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Diagnostic Criteria and Treatment of Common Psychiatric Illnesses

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1. MAJOR DEPRESSIVE DISORDER (MDD)

DSM-5-TR Diagnostic Criteria

• Symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning
• Episode not attributable to physiological effects of a substance or another medical condition
• Not better explained by a psychotic disorder
• No history of manic or hypomanic episodes (if so, consider bipolar disorder)

Treatment

• SSRIs (sertraline, fluoxetine, escitalopram, paroxetine) - preferred initial agents; onset 3-6 weeks, up to 12-14 weeks for full remission (STAR*D trial)
• SNRIs (venlafaxine, duloxetine) - especially useful for comorbid pain
• Bupropion - activating; avoids sexual dysfunction; good for fatigue/concentration
• Mirtazapine - useful when insomnia and appetite loss are prominent

• Lithium augmentation, atypical antipsychotics (aripiprazole, quetiapine, olanzapine)
• Tricyclic antidepressants (TCAs), MAOIs - for treatment-resistant cases

• Cognitive-Behavioral Therapy (CBT) - first-line
• Interpersonal Therapy (IPT)
• Behavioral Activation
• Psychodynamic Therapy
• Combined pharmacotherapy + psychotherapy is superior to either alone

• Psychotic depression: antidepressant + antipsychotic, or ECT
• Treatment-resistant MDD: ECT, TMS (transcranial magnetic stimulation), esketamine (nasal spray, FDA-approved)
• Duration: Treat acute episode for 6-12 months minimum; recurrent episodes often require long-term maintenance

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2. BIPOLAR DISORDER

DSM-5-TR Diagnostic Criteria

Manic Episode (required for Bipolar I)

• Distinct period of abnormally and persistently elevated, expansive, or irritable mood AND increased goal-directed activity or energy
• Duration: at least 7 days (or any duration if hospitalization required)
• 3 or more of the following (4 if mood is only irritable) - DIG FAST:
  • Distractibility
  • Impulsivity / Indiscretion (risky behavior)
  • Grandiosity
  • Flight of ideas
  • Activity increase (goal-directed) / Agitation
  • Sleep decreased (need less, not insomnia)
  • Talkative / pressured speech
• Severe enough to cause marked social/occupational impairment or requires hospitalization, OR psychotic features present
• Not due to substances or another medical condition

Hypomanic Episode (required for Bipolar II)

• Same symptom criteria as mania, but duration at least 4 consecutive days
• Not severe enough to cause marked impairment or require hospitalization
• No psychotic features

Bipolar I

• At least one manic episode (major depressive episodes are common but not required)

Bipolar II

• At least one hypomanic episode AND at least one major depressive episode
• No manic episodes ever

Cyclothymic Disorder

• Numerous periods of hypomanic symptoms AND depressive symptoms (not meeting full criteria) for at least 2 years (1 year in children/adolescents)

Treatment

• Lithium - narrow therapeutic index; monitor levels (0.6-1.2 mEq/L), renal function, thyroid; best evidence for suicide prevention
• Valproate - teratogenic (avoid in women of childbearing age if possible); monitor LFTs, CBC
• Lamotrigine - preferred for bipolar depression maintenance; requires slow titration to avoid Stevens-Johnson syndrome
• Antidepressants alone are contraindicated in bipolar disorder (risk of precipitating mania or rapid cycling)
• Psychosocial interventions: psychoeducation, family therapy, CBT, interpersonal and social rhythm therapy (IPSRT)

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3. SCHIZOPHRENIA

DSM-5-TR Diagnostic Criteria (Table 362-11, Goldman-Cecil Medicine)

1. Delusions
2. Hallucinations
3. Disorganized speech (derailment, incoherence)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms (affective flattening, alogia, avolition, anhedonia, asociality)

• Major impairment in social/occupational functioning (below previous level)
• Continuous signs of disturbance for at least 6 months (may include prodromal/residual phases)
• Not better explained by schizoaffective disorder, depressive/bipolar disorder with psychotic features
• Not attributable to substances or another medical condition
• If autism spectrum disorder history: schizophrenia diagnosed only if prominent delusions/hallucinations present for at least 1 month

• Brief Psychotic Disorder - schizophrenia-like episode lasting <1 month, with return to baseline
• Schizophreniform Disorder - duration 1-6 months
• Schizoaffective Disorder - psychotic episodes AND mood episodes (depression or mania), with at least 2 weeks of psychosis in the absence of a mood syndrome
• Delusional Disorder - one or more nonbizarre delusions ≥1 month; no prominent hallucinations; functioning not markedly impaired outside the delusion

Treatment

Antipsychotic Medications (Goldman-Cecil Medicine, Table 362-12)

• EPS (extrapyramidal side effects): dystonia, akathisia, parkinsonism, tardive dyskinesia
• Neuroleptic Malignant Syndrome (NMS): rare but life-threatening

• Assertive Community Treatment (ACT)
• Social skills training
• Cognitive remediation
• Supported employment
• Family psychoeducation
• Early intervention programs at first episode improve long-term outcomes

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4. ANXIETY DISORDERS

4a. Generalized Anxiety Disorder (GAD)

• Excessive anxiety and worry about multiple events/activities occurring more days than not for at least 6 months
• Difficulty controlling the worry
• 3 or more of the following (1 for children): SMART-W
  • Sleep disturbance
  • Muscle tension
  • Annoyance / irritability
  • Restlessness / feeling keyed up
  • Tiredness / fatigue easily
  • Worry difficulty concentrating / mind going blank
• Causes significant distress or impairment
• Not attributable to substances or another medical condition; not better explained by another mental disorder

4b. Panic Disorder

• Recurrent unexpected panic attacks: an abrupt surge of intense fear reaching a peak within minutes, with 4 or more of:
  • Palpitations, pounding heart, or accelerated heart rate
  • Sweating
  • Trembling or shaking
  • Shortness of breath or smothering
  • Choking feelings
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Dizziness, lightheadedness, or faintness
  • Chills or hot flashes
  • Paresthesias
  • Derealization or depersonalization
  • Fear of losing control or "going crazy"
  • Fear of dying
• At least one attack followed by 1 month or more of:
  • Persistent concern about more attacks OR
  • Significant maladaptive behavioral change (e.g., avoiding exercise)

4c. Social Anxiety Disorder (Social Phobia)

• Marked fear or anxiety about social situations where scrutiny by others may occur
• Fear that one will act in a way that will be humiliating or embarrassing
• Social situations almost always provoke fear/anxiety
• Situations are avoided or endured with intense distress
• Fear is out of proportion to actual threat
• Duration 6 months or more
• Causes significant impairment

4d. Specific Phobia

• Marked fear about a specific object/situation (e.g., heights, blood, animals)
• Immediate anxiety response, avoided or endured with distress
• Duration ≥ 6 months

Treatment of Anxiety Disorders (Goldman-Cecil Medicine)

• SSRIs (sertraline, paroxetine, escitalopram) - first-line for GAD, panic disorder, social anxiety disorder
• SNRIs (venlafaxine, duloxetine) - equally effective first-line alternatives
• Buspirone - effective for GAD, non-habit-forming; slow onset (2-4 weeks)
• Benzodiazepines (lorazepam, clonazepam, alprazolam) - rapid relief of acute anxiety; not recommended as long-term treatment due to dependence risk, cognitive impairment, fall risk
• Beta-blockers (propranolol) - situational social anxiety (e.g., performance); NOT for chronic use

• Cognitive-Behavioral Therapy (CBT) - first-line for all anxiety disorders, especially specific phobias (exposure therapy)
• Combined CBT + pharmacotherapy for severe/treatment-refractory anxiety

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5. OBSESSIVE-COMPULSIVE DISORDER (OCD)

DSM-5-TR Criteria

• Presence of obsessions, compulsions, or both
• Obsessions: Recurrent, persistent, intrusive thoughts/urges/images that are experienced as unwanted; person attempts to ignore or suppress them with another thought or action
• Compulsions: Repetitive behaviors (e.g., handwashing, checking, ordering) or mental acts (e.g., counting, praying) that the person feels driven to perform in response to an obsession OR according to rigid rules; aimed at preventing distress or dreaded event, but not realistically connected
• Obsessions/compulsions are time-consuming (>1 hr/day) or cause clinically significant distress/impairment
• Not attributable to substances or another medical condition
• Not better explained by another mental disorder
• Insight specifier: good/fair insight, poor insight, or absent insight/delusional beliefs

Treatment

• First-line: SSRIs at higher doses than used for depression (e.g., fluoxetine 40-80 mg, fluvoxamine, sertraline, paroxetine); response may take 8-12 weeks
• Clomipramine (TCA) - highly effective but more side effects; used when SSRIs fail
• Exposure and Response Prevention (ERP) therapy - behavioral component of CBT; most effective psychotherapy
• Augmentation: antipsychotics (aripiprazole, risperidone) added to SSRI for partial responders

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6. POST-TRAUMATIC STRESS DISORDER (PTSD)

DSM-5-TR Criteria

Treatment

• First-line psychotherapy: Trauma-focused CBT, Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), EMDR (Eye Movement Desensitization and Reprocessing)
• First-line pharmacotherapy: SSRIs (sertraline, paroxetine - FDA-approved); SNRIs (venlafaxine)
• Prazosin - for trauma-related nightmares
• Avoid benzodiazepines in PTSD (may worsen outcomes)

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7. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD)

DSM-5-TR Criteria

• Fails to give close attention to details
• Difficulty sustaining attention
• Does not seem to listen when spoken to directly
• Does not follow through on instructions
• Difficulty organizing tasks
• Avoids sustained mental effort
• Loses things necessary for tasks
• Easily distracted by extraneous stimuli
• Forgetful in daily activities

• Fidgets or squirms
• Leaves seat inappropriately
• Runs/climbs inappropriately (adults: feeling restless)
• Unable to play quietly
• "On the go" or driven by a motor
• Talks excessively
• Blurts out answers
• Difficulty waiting turn
• Interrupts or intrudes

Treatment

• Stimulants (first-line): Methylphenidate (Ritalin, Concerta), amphetamine salts (Adderall, Vyvanse)
• Non-stimulants: Atomoxetine (NRI, FDA-approved), guanfacine, clonidine (especially for hyperactivity/tics)
• Behavioral therapy - especially in children <6 years (before stimulants); parent training
• Combined medication + behavioral therapy is most effective

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8. EATING DISORDERS

8a. Anorexia Nervosa

• Restriction of energy intake relative to requirements leading to significantly low body weight
• Intense fear of gaining weight or persistent behavior that interferes with weight gain
• Disturbed experience of body weight/shape; lack of recognition of seriousness of low weight

8b. Bulimia Nervosa

• Recurrent binge eating episodes: eating large amounts in 2-hr period + sense of lack of control
• Recurrent compensatory behaviors (self-induced vomiting, laxatives, diuretics, fasting, excessive exercise)
• Binge/compensatory behaviors occur at least once/week for 3 months
• Self-evaluation unduly influenced by body shape and weight
• Does not occur exclusively during anorexia nervosa

8c. Binge Eating Disorder

• Recurrent binge eating (≥once/week for 3 months) WITHOUT compensatory behaviors
• Associated with ≥3 of: eating rapidly, eating until uncomfortably full, eating when not hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty afterward
• Marked distress

Treatment

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9. SUBSTANCE USE DISORDERS

DSM-5-TR Criteria (general framework)

1. Taking more than intended
2. Persistent desire or unsuccessful efforts to cut down
3. Great deal of time obtaining/using/recovering
4. Craving
5. Failure to fulfill major role obligations
6. Continued use despite social/interpersonal problems
7. Social, occupational, recreational activities given up
8. Use in physically hazardous situations
9. Use despite physical/psychological problems
10. Tolerance
11. Withdrawal

Treatment (Key agents)

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10. PERSONALITY DISORDERS (Overview)

• Enduring pattern of inner experience and behavior deviating markedly from cultural expectations
• Pervasive and inflexible across situations
• Onset in adolescence or early adulthood
• Stable and of long duration
• Causes distress or impairment

• Pervasive pattern of instability in interpersonal relationships, self-image, and affect, plus marked impulsivity (≥5 of 9 criteria)
• Treatment: Dialectical Behavior Therapy (DBT) - gold standard; SSRIs for mood instability

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Quick Reference: First-Line Pharmacotherapy Summary

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Clinical note: Diagnosis of all psychiatric disorders requires that symptoms cause clinically significant distress or functional impairment and are not better explained by substances, another medical condition, or another mental disorder. Always rule out organic causes (e.g., thyroid disease, CNS lesions, substance intoxication/withdrawal) before making a primary psychiatric diagnosis.