Chapter 184. Clinical Features of Behavioral Disorders

Dementia

Dementia is a disorder consisting of a pervasive disturbance in cognition that impairs memory, abstraction, judgment, personality, and higher critical functions such as language. Its onset is typically gradual, and the patient's normal level of consciousness is maintained. The presence of global cognitive impairment can be detected by using a bedside screening test such as the Mini-Mental State Exam. Potentially reversible causes of dementia include metabolic and endocrine disorders, adverse drug effects and interactions, and depression.

Delirium

Delirium is characterized by acute development of impairment in cognitive function, diminished level of consciousness, inattention, and sensory misperceptions that fluctuate over the course of hours. Visual hallucinations are common. The causes of delirium are frequently treatable and include infection, electrolyte abnormalities, toxic ingestions, and head injury. Treatment is directed toward correcting the underlying cause.

Amnestic Disorders

Amnestic patients cannot learn new information or recall previously learned information. Amnesia may be due to 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. Judgment, perception, attention, and emotional control may be affected. Repeated use (substance abuse) may lead to physical or psychological dependence. Substance withdrawal symptoms may develop when the amount ingested is reduced or stopped. Symptoms and timing of withdrawal depend on the substance of abuse.

Schizophrenia and Other Psychotic Disorders

Schizophrenia is a chronic disease characterized by functional deterioration. Clinical features include “positive symptoms” such as hallucinations, delusions, disorganized speech or behavior, or catatonic behavior, “negative symptoms” such as blunted affect, emotional withdrawal, lack of spontaneity, anhedonia, or impaired attention, as well as cognitive impairment with loose associations or incoherence and the relative absence of a mood disorder. Patients may present to the emergency department for worsening psychosis, suicidal ideations, bizarre or violent behavior, or adverse medication events. Older antipsychotic medications, such as haloperidol, effectively treat the “positive symptoms,” and newer antipsychotic medications, such as aripiprazole, quetiapine, olanzapine, risperidone, ziprasidone, and clozapine, effectively treat “positive” and “negative” symptoms. The diagnosis of schizophreniform disorder is made 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 in response to a traumatic life experience, such as sexual assault, natural disaster, combat, or death of a loved one.

Mood Disorders

Major Depression

Major depression is characterized by a persistent dysphoric mood or a pervasive loss of interest and pleasure in usual activities (anhedonia) that lasts longer than 2 weeks. Associated psychological symptoms include feelings of guilt over past events, self-reproach, worthlessness, hopelessness, and recurrent thoughts of death or suicide. Physiologic symptoms include loss of appetite and weight, sleep disturbances, fatigue, inability to concentrate, and psychomotor agitation or retardation. The diagnosis should be entertained in any patient presenting with multiple vague complaints. The lifetime risk of suicide in patients with this disorder is 15%. Consequently, all patients suspected of having major depression should be questioned about suicidal thoughts. An appropriate psychiatric consultation and referral are needed for those with suicidal thoughts.

Bipolar Disorder

Bipolar disorder is characterized by recurrent, cyclic episodes of manic and depressive symptoms, with depressive episodes being more common than manic episodes. Manic individuals experience an elated mood that can quickly deteriorate to irritability and hostility should their expectations not be met. They appear energetic and expansive, with a decreased need for sleep, poor impulse control, racing thoughts, and pressured speech. They have grandiose ideas. Complications include suicide, substance abuse, and marital and occupational disruptions. Valproic acid and lithium salts are commonly prescribed as chronic mood stabilizers.

Anxiety Disorders

Panic disorder consists of recurrent episodes of severe anxiety and sudden, extreme autonomic symptoms. It is a diagnosis of exclusion as these symptoms can also occur in life-threatening cardiovascular and pulmonary disorders. Benzodiazepines, such as alprazolam and lorazepam, are effective in treating acute episodes of anxiety. The diagnosis of generalized anxiety disorder can be made when a patient experiences persistent worry or tension without discrete panic attacks for at least 6 months. Phobias consist of symptoms of anxiety, recognized as excessive by the person, prompted by the exposure to, or the anticipated exposure to, a specific stimulus. Posttraumatic stress disorder is an anxiety reaction to a severe, psychosocial stressor, typically perceived as life threatening. The individual experiences repetitive, intrusive memories of the event. Nightmares, feelings of guilt and depression, and substance abuse are common. Individuals with obsessive-compulsive disorder experience intrusive thoughts or images that create anxiety (obsessions). To control these thoughts and anxiety, the individual engages in repetitive behaviors or rituals (compulsions).

Individuals with a personality disorder exhibit a lifelong pattern of maladaptive behavior that is not limited to periods of illness. Personality disorders include paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.