres cribe medications s hould explain diagnosis, risks, and benefits of the drug within reason 4886 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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as circums tances permit (T able 54.1-1). Obtaining competent informed cons ent may be problematic if a ps ychiatric patient has diminis hed cognitive capacity because of mental illness or cognitive impairment. A legally permiss ible s ubs titute health care decision may need to provide cons ent.

Table 54.1-1 Informed C ens ent: R eas onable Information to be Dis c los ed Although there exis ts no consis tently accepted standard for information disclos ure for any given medical or ps ychiatric s ituation, as a rule of five areas of information are generally provided:    Diagnosisdescription of the condition or    T reatmentnature and purpos e of propos ed treatment    C onsequencesris ks and benefits of the treatment    Alternatives viable alternatives to the propos ed treatment, including risks and benefits    P rognosis projected outcome with and without

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treatment

F rom S imon R I. C linical P s ychiatry and the L aw. ed. Was hington, DC : American P sychiatric P res s; 1992, with permis sion.

Informed cons ent should be obtained each time that a medication is changed and a new drug is introduced. If patients are injured because they were not properly informed of the ris ks and benefits of taking a sufficient grounds may exist for a malpractice action.

Other Other areas of negligence involving medication that res ulted in malpractice actions include failure to treat advers e effects that have or s hould have been failure to monitor a patient's compliance with limits, failure to prescribe medication or appropriate of medication according to the treatment needs of the patient, prescription of addictive drugs to vulnerable patients, failure to refer a patient for cons ultation or treatment by a specialist, and negligent withdrawal of medication treatment.

S plit Treatment T he following clinical vignette illus trates a common problem with s plit treatment in managed care settings:

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A ps ychiatris t provided medications for a depress ed year-old woman. A master's degreelevel counselor s aw patient for outpatient ps ychotherapy. T he psychiatrist the patient for 20 minutes during the initial evaluation prescribed a tricyclic drug. T ricyclic drugs had proved effective in alleviating the patient's depress ions in the T hereafter, he s aw the patient every 30 days for followT he patient was pres cribed 1 month's s upply of antidepres sant medication. T he P sychiatrist's initial diagnosis was recurrent major depress ion. T he patient denied suicidal ideation. Appetite and s leep were markedly diminis hed. T he patient had a long his tory of recurrent depres sion with s uicide attempts. T he borderline pers onality disorder was not diagnosed. No further collaborative dis cus sions were held after the brief phone call with the counselor. T he counselor, who saw the patient once a week for 30 minutes , was of the severity of the patient's borderline pers onality disorder. T he patient had a his tory of chronic alcohol abuse. Within 3 weeks after her las t visit with the ps ychiatris t, a brief romantic relationship failed. T he patient stopped taking her antidepres sant medication during an alcohol binge. Her depres sion wors ened S he stopped attending ps ychotherapy. T he ps ychiatris t was not informed by the couns elor of the patient's appointments . T he patient committed s uicide with an overdose of the antidepres sant drug. T he counselor ps ychiatris t were sued for negligent diagnos is and treatment. P sychiatrists mus t do an adequate evaluation, s hould obtain prior medical records , if pos sible, and recognize that there is no s uch thing as a partial patient. S plit 4889 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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treatments are potential malpractice traps, becaus e patients can fall between the cracks of fragmented T he ps ychiatris t retains full respons ibility for the care in a split treatment s ituation. T his does not the res ponsibility of the other mental health involved in the patient's treatment. S ection V , 3 of the P rinciple s of Me dical E thics with Annotations E s pecially Applicable to P s ychiatry s tates: W hen the ps ychiatris t as sumes a collaborative or supervisory role with another mental health worker, he/s he must sufficient time to ass ure that proper care is given. T he ps ychiatris t must be more than jus t a medication technician. F ragmented care in which the psychiatrist dispenses medication, while remaining uninformed the patient's overall clinical s tatus, constitutes treatment that may lead to a malpractice action. At a minimum, s uch a practice diminis hes the efficacy of the drug treatment itself or may even lead to the patient's failure to take the pres cribed medication. S plit treatment situations require that the psychiatrist remain fully informed of the patient's clinical s tatus , as as the nature and quality of treatment that the patient is receiving from the nonmedical therapist. In a relations hip, the respons ibility for the patient's care is shared according to the qualifications and limitations of each discipline. T he res ponsibilities of each discipline not diminis h those of the other dis ciplines. P atients be informed of the separate res ponsibilities of each discipline. T he ps ychiatrist and the nonmedical should periodically confer with each other to evaluate patient's clinical condition and requirements to whether the collaboration s hould continue. On 4890 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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termination of the collaborative relationship, both should inform the patient s eparately or jointly. In split treatments , if P.3973 the nonmedical therapis t is sued, the collaborating ps ychiatris t is likely to be sued and vice vers a. P sychiatrists who pres cribe medications in a split treatment arrangement s hould be able to hospitalize a patient, if that should become necess ary. If the does not have admitting privileges , prearrangements should be made with other psychiatrists who can hospitalize patients if emergencies arise.

Tardive Dys kines ia It is estimated that at leas t 10 to 20 percent of patients perhaps as high as 50 percent of patients treated with neuroleptic drugs for more than 1 year exhibit some probable tardive dys kines ia. T hes e figures are even for elderly patients. Despite the poss ibility for a large number of tardive dys kinesiarelated suits , relatively few ps ychiatris ts have been s ued. One explanation is that patients who develop tardive dys kines ia may not have phys ical energy and motivation to pursue litigation. Allegations of negligence involving tardive dys kines ia based on failure to evaluate a patient properly, failure obtain informed cons ent, negligent diagnosis of a condition, and failure to monitor. Most of these of negligence were claimed in the landmark cas e, S tate (1982). T he plaintiff was a mentally retarded man who was institutionalized from 11 years of age. He was treated with major tranquilizers from 18 to 23 years of 4891 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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After tardive dyskinesia was diagnosed at age 23, the plaintiff's family s ued. T he family claimed that the defendants negligently pres cribed medication, did not inform the patient of the poss ibility of developing dyskinesia, and failed to monitor and s ubs equently to the patient for the adverse effects of the drugs . T he found for the plaintiff and awarded damages in the amount of $760,165. T his award was affirmed on T he appellate court ruled that the defendants were negligent and deviated from the standards of the Among the deviations that the court noted were the failure to conduct regular physical examinations and laboratory tests , the failure to intervene at the firs t tardive dyskinesia, the inappropriate use of multiple medications at the s ame time, the us e of drugs for convenience (e.g., behavior management) rather than therapy, and the failure to obtain the plaintiff's informed cons ent. Appropriate clinical management and competent informed cons ent from the patient or subs titute decision maker significantly lower the practitioner's liability exposure.

E lec troc onvuls ive Therapy E C T is a valuable treatment for carefully s elected with certain mental disorders . It has been es timated to 5 percent of all ps ychiatric inpatients in the United S tates receive E C T . T hus , the potential number of actions alleging negligence ass ociated with E C T is low. Nevertheles s, laws uits involving E C T are occasionally brought agains t ps ychiatris ts . E C T -related injuries have occurred in a variety of circumstances in which has been alleged. T hese cases fall into three groups: 4892 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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pretreatment, treatment, and pos ttreatment. T he AP A T as k F orce on E C T recommends the pretreatment procedures : (1) a psychiatric history and examination to evaluate the indications for E C T , (2) a medical examination to determine ris k factors, (3) anesthes ia evaluation, (4) written informed consent, (5) an evaluation by a phys ician privileged to E C T . T hes e recommendations do not define, in any absolute sense, the standard of care for E C T . the tas k force report is likely to be proffered as the standard of care in malpractice suits involving E C T . T reatment guidelines should not be considered a subs titute for the P sychiatrist's sound clinical judgment. However, failure to adequately conduct pretreatment procedures could endanger the welfare of the patient secondarily could result in a laws uit for negligence. C as es of E C T -related injuries in which negligence has occurred in the actual treatment process include (1) to use a mus cle relaxant to reduce the chance of a fracture, (2) negligent adminis tration of the procedure, (3) failure to conduct an evaluation of the patient, including the us e of X-rays before initiating or treatment. P atients commonly experience certain advers e effects, such as temporary confus ion, disorientation, and loss after E C T . S ound clinical practice requires that ps ychiatris ts provide reas onable pos ttreatment care safeguards . C ourts have held that the failure to attend to a patient for a period of time after E C T can in malpractice liability. P os ttreatment circumstances in which negligence may be claimed include (1) failure to evaluate complaints of pain or dis comfort after 4893 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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(2) failure to evaluate a patient's condition before res uming E C T treatments , (3) failure to monitor a properly to prevent falls, and (4) failure to s upervis e a patient properly who had been injured as a result of E C T -related laws uits today are infrequent and do not represent a s ignificant litigation problem for Administering E C T is no longer as sociated with liability insurance premiums . R ecent developments in right-to-refuse-treatment law and increased statutory regulation of intrus ive therapies , however, ens ure continued clos e legal scrutiny of E C T .

S uic idal Patients P sychiatrists are more likely to be s ued when their commit s uicide, particularly with psychiatric inpatients. P sychiatrists are as sumed to have more control over inpatients , presumably making the s uicides T he evaluation of suicide risk is one of the mos t dauntingly difficult clinical tasks in ps ychiatry. S uicide is rare event. In the current state of knowledge, clinicians cannot accurately predict when or if a patient will suicide. No profes sional standards exist for predicting will commit suicide. P rofes sional standards do exis t for as sess ing suicide risk, but, at bes t, only the degree of suicide ris k can be judged clinically after a ps ychiatric as ses sment. A variety of clinically us eful as sess ment approaches available to practitioners. P ractitioners can design their own suicide risk as ses sment methodology bas ed on training, clinical experience, and the ps ychiatric S uicide risk ass es sments are here-and-now 4894 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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whos e us efulness erodes rapidly over time. S uicide as sess ment has much in common with weather forecasting. As tronomical events, s uch as eclipses, can predicted with 100 percent accuracy. W eather are made only within certain probabilities . S uicide risk as sess ments, like weather forecas ts, require frequent updating. P sychiatris ts should frequently as ses s the violence and s hould update ris k ass es sments at clinical junctures (e.g., room and ward changes, privileges, off-ward pas ses , discharge). S hort-term as sess ments (24 to 48 hours) are more accurate than longer-term as sess ments . In the s hort term, factors influence future patient behaviors can be identified precis ely. S uicide risk ass es sment evaluates ris k and protective factors . S pecific ris k factor categories include individual (unique to patient), clinical, interpers onal, s ituational, demographic factors. S uicide ris k as sess ment is a not an event. Ass es sing s uicide ris k involves three steps : (1) patients at s uicide ris k, (2) as sess ing the overall after evaluating s pecific s uicide risk factors , and (3) providing treatment and s afety interventions that are informed by the s uicide ris k ass es sment. S uicide risk evaluation should be standard practice patients, even if they do not exhibit overt suicidal symptoms. A significant number of patients with major affective dis orders who commit suicide deny s uicidal ideation. S imply as king patients if they are P.3974

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suicidal and obtaining a no-harm contract is layman could just as easily ask these same ques tions. E specially with new patients, there is no credible bas is relying on such reas surances. T he clinician's expertis e taking an adequate ps ychiatric history and performing recording a competent s uicide ris k ass ess ment that informs clinical interventions. A review of the case law on s uicide reveals that certain affirmative precautions should be taken with a or confirmed s uicidal patient. F or example, failing to perform a reasonable ass ess ment of a s uicidal for suicide or to implement an appropriate plan is likely to render a practitioner liable. T he law to ass ume that s uicide is preventable if it is C ourts s crutinize the P s ychiatrist's management of the patient in suicide cas es to determine the the ris k ass es sment process and whether a patient's suicide was fores eeable. F ore s e e ability is a vague legal term that has no comparable clinical counterpart. T he legal definition of fore s e e ability is the reasonable anticipation that harm or injury is a likely from certain acts or omis sions . It is a common-sens e cons truct rather than a scientific cons truct. T he performance and recording of s ys tematic risk that inform patient treatment and s afety management should be sufficient to meet a fair legal interpretation of foreseeability. T hus , a risk of suicide is fores eeable than the s uicide itself. F ores eeability does not (and not) imply that clinicians can predict s uicide. In W illiams on v. L iptzin (1998), the ps ychiatris t was his former patient for not fores eeing the violence perpetrated by the patient during a murderous 4896 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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that occurred 8 months after the termination of T he appellate court held that F urthermore, evidence of factors for potential violence, s uch as gun ownership, being under a certain age, or being of a certain gender, implicates a large portion of our population and is insufficient in and of itself to prove foreseeability. However, the court did not directly addres s whether systematic as sess ment would have es tablis hed foreseeability. A pas t history of violence or violent may have individualized the ris k ass ess ment and led to conclus ion that the violence was fores eeable, which not pos sible with demographic factors alone. As in W illiams on v. L iptzin, courts are likely to dismis s as sess ment of isolated risk factors (e.g., demographic factors ) as s imply ins ufficient in establishing in the abs ence of systematic ass es sment. W illiams on L iptzin is a case about the fores eeability of violence. However, the court's comments could be applied just easily to s uicide cases and ris k ass es sment. C ourts find s ys tematic s uicide ris k ass ess ment useful in determining re as onably fores e eable risk. When s uicide as sess ments are performed and documented, the is able to identify treatable and modifiable risk factors . also provides the clinician with a sound legal defens e malpractice litigation. F oreseeability s hould not be confused with In hinds ight, many s uicides s eem preventable that not foreseeable. W hen cons idering treatment interventions for the s uicidal patient, the clinician must as sess ris ks and benefits. T he clinician who is guided by ris k ass es sment is practicing defensive psychiatry to poss ible detriment of the patient's care. 4897 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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When making decis ions about off-ward privileges , and discharges, ps ychiatris ts s hould record the as sess ment that guides their judgment. T he risks and benefits of greater freedom mus t be weighed against those of continued hospitalization. T his is good clinical practice and s ound clinical ris k management. If a claim is made, carefully documented riskbenefit as sess ments that inform the court about the clinician's contemporaneous decis ion-making process can solid malpractice defens e.

S uic de P reventations C ontrac ts S uicide prevention or no-harm contracts (oral or between therapists and patients are des igned to encourage patients to as k for help rather than to suicide. T hese contracts have no legal authority. Nocontracts are used extensively in managed care which there is rapid turnover of sick patients. T he ps ychiatris t may place too great a reliance on the and may be fals ely reas sured that the patient is s afe. S uicide prevention pacts between psychiatrists and patients s hould not replace adequate s uicide ris k as sess ments. T he suicide prevention contract can be clinically us eful when it s trengthens the therapeutic alliance. F or the patient may be reass ured by the clinician's concern and availability. T he contract agains t suicide is the most useful when the patient refus es to accept it. T hen, at least, the clinician is not deceived by a disingenuous as sent and a false sense of s ecurity. patients, however, refus e no-harm contracts to stay in the hospital. 4898 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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Defens es T here are a number of legal defenses against a s uicide malpractice claim. An open-door policy that allows patients more therapeutic freedom of movement has produced a split in court decis ions. C ourts consider the specific facts of the cas e and the hospital staff's reasonablenes s in applying open-door policies. juries and judges have difficulty giving credence to an abstract treatment idea when confronted with a dead patient. T he doctrine of sovereign or governmental immunity bar by s tatute a finding of legal liability against a state federal facility. A s uicide may be caus ed by factors unrelated to the P sychiatrist's treatment of the patient. F or example, a borderline patient may experience an overwhelming rejection between s es sions and may commit suicide without firs t attempting to contact the ps ychiatris t. T he unfores een rejection, a s uperseding, intervening likely precipitated the suicide, not negligent treatment. T he best-judgment defense can often be s ucces sfully argued when the s uicidal patient was properly and treated. In ess ence, the defense as serts that the patient committed s uicide des pite receiving reasonable care. T he following vignette illus trates the importance conducting adequate suicide risk ass es sments: A 42-year-old, s ingle, male patient committed s uicide while on a 4-hour therapeutic pass from the hospital before anticipated discharge. T he patient was with a diagnos is of major depress ion, s ingle epis ode, 4899 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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suicidal ideation. T he managed care company week of inpatient treatment. T he patient steadfastly denied suicidal thoughts or impulses after admiss ion. experienced moderate to s evere depress ion, global insomnia, hopeles sness , agitation, and los s of appetite. T he patient s igned a s uicide prevention promis ing to inform the psychiatrist or staff immediately any s uicidal ideation or impulses. After antidepress ant treatment was started, the patient's energy level T he ps ychiatris t and the hos pital were s ued by the patient's parents for wrongful death. In court, the expert tes tified that a formal (systematic) suicide risk as sess ment would have determined that the patient at significant s uicide ris k and that no pass s hould have been is sued. T he expert found no evidence in the ps ychiatric record that a formal s uicide ris k ass ess ment was conducted before the pass was is sued. S he that not recording a suicide risk as sess ment was a of the standard of care. S he further tes tified that the patient was at greater ris k of s uicide after an antidepress ant drug, because the patient now had more energy to carry out his s uicidal intent. F inally, the expert opined that the ps ychiatris t s hould not have on a no-harm contract to prevent s uicide in lieu of performing a s uicide ris k ass ess ment. P.3975 T he defendant psychiatrist testified that the patient's willingnes s to sign a no-harm contract indicated the presence of a therapeutic alliance and the motivation to get well. T he ps ychiatris t further testified that he had 4900 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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performed a systematic suicide risk as sess ment that indicated a low to moderate s uicide ris k. It was an overs ight on his part not to record the suicide risk as sess ment. In the P sychiatrist's judgment, the benefit of a pass outweighed the low to moderate ris k. T he ps ychiatric expert for the defens e testified that the ps ychiatris t met the s tandard of care by ass ess ing the of suicide and weighing the s uicide ris k against the therapeutic benefits of a pas s. T he expert noted that ps ychiatris t had not placed total reliance on the nocontract but had used it appropriately to ass es s the working alliance with the patient. On cros s the defens e expert admitted that the s uicide ris k as sess ments should have been recorded, but he feels this was not the proximate caus e of the patient's T he expert concluded by stating that a patient who is intent on committing s uicide cannot be s topped from doing so by the ps ychiatris t or the hos pital, even if the patient is totally locked up. T he jury found for the plaintiffs, awarding $350,000 in monetary damages . When the jurors were polled by defens e attorney immediately after rendering the they s tated that a lack of documentation of the P sychiatrist's decis ion-making process prevented their giving credibility to his testimony.

Violent Patients P sychiatrists who treat violent or potentially violent patients may be sued for failure to control aggress ive outpatients and for the dis charge of violent inpatients. Heightened liability exposure exis ts if it was reas onable 4901 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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the ps ychiatris t to have known about the patient's tendencies and if the ps ychiatris t could have done something that could have safeguarded the public. In landmark cas e, T aras off v. R ege nts of the U nive rs ity of C alifornia, the C alifornia S upreme C ourt ruled that health profess ionals have a duty to protect identifiable, endangered third parties from imminent threats of harm made by their outpatients. After T aras off, courts in other juris dictions have the case various ly. S ome s tates have adopted the holding, whereas others have limited or extended its and reach. In a majority of s tates , psychotherapis ts duty, established by cas e law or s tatute, to act to protect an endangered third party from a patient's violent or dangerous acts . A few courts have declined find a T aras off duty in a specific case, whereas some have simply rejected the T aras off duty (e.g., E vans v. S tate s , 1995; G re en v. R os s , 1997). In T hapar v. (1999), the T exas S upreme C ourt ruled that the s tate statute pe rmits but does not re quire disclos ures by therapists of threats of harm to endangered third by their patients . T he duty to protect patients and endangered third should be cons idered primarily a profess ional and obligation and, only secondarily, a legal duty. Most ps ychiatris ts acted to protect their patients and others from violence long before T aras off. Nonetheles s, if a patient threatens harm to another person, most s tates require that the ps ychiatris t some intervention to prevent the harm from occurring. states with duty-to-warn statutes , the options available ps ychiatris ts and psychotherapists are defined by law. 4902 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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states offering no s uch guidance, health care providers required to use clinical judgment that protects endangered third persons. T ypically, a variety of warn and to protect are available, including voluntary hospitalization, involuntary hospitalization (if civil commitment requirements are met), warning the victim of the threat, notifying the police, adjusting medication, and seeing the patient more frequently. duty to protect allows the psychiatrist to cons ider a number of clinical options . W arning others of danger, its elf, is us ually insufficient. P s ychiatris ts s hould the T aras off duty to be a national standard of care, they practice in states that do not have a duty to warn to protect. A number of states have enacted immunity statutes limiting the res ponsibility of therapis ts for their patients violent acts . Most of thes e s tatutes provide immunity disclos ures made to fulfill the duty to protect. T he of states pas sing s uch s tatutes increas es every year. Definitions vary considerably concerning when the duty arises and how to discharge it. Most s tatutes require an actual threat made agains t a clearly identifiable victim before a duty to warn or to protect aris es. Discharging duty usually involves warning the intended victim and enforcement authorities. Unfortunately, the duty to rather than to protect, is more often relied on by statutes. T hus , the duty to warn may be defens ively invoked as a risk management tool. S ometimes, by its elf may induce violence. T hus , immunity s tatutes encourage reflexive rather than reflective patient management. If a patient gives the ps ychiatris t sufficient reason to 4903 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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believe that a warning s hould be is sued to an third party, the confidentiality of the communication that gave rise to the warning may be lost. In one case, the warning of endangered third parties resulted in the ps ychiatris t being compelled to tes tify in criminal cas es . T he court held that warning a third party polluted the confidentiality privilege. T he T aras off duty was originally applied to the setting. However, the same legal duty to protect individuals and s ociety from harm by mental patients arises concerning the releas e of violent patients . T he of the duty to warn is us ually narrower than the duty to release a violent patient. In cas es involving failure to warn and to protect an endangered third party, courts have held that the violence must be serious and imminent, and the victim mus t be identifiable and foreseeable. T he duty not to releas e a violent patient broader scope, because these patients often do not expres s specific threats toward pers ons or groups and pose a threat to the general public. In releas e cases, have extended the therapist's duty beyond that owed to readily identifiable victims. T he number of malpractice suits alleging negligent release is at leas t five to s ix the number of outpatient cases alleging a T aras off T he ps ychiatris t has a general duty to protect other members of s ociety. T his duty is not new to the law. doctorpatient relationship often gives the ps ychiatris t insider information about the potential for violence that endangered individuals do not poss es s. T he duty to and to protect aris es from the concept of latent dangers which the psychiatrist is privy. P sychiatrists s hould not discharge patients without 4904 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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arranging for adequate aftercare. Doomed-to-fail discharges mus t be avoided by cons idering what is different in the patient's clinical condition and circums tances at anticipated dis charge. T he patient's willingnes s to cooperate with the ps ychiatris t is critical follow-up treatment. T he ps ychiatris t s hould s tructure follow-up visits to encourage compliance. S cheduling patient as soon as poss ible for appropriate treatment programs that are readily access ible facilitates patient adherence. A s tudy of V eterans Affairs (V A) outpatient referrals s howed that, when inpatients were referred to V A mental health clinic, approximately 50 percent keep their firs t appointment. However, the ability to ensure follow-up care is limited. Mos t patients retain the right to refus e treatment after dis charge. T his must be acknowledged by the psychiatric and legal communities. T he treatment of ps ychiatric inpatients has changed dramatically in the managed care era. Mos t psychiatric units , particularly thos e in P.3976 general hospitals , have become s hort-stay, acute-care, ps ychiatric facilities. Under managed care, only the most acute patients are admitted and, then, only for term hospitalization. S trict s crutiny by utilization ensures that thes e patients are hospitalized for brief periods. T he purpos e of hospitalization is crisis intervention management, safety, and s tabilization of patient. T reatment is provided by a variety of mental health profess ionals ; yet, the psychiatrist often bears burden of liability for treatments gone awry. Little 4905 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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opportunity is us ually available during the hos pital s tay develop a therapeutic alliance with patients. T he P sychiatrist's stock in trade, the ability to communicate with patients, is s everely curtailed. All of thes e factors greatly increase the risk for a malpractice s uit alleging premature or negligent dis charge of potentially violent patients. Managed care restrictions on length of stay mus t not be allowed to interfere with clinically decis ions indicating a need for continued T he American Medical As sociation has is sued for dis charging inpatients, entitled E vidence-B as ed P rinciples of Discharge and Dis charge C riteria. In outpatient or inpatient s ettings , psychiatris ts are to meet the s tandard of care if they reas onably as sess patient's potential ris k for violence, which then informs choice of clinical interventions . F or example, a his tory past violence s hould alert the clinician to future P rofess ional s tandards are described in the psychiatric literature for the as sess ment of the risk of violence. However, no s tandard of care exis ts for the prediction individual violent behavior. In as sess ing the risk of violence, ps ychiatris ts should as ses s risk and factors frequently, updating risk as sess ments at clinical junctures (e.g., room and ward changes , privileges, off-ward pas ses , and discharge). As sess ing ris k of violence is a here-and-now determination. P robability ris k ass es sments of violence become progres sively less accurate beyond the immediate term (e.g., 24 to 48 hours ). A riskbenefit as ses sment be conducted and recorded that explains the clinician's reasoning for and against is suing a pas s or dis charge.

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A ps ychiatris t evaluates a 38-year-old man and makes diagnosis of delusional disorder, jealous y type, after obtaining the following history: Approximately 6 months before the evaluation, the began to believe that his wife was having an affair with boss . T his idea grew into a conviction. T he wife vehemently denied his accus ations and demanded that the patient s ee a ps ychiatris t after he began making threats agains t her boss . He acquies ced, although he believed that there was nothing wrong with him. After making the diagnosis, the psychiatrist continued outpatient visits and medication and the pos sibility of hospitalization. Involuntary hospitalization was not considered becaus e of a requirement of a recent overt violent act in the commitment statute. T he ps ychiatris t ass ess ed the risk violence as high. T he patient refus ed to come back for another visit, saying that he would make no further threats . T here was no history of violence. When the ps ychiatris t informed the patient that s he had a duty to warn the bos s of the danger, the patient replied, G o he knows anyway. As required by state law, the ps ychiatris t called the threatened individual, informing him of the patient's threats and high risk for violence. boss dis miss ed the threats as s o much nonsense. In addition, the ps ychiatris t informed the law enforcement authorities . S ix weeks later, the ps ychiatris t read in the paper that patient shot and killed the bos s, his wife, and himself. A year later, the ps ychiatris t was s ued by the boss 's a failure to warn and to protect the murdered individual. the suit, the estate claimed that the ps ychiatris t neither 4907 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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stress ed the serious nes s of the threat s ufficiently nor properly as sess ed the patient for involuntary hospitalization. T he complaint s tated that a medical certification for involuntary hospitalization should have been obtained by the psychiatrist, so that the court decide on the appropriatenes s of the petition. Her clearly documented the diagnos is , treatment recommendations , the s erious warning to the bos s, the informing of law enforcement authorities. T he state s tatute governing T aras off-type cases an immunity provis ion that precludes the impos ition of legal liability against mental health profes sionals when endangered third parties are warned of potential threatened by a patient and when the police are also informed. T he lawsuit was dismis sed by the court on a motion for summary judgment made by the attorney. T he lawsuit was precluded by the s tate statute. T he claim that the psychiatris t did not cons ider involuntary hos pitalization was also dis miss ed, the state's commitment s tatute required an overt act of violence within 30 days of an evaluation. T hus , the did not meet s ubs tantive criteria for civil commitment. A s tate superior court jury awarded W endell former Univers ity of North C arolina law student, holding psychiatrist Myron B . Liptzin liable for negligent treatment that resulted in his former patient's violent on J anuary 26, 1995, after treatment ended on May 25, 1994. In the criminal trial, W illiamson was found not by reason of ins anity in the random s hooting murders two men and the serious injury of a police officer near campus. W illiams on was institutionalized with a of paranoid s chizophrenia. 4908 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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In the civil suit, W illiamson alleged that Dr. Liptzin, then director of student health psychiatric services, failed to diagnose correctly and to explain the s eriousnes s of illness . In spite of improvement with antipsychotic medication while under Dr. Liptzin's care, the plaintiff claimed that his treatment was mismanaged by not properly arranging a referral to another ps ychiatris t Dr. Liptzin's retirement. Dr. Liptzin countered that he encouraged Williams on to attend a mental health clinic during the summer; however, he did not make a referral. He had given the 26-year-old W illiamson a 30supply of antips ychotic medication and had urged the patient to have his family physician refill the medication he did not contact a ps ychiatris t. After discharge, Williams on stopped taking his medication. A judge the $500,000 jury award, but the decision was Dr. Liptzin appealed the lower court ruling on grounds his alleged negligence was not the proximate caus e of Williams on's injury. T he North C arolina C ourt of agreed with Dr. Liptzin (W illiams on v. L iptzin, 2000) that the plaintiff's injuries were unforeseeable. T he reasoned that W illiamson's injuries were too remote in time and that the chain of events leading to injuries were too attenuated for Dr. Liptzin's alleged negligence to be the proximate cause of W illiamson's injuries. T he patient did not appear violent nor did he make any violent threats at the time of termination. P sychiatrists other mental health profes sionals cannot provide with guarantees of s afety during or after treatment. patients retain the right to refuse treatment and to stop their medications . V iolent behaviors are the res ult of 4909 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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complex, dynamic interactions among a variety of personality, social, and environmental factors that vary acros s time and situations . An important, evolving trend is the application of the T aras off duty to s exual abus e cas es by an alleged pedophile. A psychiatrist was s ucces sfully s ued for not reporting to the medical s chool that his patient was a pedophile (G aramella v. N ew Y ork Me dical C olle ge , P.3977 1998). T he patient, a ps ychiatric res ident, molested a at a hospital crisis center. T he court reasoned that the defendant P s ychiatris t's control over the psychiatric res ident was far greater than the typical relations hip. A T aras off duty was also found in a cas e which a spous e had knowledge of her husband's abusive behavior against children in the neighborhood v. R T , 1998) (T ouche tte v. G anal, 1996). In another court found that a T aras off duty could exist but find the parents of a babys itter liable for his dangerous sexual behavior (P eople v. R os e , 1998). T he court determined that no evidence exis ted that the parents knew of their son's proclivity to commit a s exual

R IG HTS OF P A TIE NTS Involuntary Hos pitalization An individual may be involuntarily hospitalized only if certain s tatutorily mandated criteria are met. T hree subs tantive criteria serve as the foundation for all commitment requirements: T he individual must be (1) mentally ill, (2) dangerous to s elf or others , or (3) 4910 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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provide for one's basic needs (gravely dis abled). language defining subs tantive criteria varies among the states . Additional criteria may include, for example, damage to property, an overt act of violence toward others within a s pecified period of time, and leas t res trictive alternative requirements . T erms s uch as me ntally ill are often loos ely described, which shifts the res ponsibility for defining the psychiatric problem to the petitioner. In addition to pers ons with mental illnes s, a number of states have enacted legislation that provides for involuntary hos pitalization of three other distinct developmentally disabled (mentally retarded), us ers (alcohol, drugs), and mentally dis abled minors. S pecial commitment provis ions govern the for admis sion and discharge of mentally dis abled addition to numerous due proces s rights afforded these individuals . C urrently, most mentally ill patients are being treated outpatients. G enerally, involuntary hospitalizations are short periods. Involuntary hos pitalization of ps ychiatric patients often occurs when violent behavior threatens erupt toward s elf or others and when patients become unable to care for themselves. T hes e patients have disorders that readily meet the s ubstantive criteria for involuntary hos pitalization. V iolent individuals who do have a mental disorder are not candidates for hospitalization; they are the res ponsibility of law enforcement authorities. C linicians do not actually commit patients . C ivil commitment comes under the s ole jurisdiction of courts quasi-judicial bodies . T he ps ychiatris t initiates medical 4911 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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certification that brings the patient before the court, us ually after a brief period of evaluation. In seeking medical certification, the ps ychiatris t must be guided by the treatment needs of the patient and the protection of the patient or others who may be endangered by the patient. T he most common type of lawsuit for involuntary hospitalization alleges that a ps ychiatris t failed to act in good faith and to adhere to s tatutory requirements, res ulting in a wrongful commitment. G enerally, these laws uits are brought under the theory of fals e imprisonment. Other areas of liability for alleged commitment include ass ault and battery, malicious prosecution, abus e of authority, and intentional of emotional distress . In mos t s tates, psychiatrists are granted qualified from liability if they use reas onable profess ional and act in good faith when petitioning for commitment. T he ps ychiatris t may be s ued if evidence exis ts of blatant, or gros s failure to adhere to s tatutorily defined commitment procedures . Most states recognize the right of inpatients to refuse treatment. E ven though the patient is involuntarily hospitalized, the hospitalization does not negate a presumption of competence. In mos t s tates , hospitalized patients who refuse medication require a separate court hearing for adjudication of and the provis ion of substituted cons ent by the court. R ecently, pers ons hos pitalized under criminal have been accorded a qualified right to refuse T he courts have found that patients constitutional right due proces s is adequately protected by the exercis e of 4912 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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profes sional judgment within the medical peer review proces s of the institution. Hos pitalized patients poss ess other rights . P atients rights of visitation, although thes e rights can be temporarily s us pended for proper caus e relating to the patient's care and treatment. F ree communication by hospitalized patients through mail, telephone, or cons idered a right, unless protection of the patient or others requires supervis ion of communications. T he to privacy includes allowing patients to have secure space, private toilet and s hower facilities , and minimum square footage of floor s pace. C onfidentiality is also protected. E conomic rights include the right to have to spend money and to handle one's own financial res ponsibly. In mos t juris dictions, involuntarily hospitalized patients do not lose their civil rights , s uch the right to manage their own money. Hos pitalized patients mus t be paid for their work in certain unles s it is truly therapeutic labor (i.e., work not with maintenance of the hos pital). P atient rights are not absolute and often must be tempered by the clinical judgment of the mental health profes sional. Inevitably, disputes over perceived or real violations of patients arise. In s ome juris dictions, a civil rights officer or ombudsman is mandated by statute to mediate thes e disputes .

Managed C are P sychiatrists have certain res pons ibilities toward treated in managed care settings, including the res ponsibilities to disclos e all treatment options , to exercise appeal rights, to continue emergency 4913 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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and to cooperate reasonably with utilization reviewers .

R es pons ibility to Dis c los e P sychiatrists have a continuing respons ibility to the patient to obtain informed cons ent for treatments or procedures . All treatment options s hould be fully disclos ed, even those not covered under the terms of a managed care plan. Most states have enacted making gag rules illegal that limit information about treatment provided to patients under managed care. MC Os cannot require affiliated physicians to limit or to withhold advice about treatment options to Medicare beneficiaries , even if thos e treatments are not covered. C ongres s has banned gag rules that prohibit health providers from advising Medicare beneficiaries who choos e the HMO option about medical treatments that HMO does not cover.

R es pons ibility to A ppeal T he American Medical As sociation C ouncil on E thical J udicial Affairs states that physicians have an ethical obligation to advocate for any care that they believe will materially benefit their patients , regardless of any allocation guidelines or gatekeeper directives.

R es pons ibility to Treat P hysicians are liable for failure to treat their patients the defined s tandard of care. T he treating phys ician sole respons ibility to determine what is medically neces sary. Managed care programs generally limit or payment for P.3978 4914 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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services , not the actual s ervices. P s ychiatris ts mus t be careful not to dis charge suicidal or violent patients prematurely merely because continued coverage of benefits is not approved by a managed care company.

R es pons ibility to C ooperate with Utilization R eview As an ally of the patient and as a provider of good care, the ps ychiatris t s hould cooperate with utilization reviewers reques ts for information on proper from the patient. W hen benefits are denied, one mus t unders tand and follow grievance procedures carefully, must return telephone calls from review agencies, and must provide documented, s olid justification for treatment.

B oundary Violations Increasingly, ps ychiatris ts and other mental health profes sionals are being sued for treatment boundary violations that lead to patient exploitation and harm. Monetary and sexual exploitation are the mos t T he therapist establishes treatment boundaries to and to s ecure the profes sional relationship that a therapeutic alliance with the patient. T he boundary guidelines lis ted in T able 54.1-2 are accepted by mos t clinicians , with certain exceptions, regardless of their treatment orientation. Absolute boundary s tandards do not exis t. Much of the variability in es tablis hing arises from the nature of the patient, the type of the nature of the therapist, and the s tatus of the therapeutic alliance. S ound treatment boundaries 4915 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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a fluctuating, reas onably flexible, ps ychological between therapis t and patient.

Table 54.1-2 B oundary for Ps yc hotherapy Maintain relative therapist neutrality F os ter psychological separatenes s of patient P rotect confidentiality Obtain informed consent for treatments and procedures Interact verbally with patients E ns ure no previous , current, or future pers onal relations hip with the patient Minimize phys ical contact P res erve relative anonymity of therapis t E stablish a s table fee policy P rovide a cons is tent, private, and profes sional setting 4916 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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Define time and length of s es sions

F rom S imon R I: T reatment boundary violations: C linical, ethical and legal considerations. B ull Am Acad P s ychiatry L aw. 1992;20:269, with

Once treatment boundaries are es tablis hed, problems about boundaries (boundary iss ues) that inevitably from the patient are gris t for the therapeutic mill. B oundary violations are s trictly created by the B oundary cross ings occur commonly in every therapy if quickly identified and rectified, cause no harm to the patient. S exual exploitation of patients is preceded by progres sively s erious boundary violations. T he earlies t boundary violations often begin at the end of the between the chair and the door. P atient and therapist their treatment roles to don a s ocial relationship. should be considered in progres s until the patient the office. T he time and s pace between the chair and door can be s crutinized for early warning indicators of boundary violations. T he principle of abstinence is central to keeping sound treatment boundaries. T herapis ts mus t abstain from patients for their personal advantage. T he therapist's personal gratification s hould come from the work with patient. Monetary payment received for the therapis t's profes sional services is the only coin of the realm 4917 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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and other nonmonetary payments should be avoided. When making interventions with patients , therapists spot check the s oundnes s of their boundaries by two bas ic ques tions: (1) Is the intervention being made advance the patient's treatment or for the personal gratification of the therapist? and (2) Is the intervention part of progress ive boundary violations ? B oundary violations need not prove fatal to the patient's treatment they are caught in time, are turned to account for the of the patient's treatment, and are self-scrutinized by therapist.

C onfidentiality C onfide ntiality refers to the right of a patient to have communications s poken or written in confidence to a ps ychiatris t kept undisclos ed to outside parties without authorization. F our general sources provide the bases recognizing and safeguarding patient confidences . 50 states and the District of C olumbia have this right of protection by creating s ome form of confidentiality provis ions in profes sional licensure laws confidentiality and privilege statutes . In 1996, the U.S . S upreme C ourt (R edmond v. J affe ) ruled that communications between ps ychotherapist and patient confidential and need not be disclos ed in federal trials . decis ion does not apply in s tate courts, where most ps ychotherapis tpatient priviledge cases are heard. T he second s ource, with the longes t tradition, comprises ethical codes of the various mental health profes sions. T hird, common law has long recognized an privilege; developing cas e law has es tablis hed similar protection for physicians and ps ychotherapis ts. F ourth, 4918 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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right of confidentiality may be subsumed under the of privacy. Although there is no explicit cons titutional of privacy, privacy rights have been s ynthes ized from various cons titutional guarantees .

B reac h of C onfidentiality Once the doctorpatient relations hip is created, the profes sional has a duty to safeguard a patient's T his duty is not abs olute, because circumstances exist which breaching confidentiality is ethical and legal. P atients may waive confidentiality in a variety of including managed care settings. Medical records routinely go to potential employers or to ins urance companies to obtain benefits. A limited waiver of confidentiality us ually exists when a patient participates group therapy. W hether a group member can be compelled in court to disclos e information s hared by another group member during group therapy remains unsettled. Many state confidentiality statutes provide statutory exceptions to confidentiality between the ps ychiatris t and the patient in one or more situations . Apart from s tatutory disclos ure requirements and compuls ion, no legal obligation exists to provide information, even to law enforcement officials. In IV , Annotation 8, the P rinciple s of Me dical E thics with Annotations E s pecially Applicable to P s ychiatry s tates: P sychiatrists at times may find it necess ary, in order to protect the patient or the community from imminent danger, to reveal confidential information disclos ed by patient. patients acces s to their own records is us ually controlled by state s tatutes . T hese statutory provisions be found under the heading of me dical records or the 4919 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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much broader term privilege . T he rules governing access to their own records are complex and vary cons iderably in each juris diction. T he material contained in the ps ychiatric record can an iatrogenic exacerbation of a patient's mental E very effort should be made to be present when review their records to clarify statements and to ans wer questions . T he phys ical record is the property of the ps ychiatris t. T he information contained in the P.3979 record belongs to the patient. T he original record not be relinquished to the patient; only a copy should provided. P atients have new s tatutory rights regarding the health information, mandated by the Health Insurance P ortability and Accountability Act of 1996 (HIP AA).

TE S TIMONIA L P R IVIL E G E T es timonial privilege, a s tatutorily created rule of permits the holder of the privilege (e.g., the patient) to exercise the right to prevent the person to whom confidential information was given (e.g., the from disclos ing it in a judicial proceeding. T he patient, the ps ychiatris t, holds the privilege that controls the releas e of confidential information. It is called privilege because it applies only to the judicial setting. P rivilege statutes represent the most common by the state of the importance of protecting information provided by a patient to a ps ychotherapist. T his recognition departs from the ess ential truth-finding purpos e of the American s ys tem of justice by insulating 4920 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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certain information from disclosure in court. T his protection is justified by the special need for privacy in doctorpatient relationship, which outweighs the quest an accurate outcome in court. P rivilege statutes cover most of the mental health profes sions. C as es have been success fully litigated in which the broader phys icianpatient category was to the psychotherapist in the absence of an applicable statute.

E xc eptions to Tes timonial Privilege P rivilege statutes also specify numerous exceptions to tes timonial privilege. T he most common exceptions include child abus e reporting, civil commitment proceedings, court-ordered examinations , competency proceedings, and cases in which a patient's mental in question as part of litigation. T his las t exception, as the patie ntlitigant e xce ption, commonly occurs in will contests , workers compensation cases , child custody disputes , personal injury litigation, and malpractice actions.

L iability An unauthorized or unwarranted breach of may cause a patient serious harm. C onsequently, a ps ychiatris t may be held liable for s uch a breach bas ed at least four legal theories: malpractice (breach of confidentiality), breach of s tatutory duty, invasion of privacy, and breach of (implied) contract.

S E X UA L MIS C ONDUC T T herapistpatient s ex is almos t always preceded by 4921 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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progres sive boundary violations in treatment. P atients us ually psychologically damaged by the precurs or boundary violations and the end-stage sexual of the therapist. S exual misconduct does not occur in is olation; it us ually involves a variety of negligent acts omis sion and commis sion.

C ivil L iability P sychiatrists who sexually exploit their patients are to civil and criminal actions in addition to ethical and profes sional licensure revocation proceedings . is the most common legal action (T able 54.1-3).

Table 54.1-3 S exual E xploitation: Legal and E thic al C ons equenc es Malpractice laws uit B reach of contract action C riminal s anctions (e.g., statutory, adultery, as sault, and rape) C ivil action for intentional tort (e.g., battery and fraud) License revocation

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E thical s anctions Dis miss al from profess ional organizations

F rom S imon R I. C linical P s ychiatry and the L aw. ed. Was hington, DC : American P sychiatric P res s; 1992, with permis sion. In a s exual exploitation case, the plaintiff has the proving that the exploitation actually took place. T his burden is met if the plaintiff can provide corroborating evidence to support the claim, such as testimony from other abus ed (former) patients, letters, pictures , hotel motel receipts , and identification of dis tinctive therapis t body markings. If the defendant practitioner admits to the sexual misconduct, then the plaintiff is left with the of showing that he or she s ustained injuries as a result. Usually, patient injury occurs in the form of emotional damage, s uch as trus t problems and a worsened ps ychiatric condition. E xpert psychiatric testimony es tablis hes the type and extent of ps ychological and affirms a breach in the s tandard of care. A number states have civil s tatutes pros cribing s exual mis conduct with patients. T hree basic types of remedies are codified in the of a number of states : reporting, civil liability, and penalties . R eporting s tatutes require the disclosure to 4923 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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authorities by a therapis t who learns of any past or therapistpatient s ex. S tates that have civil s tatutes proscribing s exual misconduct incorporate a standard care that makes malpractice suits eas ier to pursue. these statutes restrict unfettered discovery of the past s exual his tory. C riminal s anctions are often the remedy for exploitative therapis ts without malpractice insurance, for therapists who are unlicensed, or for therapists who do not belong to profes sional organizations .

C riminal S anc tions A number of states have pass ed statutes that make activity by a therapis t with a patient a criminal act. Moreover, sexual exploitation of a patient, under circums tances , may be cons idered rape or s ome sexual offense and may therefore be criminally T ypically, the criminality is determined by one of three factors : the practitioner's means of inducement, the the victim, or the availability of a relevant state criminal code. S ex with a current patient may be prosecuted under criminal sexual as sault statutes if the state can prove beyond a reas onable doubt (i.e., with 90 to 95 percent certainty) that the patient was coerced into engaging in the s exual act. Usually, this type of evidence is limited the us e of some form of s ubs tance to induce or to reduce res is tance. However, a variety of methods have been us ed by therapis ts to coerce patients into sexual s ubmis sion, s uch as anesthesia, E C T , drugs, alcohol, force, and threats of harm. T o date, of ps ychological coe rcion through manipulation of 4924 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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transference phenomena have not success fully met the level of proof necess ary to prosecute a criminal cas e. cases involving a minor patient, cons ent or coercion is irrelevant, because minors and incompetent persons (including adult incompetent persons) are cons idered unable to provide valid cons ent. T herefore, sex with a or an incompetent pers on is automatically considered a criminal act.

L ic ens ure and E thic al C odes S tate licensing organizations, unlike profess ional as sociations, may dis cipline offending profess ionals P.3980 more effectively and punitively by s uspending or their licens es. Licens ing boards are not as cons trained the courts , which require rigorous rules of evidence in procedures . It is generally less difficult for the patient to seek redress through this means . In the majority of which the evidence was reasonably s ufficient to subs tantiate a claim of sexual exploitation, the profes sional's license was revoked or the profess ional suspended from practice for a period of time. P atients can bring ethical charges against ps ychiatris ts before the district branches of the AP A. T here is no limit for bringing ethical charges. E thical violators may reprimanded, s us pended, or expelled from the AP A. All national organizations of mental health profes sionals proscribe sexual relations between therapis t and E thical charges can be filed only against members of a profes sional group; this option is not available to of therapis ts who do not belong to a profess ional 4925 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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organization.

R E C OVE R E D ME ME OR E IS T he controvers y concerning recovered memories of abuse has generated intense pas sions that have driven increasing number of recovered memory cas es into the courts . P atients alleging recovered memories of abuse have s ued parents and other alleged perpetrators . In a number of ins tances , the alleged victimizers have s ued therapists who, they claim, negligently induced false memories of sexual abuse. In an about-face, some have recanted and joined forces with others (usually parents ) to sue therapists . T he memory debate has polarized many therapis ts into believers and disbelievers. S ome therapis ts have judgment about the validity of recovered memories of sexual abus e. S trongly held pers onal bias es about recovered memories represent a new occupational for clinicians. S uch feelings can undermine the duty of neutrality to their patients, creating deviant treatment boundaries and the provision of subs tandard care. C ourts have handed down multimillion dollar judgments agains t mental health practitioners . F or example, a jury awarded more than $10 million to the plaintiffs in a alleging that the therapis t implanted memories of sexual abus e. A fundamental allegation in thes e cas es that the therapist abandoned a pos ition of neutrality to suggest, to persuade, to coerce, and to implant false memories of childhood sexual abuse. T he guiding principle of clinical ris k management in recovered cases is maintenance of therapist neutrality and 4926 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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es tablis hment of s ound treatment boundaries. F urther complicating the matter is the empirical about memory mechanisms , which (as is typical for any emerging s cience) reveals contradictory findings about how and what persons retain in memory and forget in various s ettings . E mpirical s tudies often fail to whether allegedly repres sed memories are not simply are not reported to res earchers. V alid risk management has a solid clinical footing and secondarily informed by awarenes s of the legal is sues. following risk management principles should be cons idered when evaluating or treating a patient who recovers memories of abuse in ps ychotherapy: 1. Maintain therapis t neutrality: Do not s ugges t abuse. 2. S tay clinically focus ed: P rovide adequate and treatment for patients pres enting problems and symptoms. 3. C arefully document the memory recovery proces s. 4. Manage personal bias and countertransference. 5. Avoid mixing treater and expert witnes s roles . 6. C los ely monitor s upervisory and collaborative relations hips . 7. C larify nontreatment roles with family members. 8. Avoid special techniques (e.g., hypnosis or sodium amobarbital [Amytal]) unless clearly indicated; cons ultation firs t. 9. S tay within profess ional competence: Do not take cases that you cannot handle. 4927 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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10. Dis tinguis h between narrative truth and his torical truth. 11. Obtain cons ultation in problematic cas es. 12. F os ter patient autonomy and s elf-determination: Do not suggest lawsuits. 13. In managed care s ettings , inform patients with recovered memories that more than brief therapy be required. 14. When making public statements , distinguis h opinions from s cientifically es tablis hed facts . 15. S top and refer, if uncomfortable with a patient who recovering memories of childhood abuse. 16. Do not be afraid to as k about abuse as part of a competent ps ychiatric evaluation.

S E C UL S ION A ND R E S TR IA NT S eclus ion and res traint raise complex ps ychiatric legal is sues. S eclusion and res traint have indications and contraindications (T ables 54.1-4 and 54.1-5). S eclusion res traint have become increasingly regulated.

Table 54.1-4 Indic ation for S ec lus ion and R es traint P revent clear, imminent harm to the patient or others 4928 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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P revent significant disruption to treatment or physical surroundings Ass is t in treatment as part of ongoing behavior therapy Decreas e s ens ory overstimulationa P atient's voluntary reas onable request

aS eclus ion

only.

Adapted from American P s ychiatric Ass ociation. P s ychiatric Us es of S e clus ion and R e s traint R eport N o. 22). W ashington, DC : American Ass ociation; 1985.

Table 54.1-5 C ontraindic ations to S ec lus ion and R es traint E xtremely uns table medical and ps ychiatric conditions a Delirious or demented patients who are unable to

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tolerate decreased stimulationa Overtly suicidal patients a P atients with severe drug reactions or overdos es who require clos e monitoring of drug dosages a F or punishment or convenience of s taff

aUnless

clos e s upervis ion and direct obs ervation provided. Adapted from American P s ychiatric Ass ociation. P s ychiatric Us es of S e clus ion and R e s traint R eport N o. 22). W ashington, DC : American Ass ociation; 1985. Legal challenges to the us e of restraints and s eclus ion have been brought on behalf of institutionalized ill and mentally retarded persons. T ypically, thes e do not stand alone but are part of a challenge to a wide range of alleged abus es. G enerally, courts hold, or cons ent decrees provide, res traints and s eclus ion be implemented only when a patient creates a ris k of harm to self or others and no res trictive alternative is available. Additional res trictions include the following: 1. R es traint and s eclusion can only be implemented 4930 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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written order from an appropriate medical official. 2. Orders are to be confined to s pecific, time-limited periods. 3. A patient's condition mus t be regularly reviewed documented. 4. Any extens ion of an original order must be and reauthorized. T he acceptability of res traint or seclusion for the of training was recognized by the S upreme C ourt in Y oungbe rg v. R omeo (1982), which challenged the treatment practices at the P ennhurs t S tate S chool and Hos pital in P ennsylvania. T he S upreme C ourt held that patients could not be restrained except to ensure their safety or, in certain undefined circums tances , to needed training. Although recognizing that the had a liberty interest in safety and freedom from bodily res traint, the S upreme P.3981 C ourt noted that thes e interes ts were not absolute nor were they in conflict with the need to provide training. S upreme C ourt als o held that decis ions made by appropriate profess ionals regarding restraining the would be presumed correct. P sychiatrists and other health profess ionals have lauded the decision, S upreme C ourt recognized that profes sionals are able than the courts to determine the needs of patients , including deciding when res traint is appropriate. Most states have enacted s tatutes that regulate the res traints , often s pecifying the circumstances in which 4931 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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res traints can be us edusually when a risk of harm to danger to others is imminent. S tatutory regulation of us e of seclusion is less common. Most states with laws regarding s eclus ion and res traint require some type of documentation of their usage. A number of courts and state statutes outline certain due process procedures must be followed before res traint or seclusion can be for nonclinically indicated, disciplinary purpos es . T hese include s ome form of notice, a hearing, and of an impartial decision maker. A new federal rule by the Health C are F inancing Administration (HC F A) requires that hos pital patients seen face to face by a phys ician or licensed practitioner (LIP ) within 1 hour from the time at which a patient is res trained. An LIP is an individual who is recognized by s tate law and hospital policy as having independent authority to order restraints and s eclus ion patients. T his requirement is part of expanded policies regulating s eclus ion and restraint applicable to all hospitals receiving Medicare and Medicaid funds . T he hour requirement differs from the corres ponding mandate, becaus e the latter allows nurses to evaluation and management tasks. T he J C AHO also permits the physician or LIP to conduct an inevaluation of the patient within 4 hours of the initiation res traint or seclusion for patients 18 years of age or F or children and adolescents younger than 17 years of the in-person evaluation must be conducted within 2 hours of the initiation of restraint and seclusion. T he 1-hour visit requirement by the HC F A is als o recommended by the AP A T ask F orce on the Uses of S eclus ion and R es traint. R egardless of 4932 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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accreditation status , Medicare- or Medicaidhospitals must meet the s tandards in the patient's C ondition of P articipation. T he HC F A is working with J C AHO to ass ure that the new Medicare requirements incorporated into J C AHO s tandards. T he J C AHO has made major revis ions to its s tandards the us e of res traint and s eclus ion, effective J anuary that s eek to reduce the us e of res traint and s eclus ion provide greater ass urance of s afety and protection of patients with psychiatric or substance abuse dis orders. revis ed s tandards res trict the uses of restraints and seclusion to emergency s ituations in which there is imminent ris k that the patient may inflict s elf-harm or harm others . R es traints are to be used only as a last T he J C AHO has agreed to work with the HC F A to the 1-hour rule in hospitals receiving Medicare and Medicaid funds .

C OMP E TE NC Y: A C ONC E P T C ompete ncy is a broad concept, encompass ing many different legal is sues and contexts. Its definition, requirements, and application can vary widely on the context, s uch as health care decision making, executing a will, standing trial, or confess ing to a crime. In general, compe te ncy refers to s ome minimal mental capacity required to perform a specific, legally act or to ass ume some legal role. W hen patients competency is in doubt, a court scrutinizes their perception of reality and memory functions , because abilities bear on the reliability of their res ponses or 4933 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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tes timony. Incompe te nt is a legal term applied to individuals who cons idered by law not to be mentally capable of performing a particular act or ass uming a particular T he adjudication of incompetence is is sue s pecific. A ps ychiatric patient who is adjudicated incompetent to execute a will may not be automatically incompetent to other things, s uch as cons enting to treatment, tes tifying a witnes s, marrying, driving, or making a legally binding contract. C linically, it is useful to distinguis h between incompe te nce and incapacity. Incompe te nce refers to a court adjudication, whereas incapacity indicates a functional inability determined by a clinician. C ompetency, in the civil and the criminal context, is commonly raised in two s ituationswhen the person is a minor (younger than 18 years of age) or is mentally disabled. Minors are not considered legally competent some situations and require the consent of a parent or designated guardian. Minors who are considered emancipated or mature or who are competent to in some cas es of medical need or emergency are an exception to this rule. Mentally disabled pers ons present more complex evaluating competency. A lack of competency cannot presumed from a person's treatment for mental illnes s from institutionalization. Mental dis ability does not neces sarily render a pers on incompetent or in all areas of functioning. F oolis h decisions by do not denote mental incompetence but are merely an inevitable cons equence of the human condition. More often, the ps ychiatris t mus t determine if any s pecific functional incapacities exist that render a person 4934 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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make a particular kind of decision or to perform a particular type of tas k.

Health C are Dec is ion Making C ompetency to consent and the right to refuse go hand in hand. Under mos t circums tances , patients have a right to refus e treatment. F orcing treatment against the wishes of a competent patient res ult in a s uit for as sault and battery, as well as malpractice. Merely because patients are psychotic not neces sarily mean that they lack sufficient health decis ion-making capacity. Involuntary hos pitalization not deprive a patient of the right to refuse treatment in most states . P sychiatric patients who have impaired mental capacity may have difficulty giving valid informed consent to propos ed diagnos tic procedures and treatments . One study of informed consent found that the schizophrenia and depres sion groups demonstrated poorer unders tanding of treatment dis clos ures , poorer in decis ion making regarding treatment, and a greater likelihood of failing to appreciate their illness es or the potential treatment benefits. T he P.3982 legal requirement that ps ychiatrists obtain competent informed cons ent for proposed treatments and procedures is not negated s imply becaus e the patient appears to need medical intervention or would likely benefit from it. P sychiatrists mus t ens ure that the or an appropriate s ubs titute decision maker has given competent cons ent before proceeding with treatment. 4935 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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F or a patient's cons ent to be informed, three es sential elements must be satisfied: competency, information, voluntarines s. T he patient mus t be given enough information to make a knowledgeable decis ion (T able 54.1-1). T he decision (cons ent) must be given by a pers on who is legally competent. G ag rules that impos ed by MC Os to keep patients from being fully informed about treatment options were obvious ly antithetical to obtaining valid informed cons ent. S ubtle differences exist between the concepts of and persuasion. P ers uas ion is defined as the aim to utilize the patient's reas oning ability to arrive at a desired res ult. On the other hand, coercion occurs the doctor aims to manipulate the patient by extraneous elements which have the effect of undermining the patient's ability to reas on. S everal exceptions exist to the requirement of informed cons ent. T he most common is the emergency which cons ent is implied when the patient is unable to give consent (e.g., unconsciousness ) and is an acute, life-threatening crisis that requires immediate medical attention. Other exceptions include (a s ubstitute decis ion maker is necess ary), therapeutic privilege (withholding full disclos ure if informing would seriously wors en patient's condition or would foreclos e rational decision making), and waiver (patient competently declines being informed). T hese should not be us ed to circumvent the requirement of obtaining informed cons ent. W hen as serting an to the obtaining of informed cons ent, the clinician's reasoning should be carefully documented. T he legal doctrine of informed cons ent is consis tent 4936 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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the provision of good clinical care. T he informeddoctrine allows patients to become partners in making treatment determinations that accord with their own needs and values. In the pas t, physicians operated the principle of do no harm. T oday, ps ychiatris ts are increasingly required to practice within the model of informed cons ent and patient autonomy. Most ps ychiatris ts find increased patient autonomy des irable fos tering development of the therapeutic alliance that is so es sential to treatment. F urthermore, patient is the goal of most psychiatric treatments.

L evels of C ompetenc y C ompete ncy is narrowly defined as cognitive capacity. firmly es tablis hed criteria exis t for determining a competence. A minimal level of decision making mus t exis t in which the patient can at least (1) unders tand particular treatment being offered; (2) make a decis ion regarding the treatment that has been offered; and (3) communicate that decis ion verbally or T his minimal s tandard of decision-making capacity only a s imple consent. T he patient does not give an informed cons ent, because riskbenefit analys is and alternative treatment choices are not provided. T here generally four standards for determining incompetency decis ion making. B as ed on levels of mental capacity required, these standards are (1) communication of (2) understanding the information provided, (3) appreciation of one's s ituation and the ris ks and options available, and (4) rational decis ion making. P sychiatrists usually prefer the rational decisionstandard of informed cons ent, but mos t courts accept 4937 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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first two standards. R ational decision making occurs a patient's consent reflects that patient's freedom of choice, pers onal needs , and values applied to the risks benefits of appropriate treatment options. Legal advice may be useful if the competency is sue cannot be by additional medical and ps ychiatric cons ultation. E xcept in an emergency, patients lacking health care decis ion-making capacity need an authorized representative or guardian appointed to make health decis ions on their behalf. T able 54.1-6 lists a number cons ent options that may be available, depending on jurisdiction.

Table 54.1-6 C ommon C ons ent Option for Patients Lac king the Mental C apac ity for Health C are Dec is ion Making P roxy consent of next of kin R ight-to-die s tatutory surrogate laws (s pous e or court-appointed guardian, when the treatment wis hes of the patient are unstated) Advance directives (living will, health care proxy, durable power of attorney) Adjudication of incompetence; appointment of 4938 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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guardian Ins titutional administrators or committees T reatment review panels S ubstituted consent of the court

Adapted from S imon R I. C linical P s ychiatry and L aw. 2nd ed. W ashington, DC : American P res s; 1992.

Guardians hip G uardians hip is a method of s ubs titute decision making for individuals who have been judicially determined to unable to act on their own behalf. His torically, the state sovereign poss ess ed the power and authority to the es tate of incompetent persons. T his traditional role is carried forward in the purpos e of guardians hip today. In a number of s tates , s eparate provis ions exist for the appointment of a guardian of pe rs on (e.g., s ubs titute health care decision maker) guardian of one's e s tate (e.g., s omeone authorized to contracts to s ell one's property). T he latter guardian is frequently called a cons e rvator, although this is not uniformly us ed throughout the United S tates. In some jurisdictions , a further distinction is made ge neral (plenary) and s pecific guardians hip. T he latter 4939 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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guardian is restricted to exercis ing decis ions about a particular area, such as major or emergency medical procedures . T he disabled pers on retains the freedom make decis ions about all other medical matters. B y contrast, general guardians have total control over the disabled individual's pers on or es tate, or both. Under the U.S . s ys tem of law, an individual is competent unles s adjudicated incompetent. In many states , the Uniform G uardians hip and P rotective P roceeding Act or the Uniform P robate C ode is us ed model for laws governing competency. T he thre s hold re quire me nt of incompe tency is defined by the Uniform G uardians hip and P rotective P roceeding Act as by reason of mental illnes s, mental deficiency, phys ical illness or disability, advanced age, chronic use of chronic intoxication, or other caus e (except minority) to the extent of lacking s ufficient understanding or to make or communicate reasonable decisions. experiencing severe ps ychiatric dis orders may meet definition. T he standard of proof required for a judicial of incompetence is clear and convincing evidence. Although the law does not as sign percentages to proof, clear and convincing evidence is in the range of 75 certainty. S tates vary in the extent of their reliance on psychiatric as sess ments in determining incompetence. personnel, including P.3983 social workers , ps ychologists , family members , friends , 4940 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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colleagues, and even the individual who is the s ubject the proceeding, may tes tify.

S ubs tituted J udgment P sychiatrists may find the time and effort required to obtain an adjudication of incompetence unduly burdens ome. It can be inimical to providing competent treatment in a timely manner. Often, families are to face the formal court proceedings neces sary to their family member incompetent, particularly when sens itive family matters may be disclos ed. A common solution is to s eek the legally authorized proxy cons ent a s pouse or relative acting as a de facto guardian when refusing patient is thought to be incompetent. P roxy cons ent by next of kin, however, is not available in state. T he P res ident's C ommiss ion for the S tudy of E thical P roblems in Medicine and B iomedical and B ehavioral R es earch (1982) recommends that the relatives of incompetent patients be chosen as proxy decis ion for three reasons: (1) T he family is generally mos t concerned about the good of the patient; (2) the family us ually the mos t knowledgeable about the patient's preferences , and values; and (3) the family des erves recognition as an important social unit to be treated, within limits , as a s ingle decision maker in matters that intimately affect its members . S ome s tates allow proxy decis ion making by statute. S ome statutes merely state that another pers on may authorize cons ent on behalf of incompetent patient; other statutes mention specific relatives . Unless proxy consent is provided by state s tatute or by 4941 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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case law, good faith consents by next of kin s hould not relied on by psychiatrists treating patients believed to incompetent. T he appropriate procedure is to s eek recognition of a family member or other s ubstitute decis ion maker. Increasingly, s tate statutes are proxy consent as an option for mentally disordered individuals lacking health care decis ion-making F or psychiatric patients who continue to lack sufficient mental capacity to make health care decis ions , an increasing number of states provide adminis trative procedures authorized by statute that permit treatment of incompetent and treatment-refusing mentally ill patients. All 50 s tates and the Dis trict of C olumbia permit individuals to create a durable power attorney, that is, one that endures even if the of the creator does not. A durable power of attorney agreement permits next of kin to consent to treatment behalf of the patient who can no longer make s uch a decis ion. T o correct deficiencies in the durable power attorney when applied to health care decisions , a of states have pass ed health care proxy laws. T he care proxy is a legal instrument s imilar to the durable power of attorney but created s pecifically for health decis ion making.

Phys ic ian-As s is ted S uic ide With increasing legal recognition of phys ician-as sisted suicide for terminally ill pers ons , ps ychiatris ts are likely be called on to become gatekeepers. T his role would radical departure from the phys ician's code of ethics prohibits participation by an ethical doctor in any intervention that hastens death. Mos t propos als for 4942 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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phys ician-as sisted s uicide require a ps ychiatric or consultation to determine the pers on's competency commit s uicide. T he presence of psychiatric dis orders as sociated with s uicide, particularly depress ion, must ruled out as the driving factor behind the reques t for phys ician-as sisted s uicide. T he ethics of this gatekeeping function are hotly dis puted. E xcept in W as hington state, prohibitions against phys ician-as sisted s uicide exist. In W as hington v. G lucks be rg (1997), the S upreme C ourt unanimous ly that the U.S . C onstitution does not guarantee right to commit s uicide with the help of a phys ician, leaving the is sue for state legislatures to decide. acknowledging that terminally ill persons can endure agony, the C ourt relied on moral and legal arguments ruling, placing greater emphasis on traditional condemnation of suicide and valuing life.

C R IMINA L P R OC E E DING S Under common law, the basic elements of a crime are the mental s tate or level of intent to commit the act (known as the me ns re a or guilty mind), (2) the act conduct ass ociated with committing the crime (known actus re us or guilty act), and (3) a concurrence in time between the guilty act and the guilty mental state. T he state mus t prove beyond a reas onable doubt that the defendant committed the criminal act with the requis ite intent to convict a pers on of a particular crime. A person's mental s tatus and reality testing can play a critical role in determining whether a defendant is required to stand trial to face criminal charges, is sentenced, is acquitted of the alleged crime, is sent to 4943 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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prison, is hospitalized, or (in some extreme cas es ) is executed. B efore any defendant can be criminally prosecuted, the court mus t es tablis h that the accused competent to stand trial; that is , the defendant mus t unders tand the charges brought against him or her and must have s ufficient rational mental capacity to as sis t couns el with the defense. T he U.S . S upreme C ourt in v. Unite d S tates (1960) established the legal standard determining pretrial competency.

C ompetenc y to S tand Trial An impairment that puts into ques tion a defendant's competence is us ually as sociated with a mental defect. However, pers ons may be found incompetent to stand trial even if they do not have a mental disease or defect. T he presence or absence of a mental illnes s is irrelevant if the defendant can meet competency requirements. Legal criteria, not medical or ps ychiatric diagnoses, govern competency. Diagnosis is relevant to the ques tion of restoring, with treatment, the defendant's competency to s tand trial. C hecklis ts and s tructured interviews are available that as sess s pecific psychological factors applicable to competency standards. T he Interdisciplinary F itness Interview can be us ed by lawyers and mental health profes sionals. It permits a detailed examination of ps ychopathology and legal knowledge, us ing explicit scales to rate each respons e in the competency E valuating C ompete ncies : F ore ns ic As s e s s me nts and Ins truments is also a s tandard reference in the field. T he presence of mental impairment does not automatically render the defendant incompetent. T he 4944 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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impairment mus t be considered in the context of the particular cas e or proceeding. F or example, mental impairment that renders an individual incompetent to stand trial in a complicated tax fraud cas e may not that individual incompetent for a mis demeanor trial. P sychiatrists mus t be able to apply their clinical the legal standards enunciated in Dus ky v. Unite d when as ses sing competency to s tand trial.

Ins anity Defens e T he insanity defens e is one of the mos t controversial in American jurisprudence. Defendants with mental impairments who are found competent to stand trial seek acquittal on the claim of insanity, alleging that were not criminally res ponsible for their actions at the the offens e was committed. T he term ins anity is a legal cons truct, not a psychiatric diagnos is. P.3984 T he MNaghten test of insanity was used in the vast majority of s tates until the 1960s. T his test originated in 1843 from the first E nglish case in which the science of psychiatry played a significant role. In a celebrated murder trial, Daniel MNaghten (F ig. 54.1-1) found to be ins ane and, thus, not guilty. MNaghten s hot and killed E dward Drummond, secretary to B ritish Minis ter R obert P eel. MNaghten experienced the that P eel and the P ope were conspiring agains t him. intended to kill P eel but shot Drummond by mis take. judicial res ponse to a parliamentary inquiry into the produced the official MNaghten tes t: 4945 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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FIGUR E 54.1-1 Daniel M'Naghten. His 1843 murder led to the establishment of rules s till observed in insanity pleas in a number of juris dictions . (C ourtesy C ulver P ictures.)

T he jurors ought to be told in all cases that every man is to be presumed to be s ane, and to poss ess a s ufficient degree of reason to be res ponsible for his crimes, until the contrary be proved to their satis faction; and that to establish a defense on ground of insanity, it must be clearly proved that, at the time of the committing of the act, the party accus ed was labouring 4946 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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under s uch a defect of reason, from disease of the mind, as not know the nature and quality of act he was doing; or, if he did know it, that he did not know he was doing what was wrong. C riminals commit crimes for a variety of reas ons . T he presumes that they do s o rationally and of their own will, thus meriting some form of punishment. However, some offenders are so mentally dis turbed that they are found to be incapable of acting rationally. C ivilized societies have deemed it a violation of fundamental principles of fairnes s and morality to punish such T o do s o would thwart two major tenets of punis hment: retribution and deterrence. No precise, generally accepted definition of le gal exis ts. T es ts of insanity have always been have undergone much modification and refinement the years . T he insanity defens e s tandard has four elements : 1. P res ence of a mental dis order 2. P res ence of a defect of reas on 3. A lack of knowledge of the nature or wrongfulness the act 4. An incapacity to refrain from the act T he presence of a mental dis order has remained the cons istent core of the ins anity defense; the other have varied in importance over time. T hus, the ins anity 4947 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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defens e s tandard varies throughout the United S tates , depending on which state or jurisdiction has control the defendant rais ing the defens e. T he most stringent insanity standard is applied to defendants tried in a federal court who are governed by the C omprehens ive C rime C ontrol Act (C C C A) of 1984. act was pas sed after public outrage over the acquittal J ohn Hinckley, J r. (F ig. 54.1-2), by reason of ins anity, his attempt to as sass inate P res ident R onald R eagan. C C C A provides an affirmative defense to all federal if, at the time of the offense, the defendant, as a result severe mental disease or defect, was unable to the nature and quality or the wrongfulnes s of his acts . Mental disease or defect does not otherwise constitute defens e. T his standard eliminates the volitional or irresistible impuls e prong of the four-part insanity stated previously. It does not permit a defens e based defendant's inability to conform his or her conduct to requirements of the law. T he defens e is limited to defendants who cannot appreciate the wrongfulnes s of their acts (i.e., the cognitive prong of the defens e). In a number of juris dictions, as well as in federal law the burden of proof has shifted from the prosecution to the defens e.

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FIGUR E 54.1-2 J ohn Hinckley, J r. In 1980, he s hot P res ident R onald R eagan and P ress S ecretary B rady. Hinckley was found not guilty by reason of insanity in 1982. T he B rady B ill, a gun control bill, became law in 1993. (C ourtes y of Wide W orld F ederal courts require the defendant to prove insanity clear and convincing evidence (approximately 75 certainty). T he burden of proof varies among the a minority of states , the pros ecution has the burden of proving beyond a reas onable doubt that the defendant was sane. In a majority of states , the defendant mus t the burden of proving by a preponderance of the that he or s he was insane. A few s tates have abolis hed special plea of insanity. At the s ame time, evidence of insanity is admis sible to negate me ns rea. 4949 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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Des pite the res trictions placed on insanity defens e standards following the Hinckley verdict, a number of states follow s ome vers ion P.3985 of the American Law Institute (ALI) tes t of insanity. T he tes t has two parts: A pers on is not respons ible for conduct if, at the time of such conduct, as a res ult of mental disease or defect, he or s he lacks substantial capacity to appreciate the criminality (wrongfulnes s) of or her conduct or to conform his or her conduct to the requirements of law. T he terms me ntal dis e as e and do not include an abnormality manifes ted only by repeated criminal or otherwise antisocial conduct. T he ALI test contains a cognitive and a volitional prong. J ohn Hinckley, J r. and J effrey Dahmer (F ig. 54.1-3) tried under the ALI tes t. F or example, Dahmer had struggled hard agains t his aberrant s exual impuls es in 7 years that elaps ed between his firs t and second However, the fact that Dahmer could plan his murders could s ys tematically dis pos e of the bodies convinced jury that he was able to control his behavior. All of the tes timony bols tered the notion that, like mos t s erial Dahmer knew what he was doing and knew right from wrong. F inally, the jury did not accept the defens e that Dahmer experienced a mental illness to the degree had disabled his thinking or behavioral controls .

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FIGUR E 54.1-3 J effrey Dahmer. His murder trial for deaths of 17 young men and boys gained notoriety after accus ations of cannibalis tic practices were made. Dahmer was killed in prison by an 1994. (C ourtes y of W ide W orld P hotos .) In making an ins anity determination, the thres hold not the exis tence of a mental dis eas e or defect per s e the lack of s ubs tantial capacity caus ed by it. T he lack mental capacity owing to causes other than mental may s uffice. F or example, under certain circums tances , mental retardation may provide an adequate bas is for insanity defens e.

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T he law recognizes s hades of mental impairment that affect me ns rea, but not neces sarily to the extent of completely nullifying it. T he concept of diminis hed was developed for thes e s ituations. Diminished capacity allows the defendant to introduce medical and ps ychological evidence that relates the me ns re a for the crime charged, without having to as sert a defense of insanity. F or example, in the crime as sault with the intent to kill, ps ychiatric testimony may permitted to addres s whether the offender acted with purpos e of committing homicide at the time of the When a defendant's me ns rea for the crime charged is nullifed by clinical evidence, the defendant is acquitted only of that charge. T he defendant may be convicted of another offense requiring less er me ns rea s uch as mans laughter. T he diminished capacity defens e does lead to total exculpation of criminal respons ibility nor to automatic commitment to a mental institution.

E xc ulpatory and Mitigating Automatis ms , intoxication, seizure disorders , and metabolic conditions have met with limited s uccess as exculpating or mitigating defenses to criminal charges .

A utomatis ms T he automatis m (or unconscious) defense recognizes some criminal acts may be committed involuntarily. Automatis m, defined as having performed in a s tate of mental unconsciousness or dis sociation without full awarenes s, is applied to actions or conduct occurring without will, purpose, or reas oned intention. F or conviction for a crime, a criminal state of mind 4952 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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re a) must be accompanied by the commiss ion of a prohibited act (actus reus ). T he phys ical act mus t be cons cious and volitional. S tatutory and common law in most jurisdictions s pecifically excludes from the actus a reflex or convuls ion, a bodily movement occurring during uncons cious nes s or sleep, acts during hypnos is res ulting from hypnotic sugges tion, and a bodily movement that is not cons cious and voluntary. T he clas sic, although rare, example of an automatism person who commits an offense while sleepwalking. C ourts have held that s uch individuals do not have cons cious control of their physical actions and act involuntarily. T his defens e exis ts for persons committing a crime during a s tate of uncons cious nes s caus ed by a concuss ion after a head injury, involuntary inges tion of drugs or alcohol, hypoxia, hypoglycemia, epileptic s eizures . T here are limitations to the automatism defens e. T he automatis m defens e is unavailable if the pers on was of the condition before the offens e and failed to take reasonable precautions to prevent the crime. If, for example, a defendant with a known his tory of poorly controlled epileptic s eizures loses control of a car seizure and kills another person, that defendant cannot as sert the defens e of automatis m. G enerally, intoxication is not a defense to a criminal charge, because it usually res ults from a person's own actions. However, most states cons ider voluntary alcoholism relevant in determining whether the poss ess ed the me ns rea necess ary to commit a intent crime or whether there was premeditation in a crime of murder. T he fact that the defendant was 4953 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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voluntarily intoxicated does not jus tify a finding of automatis m or insanity. A distinct difference exists when, because of chronic, heavy alcohol use, the defendant is experiencing an alcohol-induced organic mental disorder. If clinical evidence is presented that an alcohol-related disorder, s uch as alcohol hallucinosis , withdrawal amnes tic disorder, or dementia ass ociated with alcoholism, caus ed s ignificant cognitive or volitional impairment, a defens e of ins anity or diminis hed may be upheld. C riminal defendants may ass ert that ass aultive was involuntarily precipitated by a s eizure dis order. condition is often diagnosed as temporal lobe epilepsy. Aggress ive behavior is alleged to primarily res ult from uncontrollable, randomly occurring, P.3986 abnormal brain dysrhythmia. T he legal argument that individuals should not be held accountable for their actions occasionally may prevail in courts, although significant empirical data s upport these claims. Mental s tate defenses based on metabolic disorders succeed. However, the notorious T winkie de fe ns e was of a s ucces sful s trategy to defend Dan W hite (F ig. charged with two counts of murder in the s hooting of F rancisco Mayor G eorge Moscone and S upervisor Milk. T he jury returned a verdict of voluntary mans laughter. White's defense was bas ed on the that the inges tion of large amounts of sugar contributed to a s tate of temporary ins anity. P ublic outrage over the 4954 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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verdict in the Dan W hite case led to the repeal of the diminis hed capacity defense by the C alifornia 1981.

FIGUR E 54.1-4 Dan W hite. T he former S an supervis or killed S an F rancisco Mayor G eorge and S upervisor Harvey Milk at C ity Hall in 1978. T winkie defens e helped reduce his crime from to manslaughter, for which he s erved 5 years , W hite committed s uicide after he was released from (C ourtesy of W ide World P hotos .)

Guilty but Mentally Ill A number of states have es tablis hed an alternative of guilty but mentally ill. Under guilty but mentally ill statutes, this alternative verdict is available to the jury if the defendant pleads not guilty by reason of ins anity. 4955 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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Under an ins anity plea, four outcomes are pos sible: not guilty, not guilty by reason of ins anity, guilty but ill, and guilty. T he problem with guilty but mentally ill is that it is an alternative verdict without a difference. It is bas ically same as finding the defendant jus t plain guilty. T he must still impose a s entence on the convicted pers on. Although the convicted person s upposedly receives ps ychiatric treatment if necess ary, this treatment is available to all prisoners. Moreover, the frequent unavailability of appropriate ps ychiatric treatment for prisoners adds an additional element of spurious nes s the guilty-but-mentally-ill verdict. G uilty but mentally ill es sentially no different than finding a defendant guilty suffering from lumbago. Moreover, res earch shows that persons found guilty but mentally ill have fewer and longer sentences .

C IVIL L ITIG A TION T he American Academy of P s ychiatry and the Law fore ns ic ps ychiatry as follows : F orens ic ps ychiatry is a subs pecialty in which scientific and clinical expertis e is applied to legal is sues in legal contexts embracing civil, criminal, correctional or legis lative matters. F orensic ps ychiatry is an officially recognized subs pecialty by American B oard of P s ychiatry and Neurology. Many forensic cons ultations are performed by general ps ychiatris ts who are not boarded in forens ic F orens ic consultation usually involves ass ess ment of litigants in civil and criminal litigation. P sychiatrists provide cons ultation and testimony in a 4956 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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number of areas of civil litigation, including malpractice, personal injury, discrimination, child custody, will workers compensation, disability claims , toxic torts, wide variety of other cases in which psychiatry and law inters ect. P sychiatrists frequently are asked by lawyers evaluate individuals with alleged posttraumatic s tres s disorder (P T S D). S pecific guidelines are available for forens ic ass es sment of P T S D in litigation. P sychiatrists who enter the legal arena must be aware the fundamentally different roles of a treating and the forensic ps ychiatric expert. T reatment and roles do not mix. F or example, unlike the orthopedis t poss ess es objective, concrete information, such as the ray of a broken limb to demons trate physical injuries in court, the treating ps ychiatris t relies on the subjective reporting of the patient. In the clinical context, ps ychiatris ts work with the patient's perception of the problems (narrative truth), not neces sarily objective (historical truth). T o maintain confidentiality, us ually avoid speaking to third parties to corroborate statements. T he law, however, is concerned with that can be reasonably established by facts . Uncorroborated, s ubjective patient reporting is likely to attacked in court as speculative, self-serving, and unreliable. T he treating ps ychiatris t is , and s hould be, a total ally the patient. P s ychiatris ts cannot effectively treat that they dis like. T his positive bias in favor of the a proper treatment s tance that fosters a working therapeutic alliance. In the clinical situation, the P sychiatrist's attention is directed toward the diagnosis and treatment of mental disorders . T his is an 4957 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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focus for the treating psychiatrist. In court, credibility is a critical as set. Oppos ing couns el pursues every opportunity to portray the treating ps ychiatris t as a s ubjective mouthpiece for the plaintiffwhich may or may not be true. Als o, court tes timony by the treating ps ychiatris t may dis close information that is not legally privileged but is perceived as private and confidential by the patient. S uch a disclos ure by the therapis t is likely to seriously harm therapeutic relations hip. In addition, ps ychiatris ts inform patients about the cons equences of releas ing treatment information, particularly in legal matters . S ection IV , Annotation 2 of the P rinciple s of Me dical with Annotations E s pe cially Applicable to P s ychiatry T he continuing duty of the psychiatrist to protect the patient includes fully appris ing him/her of the connotations of waiving the privilege of privacy. T his become an is sue when the patient is being investigated a government agency, is applying for a pos ition, or is involved in legal action. When the treating ps ychiatris t testifies concerning the patient's need for future treatment, an inherent conflict interes t emerges. P s ychiatris ts s tand to benefit economically from treatment recommendations P.3987 made in court about their patients . Although this may be the intention of the ps ychiatrist at all, opposing is sure to point out that the psychiatrist has a financial interes t in the case. Although oppos ing couns el may depict forens ic experts 4958 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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hired guns , they are free of conflicting treatment roles. doctorpatient relations hip is created during forens ic evaluation with its accompanying treatment bias es the patient. T he expert usually can review a wide records and can interview numerous people who know litigant. F urthermore, the forensic expert cons iders the poss ibility of exaggeration or malingering becaus e of litigation context and the absence of treatment bias. forens ic psychiatrist is not burdened by the appearance an economic conflict of interest, as is the treating ps ychiatris t who comes to court. T reating ps ychiatris ts should remain solely in a role with their patients . If testimony on behalf of a is required, the ps ychiatris t s hould testify as a fact rather than as an expert witness . As a fact witnes s, the ps ychiatris t is questioned about the number and length visits, diagnos is , and treatment. No opinion evidence concerning caus ation of the injury or extent of us ually given. In s ome juris dictions, the court may to convert a fact witnes s into an expert witnes s when treating ps ychiatris t takes the stand. P sychiatrists must remain ever mindful of the many double-agent roles can develop when mixing ps ychiatry and litigation.

C HIL D C US TODY P sychiatrists become involved in child cus tody cases throughout the s eparation and divorce process . P sychiatrists may be asked to give opinions in the following s ituations: 

C us tody decis ions (request by parents before litigation) 4959

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





C hild cus tody litigation T o ass is t a guardian ad litem (attorney appointed court to represent a child) C hild care agency (us ually court ordered after allegations of abus e)



Divorce mediation procedures



V is itation



P sychiatric treatment of parent or child

T he guiding principle in child custody decisions is the recognition of children's rights through application of standard of thebe s t inte re s ts of the child. P s ychiatris ts do child custody decis ions s hould have s pecialized training in child ps ychiatry. T he general ps ychiatris t performs child custody evaluations mus t recognize any limitations in training and experience. C onsultation with child ps ychiatris t may be necess ary. T he AP A provides guidelines for child custody evaluations . When performing child custody evaluations, the ps ychiatris t s hould s ee all parties to the litigation. T he ethical guidelines of the American Academy of and the Law (S ection IV ) state the following: In cus tody cas es, honesty and striving for objectivity require all parties be interviewed, if poss ible, before an opinion is rendered. W hen this is not poss ible, or if for any reason not done, this fact s hould be clearly 4960 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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indicated in the forensic P sychiatrist's report and tes timony. W here one parent not been s een, even after deliberate effort, it may be inappropriate to comment on parent's fitness as a parent. Any comments on that parent's should be qualified and the data for the opinion be clearly indicated. C hild cus tody disputes often res ult in hardball litigation. one parent accus es the other of child s exual abuse, warfare breaks out. Many adequately trained avoid child custody evaluations because of their fears being excoriated by aggress ive attorneys . F orens ically informed ps ychiatris ts are usually able to function more effectively in s tres sful litigation. C hild cus tody evaluation presents special challenges rewards. P s ychiatris ts mus t be willing to commit the neces sary to do extens ive interviewing, as well as to manage the emotional strain of child cus tody cases. E valuators must be careful to identify and to correct personal bias es , as well as not to allow thems elves to influenced by importuning attorneys . made by the psychiatrist are likely to have a profound influence on the child's life. T he psychiatrist mus t as siduously maintain a position of advocate for the best interests . Optimally, the P sychiatrist's evaluation should contribute to healthy child development and a sound foundation for adult life. 4961 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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After a divorce is final, one parent us ually is granted custody of any minor children. T he cus todial parent the health care decis ion-making power. P s ychiatris ts be as ked to perform an examination or evaluation of a minor child at the reques t of a noncustodial parent. P sychiatrists who perform s uch examinations expose thems elves to legal action. Although no court has ps ychiatris t liable for failure to obtain the custodial parent's consent before examination or evaluation, decis ions appear likely. C ourt decisions (G ary v. G ary, and s tatutory interpretations (T exas F am C ode Ann (C )(I)[V ernon 1990]) of the term pare nt have limited the of that word to the parent awarded cus tody under a divorce decree's term. B efore performing an evaluation examination of a minor child, the psychiatrist s hould obtain the consent of the parent with legal custody. T he ethical and legal is sues surrounding the treatment management of ps ychiatric patients are challenging complex. T he legally informed psychiatrist is in a strong position to provide good clinical care to the patient the burgeoning regulation of ps ychiatry by the courts through governmental legislation. Moreover, will be increas ingly required to tes tify in court ps ychiatric patients. F amiliarity and comfort with the of a fact or expert witnes s will facilitate competent ps ychiatric tes timony.

S UG G E S TE D C R OS S C ompetence is linked to delirium and dementia, in C hapter 10; to schizophrenia, dis cus sed in C hapter delus ional dis orders , discus sed in S ection 12.15c; to impulse-control disorders , discuss ed in C hapter 21; 4962 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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Alzheimer's disease, dis cuss ed in S ection 51.3e. disorders are dis cus sed in C hapter 16, and malingering discuss ed in S ection 26.1. C riminality is discus sed in S ection 26.2. E mergency ps ychiatry, including suicide, discuss ed in C hapter 29. B iological therapies are in C hapter 31. Mental retardation is dis cuss ed in 34. C hild abus e is discus sed in S ection 49.3. Medicalis sues and ethical iss ues in geriatric care are S ections 51.6b and 51.6c, respectively. Hospital and community psychiatry is discus sed in C hapter 52. ps ychiatry is dis cus sed in S ection 54.2.

R E F E R E NC E S American P s ychiatric Ass ociation. C hild C us tody C ons ultation. W ashington, DC : American P sychiatric Ass ociation; 1982. American P s ychiatric Ass ociation. T as k F orce 22. 1985. American P s ychiatric Ass ociation. T ardive T as k F orce R eport of the Ame rican P s ychiatric Was hington, DC : American P sychiatric As sociation; 1992. P.3988 American P s ychiatric Ass ociation. T he P ractice of E le ctroconvuls ive T he rapy: R e commendations for T re atme nt, T raining and P rivile ging. A T ask F orce 2nd ed. Was hington, DC : American P s ychiatric 4963 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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Ass ociation; 2000. American P s ychiatric Ass ociation. E thics P rime r. Was hington, DC : American P sychiatric As sociation; 2001. *American P s ychiatric Ass ociation. T he P rinciple s of Me dical E thics with Annotations E s pe cially P s ychiatry. W ashington, DC : American P sychiatric Ass ociation; 2001. Appelbaum P S . Almos t a R e volution: Mental He alth and the L imits of C hange. New Y ork: Oxford P res s; 1994. B eahrs J O, G utheil T G : Informed consent in ps ychotherapy. Am J P s ychiatry. 2001;158:4. B illick S B , C iric S J . R ole of the ps ychiatric evaluator child custody dis putes . In: R osner R , ed. P rinciple s P ractice of F ore ns ic P s ychiatry, 2nd ed. New Y ork: C hapman & Hall; 2003. *Department of Health and Human S ervices : R ights C ondition of P articipation. F e deral R e gis te r (1999). G ris so T . E valuating C ompete ncies : F ore ns ic and Ins truments . New Y ork: P lenum P ublis hing; G ris so T , Appelbaum P S : C omparison of s tandards as sess ing patients capacities to make treatment 4964 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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decis ions. Am J P s ychiatry. 1995;152:1033. G ris so T , Appelbaum P S : T he MacArthur T reatment C ompetence S tudy. III: Abilities of patients to ps ychiatric and medical treatments . L aw Hum 1995;19:149. G utheil T G . T he P s ychiatris t as E xpe rt W itne s s . Was hington, DC : American P sychiatric P ress ; 1998. G utheil T G . T he P s ychiatris t in C ourt: A S urvival Was hington, DC : American P sychiatric P ress ; 1998. G utheil T G , Appelbaum P S . C linical Handbook of P s ychiatry and the L aw. 3rd ed. B altimore: Williams & W ilkins ; 2000. G utheil T G , S imon R I: B etween the chair and the B oundary is sues in the therapeutic trans ition zone. R ev P s ychiatry. 1995;2:336. G utheil T G , S imon R I: R isk management principles recovered memories cas es : T he importance of the clinical foundation. P s ychiatr S erv J . 1997;48:1403. *G utheil T G , S imon R I. Mas te ring F ore ns ic P ractice : Advanced S trate gie s for the E xpe rt W itne s s . DC : American P s ychiatric P res s; 2002. Health C are F inancing Administration (HC F A), 42 482.13 (1999).

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J acobs DG , ed. T he Harvard Medical S chool G uide S uicide As s e s s ment and Inte rve ntion. S an J oss ey-B as s; 1999. J oint C ommis sion on Accreditation of Healthcare Organizations. C omprehe ns ive Accreditation B ehavioral He alth C are . R es traint and S e clus ion for B e havioral He alth. C hicago, IL: J oint Accreditation of Healthcare Organizations , 2001. Malcolm J G . Informed consent in the practice of ps ychiatry. In: S imon R I, ed. Ame rican P s ychiatric R eview of C linical P s ychiatry and the L aw. V ol 3. Was hington, DC : American P sychiatric P res s; 1992. Melton G B , P etrilla J , P oythres s NG , S lobogin C . P s ychological E valuations for the C ourt. 2nd ed. Y ork: G uilford; 1997. Mishkin B : Determining the capacity for making care decisions . Adv P s ychos om Med. 1989;19:151. R os ner R , ed. P rinciple s and P ractice of F ore ns ic P s ychiatry. 2nd ed. New Y ork: C hapman & Hall; S chetky DH, B enedek E P , eds . P rinciple s and C hild and Adole s ce nt F orens ic P s ychiatry. DC : American P sychiatric P ublis hing; 2002. S chreiber J , R oes ch R , G olding S : An evaluation of procedures for ass es sing competency to stand trial. 4966 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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Am Acad P s ychiatry L aw. 1987;155:187. S ederer LI, E llis on J , K eyes C : G uidelines for ps ychiatris ts in cons ultative, collaborative, and supervis ory relations hips. P s ychiatr S erv. S imon R I: T he credible forens ic ps ychiatric sexual haras sment litigation. P s ychiatr Ann. S imon R I. T he suicidal patient: Accepting patient and therapist anxiety. In: Lifs on LE , S imon R I, eds. Me ntal H ealth C linician and the L aw: A Handbook. C ambridge, MA: Harvard Univers ity 1997. S imon R I: P sychiatrists duties in discharging sicker potentially violent inpatients in the managed care P s ychiatr S erv J . 1998;49:62. S imon R I. B ad Me n Do W hat G ood Me n Dre am: A P s ychiatris t Illuminate s the Darker S ide of H uman B ehavior. W ashington, DC : American P sychiatric 1999. S imon R I: C hronic pos ttraumatic stress dis order: A review and checklis t of factors influencing prognosis. Harv R ev P s ychiatry. 1999;6:304. *S imon R I: T he suicide prevention contract: C linical, legal and ris k management iss ues. J Am Acad L aw. 1999;27:445.

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S imon R I: T aking the sue out of suicide: A forensic P sychiatrist's perspective. P s ychiatr Ann. S imon R I. C oncis e G uide to P s ychiatry and L aw for C linicians . 3rd ed. Was hington, DC : American P ublis hing, Inc; 2001. S imon R I, ed. P os ttraumatic S tres s Dis orde r in 2nd ed. Was hington, DC : American P sychiatric P ublis hing, Inc; 2003. S imon R I. As s es s ing and Managing S uicide R is k: G uide lines for C linically B as e d R is k Manage me nt. Was hington, DC : American P s ychiatric P ublishing; S imon R I, G old LH. T he Ame rican P s ychiatric T e xtbook of F orens ic P s ychiatry. W ashington, DC : American P s ychiatric P ublishing; 2004. *S imon R I, S human DW , eds . R etros pe ctive Me ntal S tate s in L itigation: P re dicting the P as t. Was hington, DC : American P sychiatric P ublis hing, 2002. S imon R I, Wettstein R M: T oward the development guidelines for the conduct of forens ic psychiatric examinations. J Am Acad P s ychiatr L aw. S lovenko R . P s ychiatry and C riminal C ulpability. Y ork: W iley; 1995. S lovenko R . P s ychothe rapy and C onfide ntiality. 4968 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/54.1.htm

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S pringfield, IL: C harles C . T homas ; 1998. S tras burger LH, G utheil T G , B rods ky A: On wearing hats: R ole conflict in s erving as both psychotherapist and expert witness . Am J P s ychiatry. 1997;154:448.

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E ditors : S adock, B e njamin J .; S adock, V irginia A T itle: K aplan & S adock's C ompre he ns ive T e xtbook of P s ychiatry, 8th E di C opyright ©2005 LippincottW illiams & W ilkins > T able of C ontents > V olume II > 55 - P s ychiatry: P as t and F uture > 55.1 His tory of P s ychia

55.1 His tory of Ps yc hiatry R alph C olp J r. M.D. P art of "55 - P sychiatry: P as t and F uture"

B E G INNING S OF P S YC HIA TR Y In the firs t civilizations in E gypt and the Near E ast, illness was attributed to the magical forces of deities, and the main therapists were priests who used religious and magical rites to counter thos e forces . those evil deities called demons after the advent of C hris tianityprevailed in many primitive s ocieties ; in the history of civilized s ocieties, credence in demons fluctuated in complex ways .

G R E E K A ND R OMA N In the civilizations of ancient G reece and R ome, was a province of religious cults for healing illness es schools of philos ophy and medicine (often part of philosophy), which viewed mental illness as mainly ps ychological, mainly somatic, or a mixture of both and s oma; thus, the three enduring psychiatric were established.

Greek Ps yc hiatry Hippoc rates T he writings of the phys ician Hippocrates (460 to 370 now thought to be the work of unknown 4970 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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authors propounded the view that the human body contains four es sential humors phlegm, yellow bile, bile, and bloodthat are s ecreted by different organs, poss ess different qualities, and vary with the s eas ons . brain was cons idered the s eat of life, and its normal functioning required a balance between the humors. excess es of phlegm caus ed a form of dementia, yellow caus ed manic rage, and black bile caus ed melancholia. S mall exces ses of these three humors and blood als o produced phlegmatic, choleric, and s anguine personalities . It was the first attempt to explain in temperaments and pers onalities .

DIS E AS E S AND TR E ATME NTS T he Hippocratic authors were the first to rationally describe and clas sify s uch diseases as epileps y, paranoia, organic toxic delirium, postpartum ps ychosis , phobias, and hys teria, which they named and believed be confined to women and caused by a wandering T hey ass ociated melancholia with an aversion to food, despondency, s leeples snes s, irritability, and and they believed that personal hygiene, bathing, and dieting were es sential to keep the humors in balance; cases of ins anity, they tried to eliminate excess humors purgatives , cathartics, and (if necess ary) bleeding. T he Hippocratic O ath came to repres ent the ideals of profes sional conduct. T wo of its mos t enduring were that a physician s hould hold in confidence what she learns from treating patients, and that a phys ician should not us e his or her pos ition to have sexual with the bodies of women or of men, whether they be men or s laves . 4971 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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P lato and A ris totle T he philos opher P lato (427 to 347 B C ) divided the soul three parts: rational, appetitive (lusts and greed), and spirited-affective. Madness occurred when the soul los t the influence of the rational soul or when a disturbance of the soul produced inspired or behavior. F or treating dis ease, P lato advocated a dialectic between a patient and a philosopher or a phys ician, a question and ans wer dialog that enabled patient to alleviate an illness by developing a state of philosophical knowledge. P lato's pupil Aris totle (384 to 322 B C ) believed that illness occurred when the soul was s ubjected to temperature, black bile, and the emotions. He was the to des cribe accurately the affections of des ire, anger, courage, envy, joy, hatred, and pity.

P hrenitis T he term phre nitis was us ed in ancient G reece to refer an inflammation that produced disturbances in both the mind and body, and whos e location was never anatomically or conceptually well defined. In the 19th century, it was replaced by de lirium, confus ion, and clouding. T he clinical behavior it des cribes continues to important to modern ps ychiatry.

P s yc hologic al Treatments In addition to Hippocratic somatic and medical the G reeks developed three ps ychological treatments: methods of inducing sleep, interpreting dreams (often performed by pries ts in temples , most notably those of 4972 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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Aes culapius , the god of healing), and us ing words to persuade, console, and gain knowledge of an illnes s when us ing P lato's dialectics ).

R oman Ps yc hiatry S toic is m and E pic ureanis m T he R omans generally followed the psychiatric of the G reeks and were influenced by G reek S toic and E picurean beliefs that pas sions and unsatis fied des ires on the soul to produce mental illness es, and that arguments and reas oning thes e illness es could be controlled to produce a mental s tate of ataraxia, or lack perturbation. (S ome modern tranquilizers have been clas sified as ataractics .)

G alen T he greates t R oman physician was G alen (130 to 200 who cons olidated and augmented G reek medical and ps ychological thinking. He conceptualized that the humors exis t in normal and abnormal forms , and that qualities hot, cold, dry, and moistare ess ential in human temperaments. T o the previous P.4014 concept of pne uma (a vital s pirit) he added the natural spirits and animal s pirits . He divided the soul three parts: reas on and intellect, courage and anger, carnal appetites and des ires . He believed that diseas es caus ed by adverse external influences (e.g., bad diet bad air) acting on an exis ting predis pos ition (an abnormality of a humor or pneuma), and that ps ychological disorders cause physical disorders and 4973 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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versa. T reatment s hould oppose what is unnatural in a disease (cooling the feverish, warming the chilled) and should be in accord with the patient's age, and way of life. G alen's writings , especially his treatise O n influenced medical thinking for nearly 15 centuries . his death, the creativity of ancient medical writing went into a profound and protracted decline.

Treatment of the Ins ane Neither G reece nor R ome took social responsibility for treating the insane. T he exceptions were a few pers ons who were admitted to Aesculapian s anctuaries and soldiers who were admitted to military hos pitals . Most the seriously insane were kept under restraint at home their families. T he R omans had laws for appointing guardians to protect the holdings of the ins ane and for declaring them legally incompetent. Insanity was evaluated by judges , not by phys icians . T he insane feared and hated (except those thought to be divinely inspired), beaten, impris oned, and driven away.

MIDDL E A G E S T he 1,000 years after the fall of the Wes tern R oman 400 to 1400 AD, saw an Arab-Is lamic empire extending from the Near E ast to S pain, an eastern C hristian empire, and C hristian wes tern E uropean feudal

C hris tian Wes tern E urope C aus es of Illnes s T he main supernatural causes of illnes s were thought 4974 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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evil as trological influences (astrology was the main scientific guide for physicians ) and demons entering body and pos ses sing the s oul. T he writings of and G alen that had s urvived in Arabic trans lations and were translated into Latin influenced some physicians . S ome observed that mental illness could be caused by somatic or psychological conditions.

Illnes s and Treatment S ome often-observed psychiatric reactions were (1) symptoms of poss es sion by the devil, who was to choke and throw its victims about; (2) dance mania, characterized by an irres is tible urge to dance and noises; and (3) acedia, a form of depres sion occurring anchorites when they experienced dis tres sful doubts about being able to live a religious ly meaningful life. T reatment was by phys icians or pers ons claiming to poss ess s pecial powers . It included exorcis m of magical techniques ; medicinal treatments by Hippocrates and G alen; time-honored folk remedies ; es oteric medicines , such as bark of a tree from and confess ion to a priest, in as sociation with R oman C atholic C hurch activities of penance and absolution. the medieval centuries wore on, in the words of S tanley J ackson (1920 to 2000), many a pries t became trained phys ician, and the intermingling of confess ion for the soul with the phys ician's remedies for the s ick body became quite common.

Hos pitals and A s ylums B ecaus e Is lam held that society is respons ible for the kindly care of the ins ane, the Arabs built hos pitals with 4975 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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ps ychiatric divis ions in B aghdad (750) and C airo (873); also built s pecial ins ane as ylums in Damascus (800), Aleppo (1270), and the Muslim-ruled S panish city of G renada (1365). C hris tian attitudes toward the ins ane fluctuated rejection and toleration. B ecaus e the insane harbored demons, they were incarcerated in madmen's towers periodically expelled from towns . An ins ane person also be condoned as a fool who lacked a mind G od's favor and needed to be cared for. T hus, in the century, s everal hos pitals in western E urope cared for mentally ill, in addition to those with physical illnes s. His torians have usually recorded that the first C hristian wes tern E uropean as ylum caring exclusively for the was in V alencia, S pain in 1409, and that it was other S panis h asylums that were built under the of Islam. Michael S tone stated that the first as ylum in E urope was built in Hamburg in 1375. Although some Hamburg's insane were confined in a tower, little is about their treatments or how they differed from those other medieval cities.

B edlam It was probably around 1400 that B ethlem Hospital in London began, for unknown reas ons , to admit the perhaps because they were verbally and phys ically they appear to have displaced the other sick. B y the century, B ethlem had ass umed its role as a madhouse. Over the following centuries , although it became known popular culture as B edlam (defined as a place of became a special and unique ins titution, pioneering in as ylum management and care of the ins ane. T he 4976 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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B ethle m (1997), by J onathan Andrews, Asa B riggs, P orter, and P enny T ucker, is a 750-page epic narrative often has vivid pas sages and will become an ess ential reference for all who are interested in the history of ps ychiatry and the asylum.

R E NA IS S A NC E Witc hes In 1486, fear of witchcraftinjury inflicted by someone supernatural devices was stimulated by the publication Malle us maleficarum (W itches Hamme r) by Henry and J ames S prenger, two theologians who had been designated by the P ope to act as papal inquis itors into witchcraft. Malleus described witches as mainly women who s howed ps ychotic or hysterical s ymptoms and delus ions, but it also s uggested that any affliction in a or woman could be a sign of witchcraft. It pres cribed inquisitorial tortures that would force confes sions of from those who were accused. T he ideas of Malleus with the ideas of other theologians (C atholic and P rotestant) of a cons piracy against C hristendom, as with popular beliefs in demonology. T he result was a witch-hunting craze that led to the execution of many thous ands of people (mos tly women) on charges of witches ; the craze abated after approximately 150

Phys ic ians and B ooks P arac els us B orn in S witzerland of G erman parents , P aracelsus 1493 to 1541) was the mos t famous phys ician of his His medical ideas were influenced by medieval 4977 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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as trology, magic, and myths and were often confused, contradictory, and controvers ial. R ejecting the humoral theory of dis eas es, he pos tulated that humans had a divine spirit and bas e animal ins tincts (lus t, covetous nes s, and the pas sions of the s oul) and that ps ychiatric illnes s was the triumph of instincts over caus ed by the s tars stimulating the ins tincts. C ons equently, the physician must study the instinct dominant in a patient and the star that corres ponds to T reatments included ps ychotherapy, venesection, trephination (perforation of the s kull), and the adminis tration of sulfurused because its sedative were thought to promote the healing P.4015 actions of S ympathy (one of the main forces in the cosmos ). B ecaus e he believed that emotions caused phys ical illness , P aracelsus has been called one of the ps ychos omaticis ts.

B ooks F ive 16th and early 17th century authors publis hed views in different areas of psychiatry. J uan Luis V ives to 1540) was born in S pain and lived mainly in Holland B elgium, where his work as a scholar was influenced humanis m of the North E uropean R enais sance. (His S panis h J ewis h parents had converted to C hris tianity then been condemned by the Inquisition.) In his O f and L ife (1538), he anticipated modern dynamic ps ychology and described for the firs t time the of psychological ass ociations in forming emotions and recollecting and forgetting pas t events. T he S panish 4978 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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phys ician J uan Huarte de S an J uan (ca. 1530 to 1592), T he E xamination of Me n's W its (1575), made an early attempt to evaluate characteristics and differences in human intelligences. T he Italian writer G iambattis ta (1535 to 1615) made a pioneer attempt in T he Human P hys iognomy (1586) to compare human morphological and ps ychological traits.

Weyer In 1563, the G erman-Dutch phys ician J ohann Weyer to 1588) published De P rae s tigiis Dae monum (T he Dece ption of Demons ), which was bas ed on 12 years observing witches . In it, W eyer emphasized the between magicians , who willingly took instruction from the devil, and witches , who were not respons ible for deeds and were often mentally unstable and ill from medical causes, and needed the help of phys icians . criticized the Malle us and s tated that s ome women only confess ed to being witches becaus e of torture. G eorge Mora observed, in his introduction to the E nglis h translation of De P rae s tigiis , that W eyer's role as a of modern ps ychiatry is difficult to as sess ; that for his work was ignored by those interes ted in psychiatric illness ; and that only recently, with the advent of ps ychodynamic theories and psychotherapies, was seen as a precurs or of these approaches .

P later T he S wis s phys ician F elix P later (1536 to 1614) two large books, P ractice of Me dicine (1602) and O bs e rvations of Dis e as e s Injurious to B ody and Mind that clas sified and des cribed all known diseases and 4979 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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advanced the proces s of s eparating ps ychological knowledge from philos ophy and theology. He als o was pioneer in recognizing degrees of mental handicap that s ome mentally handicapped pers ons may have exceptional ability in one area and that s ome are disturbed and some are not) and in making autopsies and s tudying the neuropathology of handicapped individuals .

Advent of S yphilis During the years 1530 to 1546, G irolamo F racastoro to 1553), an Italian phys ician and humanis t, published accounts of a new epidemic illnes s with loaths ome and disfiguring s ymptoms and significant mortality. He it s yphilis and correctly stated that it was caus ed by contact between two pers ons . T he concept of sexual contagion was new, and s yphilis caus ed a unique and unprecedented mass fear about the danger of s exual activitya fear that was later s us tained when chronic was recognized as a major caus e of dementia. T hat was equaled only by recent fears of acquired immunodeficiency syndrome.

S E VE NTE E NTH C E NTUR Y S eventeenth-century thought on mental illness was influenced by the work of two eminent E nglish T homas W illis (1621 to 1675) and T homas S ydenham to 1689); an Italian papal physician, P aolo Zacchia 1659); and an Oxford dean of divinity, R obert B urton to 1640). Willis, who performed autopsies on s ome of his recognized the difference between mental symptoms of 4980 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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gross brain disease and dis eases in which the brain seemed normal, which he attributed to dis turbed spirits. S ydenham gave a comprehensive account of many symptoms of hysteria, obs erved that it occurred both men and women, and as cribed it to abnormal spirits. His clas sification of the causes of disease into remote or external (inordinate actions of the body mind), immediate (a dis order of animal s pirits ), and antecedent (a faulty dis pos ition of the animal spirits) res embled the modern ps ychiatric endeavor of cons tructing atheoretical clas sifications of mental S ydenham's class ification may also have been the first attempt to incorporate contemporary phys iological and ps ychological knowledge into a s ys tematic analys is of insanity. Zacchia, in Q ues tiones me dico-le gale s (1621 to 1635), insis ted that the physician, rather than the lawyer, evaluate the mental state of a person. T hat view was beginning of forensic ps ychiatry. B urton, in T he Me lancholy (1621), provided authoritative summaries writings on melancholy from ancient times through the R enais sance. T he Anatomy was widely read and some forms of melancholy to become fas hionable in E ngland.

Inc arc eration of the Ins ane In 1656, an edict of the F rench monarchy created a hospital adminis trative organization for P aris that cons isted of as ylums for the ins ane and other each with directors who were empowered to detain persons for indefinite periods and who, over the next century, locked up groups of insane persons along with 4981 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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indigents , orphans, prostitutes, homos exuals , aged persons, and the chronically ill. S imilar incarcerations occurred in G ermany. However, few ins ane persons were confined in other E uropean countries . In E ngland, after 1660, mos t persons were kept at home or left to roam; only a few sent to private madhous es or new public as ylums in towns.

E IG HTE E NTH C E NTUR Y With the influence of the 18th century E nlightenment, belief in the power of rational thinking replaced belief in Hippocratic, G alenic, and demonic ideas and led to theories of mental illness .

Hypoc hondrias is Different accounts and explanations of overconcern about body functionswere publis hed in books : B ernard de Mandeville (1670 to 1733), A the Hypochondriak and Hys te ric P as s ions (1711); B lackmore (1654 to 1729), A T re atis e of the S ple en V apours : or, Hypochondriacal and H ys te rical Affe ctions (1725); G eorge C heyne (1671 to 1743), T he E nglis h or, a T re atis e of Nervous Dis e as e s of all K inds , as V apours , L owne s s of S pirits , Hypochondriacal, and Dis tempers , e tc. (1733); and R obert W hytt (1714 to O bs e rvations on the Nature , C aus e s and C ure of Dis e as es W hich are C ommonly C alle d Ne rvous , Hypochondriac or Hys te ric (1764).

S auvages and Nos ology T he F rench physician B oiss ier de S auvages (1706 to 4982 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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in his Nos ologia me thodica (1763), divided all known diseases into natural clas ses, orders , genera, s pecies , varieties (similar to the way naturalis ts had divided and animals ). T here were ten class es of dis eas es, with eight P.4016 containing s pecies of psychiatric illness es . T he was artificial, but it s timulated physicians to rethink concepts of dis eas e.

C ullen and Neuros is T wo years after S auvages 's nosology, the E nglis h William C ullen (1710 to 1790) published his own He used for the first time the term ne uros is and its adjective form, ne urotic, to describe a variform group of mental diseases (including apoplexy, paralys is, hypochondriasis, epileps y, and hysteria), which he were caused when parts of the brain were in unequal s tates of excitement and collaps e. Later, the meaning of the term ne uros is would undergo s everal changes.

Gall and Phrenology F ranz J os eph G all (1758 to 1828) was a G erman who taught that the brain contained s eparate organs occupied specific areas and shaped the personality, that those organs were revealed in the configurations the head and could be mapped on its surface. T his doctrine, with modifications by G all's pupil J ohann S purzheim (1776 to 1832) and the E nglis h lawyer C ombe (1788 to 1858), became the s cience of 4983 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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B ecaus e it offered views on human nature, phrenology became popular during the early 19th century in F rance, and the United S tates .

Treatment of the Ins ane F or mos t of the 18th century, the insane inmates in mental as ylums were regarded as having incurable diseases and s ubjected to physical res traints , beatings , cons tant fear (in s ome private as ylums, treatment was more lenient). T oward the end of the century, that treatment was changed by reforms that abolished mos t res traints and created an asylum regimen in which the mental patient was res pected as a person. T hese were carried out by the Italian phys ician V incenzo (1759 to 1820) in the hospitals of S anta Maria Nuova B onifazio in F lorence, Italy, in 1789; by the E nglis h and Quaker, W illiam T uke (1732 to 1822), who in 1796 founded the Y ork R etreat outside the E nglish city of and by J ean B aptiste P uss in (1746 to 1809? ), as sistant the F rench physician P hillippe P inel (1745 to 1826), 1797 removed the fetters from the inmates in the P aris hospital of B ictre.

P inel's E mpiric is m and Moral In his influential 1801 book A T re atis e on Ins anity, empirical observations of patients in the B ictre, P inel a new clas sification of mental illnes sesmania, idiocy, and dementiaand stated that they were caused mainly by heredity and influences from the He also des cribed how, through an as ylum regimen of education, reasoning, and persuasion, many s ymptoms insanity could be alleviated. He called this regimen the 4984 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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moral treatment of insanity.

E A R L Y NINE TE E NTH C E NTUR Y During the first half of the 19th century, the view that mental retardation was a defect of intellectual function, different from insanity or dementia, became well es tablis hed; ps ychiatry became a s pecialty apart from medicine; and leading psychiatrists in F rance, E ngland, United S tates , and G ermany were usually guided by principles of moral therapy in their work with patients.

Franc e E s quirol J ean E tienne Dominique E squirol (1782 to 1840) was most influential psychiatrist of his time. He further developed the theory and practice of moral therapy, seeing the as ylum as the mos t powerful weapon mental illness , and was one of the authors of an 1838 that provided an as ylum in every department of F rance and included detailed provisions for patient care, a truly comprehensive law that remained in force in the late century. His influential book Me ntal Maladie s : a Ins anity (1838), guided by P inel's empirical approach, differentiated between hallucination (a term he coined) and illus ion; he divided ins anities into monomania, a partial insanity that included paranoia and obsess ivecompuls ive disease (an early clinical recognition of obs e s s ive -compuls ive dis order [OC D]), and a general delirium-like mania. He inaugurated what was probably the first course in psychiatry and trained physicians to as ylum directors. Among his pupils, J ean-P ierre F alret (1794 to 1870) and J ules B aillarger (1809 to 1890) 4985 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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independently described and named circular ins anity, J acques -J oseph Moreau de T ours (1804 to 1884) the ps ychotic effects of taking the drug has his h. He the firs t psychiatris t to delineate the symptoms of a induced psychosis.

E ngland In 1813, S amuel T uke (1784 to 1857), grands on of T uke, made the Y ork R etreat into one of the most renowned moral treatment as ylums in the world by publishing a widely read book, Des cription of the 1839, the phys ician J ohn C onolly (1794 to 1866) movement to abolis h mechanical res traints and, later, chemical restraints , s uch as bromide and chloral for overactive as ylum patients . Nonrestraint was at the firs t (1841) meeting of the As sociation of Medical Officers of Hos pitals for the Insane, today the R oyal of P sychiatrists , which in 1853 founded the As ylum today the B ritis h J ournal of P s ychiatry.

United S tates R us h B enjamin R ush (1745 to 1813) was the mos t famous American phys ician of his time and became known as father of American psychiatry; his book Me dical and O bs e rvations upon the Dis e as e s of the Mind the firs t comprehens ive book on mental illness by an American. However, R us h's belief in somatic causation (what he believed to be the morbid actions of cerebral blood ves sels ) and his nonacceptance of moral caus ed his influence to wane after his death, when prominent s uperintendents of American asylums were 4986 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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practicing moral treatment.

A meric an P s yc hiatric A s s oc iation In 1844, 13 as ylum s uperintendents founded the Ass ociation of Medical S uperintendents of American Ins titutions for the Insane (today called the Ame rican P s ychiatric As s ociation [AP A]) and its official Ame rican J ournal of Ins anity (today called the J ournal of P s ychiatry). Imbued with a belief in moral treatment, thos e 13 founders (in the view of C onstance McG overn) took on the responsibility for the mentally convinced thems elves they could manage and cure the insane, and s et out to persuade everyone els e. T heir was , at firs t, enhanced by lay reformersmost notably Dorothea Dix (1802 to 1887)who influenced legislators create or expand more than 30 institutions for the

Germany After J ohann R eil (1759 to 1813), in R haps odie s about Application of P s ychothe rapy to Me ntal Dis turbance s and J ohann C hristian Heinroth (1773 to 1843), in Dis turbance s of the Mind (1818) had emphas ized the ps ychological factors in mental illness , W ilhelm (1817 to 1868) took an P.4017 oppos ing somatic view in Me ntal P athology and T he rape utics (1845) and argued that mental diseases brain dis eas es, even though it was not yet pos sible to correlate s pecific brain damage with a s pecific disease. G ries inger later became a profes sor of and neurology in B erlin, directing university clinics and 4987 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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laboratories in s tudies of the anatomy and the of the brain. T his work, and the dis covery in 1861 of a speech center in the brain by the F rench phys ician B roca (1824 to 1880), led to the s chool of brain represented by T heodore Meynert (1833 to 1892) in V ienna and C arl Wernicke (1848 to 1905) in B reslau, attempted to localize psychiatric phenomena in real or imagined brain s tructures .

L A TE NINE TE E NTH A ND E A R L Y TWE NTIE TH C E NTUR IE S Theory of Degeneration A theory of mental illnes s, propounded by two F rench ps ychiatris ts, B enedict-Augustin Morel (1809 to 1873) V alentin Magnan (1835 to 1916), held that a variety of mental illness es, ranging from insanity to obsess ions compuls ions, could be congenitally inherited from who were afflicted by s imilar dis eas es , and that the predis pos ition could s lowly become activated into a disease by repeated trans miss ion from parent to child could suddenly be activated by the effects of such events as s ocial traumas , alcoholism, s yphilis, and infections. T he concept of degeneration was , for a time, accepted prominent ps ychiatris ts . T he G erman ps ychiatris t von K rafft-E bing (1840 to 1902), in P s ychopathia presented various cases of s exual perversions (he firs t coined the terms s adis m, mas ochis m, and s e xual and homosexuality, s tating that they were often caused degeneration. His book won res pect from lawyers and scientis ts , and founded the science of s exology. T he 4988 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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ps ychiatris t C es are Lombros o (1836 to 1909), in T he Delinque nt Man (1876) and T he F e male O ffender postulated that criminals repres ent a degenerate biological phenomenon that can be identified on the of physiognomy. Although those pos tulations were incorrect, Lombros o's books ins pired a school of anthropology in Italy, out of which developed the of criminality.

C las s ific ation of Func tional K raepelin When E mil K raepelin (1856 to 1926) was a profes sor ps ychiatry at the universities of Dorpat (then a part of R us sia) and Heidelberg and Munich in G ermany, he studied the objective s ymptoms and clinical life of thous ands of ps ychotic patients . In 1899, in the sixth edition of his textbook of ps ychiatry, K raepelin the major psychoses into two groups : Manicps ychos is (formerly called circular ins anity), in which patients usually recovered, and de me ntia prae cox, deteriorated to dementia and cons is ted of three subgroups he bephrenia and catatonia, described by Hecker (1843 to 1909) and K arl K ahlbaum (1828 to 1871 and 1874, and de me ntia paranoia, described by K raepelin and s eparated from paranoia and T he clas sification excluded causes and psychological influences and was based on morbid outcome, K raepelin later conceded that some patients with dementia praecox recovered. It gave clinical meaning many disconnected facts and created new dis eas e

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T he S wis s psychiatris t E ugen B leuler (1857 to 1939), Deme ntia P rae cox or the G roup of S chizophre nias showed that becaus e dementia praecox does not become dementia, it could more accurately be called s chizophre nia. He als o introduced the terms autis m ambivale nce and described the s chizoid personality.

S hoc k Treatments In the 1920s and 1930s, convulsions produced by given by the Hungarian ps ychiatris t Ladis las Meduna to 1964), and insulin, us ed by the V iennese physician Manfred S akel (1900 to 1957), res ulted in remis sions in symptoms of s chizophrenic patients . In April of 1938, Italian ps ychiatris ts , Ugo C erletti (1877 to 1963) and B ini (1908 to 1964), produced convulsions by means of electroshock. E le ctroconvuls ive the rapy (E C T ) largely replaced metrazol and insulin in the treatment of schizophrenia in the 1940s and early 1950s and was to be mos t effective in treating mood disorders . T oday, although its us e has declined becaus e of the use of antips ychotic and antidepress ant medications , modified forms of E C T are s till us ed to treat mood disorders .

Des c riptions of Ps yc hos es Wernic ke-K ors akoff S yndrome In 1881 and 1890, the G erman physician K arl (1848 to 1905) and the R us sian phys ician S ergei (1853 to 1900) described a syndrome caus ed by alcoholism that is characterized by multiple neuritis , of memory, ps eudoreminiscences , and disorientation. K ors akoff is usually cons idered the first notable 4990 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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in R uss ia.

A lzheimer's Dis eas e In 1906, the G erman neuropathologist Alois Alzheimer (1864 to 1915) reported a cas e of progress ive and dementia in a 51-year-old woman with degeneration and plaques in the brain. T he disorder named after him and repres ented a form of presenile dementia.

G eneral P ares is In 1826, the F rench physician Antoine B ayle (1799 to stated that general pares is, then probably the mos t common organic ps ychotic disease, was a s eparate entity. T hat as sertion was then ignored or dis puted. in 1912, after advances in bacteriology, immunology, pathology, were the s yphilitic origin and pathogenes is general paresis demonstrated.

Medic al Treatment of Ps yc hos es F ever In 1917, the Aus trian ps ychiatris t J ulius von W agnerJ auregg (1857 to 1940) caus ed remiss ions in general paresis with malaria-induced fever. F or that he became 1927) the first psychiatrist to receive the Nobel P rize. In 1940s , malaria therapy for general paresis was by penicillin.

P ellagra and Vitamin Defic ienc y P ellagra, a major caus e of dementia in the s outhern S tates, was cured between 1912 and 1937 by the of foods containing pellagra-preventive factor, now 4991 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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as niacin or nicotinic acid.

C las s ific ation of Neuros es In the late 19th century, ne uros is had come to mean a ps ychiatric illnes s that was caused by changes in brain function in which no organic lesion could be found and (unlike a psychos is) was not inherited. T he two major neuros es were neuras thenia and hysteria.

Neuras thenia T he term ne uras the nia was firs t used by the American neurologis t G eorge Miller B eard (1840 to 1883) in describe a syndrome of phys ical and mental that had previous ly been called hypochondrias is . T he syndrome was prevalent P.4018 and fas hionable among American and E uropean clas s persons until approximately 1920 and was res t cures (often consis ting of is olation from the parents ), exercis e, mas sage, and electrical s timulation various parts of the body.

Hys teria C oncepts of hysteria were influenced by the of hypnosis. An unrecognized form of hypnos is was practiced in the 18th century by the Aus trian phys ician F ranz Anton Mes mer (1734 to 1815), who succes sfully treated hys teria and many other illness es by putting patients in a trance and invoking the healing powers of invis ible and impalpable fluid that he called animal magnetis m. In 1843, the E nglish surgeon J ames B raid 4992 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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(1795 to 1860) s howed that Mes mer's influence could self-induced by fixating on an inanimate object and was caus ed not by animal magnetism, but by a s ubjective impres sion made on the nervous center. B raid called it neurohypnotis m, which was subsequently s hortened to hypnos is . During the 1880s, J ean-Martin C harcot 1893), firs t profess or of diseases of the nervous the Univers ity of P aris (who made P aris an center for neurological s tudies ), began using hypnos is study the symptoms of the female patients in the T hrough hypnos is , he was able to produce many of symptoms, and he erroneously claimed that hypnosis a pathological s tate that occurred only in hys terics . claim was disputed by two leading F rench hypnotis ts, Ambrois e Augus t Libeault (1823 to 1904) and B ernheim (1840 to 1919), who correctly claimed that persons could be hypnotized and that hypnos is could us ed as a ps ychotherapeutic procedure in neurotic illness es.

Freud and the C reation of Ps yc hoanalys is T he disputes about neurotic patients and hypnosis stimulated the young V iennes e phys ician S igmund (1856 to 1939), who had s tudied with C harcot and observed the work of Libeault and B ernheim, to s tudy these patients. In the 1890s, he began diagnosing suffering from separate clinical illness es , which he anxieties , phobias , and obses sions , terms that would subs equently influence the diagnosis and clas sification neuros es. At first, F reud, along with his phys ician friend J oseph 4993 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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B reuer (1841 to 1925), treated thes e patients with hypnosis . T hen, by himself, he originated a new that cons isted of free thought as sociation and interpretation of dreams , which in 1896 he firs t called ps ychoanalys is. Using this method, he was able to that neurotic patients suffer from memories of past traumatic events that they repres sed into the parts of their mind, and that when those memories brought into cons cious nes s by ps ychoanalys is and reexperienced with the support of the ps ychoanalys t, neurotic s ymptoms were alleviated. T he method that the illness es of these patients (i.e., their hysterical symptoms, anxieties , phobias, and obsess ions ) were caus ed by unconscious memories of past illicit sexual encounters . T he concept of the unconscious had been known to philosophers since the 17th century; no one had thought that it could be us ed to investigate and treat ps ychiatric illness es. In 1900, T he Inte rpre tation of Dre ams was published. It F reud's mos t insightful work, and it revolutionized ps ychiatric thought and practice, as well as other areas thought. In it, F reud s howed how proces ses of condensation, distortion, disguis e, and s econdary elaboration transform uncons cious latent dream into cons cious manifest content. His analys is of his dreams , which was part of his s elf-analysis, was one of most revealing psychological intros pections ever recorded. F reud's T hre e E s s ays on the T heory of (1905), with its explanations of the s tages of sexual development and the ps ychological origins of what then called the s exual pervers ions , altered s cientific moral views of sexuality. 4994 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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F reud was approximately 50 years old when he formed main ps ychoanalytic ideas. F or the remaining 30 years his life, he developed thos e ideas and trained a number of adherents to become ps ychoanalys ts. P sychoanalytic societies were formed in E urope and United S tates ; members were required to complete a didactical pers onal analysis and adhere to F reud's tenets . F reud's work became well known in the United S tates after the C lark Univers ity conference in 1909 55.1-1).

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FIGUR E 55.1-1 A: P s ychological C onference, C lark Univers ity, W orces ter, MA, S eptember 1909. B : 1, B oas; 2, E . B . T itchener; 3, William J ames*; 4, W illiam 5, Leo B urgerstein; 6, G . S tanley Hall*; 7, S igmund C arl G . J ung*; 9, Adolf Meyer*; 10, H. S . J ennings ; 11, S eashore; 12, J oseph J as trow; 13, J . McK . C attell; 14, B uchner; 15, E . K atzenellenbogen; 16, E rnes t J ones*; A. B rill*; 18, W . H. B urnham; 19, A. F . C hamberlain; 20, S chinz; 21, J . A. Magni; 22, B . T . B aldwin; 23, Lymna 24, G . M. F orbes; 25, E . A. K irkpatrick; 26, S andor 27, E . C . S anford; 28, J . P . P orter; 29, S akyo K ando; K akis e; 31, G . E . Daws on; 32, S . P . Hayes ; 33, E . B . S . B erry; 35, G . M. W hipple; 36, F rank Drew; 37, J . W. Y oung; 38, L. N. W ils on; 39, K . J . K arls on; 40, H. H. 41, H. L. K lopp; 42, S . C . F uller. (*S ubsequently their interest in ps ychoanalys is .) (C ourtesy of American P sychiatric As sociation.)

Other C onc epts of P s yc hoanalys is of the Unc ons c ious S everal of F reud's followers Alfred Adler (1870 to C arl G us tav J ung (1875 to 1961), Otto R ank (1884 to K aren Horney (1885 to 1952), and S andor R ado (1890 1972)had theoretical differences with him that often centered on the importance that he had as signed to the effects of early s exual experiences on the adult T hese differences led them to create their own ps ychoanalys is and psychotherapy. T wo psychiatrists made obs ervations of the unconscious that were independent of ps ychoanalysis: the American, Morton 4996 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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P rince (1854 to 1929), gave an account of a multiple personality; the F renchman, P ierre J anet (1859 to originated the concept of ps ychas the nia, a weaknes s in nervous s ys tem that resulted in the diss ociation of cons ciousnes s, obsess ions, phobias, and anxieties . He postulated that traumatic experiences caused hysteria, with dis sociation of feelings and memories related to experiences .

Projec tive Ps yc hologic al Tes ts C oncepts of the uncons cious were used in projective ps ychological tests , in which persons projected unconscious feelings and conflicts into their various vis ual stimuli. T wo tests us ed frequently in diagnostic evaluations of psychiatric patients were the 1921 inkblot tes t of the S wiss ps ychiatris t Hermann R ors chach (1884 to 1922) and the 1935 T hematic Apperception T est (T AT ) of the American phys ician ps ychologist Henry Murray (1893 to 1988).

Americ an Ps yc hiatry Treatment of the Ins ane AS YL UMS In the late 19th and early 20th centuries, mental changed from practicing the therapeutic ideas of moral therapy into institutions for custodial care, in which patients lived crowded together in uns anitary suffered from diseas es, hopeles snes s, and abus e; and little therapeutic contact with thos e who cared for them. One reas on for these changes was an increas e in who were chronically ill, cons is ting in part of poor 4997 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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immigrants who were unable to work, elderly persons were trans ferred from alms houses to mental hos pitals , an influx of patients with neurosyphilis . F urthermore, ps ychiatris ts and thos e who worked in as ylums had developed negative views about their work and the incurability of thos e with chronic ps ychoses .

PS YC HIATR IC HOS PITAL S AND HYG IE NE In respons e to the need for hos pital treatment of with acute ps ychos es , ps ychiatric hos pitals were In New Y ork C ity, B ellevue Hos pital (1879) and the P athological Institute of the New Y ork state hospital system (1895), later called New Y ork S tate P sychiatric Ins titute, were founded. B os ton P sychopathic Hos pital (later called the Mas sachusetts Mental Health C enter) founded (1912) as a department of B os ton S tate the firs t ps ychiatric hospital connected with an asylum the firs t to open an outpatient department to s tudy the ps ychiatric illnes ses of children. S imilar hospitals were founded in Albany, New Y ork, and in Illinois, and Michigan. T he s taffs of those hos pitals later such new psychiatric profes sionals as psychiatric workers, clinical ps ychologis ts , and occupational therapists . P.4019 In 1908, C lifford B eers 's book A Mind T hat F ound Its elf published. It was a widely read memoir of the bad treatment he had received as a mental patient in three as ylums . In 1909, B eers founded the National for Mental Hygiene, which aimed at controlling and 4998 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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preventing mental disorders and began what was the mental hygiene movement by the rising S wis s-born American psychiatrist Adolf Meyer.

Meyer When Adolf Meyer (1866 to 1950) was approximately years of age, he stated in an article in the Ame rican of Ins anity his fundamental ps ychiatric belief that purely somatic nor a psychological approach would by its elf, but that all mental activity must have its phys iological side and its anatomical subs tratum combinations of [nerve] cells . A disease of thes e cells means at the same time a phys iological and a disorder: destruction of thes e cells , a destruction of phys iological and ps ychological function. F rom 1912 to 1940, Meyer was the director of the P hipps P s ychiatric C linic and profess or of psychiatry at J ohns Hopkins S chool of Medicine in B altimore. As the dominant figure in American psychiatry, he developed previous belief into the concept of ps ychobiology, regarded a psychiatric patient as a biological entity who experienced unique reactions to biological and s ocial influences. W hen those reactions were delineated by a phys ician's taking the patient's life they revealed (in the words of Leston Havens ) a broadening perception of the s ignificant reality for unders tanding pathological human nature and the gradual admis sion of factors hitherto unrelated to illness into an understanding of it. In treating patients , Meyer s tres sed common-sens e couns eling, s ocial service, psychotherapy administered community clinics by psychiatrists and s ocial workers, 4999 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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child-guidance clinics , and aftercare for dis charged and hospital patients . His work has become so much a of contemporary American psychiatry that his influence often is overlooked.

National Mental Health A c t and the National Ins titute for Mental Health During W orld W ar II, the need for ps ychiatry was when S elective S ervice boards rejected more than one million men because of mental disorders . B rief ps ychotherapy was able to return many s ervicemen had experienced psychological problems back to active duty. At the end of the war, many ps ychiatris ts P.4020 were imbued with therapeutic optimism, and there was popular belief that environmental stress contributed to mental maladjustment and purposeful human interventions could alter ps ychological outcomes. T hat attitude led C ongres s in 1946 to pass the National Mental Health Act, which for the first time in American history provided generous financial s upport for education and res earch. It also founded the National Ins titute of Mental Health, with the goals of conducting res earch into mental illness (es pecially schizophrenia) training large numbers of mental health personnel to provide ps ychiatric care. T hes e events positioned the United S tates in the forefront of advances in ps ychiatry.

L obotomies During the late 1940s and early 1950s, under the of two neurologists E gas Moniz (1874 to 1955) and 5000 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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F reeman (1895 to 1972)many intractable psychotic and obses sive-compuls ive patients were treated by lobotomies, the des truction of the white matter of the frontal lobes of the brain. S ome patients improved, but others experienced s evere and irreversible personality deterioration. W ith the advent of the ps ychotropic the us e of lobotomies declined markedly. In 1949, along with the S wis s neurophys iologist W alter Hes s, awarded the Nobel P rize in P hys iology and Medicine.

MID-TWE NTIE TH C E NTUR Y TO B E G INNING OF TWE NTY-FIR S T C E NTUR Y S ince 1950, the development of psychiatry, es pecially the United S tates , has taken many forms, four of which have been unprecedented growth in res earch, and the diagnosis and clas sification of mental deins titutionalization and community care of patients ; economic cons traints in giving long-term to patients ; and a proliferation of serious s tudies on as pects of the history of ps ychiatry.

Double-B lind Tes ts In double-blind tes ts, a drug or a procedure and a are compared in such a way that neither the patient nor the therapist involved in the treatment knows which preparation is being adminis tered. T he tests were used medicine in 1937 by the American phys ician Harry and in ps ychiatry in 1954 by Mogens S chou (1918) to evaluate lithium, and by J ohn Hampson, David and J erome F rank to evaluate the effectiveness of mephenes in in relieving ps ychiatric symptoms. S ince 5001 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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the tes ts have been used in ps ychiatry to evaluate the effectivenes s of various drugs and procedures .

Ps yc hotropic Drugs C hlorpromazine In 1952, two F rench psychiatrists , J ean Delay (1907 to 1987) and P ierre Deniker (1917 to 1999), reported that new drug, chlorpromazine (T horazine), s ignificantly tranquilized hos pitalized patients with chronic schizophrenia without causing undue depres sion. C hlorpromazine was called a neuroleptic becaus e it reduced, rather than paralyzed, nervous activity; it also came to be called a typical antipsychotic, because it produced extrapyramidal s ide effects at clinically doses . T hese effects included parkinsonis m (muscle rigidity and los s of as sociated movements ), acute reactions , res tless nes s, and tardive dyskines ia. In the United S tates, double-blind tes ts conducted by National Institute for Mental Health showed that the chlorpromazine and other newly developed shortened the hos pitalizations of s ome acutely patients and helped s ome chronically ps ychotic either live outside an asylum for the first time or better tolerate living in an as ylum.

B enzodiazepines In 1960 to 1963, the American pharmaceutical Hoffman-La R oche marketed two benzodiazepine compounds, chlordiazepoxide (Librium) and diazepam (V alium), which largely replaced meprobamate Miltown) as anxiolytic drugs in cases of nonps ychotic 5002 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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anxiety. Hoffman-La R oche and other companies then developed other anxiolytic benzodiazepines , including clonazepam (K lonopin) in 1975, lorazepam (Ativan) in 1977, and alprazolam (Xanax) in 1981. T hey became among the most widely prescribed drugs in America.

Tric yc lic Drugs and Monoamine Inhibitors After the 1957 reports of the S wis s psychiatrist R oland K uhn (1912) and the American psychiatrist Nathanial (1916 to 1983) and his ass ociates, two class es of were found effective in the treatment of depress ions: imipramine (T ofranil)-type drugs (the tricyclic antidepres sants) and the monamine oxidas e inhibitors (MAOIs ). T he MAOIs caus ed epis odes of severe hypertens ive crisis. B ritis h psychiatris t B arry B lackwell (1934) s howed that the episodes were related to eating certain foods , es pecially cheese containing tyramine, the MAOIs could be used if thos e foods were omitted. In the late 1950s and early 1960s , American and ps ychiatris ts found that tricyclic drugs and MAOIs certain s evere s tates of anxiety.

S elec tive S erotonin R euptake S ele ctive s e rotonin re uptake inhibitors (S S R Is ) have developed for the treatment of depress ion by different American pharmaceutical companies s ince 1988 and include fluoxetine (P rozac), paroxetine (P axil), and sertraline (Zoloft). T hey have s hown fewer adverse than the tricyclics and MAOIs , and they have largely supers eded the us e of the older antidepres sants and been therapeutically success ful in various recurrent 5003 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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disorders , including chronic depress ive and dysthymic disorders . T hey als o have been us ed for OC Ds. T he diagnostic advances of the last three editions of the Diagnos tic and S tatis tical Manual of Me ntal Dis orde rs have made the clinical indications for their us e more precis e, so that many cas es of depres siononce the province of psychiatrists can now be adequately by primary care phys icians.

L ithium In 1949, the Aus tralian psychiatrist J ohn C ade (1912 to 1980) wrote an article for the Me dical J ournal of showing that lithium quieted a group of hospitalized patients with mania and that their mania recurred when lithium was withdrawn. In 1954, the Danish ps ychiatris t Mogens S chou (1918) validated C ade's work in a blind study. However, many psychiatrists questioned lithium's therapeutic effectiveness and emphasized its toxicity, and not until 1970 did the U.S . F ood and Drug Administration (F DA) approve the us e of lithium in America. S ince the 1980s, the drugs carbamazepine (T egretol), valproate (Depakene), neurontin lamictal (Lamotrigine), and topamax (T opiramate) have been used to treat patients with mania who did not res pond well to or were intolerant of lithium.

P s yc hos timulants In 1937, the American pediatrician C harles B radley 1979) reported in the Ame rican J ournal of P s ychiatry treatment with B enzedrine (amphetamine) had the behavior of a group of children who had been hospitalized because of (what was then diagnosed as ) 5004 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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behavior dis orders. P.4021 F or decades afterward, there were occasional reports stimulants being us ed to treat dis turbed behavior in children and adults. In the 1980s and 1990s , with the development of the diagnosis of attentiondeficit/hyperactivity dis orders (ADHD) in children and adults , s uch stimulants as amphetamine and methylphenidate (R italin) began being regularly used to succes sfully treat some patients with these disorders .

S erotonin-Dopamine A ntagonis ts C lozapine (C lozaril) was developed in the 1970s , but because of the risk of agranulocytosis, the F DA did not permit its us e in the United S tates for years . In 1988, American psychiatrist J ohn K ane (1945) s howed that it an efficacious antips ychotic medication, and in 1989 F DA permitted its American marketing, along with the safeguards of weekly white blood cell counts and drug dispens ations. R isperidone (R isperdal) was in 1984, and in the 10 years before the F DA permitted marketing, it was tested in large populations and be effective and safe in the treatment of psychos es. 1994, clozapine and ris peridone have been success ful treating persons with schizophrenia who were to other medications and in ameliorating positive and negative symptoms of schizophrenia (including hallucinations , blunting of affect, and avolition). Olanzapine (Zyprexa) was approved for us e by the 1996. Like clozapine and risperidone, it was effective agains t positive and negative s ymptoms of 5005 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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It has been found to be more effective than haloperidol the treatment of schizoaffective disorder and in the treatment of general ps ychotic symptoms . It appears clozapine and olanzapine have similar antipsychotic efficacy, that ris peridone may be s omewhat les s and that clozapine was most effective in treating symptoms. C lozapine, risperidone, and olanzapine been called atypical antips ychotics because they have fewer tendencies to cause extrapyramidal s ide effects clinically effective dos es . Other atypical or secondgeneration antipsychotic drugs have since been developed (s ee S ection 31.25).

C hemic al Theories of Mental Illnes s T he clinical advances in ps ychopharmacology res earch in neurochemis try and the development of concepts about the chemical causes of ps ychiatric diseases . B ecause success ful psychopharmacological decreased the brain chemical dopamine in patients schizophrenia and increas ed the brain chemicals norepinephrine and serotonin in patients with neuros cientists theorized that some cas es of were caused by increased dopamine concentration and that two subtypes of depres sive illnes s exis t: one by norepinephrine deficiency and the other by deficiency. Although these theories are unproved and perplexing, they have continued to guide in their s earch for new drugs . T he concept that mental health is influenced by the fluctuations of body chemicals resembled in s ome the 2,500-year-old Hippocratic concept that mental and phys ical health depend on the equilibrium of the four 5006 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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body humors.

Deins titutionalization In the United S tates, some of the influences for the deins titutionalization of mental patients were public criticis ms of the s nake-pit environments of state as ylums ; the 1949 to 1956 open-door policy of several E nglis h hospitals (meaning both unlocked doors and a higher dis charge rate of hos pital inmates ); a reduction as ylum patients , which began in 1956 (for decades previous ly, the asylum population had been increas ing) and was only partly caus ed by the us e of the new antips ychotic drugs ; and a 1958 presidential addres s to AP A by Harry S olomon, as serting that the s tate were bankrupt and s hould be liquidated. In 1961, the J oint C ommis sion on Mental Illness and Mental Health (an interdisciplinary organization representing 36 medical and paramedical including the American psychiatric, psychological, and medical as sociations) iss ued a report, Action for Mental Health, recommending that the large state asylums be converted to s mall regional centers for intensive patient evaluation and treatment, and that community mental health clinics , general hos pitals , and mental hospitals es tablis hed. In October 1963, P resident J ohn F . signed the C ommunity Mental Health C enters Act, directed that thes e recommendations be carried out.

C ommunity C are S ince the mid-1970s , as the number of patients treated as ylums declined (there was an 82 percent reduction in long-term as ylum inmates in the period 1950 to 1989), 5007 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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other institutions for treatment appeared. Acutely ill patients are now mainly treated in the psychiatric units general hospitals and s ometimes in nonhospital private homes or specially formed hous eholds . Most chronically ill patients, especially aged adults , are in nurs ing homes and also in board-and-care homes, halfway houses (s o called because, in the course of a patient's therapy, they were located between the and full community living), s upervised or apartments , and other facilities (including partial programs, psychosocial clubhous es , s upported employment, vocational rehabilitation, and s upported education). Although many as pects of community care are problematic, fragmented, and in need of integration, although, for unknown reasons, the homeles s (which contains many mentally ill individuals ) has been growing, thes e s hortcomings (in the words of G erald should not be permitted to conceal the more important fact that a large proportion of s everely and persistently mentally ill persons have [because of the programs and institutions of community care] made a more or less succes sful transition to community life.

National Allianc e for the Mentally Ill Although community care often increas ed contacts between mentally ill persons and their families , little attention had been given to the needs of s uch families . In S eptember 1979, the National Alliance for Mentally Ill was founded, and it has since become (in opinion of David A. R ochefort) perhaps the mos t potent cons umer lobbying force ever to manifest itself in the 5008 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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mental health arena. It is a pass ionate advocate for res earch into the biological causes of ins anity and for better care and support for the insane and their T he National Alliance for the Mentally Ill als o functions mutual-help organization.

Nos ology In 1974, a task force (later called a work group) of the chaired by R obert S pitzer, prepared the third edition of DS M (DS M-III); a revis ion, DS M-III-R , with J anet text editor, was publis hed in 1987. T hose two editions differed radically from the two previous editions in that they approached psychiatric disorders in two ways. the objective clinical manifes tations of a dis order were carefully delineated, with emphasis on s ymptoms and deemphas is on causes . B ecause this approach that of K raepelin, it was called the neo-K raepelin S econd, disorders were given new class ifications and names , which often conveyed both the precise of the dis order and advances in P.4022 knowledge. F or example, inade quate pe rs onality was replaced by three pers onality disorders : narcis s is tic, borderline , and de pendent; bulimia was firs t clas sified; advances in s exology necess itated new delineations of paraphilias and types of sexual dysfunctions; advances child ps ychiatry necess itated des cribing and naming new dis orders of childhood; alcoholic dis orders were clas sified into a number of new diagnostic categories , with its list of s pecific diagnostic s ymptoms; from a mixture of cognitive and behavioral abnormalities, a 5009 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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of s ymptoms in adults and children was des ignated attention-deficit disorder, whereas other behavioral symptoms were grouped as conduct dis order; and, as res ult of the psychiatric s ymptoms experienced by American s oldiers in the V ietnam War, the diagnos is of pos ttraumatic s tre s s dis order (P T S D) was described (in II, traumatic s tres s respons e had been subsumed rubric adjus tme nt dis orde r of adult life .) Although these two DS Ms had s ome limitations (e.g., nonps ychotic illness es presented not as distinct but as fluctuating mixtures of anxiety and mood disturbances that did not run dis tinct courses ), they the firs t diagnos tic manuals to be widely accepted academically and clinically, and they became the diagnostic B ible to thos e who treated ps ychiatric F rom 1988 to 1994, a new AP A tas k force, chaired by F rances, with Harold P incus as vice-chairpers on and Michael F irs t as text editor, worked on preparing the edition of the DS M. P reparations for this edition drew the res earch on diagnosis that was generated in part the DS M-III and DS M-III-R and involved a systematic review of the relevant literature, analys is reanalys is of the collected data, and field trials that compared alternative options and s tudied the poss ible impact of suggested changes . T he res ulting volume published as the DS M-IV in 1994. It continued the descriptive, atheoretical approach of the two previous DS Ms . S ome of its changes were discus sions of diagnosis, course, prevalence, and other aspects of illness es; elimination of the term organic me ntal because it incorrectly implied that other mental do not have a biological component; deletion of 5010 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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aggres sive pers onality disorder and addition of personality disorder; renaming multiple pers onality disorder dis s ociative identity dis orde r; and adding an appendix that noted the influence of culture and on ps ychiatric illnes ses and diagnosis. B eginning in 1997, an AP A tas k force of Allen F rances , Harold P incus, and Michael F irst worked on a new of the DS M, which was published in 2000 as the DS MT R . T his edition contained updated information about as sociated features , culture, age, gender features , prevalence, cours e, and familial pattern of mental disorders . S ome of the new content included greatly increased information on Asperger's syndrome (an life, s evere impairment of s ocial interactions , with repetitive activities) and that s ome cases of R ett's syndrome (early mental retardation) are caus ed by a genetic mutation. S ome cases of schizophrenia have updated to include s eparate discus sions of s tructural functional neuroimaging and neurophys iological abnormalities ; s ome major depress ive epis odes have updated and expanded to include additional neurobiological abnormalities (alterations in peptides other hormones in respons e to challenge tes ts ) and functional brain imaging res ults; information regarding comorbidity with other mental dis orders has been updated in obs es sive-compuls ive disorder; and the as sociated features of delirium have been modified to emphasize the presence of two varieties of deliriumhyperactive and hypoactive.

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the care of s pecial groups of patients led the American B oard of P sychiatry and Neurology to create several board-certifiable s pecialties: child psychiatry (1959), geriatric psychiatry (1991), addiction psychiatry (1992), forens ic ps ychiatry (1992).

Ps yc hotherapies T he aims and scope of psychotherapy have grown the treatment and alleviation of s ymptoms in patients to the management of a wide variety of personality dis tres ses (e.g., unhappiness and social malaise, and s ocial isolation), with the aim of providing greater s elf-as sertion and greater emotional fulfillment.

Types of P s yc hotherapy B ecaus e psychotherapis ts often are guided by theories that they modify to meet the particular needs of the history of their work has been characterized by divers ity and the evolution of perhaps 100 types of ps ychotherapy.

PS YC HOANALYTIC THE R APIE S Melanie K lein (1882 to 1960) and Anna F reud (1895 to 1982) formed two different ways of applying ps ychoanalys is to play therapy with children and concepts of child development. Harry S tack S ullivan to 1949) formed the interpersonal theory, s tres sing the interpersonal reactions of persons, and coined the participant obs e rve r and cons e ns ual validation to the reactions between patient and therapis t. E rik H. (1902 to 1994) developed concepts of adult identity, 5012 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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identity diffusion, and cris is . Donald W innicott (1896 to 1971) observed transitional objects and transitional phenomena to which persons become deeply attached and was part of the Independent G roup of in E ngland. J acques Lacan (1901 to 1981) emphas ized language and the need to make contact with the prelanguage period in the uncons cious and was in F rench psychiatry. Heinz K ohut (1913 to 1981) originated self-ps ychology and three new views of transference. J ames Masters on (1926) and Otto (1928) developed two different concepts for diagnos ing and treating borderline and narciss istic dis orders.

B E HAVIOR AL THE R APY B ehavioral therapy originated in the experiments of the American ps ychologist J ohn W atson (1878 to 1958) on behaviorism and the R uss ian phys iologist Ivan P avlov (1849 to 1936) on conditioned reflexes . It was shaped several trends , including Andrew S alter's (1914) conditioned reflex therapy, B . F . S kinner's (1904 to operant conditioning, J oseph W olpe's (19151997) ps ychotherapy by reciprocal inhibition, and trends that emphasized cognitive process es and their adaptive T oday, behavioral therapy cons ists of a blend of and behavioral approaches that are aimed at maladaptive behaviors .

OTHE R THE R APIE S B rief ps ychotherapy aims at producing ins ight and personality changes in a s hort time. Aaron B eck's cognitive therapy aims at rearranging a person's maladaptive thoughts and actions . C arl R oger's (1902 5013 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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1987) client-centered psychotherapy has patients take res ponsibility for their feelings and direct the course of their therapy. F ritz P erls 's (1893 to 1970) gestalt holds that a neurotic patient is repress ing one part of whole (G erman ge s talt) and that, by therapeutically reliving a painful experience, the patient can res tore wholeness . E ric B erne (1910 to 1970), in trans actional analysis, postulates that a life s cript created by parents early childhood shapes and inhibits a person's life, and inhibition can be overcome by deciphering that s cript. E xistential ps ychotherapy, propounded by the G erman ps ychiatris t and philosopher K arl J aspers (1883 to emphasized here-and-now interactions and feelings than past events and rational thinking. Milton E ricks on (1901 to 1980) developed hypnotic ps ychotherapy, in which hypnos is was used to overcome patients to therapeutic changes. T hose therapies involve one patient; other therapies involve couples (marital and sex therapy), families, and groups . In 1935, two American alcoholics founded a step movement of group psychotherapy for the of alcoholis m (Alcoholics Anonymous ), which has since evolved to cover a wide range of addictive or as sumedaddictive behaviors (including food-related disorders , codependency, gambling, and drug and tobacco addiction), as well as the impact of addictive behavior family members (Al-Anon) and the teenaged children of alcoholics (Alateen). P.4023

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S ince the mid-1980s , ps ychological treatments have shown effective in patients with neurotic s ymptoms and moderate personality dis orders. However, patients to variable degrees; much remains to be learned about type of ps ychotherapy and the characteris tics of patient and therapist in each particular treatment.

B iofeedbac k T hrough the us e of ins truments , biofeedback provides persons with repres entations of involuntary or subthreshold physiological process es that they may be able to control voluntarily by changing their B iofeedback has been us ed to treat various diseases . B ecause it can detect the phys iological of a patient's denial, resistance, and other defens e mechanisms, biofeedback also may be considered as adjunct for most of the ps ychotherapies mentioned previous ly.

S oc ial Influenc es T he practice of ps ychotherapy was influenced by in mental health laws and managed care.

Mental Health L aws T he late 1960s saw radical reforms in mental health they peaked in the 1970s and subsided by the midbut they left changes . T hey emphasized the rights of mentally ill to contes t involuntary hos pitalization and refuse treatments, so that it became, in the words of Applebaum, axiomatic that [ps ychiatric] services must provided in a manner that minimizes intrus ions on individual rights and maximizes recourse to 5015 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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review when infringements occur. A s hift of the ins anity defens e from not guilty by reason of ins anity to guilty mentally ill, allowed the courts to monitor an individual's post-trial psychiatric treatment. T wo notable cas es in which ps ychotherapis ts were s ued by third parties who were involved with patients the ps ychotherapis ts were treatingT aras off, 1976, and R amona, 1994alerted to the risks pos ed to them by third parties and the need protect thems elves agains t these ris ks , s ometimes by warning potential victims about the danger posed by patients they are treating.

Managed C are T he increasing cos ts of ps ychotherapy led to the development of managed care, which curtails costs in various ways , including requiring that a treating submit frequent, written progress reports to a managed care panel and sometimes limiting the number of ps ychotherapy s es sions to five to 20 a year. T hus, the confidential ps ychiatristpatient relationship that all third parties and the therapeutic options of to treat patients in ways they deemed most appropriate (e.g., doing insight-oriented therapy that often required frequent sess ions over a prolonged period of time) cons trained in the interes ts of cos t effectivenes s. T wo res ults of these cons traints were that s ome were forced to curtail their ps ychotherapy work (with ps ychotherapy being performed to an increas ing extent ps ychologists , s ocial workers , and nonmedical health providers ) and the number of graduates of American medical schools who desired to become ps ychiatris ts decreased. 5016 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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HIS TOR IE S OF P S YC HIA TR Y G eneral histories of ps ychiatry were published by C . Lewis (1941), G regory Zilboorg and G eorge Henry (1941), J erome S chneck (1960), F ranz Alexander and S heldon S elesnick (1966), E rwin Ackernecht (1959, and Michael S tone (1996). In 2002, R oy P orter, in A B rie f H is tory, s urveyed interpretations of madnes s antiquity to the present. In 1997, E dward S horter published A H is tory of P s ychiatry: F rom the E ra of the to the Age of P rozac. T he history of American been the s ubject of articles that have appeared in two books : O ne Hundre d Y ears of Ame rican P s ychiatry edited by J . K . Hall, G regory Zilboorg, Henry Alden E arl D. B ond, C larence B . F arrar, C lements C . F ry, Henry, W illiam C . Menninger, Albert Deutsch, and S igeris t (1944); and Ame rican P s ychiatry After W orld (19441994), edited by R oy W. Menninger and J ohn C . Nemiah (2000). J ohn Howells edited W orld His tory of P s ychiatry (1975), consisting of accounts by 42 of the his tories of ps ychiatry in mos t of the countries regions of the world; B enjamin W olman's Inte rnational E ncyclope dia of P s ychiatry, P s ychology, Neurology (1977) contained s hort, concise biographies histories ; and S haron R omm and R on F riedman edited His tory of P s ychiatry (1994), which offers s cholarly of psychiatric theories , treatments , and institutions . have been E nglis h translations of the works (in whole part) of Hippocrates, G alen, P aracelsus , W eyer, P inel, E squirol, Mes mer, Heinroth, C harcot, G ries inger, Meynert, and K raepelin, along with their biographies new biographies of W agner-J auregg by Magda (1993); of C harcot by C hristopher G oetz, Michael 5017 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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B onduelle, and T oby G elfand (1995); and of Dorothea by T homas B rown (1998). Ida Macalpine and R ichard Hunter edited T hre e Hundred Y e ars of P s ychiatry: (1964), a s ourcebook of s elected E nglis h texts and translations of influential E uropean texts that chronicles the growth of E nglish ps ychiatry up to the time when it became an es tablis hed branch of medicine. Allan in P atte rns of Madnes s in the E ighte e nth C e ntury, a (1998), has collected vivid accounts of madnes s by who experienced it, along with medical and literary attempts to explain madnes s. C hris T homps on edited O rigins of Mode rn P s ychiatry (1987), which contains important psychiatric texts from 1856 to 1938.

S P E C IA L A R E A S OF S ince 1975, there has been a proliferation of histories confined to particular areas, by authors from various disciplines: s ocial, intellectual, and legal his torians ; sociologis ts; criminologis ts; anthropologists; historians science and medicine; and ps ychiatris ts and other health profess ionals . T he histories that focus on in a historical period emphasize the intellectual, s ocial, cultural matrices from which ideas about mental illness and mental deviance have developedfor example, S imon's Mind and Madne s s in Ancie nt G ree ce : T he R oots of Modern P s ychiatry; Michael W . Dols 's Madman in Me die val Is lamic S ocie ty; Michael Mys tical B e dlam: Madne s s , Anxie ty, and He aling in C entury E ngland; J onathan Andrews and Andrew C us tome rs and P atrons of the Mad-T rade: T he of L unacy in E ightee nth-C entury L ondon with the T ext of J ohn Monro's 1766 C ase B ook; R oy P orter's F orgd Manacle s : A His tory of Madne s s in E ngland from 5018 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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R es toration to the R ege ncy; C onstance McG overn's of Madne s s : S ocial O rigins of the Ame rican P s ychiatric P rofe s s ion; J an G olds tein's C ons ole and C las s ify: T he P s ychiatric P rofe s s ion in the 19th C e ntury; E ric C linical P s ychiatry in Impe rial G e rmany: His tory of P ractice ; G eorge Drinka's T he B irth of Ne uros is : Myth, Malady, and the V ictorians ; J anet Oppenheim's Nerve s : Doctors , P atie nts and Depre s s ion in V ictorian E ngland; T om Lutz's Ame rican Ne rvous ne s s , 1903: An Ane cdotal His tory; and F rancis G eorge G osling's F re ud: Ne uras the nia and the American Me dical 18701910. P.4024 T he intellectual-cultural emphas is als o was applied to following histories of theories, treatments, and Wes ley S mith's T he Hippocratic T radition; Oswei G ale nis m: R is e and De cline of a Me dical P hilos ophy, F alling S icknes s : A His tory of E pileps y from the G re e ks B eginnings of Modern N eurology, and Hippocrate s in a of P agans and C hris tians ; J os e P inero's His torical the C oncept of N euros is ; S tanley J acks on's Depre s s ion: F rom H ippocratic T ime s to Modern T ime s ; C rabtree's F rom Me s me r to F re ud: Magnetic S le ep and R oots of P s ychological H ealing; Alan G auld's A H is tory Hypnotis m; and Lon C hertok and Isabelle S tengers, A C ritique of P s ychoanalytic R eas on: Hypnos is as a P roblem from L avois r to L acan. T hree recent books, G ilman, Helen K ing, R oy P orter, G . S . R ouss eau, and S howalter's , Hys teria B e yond F re ud (1993); Mark Approaching H ys te ria: Dis eas e and Its Interpre tations and Helen K ing's Hippocrate s W oman: R eading the 5019 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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B ody in A ncie nt G re ece (1998) have revolutionized the historiography of hys teria and ancient G reek ideas the nature of women's bodies . G erman B errios and R oy P orter edited A H is tory of P s ychiatry: T he O rigin and His tory of P s ychiatric (1995), which delineates the history of major disorders (dementia, s troke, P arkinson's disease, schizophrenia, depress ion, neuros es, and personality disorders ) from clinical and the social-historical perspectives . S tanley F inger wrote O rigins of A H is tory of E xplorations into B rain F unction (1993) Minds B e hind the B rains : a His tory of the P ione e rs and Dis coverie s (2000).

Anorexia Nervos a S onja vant Hof's Anore xia N ervos a: T he H is torical and C ultural S pecificity: F allacious T he orie s and T e nacious (1994) gives a history of howfrom 1860 to the 1940s the illness came to be recognized as a clinical entity. S he discuss es its epidemiology and contends that, contrary some opinions, it has not increas ed.

Forens ic Ps yc hiatry Daniel R obinson's W ild B e as ts & Idle H umours (1996) history of the ins anity defense from antiquity to the present, and P aul S . Applebaum's Almos t a R evolution: Mental Health Laws and the Limits of C hange (1994) discuss es the changes in American mental health laws from 1970 to 1993.

C hild Ps yc hiatry Michael S tone's C hild P s ychiatry before the T wentieth 5020 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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C entury gives s ome of the opinions on the ps ychology normal (and sometimes aberrant) children from the through 19th centuries , before child psychiatry became clinical s pecialty.

Military Ps yc hiatry B en S hepard's A W ar of Ne rve s : S oldie rs and the T wentie th C entury (2001) is a history of changing concepts of psychiatric illnes ses in (mainly B ritis h and American) s oldiers from W orld W ar I through the G ulf

His tories of As ylums S tudies of the changes in the characteristics of the and mental institutions for the ins ane in 19th-century E ngland and America have been published by Andrew S cull in Mus e ums of Madne s s : T he S ocial O rganization P s ychiatry in N ine tee nth C e ntury E ngland, T he Mos t of Afflictions : Madnes s and S ocie ty in B ritain Mas te rs of B e dlam: T he T rans formation of the MadT rade ; G erald G rob in Me ntal Ins titutions in America; P olicy to 1875 and Me ntal Ins titutions and Me ntal Ame rican S ocie ty, 18751940; and David R othman in Dis covery of the As ylum. T hes e three authors about the meanings of the changes that they B ook-length studies have been published on the 19th and early 20th century mental hospitals: T icehurst private as ylum and the Y ork R etreat, both in E ngland (C harlotte MacK enzie and Anne Digby); the Hos pital for the Ins ane in P hiladelphia (Nancy T omes); New Y ork S tate Lunatic As ylum at Utica and the Asylum for the C hronic Ins ane (E llen Dwyer); the S tate Hos pital in W illiams burg, V irginia (Norman Dain); 5021 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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New Y ork S tate P s ychiatric Ins titute (Lawrence K olb Leon R oizen); the B os ton P sychopathic Hospital Lunbeck); and McLean Hos pital in B elmont, (Alex B ean).

Deins titutionalization T wo views on the causes and meaning of deins titutionalization have been propounded, first by in Decarce ration: C ommunity T re atme nt and the R adical V ie w and then by G rob in F rom As ylum to C ommunity: Me ntal H ealth P olicy in Mode rn Ame rica T he Mad Among Us : A His tory of the C are of Ame rica's Me ntally Ill.

Ac c ounts of Freud, Ps yc hoanalys is , Ps yc hoanalys ts F reud has become the most written-about figure in the history of ps ychiatry. After publication of P eter G ay's comprehensive biography, F re ud: A L ife for O ur T ime there has been an unceasing outpouring of books on special aspects of F reud's life and work. S ome include book by Lis a Appignanes i and J ohn F orrester, F re ud's W ome n (1992), on F reud's relationships with women, including family members , patients , dis ciples, and and how he developed his theories of s exual and female s exuality. S ander G ilman's two 1993 F re ud, R ace , and G e nde r and T he C as e of S igmund Me dicine and Ide ntity at the F in de S icle , offer new F reud's attitudes toward his J ewis h origins and on the influences that shaped his identity as a physician. J ohn K err's A Mos t Dange rous Me thod: T he S tory of J ung, and S abina S pielre in (1993), pres ents new information 5022 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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the conflict between F reud and J ung and on early ps ychoanalytic ideas and treatments ; P eter Newton's F re ud: F rom Y outhful Dre am to Mid-L ife C ris is (1995) describes how ps ychoanalysis originated during a developmental periods and transitions in F reud's early middle years ; and P aul S tepansky's F re ud, S urgery, S urge ons (1999) delineates the influences on F reud of contemporary views of surgeons, the rise of aes thetic surgery, and the s urgical operations that he underwent. His tories of ps ychoanalys is have been written by F ine in 1979 and by J os eph S chwartz in 1999. Nathan Hale's two volumesF re ud and the Ame ricans and T he and C ris is of P s ychoanalys is in the Unite d S tate s give account of the development of psychoanalysis in from 1876 to 1985. Accounts of ps ychoanalys is in and Argentina have been written: F re ud and the P s ychoanalys is in Impe rial R us s ia and the S ovie t by Martin Miller, and F re ud on the P ampas : the and Deve lopme nt of a P s ychoanalytic C ulture in (2001) by Mariano B en P lotkin. E dith K urzwell, in T he F re udians : A C omparative P ers pe ctive (1989), varying impacts of ps ychoanalysis on areas of culture, medicine, and ps ychiatry in five countries : G ermany, Aus tria, F rance, E ngland, and the United S tates . B ook-length biographies have been written about the following ps ychoanalys ts: Alfred Adler (P aul Marie B onoparte (C elia B ertin), Anna F reud (E lis abeth Y oung-B ruehl), Helene Deutsch (P aul R oazen), E rik (Lawrence F riedman), E rnes t J ones (V incent B rome), R ank (J ames Lieberman), C arl J ung (Deirdre B air), Horney (B ernard P aris ), Harry S tack S ullivan (Helen Wilhelm R eich (Myron S haraf), S andor F erenczi 5023 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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P.4025 S tanton), Melanie K lein (P hyllis G ros kurth), Henry A. (F orest R obinson), S andor R ado (R oazen and B luma S werdloff), Donald W innicott (F . R obert R odman), and K ohut (C harles S trozier). P aul S tepans ky compiled and edited T he Me moirs of Margare t S . Mahler (1998), and van Dijken wrote J ohn B owlby: H is E arly L ife, A J ourne y into the R oots of Attachme nt T he ory (1998). R oudinesco, in J acques L acan and C o. A His tory of P s ychoanalys is in F rance , 19251985 (1990) (an E nglish translation of the second volume of R oudinesco's 1982 1986, two-volume his tory of psychoanalys is in F rance 1885 to 1985 titled L a B ataille de C e nt Ans [T he Y ears B attle]), gives an account of Lacan and his work touches on much of the culture and intellectual life of century. T oday, although the influence of ps ychoanalysis on American ps ychiatry has declinedas shown by the of the las t four DS Ms and although there continues to be intens e controversy about its value and validity, Micale P orter have commented that F reud's place as one of supreme makers of the 20th century mind, alongside Darwin, Marx, and E ins tein, remains secure.

Ac c ounts of B ehavioral Therapy T wo his tories of behavioral therapy have been Alan E . K azedin's His tory of B e havior Modification J ohn A. Mills C ontrol: A His tory of B e havioral (2000). T here are book-length biographies of Ivan P . B abkin), J ohn Watson (K erry B uckley), and B . F . (Daniel B jork). 5024 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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Ps yc hotherapy S tanley J ackson, in C are of the P s yche: A H is tory of P s ychological He aling (1999), has written about his in an unusual way. Instead of providing a chronology of individuals and schools of thought, he studies the bas ic elements that have recurrently appeared in the healersufferer relationship. T hes e include talking and confess ion, catharsis and abreaction, therapeutic uses the pas sions and imagination, cons olation, s uggestion persuasion, ins ight and self-observation, and with rewards and punis hments . S uccess ive chapters of C are of the P s yche s how how these bas ic elements persis ted since the time of the ancient G reeks, so that threads of continuing meaning survive from era to era. At the end of his book, J ackson obs erves how healers different s chools of thought have us ed various combinations of these elements in their treatments of patients. T heir aims are to provide an attentive, ear; to allow confiding, confess ional, and cathartic moments ; to comfort and console; to evoke and deal emotions ; to arouse and s us tain hope; to provide thoughtful sugges tion or pers uas ion; to integrate explanation or interpretation with these other to promote self-unders tanding and the potential for mastering difficult illnes s -related situations . C are of the P s yche is noteworthy not only for its his torical but also for its empathy for the roles of healer and

Ps yc hiatry and Ps yc hiatric Drugs F rank Ayd and B arry B lackwell edited Dis coverie s in B iological P s ychiatry (1984), which contains 5025 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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by the discoverers or thos e clos e to them of the main ps ychiatric drugs, and Ayd added the es say T he E arly His tory of Modern P s ychopharmacology in 1990. Maxwell and S hohreh E ckhardt, in the section on ps ychiatric drugs in Drug Dis cove ry: A C as e book and Analys is (1990), provide detailed accounts of the proces ses that revealed the therapeutic us es of chlorpromazine, haloperidol, imipramine, the MAOIs, lithium, and the benzodiazepines. S olomon S nyder's and the B rain (an updated 1996 edition of a book first published in 1986) provides a comprehensive survey of major psychoactive drugs , explains how they act on the brain and affect behavior, and traces the his tory of how they came to be us ed. David Healy has publis hed five histories : three volumes of interviews , T he P s ychopharmacologis ts (1996 to 2000), in which ps ychopharmacologis ts dis cus s aspects of the growth profes sionalization of their work with the founding of journals, ins titutes , and s ocieties; T he Antidepre s s ant (1997); and T he C reation of P s ychopharmacology which gives the history of ps ychopharmacology from discovery of chlorpromazine to the current us es of and clozapine, emphas izing what the new drugs reveal about the workings of the brain and the s ociology of marketing. T he quarterly, multidisciplinary J ournal of the H is tory of B ehavioral S cie nce s has appeared since 1965. In 1990, the quarterly journal His tory of P s ychiatry the firs t E nglis h-language journal devoted entirely to history of ps ychiatry. It is published in E ngland and was edited by two E nglis h s cholars, B errios (1940) and (1946 to 2002) until J une 2001; it has been edited by 5026 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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B errios since S eptember 2001. S ince its inception, it been (as s tated in its first iss ue) completely both in terms of contributions and contributors and has published articles by varied contributors (including historians, historians of medicine and ps ychiatry, and practitioners of medicine and ps ychiatry) who have provided important primary information on all as pects illness . In 1993, Micale (1957) and P orter edited and publis hed Dis covering the His tory of P s ychiatry, the first bookcollection of es says by leading authorities on the lives work of the major historians of ps ychiatry and ps ychoanalys is. It also contained ess ays on other and topics in the history of ps ychiatry, including the of myths and the position of women. Dora W einer, in geste de P inel: T he His tory of a P s ychiatric Myth, that the famous epis ode of P inel's freeing the F rench insane from their chains in 1793 was a myth created largely by P inel's son and s tudents ; that the insane first freed in 1797 by P uss in, an ass is tant to P inel; and the latter then approved and followed up on P uss in's action. T omes , in F eminis t His tories of P sychiatry, emphasizes the abs ence of women in the histories of ps ychiatry before the 1960s and shows how the recent work of feminis t historians has depicted V ictorian as ps ychiatric patients in and outside of as ylums, madwomen in literature, scientific objects in maleauthored textbooks of ps ychology and medicine, and practitioners of psychiatry and ps ychoanalys is . T hose feminist his torians have formed a new and growing subs pecialty in the history of ps ychiatry. In the Introduction to their book, R eflections on 5027 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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and Its His tories, Micale and P orter s ummarize some many divers e factors that have influenced writings on history of ps ychiatry. P sychiatric his tory may inform, instruct, and entertain. It may reflect the intellectual the cultural background, or the emotional temperament of the historian. It may be informed by internal disciplinary dimensions a clinical, theoretical, or profes sional nature. And it may shaped externally by contemporary social movements or political exigencies. It may embody cultural structures and proces ses of a deeper and term nature. P sychiatric historiography has s erved purpos es that are antiquarian, pedagogical, jus tificatory, and ideological. Micale and P orter further state that a study of the methodology and epis temology of the history of ps ychiatry is needed. P.4026

Future His tories of Ps yc hiatry B ennett S imon (1933), in a 1996 review of s everal 5028 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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of ps ychiatry, contends that there is no good onehistory of ps ychiatry, because the field is in a s tate of creative flux, with so many varied and different that no one his tory can please all. S imon believes that we are also living in a time of heroes the idealizations that allowed certain unified histories be written have been analyzed, deconstructed, demythologized, and at times found to be bas ed more fiction than fact. T hese idealizations als o allowed a unified field of ps ychiatry. My hope is that the kinds of history ps ychiatry now being written and the attendant debates about that history may contribute to a renewal and revitalization of the currently decentered and at demoralized field of ps ychiatry. F igures like P inel and C harcot, perhaps even F reud, may once again become centers of discours e, but this time for an audience aware of the pitfalls of idealization and the obfuscation which idealization can be put. I believe we will begin to s ee a return to an appreciation of and heroines in the past, but an appreciation more solidly 5029 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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grounded in an appreciation of the complexities and ambiguities within which they worked. might help us thus s ee the new kinds of heroism required in the confusing and difficult state of ps ychiatry today, the ability to have vis ion and purpos e and steadfastnes s but not be blind to the legitimate tensions and disagreements that are part and parcel of our enterprise. S ome of the major individuals and events in psychiatry, past and present, are described in T able 55.1-1.

Table 55.1-1 Pers ons and E v Pers on or

C ountry

Public ations

Hippocrates of C os (ca. BC)

G reece

Hippocratic W ritings (P elican C lass ics, 1978)

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P lato (427347 BC)

G reece

T he Dialogue s of P la trans. B . J owett (R an Hous e, New Y ork, 19

Aris totle BC)

G reece

W. D. R oss , Aris totle 1955

G alen of P ergamum (AB 130200)

Asia Minor (T urkey) in the R oman E mpire

O n the A ffe cte d P arts and ed. R . S iegel B as el, 1976)

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S t. Augus tine (354430)

T ages te (Numidia, North Africa)

C onfe s s ions , trans . E P us ey (Modern Libra New Y ork, 1949); G a Wills : S aint Augus tin (Lipper/V iking, New Y 1999)

Avicenna (9801037)

P ers ia

A T re atis e on the C a Me dicine of Avice nna (G runner, London, 19

C ons tantius Africanus (ca. 10101087)

C arthage, North Africa

C ons tantino L'African Della melancolia (R o 1959)

P etrarch (13041374)

Italy

De re me diis utrius qu fortunae

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Henry K ramer and J ames S prenger (15th century)

G ermany

Malle us maleficarum (W itche s ' H amme r)

P aracelsus (ca. 14931541)

Walter P agel, E insiedeln (S witzerland), Dis eas e and the S tar then E urope Animal in Man and T he P sychiatry of P aracelsus , pp 1501 (K arger, B asel, 2nd ed., 1982)

J uan Luis V ives (14931540)

B orn in S pain; from the age of yrs lived mainly in Holland and B elgium

De anima e t vita (O f and L ife) (1538); C ar Nora, J uan L uis V ive the E motions (S outh Illinois Univers ity P re C arbondale, IL, 1989

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J ohann W eyer (15151588)

Holland

De praes tigiis dae mo (T he Dece ption of (1563), publis hed in G eorge Mora, ed. Devils , and Doctors i R enais s ance (B inghampton, NY : for Medieval and E ar R enais sance S tudies

J uan Huarte de S an J uan (ca. 15301592)

S pain

T he E xamination of W its (1575)

G iambattis ta P orta

Italy

De humana (1586)

F elix P later (15361614)

S witzerland

P ractice of Me dicine O bs e rvations of Injurious to B ody and (1614)

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R obert B urton (15771640)

E ngland

T he Anatomy of (1621)

P aolo Zacchia (15841659)

Italy

Q ues tiones me dico(16211635)

T homas S ydenham (16241689)

E ngland

Dis sertatio epistolaris (1682) in T he E ntire of Dr. T homas Newly Made E nglis h

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T homas W illis (16211675)

E ngland

T wo Dis cours es the S oul of B rute s (1

G eorg E rns t (16601734)

G ermany

T he oria me dica vera De animi morbis (170

William B attie

E ngland

A T re atis e of Madne s

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(17031776)

(1758)

B oiss ier de S auvages (17061767)

F rance

Nos ologia me thodica (1765)

J ohn Aiken (17471822)

E ngland

T houghts on Hos pita (1771)

F ranz Anton Mesmer (17341815)

Aus tria, F rance

Me moire s ur la dcou magne tis m animal (1

V incenzo C hiarugi (17591820)

Italy

R egulations of the of S anta Maria N uov of B onifazio (1789)

William C ullen

S cotland

Nos ology, or a

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Arrangeme nt of Dis e (1800)

(17101790)

P hilippe P inel (17451826)

F rance

A T re atis e on Ins anit W hich Are C ontained P rinciple s of a N ew a More P ractical Nos ol Me ntal Dis orde rs (18

J ohann R eil (17591813)

G ermany

R haps odie s about th Application of P s ychothe rapy to Me Dis turbance s (1803)

B enjamin R ush (17451813)

United

Me dical Inquirie s and O bs e rvations upon th Dis e as es of the Mind C . F arr: B enjamin R u American P s ychiatry P s ychiatry. S es quicentennial S u 1994;151:65

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T homas S utton 17671835)

E ngland

T racts on De lirium (1813)

William T uke (17321822); S amuel T uke (17841857), grands on of William T uke; Daniel Hack (18271895), youngest son of S amuel T uke; J ohn C harles B ucknill (18171895)

E ngland

Des cription of the an Ins titution ne ar Y o Ins ane P ers ons of th S ocie ty of F rie nds , b T uke (Y ork, 1813); A Manual of P s ycholog Me dicine C ontaining His tory, Nos ology, Des cription, S tatis tics Diagnos is , P athology T re atme nt of Ins anity T uke and B ucknill 1858)

J oseph Adams (17561818)

E ngland

A T re atis e on the Here ditary P ropertie s Dis e as es P articularly Madne s s and S crofu (1814)

F ranz J os eph (17581828), J ohann G as par

Aus tria, G ermany

T he P hys iognomical of Drs . G all and founde d on an

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and phys iological examination of the s ys te m in gene ral an brain in particular(18

S purzheim (17761832)

J ohann Heinroth (17731843)

G ermany

Dis turbance s of the M (1818); Hansen LA: Metaphors of Mind a S ociety: the Origins o G erman P s ychiatry in R evolutionary E ra. Is 1998;89:387409; and C auwenbergh LS : J Heinroth (17731843) ps ychiatris t of the R omantic era. His t P s ychiatry.

R obert G ooch (17841830)

E ngland

An Account of Dis eas P eculiar to W omen

J ames C owles P ritchard (17861848)

E ngland

A T re atis e on Ins anit O the r Dis orders Affe the Mind (1835)

J ean E tienne Dominique

F rance

Me ntal Maladie s : A on Ins anity (1838)

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E squirol (17821840)

Is aac R ay (18071881)

United

T re atis e on Me dical J uris prude nce of Ins a (1838)

J ames B raid (17951860)

E ngland

Neurypnology; or, the R ationale of Nervous (1843)

Daniel M'Naghton (18131865)

E ngland

Daniel M'Naghton: H and the Afte rmath, W J ., Walk A., eds. (G a B ooks , London, 1977

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Wilhelm G ries inger (18171868)

G ermany

Me ntal P athology an T he rape utics (1845)

J acques -J oseph Moreau de (18041884)

F rance

Du has chich e t de me ntale (1845)

Walter C ooper Dendy (17941871)

E ngland

P sychotherapeia, or R emedial Influence o Mind. J P s ychol Med P athol. 1853;6:268

J ean-P ierre (17941870), B aillarger

F rance

B aillarger, La folie do forme and F alret, La circulaire, both in B u

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de l'acadmie impe ria me de cine . 18531854;19:340, 38 P ierre P ichot, T he bi the bipolar disorder, E uropean P s ychiatry 1995;10:110

(18091890)

T homas (18091883)

United

O n the C ons truction, O rganis ation, and Arrangeme nts of for the Ins ane (1854)

J ohn C onolly (17941866)

E ngland

T he T re atme nt of the without Me chanical R es traints (1856)

G eorge (18211875)

E ngland

O n the P re vention an T re atme nt of Me ntal Dis orde rs (1859)

G ustav T heodor F echner (18011887)

G ermany

E le me nts of (1860)

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B enedictAugustin Morel (18091873)

F rance

T rait de s maladie s (1860)

T homas (18121876)

E ngland

Mind and B rain (1860

F orbes B . Winslow (18101874)

E ngland

O n O bs cure Dis e as e B rain and Dis orde rs Mind (1860)

E wald Hecker (18431909)

G ermany

Die Hebephrenie. Ar P athol Anat P hys iol. 1871:52

K arl K ahlbaum (18281899)

G ermany

Die K atatonie ode r d S pannungs irres e in 1874)

G eorge Miller

United

A P ractical T reatis e o

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Nervous E xhaus tion (N euras the nia) (1880

B eard

R ichard von K raft-E bing (18401902)

G ermany

P s ychopathia s e xual (1886); H. Oosterhui S te pchildre n of Natu K raft-E bing, P s ychia the Making of S exua Ide ntity (Univers ity of C hicago P res s, C hic 2000)

P ierre J anet (18591947)

F rance

L 'automatis me ps ychologique : es s a ps ychologie s ur le s forme s infe rie l'active (P aris, 1889); der K olk B A, van der O: P ierre J anet and t breakdown of adapta in ps ychological trau

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Am J P s ychiatry. 1989;146:1530

Herman E mminghaus (18451904)

G ermany

P s ychic Dis turbance s C hildhood (1887)

J ean-Martin C harcot (18251893)

F rance

Hys teria, Hypnos is , a Healing: T he W ork o C harcot, by A. R . G . (G arrett P ublications Y ork, 1971); C harcot C ons tructing N eurolo C . G oetz, M. B ondue T . G elfand (Oxford Univers ity P res s, Oxf 1995)

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G eorges G illes la T ourette (18571904)

F rance

E tude s ur une affecti nerveuse caractrise p l'incoordination motri accompagne d'echol coprolalie. Archive s d ne urologie . (P aris) 1885;ix:1942, 15820 T rans. and with an introduction by G raem Y ors ton and Nick S tudy of a nervous disorder characterize motor incoordination echolalia and coprola His t P s ychiatry. Howard I. K ushner, A C urs ing B rain? T he of T oure tte S yndrom (Harvard University C ambridge, MA, 199

C es are (18351909)

Italy

G e nius and Ins anity T he Delinque nt Man T he F e male O ffende

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E mil K raepelin (18561926)

G ermany

P s ychiatrie: E in L e hr S tudere nde und Ae rz ed (1899); E mil Me moirs (S pringerB erlin, Heidelberg, N Y ork, London, P aris, 1987)

J ohn Hughlings J ackson (18341911)

E ngland

S ele cte d W ritings of Hughlings J acks on (London, 19311932)

S igmund F reud (18561939)

Aus tria

T he Inte rpre tation of (1900); T hre e E s s ays T he ory of S e xuality Introductory L e ctures

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P s ychoanalys is

Morton P rince (18541929)

United

T he Dis s ociation of a P ers onality (1905)

C lifford B eers (18761943)

United

A Mind T hat F ound I (1908)

E ugen B leuler (18571939)

S witzerland

Deme ntia P rae cox o G roup of S chizophre (1911)

Alfred B inet (18571911)

F rance

A Me thod of Me as uri Deve lopme nt of the Inte llige nce of Y oung C hildre n, with T . S im (1911), E nglish 1913

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Hideyo Noguchi (18761928)

United

Noguchi H, Moore J W demonstration of the T re pone ma pallidum brain in cases of gen paralysis. J E xp Me d 1913:17

Alfred Adler (18701937)

Aus tria

S tudy of O rgan Infe ri and Its P s ychical C ompens ations (191 E . S tepansky, In F re S hadow: Adler in C o (T he Analytic P ress , Hillsdale, NJ , 1983)

Hermann R ors chach (18841922)

S witzerland

P s ychodiagnos tik (19

J ulius von Wagner(18571940)

Aus tria

T he rape utic Malaria de R udoli (1927); J auregg J : T he histo the malaria treatmen

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general pares is. Am P s ychiatry. S es quicentennial S u 1994;151:231; B rown Why W agner-J aureg the Nobel P rize for discovering malaria therapy for general of the ins ane. His t P s ychiatry. Otto R ank (18841939)

Aus tria, F rance, United

T he Myth of the B irth Hero (1909); T he T ra B irth (1924); W ill T he (1936); E . J ames Lieberman, Acts of W L ife and W ork of O tto (F ree P res s, Macmill New Y ork, 1985)

T he American B oard of P sychiatry and Neurology (AB P N)

United

F reeman W , E baugh B oyd D J r: T he found the American B oard P sychiatry and Inc. Am J P s ychiatry 1959;115:769778

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Henry A. Murray (18931988)

United

T he matic Appe rce pti (Harvard University C ambridge, MA, 194

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C harles B radley (19021979)

United

B radley C : T he beha children receiving benzedrine. Am J P s ychiatry. 1937;577 MD: Origin of s timula for treatment of atten deficit disorder. Am J P s ychiatry. 1995;152 298299

C ure of pellagra

United

D. R oe, A P lague of T he S ocial His tory of P ellagra (C ornell P res s, Ithaca, 1973)

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G enetics of schizophrenia

G ermany, United

E rns t R din (1874195 S tudie n be r V e rebun E nts te hung geis tiger S trunge n. I. Zur und N eue ts te hung de Deme ntia P rae cox. on the He redity and of Me ntal Dis eas es . Here dity and New F ormation of De men P rae cox] B erlin: V erl J ulius S pringer, 1916 J oseph K allman (18971965), T he S chizophre nia (J . J . Augustin P ublisher, N Y ork, 1938); J ohn D. T he contributions of J . K allmann to the of schizophrenia. In: C ancro R , Dean S R , R es e arch in the S chizophre nic Dis ord T he S tanley R . Dean L e cture s . V ol 2. J am

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NY : S pectrum 1985

ECT

Italy

Abrams R : T he treatm that will not die. P s yc C lin N Am. B errios G : T he s cien origins of electroconvuls ive a conceptual history. P s ychiatry. 1997;8:

K aren Horney (18851952)

G ermany until 1932, then United S tates

T he Neurotic P ers on O ur T ime (1937); Ne in P s ychoanalys is Neuros is and Human G rowth: T he S truggle T oward S e lf-R ealizat

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(1950); B ernard P ari Horne y: A S earch for S e lfUnde rs tanding (Y ale Univers ity P res s, New Haven, C T , 1994) Adolf Meyer (18661950)

S witzerland until 1893, then United S tates

Meyer A: A s hort ske the problems of Am J Ins anity. 18961897;53:538; Li Adolf Meyer and the development of Ame ps ychiatry. Am J 1996;123:320; Adolf In: Havens L. the Mind (Little, B row B os ton, 1973)

C ons titution, personality, and mental illness

G ermany, United

E rns t K retschmer (18881964), B ody B u C haracte r (1922); W H. S heldon (1899197 V arie tie s of H uman P hys ique (1940)

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F hrer decree (1939)

G ermany

T he Nazi doctors. 2 in E uthanas ia: Dire Me dical K illing, by R . Lifton (B asic B ooks, Y ork, 1986); B y T rus B etraye d: P atients , P hys icians , and the to K ill in the T hird R e H. G . G allagher (Hen New Y ork, 1990); T h Doctors and the C ode . H uman R ights Human E xperime nta Annas G J , G rodin MA Oxford: Oxford Unive P res s; 1992

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MMP I

United

B uchanan R : T he development of the Minnesota Multiphas P ers onality Inventory B ehav S ci.

Leo K anner (18941981)

Aus tria, United

C hild P s ychiatry (193 T homas, S pringfield, Autistic dis turbances affective contact. Ne C hild. 1943;2:217250

Melanie K lein

C entral

T he P s ychoanalys is

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(18821960), F reud (18951982)

E urope, E ngland

C hildre n, K lein (1932 K ernberg. Melanie K K aplan, F reedman, a S adock, eds. C omprehe ns ive P s ychiatry, 3rd ed. (W illiams & W ilkins , B altimore, 1980); P . G ross kurth, Me lanie Her W orld and He r W (Alfred A. K nopf, New 1986); Anna F reud, T and the Me chanis ms Defe nce (1936), T he P s ychoanalytic of C hildren (1946), A history of child analy P s ychoanal S tudy C h 1966;21:714; E Y oun B ruehl, Anna F re ud: B iography (S ummit New Y ork, 1988)

Helene Deuts ch (18841982)

E urope until 1935, then United

T he P s ychology of 2 vols (1945); S ome of emotional dis turba and their relations hip schizophrenia (As If) In: Deuts ch. Neuros e C haracte r T ype s (19

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R oazen, Hele ne P s ychoanalys t's L ife (Anchor G arden C ity, NJ , 198

Ivan P etrovich P avlov (18491936), Andrew S alter (1914)

R us sia, United

L e cture s on C onditio R efle xe s , IP P avlov, T ranslated and edite Dr. W . H. G antt. 2 vo (International P ublis h New Y ork, 1941); B . B abkin, P avlov: A (Univers ity of C hicag P res s, C hicago, 1949 S alter, C onditione d T he rapy (F arrar, S tra New Y ork, 1949)

NMHA (1946), NIMH (1949)

United

G . N. G rob, C hs 24 i As ylum to C ommunit Me ntal H ealth P olicy Mode rn Ame rica Univers ity P res s, NJ , 1991); R omano J R eminiscences: 1938 since. Am J P s ychiat

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1990;147:785

E rik H. E rikson (19021994)

E urope; United since 1930s

C hildhood and S ocie (1950); Ide ntity and t C ycle (1959); Lawren F riedman, Ide ntity's Archite ct: A B iograph E rik H. E riks on (S crib New Y ork, 1999); R o Wallers tein, Leo G oldberger, eds. Ide Ide ntitie s : the L ife an of E rik E riks on Univers ities P ress , Madis on, C T , 1999)

Donald Winnicott (18961971)

E ngland

T ransitional objects a transitional phenome (1951), in D. W innico C ollected P ape rs : P ae diatrics to P s ychoanalys is London, 1958); H. T he B ritis h S chool of P s ychoanalys is : T he Indepe nde nt T raditio Univers ity P res s, New Haven, C T , 1986); F

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R odman, W innicott: L and W ork (P ers eus P ublis hing, 2003)

J ean Delay (19071987), P ierre Deniker (19171999)

F rance

Delay J , Deniker P : L traitement des ps ych par une mthode neurolytique drive de l'hibernothrapie. C R Me d Alin Ne urol F ran 1952;50:497; J T huil Y ears that C hange d F ace of Me ntal Illne s (Martin Dunitz, Londo 1999); David Healy, C reation of P s ychopharmacology (Harvard University C ambridge, MA, 200

Harry S tack S ullivan (18921949)

United

H. S . P erry, M. L. G a T he Inte rpe rs onal T h P s ychiatry(1953); He S wick P erry, P s ychia Ame rica: the L ife of H S tack S ullivan (T he P res s of Harvard P res s, C ambridge, M

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London, 1982)

E gas Moniz (18741955), Walter F reeman (18951972)

United S tates, E urope

E . S . V alenstein, G re Des perate C ure s : T h and Decline of P s ychos urge ry and O R adical T re atme nts f Me ntal Illne s s (B as ic New Y ork, 1986); J . P res sman, L as t R e s o P s ychos urge ry and t L imits of Me dicine (C ambridge Universi P res s, C ambridge, M 1998)

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Advent of the double-blind

United

G old H, K wit NT , Ott T he xanthines (theobromine and aminophylline) in the treatment of cardiac J AMA. 1937;108:217 Hampson J L, R os ent F rank J : A comparati study of the effect of mephenes in and plac on the symptomatolo a mixed group of ps ychiatric outpatien B ull J ohns H opkins 1954;95:170

C arl G ustav (18751961)

S witzerland

P s ychological T ype s T wo E s s ays on Analy P s ychology (191219

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S tructure and Dynam the P s yche (1916195 Archetype s and the C ollective U ncons cio (19341955); T homas T he J ungians : A C omparative and P ers pe ctive (R outled London, 2000); Deird B lair, J ung: A B iogra (Little, B rown & C o., B os ton, 2003) Antidepress ant drugs

S witzerland, United

K uhn R : T he treatme depres sive s tates wit iminodibenzyl derivat (G 22355). S wis s Me 1957;87:1135; Loom S aunders J C , K line N clinical and pharmacodynamic evaluation of iproniaz a psychic energizer. P s ychiatr R e s R e p. 1957;8:129; David H T he Antide pres s ant E (Harvard University C ambridge, MA, 199

B . F . S kinner

United

B . F . S kinner, S cienc

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(19041990), J oseph W olpe (19151997)

S tates, Africa

Human B e havior (F re P res s, New Y ork, 19 Wolpe, P s ychothe rap R eciprocal Inhibition (S tanford University S tanford, C A, 1958)

Development of child ps ychiatry

United

F rank R afferty, E ffec health delivery syste child and adoles cent mental health care; J S chowalter, R ecruitm training, and certifica in child and adoles ce ps ychiatry in the Unit S tates; Dorothy T he discovery of the a his torical pers pecti child and adoles cent ps ychiatry, C hapters 123, and 127 in Melv Lewis, ed. C hild and Adoles ce nt P s ychiatr C omprehe ns ive 2nd ed (W illiams & B altimore, 1996)

K arl J aspers (18831969)

G ermany

G eneral (1s t ed, 1913; 7th ed (E nglis h translation,

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K urt S chneider (18871967)

G ermany

P s ychopathic (C as sell, London, 19 C linical P s ychopatho (G rune & S tratton, N Y ork, 1959)

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Michel F oucault (19261984)

F rance

His toire de la folie (1 E nglis h translation, Madne s s and C iviliza His tory of Ins anity in of R e as on (P antheon New Y ork, 1965)

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B enzodiazepine drugs

United

C ohen IM. T he benzodiazepines. In: F J J r, B lackwell B , ed Dis coverie s in B iolog P s ychiatry. B altimore Medical 1984:130

Haloperidol in the treatment of G illes de la

F rance

S eignot J N: Un cas d maladie des tics de G de la T ourette guri pa

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1625. Ann Me d P s yc 1961;cxix:578579. T ranslated and with a introduction by Hugh R ickards, Nicola Har and Mary M. R oberts T he case of G illes de T ourette syndrome: a condition of nervous cured by R .1625. In: of P s ychiatry, 8 (199

T ourette's syndrome

J oint C ommiss ion on Mental Illnes s and Mental Health (19551961)

United

Action for Mental He (1961); C ommunity Health C enters Act o

R ene S pitz (18871974)

E urope, United

T he F irs t Y e ar of L ife P s ychoanalytic S tudy Normal and De viant

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Deve lopme nt of O bje R elations (Internation Univers ities P ress , N Y ork, 1965)

C las sification of mental

United

DS M-I prepared by th C ommittee on Nomenclature and S tatistics of the AP A R aines , chair (Menta Hos pital S ervice, Was hington, DC , 195 DS M-II prepared by t C ommittee on Nomenclature and S tatistics of the AP A G ruenberg, chair (AP Was hington, DC , 196 G rob G : Origins of D study in appearance

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reality. Am J P s ychia 1991;148:421 E pidemiological evidence for the genetic transmis sion of schizophrenia

United S tates, Denmark

K ety S S , R os enthal D Wender P H. A as sess ment of the parents of T he types and of mental illnes s in th biological and adopti families of adopted schizophrenics ; and S chizophrenics' offsp reared in adoptive In: R osenthal D, K ety eds. T he T rans mis s io S chizophre nia. Lond P ergamon P res s; 345, 377; K ety S S , P H, et al: Mental illne the biological and adoptive relatives of schizophrenic adopte replication of the C openhagen study in res t of Denmark. Arc P s ychiatry. 1994;51:4

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Lithium therapy for psychotic excitement

Aus tralia, Denmark, United

C ade J : Lithium s alts treatment of ps ychot excitement. Me d J A 1949;36:349; S chou J uel-Nielsen N, E , V oldby H: T he of manic ps ychos es adminis tration of lithi salts . J Ne urol Neuro P s ychiatry. 1954;17: S chou M: F orty years lithium treatment. Arc G e n P s ychiatry.

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William H. Masters (19152001), V irginia E . J ohns on (1925)

United

Human S e xual R e s p (1966); Human S e xu Dys function (1970)

Margaret (18971985)

C entral E urope until 1938, then United

M. Mahler, F . P ine, a B ergman, T he B irth of the Human In S ymbios is and (B as ic B ooks, New Y 1975); T he Me moirs Margare t S . Mahler, compiled and edited

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P aul E . S tepansky (T P res s, a division of Macmillan, Inc., New 1988) J ohn B owlby (19071990)

E ngland

Attachment (1969); S eparation; Anxie ty & (1973); L os s ; S adnes Depre s s ion(1980); A B as e: C linical of Attachme nt T heory (1988); J eremy Holm J ohn B owlby and Attachment T he ory(1

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J acques Lacan (19011981), the F rench F reud

F rance

J . Lacan, T he L angu the S elf: T he F unctio L anguage in P s ychoanalys is , tran Wilden (1968); S . T u P s ychoanalytic P oliti F re ud's F re nch (1978); R oudines co, J acques L acan & C o His tory of F rance , 19251985 (1

Heinz K ohut (19131981)

Aus tria until 1940, then

T he Analys is of the S (1971); T he R es torat

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J ean P iaget (18961980)

United

the S elf (1977); T he analyses of Mr. Z. In P s ychoanal. 1979;60 B aker H, B aker M: H K ohut's s elf psycholo overview. Am J 1987;144:1; S trozier Heinz K ohut: T he Ma a P s ychoanalys t. Ne F arrar, S traus and 2001

S witzerland

G reenspan, C urry J . P iaget's approach to intellectual functionin K aplan HI, S adock B C omprehe ns ive P s ychiatry. 6th ed.

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NAMI

United

NAMI: W e Are F amily page brochure descr work of NAMI (NAMI Arlington, V A, 1979)

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S ociobiological ps ychiatry

United S tates, Holland

V an P raag H: S ociobiological C ompr P s ychiatry. 1981;22:441

R oger S perry (19131994)

United

S ome effects of disconnecting the hemis pheres . S cienc 1982;217:1223; R og S perry and R ita Levi Montalcini, in S tanley F inger's Minds B e hin B rain: A H is tory of th P ionee rs and T he ir Dis coverie s (Oxford Univers ity P res s, Ne 2000)

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B rief ps ychotherapy

United S tates, E ngland

Malan D. A S tudy of P s ychothe rapy. New P lenum; 1976; Mann G oldman R . A C as eb T ime -L imite d P s ychothe rapy. New McG raw-Hill; 1982; Davanloo H. S hort-T Dynamic P s ychother New Y ork: Aronson; S ifneos P . S hort-T e r Dynamic P s ychother E valuation and New Y ork: P lenum; 1 C rits -C ris toph P : T he efficacy of brief dyna ps ychotherapy: A me analysis. Am J 1992;149:151

P sychology of

United

Miller J B . T owards a

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P s ychology of W ome B os ton: B eacon P res 1976; G illigan C . In a Diffe rent V oice: P s ychological T he ory W ome n's Deve lopme C ambridge, MA: Har Univers ity P res s; 198 Levinson D, in collaboration with Levinson J . T he S ea W oman's L ife . New Y Alfred K nopf; 1996

women

NAR S AD

United

NAR S AD activities a reported in R es e arch brochures and

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C hanges in the diagnosis and clas sification of homos exuality

United

B ayer R . Homos e xua Ame rican P s ychiatry P olitics of Diagnos is . Y ork: B as ic B ooks; 1 DS M-III (1980); DS M (1987)

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C las sification of mental

United

DS M-III; DS M-III-R ; M: DS M-III and the transformation of American psychiatry: history. Am J P s ychia 1993;150:399

J ames (1926), Otto K ernberg (1928)

United

Masterson J . of the B orde rline Adu Deve lopme ntal New Y ork: 1976; Narcis s is tic an B orde rline Dis orde rs Inte grate d

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New Y ork: 1981; Mas ters on J , K eds. P s ychothe rapy Dis orde rs of the S elf: Mas te rs on Approach Y ork: B runner/Mazel K ernberg O: B orde rli C onditions and Narcis s is m. New Y or Aronson; 1975; S eve P ers onality Dis orde rs P s ychothe rape utic S trate gie s . New Hav Y ale Univers ity P res s P sychology and neurophys iology of dreams

United

Hobs on J A, McC arle T he brain as a dream generator: an activat synthes is hypothesis one dream process . P s ychiatry. 1977;134 McC arley R W . Dream disguis e of forbidden wis hes or trans paren reflections of a distin brain s tate? In: B ilde Lefever F F , eds . Neuros cie nce of the O n the C ente nnial of P roje ct for a S cie ntifi

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P s ychology. New Y o Y ork Academy of 1998:116133; R eiser T he dream in contemporary ps ychi Am J P s ychiatry. 2001;158:351

T heories on the ps ychology of love

United

B ergmann MS . T he Anatomy of L oving. N Y ork: C olumbia

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P res s; 1987; S ternbe T he T riangle of L ove Intimacy, P as s ion, C ommitme nt. New Y B as ic B ooks; 1987; S ternberg R J , B arne eds. T he P s ychology New Haven, C T : Y al Univers ity P res s; 198 G aylin W , P ers on E , P as s ionate Attachme T hinking about L ove . Y ork: F ree P res s; 19 P ers on E . Dreams of and F ate ful E ncounte P owe r of R omantic New Y ork: Norton; 19 E valuations of ps ychotherapy

United

S loane R B , et al. P s ychothe rapy ve rs u B ehavior T he rapy. C ambridge, MA: Har Univers ity P res s; 197 E lkin I, et al.: Nationa Ins titute of Mental He T reatment of Depres C ollaborative R esear P rogram: G eneral effectivenes s of treatments . Arch G e n

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P s ychiatry. 1989;48: E ric K andel (1929)

Aus tria, United after 1939

P sychotherapy and t single s ynaps e: the of ps ychiatric neurobiological resea N E ngl J Me d. 1979;301:1028; F rom metapsychology to molecular biology: explorations into the nature of anxiety. Am P s ychiatry. K andel E , S chwartz J P rinciple s of Ne ural 2nd ed. New Y ork: 1985; G enes , nerve and the remembranc things past. J Neurops ychiatry. 1989;1:103; B iology the future of ps ychoanalys is: a ne intellectual framewor ps ychiatry revisited. A P s ychiatry. 1999;156

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Aaron B eck (1921)

United

B eck A. C ognitive and the E motional Dis orde rs . New Y ork International Univers P res s; 1976; B eck A, AJ , S haw B F , E mery C ognitive T herapy of Depre s s ion. New Y o G uilford; 1979; B eck E mery G , G reenberg Anxie ty Dis orde rs an P hobias : A C ognitive P ers pe ctive . New Y o B as ic B ooks; 1985; B F reeman A, et al. T he rapy of P e rs onali Dis orde rs . New Y ork G uilford; 1990; W eis Aaron T . B e ck. K e y C ouns e lling and P s ychothe rapy. Lond S age; 1993; B arsky A Ahern DK . C ognitive behavioral therapy fo hypochondriasis. A randomized controlle trial. J AMA.

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K arl Menninger (18931990), William Menninger (19001966)

United

F aulkner H, P ruitt V , T he S ele cte d C orre s ponde nce of K Me nninge r. New Hav Y ale Univers ity P res s F riedman LJ . Me nnin T he F amily and the New Y ork: K nopf; 19

F rederick K . G oodwin K ay R edfield

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Manic-Depre s s ive New Y ork: Oxford Univers ity P res s; 199

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J amison (1946)

S S R Is

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J erome F rank (1909), E . F uller T orrey (1937)

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F rank, P ers uas ion an Healing: A C omparat S tudy of P s ychothe ra (J ohns Hopkins P res B altimore, 1961); 2nd revis ed edition, same publisher (1973); 3rd revis ed edition, same publisher, with J ulia B F rank as s econd aut (1991); T orrey, T he M G ame : W itchdoctors P s ychiatris ts (E mers New Y ork, 1972); W itchdoctors and P s ychiatris ts : T he R oots of P s ychothe ra Its F uture (Harper & New Y ork, 1986) (a edition of T he Mind

P sychiatric epidemiology

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R obins LN, R egier D P s ychiatric Dis orders Ame rica: T he C atchme nt Are a S tud Y ork: F ree P res s; 19

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F orens ic ps ychiatry

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B urs ztajn H, S cherr A B rodsky A: T he rebir forens ic psychiatry in

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of recent historical tre in criminal res ponsib P s ychiatr C lin N Am. (3): 611635; P rentice history of in forensic psychiatry Am Acad P s ychiatry 1995;23(2):195203

E pidemic of and of pers ons infected with the AIDS virus (1981)

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G rmek M. His tory of E me rge nce and O rig Mode rn P ande mic. P rinceton, NJ : P rince Univers ity P res s; 199 B erridge V , S trong P AIDS and C ontempo His tory. C ambridge: C ambridge University P res s; 1993; F eldma Miller J , eds . T he AID A Docume ntary His to Wes tport, C T : P res s; 1998; B ayer R

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Oppenheimer G , eds Doctors : V oice s from E pidemic. Oxford, Ne Y ork: Oxford Univers P res s; 2000; P ractice guideline for the of patients with Am J P s ychiatry. 2000;157:11 C las sification of mental

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American P s ychiatric Ass ociation. Diagnos S tatis tical Manual of Dis orde rs , F ourth E d 4th ed. T ext rev. (DS T R ). W ashington, DC American P s ychiatric Ass ociation; 2000

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C lozapine, ris peridone, and olanzapine in treatment of schizophrenia

United S tates, C anada, E urope, E ngland, S outh America, S outh Africa

K ane J , Honigfield G S inger J , Meltzer H, C lozaril C ollaborative S tudy G roup: C lozap the treatment-res is ta schizophrenic. A dou blind comparison wit chlorpromazine. Arch P s ychiatry. 1988;45: K ane J , Marder S R : C lozapine benefits a ris ks . S chizophr B ull. 1994;20:23; Ayd F J J R is peridone (R is perd unique antipsychotic Drug T he r Ne ws le tt.

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1994;29:5; Marder S Meibach R C : the treatment of schizophrenia. Am J P s ychiatry. K ane J : R is peridone. P s ychiatry. B easley C , T ollefs on P , S atterlee W , S ang Hamilton S : Olanzap versus placebo and haloperidol acute pha res ults of the North American double-blin olanzapine trial. Neurops ychopharma 1996;14: 111123; G , K untz A: R eview o recent clinical studies olanzapine. B r J 1999;37:3035; V olav C zobor P , S heitman Lindenmayer J P , C itr McE voy J P , C opper C hakos M, Lieberma C lozapine, olanzapin ris peridone, and haloperidol in the treatment of patients chronic s chizophreni

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schizoaffective disord Am J P s ychiatry. 2002;159:255268 P ublications in ps ychohistory and ps ychobiography

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Lawton H. T he P s ychohis torian's Handbook. New Y ork P sychohistory P ress ; E lovitz P , ed. C lio's Unde rs tanding the W C ulture, C urrent E ve His tory, and S ocie ty quarterly periodical published by the P sychohistory F orum Dakota T rail, F ranklin Lakes , NJ 07417; A, ed. P s ychoanalys His tory, vol. 1, no. 1, 19981999. London: Artes ian B ooks (sinc first iss ue, this His tor appeared at regular intervals of twice a ye S zaluta J : P s ychohis T he ory and P ractice . Y ork: P eter Lang; 19 E lovitz P , P sychoana scholars hip on Amer P res idents . Annu

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P s ychoanal. 2003;31:135149

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P aul W ender (1934)

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C omputers and the Internet

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T wo articles about th Internet are Ales si N Internet and the futur ps ychiatry. Am J 1996;153: 861869; a R ajendran P R : T he us hering in a new era medicine. J AMA. 2001;285:804

 

 

 

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Dis coveries of genetic variations as caus es of illness es

United S tates, C anada, E ngland, E urope, Aus tralia

Oberl I, R ouss eau F , D, K retz G , Davys D, Hanauer A, B ou J , MF , Mandel J L: Insta of a 550base pair DN segment in fragile X syndrome. S cience . 1991;252:1097; Y u S P ritchard M, K remer Lynch M, Nancarrow B aker E , Holman K , J C , W arren S T , D, S utherland G R , R I: F ragile X genotyp characterized by an unstable region of DN S cience . 1991;252:1 Y ing-Hui F u, K uhl DP P izzuti A, P ieretti M, S utcliffe J S , R ichards V erkerk AJ , Holden J F enwick R G J r, W arr Oostra B A, Nelson D C as key C T : V ariation C G G repeat at the fr site results in genetic instability: res olution

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the S herman parado 1991;67:1047; S chellenberg G D, B i Wijsman E M, Orr T , Anderson L, Nemens White J A, B onnycas t Alonso ME , P otter H, Hes ton LL, Martin G M G enetic linkage of evidence for a familia Alzheimer's disease on chromosome 14. S cience . 1992;258: 6 Mullen M, Houlden H Windelspecht M, F id Lombardi C , Diaz P , M, C rook R , Hardy J , C rawford F : A locus f familial early-onset o Alzheimer's disease long arm of chromos 14, proximal to the αantichymotryps in gen Nat G e ne t. 1992;2:34 Huntington's Disease C ollaborative R es ear G roup: A novel gene containing a trinucleo repeat that is expand and unstable on

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Huntington's dis eas e chromosome. C ell. 1993;72:971  

 

Amir R E , V an den Wan M, T ran C Q, F r Zoghbi HY : R ett is caus ed by mutatio X-linked ME C P 2, methyl-C pG -binding protein 2. Nat G e ne t. 1999;23:185

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Hyman S , Moldin S . G enetic science and depres sion: implicati for research and In: W eiss man MM, e T re atme nt of Depre s B ridging the 21s t Was hington, DC : P sychiatric Ass ociati 2001:98; Andreas en S chizophrenia. C hap B rave Ne w B rain: C onquering Mental the E ra of the G e nom Y ork, Oxford: Oxford Univers ity P res s; 2001:199200

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J ackson S W . C are o P s yche: A His tory of P s ychological He alin Haven, C T : Y ale P res s; 1999; S abo A

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Havens L, eds . T he R W orld G uide to P s ychothe rapy P ract C ambridge, MA and London: Harvard P res s; 2000; Hers en S ledge W H, eds. E ncyclope dia of P s ychothe rapy. 2 vo Diego: Academic P re 2002

E ducation of ps ychiatris ts

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Luhrmann T M. O f T w Minds : T he G rowing Dis orde r in Ame rican P s ychiatry. New Y ork Alfred A. K nopf; 2000

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T heory and treatment of depres sion

United S tates, E ngland, S witzerland

In a March 1999 New C ity meeting of the American P sychopathological Ass ociation, leading clinical s cientists gav papers on the topic T reatment of Depres all of which were published as : W eis s m MM, ed. T re atme nt o Depre s s ion: B ridging 21s t C e ntury. DC : American P s ych Ass ociation; 2001

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Neuroimaging

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Andreas en NC . Map the mind. C hap 6. In: New B rain: C onque ri

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Me ntal Illne s s in the the G e nome . Oxford, Y ork: Oxford Univers P res s; 2001:130159; Morihisa J M, ed. in B rain Imaging. Was hington, DC : P sychiatric Ass ociati 2001  

 

After this discovery, w were known as funct techniques of neuroimagingincludin functional MR I, single photon emis sion computed tomograph and P E T were applied studying changes in activity (blood flow) in mental illness . Althou Andreas en s tates tha most of these techniq are still research too also obs erves that in illness es P E T permit study the relationship between drug dos e a clinical res ponse bas a measurement of th

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levels and activity in brain. T he effects of traumatic on individuals

United S tates, E ngland, F rance, G ermany, and Italy

Micale MS , Lerner P , T raumatic P as ts , and T rauma in the Age , 18701930. C ambridge University P res s, 2001

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Diagnos is and treatment of borderline personality disorder

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G underson J G . P ers onality Dis orde r: C linical G uide . DC : American P s ych Ass ociation; 2001; American P s ychiatric Ass ociation. P ractice G uide line for the of P atie nts with P ers onality Dis orde r. Was hington, DC : P sychiatric Ass ociati 2001; Oldham J M: A year-old woman with borderline pers onality disorder. J AMA. 2002;287:10311037

S eptember 11, 2001 terroris t attacks on the World T rade

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K leinfield NR , C onne 9/11 s till s trains New ps yche. P oll finds widespread unease a

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C enter and the P entagon

Overviews of ps ychoanalys is

lingering fear of terro New Y ork T ime s . 200 8:A1A2; S heehy G : Middletown Ame rica. T own's P as s age from T rauma to Hope . New R andom Hous e; 200 C ancelmo J A, T ylim Hoffenberg J , eds. T e rroris m and the P s ychoanalytic S pac Inte rnational from G round Ze ro. N Y ork: P ace University 2003 United

E rwin E , ed. T he F re E ncyclope dia: T he ory T he rapy, and C ulture Y ork: R outledge; 200 Zaretsky E . S ecrets o S oul: A S ocial and His tory of New Y ork: Alfred A. 2004

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C onfinement of the mentally ill as ylums

S outh S witzerland, F rance, C anada, Aus tralia,

P orter R , W right D, e C onfine me nt of the Inte rnational 18001965. C ambridg C ambridge University

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T reatment of schizophrenia

G ermany, United S tates, Argentina, Mexico, India, Nigeria, Ireland, and E ngland

P res s; 2003

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American P s ychiatric Ass ociation. P ractice

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G uide line for the of P atie nts with S chizophre nia, 2nd e Was hington, DC : P sychiatric Ass ociati 2004

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ADHD, attention-deficit/hyperactivity disorder; AIDS , acq AP A, American P s ychiatric Ass ociation; C NS , central ne factor; C T , computed tomography; DS M, Diagnos tic and electroconvuls ive therapy; F DA, U.S . F ood and Drug Ad immunodeficiency virus ; MAOI, monoamine oxidase inh P ers onality Inventory; MR I, magnetic resonance imaging Mentally Ill; NAR S AD, National Alliance for R es earch on National Ins titute for Mental Health; NMHA, National Me compuls ive disorder; P E T , positron emiss ion tomograph S S R I, s elective serotonin reuptake inhibitor; T R , text rev P.4027 P.4028 P.4029 P.4030 P.4031 P.4032 5121 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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P.4033 P.4034 P.4035 P.4036 P.4037 P.4038 P.4039 P.4040 P.4041 P.4042 P.4043 P.4044 P.4045 P.4046

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S UG G E S TE D C R OS S Many sections of this text contain his torical information related to their s pecific s ubjects . Of particular interes t S ection 4.1 on anthropology and psychiatry, S ection sociology and psychiatry, S ection 5.1 on epidemiology, S ection 6.1 on ps ychoanalysis, S ection 6.3 on other ps ychodynamic s chools , S ection 9.1 on the mental disorders , and S ection 49.5 on the ps ychiatric as pects of acquired immunodeficiency syndrome. 31 covers drugs us ed in psychiatry and other biological therapies. S ection 32.1 gives an overview of child ps ychiatry, S ection 54.1 discus ses forens ic iss ues in ps ychiatry, S ection 24.1 gives a his tory of medicine, S ection 30.11 gives an evaluation of ps ychotherapy, and S ection 55.3 discus ses the future ps ychiatry.

R E F E R E NC E S Alexander F G , S els nick S T . T he His tory of Y ork: Harper & R ow; 1966. Andrews J , B riggs A, P orter R , T ucker P , T he His tory of B e thle m. London and New Y ork: R outledge; 1997. Applebaum P S . Almos t a R e volution: Mental He alth and the L imits of C hange. New Y ork: Oxford P res s; 1994. Ayd F J J r: T he early history of modern ps ychopharmacology. Neurops ychopharmacology. 5123 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/55.1.htm

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K APL AN AND S ADOC K 'S C OMPR E HE NS IVE TE XTB OOK OF PS YC HIATR Y 8th E DITION Front of B ook E ditors Authors Dedication About the E ditors Prefac e

Table of C ontents Volume I 1 Neural S c ienc es 1.1 Neural S ciences Introduction and 1.2 F unctional Neuroanatomy 1.3 Neural Development and Neurogenes is 1.4 Monoamine Neurotransmitters 1.5 Amino Acids As Neurotrans mitters 1.6 Neuropeptides B iology, R egulation, and in Neuropsychiatric Disorders 1.7 Neurotrophic F actors 1.8 Intraneuronal S ignaling P athways 1.9 B as ic E lectrophys iology 1.10 G enome, T ranscriptome, and P roteome 1.11 P s ychoneuroendocrinology 1.12 Immune S ystem and C entral Nervous S ys tem Interactions 1.13 C hronobiology 1.14 Applied E lectrophysiology 1.15 Nuclear Magnetic R esonance Imaging P rinciples and R ecent F indings in 5129 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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Neurops ychiatric Disorders 1.16 R adiotracer Imaging B as ic P rinciples E xemplary F indings in Neurops ychiatric Dis orders 1.17 P opulation G enetics and G enetic E pidemiology 1.18 G enetic Linkage Analysis of the Dis orders 1.19 T ransgenic Models of B ehavior 1.20 B as ic S cience of S leep 1.21 Appetite 1.22 Neural B asis of S ubs tance Abus e and Dependence 1.23 F uture Directions in Neuroscience and P sychiatry 2 Neurops yc hiatry and B ehavioral Neurology 2.1 Neuropsychiatric Approach to the P atient 2.2 Neuropsychiatric As pects of Dis orders 2.3 Neuropsychiatric As pects of B rain 2.4 Neuropsychiatric As pects of E pileps y 2.5 Neuropsychiatric As pects of T raumatic Injury 2.6 Neuropsychiatric As pects of Movement Dis orders 2.7 Neuropsychiatric As pects of Multiple S cleros is and Other Demyelinating Disorders 2.8 Neuropsychiatric As pects of HIV Infection and AIDS 2.9 Neuropsychiatric As pects of Other Dis eas es (Non-HIV ) 2.10 Neurops ychiatric Aspects of P rion 5130 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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2.11 Neurops ychiatric Aspects of Headache 2.12 Neurops ychiatric Aspects of Neuromuscular Disease 2.13 P s ychiatric Aspects of C hild Neurology 3 C ontributions of the Ps yc hological S ciences 3.1 S ens ation, P erception, and C ognition 3.2 E xtending J ean P iaget's Approach to Intellectual F unctioning 3.3 Learning T heory 3.4 B iology of Memory 3.5 B rain Models of Mind 3.6 Neuroscientific B as es of C onsciousness Dreaming 3.7 Normality and Mental Health 4 C ontributions of the S oc iocultural S c ienc es 4.1 T he P sychiatric S cientis t and the P sychoanalyst 4.2 S ociology and P sychiatry 4.3 S ociobiology 4.4 S ociopolitical T rends in Mental Health T he C ons umer/S urvivor Movement and Multiculturalis m 5 Quantitative and E xperimental Methods in Ps yc hiatry 5.1 E pidemiology 5.2 S tatistics and E xperimental Design 5.3 Mental Health S ervices 5.4 Animal R esearch and Its R elevance to P sychiatry 6 Theories of Pers onality and Ps yc hopathology 6.1 C las sic P s ychoanalys is 6.2 E rik H. E rikson 5131 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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6.3 Other P s ychodynamic S chools 6.4 Approaches Derived from P hilosophy P sychology 7 Diagnos is and Ps yc hiatry E xamination of the Ps yc hiatric Patient 7.1 P sychiatric Interview, History, and Mental S tatus E xamination 7.2 Interviewing T echniques with the Difficult P atient 7.3 P sychiatric R eport, Medical R ecord, and Medical E rror 7.4 S igns and S ymptoms in P s ychiatry F UT UR E DIR E C T IONS

7.5 C linical Neurops ychology and Intellectual Ass es sment of Adults 7.6 P ers onality As ses sment Adults and 7.7 Neuropsychological and C ognitive Ass es sment of C hildren 7.8 Medical Ass ess ment and Laboratory in P sychiatry 7.9 P sychiatric R ating S cales 7.10 T elemedicine, T elepsychiatry, and T herapy 8 C linical Manifes tations of Ps ychiatric 9 C las s ific ation in Ps yc hiatry 9.1 P sychiatric C lass ification 9.2 International P s ychiatric Diagnos is 10 Delirium, Dementia, and Amnes tic and Other C ognitive Dis orders and Mental Dis orders Due General Medic al C ondition 10.1 C ognitive Disorders Introduction and Overview 5132 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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10.2 Delirium 10.3 Dementia 10.4 Amnes tic Dis orders 10.5 Other C ognitive Dis orders and Mental Dis orders Due to a G eneral Medical 11 S ubs tance-R elated Dis orders 11.1 S ubstance-R elated Disorders and Overview 11.2 Alcohol-R elated Disorders 11.3 Amphetamine (or Amphetamine-like) related Dis orders 11.4 C affeine-R elated Disorders 11.5 C annabis -R elated Disorders 11.6 C ocaine-R elated Disorders 11.7 Hallucinogen-R elated Disorders 11.8 Inhalant-R elated Disorders 11.9 Nicotine-R elated Disorders 11.10 Opioid-R elated Disorders 11.11 P hencyclidine (or P hencyclidine-like) related Dis orders 11.12 S edative-, Hypnotic-, or AnxiolyticDis orders 11.13 Anabolic-Androgenic s teroid abus e 12 S chizophrenia and Other Ps ychotic 12.1 C oncept of S chizophrenia 12.2 S chizophrenia S cope of the P roblem 12.3 S chizophrenia G enetics 12.4 S chizophrenia E nvironmental E pidemiology 12.5 Developmental Model of S chizophrenia 12.6 Neuroimaging in S chizophrenia Linking Neurops ychiatric Manifestations to 5133 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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Neurobiology 12.7 S chizophrenia Neuropathology 12.8 S chizophrenia C linical F eatures and P sychopathology C oncepts 12.9 S chizophrenia C ognition 12.10 S chizophrenia S ensory G ating Deficits T ranslational R esearch 12.11 S chizophrenia P s ychos ocial T reatment 12.12 S chizophrenia S omatic T reatment 12.13 P s ychiatric R ehabilitation 12.14 S chizophrenia Integrative T reatment F unctional Outcomes 12.15 S chizophrenia S pectrum P athology T reatment 12.16 Other P s ychotic Dis orders 12.16a Acute and T ransient P sychotic and B rief P sychotic Dis order 12.16b S chizophreniform Disorder 12.16c Delusional Dis order and S hared P sychotic Dis order 12.16d S chizoaffective Disorder 12.16e P os tpartum P s ychos is 12.16f C ulture-B ound S yndromes with F eatures 12.16g P sychosis Not Otherwis e S pecified 12.16h T reatment of Other P s ychotic 12.17 S chizophrenia and Other P sychotic Dis orders S pecial Iss ues in E arly Detection Intervention 13 Mood Dis orders 13.1 Mood Disorders His torical Introduction C onceptual Overview 5134 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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13.2 Mood Disorders E pidemiology 13.3 Mood Disorders G enetics 13.4 Mood Disorders Neurobiology 13.5 Mood Disorders Intraps ychic and Interpersonal As pects 13.6 Mood Disorders C linical F eatures 13.7 Mood Disorders T reatment of 13.8 Mood Disorders T reatment of B ipolar Dis orders 13.9 Mood Disorders P sychotherapy 14 Anxiety Dis orders 14.1 Anxiety Disorders Introduction and Overview 14.2 Anxiety Disorders E pidemiology 14.3 Anxiety Disorders P sychophysiological Aspects 14.4 Anxiety Disorders Neurochemical 14.5 Anxiety Disorders Neuroimaging 14.6 Anxiety Disorders G enetics 14.7 Anxiety Disorders P sychodynamic 14.8 Anxiety Disorders C linical F eatures 14.9 Anxiety Disorders S omatic T reatment 14.10 Anxiety Disorders C ognitiveT herapy 15 S omatoform Dis orders 16 Fac titious Dis orders 17 Dis s oc iative Dis orders 18 Normal Human S exuality and S exual and Identity Dis orders 18.1a Normal Human S exuality and S exual Dys functions 18.1b Homos exuality, G ay and Les bian 5135 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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Identities , and Homos exual B ehavior 18.2 P araphilias 18.3 G ender Identity Disorders 18.4 S exual Addiction 19 E ating Dis orders 20 S leep Dis orders 21 Impuls e-C ontrol Dis orders Not E ls ewhere C las s ified

Volume II 22 Adjus tment Dis orders 23 Pers onality Dis orders 24 Ps yc hologic al Fac tors Affecting Medic al C onditions 24.1 His tory of P sychosomatic Medicine 24.2 G as trointes tinal Dis orders 24.3 Obes ity 24.4 C ardiovas cular Dis orders 24.5 R es piratory Dis orders 24.6 E ndocrine and Metabolic Dis orders 24.7 P s ychocutaneous Dis orders 24.8 Mus culoskeletal Disorders 24.9 S tress and P sychiatry 24.10 P s ycho-Oncology 24.11 C onsultation-Liais on P s ychiatry 25 R elational Problems 26 Additional C onditions That May B e a Foc us C linic al Attention 26.1 Malingering 26.2 Adult Antis ocial B ehavior, C riminality, V iolence 26.3 B orderline Intellectual F unctioning and 5136 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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Academic P roblem 26.4 Other Additional C onditions T hat May F ocus of C linical Attention 27 C ulture-B ound S yndromes 28 S pec ial Areas of Interes t 28.1 P s ychiatry and R eproductive Medicine 28.2 P remenstrual Dysphoric Dis order 28.3 G enetic C ounseling 28.4 E nd-of-Life and P alliative C are 28.5 Death, Dying, and B ereavement 28.6 P hysical and S exual Abuse of Adults 28.7 S urvivors of T orture 28.8 Alternative and C omplementary Health P ractices 28.9 Military and Dis aster P sychiatry 28.10 F amous Named C as es in P s ychiatry 29 Ps yc hiatric E mergencies 29.1 S uicide 29.2 Other P sychiatric E mergencies 30 Ps yc hotherapies 30.1 P s ychoanalysis and P s ychoanalytic P sychotherapy 30.2 B ehavior T herapy 30.3 Hypnos is 30.4 G roup P sychotherapy and C ombined Individual and G roup P sychotherapy 30.5 F amily T herapy and C ouple T herapy 30.6 C ognitive T herapy 30.7 Interpersonal P sychotherapy 30.8 Dialectical B ehavior T herapy 30.9 Intens ive S hort-T erm Dynamic P sychotherapy 5137 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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30.10 Other Methods of P s ychotherapy 30.11 E valuation of P sychotherapy 30.12 C ombined P sychotherapy and P harmacology 31 B iologic al Therapies 31.1 G eneral P rinciples of 31.2 P harmacokinetics and Drug Interactions 31.3 Drug Development and Approval in the United S tates 31.4 Medication-Induced Movement 31.5 α2-Adrenergic R eceptor Agonis ts and G uanfacine 31.6 β-Adrenergic R eceptor Antagonis ts 31.7 Anticholinergics and Amantadine 31.8 Anticonvuls ants 31.9 Antihistamines 31.10 B arbiturates and S imilarly Acting S ubstances 31.11 B enzodiazepine R eceptor Agonists Antagonists 31.12 B upropion 31.13 B uspirone 31.14 C alcium C hannel Inhibitors 31.15 C holines teras e Inhibitors and S imilarly Acting C ompounds 31.16 Dopamine R eceptor Antagonists Antips ychotics ) 31.17 Lithium 31.18 Mirtazapine 31.19 Monoamine Oxidase Inhibitors 31.20 Nefazodone 31.21 Opioid R eceptor Agonists Methadone, 5138 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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Levomethadyl, and B uprenorphine 31.22 Opioid R eceptor Antagonists and Nalmefene 31.23 S elective S erotonin Norepinephrine R euptake Inhibitors 31.24 S elective S erotonin R euptake 31.25 S erotonin-Dopamine Antagonis ts (Atypical or S econd-G eneration 31.26 S ympathomimetics and Dopamine R eceptor Agonis ts 31.27 T hyroid Hormones 31.28 T razodone 31.29 T ricyclics and T etracyclics 31.30 E lectroconvuls ive T herapy 31.31 Neuros urgical T reatments and Deep S timulation 31.32 Other P harmacological and B iological T herapies 31.33 Drug Augmentation 31.34 R eproductive Hormonal T herapy and P ractice 32 C hild Ps ychiatry 32.1 Introduction and Overview 32.2 Normal C hild Development 32.3 Normal Adolescence 33 Ps yc hiatric E xamination of the Infant, C hild, Adoles cent 34 Mental R etardation 35 L earning Dis orders 35.1 R eading Dis order 35.2 Mathematics Dis order 35.3 Dis order of W ritten E xpres sion and 5139 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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Learning Dis order Not Otherwis e S pecified 36 Motor S kills Dis order Developmental C oordination Dis order 37 C ommunication Dis orders 37.1 E xpres sive Language Dis order 37.2 Mixed R eceptive-E xpres sive Disorder 37.3 P honological Dis order 37.4 S tuttering 37.5 C ommunication Dis order Not Otherwis e S pecified 38 Pervas ive Developmental Dis orders 39 Attention-Defic it Dis orders 39.1 Attention-Deficit/Hyperactivity Disorder 39.2 Adult Manifes tations of AttentionDeficit/Hyperactivity Disorder 40 Dis ruptive B ehavior Dis orders 41 Feeding and E ating Dis orders of Infanc y and E arly C hildhood 42 Tic Dis orders 43 E limination Dis orders 44 Other Dis orders of Infanc y, C hildhood, and Adoles cence 44.1 R eactive Attachment Disorder of and E arly C hildhood 44.2 S tereotypic Movement Dis order of 44.3 Dis orders of Infancy and E arly Not Otherwis e S pecified 45 Mood Dis orders in C hildren and Adoles c ents 45.1 Depress ive Dis orders and S uicide in C hildren and Adoles cents 45.2 E arly-Onset B ipolar Disorders 46 Anxiety Dis orders in C hildren 5140 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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46.1 Obs ess ive-C ompulsive Disorder in 46.2 P os ttraumatic S tres s Disorder in and Adoles cents 46.3 S eparation Anxiety Disorder and Other Anxiety Dis orders 46.4 S elective Mutis m 47 E arly-Ons et S c hizophrenia 48 C hild Ps ychiatry Ps ychiatric Treatment 48.1 Individual P s ychodynamic 48.2 S hort-T erm P s ychotherapies for the T reatment of C hild and Adoles cent Disorders 48.3 C ognitive-B ehavioral P sychotherapy for C hildren and Adoles cents 48.4 G roup P sychotherapy 48.5 F amily T herapy 48.6 P ediatric P sychopharmacology 48.7 P artial Hospital and Ambulatory Health S ervices 48.8 R es idential and Inpatient T reatment 48.9 C ommunity-B as ed T reatment 48.10 P s ychiatric T reatment of Adoles cents 49 C hild Ps ychiatry S pec ial Areas of Interes t 49.1 P s ychiatric Aspects of Day C are 49.2 Adoption and F oster C are 49.3 C hild Maltreatment 49.4 C hildren's R eaction to Illnes s and Hos pitalization 49.5 P s ychiatric S equelae of HIV and AIDS 49.6 C hild or Adoles cent Antisocial B ehavior 49.7 Dis sociative Dis orders in C hildren and Adoles cents 49.8 Identity P roblem and B orderline 5141 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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in C hildren and Adolescents 49.9 Adoles cent S ubstance Abuse 49.10 F orensic C hild and Adolescent 49.11 E thical Iss ues in C hild and Adoles cent P sychiatry 49.12 S chool C onsultation 49.13 P revention of P sychiatric Dis orders in C hildren and Adoles cents 49.14 Neuroimaging in C hild and Adolescent P sychiatry 49.15 C hild Mental Health S ervices 49.16 Impact of T erroris m on C hildren 50 Adulthood 51 Geriatric Ps ychiatry 51.1 Overview 51.2 As ses sment 51.3 P s ychiatric Disorders of Late Life 51.4 T reatment of P s ychiatric Disorders 51.5 Health C are Delivery S ystems 51.6 S pecial Areas of Interes t 52 Hos pital and C ommunity Ps yc hiatry 52.1 P ublic and C ommunity P sychiatry 52.2 Health C are R eform 52.3 R ole of the P sychiatric Hos pital in the T reatment of Mental Illnes s 52.4 P s ychiatric R ehabilitation 53 Ps yc hiatric E duc ation 53.1 G raduate P sychiatric E ducation 53.2 E xamining P s ychiatris ts and Other P rofess ionals 53.3 An Anthropological V iew of P sychiatry 54 E thic s and Forens ic Ps ychiatry 5142 mk:@MSITStore:D:\@in\@7-3\New%20Folder\kaplan_ctp_8th.chm::/index.htm

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54.1 C linical-Legal Iss ues in P sychiatry 54.2 E thics in P sychiatry 54.3 C orrectional P sychiatry 55 Ps yc hiatry Pas t and Future 55.1 His tory of P sychiatry 55.2 W orld As pects of P s ychiatry 55.3 F uture of P s ychiatry

B ac k of B ook Appendic es Drugs Used in P sychiatry C olor P lates Index

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