Psychiatry 3rd Edition

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PSYCHIATRY
T H I R D E DI T I O N

Janis L. Cutler, MD
Professor of Psychiatry at Columbia University Medical Center
Director of Medical Student Education, College of Physicians
and Surgeons of Columbia University and New York State
Psychiatric Institute
Faculty, Columbia University Center
for Psychoanalytic Training and Research

1
1
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Library of Congress Cataloging-in-Publication Data
Psychiatry (Cutler)
Psychiatry / [edited by] Janis L. Cutler.—Third edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978–0–19–932607–5 (alk. paper)
I. Cutler, Janis L., editor of compilation. II. Title.
[DNLM: 1. Mental Disorders. WM 140]
RC454
616.89—dc23
2013042497
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However, in light of the possibility of human error or changes in the practice of medicine, neither
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To RCP, with love
CONTENTS

Acknowledgments ix
Contributors xi
Introduction xv

1. Psychiatric Assessment and Treatment Planning 1

Janis L. Cutler

2. The Psychiatric Interview 22

Anand Desai and Lyle Rosnick

3. Mood Disorders 46
Licínia Ganança, David A. Kahn, and Maria A. Oquendo

4. Schizophrenia and Other Psychotic Disorders 97

Matthew D. Erlich, Thomas E. Smith, Ewald Horwath, and Francine Cournos

5. Neurocognitive Disorders and Mental Disorders Due to Another

Medical Condition 129
Jennifer M. Rucci and Robert E. Feinstein

6. Anxiety, Obsessive-Compulsive, and Stress Disorders 168

Franklin R. Schneier, Hilary B. Vidair, Leslie R. Vogel, and Philip R. Muskin

7. Substance-Related and Addictive Disorders 204

Benjamin R. Bryan and Frances R. Levin

8. Personality Disorders 257

Eve Caligor, Frank Yeomans, and Ze'ev Levin

9. Feeding and Eating Disorders 291

Michael J. Devlin and Joanna E. Steinglass

10. Somatic Symptom and Related Disorders 323

Kelli Jane K. Harding and Brian A. Fallon

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viii╇ / / ╇ C ontents

11. Psychological Factors Affecting Medical Conditions 351

Sara Siris Nash, Lucy Hutner, and Eve Caligor

12. Suicide 387

Brian Rothberg and Robert E. Feinstein

13. Violence 403

Robert E. Feinstein and Brian Rothberg

14. Child, Adolescent, and Adult Development 418

Jonathan A. Slater, Katharine A. Stratigos, and Janis L. Cutler

15. Child and Adolescent Psychiatry 456

Daniel T. Chrzanowski, Elisabeth B. Guthrie, Matthew B. Perkins,
and Moira A. Rynn

16. Pharmacotherapy, ECT, and TMS 513

Jessica Ann Stewart, L. Mark Russakoff, and Jonathan W. Stewart

17. Psychotherapy 557

David D. Olds and Fredric N. Busch

Index 611
ACKNOWLEDGMENTS

I am fortunate to have spent my entire psychiatric career in the Department of Psychiatry

at the College of Physicians and Surgeons of Columbia University and New York State
Psychiatric Institute. I am grateful to the medical school and departmental leadership, my
faculty colleagues, and the bright, idealistic, intellectually curious medical students with
whom I have had the privilege of working. In particular, I would like to thank Dr. Jeffrey
Lieberman, Department Chair, and Dr. Maria Oquendo, Vice-chair for Education,
for their support of medical student education, as well as Dr. Ronald Rieder, previous
Vice-chair for Education, for his support and mentorship. Dr. Eric Marcus, Director of
the Columbia University Psychoanalytic Center for Training and Research, inspired and
co-edited the previous two editions of Psychiatry. He is an exemplary role model of a great
teacher who has devoted his career to psychiatric education.
I have also had the good fortune to learn about psychiatry and psychiatric educa-
tion from my colleagues nationwide in the Association for Directors of Medical Student
Education in Psychiatry. I am grateful for their enthusiasm and creativity. In particular
I would like to thank Dr. John Spollen for his suggestions with regard to the reorganiza-
tion of the Suicide and Violence chapters.
Edith White deserves special recognition and gratitude for her long-standing role as
administrator for the Division of Medical Student Education. It has been a pleasure to
work with Christopher Reid and Craig Panner of Oxford University Press. Finally, the
continued support of my family makes the work worthwhile. Special thanks and appre-
ciation go to Dr. Reed Perron and Alexander and Joshua Weiss.

ix
CONTRIBUTORS

Benjamin R. Bryan, MD Janis L. Cutler, MD

Instructor in Clinical Psychiatry Professor of Psychiatry at Columbia
College of Physicians and Surgeons of University Medical Center
Columbia University Director of Medical Student Education in
New York, NY Psychiatry
College of Physicians and Surgeons of
Fredric N. Busch, MD Columbia University and New York
Clinical Professor of Psychiatry State Psychiatric Institute
Weill Cornell Medical College Faculty, Columbia University Psychoanalytic
Faculty, Columbia University Center for Center for Training and Research
Psychoanalytic Training and Research New York, NY
New York, NY
Anand Desai, MD
Eve Caligor, MD Assistant Clinical Professor of Psychiatry
Clinical Professor of Psychiatry College of Physicians and Surgeons of
NYU School of Medicine Columbia University and New York
Director, Psychotherapy Division State Psychiatric Institute
Columbia University Center for New York, NY
Psychoanalytic Training and Research
New York, NY Michael J. Devlin, MD
Professor of Clinical Psychiatry
Daniel T. Chrzanowski, MD College of Physicians and Surgeons of
Assistant Clinical Professor of Psychiatry Columbia University
College of Physicians and Surgeons of Associate Director, Eating Disorders
Columbia University Research Unit
New York, NY New York State Psychiatric Institute
Attending Psychiatrist, New York
Francine Cournos, MD Presbyterian Hospital, Columbia
Professor of Clinical Psychiatry (in University Medical Center
Epidemiology) New York, NY
Mailman School of Public Health,
Columbia University
New York, NY

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xii / / C ontributors

Matthew D. Erlich, MD Ewald Horwath, MD, MS

Assistant Professor of Clinical Psychiatry Professor and Chair, Department of
College of Physicians and Surgeons of Psychiatry
Columbia University Case Western Reserve University
Director, OMH Consultation Service The Metro Health System
New York State Office of Mental Health Cleveland, OH
New York, NY
Lucy Hutner, MD
Brian A. Fallon, MD Assistant Professor of Psychiatry
Professor of Psychiatry at Columbia Associate Director of Residency Training
University Medical Center NYU School of Medicine
Director, Center for Neuroinflammatory Adjunct Assistant Clinical Professor of
Disorders and Biobehavioral Medicine Psychiatry
New York State Psychiatric Institute College of Physicians and Surgeons of
Director, Lyme & Tick-Borne Diseases Columbia University
Research Center New York, NY
Columbia University Medical Center
New York, NY David A. Kahn, MD
Diane Goldman Kemper Family Professor
Robert E. Feinstein, MD of Psychiatry Emeritus
Professor of Psychiatry Columbia University Medical Center
Vice Chair of Clinical Education Quality New York, NY
& Safety
Practice Director Psychiatry Frances R. Levin, MD
University of Colorado Hospital Kennedy-Leavy Professor of Psychiatry at
Aurora, CO Columbia University Medical Center
New York State Psychiatric Institute
Licínia Ganança, MD New York, NY
Columbia University
Division of Molecular Imaging and Ze'ev Levin, MD
Neuropathology Clinical Professor of Psychiatry
New York State Psychiatric Institute NYU School of Medicine
New York, NY New York, NY

Elisabeth B. Guthrie, MD Philip R. Muskin, MD

Associate Professor of Psychiatry and Professor of Psychiatry
Pediatrics at Columbia University Columbia University Medical Center
Medical Center Chief, Consultation-Liaison Psychiatry
Associate Director, New York Presbyterian NY-Presbyterian Hospital/
Child and Adolescent Psychiatry Columbia Campus
Residency Training Program of Faculty, Columbia University
Columbia and Cornell Universities Psychoanalytic Center
New York, NY Research Psychiatrist, New York State
Psychiatric Institute
Kelli Jane K. Harding, MD New York, NY
Assistant Professor of Psychiatry at
Columbia University Medical Center Sara Siris Nash, MD
Emergency Psychiatry Attending Assistant Professor of Psychiatry
NY-Presbyterian Hospital/ Consultation Liaison Division
Columbia Campus Columbia University Medical Center
New York, NY New York, NY
 Contributors / / xiii

David D. Olds, MD Moira A. Rynn, MD

Clinical Professor of Psychiatry Chief, Division of Child and Adolescent
College of Physicians and Surgeons of Psychiatry
Columbia University Associate Professor of Clinical Psychiatry
New York, NY College of Physicians and Surgeons of
Columbia University and New York
Maria A. Oquendo, MD State Psychiatric Institute
Professor of Psychiatry and Vice-Chair for New York, NY
Education
Columbia University Medical Center Franklin R. Schneier, MD
Research Psychiatrist, New York State Professor of Psychiatry
Psychiatric Institute Columbia University Medical Center
Residency Training Director, Department Research Scientist, New York State
of Psychiatry Psychiatric Institute
College of Physicians and Surgeons of New York, NY
Columbia University
New York, NY Jonathan A. Slater, MD
Clinical Professor of Psychiatry
Matthew B. Perkins, MD, MBA, MPH College of Physicians and Surgeons of
Medical Director, Division of Children and Columbia University
Family Services Director, Consultation and Emergency
New York State Office of Mental Health Service
New York, NY Morgan Stanley Children's Hospital of
Lyle Rosnick, MD New York
Assistant Professor of Clinical Psychiatry New York, NY
College of Physicians and Surgeons of
Thomas E. Smith, MD
Columbia University
Associate Professor of Psychiatry
Assistant Attending Psychiatrist, New York
Columbia University Medical Center
Presbyterian Hospital, Columbia
New York, NY
University Medical Center
Faculty, Columbia University Joanna E. Steinglass, MD
Psychoanalytic Center for Training and Assistant Professor
Research Columbia University Medical Center
New York, NY New York State Psychiatric Institute
Brian Rothberg, MD New York, NY
Assistant Professor
University of Colorado School of Medicine Jessica Ann Stewart, MD
Aurora, CO Clinical Fellow in Child and Adolescent
Psychiatry
Jennifer M. Rucci, MD New York Presbyterian Hospital
OnsiteCare New York, NY
Director of Mental Health
Charlotte, NC Jonathan W. Stewart, MD
Davis Regional Medical Center Professor of Clinical Psychiatry
Attending psychiatrist College of Physicians and Surgeons of
Statesville, NC Columbia University
Research Psychiatrist, New York State
L. Mark Russakoff, MD Psychiatric Institute
Director of Psychiatry New York, NY
Phelps Memorial Hospital Center
Sleepy Hollow, NY
xiv / / C ontributors

Katharine A. Stratigos, MD Frank Yeomans, MD

Assistant Clinical Professor of Psychiatry Clinical Associate Professor of Psychiatry
College of Physicians and Surgeons of Director of Training
Columbia University Personality Disorders Institute
New York, NY Weill Medical College of Cornell
University
Hilary B. Vidair, PhD Adjunct Associate Professor
Co-Director of Clinical Training Columbia University Psychoanalytic
Assistant Professor, Clinical Psychology Center for Training and Research
Doctoral Program New York, NY
Long Island University
Brookville, NY

Leslie R. Vogel, MD
Private Practice
New York, NY
INTRODUCTION

Psychiatry is the field of medicine that concerns itself with those illnesses that have
emotional or behavioral manifestations. Psychiatric illnesses are extremely common
and exact a great personal and social cost in disability, suffering, and even death. This
book is intended as an introductory text that prepares medical students, physicians, and
other health professionals for the clinical task of working with psychiatric patients. As
such, it emphasizes recognition and assessment of psychiatric illness. The text’s clinical
orientation is equally well suited for medical students during their preclinical introduc-
tion to psychiatry course and core psychiatry clerkship, as well as nonpsychiatric physi-
cians, psychiatric residents, and other health professionals who work with patients with
psychiatric disorders, including psychologists, social workers, nurses, and occupational
therapists.
Patients with emotional and behavioral difficulties are often discouraged from seek-
ing help by the stigma that they, their families, and even physicians tend to attach to psy-
chiatric illnesses. All health care providers should be sensitive to the shame that patients
with psychiatric problems may have. Being well informed about the signs and symptoms
of the most common psychiatric disorders improves the physician’s chances of recogniz-
ing these disorders in patients. Familiarity with the course and prognosis of these condi-
tions enhances the ability to refer patients for appropriate treatment and to complete the
first step in the referral process, which is frequently education and reassurance.
The first two chapters in the book provide a framework for the evaluation of psychiat-
ric patients, focusing on clinical assessment and the psychiatric interview. These chapters
demonstrate how to obtain and synthesize clinical data and generate an appropriate dif-
ferential diagnosis and treatment plan. Subsequent chapters cover the major psychiat-
ric disorders; the special topics of suicide, violence, and the medically ill patient; and an
overview of the stages of child, adolescent, and adult development. An additional chapter
is devoted to the assessment and treatment of children and adolescents. The book con-
cludes with chapters covering pharmacotherapy and psychotherapy.

DIAGNOSTIC AND CLINICAL FEATURES

The use of diagnostic categories has a particular history in psychiatry, and over the past
several decades, the field has been concerned with improving diagnostic reliability and
consistency. Throughout this book, reference is made to the Diagnostic and Statistical
Manual of Mental Disorders, 5th edition (DSM-5), which is published by the American
Psychiatric Association, the professional organization of psychiatrists in the United
States. The publication of the DSM-5 in 2013 incorporates a more dimensional approach
to psychiatric diagnosis. Previous editions of the DSM had used a polythetic approach

xv
xvi / / I ntroduction

(i.e., more than one combination of symptoms will qualify for a particular diagnosis). The
aim of the DSM system is descriptive. It is the best and most widely referenced psychiat-
ric diagnostic system currently available. It is not, however, a perfect system but rather an
evolving one. Ultimately, the criteria are intended only as guidelines for physicians who
must use their own best judgment in making an appropriate diagnosis.

THE INTERVIEW
In all of medicine the clinical interview is the basis by which diagnoses are made and
therapeutic alliances between patients and physicians are forged. Even in this age of
advanced medical technology, no sophisticated test can take the place of a careful, com-
plete history that is empathically obtained. Clinical interviewing as a sophisticated art is
perhaps nowhere more apparent than in psychiatry. The central importance of the clini-
cal psychiatric interview is reflected in the central positioning of a section devoted to the
interview, accompanied by Interviewing Guideline summaries, in each disorder chapter.

ETIOLOGY
As in the rest of medicine, the description of psychiatric syndromes and their effective treat-
ments has generally preceded an understanding of their pathophysiology and etiology. The
past several decades has witnessed an explosion in the understanding of some of the neuro-
biological mechanisms that underlie many psychiatric disorders. Advances in neuroimag-
ing, molecular genetics, and other basic science techniques hold the promise for even more
knowledge in the not too distant future. But enthusiasm must be tempered by the sobering
realization that the mind and the ways in which it can become disturbed are exceedingly
complex—so much so that, for example, researchers struggling to understand the etiology
of schizophrenia have compiled many probably significant but currently isolated observa-
tions and thus do not seem to be much closer to solving the mystery of how and why 1% of
the world’s population is afflicted with this devastating illness.
Some in the field have worried that the emphasis on neurobiology has replaced the
previous tradition of the biopsychosocial model, which attempts to consider the whole
patient, encompassing a biologically endowed human being with a particular psychology
and social context. Psychiatrists continue to struggle with the issue of how much of an
effect external factors such as family, environment, and psychic trauma have on the onset
and course of psychiatric disorders. A fundamental assumption of this book is that, in the
“nature versus nurture” debate, both sides have validity: Genetic loading and intrauter-
ine exposure may play important roles in the etiology of many psychiatric disorders, but
interpersonal, developmental, and other “nurture” issues seem to be crucial as well.

TREATMENT
Patients come to physicians and other health professionals to receive help. Treatment
planning requires a collaborative effort between patient and clinician. While detailed
treatment guidelines are beyond the scope of this book, a summary of specific treatment
options available for each of the major psychiatric illnesses, including psychotherapeutic
and pharmacotherapeutic modalities, is provided. Psychiatry’s strong clinical tradition
should serve its patients and the entire field of medicine well. It is the intent of this book
to provide the practicing clinician with a foundation that is biopsychosocially based and
psychiatrically well informed.
 Introduction / / xvii

USE OF THE BOOK

We have strived to maintain an appropriate balance between thoroughness and ease
of use. Clinical illustrations, included to bring the material to life, are set off from the
main text. Essential information is highlighted in tables and with key words to allow
Psychiatry’s use as a resource for successful exam preparation.