Lance H. Hoffman
PSYCHIATRIC SYNDROMES (AXIS I DISORDERS)
DEMENTIA, DELIRIUM, AND AMNESTIC DISORDERS
Dementia is a disorder consisting of a pervasive disturbance in cognition-impairing memory, abstraction, judgment, personality, and higher critical functions such as language in which the onset is typically gradual, and the patient’s normal level of consciousness is maintained.
Metabolic and endocrine disorders, adverse drug effects and interactions, and depression are potentially reversible causes of dementia.
Delirium is characterized by a global impairment in cognitive functioning that is usually acute in onset with a fluctuating severity of symptoms in which a diminished level of consciousness, inattention, and sensory misperceptions, such as visual hallucinations, are experienced.
Most causes of delirium are reversible and include infection, electrolyte abnormalities, toxic ingestions, and head injury. Treatment should be directed toward correcting the underlying cause.
Amnestic patients cannot learn new information or recall previously learned information.
Causes of amnesia can include brain trauma, stroke, anoxic brain injury, substance abuse, and chronic nutritional deficiencies.
SUBSTANCE-INDUCED DISORDERS
Intoxication is an exogenous substance-induced syndrome that results in maladaptive behavior and impaired cognitive functioning and psychomotor activity.
Repeated use of such a substance is defined as substance abuse and may lead to physical or psychological dependence on the substance.
Substance withdrawal entails a collection of symptoms specific to a substance of abuse that result from the reduction or cessation of use of that substance with symptoms promptly subsiding with continued use of the exogenous substance.
SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS
Schizophrenia is a chronic disease characterized by functional deterioration; the presence of hallucinations, delusions, disorganized speech or behavior, or catatonic behavior (“positive symptoms”); the presence of blunted affect, emotional withdrawal, lack of spontaneity, anhedonia, or impaired attention (“negative symptoms”); cognitive impairment expressed as loose associations or incoherence; and the relative absence of a mood disorder.
Schizophreniform disorder is diagnosed when an individual experiences symptoms and demonstrates signs consistent with schizophrenia for less than 6 months.
A brief psychotic disorder is a psychosis that lasts less than 4 weeks and is a response to a traumatic life experience.
MOOD DISORDERS
Major depression consists of a persistent dysphoric mood or a pervasive loss of interest and pleasure in usual activities (anhedonia) lasting longer than 2 weeks.
Associated psychological symptoms of major depression include feelings of guilt over past events, self-reproach, worthlessness, hopelessness, and recurrent thoughts of death or suicide.
Vegetative symptoms of major depression affecting physiologic functioning include a loss of appetite and weight, sleep disturbances, fatigue, inability to concentrate, and psychomotor agitation or retardation.
The lifetime risk of suicide in patients with major depression is 15%.
Bipolar disorder is characterized by recurrent, cyclic episodes of manic and depressive symptoms, with depressive episodes being more common than manic episodes.
Manic individuals demonstrate an elated or irritable mood; act energetically and expansively; and demonstrate a decreased need for sleep, poor impulse control, racing thoughts, and pressured speech.
ANXIETY DISORDERS
Panic disorder consists of recurrent episodes of severe anxiety and sudden, extreme autonomic symptoms that peak quickly.
Panic disorder is a diagnosis of exclusion because its symptoms can mimic those of life-threatening cardiovascular and pulmonary disorders.
Post-traumatic stress disorder is an anxiety reaction to a severe, psychosocial stressor, typically perceived as life threatening in which the individual experiences repetitive, intrusive memories of the event.
Obsessive-compulsive disorder patients experience intrusive thoughts or images that create anxiety (obsessions) and are controlled by the patients by engaging in repetitive behaviors or rituals (compulsions).
PERSONALITY DISORDERS (AXIS II DISORDERS)
Individuals with a personality disorder exhibit a lifelong pattern of maladaptive behavior that is not limited to periods of illness.
Ten personality disorders named according to their characteristic maladaptive behavior exist and include paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 284, “Behavioral Disorders: Diagnostic Criteria,” by Leslie Zun.