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Mosby's Handbook of Medical Psychiatry 2nd Edition (2004)

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  IIIIII   Handbook of Medical Psychiatry   SECOND EDITION David P. Moore M.D. Associate Clinical Professor of Psychiatry, University of Louisville School of Medicine; Frazier Rehab Institute, Louisville, Kentucky James W. Jefferson M.D. Distinguished Senior Scientist, Madison Institute of Medicine, Inc.; Clinical Professor of Psychiatry, University of Wisconsin Medical School, Madison  IV ELSEVIER   MOSBY  An Affiliate of Elsevier 170 S Independence Mall W. 300E. Philadelphia, PA 19106-3399HANDBOOK OF MEDICAL PSYCHIATRY, 2nd EditionãISBN 0-323-02911-6  Copyright © 2004, 1996,Mosby, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 238 7869, fax: (+1) 215 238 2239, e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com.proxy.hsclib.sunysb.edu), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’.  NOTICE Medicine is an ever-changing field. Standard safety precautions must be followed, but as new research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current product information provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications. It is the responsibility of the licensed physician, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the editor assumes any liability for any injury and/or damage to persons or property arising from this publication. Previous edition copyrighted 1996. Library of Congress Cataloging-in-Publication Data  Moore, David P. Handbook of medical psychiatry/David P. Moore, James W. Jefferson.—2nd ed. ãããp. ; cm. ããIncludes bibliographical references and index. ããISBN 0-323-02911-6 ãã1. Biological psychiatry—Handbooks, manuals, etc. I. Title: Medical psychiatry. ããII. Jefferson, James W. III. Title. ãã[DNLM: 1.Mental Disorders—Handbooks. WM 34 M821h 2004] ãRC455.4.B5M64 2004 ã616.89—dc22ã2004044821  Acquisitions Editor:  Susan F. Pioli  Editorial Assistant:  Joan Ryan Publishing Services Manager:  Joan Sinclair Project Manager:  Mary StermelPrinted in the United States of AmericaLast digit is the print number: 10 9 8 7 6 5 4 3 2 1 V Scribere actum fidei est.  To my wife Nancy G. Moore, Ph.D.  my children, Ethan, Nathaniel  and Joshua  and to my editor Susan Pioli  who has been, and remains, a godsend DPM Cui dono lepidum novum libellum   arido modo pumice expolitum?    Catullus c.84–c.54 BC To Susan Mary Cole  my wife of many years, Lara, Shawn  and James,  my children of quite a few years, and Cole  and Dean,  my grandchildren JWJ VIVII   Preface to the Second Edition  In the preface to the first edition of the  Handbook of Medical Psychiatry  we stated that it was our intention to write a comprehensive, thorough and practical textbook of psychiatry, presented firmly within the medical model. We are happy to say, judging by the reviews the  Handbook   received in many journals, that it appears we succeeded.This second edition builds on the strengths of the first. The  Handbook   continues to cover almost every psychiatric, neurologic and general medical condition capable of causing disturbances in thought, feeling or behavior, together with almost every psychopharmacologic agent currently available in America. Further, it continues to provide sufficient detail such that the reader will be better equipped to assess, diagnose and treat whatever case may be encountered in the clinic, on the ward or during consultations. Finally, at its heart, it remains extremely practical – the sort of text that the student and resident will keep on the ward (and next to the phone at night), and to which the practitioner may refer when in need of a refresher or when confronted with a rare or unusual condition.The pace of research in psychiatry has quickened since the first edition, and we have aimed to keep the  Handbook   current. To that end, the entire text has been revised and updated, and 26 new chapters have been added.We trust, as we did before, that the reader will find this text useful, and we hope that it will further solidify psychiatry’s place as a medical specialty. David P. Moore James W. Jefferson VIII   Section I - General Symptomatology   1 Chapter 1 - General Symptomatology As is the case with all medical specialty areas, the symptoms described in this chapter are of varying specificity and sensitivity. In some cases specificity is fairly high; for example, Schneiderian delusions, although not specific for schizophrenia, are strongly suggestive of this disorder.  Unfortunately, this degree of specificity is rare for most symptoms in psychiatry; rather, most symptoms, such as depressed mood, may be found in a host of disorders.Given the relative nonspecificity of most of the symptoms described below, becoming familiar with, at the least, the most common disorders described in this book is necessary. The importance of the overall clinical picture cannot be overstressed; in most cases one cannot rely on any one or two symptoms. The box on p. 2 lists the signs and symptoms covered in this chapter. 1.A APPEARANCE The overall appearance of the patient may offer valuable diagnostic clues. Dress, grooming, and demeanor may be an integral part of the symptomatology of an illness.Some patients may appear bizarre, unkempt or disheveled. The hair may be uncut, dirty, and uncombed; the fingernails long and likewise dirty. The clothing may be torn, mismatched for color and pattern, and is often layered with redundant shirts, sweaters, and socks. Ornaments and bits of jewelry may be oddly placed; some patients may wear tin foil to keep off noxious influences, or have their ears plugged with cotton to keep away the voices. Such an overall appearance may be seen in schizophrenia.Depression, when severe, may render certain aspects of dress and grooming such an effort that they are left undone. The hair, though perhaps clean, may only be halfheartedly combed; women may omit their makeup. When less severe, patients may be able to keep up appearances, but their overall demeanor may indicate their illness. The shoulders sag, the posture is slumped, the head may be hung, and the over-all impression is of a body drained of life. In some cases this drained appearance can be truly remarkable. During depression the skin may become deeply lined and lack turgor, the hair appear lifeless and dull, and the eyes lack any vibrancy. Upon recovery the change may be startling. Patients may appear to have become 10 years younger; the eyes may sparkle, the hair appear almost lustrous, and the skin appear smooth and vital.In contrast with depressed patients, manic patients may appear overvitalized. Dress is often overly colorful, at times clashing. Jewelry may be in abundance and overly gaudy; at times patients may be absolutely festooned with jewelry. Veritable headdresses may be worn, and women may plait their hair, often intertwining it with flowers or colorful ribbons. Colorful appearance may also be seen in patients with a histrionic personality disorder. The dress of histrionic patients, however, though perhaps tastefully colorful, rarely becomes as garish as that sported by the manic.Some patients with anorexia nervosa attempt to hide their emaciation with long hair, bulky sweaters, and long heavy skirts. The drawn, sunken face, however, belies the robust impression offered by the dress. 1.B DISTURBANCES OF ACTIVITY 1.B1 Inactivity Inactivity may stem from a variety of causes including psychomotor retardation and lack of interest (or anhedonia), as seen in depression, a general slowing of all processes as may be seen in hypothyroidism, ambivalence and “annihilation of the will” as in schizophrenia, abulia of the frontal lobe syndrome, and the peculiar combination of paralyzing ambivalence and tension seen in catatonic stupor.In depression patients lose their hedonic capacity: they take no pleasure in things; nothing excites or motivates them; and they lose interest in former pleasures. For them, all the color seems drained away from life, leaving it stale and tasteless, a wearisome burden. Coupled with this lack of interest, there is typically a more or less profound anergia, or lack of energy. Patients complain of feeling fatigued, drained, and exhausted. Some also experience an oppressive heaviness and a sense of painful inhibition of all processes. At times the oppressive fatigue may be so severe as to make simple actions, such as picking up a fork, impossible.Thus fatigued and unexcited by life, depressed patients may sit motionless for hours; simple tasks are accomplished only with the greatest of effort. They may speak little, and, when they do, it may be but a whisper, soon to trail off again into silence.The slowing seen in hypothyroidism primarily consists of fatigue and lack of energy. In contrast to depressed patients, hypothyroid patients often retain some interest, and rarely complain of a sense of oppressive inhibition.The ambivalence seen in schizophrenia may paralyze the patient into inaction. Here it is not so much a case of an inability to exert the will, but rather the simultaneous appearance of two opposite but equally strong inclinations. When faced with a choice, the patient may thus be unable to commit to one or another course of action. In one case, a patient, though hungry, sat through a meal without eating, being unable to decide whether to use a fork or a spoon.In other cases of schizophrenia, an actual annihilation of the will may be seen: the capacity to act volitionally, to conceive of a purpose and follow it, may be lost. Such patients are unable to summon themselves to purposeful activity and may spend their

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