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of mood disordersand obsessive-compulsive
disorder (OCD).
IV.DifferentialDiagnosis of BodyDysmorphic
Disorder
A. Neurological neglect is seen in
parietal lobe lesions, and it can be
mistaken for dysmorphic disorder.
B. Anorexia Nervosa. Preoccupation
aboutbodyimage are limited toconcerns
about being fat.
C. Gender IdentityDisorder.Characterized
by discomfort with the patient s own
sex and persistent identification with
the opposite sex.
D. Narcissistic Personality Disorder.
In this disorder, concern with a body
partis onlyone feature in broad constelation
l
of other personality features.
V. Treatment Bodyof Dysmorphic Disorder.
SSRI antidepressants and clomipramine
are effective.Coexistingpsychiatric conditions,
such as a mood disorders, should be
treated. Surgical repair of the defect
is rarely successful.
Factitious Disorder
I. DSM-IV Criteria
A. Intentional production of physical
or psychological symptoms.
B. The patients motivation is to assume
the sick role.
C. External motives (financial gain)
are absent.
II. Clinical Features of Factitious Disorder
A. Identity disturbance and dependent
and narcissistic traits are frequent.
Patients with physical symptoms
often have histories of many surgeries
and hospitalizations.
B. Patients are able to provide a detailed
history and describe symptoms of
a particular disease and mayintentionally
produce symptoms (eg, use of drugs
such as insulin, self-inoculation to
produce abscesses). Common coexisting
psychological symptoms include
depression or factitious psychosis.
C. Great effort should be made to confirm
the facts presented by the patient
and confirm the past medical history.
An outside informant should be sought
to provide corroborating information.
III. Epidemiology of Factitious Disorder
A. Begins in early adulthood.
B. More frequent in men and among
health-care workers.
IV. Classification of Factitious Disorder
A. With predominantly psychological
signs and symptoms.
B. With predominantly physical signs
andsymptoms (also known as Munchausen
Syndrome).
C. With combined psychological and
physical symptoms.
D. Factitious disorder byproxyischaracterized
bythe production of feigning of physical
signs or symptoms in another person
who is under the person s care (typically
a child). This is considered to be
a form of child abuse.
V. Differential Diagnosis
A. Somatoform Disorders: Somatoform
disorder patients are less willing
to undergo medical procedures, such
as surgery. Symptomsare notfabricated.
B. Malingering: A recognizable goal
for producing symptoms is present.
C. Ganser s syndromerefers toa condition
associated with prison inmates who
give ridiculous answers to questions
(1+ 1= 5)inaneffort toavoid responsibility
for their actions.
VI. Treatment of Factitious Disorder
A. No specific treatment exists, and
the prognosis is generally poor.
B. The condition should be recognized
early,and needless medical procedures
should be prevented.Close collaboration
between the medical staff and psychiatrist
is recommended.
References
References, see page 121.
Sleep Disorders
Primary Insomnia
Primary insomnia is characterized by the
inability to initiate or maintain sleep.
I. DSM-IV Criteria
A. Difficulty initiating or maintaining
sleep when there is no known physical
or mental condition (including drug
related), resulting in significant distress
or impairment.
B. The disorder causes significant distress
or impairment in social or occupational
functioning.
C. The disorder is not due to the effects
of medication, drugs of abuse, or
a medical condition.
II. Clinical Features
A. Anxiety or depression commonly
coexist with insomnia.
B. Mood disorders account for less
than 50% of insomnia.
C. Schizophrenia is associated with
fragmented sleep.
III. Differential Diagnosis
A. Dyssomnias, substance abuse, mood,
anxiety, or psychotic disorders may
present with insomnia.
B. Many medical conditions can cause
insomnia including asthma, gastritis,
peptic ulcer disease, headaches.
C. Manydrugs can disrupt sleep including
beta-blockers, calcium channel blockers,
steroids, decongestants, nicotine,
stimulating antidepressants, thyroid
hormones, and bronchodilators.
IV. Treatment
A. Temporaryuse (less than one month)
of short-acting benzodiazepines is
especially helpful when there is an
identifiable precipitant (eg, death
of a loved one).
B. Zolpidem (Ambien) and zaleplon
(Sonata) have the advantageofachieving
hypnotic effects with less tolerance
and less daytime sedation.
C. The safety profile of benzodiazepines
and benzodiazepine receptor agonists
is good; lethal overdose is rare, except
when benzodiazepines are taken
with alcohol.
D. Zolpidem (Ambien)is a benzodiazepine
agonist with a short elimination half-life
that is effective in inducing sleep
onset and promoting sleep maintenance.
Zolpidem is associated with greater
residual impairment in memory and
psychomotorperformance than zaleplon.
E. Zaleplon (Sonata) is a benzodiazepine
receptor agonist that is rapidlyabsorbed
(Tmax = 1 hour) and has a shortelimination
half-life of one hour. Zaleplon does
not impair memory or psychomotor
functioning on morning awakening.
Zaleplon does not cause residual
impairment when the drug is taken
in the middle of the night. It can be
used at bedtime or after the patient
has tried to fall asleep naturally.
F. Benzodiazepines with long half-lives,
such as flurazepam (Dalmane), may
be effective in promoting sleep onset
and sustaining sleep. These drugs
tend to accumulate and have effects
that extend beyond the desired sleep
period, resulting in daytime sedation
or functional impairment.
G. Sedating antidepressantsare sometimes
used as analternativetobenzodiazepines
or benzodiazepine receptor agonists.
Amitriptyline (Elavil), 25-50 mg at
bedtime, or trazodone (Desyrel),
50-100 mg, are common choices.
H. Sleep Hygiene:
1. Encourage patient to keep a consistent
pattern of waking, and sleeping
at the same time each day.
2. Avoid large meals before bedtime.
3. Discontinue stimulant caffeine,
alcohol, or nicotine.
4. Avoid daytime naps.
5. Engage in regular exercise, but
avoid exercise before sleeping.
6. Allow for a period of relaxation
before bedtime (hot bath).
Agents Used for Insomnia
Agent Dos- Ave Com-
age Half- ments
life of
Meta
bolite
s
Zolpid 5-10 3 Non-
em mg hours benzo-
(Ambi qhs diazepine
en) ; no day-
time
hangover
Zalepl 5 -10 1 Non-
on mg hour benzo-
(So- diazepine
nata) ; no day-
time
hangover
Triazo 0.12 2 Short act-
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