Drug Use Disorder

Drug use disorder refers to the presence of any of a collection of drug-specific diagnoses that are characterized by cognitive, behavioral, and physiological symptoms accompanying repeated use of a drug despite significant substance-related problems causing harm to the user or to others. Common drugs of abuse in contemporary American society include cannabinoids, opioids, amphetamines, cocaine, and many other drugs. The popularity of specific drugs has varied over time in relation to drug availability and cost. The most recent trend has been an influx of “designer drugs,” substances developed synthetically by manipulating the molecular structure to avoid classification as illicit drugs (hence circumventing prosecution) while retaining the psychoactive properties of illicit drugs.

Borderline Personality Disorder

Borderline personality disorder is a fairly recent label of a variously conceptualized phenomenon which has been characterized by affective instability and emotional crises, cognitive problems, impulsivity, and intense and unstable personal relationships. This chapter reviews the historical background, epidemiology, and clinical picture (including comorbidity) of borderline personality disorder. Although progress toward validation of this diagnosis has been made, the current definition does not appear to meet the accepted gold standard criteria for a syndrome that is currently considered valid (and reliable). The natural history of what is known is reviewed, as well as the common complications, including self-mutilation and suicide attempts. Treatment remains challenging at best, with few interventions meeting rigorous randomized controlled trial standards.

Panic and Phobic Disorders

Panic and phobic disorders are among the most common psychiatric syndromes. Panic disorder is a chronic illness characterized by recurrent, acute panic attacks, which are discrete episodes of anxiety or fearfulness with definite onset, rapid increase, and spontaneous termination. Phobic disorder is a chronic condition dominated by one or more phobias. Different types of phobias include specific phobias (e.g., fear of animals), social phobias (e.g., fear of public speaking), and agoraphobia (fear of being in places where help might not be available in the event of an anxiety attack). Panic disorder and agoraphobia are currently diagnosed independently of one another, but previously these diagnoses were linked diagnostically (panic disorder with or without agoraphobia and agoraphobia without panic disorder).

Schizophrenic Disorders

Schizophrenia and mood disorders comprise the main psychotic disorders. The schizophrenic disorders generally tend to have a more chronic and unremitting long-term prognosis compared with psychotic mood disorders. Schizophrenic conditions have considerable variability in outcome, but many patients may experience a chronic or deteriorating course. It is thought that schizophrenic disorders comprise a number of different conditions, but efforts to divide them into valid subgroups have had limited success. The main clinical features of schizophrenia include persistent hallucinations, delusions, disorganized speech and behavior, inappropriate or flattened emotional expression, lack of motivation, social withdrawal, and inability to initiate and sustain goal-directed activities, and neurocognitive difficulties, especially in memory, attention, and executive functions. Most patients experience a decline in work and interpersonal functioning, and some are unable to maintain self-care functions.

Delirium and Dementia (Neurocognitive Disorders)

Delirium and dementia (now subsumed under the label of neurocognitive disorders) are often referred to as organic brain syndromes, and this chapter reviews these disorders at length. Delirium is usually brief and reversible. It is defined as an impairment in consciousness (i.e., reduced awareness of the environment) and memory (i.e., reduced recent memory). It is a topic of particular medical interest currently. Amnestic disorders are rare and characterized as disorders of memory. Dementias are frequently progressive, and chances of recovery are rare except for several uncommon illnesses. Dementias are characterized by impairment in consciousness and inattention, orientation, memory, and other intellectual or cognitive functioning. Because many of these dementing disorders (Alzheimer’s, Pick’s, and Lewy body diseases) have neurological findings previously described at autopsy, historical review is provided.

Somatization Disorder

Somatization disorder is a more recent name for hysteria, which has been described for more than 4,000 years. This chapter formally reviews the last 160 years’ descriptions (Briquet’s syndrome) and recent conceptualizations, with emphasis on the most recent 60 years. The debate over the most recently proposed 2013 relabeling/criteria change is reviewed. The epidemiology of various criteria sets and divergent presentations are reviewed. The natural history, family studies, and potential dramatic complications, including death, are considered. This chapter describes in-depth the potential for the disorder to masquerade as a multitude of potential medical illnesses and it covers formal efforts of clinical management.

Mood (Affective) Disorders

Descriptions of mood disorders go back to the time of Hippocrates. Mood disorders are primarily characterized by depressed and/or elevated (manic) moods. The essential feature of mood disorders is an episode that is a distinct and persistent change from a person’s typical mood (depression or mania), accompanied by other depressive and manic symptoms, lasting 2 weeks for a major depressive episode and 1 week for a manic episode. Such episodes typically remit and recur over the course of time. Manic episodes define bipolar disorder. Severe depression without manic episodes is diagnosed as major depressive disorder. Mood disorders present a 10- to 30-fold risk for suicide. Effective treatments for mood disorders include medications, brain stimulation modalities, and psychotherapy.

Evolution of Psychiatric Diagnosis

This chapter considers the evolution of psychiatric diagnosis in the United States at length, with references to earlier European contributions. It reviews the medical model in psychiatry movement by the Washington University, St. Louis group in the United States to develop psychiatric diagnosis validity parameters and reliable criteria sets to facilitate communication, research, and clinical application for the major mental illnesses. Challenges to this model are considered and ultimate scientific solidification in DSM-III is reviewed. Over time (33 years), dissent and the continual failure to discover a neurobiological basis for any major psychiatric illness have placed a strain on the medical diagnostic process, and these controversies are reviewed at length. Outlined are the reasons that psychiatry should remain resolute in endorsing what we know scientifically instead of what expert consensus constructs.

Eating Disorders

The major eating disorders are anorexia nervosa and bulimia nervosa. Anorexia nervosa is characterized by peculiar attitudes toward eating and weight that lead to obsessive refusal to eat, profound weight loss, and, when the disorder occurs in girls, persistent amenorrhea. Bulimia refers to a behavior of gorging of food, typically followed by induced vomiting or purging. Bulimia is seen in many patients with anorexia nervosa, but it is the predominant clinical feature in bulimia nervosa. Anorexia nervosa is not a common illness, occurring in about 1% of the population, and the incidence of these disorders has increased in recent decades. Anorexia nervosa is fatal in 5%–10% of adult cases; however, half of patients recover, and many more improve as they age.

Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a disorder that can emerge after exposure to an extreme traumatic stressor involving actual or threatened death or serious injury. PTSD has not been demonstrated to represent a unified construct such as that established for other validated psychiatric disorders identified in this text, but a developing knowledge base for PTSD is promising for future validation of this diagnosis. PTSD is an unusual diagnosis because of the conditional nature of this disorder that requires exposure to a traumatic event for consideration of the diagnosis. Individuals who have not been exposed to a traumatic event cannot meet criteria for PTSD. This feature of PTSD has created difficulties in applying this diagnosis in both clinical and research settings.