Case Files Psychiatry 4th Edition PDF

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FOURTH EDITION CASE FILES® Psychiatry Eugene C. Toy, MD The John S. Dunn, Senior Academic Chair and Program Director The Methodist Hospital Ob/Gyn Residency Program Houston, Texas Vice Chair of Academic Affairs Department of Obstetrics and Gynecology The Methodist Hospital Houston, Texas Clinical P...

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FOURTH EDITION

CASE FILES® Psychiatry Eugene C. Toy, MD The John S. Dunn, Senior Academic Chair and Program Director The Methodist Hospital Ob/Gyn Residency Program Houston, Texas Vice Chair of Academic Affairs Department of Obstetrics and Gynecology The Methodist Hospital Houston, Texas Clinical Professor and Clerkship Director Department of Obstetrics and Gynecology University of Texas Medical School at Houston Houston, Texas Associate Clinical Professor Weill Cornell College of Medicine

Debra Klamen, MD, MHPE Associate Dean of Education and Curriculum Professor and Chair, Department of Medical Education Professor, Department of Psychiatry Southern Illinois University School of Medicine Springfield, Illinois

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Copyright © 2012 by The McGraw-Hill Companies, Inc. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. ISBN: 978-0-07-176029-4 MHID: 0-07-176029-6 The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-175391-3, MHID: 0-07-175391-5. All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the trademark. Where such designations appear in this book, they have been printed with initial caps. McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate training programs. To contact a representative please e-mail us at [email protected]. Previous editions copyright © 2009 and 2007 and 2004 by The McGraw-Hill Companies. Case Files® is a registered trademark of The McGraw-Hill Companies, Inc. All rights reserved. Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standard accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the editors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. TERMS OF USE This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise.

DEDICATION

In loving memory of my grandparents, Lew Yook Toy and Manway Toy, who courageously pioneered our family’s legacy in this great country. – ECT To my wonderful husband, Phil, who loves me and supports me in all things. To my mother, Bonnie Klamen, and to my late father, Sam Klamen, who were and are always there. – DLK

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CONTENTS

Contributors / vii Preface / xi Acknowledgments / xiii Introduction / xv Section I How to Approach Clinical Problems ........................................................................ 1 Part 1. Approach to the Patient ................................................................................ 2 Part 2. Approach to Clinical Problem Solving ....................................................... 11 Part 3. Approach to the Diagnostic and Statistical Manual of Mental Disorders ....................................................................................... 13 Part 4. Approach to Reading .................................................................................. 14 Section II Psychiatric Therapeutics ........................................................................................ 21 Part 1. Psychotherapy ............................................................................................. 22 Part 2. Psychopharmacotherapy ............................................................................ 23 Section III Clinical Cases .......................................................................................................... 41 Sixty Case Scenarios ............................................................................................... 43 Section IV Listing of Cases..................................................................................................... 453 Listing by Case Number ....................................................................................... 455 Listing by Disorder (Alphabetical) ....................................................................... 456 Listing by DSM-IV Categories .............................................................................. 458 Index / 461

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CONTRIBUTORS

Staci Becker, RN, MS Nurse Educator Adjunct Instructor Department of Medical Education Southern Illinois University School of Medicine Springfield, Illinois Acute Stress Disorder Borderline Personality Disorder Dependent Personality Disorder Dysthymic Disorder Factitious Disorder Major Depression, Recurrent Narcissistic Personality Disorder Pain Disorder Paranoid Personality Disorder Schizotypal Personality Disorder Sean M. Blitzstein, MD Director, Psychiatry Clerkship Clinical Associate Professor of Psychiatry University of Illinois at Chicago Chicago, Illinois Alcohol Dependence Cocaine Intoxication and Cocaine Dependence Conversion Disorder Hypothyroidism with Depression Extrapyramidal Symptoms (Acute Dystonic Reaction) Neurosis Opioid Withdrawal Panic Disorder versus Thyroid Medication Overuse Posttraumatic Stress Disorder Psychotic Disorder Not Otherwise Specified

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CONTRIBUTORS

Philip Pan, MD Assistant Professor Director, Adult Outpatient Services Chief, Division of Forensic Psychiatry Department of Psychiatry Southern Illinois University School of Medicine Springfield, Illinois Adjustment Disorder Alcohol Withdrawal Amphetamine Intoxication Antisocial Personality Disorder Avoidant Personality Disorder Benzodiazepine Withdrawal Cocaine-Induced (Substance-Induced) Mood Disorder Malingering Phencyclidine Intoxication Schizoid Personality Disorder Stephen M. Soltys, MD Professor and Chair Department of Psychiatry Southern Illinois University School of Medicine Springfield, Illinois Attention-Deficit/Hyperactivity Disorder Bipolar Disorder (Child) Bulimia Nervosa Gender Identity Disorder Hypochondriasis Major Depression with Psychotic Features Mild Mental Retardation Primary Insomnia Separation Anxiety Disorder Tourette Disorder Thomas E. Wright, MD Assistant Clinical Professor of Psychiatry University of Illinois College of Medicine Chief Medical Officer, Rosecrance Health Network Rockford, Illinois Anorexia Nervosa Autistic Disorder Conduct Disorder Fetishism Histrionic Personality Disorder Obsessive-Compulsive Disorder (Child) Obsessive-Compulsive Personality Disorder Schizoaffective Disorder Sleep Terror Disorder Social Phobia

CONTRIBUTORS

Melanie Zupancic, MD Department of Internal Medicine Division of Medicine/Psychiatry Southern Illinois University School of Medicine Springfield, Illinois Anxiety Disorder Secondary to a General Medical Condition Bipolar Disorder, Manic (Adult) Dementia Delirium Dissociative Fugue Generalized Anxiety Disorder Major Depression in Elderly Patients Psychosis Caused by a General Medical Condition Schizophrenia, Paranoid Somatization Disorder

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PREFACE

We appreciate all the kind remarks and suggestions from the many medical students over the past 3 years. Your positive reception has been an incredible encouragement, especially in light of the short life of the Case Files® series. In this fourth edition of Case Files®: Psychiatry, the basic format of the book has been retained. Improvements were made in streamlining many of the chapters and adding proposed DSM-V criteria. Also, numerous clinical cases were rewritten to be representative of more typical patient presentations rather than the “flamboyant” presentation. We debated about whether to group the cases together so that students could compare related disorders, such as cases 1 through 10 would be “personality disorders” to allow for side-by-side comparison. We decided not to use this systematic grouping approach because patients do not present to their doctors in the real world in this manner. Rather, patients present with symptoms and signs, and it is the “job” of the student and clinician to sort out whether there is a psychiatric issue, and which diagnosis is likely. Nevertheless, the case listing in the back of the book and the index will allow a student to quickly reference similar cases for the sake of comparison. The multiple choice questions have been carefully reviewed and rewritten to ensure that they comply with the National Board and USMLE Step 2 CK format. Some new psychiatric medications have been introduced as well. By using this fourth edition, we hope that the reader will continue to enjoy learning psychiatry through the simulated clinical cases. It is certainly a privilege to be a teacher for so many students, and it is with humility that we present this edition. The Authors

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ACKNOWLEDGMENTS

The curriculum from which the ideas for this series evolved was inspired by two talented, forthright students, Philbert Yau and Chuck Rosipal, who have since graduated from medical school. It has been a great joy to work with Debra Klamen, a brilliant psychiatrist, educator, and lover of horses, and with all the excellent contributors. I appreciate McGraw-Hill’s belief in the concept of teaching through clinical cases. I am greatly indebted to my editor, Catherine Johnson, whose exuberance, experience, and vision helped shape this series and to the incomparable Cindy Yoo, Production Editor. I am also grateful to Catherine Saggese for her excellent production expertise. I appreciate the outstanding work of Tania Andrabi, Project Manager for this book. At Southern Illinois University, I thank Dr Kevin Dorsey for his help and support in completing this project. At the Methodist Hospital, I appreciate the support of my chairman, Dr Alan Kaplan, and I applaud the finest administrators I have encountered: Drs Marc Boom, Judy Paukert, H. Dirk Sostman, and Karin Larsen-Pollock, and Ms Debby Chambers for their commitment to medical education. I am grateful to Linda Bergstrom for her sage advice and support. Without my esteemed colleagues, Drs Konrad Harms, Priti Schachel, and Gizelle Brooks-Carter, this book could not have been written. Most of all, I appreciate my loving wife, Terri, and my four wonderful children, Andy, Michael, Allison, and Christina, for their patience and understanding. Eugene C. Toy

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INTRODUCTION

Mastering the cognitive knowledge within a field such as psychiatry is a formidable task. It is even more difficult to draw on that knowledge, procure and filter through the clinical data, develop a differential diagnosis, and finally form a rational treatment plan. To gain these skills, the student often learns best by directly interviewing patients, guided and instructed by experienced teachers and inspired toward selfdirected, diligent reading. Clearly, there is no replacement for education at the patient’s side. Unfortunately, clinical situations usually do not encompass the breadth of the specialty. Perhaps the best alternative is to prepare carefully crafted cases designed to simulate the clinical approach and decision making. In an attempt to achieve this goal, we have constructed a collection of clinical vignettes to teach diagnostic or therapeutic approaches relevant to psychiatry. Most important, the explanations for the cases emphasize mechanisms and underlying principles rather than merely rote questions and answers. This book is organized for versatility: to allow the student “in a rush” to read the scenarios quickly and check the corresponding answers, as well as to provide more detailed information for the student who wants thought-provoking explanations. The answers are arranged from simple to complex: a summary of the pertinent points, the bare answers, an analysis of the case, an approach to the topic, a comprehension test at the end for reinforcement and emphasis, and a list of resources for further reading. The clinical vignettes are purposely presented in random order to simulate the way that real patients present to a practitioner. A listing of cases is included in Section IV to aid students who desire to test their knowledge of a certain area or to review a topic, including the basic definitions. Finally, we intentionally did not primarily use a multiple-choice question (MCQ) format because clues (or distractors) are not available in the real world. Nevertheless, several MCQs are included at the end of each scenario to reinforce concepts or introduce related topics.

HOW TO GET THE MOST OUT OF THIS BOOK Each case is designed to simulate a patient encounter by using open-ended questions. At times, the patient’s complaint differs from the issue of greatest concern, and sometimes extraneous information is given. The answers are organized into four different parts.

PART I 1.

2.

A Summary: The salient aspects of the case are identified, filtering out extraneous information. The student should formulate a summary of the case before looking at the answers. A comparison with the summation appearing in the answer will help improve the student’s ability to focus on the important data while appropriately discarding irrelevant information, a fundamental skill required in clinical problem solving. A Straightforward Answer to each open-ended question. xv

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3.

INTRODUCTION

An Analysis of the Case consisting of two parts: a. Objectives: A listing of the two or three main principles that are crucial for a practitioner in treating the patient. Again, the student is challenged to make “educated guesses” about the objectives of the case on initial review of the case scenario, which helps sharpen his or her clinical and analytical skills. b. Considerations: A discussion of the relevant points and a brief approach to the specific patient.

PART II An Approach to the Disease Process consisting of two distinct parts: a. Definitions: Terminology pertinent to the disease process. b. Clinical Approach: A discussion of the approach to the clinical problem in general, including tables and figures.

PART III Comprehension Questions: Each case contains several MCQs that reinforce the material presented or introduce new and related concepts. Questions about material not found in the text are explained in the answers.

PART IV Clinical Pearls: A listing of several clinically important points that are reiterated as a summation of the text and allow for easy review, such as before an examination, and includes some proposed changes for DSM-V.

SECTION I: HOW TO APPROACH CLINICAL PROBLEMS

SECTION I

How to Approach Clinical Problems Part 1

Approach to the Patient

Part 2

Approach to Clinical Problem-Solving

Part 3

Approach to the Diagnostic and Statistical Manual of Mental Disorders

Part 4

Approach to Reading

1

2

CASE FILES: PSYCHIATRY

Part 1. Approach to the Patient It is a difficult transition from reading about patients with psychiatric disorders, and reading the diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), to actually developing a psychiatric diagnosis for a patient. It requires the physician to understand the criteria and be able to sensitively elicit symptoms and signs from patients, some of whom have difficulty providing a clear history. The clinician must then put together the pieces of a puzzle in order to find the single best diagnosis for the patient. This process can require further information from the patient’s family, additions to the medical and psychiatric history, careful observation of the patient, a physical examination, selected laboratory tests, and other diagnostic studies. Establishing rapport and a good therapeutic alliance with patients is critical to both their diagnosis and their treatment.

CLINICAL PEARL 䉴

A patient’s history is the single most important tool in establishing a diagnosis. Developing good rapport with patients is key to effective interviewing and thorough data gathering. Both the content (what the patient says and does not say) and the manner in which it is expressed (body language, topic shifting) are important.

HISTORY 1. Basic information: a. Identifying information includes name, age, marital status, gender, occupation, and language(s) spoken other than English if applicable. Ethnic background and religion can also be included if they are pertinent. ...