Psychopharmacology For Non Psychiatrists

Daniel P.
Greenfield, MD, MPH, MS, FASAM
Psychopharmacology
for NonPsychiatrists
A Primer
Psychopharmacology for Nonpsychiatrists
Daniel P. Greenfield
Psychopharmacology for
Nonpsychiatrists
A Primer
Daniel P. Greenfield
Clinical Professor of Neuroscience (Psychiatry)
Seton Hall University
Short Hills
NJ
USA
ISBN 978-3-030-82506-5 ISBN 978-3-030-82507-2 (eBook)

https://doi.org/10.1007/978-3-030-82507-2
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As with my previous volumes, this
Primer is dedicated to my family,
children, and grandchildren (now
six of them!), and to the colleagues,
students, and friends who shared
their interests and experiences with
me over the years, and gave me the
database for this book.
– Daniel P. Greenfield
Clinical Foreword
After years of teaching in a physician assistant (PA) program, I am gradually com-

ing to the conclusion that the undergraduate coursework premedical programs
require of their students may be doing a disservice in preparing these students for
their training program. An unfortunate consequence of heavy basic science prepara-
tion is that it can lead to very “black and white” thinking. By the time students finish
a chemistry course, they can determine precisely what will be synthesized when a
mole of compound A is added to a mole of compound B. At the conclusion of a
physics course, students can calculate to the millimeter where a projectile will land.
Students master this coursework and eagerly move on to their medical training. It
does not take long for these students to realize that people are extraordinarily, bio-
logically complex.
Mental and behavioral health—and the associated neuroscience—present a spe-
cial challenge to a clinician in training. Many pathologic processes in medicine are
fairly understandable and certain diagnoses can be arrived at using cultures and
biopsies, and the mechanisms for medications like analgesics and antibiotics are
generally readily understood. However, diagnosis and treatment in psychiatry and
mental and behavioral health can often seem mysterious. Diagnostic criteria are
fluid, and medication regimens can be complex with effects only becoming appar-
ent over the course of weeks.
Thus, the need for this Primer.
Dr. Daniel Greenfield has proven to be a talented educator in the almost two
decades he has been involved in teaching psychiatry and mental and behavioral
health to PA students. His coursework is devoted less to conveying facts and more
toward inculcating a manner of clinical reasoning and thinking in students.
Psychopharmacology is frequently a single topic among many covered at a light-
ning pace during a pharmacology course. His latest effort will provide valuable
additional foundational information for students who wish to cultivate a deeper
understanding of an often-mysterious medication family.
This book helpfully locates psychopharmacology within the larger context of
psychiatric treatment and briefly discusses the variety of therapeutic and somatic
techniques available to providers and their patients. In addition, since many patients
vii
viii Clinical Foreword
with psychiatric conditions unfortunately find themselves interacting with the jus-
tice system, Dr. Greenfield concludes with useful considerations related to the inter-
section of mental health and the law.
Many areas of the country are experiencing an acute shortage of mental health-
care providers. This shortage is greatly exacerbated by the opioid abuse crisis and
the COVID-19 pandemic our nation faces. Primary care providers will increasingly
find themselves in a position of needing to initiate and monitor psychopharmaco-
logic therapy. Dr. Greenfield’s extensive experience has allowed him to create an
easily readable book that will serve as a welcome information source as these clini-
cians work to develop a sound therapeutic plan for their troubled patients.
June, 2020 Christopher J. Hanifin

Chairperson and Program Director
Physician Assistant Program
Seton Hall University
South Orange, NJ
USA
Legal/Forensic Foreword
This latest work by Dr. Daniel Greenfield on psychopharmacology is a must read

for any person involved in the legal system in any capacity whether judge, lawyer,
litigant, or party. I have been engaged in the legal system for almost 50 years as an
attorney, judge and currently as full-time faculty in justice at a university. My pro-
fessional experience, particularly as a trial Judge for over 27 years, provides me a
unique perspective of the value, necessity, and need to have a forensic psychiatric
expert who possesses the education, expertise, forensic qualifications, and “real-
world” experience to render a credible opinion on the effect of drug use on civil or
family law cases.
I have known Dr. Greenfield professionally for over two decades. We have inter-
acted in cases when he testified in my court as a psychiatric expert to the compe-
tence, sanity, or insanity of a defendant in cases. I have attended his presentations
on “Forensic Science and Psychiatry” and, upon retiring from the bench, as co-
panelist discussing mental health legal issues for the benefit of members of the legal
profession.
His vast experience can be shared once again by reading this wonderfully com-
prehensive Primer that gives invaluable knowledge and insight to any person
involved in court cases concerning psychopharmacological and mental capacity
issues. He clearly presents an overview of drug use in court cases with great clarity,
while also providing a roadmap for the basic questions to ask when selecting an
expert. He explains how to assess the appropriate expert’s true knowledge of the
subject of the case. He does this by giving examples and suggestions of what ques-
tions to ask the proposed expert.
The author’s research then statistically enumerates types and numbers of cases in
which psychopharmacology issues are mentioned, relating these statistics to issues
in civil and family court cases. Next, he expertly explains the various ways legal
issues manifest themselves in particular cases. The author’s unparalleled research
provides the reader with statistically concise information on the effect of a multi-
tude of identified substances in different types of court cases, which is of inestima-
ble value to one involved in or studying such litigation. This book provides insight
ix
x Legal/Forensic Foreword
into the possible impact on a court case by psychopharmacological, psychopharma-

cotherapy, and psychiatric issues raised in a variety of court cases.
Additionally, this well-respected doctor provides definitions and statistics that
break down the most complex issues with clarity for a layperson to understand
when addressing the difficult problems of legal insanity, diminished capacity, and
other mental health problems.
I highly recommend this Primer as a marvelous, must-have resource that will
guide one through the various issues as explained by a psychiatrist who possesses
40 years of experience not only as a highly respected academician but as a widely
recognized forensic expert witness.
June, 2020 Kevin G. Callahan

Superior Court of New Jersey (Hudson Vicinage),
Professor of Criminal Justice
Saint Peter’s University
Jersey City, NJ
USA
About the Cover
This book’s cover is a stylized version of an ancient

Cretan labyrinth, or “maze.” When the Bronze Age
site at Knossos was excavated by explorer Arthur
Evans, the complexity of the architecture prompted
him to suggest that the palace had been the Labyrinth
of Daedalus. Evans found a depiction of a labrys
carved into the walls. On the strength of a passage in
the Iliad, it has been suggested that the palace was the
site of a dancing-ground made for Ariadne by the
craftsman Daedalus, where young men and women,
of the age of those sent to Crete as prey for the Minotaur, would dance together. By
extension, in popular legend, the palace is associated with the myth of the Minotaur.
As we also learn from Greek mythology, the labyrinth is a puzzling place, originally
the work of the fabled architect Daedalus. The labyrinth’s purpose, which Daedalus
built for King Minos of Crete, was as a prison in which to hold the monstrous
Minotaur.
Our cover’s labyrinth symbolizes the convoluted and oft-times confusing path to
find and subdue the demon lurking in the mind of a patient or client.
By elongating the shape of the original labyrinth, we also convey a lateral view
of the human brain.
Additionally, the Greek key symbol was derived from the labyrinth design and
evokes the twists and turns of the river of life.
All in all, walking that winding path to find and understand the best remedies for
a mind in distress is a noble and important work. We hope that this Primer can help
you find your way on that journey.
xi
Author’s Disclaimer
I have attempted to ensure that the information, details, facts, and discussions con-
tained in this book are accurate and up to date as of the time of its publication, and
consistent with applicable clinical practice and practice standards. However, phar-
macology, psychopharmacology, and clinical practice generally are dynamic fields,
constantly changing and advancing, so that particular points in this Primer may not
apply in a particular case or cases. For these reasons, the reader is encouraged to
supplement their knowledge by consulting applicable sources and references,
including books, textbooks, articles, monographs, electronic databases (such as the
Physician’s Desk Reference, or the PDR), other Internet sources, and other such
resources. A number of such sources are given in the Selected References section of
this Primer, as well as other references and sources cited in this book.
In that context, in the three legal/forensic chapters (Chaps. 10, 11, and 12) espe-
cially, the information conveyed should not be construed or taken as legal advice,
which, not being an attorney or legal professional, the author is not competent to
give, and which can be given only by a licensed attorney or qualified legal
professional.
xiii
Preface
During the time I am writing this Preface, the world is struggling with the COVID-19
pandemic crisis of 2020. We all hope that when the crisis is over, the world will
return to “normal” (whatever that is!), and that this crisis, or another such cata-
clysm, will not happen again.
But for this book, that fact and the age of the author of this book are relevant in
two ways:
1. During the COVID-19 crisis, we did less. Less travel, less complex entertain-
ment, less activity, less congregating, less consumption, and the like. A regres-
sion, in a way, to slower and simpler times. The obvious exceptions to this
observation were those who had to work in dangerous conditions: first respond-
ers and direct-care healthcare professionals; food production and service work-
ers; and the workers in the facilities, shops, and stores which provided essential
products and services to consumers.
2. In my 40-plus years of clinical practice, and historically before that, I have seen
the evolution of psychiatric practice and psychopharmacology through several
dramatic quasi-paradigm shifts. I have seen organized psychiatry’s view of itself
and the public’s view of the profession change dramatically. And, of late, those
views of the profession have become intertwined with their views of psycho-
pharmacology (or, more properly, “psychopharmacotherapy,” as discussed later
in this book).
Concerning point (1), the notion of “doing more with less,” as we will see in the
practical notion of a conservative and minimalist approach to psychopharmacology
expressed in this book and in the “deprescribing” climate of today, is being learned
in the COVID-19 crisis. This lesson will likely prove to be a useful global caution-
ary tale. The lesson from this metaphor for psychopharmacology, likewise, is “do
more with less.” That lesson will be an ongoing theme throughout this book.
xv
xvi Preface
In addition, the COVID-19 experience has been extremely anxiety-producing

and depressing for almost everybody, including those directly exposed to the virus
on a daily basis (health-care workers, food delivery and other transportation work-
ers, pharmacy workers, and other essential workers) and everyone else, most quar-
antined for long periods of time at home, with many working remotely at their jobs
and many who have lost their jobs due to the restrictions of the pandemic. The
“Household Pulse Survey” of the National Center for Health Statistics (NCHS) of
the Centers for Disease Control and Prevention (CDC), for example, identified an
increase of over 30% in psychological symptomatology—including anxiety, depres-
sion, or mixed symptoms—compared to the same time period in 2019. This increase
was attributed to the many and varied effects of the COVID-19 pandemic: psycho-
logical, economic, family-related, occupational, and others (National Center for
Health Statistics. [June, 2020]. Anxiety and Depression: Household Pulse Survey.
In Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/covid19/
pulse/mental-health.htm).
Since this increase in psychiatric morbidity will undoubtedly herald an increase
in individuals seeking mental health evaluation and treatment; since many of the
readers of this book will be sought for that evaluation and treatment; and since psy-
chotropic medications are one of the main tools available to these front line mental
health care providers, it is hoped that this book can be a help to those providers as
they respond to the influx of new, current, and past patients/clients brought by the
COVID-19 pandemic and its aftermath.
Concerning point (2), broadly speaking, five historical trends and positions for
psychiatry may be identified in psychiatry over about the past 150 years (recogniz-
ing that psychiatry got its start in medieval times through dealing with witchcraft,
asylums, often cruel and punishing detention and warehousing of the chronic and
serious mentally ill). They are: (1) The strongly neurobiologically based, “organic”
psychiatry of Emil Kraepelin (“Dementia Praecox”) and Eugen Bleuler (“the
schizophrenias”), an era during which neurologists and psychiatrists were closely
linked, later drifting apart, and currently coming back together; (2) The classical
psychoanalytic and psychotherapy-based approach in the first half of the twentieth
century;1 (3) The “anti-psychiatry” movement beginning in the 1960s and to some
extent, continuing to the present day; (4) The ascent and dominance of psychophar-
macology in mental health practice and psychiatry also beginning in the 1960s,
peaking only recently; and leading to (5) The “deprescribing” movement beginning
in the 2010s which is, and in the view of this author and others, currently signifi-
cantly gaining momentum.
Table P.1 (p. xvii) summarizes these five trends.
1
In this vein, the often-quoted, somewhat paraphrased, words of Harvard Medical School/
Massachusetts General Hospital child psychiatrist and Professor of Psychiatry, Leon Eisenberg,
MD, in about 1995 ring true: “Let’s not allow the brainlessness of psychiatry in the 1930s through
1950s be replaced with the mindlessness of psychiatry in the 1980s and 1990s…”
Preface xvii
Table P.1 Historical trends in psychiatry, ca. 1850-present

Time frame Trend
1. ca. 1850–1900 “Organic” neuropsychiatry of Kaepelin and Bleuler
2. ca. 1900–1950 Classical psychoanalytic/psychodynamic psychiatry
3. ca. 1960–1970s and beyond “Anti-psychiatry” movement of Szasz, Laing, Scheff, and
others
4. ca. 1960-present “Monotherapy,” then “Polypharmacy;” eclipse of
psychotherapy and counseling in psychiatric practice
5. Current (2020) “Deprescribing” movement
The foregoing leads logically to the question “Why write (or read) yet another
textbook of psychopharmacology?”
The answer is straightforward. It recognizes and accepts that the professional
literature in psychopharmacology is awash with encyclopedic and scholarly tomes
and articles, in turn abounding in information, details, protocols, flow charts, data,
tables, figures, studies, and the like. These sources provide incredibly detailed and
often unnecessary, inapplicable, or even untranslatable information for the practitio-
ner working with, say, anxious and/or depressed patients—the “common colds” of
psychiatry.
Therefore, the answer to the question posed above is that this present Primer is
intended for: (1) The prescribing “front-line” practitioner, including Physician
Assistant (PA); Advanced Practice Nurse/Nurse Practitioner (APN/NP);
Psychologist with prescribing privileges (in a jurisdiction in which that occurs),
and other such professionals, this book is intended as a practical and useful guide
applicable to their practices; (2) Other mental health professionals, counselors,
therapists, and practitioners who do not themselves prescribe, but whose patients/
clients are prescribed psychotropic medications by others, or might benefit from
them, this book is intended as a guide to psychopharmacology and “psychophar-
macotherapy” (i.e., the therapeutic use of psychopharmacologic agents and medi-
cations); (3) Teachers, educators, and academic/school administrators whose
students and staff may need mental health evaluations and/or treatment, and/or
who might benefit from such evaluations and/or treatment; (4) Nonpsychiatric
physicians or dentists whose practices, as many do, involve psychopharmacother-
apy; (5) Prescribing health care professionals—such as naturopaths, homeopaths,
physical therapists, occupational therapists, speech/language therapists, recre-
ation therapists, and many others—this book is intended as a concise practical
guide to psychopharmacology for their patients/clients who are currently on psy-
chotropic drugs or who might benefit from psychopharmacotherapy; (6) Legal and
other professionals who are not themselves healthcare professionals, but who
interact with healthcare professionals, this book is intended to provide a practical
and user-friendly basic understanding of psychopharmacology and psychophar-
macotherapy; and (7) Students and trainees in all of these areas and professions,
this book is intended as a concise guide and practical handbook of psychopharma-
cology and psychopharmacotherapy. The only healthcare professionals for whom
xviii Preface
Table P.2 The intended audience for this Primer

Prescribing “first-line” practitioners: APNs/NPs, PAs, prescriptive-privileged psychologists,
others
Non-prescribing mental health professionals whose patients/clients are on (or might benefit
from) psychotropic medications (psychologists, social workers, LPCs, other counsellors, drug/
alcohol counsellors, pastoral counsellors/hospital chaplains)
Educators (Special Education teachers; classroom teachers; school principals and administrators;
Child Study Team members) with students and/or colleagues on psychotropic medications
Non-psychiatric physicians or dentists whose patients/clients are on (or might benefit from)
psychotropic medications
Non-prescribing healthcare professionals (chiropractors, PTs, OTs, SLPs [speech and language
pathologists], social workers, LPCs, other counsellors, hospital chaplains, RTs [recreation
therapists]) whose patients/clients are on (or might benefit from) psychotropic medications
Administrators, legal professionals, and other non-healthcare professionals whose work involves
interactions with healthcare professionals
Students and trainees in all of these areas
this present book is not intended are practicing and research psychiatrists, and
psychiatry trainees (residents). However, medical students interested in psychiatry
would likely find this book a useful vade mecum and examination prepara-
tion book.
Table P.2 (p. xviii) summarizes the individuals for whom this book is intended.
This Primer is organized in four parts, as also indicated in its Table of Contents:
Part I, “Essentials of Psychopharmacology and Psychopharmacotherapy,” is the
“Basic Principles of Pharmacology, Psychopharmacology, and
Psychopharmacotherapy” (Chap. 2); “The Four ‘Major Anti-s’” (Chap. 3); “The
Sixteen ‘Minor Anti-s’” (Chap. 4); “Illicit Substances and Drugs” (Chap. 5); and
“Botanicals, Herbals, Nutraceuticals, and (Dietary) Supplements (“Natural
Products”)” (Chap. 6).
Part II, “Therapies That May Involve Psychopharmacology/Psychopharma
cotherapy,” provides a succinct overview of selected and representative types of
psychotherapy and counseling in contemporary psychiatry and psychology. This
Part is geared toward all of the potential readers of this book. The chapters in
this Part recognize that, despite the current psychiatric orientation toward largely
psychopharmacologic treatment in psychiatric practice, there is more to “psy-
chopharmacotherapy” than simply “pharmacology.” The orientation endorsed in
this book is toward a conservative and minimalist approach to psychopharmaco-
therapy, and that “putting the therapy back into psychopharmacotherapy”
(S.L. Feder, private communication, 1979) is a worthwhile goal. “An Overview
of Therapies in Mental Health Care” (Chap. 7) introduces the two broad catego-
ries of psychotherapeutic treatment in psychology, specifically “psychological”
and “somatic,” and outlines subcategories of treatment within those two broad
categories. “Psychotherapies and Counseling” (Chap. 8) and “Somatic Therapies
(Somatotherapies)” (Chap. 9) present and discuss examples of those types of
treatment.
Preface xix
Recognizing that no prescribing practitioner can be “all things to all people,” this
book, and this Part in particular, address referrals and consultations for non-
pharmacotherapeutic interventions from a variety of practitioners and profes-
sionals. The emphasis throughout this Primer, in that vein, is on interdisciplinary
and holistic treatment approaches to individuals with the conditions and con-
cerns presented and discussed in this book.
Part III, “Forensic and Legal Applications of Psychopharmacology/
Psychopharmacotherapy,” draws on this author’s long experience in various
aspects of forensic psychiatry and recognizes both the extent and usefulness of
knowledge on a legal professional’s part of psychopharmacotherapy in its myr-
iad potential applications in the law. “Overview” (Chap. 10) gives a survey of
these applications. “Selection and Use of Experts: Five Questions” (Chap. 11)
and “Evaluating Versus Treating Doctor/Therapist: A Word to the Wise” (Chap.
12) both focus on practical and sometimes problematic areas that frequently
occur for trial attorneys and legal professionals generally.
Part IV, “Synthesis and Conclusions” (Chap. 13), pulls together salient points
reviewed in this book in order to assist the reader in the practical psychopharma-
cotherapeutic treatment of patients/clients.
Last, for the purposes of this Preface, I emphasize that this Primer is not intended
as a comprehensive or encyclopedic research or reference source, or as a guide or
cookbook for actual prescribing of the psychotropic medications discussed in the
Primer. For that purpose and for such detailed information, the reader is directed to
the applicable detailed Selected References listed at the end of this Preface. I also
reemphasize two points made in the Author’s Disclaimer earlier in this book, namely
that (1) Although I have attempted to ensure accuracy and current information in
this Primer, in the rapidly-changing field of psychopharmacology, some informa-
tion will necessarily be outdated by the time this volume is published. The inter-
ested and questioning reader is advised and encouraged to supplement or expand
their information from this Primer by consulting the Selected References, compa-
rable works, electronic databases, Internet sources, and the like; and (2) Since this
book is also not intended as a textbook or manual for the psychopharmacotherapeu-
tic treatment and management of patients/clients with psychiatric disorders, the
reader is also advised to consult their healthcare professional/treatment provider for
treatment advice. Similarly, this Primer does not purport to provide formal legal
advice or counsel, which can only be given by a qualified legal professional.
A Note On References
Rather than burdening the reader with excessive and detailed references and cita-
tions in this Primer, given below are particularly useful selected references. In addi-
tion, other specific references and citations will be given in parentheses throughout
the Primer. For further information and details about any topics presented and
xx Preface
discussed in this book, the interested reader is referred not only to the following list
of selected references, but also to applicable textbooks, monographs, electronic
databases, print articles and materials, Internet sources, and other applicable
resources.
Selected References
Black DW, Andreasen NC. Introductory textbook of psychiatry. 6th ed. American
Psychiatric Publishing, Inc.; 2014. (A solid basic textbook of psychiatry.)
Multiple Authors. Diagnostic and statistical manual of mental health disorders
(DSM-5). 5th ed. American Psychiatry Association, Inc.; 2013. (This book is the
controversial “bible” for primarily American and Canadian psychiatric
diagnoses.)
The comparable international work to the DSM-5 is currently the 2019 International
classification of diseases (ICD-10). 10th ed. World Health Organization. (The
ICD-11 was due for adoption in 2020.)
Frances A. Saving normal: an insider’s revolt against out-of-control psychiatric
diagnosis, big pharma, and the medicalization of ordinary life. Harper Collins
Publishers; 2013. (The subtitle says it all! See Chap. 4 in this Primer.)
Ghaemi SN. Clinical psychopharmacology: principles and practice. Oxford
University Press; 2019. (A scholarly, detailed, and lengthy overview of psycho-
pharmacology, also covering social practice and research/methodologic aspects
of the field.)
Hales RE, Yudofsky ST, Roberts LW, editors, et al. The American Psychiatric
Publishing textbook of psychiatry. 6th ed. American Psychiatric Publishing, Inc.;
2014. (A standard, detailed encyclopedic textbook tome, for reference. A seventh
edition is available, copyright 2019, with updated coverage in a number of areas.)
Harrington A. Mind fixers: psychiatry’s troubled search for the biology of mental
illness. W.W. Norton and Company; 2019. (A historical and scholarly review of
the topic, including some of the same topics as Saving Normal listed above.)
Puzantian T, Carlat DJ. Medication fact book for psychiatric practice. 6th ed. Carlat
Publishing, LLC; 2020. (A very useful “cookbook” for psychotropic prescribing,
conveniently organized and presented for the practitioner.)
Watters E. Crazy like us: the globalization of the American psyche. Free Press;
2010. (Psychiatric diagnostic issues similar to those in Saving Normal, with an
international focus.)
Weil A. Mind over meds: know when drugs are necessary, when alternatives are
better—and when to let your body heal on its own. Little, Brown and Company;
2017. (A balanced and holistic approach to pharmacology and psychopharma-
cology by the popular “guru” of these fields.)
Preface xxi
Selected Internet References
With the surfeit of internet resources, websites of all imaginable types and quality,
and numerous related electronic sources of information and data, the reader, clini-
cian, researcher, and member of the public—patient/client or not—may easily
become confused about where to go and what to accept in learning psychopharma-
cology and psychopharmacotherapy. In this vein, a productive way to navigate the
bewildering array of such sources consists of dividing them into several catego-
ries, viz.
1. Refereed (“peer-reviewed;” “juried”) scientific, technical, and professional jour-
nals, newsletters, and the like, including e-journals, e-newsletters, and other
open-source e-publications. Selected examples include:
• Journal of Clinical Psychopharmacology (peer-reviewed independent profes-
sional journal)
• Experimental & Clinical Psychopharmacology (peer-reviewed professional
journal of the American Psychological Association)
• Journal of Psychopharmacology (peer-reviewed professional journal of the
British Association for Psychopharmacology)
• Psychopharmacology (Berlin/Heidelberg; Springer Publications)
2. Government and academic/research institutions, publications and e-publications,
and associated websites. Selected examples include:
• National Institute of Mental Health (NIMH) website, affiliated institutes, pro-
grams, centers, websites, and publications (electronic and print)
• National Institute on Alcoholism and Alcohol Abuse (NIAAA) website, affili-
ated institutes, programs and centers, and websites and publications (elec-
tronic and print)
• National Institute on Drug Abuse (NIDA) website, affiliated institutes, cen-
ters, programs and websites, and publications (electronic and print)
• Canadian Centre on Substance Abuse (CCSA), affiliated programs and publi-
cations (electronic and print)
• National Center on Addiction and Substance Abuse at Columbia University
(NCASACU), programs and publications (electronic and print)
3. Journals, magazines, societies, and associated websites. Selected examples
include:
• Psychology Today
• Scientific American
• Scientific American Mind
xxii Preface
As a practical matter, in researching particular topics electronically in psychophar-

macology/psychopharmacotherapy, the logical rule—as with everything else—is to
search for topic(s), keyword(s), and the like on a search engine, then to narrow the
search with entries given by the search engine. An important factor to keep in mind
here is the reliability, accuracy, and quality of the source: Sources from (1) and
(2)—above—are considered more reliable than those in (3), generally. Those in (3),
in turn, are generally considered more reliable than personal blogs, newsletters,
product websites, company websites, and the like.
In the final analysis, the success of this Primer will depend on its helpfulness to
you, the reader. For that reason, this author welcomes feedback and suggestions to
make this book as practical and useful as possible. Please feel free to contact me
with suggestions at dpgreenfieldmdpsychiatry@msn.com.
Finally, this book is also not intended as a treatment guide for the clinical care of
patients/clients. The reader should consult their healthcare professionals/treatment
providers for that purpose.
Short Hills, NJ, USA Daniel P. Greenfield

Acknowledgments
I am particularly grateful to Joann Codella, my dedicated assistant and typist, who

worked long, hard, and very well on the manuscript for this book, making this
Primer possible.
I am also particularly grateful to Joan Van der Veen, my private office manager,
whose background and experience in publishing and graphics made her an invalu-
able asset with the production of this Primer.
Many thanks to my friends and colleagues in the Department of Physician
Assistant at Seton Hall University, who supported and encouraged this undertaking.
Heartfelt thanks to Christopher J. Hanifin, MS, PA-C, EdD, Chairperson and
Program Director of the Department of the Physician Assistant at Seton Hall
University, who wrote the Clinical Foreword for this book.
Heartfelt thanks, too, to the Honorable Kevin G. Calahan, JSC (retired) of the
Superior Court of New Jersey (Hudson Vicinage) and Professor of Criminal Justice
at Saint Peter’s University (Jersey City, New Jersey), who wrote the Legal/Forensic
Foreword for this book.
Heartfelt thanks, too, to John W. Sensakovic, MD, PhD, a friend and colleague
for over thirty years, who first introduced me to Seton Hall University and who has
enthusiastically supported and endorsed this book.
Saving the best until last, I acknowledge Alma Scott Greenfield, my oldest
grandchild (now 13 years old), for her extraordinary help in organizing the Index for
this book. Alma succeeded where others, with many more years and much more
experience than she, did not. Alma was a baby when she made her first appearance
in the “Dedication” of one of my books. This time, she’s been an invaluable part of
the publishing process. Thank you, Alma. I couldn’t be more proud!
Thank you all very much for your help: I could not have done this Primer
without you.
xxiii
Contents
1 Introduction: Epidemiologic Triangle Model, Diagnosis,

Psychiatric Diagnosis, and Other Necessary Preliminaries �� 1
A Note on References�� 4
Selected References �� 4
Selected Internet References�� 5
Part I Essentials of Psychopharmacology and Psychopharmacotherapy

2 Basic Principles of Pharmacology, Psychopharmacology,
and Psychopharmacotherapy �� 9
Classes of Pharmacologic and Psychopharmacologic Agents �� 12
Three Additional Classes �� 17
Two Additional Concepts (For All Pharmacologic Agents)�� 20
COVID-19, Telemedicine, Telepsychiatry, and Psychopharmacology�� 22
3 The Four “Major Anti-s”�� 27
Antianxiety Agents�� 28
Antidepressant Agents �� 30
Antimanic Agents�� 35
Antipsychotic Agents �� 37
4 The Sixteen “Minor Anti-s”�� 45
Anti-addiction Agents�� 45
Anti-aggression Agents�� 50
Anti-appetite Agents�� 52
Anti-attention Deficit Hyperactivity Disorder (ADHD) Agents�� 54
xxv
xxvi Contents
Anti-dementia Agents�� 57

Anti-feeding/eating Agents�� 60
Anti-impotence Agents�� 61
Anti-insomnia Agents�� 64
Anti-obsessive-compulsive Agents�� 67
Anti-pain Agents�� 69
Anti-panic Agents�� 76
Antiparkinsonian Agents�� 77
Anti-pseudobulbar Affect Agents�� 80
Anti-sex Agents�� 80
Anti-trauma Agents�� 82
5 Illicit Substances and Drugs�� 87
Controlled Dangerous Substances (CDS)�� 90
DSM-5 Considerations �� 92
Chemical and Behavioral Addictions�� 93
Medication-assisted Treatment (MAT)�� 93
Treatment Settings for the Addictions: A Continuum of Care�� 94
Psychedelics�� 95
Evaluating and Treating Addicts and Alcoholics �� 97
6 Botanicals, Herbals, Nutraceuticals, and (Dietary)
Supplements (“Natural Products”)�� 101
Part II Therapies That May Involve Psychopharmacology/

Psychopharmacotherapy
7 A Selective Overview of Therapies in Mental Health Care�� 111
8 Psychotherapies and Counseling�� 117
Non-behavioral Psychotherapies�� 118
Behavioral Psychotherapies �� 122
Behavioral Therapy (Generally)�� 123
Rational-Emotive Behavior Therapy (REBT)�� 124
Contents xxvii
Cognitive Behavior Therapy�� 125

Dialectical Behavior Therapy�� 126
Hypnosis and Hypnotherapy�� 126
Eye Movement Desensitization and Reprocessing (EMDR)�� 127
Mindfulness and Meditation�� 128
Metacognitive Therapy�� 129
Psychotherapy and Counseling During the COVID Pandemic�� 129
9 Somatic Therapies (Somatotherapies) �� 133
Part III Forensic and Legal Applications of Psychopharmacology/

10 Overview �� 141
11 Selection and Use of Experts: Five Questions �� 149
Liability of Experts�� 158
12 Evaluating Versus Treating Doctor/Therapist:
A Word to the Wise�� 163
Part IV Synthesis and Conclusions

13 Synthesis and Conclusions�� 171
Index�� 177
About the Author
Daniel P. Greenfield, MD, MPH, MS, FASAM is

a practicing psychiatrist, addiction medicine special-
ist, and preventive medicine specialist. He was edu-
cated at Oberlin College, the University of North
Carolina, the University of London, Cornell
University Medical Center, Rutgers University, and
Harvard University.
In addition to his clinical and forensic practice, he
formerly taught at the Albert Einstein College of
Medicine as an attending physician and at Montefiore
Medical Center (Bronx, New York) as a Clinical
Associate Professor of Psychiatry and Behavioral Science.
He currently teaches at Seton Hall University, where he is a Clinical Professor of
Neuroscience (Psychiatry) at the JFK Neuroscience Institute Hackensack Meridian
Health/JFK University Medical Center (South Orange, Nutley, and Edison, New
Jersey).
He has lectured, published, and testified widely in areas of his background, train-
ing, and expertise, in academic, business, community, courtroom, government, and
professional forums, as well as on television and radio.
Psychopharmacology for Nonpsychiatrists: A Primer is one of his latest books.
Dr. Greenfield can be reached at dpgreenfieldmdpsychiatry@msn.com.
xxix
Chapter 1
Introduction: Epidemiologic Triangle
Model, Diagnosis, Psychiatric Diagnosis,
and Other Necessary Preliminaries
In a thought-provoking essay entitled “How Prozac Slew Freud,” Edward Shorter,

historian of science at the University of Toronto, asserted that the psychoanalytic
orientation in psychiatry is outmoded and ineffective and that psychopharmacology
is the proper orientation and basic skill set for psychiatry. Shorter’s opinion is an
accurate, if somewhat controversial, depiction of the current state of psychiatry as a
branch of medicine. Shorter’s assertion highlights the importance of understanding
the complexity of psychopharmacology as applied not only in clinical contexts but
in forensic and other contexts discussed in this volume, as well. This assertion, in
turn, leads to the need to structure psychopharmacology in some way, in order to
understand this vast field in comprehensible parts. To start this process, this Primer
proposes two broad topics leading to proper diagnosis.
The first of these topics is the Epidemiologic Triangle model, consisting of three
components, viz., host, environment, and agent. Each component is to be evalu-
ated in the context of its own properties and its interactive effects on the others. A
dramatic recent example of this is the COVID-19 epidemic: Specifically, the effect
on the host (people) of quarantining and “social distancing” (environment) from the
agent (the COVID-19 virus). Medical experts opined that changing the environment
earlier in the course of the epidemic to stricter quarantining and social distancing
would have considerably reduced the death toll from the epidemic. In psychiatry,
for present purposes, we consider the “host” to be the psychiatric patient; the “envi-
ronment” to be the patient’s life circumstances, broadly speaking; and the “agent”
to be the psychotropic medication or medications taken by the patient/client.
The second basic topic is “diagnosis.” The concept of “diagnosis” (from the
Greek “dia-” meaning “thoroughly” or “completely,” and “-gnosis” meaning “to
know”) is an ancient and fundamental cornerstone of medicine. It may be defined as
the process of determining by examination the cause and nature of a disease, illness,
or condition and is considered essential for proper treatment. Borrowing again from
the field of epidemiology, two types of criteria are used to categorize ill persons into
groups (i.e., disease entities), namely:
© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2022
D. P. Greenfield, Psychopharmacology for Nonpsychiatrists,
https://doi.org/10.1007/978-3-030-82507-2_1
2 1 Introduction: Epidemiologic Triangle Model, Diagnosis, Psychiatric Diagnosis…
1. Manifestational criteria, in which ill persons are grouped according to similar-

ity with respect to signs, symptoms, changes in body chemistry, physiologic
function, and the like. Examples include idiopathic fever of unknown origin
(FUO), intellectual disability and—for present purposes—most psychiatric dis-
orders except for those with putative underlying organic causes (Alzheimer’s
disease; seizure disorders).
2. Causal criteria, in which ill persons are grouped according to their similarity
with respect to common experience(s) believed to be the cause, or etiology (from
the Greek “etios-” meaning “cause,” and “-logos” meaning “study of”) of their
disease, illness, or condition. Examples include coronavirus infections, lead poi-
soning, and neural tube defect disability. In studying diseases, historical trends
have progressed from manifestational (e.g., “pox”) to causal (e.g., “syphilis”)
understanding of a disease.
The concept of “differential diagnosis” in this context is an extension of “diag-
nosis” and is central to clinical-thinking, reasoning, and problem-solving.
“Differential diagnosis” refers to a group, or listing, of potential “causes” of the
constellation of signs and symptoms (predominantly manifestational in psychiatric
conditions) which best account for the condition or “diagnosis,” under consider-
ation. The several potential “causes” of crushing substernal chest pain and shortness
of breath—myocardial infarction (“heart attack”), acute respiratory insufficiency
from COVID-19 infection, pneumonia, and many others—come to mind as exam-
ples from general medicine.
In psychiatric conditions manifesting as acute paranoia, the “differential diagno-
sis” would include amphetamine overdose, cocaine intoxication, acute psychotic
episode, mini-psychotic episode from underlying borderline personality disorder,
and others. All of these possibilities need to be “ruled out,” or excluded, through
appropriate history-taking, testing (including urine drug screen [UDS] or “tox”
screen), and other such diagnostic procedures, in order to arrive at a plausible under-
lying diagnosis and a treatment plan likely to be successful. This is the same model
and clinical methodology as with the disciplines of general medicine and surgery.
The third basic concept preliminary to discussing substantive aspects of psycho-
pharmacology and psychopharmacotherapy is “psychiatric diagnosis.” This particu-
lar system—presently embodied in the Fifth Edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) of the American Psychiatric Association,
copyright 2013—is a hybrid classification system based predominantly on manifes-
tational criteria. With this system, the use of “psychotropic” (from the Greek “psy-
cho-” meaning “soul,” and “-tropos” meaning “way” or “manner”) medications to
ameliorate or control symptomatology due to a putative underlying cause, but not
necessarily to address, or “cure,” or “eliminate” the cause itself. In that sense, most
psychotropic medications act to counter undesirable symptomatology, such as
“depression” with “antidepressants,” or “psychosis” with “antipsychotics,” with
varying understandings of the reasons—“mechanism of action” (MOA)—of the
underlying disease (“disorder”) process. Notwithstanding this limitation, the pres-
ent iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),
and its six predecessors—going back to 1952—have been called the “bible” for
psychiatric disorders in organized psychiatry.
1 Introduction: Epidemiologic Triangle Model, Diagnosis, Psychiatric Diagnosis… 3
For present purposes in addressing the need to have a basic understanding of the
DSM-5 for discussing substantive aspects of psychopharmacology/psychopharma-
cotherapy, the following excerpts from the “Cautionary Statement for Forensic Use
of DSM-5” (about the inapplicability of adopting the DSM-5 wholesale for forensic
psychiatric purposes) are instructive:
Although the DSM-5 diagnostic criteria and text are primarily designed to assist clinicians in
conducting clinical assessment, case formulation, and treatment planning, DSM-5 is also used as
a reference for the courts and attorneys in assessing the forensic consequences of mental disor-
ders. As a result, it is important to note that the definition of mental disorder included in DSM-5
was developed to meet the needs of clinicians, public health professionals, and research investi-
gators rather than all of the technical needs of the courts and legal professionals… the use of
DSM-5 should be informed by an awareness of the risks and limitations of its use in forensic
settings… These dangers arise because the imperfect fit between the questions of ultimate con-
cern to the law and the information contained in a clinical diagnosis… [for example]… having
the diagnosis in itself does not demonstrate that a particular individual is (or was) unable to
control his or her behavior at a particular time… (page 25 of the DSM-5)
Put more concisely, in the context of forensic psychiatry (see Part III of this
book), the presence of a DSM-5 diagnosis does no more to pinpoint a particular
disability (level of functioning, or symptomatology, for example) than does the
presence of that diagnosis to pinpoint a specific etiology, causes or mechanism of
action, for that diagnosis. This is an important concept in psychopharmacology/
psychopharmacotherapy and will be developed and revisited throughout this book.
Recognizing and accepting these limitations and restrictions in psychiatric diag-
nosis, however, the basis for the several “anti” categories of psychopharmacologic
agents in this book (see Part I) will be the DSM-5, owing to its widespread accept-
ability and use in the psychiatric community. In this regard, the reader must be
aware of and careful about what one prominent psychiatric insider and commenta-
tor has called “diagnostic inflation.” This concept refers to increasing apparent prev-
alence (presence, or frequency), of given psychiatric disorders and conditions based,
in part, on DSM definitions and diagnostic criteria in successive editions of the DSM
over the years, regardless of the underlying neurobiological mechanism of action,
causes, or etiology of the disorder at issue. This concept is particularly relevant to
psychopharmacology/psychopharmacotherapy in terms of the reasons, or clinical
indications, for prescribing given agents for particular disorders. If, for example, the
apparent prevalence of a psychiatric disorder in a given population increases because
of a change—a broadening or widening—in DSM-5 diagnostic criteria (whether or
not that change reflects a true increase in that prevalence), then the prescribing clini-
cian will necessarily prescribe a given psychopharmacologic/psychopharmacother-
apeutic agent for more patients or for a broader range of patients with related
diagnoses than if the DSM diagnostic change had never occurred. This “inflation”
has been identified for a number of psychiatric disorders, including attention-deficit
hyperactivity disorder (ADHD), eating disorders (anorexia and bulimia), and post-
traumatic stress disorder (PTSD), among others.
With all these caveats, Table 1.1 lists the current major categories of psychiatric
disorders as given in the DSM-5.
In the next part of this book—the core of the book—I will present and discuss
substantive and practical aspects of psychopharmacology/psychopharmacotherapy.
Table 1.1 DSM-5 major Neurodevelopmental disorders

diagnostic categories
Schizophrenia spectrum and other psychotic disorders
Bipolar and related disorders
Depressive disorders
Anxiety disorders
Obsessive-compulsive and related disorders
Trauma and stressor-related disorders
Feeding and eating disorders
Elimination disorders
Sleep-wake disorders
Sexual dysfunction
Gender dysphoria
Disruptive, impulse-control, and conduct disorders
Substance-related and addictive disorders
Neurocognitive disorders
Personality disorders
Paraphilic disorders
Other mental disorders
A Note on References
the Primer. For further information and details about any topics presented and dis-
cussed in this book, the interested reader is referred not only to the following list of
selected references but also to applicable textbooks, monographs, electronic data-
bases, print articles and materials, internet sources, and other applicable resources.
Selected References
• Black DW, Andreasen NC. Introductory textbook of psychiatry. 6th ed. American
• Multiple Authors. Diagnostic and statistical manual of mental health disorders
diagnoses.)
• The comparable international work to the DSM-5 is currently the 2019
International Classification of Diseases (ICD-10). 10th ed. World Health
Organization. (The ICD-11 was due for adoption in 2020.)
• Frances A. Saving normal: an insider’s revolt against out-of-control psychiatric
Publishers: 2013. (The subtitle says it all! See Chap. 4 of this Primer.)
A Note on References 5
• Ghaemi SN. Clinical psychopharmacology: principles and practice. Oxford

University Press: 2019. (A scholarly, detailed, and lengthy overview of psycho-
of the field.)
• Hales RE, Yudofsky ST, Roberts LW, et al., editors. The American Psychiatric
Publishing textbook of psychiatry. 6th ed. American Psychiatric Publishing,
Inc.; 2014. (A standard, detailed encyclopedic textbook tome, for reference. A
seventh edition is available, copyright 2019, with updated coverage in a number
of areas.)
• Harrington A. Mind fixers: psychiatry’s troubled search for the biology of mental
• Puzantian T, Carlat DJ. Medication fact book for psychiatric practice. 6th ed.
Carlat Publishing, LLC; 2020. (A very useful “cookbook” for psychotropic pre-
scribing, conveniently organized and presented for the practitioner.)
• Watters E. Crazy like us: the globalization of the American psyche. Free Press;
• Weil A. Mind over meds: know when drugs are necessary, when alternatives are
ries, viz.
sional journal)

tronic and print)
include:
As a practical matter, in researching particular topics electronically in psycho-
pharmacology/psychopharmacotherapy, the logical rule—as with everything else—
is to search for topic(s), keyword(s), and the like on a search engine, then to narrow
the search with entries given by the search engine. An important factor to keep in
mind here is the reliability, accuracy, and quality of the source: Sources from (1) and
Part I
Essentials of Psychopharmacology
and Psychopharmacotherapy
Chapter 2
Basic Principles of Pharmacology,
Psychopharmacology,
and Psychopharmacotherapy
Concerning concepts and terms in human biology and medicine, the most funda-
mental life science underlying all of the sciences discussed in this chapter is physi-
ology. The term derives from the Greek “physio-” meaning “nature,” and “-logia”
meaning “study of.” As a basic clinical science, human physiology encompasses the
physical and chemical functioning of the normal human organism, unaffected,
unchanged, and uninfluenced by disease, licit or illicit substances, “xenobiotics”
(foreign substances, from the Greek, “xeno-” meaning “foreign,” and “-biota”
meaning “living things”), or other such entities.
In contrast, pharmacology (from the Greek, “pharmakon” meaning “drug”)
refers to the science of the effects on the human organism of foreign substances or
agents (i.e., not normally found in the organism or in any of its organ systems or
subsystems). Toxicology (from the Greek, “toxikon” meaning “poison”) is gener-
ally considered a parallel science, or sub science, of pharmacology. Its relationship
to pharmacology was captured some 500 years ago in the words of Paracelsus
(Philippus Aureolus Theophrastus Bombastus von Hohenheim, a sixteenth-century
Swiss physician and natural philosopher who lived from 1493 to 1541), known as
the “father of toxicology,” who wrote that “…all substances are poisons; there is
none which is not a poison. The right dose differentiates a poison from a remedy…”
(Klaassen K, et al. Introduction. In Casarett and Doull’s toxicology. 4th ed. McGraw-
Hill; 1990.)
Finally, psychopharmacology (from the Greek “psyche-” meaning “soul”) is the
branch of pharmacology which deals with pharmacologic agents, drugs, or medica-
tions which act on (psychoactive) or influence (psychotropic) the mind (or in more
current neuroscientific terminology, the brain and nervous system; see above).
Concerning basic principles of pharmacology and psychopharmacology from
the perspective of what happens to active psychopharmacologic agents, or drugs/
medications, when they interact with the human host who is taking them, in any
environment in which that individual is taking these agents (i.e., the Epidemiologic
Triangle model as discussed in Chap. 1), three concepts are of considerable

Switzerland AG 2022
https://doi.org/10.1007/978-3-030-82507-2_2
10 2 Basic Principles of Pharmacology, Psychopharmacology, and Psychopharmacotherapy
importance. These are (1) dose–response relationships; (2) desired or undesired

(“side”) effects; and (3) pharmacologic interactions1. Each of these will be dis-
cussed, in turn, below.
1. Dose–Response Relationship
The concept of the dose–response relationship states that as a pharmacologic
agent increases in amount in a host, or organism, the organism’s reaction, or
response, to that agent increases in a predictable pattern, resulting in one of two
characteristic dose–response curves, depending on the nature of the agents and
of the host. Generally, this response pattern will demonstrate a greater response
to an increased dose, after an initial lag, or induction phase, and will then pla-
teau at the end of the maximal beneficial dose. Graphically, this pattern is dem-
onstrated in an s-shaped or sigmoid dose–response curve, as illustrated in
Fig. 2.1.
Another dose–response curve is referred to as a “therapeutic window,” in which an
initial lag (induction) phase is followed by a rapid increase, then slowing, then
plateauing, then a declining response phase, such that an effective range, or
“therapeutic window” of response occurs within a low and high dose range of the
agent, but not before or after that range. This is illustrated in Fig. 2.1 (below), in
which the effective dose range is between the two asterisks on the “Dose” axis of
Fig. 2.1.
The development of tolerance to a drug or medication—defined as a state of
reduced responsiveness to a drug or medication generally as a result of long-
term, repeated exposure to that agent—may alter the dose–response relationship
of a person to a particular agent. This phenomenon is particularly characteristic
of alcohol and depressant medication, for present purposes.
1
Basic pharmacology distinguishes in this context between pharmacokinetics (“What the body
does to the drug: absorption, distribution, metabolism, and excretion”) and pharmacodynamics
(“What the drug does to the body: inhibition, facilitation, synergy, or competition between or
among drugs at target and receptor sites; drug–drug, drug–food interactions”). In these areas, the
hepatic cytochrome oxidase P-450 (CYP) system metabolizes different pharmacologic agents in
different ways, requiring the prescriber to know about these ways in terms of drug–drug interac-
tions. Some drugs, for example, operating on certain CYP systems, will competitively accelerate
the metabolism of other drugs, making it necessary to prescribe higher doses of the affected agent
to obtain the desired effect. The opposite can also occur, in which one drug will competitively
inhibit the metabolism of other drugs, making it necessary to prescribe lower doses of the affected
agent to obtain the desired effect. These CYP system relationships are generally well known and
well documented (in hard-copy tables and electronically) for psychotropic medications, and the
prescriber of prospective psychotropic agents should be aware of these potential drug–drug inter-
actions before prescribing any such medication.
2 Basic Principles of Pharmacology, Psychopharmacology, and Psychopharmacotherapy 11
2. Desired and Undesired (“Side”) Effects

The concept of desired and undesired (“side”) effects, simply stated, asserts
that no active pharmacologic or psychopharmacologic agent exhibits only the
desired beneficial effects for which it is intended, for a variety of reasons. For
example, one such reason, recently understood, asserts that by virtue of their
molecular pharmacology, some pharmacologic agents have more than one thera-
peutic mechanism of action and can be used for different clinical reasons, or
indications, in different dose ranges. These agents are called “multifunctional
drugs,” one widely used example of which is trazadone, an antidepressant (see
Chap. 3) with sedating properties.
In any event, all active pharmacologic and psychopharmacology agents will
manifest some undesirable (“side”) effects to a greater or lesser degree. These
side effects may be dose-related (as described in Fig. 2.1) or may be “idiosyn-
cratic” and unpredictable, occurring if a threshold dose of the agent is reached,
as in unexpected allergic reactions. In addition, these undesired or side effects
may be specific (i.e., related to the desired effect of the agent itself, such as
excessive sedation from a sedative-hypnotic [sleep-inducing] drug) or non-
specific (i.e., not related to the desired effect of the pharmacologic agent, such as
nausea and diarrhea caused by some antibiotics). The term commonly applied to
situations in which an active pharmacologic agent produces an undesired (side
effects) response is “adverse drug reactions” (ADR). The current print and/or
electronic version of the Physician’s Desk Reference (PDR) and other such elec-
tronic databases gives detailed current information about desired and side effects
of the medications licensed and approved by the Food and Drug Administration
(FDA) in the United States.
Fig. 2.1 Theoretical 1

dose–response curves.
(Adapted from Greenfield
D. Pharmacology and
psychopharmacology. In
McDonald JJ, Kulick FB,
editors. Mental and
emotional injuries in
RESPONSE
employment litigation, 2nd

ed. BNA Books; 2001)
2
DOSE
1 = sigmoid; 2 = therapeutic window
3. Pharmacologic Interactions
The third fundamental concept in pharmacology, for present purposes, is phar-
macologic interactions. This concept recognizes that once a pharmacologic agent
(i.e., drug; medication) is in the body (see footnote 1), chemical interactions with
other substances in the body can influence that agent’s actions and effectiveness
and may require upward or downward changes in doses of that agent (drug/medi-
cation) for it to have its desired effects. The most commonly described such inter-
actions are with other drugs (called “drug–drug interactions,” or DDIs), with food
(called “drug–food interactions” or DFIs), or with underlying medical conditions
(such as absorption and metabolic disorders, including malabsorption, diabetes
mellitus, and renal insufficiency disorders). The practical implications of these
interactions include the potential need for adjustment in doses of a medication in
order for it to have its desired and expected response.
Awareness of these interactions will allow the prescribing practitioner to
understand better the potential issues involved in individuals’ psychiatric disor-
ders which are being treated by psychotropic medications. In such situations, the
variety of factors described in the Epidemiologic Triangle model should be con-
sidered, including drug–drug interactions (in the host), the living situation of the
host (environment), the dose–response characteristic of drugs and medications
(agents), and the interactions of all of these factors.
Classes of Pharmacologic and Psychopharmacologic Agents
For present classification purposes, the initial division of pharmacologic agents will
be into non-psychotropic and psychotropic agents, recognizing that a variety of
undesired (“side”) effects of a psychiatric, neuropsychiatric, or neurologic nature
(e.g., dizziness, fatigue, lethargy, transient sensory disturbances, depression, mal-
aise, and others) may occur with both of these broad classes of pharmacologic
agents. The vast majority of both psychotropic and non-psychotropic medications
are prescribed by non-psychiatric physicians (primary care physicians, internists,
obstetricians-gynecologists, surgeons, orthopedics, and others) and other healthcare
providers who may prescribe medications and drugs (e.g., physician assistants,
advanced practice nurses, psychologists with prescribing privileges, and others).
This is the case simply because there are so many more nonpsychiatrist providers
prescribing these agents than there are psychiatrists.
Non-psychotropic medications may be further classified in several ways,
including the organ system they are intended to affect (e.g., cardiovascular drugs;
pulmonary drugs) and the disease they are intended to treat (e.g., antineoplastic
[anticancer] medications; antidotes for poisoning), with some overlap between the
two (e.g., antituberculosis drugs as an example of an anti-infectious agent which
primarily affects pulmonary, or lung function, by virtue of the main site of infection
of the tuberculosis-causing bacteria). Tables 2.1 and 2.2 give examples of medica-
tions/drugs in these two subclasses of non-psychotropic medications.
Examples of side effects of members of both of these classes of non-psychotro-
pic medications are given in Table 2.1.
Classes of Pharmacologic and Psychopharmacologic Agents 13
Table 2.1 Selected Organ system Agent (medication)

examples of
Cardiovascular Digitalis preparations (cardiac):
non-psychotropic
Digoxin (various preparations)
medications classified
Antihypertensives:
by the organ system
Atenolol (Tenormin®)
affected
Alphamethyldopa (Aldomet®)
Beta-propranolol (Inderal®)
Gastrointestinal Motility agents:
Metoclopramide (Reglan®)
Antacids:
Maalox®
Mylanta®
Histamine blockers:
Cimetidine (Tagamet®)
Ranitidine (Zantac®)
Endocrine/ Diabetes mellitus preparations:
metabolic Humulin®
NPH
Oral hypoglycemic
Thyroid replacement preparations:
Cytomel®
Synthroid®
Pulmonary Bronchodilators:
Isoproterenol (Isuprel®)
Epinephrine
Integumentary Topical steroids:
(skin) Retin-A®
Cortisone®
Table 2.2 Selected examples of non-psychotropic medications classified by diseases treated

Disease Agent (medication)
Infectious diseases (pneumonia, meningitis, AIDS) Antibiotics and antivirals:
Penicillin
Cephaloxin (Keflex®)
Erythromycin
Zidovudine (Retrovir®)
Neoplastic diseases (cancers) Methotrexate
Steroids
Aspirin
Nonsteroidal anti-inflammatory drugs
(NSAIDs)
Immunological diseases Steroids
Azulfidine
Imuran®
Degenerative central nervous system (CNS) diseases L-Dopa, Sinemet® (for Parkinson’s
disease)
Poisoning Syrup of ipecac
Chelating agents:
EDTA
Penicillamine
Psychotropic Medications, for purposes of the “anti” classification system pre-

sented in this book, may be further divided in several ways, with overlap among mem-
bers of these divisions. These divisions are (1) Licit and Illicit drugs and medications
(so designated according to the lawfulness of their use. Stimulants, depressants, and
hallucinogens are medications/drugs in this class) and (2) twenty categories of medi-
cations and drugs, for present purposes (so designated according to the predominant
clinical indication, or reason, or condition/psychiatric disorder treated with the medi-
cation, recognizing that many of these are indicated—FDA-approved or off-label2—
for treatment of more than one condition or illness), as presented and discussed in
further detail in Chaps. 3 and 4 of this volume. Table 2.3 illustrates these two classifi-
cation systems of psychotropic drugs/medications.
Table 2.3 Licit and illicit psychotropic agents

Licit psychotropic Illicit psychotropic
Drugs/medications Drugs/medications
“Twenty Anti-s” (see Table 2.5 below; Stimulants, depressants, hallucinogens
see Chaps. 3 and 4) (see Chap. 5)
2
“Approval by the Food and Drug Administration (FDA) implies that available evidence shows
that a drug is safe and effective for the specific indication (disease or symptom) for which it is
tested…” whereas the term off-label as currently used “…commonly refers to prescribing cur-
rently available medication for an indication (disease or symptom) for which it has not received
FDA approval…[that it is] not the same as experimental or research use… Once a drug is FDA-
approved for a specific indication, legally it can be used for any indication…” (Furey K, Wilkins
K. AMA Journal of Ethics, 2016). As will be discussed later in this Primer, many available psy-
chotropic agents are frequently prescribed off-label today. Practically speaking, these prescribing
patterns are so much the case, for example, that there is a specific section for each of the entries for
specific psychotropic medications in Puzantian and Carlat’s Medication Fact Book (see Selected
References, in the Preface of this book) is for “off-label uses.”
Classes of Pharmacologic and Psychopharmacologic Agents 15
1. Classification according to Lawfulness of Use (Licit and Illicit

Psychotropic Agents)
“Licit” agents are those that may be prescribed and taken legally (such as
prescription medications and over-the-counter [OTC] medications, which may
be obtained without a prescription), and “Illicit” agents are those that may not.
The latter are typically drugs of abuse, or “street drugs,” although areas of over-
lap are often seen between these two categories. One such example is diversion
(from a prescription) to the street of alprazolam (Xanax®), a widely used anti-
panic and antianxiety medication (see Chaps. 3 and 4). Another example is the
street use of illicitly manufactured psychostimulants, such as methamphetamines
(“crystal meth”), a widely used psychostimulant drug of abuse with a wide range
of devastating medical and psychiatric consequences. Chapter 5 in this book
discusses examples of illicit substances in further detail.
2. Classification according to the Predominant Psychoactive Effect
Psychotropic agents generally produce one of three psychoactive effects in
their users, viz., stimulation (excitement, agitation, acceleration of thought and
speech, and otherwise “speeding up” of the user); depression (dulling, decelera-
tion of thought and speech, and otherwise “slowing down” of the user); and
psychosis (a break with reality, having hallucinations, and/or having delusional
thoughts. “Hallucinogens” which caused these symptoms, such as PCP, are also
known as “psychomimetics” or “mimicking psychosis”). Table 2.4 gives repre-
sentative examples of drugs (illicit) and medications in these three classes.
Table 2.4 Examples of illicit (and divertible; see Chap. 5) psychotropic agents
Stimulants
Amphetamines and related compounds (sympathomimetics)
Cocaine
Depressants
Alcohol (ethanol)
Heroin and other opioids
Sedative-hypnotics
Anxiolytics
Hallucinogens (“psychotomimetic”)
Inhalants (especially nitrates)
Lysergic acid diethylamide (LSD)
Marijuana (cannabinol and related compounds)
MDMA (“ecstasy”) and other “designer drugs”
Phencyclidine (PCP)
Psilocybin
3. Classification according to Predominant Clinical Indication Or Reason for

Prescribing
As briefly noted in Table 2.3, members of this group of “licit” drugs and
medications may be divided into 20 classes, according to the predominant clini-
cal condition or disorder treated. They are designated with an “anti” prefix to
convey their use in “combating” manifestational symptomatology of the intended
disorder to treat, regardless of the potential underlying cause, or mechanism,
symptoms of the disorder. As with any drug or medication, they can be abused or
diverted from legitimate use. But their inclusion in the “licit” category of psy-
chotropic agents, for present purposes, is intended to emphasize that when legiti-
mately used as directed, these drugs and medications have bona fide and legal
clinical indications. Chapter 3 (“The Four ‘Major Anti-s’”) of this book dis-
cusses the four most widely used classes of psychotropic medications. Chapter 4
(“The Sixteen ‘Minor Anti-s’”) discusses the 16 less widely used classes of psy-
chotropic medications, especially by psychiatrists and other mental health prac-
titioners (Table 2.5).
Table 2.5 Licit psychotropic agents: the “twenty anti-s”
Anti-addiction agents
Anti-aggression agents
Antianxiety agents (anxiolytics; minor tranquilizers)
Anti-appetite agents (anorexiants)
Anticonvulsant agents (antiseizure agents; antiepileptic drugs [AEDs])
Anti-dementia agents (cognition enhancers)
Antidepression agents (mood elevators; thymoleptics)
Anti-feeding and eating agents
Anti-hyperactivity agents (psychostimulants)
Anti-impotence agents
Anti-insomnia agents (sedative-hypnotics)
Antimanic agents (mood stabilizers and thymoleptics)
Anti-obsessive-compulsive disorders (OCD) agents
Antipain agents (analgesics)
Antipanic agents
Antiparkinsonian agents
Antipseudobulbar affect agents
Antipsychotic agents (neuroleptics; major tranquilizers)
Antisex agents
Antitrauma agents
Three Additional Classes 17
Three Additional Classes
Three heterogeneous types of drugs and medications whose members are frequently
encountered in clinical and legal/forensic practice which have considerable overlap
with the more discrete and unitary 20 subclasses of “Anti-Agent” medications dis-
cussed above and in Chaps. 3, 4, and 5 of this book are “Over-the-Counter (OTC)
Agents;” “Anticholinergic Agents;” and “Botanicals, Herbals, Nutraceuticals, and
(Dietary) Supplements” (BHNSs). These agents do not “fit” conveniently into the
other categories or classes presented in this book, and will therefore be discussed as
separate categories.
1. Over-the-Counter (OTC) Drugs and Medications
Over-the-Counter (OTC) drugs and medications are a heterogeneous collec-
tion of wide-ranging agents, many of which have psychoactive properties, and
some of which are marketed as psychotropic medications. The only feature com-
mon to these agents, for present classification purposes, is that they are available
without prescription, and in that sense—for present purposes—may be consid-
ered as comparable to botanicals, herbals, nutraceuticals, and (dietary) supple-
ments (BHNSs; see Chap. 6). The regulation of OTC preparations by the Federal
Food and Drug Administration (FDA) periodically permits what the National
Pharmaceutical Manufacturers Association calls a “prescription-to-OTC switch,”
which is generally of considerable financial advantage to the pharmaceutical
company that manufactures the switched medication. Bases for such switches
include a switch of the medication itself with respect to OTC status and switch
approval of a reduced dose level of a medication (such as cimetidine, or
Tagamet®, for treatment of gastric hyperacidity). Since these switches may
occur with medications which have psychoactive effects and DDIs and DFIs
with both psychoactive and non-psychoactive undesired (“side”) effects, it
behooves prescribers, and anybody else evaluating medical and clinical records
(e.g., forensic experts) to be aware of the potentially confounding symptomatic
effects OTC medications and drugs may have on patients. Put more simply,
when possible, a drug and medication history should always be taken from the
evaluee, including both prescribed and OTC medications.
2. Anticholinergic Drugs and Medications
In terms of the anatomy and physiology of the human nervous system,3 like
all nerve cells in the nervous system generally, those of the parasympathetic
3
Very briefly, the human nervous system may be classified into two pairs of dichotomous catego-
ries. Anatomically, the nervous system consists of the central nervous system, or “CNS” (the
brain and spinal cord) and the peripheral nervous system, or “PNS” (all other parts of the nervous
system outside the brain and spinal cord). Physiologically, and functionally, the nervous system
consists of the voluntary nervous system and the involuntary, or autonomic nervous system
(ANS). The voluntary nervous system mediates and coordinates involuntary human activities such
as digestion, salivation, heart activity, and many others. In many body functions—such as breath-
ing—voluntary and involuntary components exist and overlap and are mediated and coordinated
with both voluntary and involuntary input. Anatomically, the ANS consists of two subsystems, the
(“slowing down” involuntary bodily functions, such as salivation, digestion, and

so forth) division of the autonomic nervous system (ANS) communicate from
one to another across a very small space that separates them (the “synapse”) with
different chemical substances called “neurotransmitters.” The predominant neu-
rotransmitter in the parasympathetic nervous system is acetylcholine, and the
functions of the parasympathetic nervous system which are mediated by this
neurotransmitter are called “cholinergic.” Medications, drugs, and other sub-
stances which interrupt, disrupt, or otherwise block the cholinergic-mediated
functions are called “anticholinergic.” A wide variety of substances, medica-
tions, drugs, and other chemicals have anticholinergic properties, and in that
sense, these substances constitute a heterogeneous group of entities which do not
have a single, unitary, or underlying pattern of clinical indications.
That varied group of substances may affect (as undesired, or “side” effects)
many of the drugs and medications in the classes of psychotropic drugs dis-
cussed in this part of this book: For that reason, psychotropic drugs and medica-
tions which block, or disrupt parasympathetic/cholinergic functioning of the
ANS, again, are said to have “anticholinergic side effects.”
“Somatic” (related to the body, in contrast to “psychic” related to the mind)
anticholinergic side effects commonly seen with anticholinergic drugs and medi-
cations include dry mouth, blurry vision, constipation, urinary hesitancy, and
tachycardia (rapid heart rate). Central nervous system (“psychic” or “psychiat-
ric/neuropsychiatric/anticholinergic”) signs and symptoms may include organic
brain symptomatology (memory impairment, disorientation, confusion, and
delirium, among others). The often-heard clinical aphorism which summarizes
both the somatic (peripheral) and psychic (central) symptomatology of the anti-
cholinergic syndrome is: “Red as a beet; dry as a bone; hot as hell; and mad as
a hatter.” Examples of medications with anticholinergic effects and side effects
include many of the anti-Parkinson’s agents (see Chap. 4), antispasmodic gastro-
intestinal and genitourinary medications, and medications for treating glaucoma
(see above).
For legal professionals reading this book in the context of litigation, the feel-
ings of discomfort, dysphoria, and irritability resulting from the anticholinergic
syndrome for legitimately prescribed drugs and medications may be incorrectly
attributed to events and experiences in the context of the litigation (i.e., rather
than to the condition for which the medications are prescribed), and/or to the
anticholinergic side effects of the medications themselves. As with all legal cases
involving any drugs or medications, the law practitioner and expert should be
sympathetic nervous system (SNS)—which speeds up involuntary body activities—and the para-
sympathetic nervous system—which slows down involuntary body activities. The central portion
of the ANS is found in two chains of nerve collections, or “ganglia,” located parallel to and on
either side of the spinal cord and vertebral column, and in the other ganglia and peripheral nerves
located throughout the body. The central part of the ANS is located within the brain and spi-
nal cord.
Three Additional Classes 19
aware of the litigant’s drug and medication history (licit and illicit), if applicable,
as well as the litigant’s present drug and medication use, if applicable.
3. Botanicals, Herbals, Nutraceuticals, and (Dietary) Supplements
The last category of psychopharmacologic agents and substances discussed
in this book is also a broad one, and also encompasses overlap among subcatego-
ries. This category consists of Botanicals, Herbals, Nutraceuticals, and “Dietary”
Supplements (BHNSs), which are reviewed in greater detail in Chap. 6. Several
common features characterize this group of four types of substances. All are
considered “natural” and many are plant-based; none is regulated by the FDA as
drugs and medications in this country; and none is represented to the public as a
medication or pharmacologic treatment for a medical condition. Definitions of
each of these four members of this varied category of substances are:
• Botanicals are plant products, or derived from plants, and are available with-
out prescription from supermarkets, health food and nutrition stores, pharma-
cies and drug stores, catalogs and internet sources, and other commercial
sources.
• Herbals—a term to be contrasted with that of a book containing the names
and descriptions of plants, usually with information on their properties—
refers to plants and plant extracts used by consumers and practitioners in
health care in the fields of “botanical medicine,” “medical herbalism,” “herbal
medicine,” “herbology,” and “phytotherapy.”
• Nutraceuticals, or Nutriceuticals, are, according to Webster’s College
Dictionary (Webster’s College Dictionary, 2000), “…food[s] or natural
substance[s] that contain or [are] supplemented with ingredients purported to
have health benefits.” The word itself is a condensation of “nutrition” and
“pharmaceutical” (from the Latin, “druggist,” originally “poisoner”), intended
to convey the therapeutic value of such compounds.
• (Dietary) Supplements, also called “food supplements” and “nutritional
supplements,” are preparations which are intended to supplement an individ-
ual’s diet. These supplements consist of vitamins, minerals, herbs, or other
botanicals (excluding tobacco and tobacco products), amino acids, fatty
acids, fiber, or other nutrients that are not consumed in sufficient quantity in
the diet (DHEA, pregnenolone [a steroid hormone], and the pineal hormone
melatonin are marketed as dietary supplements in the United States).
For both clinical and legal practitioners, for present purposes, similar feelings of
discomfort, dysphoria, anxiety, irritability, depression, and other such symptomatol-
ogy may also result from the use of BHNSs in a variety of circumstances, even
though public perception of these substances is that they are beneficial and benign
(Blendon R, et al. Annals of internal medicine. American College of Physicians;
2001). For that reason, as with all situations involving drugs and/or medications, the
practitioner should be aware of patients’ (or litigants,’ for the legal professional)
BHNS history and current use, if applicable, as well as of the patient’s or litigant’s
drug and medication history and current use (licit and illicit), if applicable. As with
drugs and medications, a thorough history of the patient’s or litigant’s BHNS use
and history are basic requirements for any clinical or legal professional in this area.
Two Additional Concepts (For All Pharmacologic Agents)
The following two aphorisms apply to two important concepts for all pharmaco-
logic agents, respectively, viz.:
Drugs don’t work in patients who don’t take them…
— C. Everett Koop, MD, Former U.S. Surgeon General (1982–1989)
The Powerful Placebo
— Title of JAMA (Journal of the American Medical Association) article in 1955 by
H. K. Beecher
These concepts—compliance/adherence and placebo/nocebo, respectively—to

which these aphorisms are valid for all pharmacologic agents, and for psychophar-
macotherapeutic medications in particular, given the often-subjective nature of psy-
chiatric and neuropsychiatric symptomatology. Each will be discussed, in turn, below.
1. Compliance/Adherence
The term, “compliance,” dates back to 1976 and refers to the extent to which
patients obey (“comply with”) healthcare providers’ instructions about medica-
tions, appointments, diet, exercise, and the like. In 2003, recognizing the author-
itarian and paternal connotations of the term “compliance,” the World Health
Organization introduced the term “adherence” as a substitute, to convey the
notion of patients’ collaboration with providers in their mutual efforts for patients
to “adhere” (“stick to”) a previously worked out and agreed upon treatment plan
(including medications).
Whatever term is used, compliance/adherence with treatment plans has been
problematic in healthcare “since forever,” and “…between thirty and 50% of
medicines for long-term conditions are not taken as prescribed…[and]…rates of
non-adherence in patients with psychotic disorders are comparable to those of
patients with other long-term conditions…” (Chapman S, Horne R. Medication
nonadherence and psychiatry. In Current opinion in psychiatry. 2020, September.
https://journals.lww.com/co-p sychiatry/Fulltext/2013/09000/Medication_
nonadherence_and_psychiatry.5.aspx).
A number of approaches for enhancing compliance/adherence among patients
has been suggested, including patient education (focusing on the reasons for
medications and anticipating and coping with side effects); pill counts, new tech-
nologies (e.g., “smart pills,” electronically monitored); simplified dosing sched-
ules; patient aids (such as weekly pill boxes); and others.
Although a detailed discussion of compliance/adherence is beyond the scope
of this chapter, for practical purposes, if a prescription for a psychotropic agent
does not seem to be producing desired results, the first possibility to occur to the
Two Additional Concepts (For All Pharmacologic Agents) 21
healthcare provider should be that their patient is not taking the medication as
prescribed, or at all. Other possibilities include an improper dose, insufficient
duration of the medication, drug–drug or drug–food interactions with the medi-
cation, treating the patient for an incorrect diagnosis for the prescribed medica-
tions, or some combination of all of these possibilities.
2. Placebo/Nocebo
Given the subjective and “anti-manifestational” nature of the symptomatol-
ogy to be addressed by psychopharmacologic agents, no discussion of them
would be complete without some attention to “placebos” (from the Latin: “I will
please”) and “nocebos” (from the Latin: “I will harm”). Both terms refer to
effects—desirable and undesirable, respectively—attributed to otherwise inert
and inactive substances which were not anticipated or expected. Placebos have
been recognized for many years, used in general medicine (sometimes with
questionable ethics, which will not be further discussed here) for some 200 years,
and recognized specifically in psychiatry for about 60 years. The use of placebo
methodology in pharmacologic study design as an indication of negative activity
(i.e., in comparison with the active drug, or agent, under study) has also been the
standard approach to such studies for many years, although recent findings have
documented neurophysiologic activity producing specific neuropsychiatric
effects in an otherwise presumably “inert” agent. (Weimer K, Colloca L, Enck
Prof. P. Placebo effects in psychology: mediators and moderators. In Lancet
psychiatry. 2015, March. https://www.thelancet.com/journals/lanpsy/article/

PIIS2215-0366(14)00092-3/fulltext).
“Placebos” and “Nocebos” in the context of psychiatry and psychopharma-
cology will each be discussed, in turn, below.
Concerning placebos in psychiatry and psychopharmacotherapy, with subjective symp-
tomatology such as pain, anxiety, and depression, the role of the “placebo effect” and in
that sense, a positive expectation of symptom relief, must always be taken into account in
the clinical assessment of a patient’s response to a trial of a new medication or treatment
intervention. If a patient does not experience expected and anticipated symptom relief, then
compliance/adherence, or other issues (see above) may be at play, or the patient may harbor
a surreptitious or unknown negative attitude (nocebo effect; see below) toward the
intervention.
Concerning nocebos in psychiatry and psychopharmacotherapy, perhaps the most practical
way to characterize the negative expectations of patients for whom a medication may prove
to have a “nocebo effect” can be appreciated in the old saw often heard from patients: “I
don’t want to be on any medication. I don’t even take an aspirin when I have a headache…”
While this saw may be a prevalent sentiment among patients, an actual nocebo effect from
a specific medication needs to be carefully evaluated on an individual basis, as a practical
matter, as part of the differential diagnosis for such unsuccessful medications.
As with considerations of compliance/adherence, a detailed discussion of place-

bos and nocebos is beyond the scope of this Primer. For further information and
details about fascinating, evolving, and widespread phenomena, the reader is
referred to the many technical and encyclopedic textbooks, articles, monographs,
and references available in psychopharmacology and pharmacology.
OVID-19, Telemedicine, Telepsychiatry,

C
and Psychopharmacology
Telemedicine and telepsychiatry are here to stay, even before the COVID-19 pan-
demic, and especially since the pandemic began. Recognition of the advantages of
this means of patient care, especially in underserved settings (e.g., rural, correc-
tional, emergency departments, dense urban areas, and the like), has resulted in the
near doubling of telepsychiatry services in the U.S. mental health facilities from
2010 to 2017 (Frank B, Peterson T, Gupta S, Peterson T. Telepsychiatry: what you
need to know. In Current psychiatry. 2020, June. https://www.mdedge.com/psychia-
try/article/222686/coronavirus-u pdates/telepsychiatry-w hat-y ou-n eed-k now).
Concerning psychopharmacotherapy, the relaxation, both formally and informally,
of some requirements for mental health patient care owing to the exigencies of the
COVID pandemic has led to modification, in this writer’s view, of one of the “sacred
cows” of prescribing, namely face-to-face examination (including physical exami-
nation) of prospective patients for whom psychopharmacotherapy may be consid-
ered as part of their treatment plan.
Without purporting to offer the final word in a changing practice environment
with multiple moving parts, I echo the caveat given in the above article in Current
Psychiatry concerning medicolegal aspects of telemedicine, telepsychiatry, and
even forensic (consulting and correctional)4 telepsychiatry.
…When conducting telepsychiatry services, clinicians need to consider several legal issues,
including federal and state regulations, as well as professional liability…[and that]…Because
state laws related to telepsychiatry are continuously evolving we suggest that clinicians
continually check these laws and obtain a regulatory response in writing so there is ongoing
documentation… (Joshi KG. Telepsychiatry during COVID-19: understanding the rules. In
Current psychiatry. 2020, June. https://www.mdedge.com/psychiatry/article/222695/
coronavirus-updates/telepsychiatry-during-covid-19-understanding-rules)
Since the varied, changing, and complex nature of telemedicine, telepsychiatry,

and “telepsychopharmacotherapy” is well beyond the scope of this brief section—
before, during, and after the COVID-19 pandemic—the reader is referred to the
burgeoning literature on this topic, several of which have been referenced in
this book.
4
For present purposes, “consultation” forensic psychiatry in contrast to “therapeutic” forensic psy-
chiatry refers to the application of principles of clinical psychiatry and human behavior in crimi-
nal, civil, and family areas of the law. “Therapeutic” psychiatry refers to clinical treatment of
individuals in civilian settings (mental health centers, hospitals, and so forth); or in custodial set-
tings (jails, prisons, federal penitentiaries, and the like, also known as “correctional psychiatry” (in
the United States) and “prison psychiatry” (in the United Kingdom).
Selected References
diagnoses.)
Publishers: 2013. (The subtitle says it all! See Chap. 4 in this Primer.)
of the field.)
ries, viz.
sional journal)
2. Government and academic/research institutions, publications and e-publications
tronic and print)
include:
Chapter 3
The Four “Major Anti-s”
In Part I of this book—the core of this Primer—the substance of psychopharmaco-

therapeutic agents used for the treatment and management of psychiatric disorders
will be presented, reviewed, and discussed. This review begins in this chapter with
the most common, or prevalent, psychiatric disorders seen in clinical practice. These
disorders are presented in Table 3.1, along with the designation used in this book of
the “anti”-psychotropic medication indicated for treatment and management of
these disorders.
Table 3.1 Prevalent psychiatric disorders and their “anti” psychopharmacotherapeutic agents: the
four “major anti-s”
Psychiatric disorders “Anti” psychopharmacotherapeutic agents

Anxiety disorders “Antianxiety agents”
Depressive disorders “Antidepressant agents”
Mood instability disorders “Antimanic agents”
Psychotic disorders “Antipsychotic agents”

Switzerland AG 2022
https://doi.org/10.1007/978-3-030-82507-2_3
28 3 The Four “Major Anti-s”
Antianxiety Agents
The first of the four most common psychiatric disorders and their psychopharmaco-
therapeutic treatment are “anxiety disorders.”
In Chap. 2 of this book, reference was made to the DSM-5 as an organizing prin-
ciple for the 20 “anti” categories of psychotropic medications endorsed in this
Primer. Reference was also made to the DSM-5 as an imperfect document, not truly
“carving nature at her joints” (à la Plato) with respect to mental illness diagnoses.
This latter point had been made earlier in a landmark New York Times article on
January 18, 2015 on “Redefining Mental Illness” by T.R. Luhrmann, as follows:
…For decades, American psychiatric science took diagnosis to be fundamental. These cat-
egories—depression, schizophrenia, post-traumatic stress disorder—were assumed to repre-
sent biologically distinct diseases, and the goal of the research was to figure out the biology
of the disease. That didn’t pan out. In 2013, the Institute’s [National Institute of Mental
Health] director, Thomas R. Insel, announced that psychiatric science had failed to find
unique biological mechanisms associated with specific diagnoses. What genetic underpin-
nings or neural circuits they had identified were mostly common across diagnostic groups…
…And so the Institute has begun one of the most interesting and radical experiments in
scientific research in years… Under a program called Research Domain Criteria, all
research must begin from a matrix of neuroscientific structures (genre, calls, circuits) that
cut across behavioral, cognitive, and social domains (acute fear, loss, arousal). To use an
example from the program’s website, psychiatric researchers will no longer study people
with anxiety; they will study fear circuitry…
For present purposes in this book, however, psychiatric research has not reached
the point of having psychopharmacology geared toward ameliorating or resolving a
dysfunctional “matrix of neuroscientific structures” which were not “common
across diagnostic groups.” For now, prescribers of psychotropic medications must
settle for the admittedly sloppy and imprecise mélange of overlapping manifesta-
tional (i.e., not causal, or etiologic; see Chap. 1) clusters of symptomatology on
which the DSM-5 is based. As pointed out earlier, most currently used psychotropic
medications are intended to counter, reduce, ameliorate, or be “anti” to symptom-
atology resulting from designated disorders. Hence, the 20 “anti” categories of psy-
chotropic medications is the classification system that is used in this book.
Starting with what have been called the “common colds” of psychiatry—“Anxiety”
and “Depression,” often with overlapping symptomatology common to both—Table
3.2 presents psychotropic medications commonly used as “anxiolytics,” “sedative-
hypnotics,” or “antianxiety drugs,” or (in older terminology) “minor tranquilizers.”1
Note that by virtue of overlapping symptomatology treated by different classes of
psychotropic medications, several types of psychotropic medications may be used for
the same clinical indication2 (e.g., SSRI antidepressants for anxiety relief).
1
So-called in the 1960s and 1970s to contrast these agents with “major tranquilizers” or antipsy-
chotic medications, used to treat “major” psychoses, not “minor” neuroses. Note that the word, or
concept, of “neurosis” is not endorsed as a level of symptomatology or as a diagnostic category and
does not appear in the DSM-5.
2
Often “off-label,” or not as a formal recognized and approved clinical indication by the Food and
Drug Administration (FDA). A substantial proportion of psychotropic medications are prescribed
in this way, by both nonpsychiatrists and psychiatrists. (See Chap. 2.)
Antianxiety Agents 29
Table 3.2 Anxiolytic/sedative (daytime)-hypnotic (nighttime) agents

Generic name* Brand name*
Benzodiazepines (BDZs) used as daytime anxiolytics
Alprazolam Xanax®; XanaxER®
Alprazolam extended release XanaxER® Librium®
Chlordiazepoxide Klonopin®
Clonazepam Tranxene®
Clorazepate Valium®
Diazepam Ativan®
Lorazepam Serax®
Oxazepam
Nonbenzodiazepines used as daytime anxiolytics
Buspirone Buspar®
Benzodiazepines used as nighttime hypnotics (GABAergic agonists)
Estazolam Prosom®
Flurazepam Dalmane®
Quazepam Doral®
Temazepam Restoril®
Triazolam Halcion®
Nonbenzodiazepines used as nighttime hypnotics (GABA-BDZ receptor agonists)
Eszopiclone Lunesta®
Zaleplon Sonata®
Zolpidem Ambien®
Zolpidem extended release AmbienCR®
Ramelteon Rozerem® (melatonin agonist)
Nonbenzodiazepines with anxiolytic/sedating effects (antihistamines)
Diphenhydramine Benadryl® (othersa)
Doxepin Sinequan® (at low doses; antipsychotic at high doses)
Hydroxyzine Atarax®; Vistaril®
Quetiapine Seroquel® (at low doses; antipsychotic at high doses)
Nonbenzodiazepines with anxiolytic/sedating effects (adrenergic receptor blocking agents)
Propranolol Inderal®
Clonidine Catapres®
*
With off-patient medications, different pharmaceutical companies may manufacture the same
psychotropic agent, resulting in different brand names for the same “generic equivalent”
Without reiterating details of types and subtypes of DSM-5 classifications of

anxiety disorders—to which the reader is referred for further information and
details—the following two case vignettes (one, an old joke, and the other an actual
brief case vignette) illustrate psychopharmacotherapeutic approaches to individuals
with generalized anxiety disorder (GAD) and panic disorder, respectively. The
reader is referred to previously mentioned sources and references for such details
and information as dosing schedules, doses, desired and side effects, indications and
contraindications, and the like.
A 38-year-old woman from the suburbs consulted her primary care physician assistant (PA)
with complaints of severe tension and anxiety, insomnia, overeating, stage fright, and a per-
vasive sense of dread and foreboding. After interviewing and examining the patient, the PA
determined that there was no obvious pathophysiologic basis for the patient’s anxiety and
prescribed a sedating benzodiazepine estazolam (Prosom®) for her. He instructed her to keep
a daily mood diary, to call the practice or follow-up a week before the next scheduled appoint-
ment, and to return for a follow-up visit in two weeks. The patient returned as scheduled,
appearing calmer, well-rested, energetic, and with a 5-pound weight loss. She told the PA
“Ever since I started giving the medication to my husband, I’ve felt 1000% better. Thank you
so much!”
AB, a 48-year-old prominent local academic psychiatric APN has had a longstanding his-
tory of stress-related panic disorder (see Chap. 4, also) which had begun abruptly (i.e., her
first “herald attacks”) in her 30s. Her attacks were associated with public speaking at aca-
demic events (conferences, symposia, meetings, and the like). At first, she accepted psycho-
pharmacotherapy alone (“monotherapy”) with alprazolam (Xanax®) but became dependent
on it after a few months. She then began a course of exercise and cognitive behavioral
therapy (CBT), supplemented with paroxetine (Paxil®), which had recently received FDA
approval for that indication. This combination—as is often the case, given synergistic inter-
active effects of different types of therapy and different classes of psychopharmacologic
agents—was and has been effective for AB for years, and she has successfully incorporated
the exercise part of her anti-panic (see Chap. 4) regimen into her daily activities.
Antidepressant Agents
A large number of psychotropic agents constitutes the second major “anti” subclass
of psychopharmacotherapeutic medications, viz., “antidepressant agents.” Also
known historically as “mood elevators” and “thymoleptics,” the biochemically based
classifications of medications in this subclass have varied over the years, as have the
approved indications for “antidepressant” agents. This point is especially true con-
cerning the overlap of anxious and depressive symptomatology in presumably
“depressed” individuals’ (for whom antidepressant medications work well for such
patients’/clients’ symptoms) anxiety, and concerning both the general ineffectiveness
for depressive symptoms in bipolar disorder and the induction of mania (the “switch
process”) in depressed patients/clients antidepressant medications may produce.
However, for present purposes, I will use predominant current nomenclature for
the several types of antidepressant medications potentially prescribed by readers of
this Primer. These include (1) Cyclic compounds (tricyclic, tetracyclic, heterocy-
clic, and polycyclic, referring to the biochemical molecular ring structures of these
medications); (2) Mono-amino oxidase inhibitors (further divided into MAOa
inhibitors, and MAOb inhibitors, depending on their pharmacologic properties; (3)
Reuptake inhibitors of various types (Table 3.3); (4) Other miscellaneous prepara-
tions; and (5) Combination preparations. Without reiterating details and nuances of
the DSM-5 classifications and subclassifications, the main clinical indication for
these antidepressant medications is major depressive disorder (“unipolar depres-
sion”), persistent depressive disorder (dysthymia), and other variants, but not bipo-
lar depression (see below).
Table 3.3 delineates the several types of reuptake inhibitors among antidepres-
sant agents, and Table 3.4 summarizes the overall subclasses of “antidepressant”
psychopharmacotherapeutic medications.
Antidepressant Agents 31
Table 3.3 Types of neurotransmitter reuptake inhibitors (mostly antidepressant agents)

Neurotransmitter reuptake Specific medications
inhibitor class Generic name (Brand name)
Serotonin reuptake Citalopram (Celexa®)
inhibitors (SRIs) Escitalopram (Lexapro®)
Paroxetine (Paxil®; PaxilER® [extended release]): at low dose
Venlafaxine (Effexor®): at low dose
Fluvoxamine (Luvox®): indicated for OCD
Trazodone (Desyrel®)
Vortioxetine (Trintellix®)
Vilazodone (Viibryd®)
Nefazodone (Serzone®): discontinued in 2003; equivalents may
be available
Norepinephrine reuptake Desipramine (Norpramin®)
inhibitors (NRIs) Nortriptyline (Pamelor®)
Atomoxetine (Strattera®): the only indicated non-stimulant for
ADHD
SRIs/NRIs (mixed action) Duloxetine (Cymbalta®, Irenka®)
Venlafaxine (Effexor®): at usual dose
Fluoxetine (Prozac®) Levomilnacipran (Fetzima®) Paroxetine
(Paxil®; Paroxetine ER® [extended release]): at usual dose
Clomipramine (Anafranil®): indicated for OCD Amitriptyline
(Elavil®)
Doxepin (Sinequan®; Adapin®)
Imipramine (Tofranil®)
SRIs/DRIs (dopamine Sertraline (Zoloft®)
receptor inhibitors)
Adapted from Ghaemi (2019)
Generally, antidepressant psychopharmacotherapy is effective in about two-

thirds of patients/clients, and more often in combination with other types of treat-
ment (e.g., counseling/psychotherapy; see Chaps. 7 and 8). One longstanding
technique to enhance that yield is “augmentation,” or supplementation, of underly-
ing psychopharmacotherapy—especially of tricyclic antidepressant medications—
with a variety of agents. These agents include lithium compounds (at relatively low
dosages), which are often effective, and electroconvulsive therapy (ECT; see Chap.
9) for individuals with treatment-resistant depression (TRD), non-responsive to
psychopharmacotherapy.
Other augmentation strategies include triiodothyronine (T3, and other thyroid
preparations, for thyroid replacement therapy, used off-label for antidepressant aug-
mentation), tryptophan (an essential amino acid used off-label for antidepressant
augmentation; see Chap. 6), methylphenidate (Ritalin® and others; see Chap. 4,
section “Anti-ADHD Agents”), and pindolol (Visken® and others; a non-selective
beta-blocker antihypertensive medication used off-label for antidepressant augmen-
tation), all with lackluster to moderate treatment responses.
Table 3.4 Antidepressant agents

Cyclic compounds
A. Tricyclics (TCAs)
Amitriptyline (Elavil®, Etrafon®, and others)
Clomipramine (Anafranil®)
Desipramine (Norpramin® and others)
Doxepin (Sinequan® and others)
Imipramine (Tofranil® and others)
Nortriptyline (Pamelor®, Aventyl®, and others)
Protriptyline (Vivactil® and others)
Trimipramine (Surmontil® and others)
B. Other cyclic compounds (tetracyclic, bicyclic, heterocyclic, polycyclic)
Amoxapine (Asendin®)
Maprotiline (Ludiomil®)
Mirtazapine (Remeron®)
Venlafaxine (Effexor®)
Desvenlafaxine (Pristiq®)
Monoamine oxidase inhibitors (MAOIs)
A. MAO-As
Isocarboxazid (Marplan®)
Phenylzine (Nardil®)
Tranylcypromine (Parnate®)
B. MAO-Bs (see also section “Antiparkinsonian Agents,” in Chap. 4, this book)
Selegiline (Zelapar®; Emsam® patch [transdermal application]; Eldepryl®)
Selective serotonin reuptake inhibitors (SSRIs) and other reuptake inhibitors (Table 3.3)
Citalopram (Celexa®)
Escitalopram (Lexapro®)
Fluoxetine (Prozac®)
Paroxetine (Paxil®; Paxil ER®; and others)
Sertraline (Zoloft®)
Vilazodone (Viibryd®)
Vortioxetine (Trintellix®)
Serotonin/norepinephrine agonist (SNA)
Mirtazepine (Remeron®)
Serotonin antagonist/agonist (mixed)
Buspirone (Buspar®)
Other agents
Bupropion (Wellbutrin®): “stimulating” and similar in chemical structure to amphetamines,
with mild dopamine and norepinephrine
Nefazodone (Serzone®)
Trazodone (Desyrel®)
Ketamine (Spravato®; nasal spray; racemic ketamine infusion)
Combination preparations
Amitriptyline (Elavil®) and perphenazine (Trilafon®): an antipsychotic; Triavil® and Etrafon®
(no longer manufactured under these names: generic equivalents may be available)
Amitriptyline (Elavil®) and Chlordiazepoxide (Librium®): an antianxiety agent; Limbitrol®
(for mixed anxiety and depression)
Antidepressant Agents 33
With the wide variety of types and classes of psychopharmacologic entities com-
prising the “Antidepressant Agents,” and the overlapping symptomatology among the
various imprecise diagnostic categories to be treated by these agents, their use may be
associated with a wide variety of undesirable (“side”) effects. These effects, in turn,
may be difficult to separate from symptomatology attributable to the condition being
presumably treated, from symptomatology attributable to other co-occurring (comor-
bid) conditions or from a combination of all of these potential sources of undesirable
effects. As with the earlier “Antianxiety Agents” section of this present chapter, I will
not reiterate details of types and subtypes of the DSM-5 classification of depressive
disorders: The reader is referred to applicable parts of the DSM-5 for that information.
Two case vignettes both illustrate psychopharmacotherapeutic approaches to
individuals with major depressive disorder and with a variant of depression, respec-
tively, and also illustrate a frequent mistake made in the treatment/management of
such individuals.
AJ, a 62-year-old widow, presented to her psychiatric PA with chief complaints of a three-
month history of initial and terminal insomnia, anorexia, and a seven-pound weight loss,
pervasive “blues” improving somewhat as the day progressed, and a pervasive sense of worth-
lessness and hopelessness. The onset of these symptoms coincided with the death of her
husband, with some feelings of blame and guilt that “the marriage could have been better.” AJ
had experienced a similar episode 23 years before, with the death of her mother; that short-
lived episode remitted spontaneously, with counseling/psychotherapy treatment. AJ’s older
sister had been psychiatrically hospitalized in her 30s for a serious depressive illness, and
responded well to a series of 10 electroconvulsive therapy (ECT) treatments. AJ’s psychiatric
PA prescribed supportive psychotherapy with a young empathetic female social worker and a
clinical trial of trazodone (Desyrel®), both to address AJ’s depression and her insomnia. After
about three to four weeks of this combined treatment, AJ felt better and more optimistic, had
more energy, slept better, and heaped praise on her psychotherapist and her psychopharmaco-
therapist for “helping me so much, the combination of both of you. I’ve even gone back to
yoga.” AJ’s improvement continued over the next nine months, to the present.
XY, a 37-year-old single stockbroker, remarked to his dentist that he had been experiencing
“the blues” over about the past four months. This was possible concomitant with a down-
turn in his work, but “probably not. I’ve been through that before.” His dentist referred him
to a practicing prescribing clinical psychologist,3 a “friend of a friend.” That psychologist
took a history, and prescribed fluoxetine (Prozac®), in that XY did not describe problems
with insomnia. At first, XY told his psychologist that he felt “a little better.” After about two
weeks, however, XY did not keep an appointment, telephoned the psychologist two days
later that “on a whim I picked up a woman in a bar, bought a Ferrari, drove to Minnesota,
had the greatest sex ever, and I never want to come back.” He eventually did return and
3
This appointment took place in Baton Rouge, Louisiana, where licensed psychologists are per-
mitted by law to prescribe psychotropic medications (i.e., “prescribing privileges”) under certain
circumstances and conditions. As of this writing, five states, Guam, the Indian Health Service (of
the U.S. Public Health Service), and the U.S. military permit prescribing privileges for psycholo-
gists with specific training in psychopharmacology. The states are Idaho, Illinois, Iowa, Louisiana,
and New Mexico, with efforts underway in additional states to grant psychologists’ prescribing
privileges.
revealed his history of several manicky episodes “a few years back,” to his psychologist,
who discontinued her patient’s fluoxetine (Prozac®). The psychologist continued counsel-
ing/psychotherapy with XY, and eventually placed him on a clinical trial of lithium (see
below), with the help of XY’s primary care physician. XY returned to a baseline level of
euthymia (normal range of mood and activity level) after a few weeks.
The first case (“AJ”) is a straightforward example of a history and proper diag-
nosis of major depressive disorder, effectively treated with antidepressant psycho-
pharmacotherapy and supportive counseling/psychotherapy. It also illustrates the
trend in contemporary mental health care for counseling/psychotherapy with
patients/clients as done by counselors and therapists of a variety of types (see Part
II of this book) and for psychopharmacotherapy, as done by primary care NPs, PAs,
physicians, and other prescribers.
The second case (“XY”) illustrates the “switch process,” in which antidepressant
medication triggered a manic episode in an individual with a variant of depression
called bipolar depression: In that situation, an individual’s depressive episode (gen-
erally more common in individuals with bipolar disorder; see below, “Antimanic
Agents”) is part of the cycle pattern of mood fluctuation in bipolar disorder, and
may respond to an antidepressant “push” by transitioning into a manic episode. This
is what happened with XY, whose prior history of manic episodes and bipolar dis-
order had not been known to his treating psychologist until after his manic episode.
In concluding this section of this chapter, I emphasize the protean and variable
types of chemical compounds that constitute “antianxiety agents” and “antidepres-
sant agents.” In addition to this resulting in multiple, overlapping, and variable
undesirable (“side”) effects, it also results in multiple uses and indications for these
medications, both off-label and FDA-approved. Table 3.5 illustrates some of
the latter.
Table 3.5 Approved (FDA) indications for uses of SSRIs and other drug classes
Major depression
Citalopram (Celexa®), escitalopram (Lexapro®), fluoxetine (Prozac®), paroxetine (Paxil®), and
sertraline (Zoloft®); TCAs; SNRIs; MAOIs; others
Obsessive-compulsive disorder
Fluoxetine, fluvoxamine (Luvox®), paroxetine, and sertraline
Social anxiety disorder (social phobia)
Fluoxetine, paroxetine, and sertraline
Panic disorder
Paroxetine and sertraline; benzodiazepines (alprazolam [Xanax®]; clonazepam [Klonopin®];
others)
Generalized anxiety disorder
Escitalopram and paroxetine; benzodiazepines (all)
Post-traumatic stress disorder
Paroxetine and sertraline; benzodiazepines (not all)
Premenstrual dysphoric disorder
Fluoxetine and sertraline
Bulimia nervosa
Fluoxetine
Adapted from Black and Andreasen (2014)
Antimanic Agents 35
Antimanic Agents
As psychopharmacologic agents for treating manic episodes in individuals, the term

“antimanic” is intended as a short and focused one emphasizing individuals with
mood instability: mood swings (“affective instability” or “mood instability”),
which include both manic and depressive episodes of varying duration.
Unlike the other “anti” subclasses of agents in this classification system,
“Antimanic Agents” are few in number: Lithium compounds, carbamazepine
(Tegretol®), valproate (Depakote®; Depakene®), and lamotrigine (Lamictal®) are all
FDA-approved for treatment of bipolar disorder. All except lamotrigine are believed
to have a mechanism of action at the neurocellular level as a “second messenger”
with neuroprotective effects. Three of the four (not including lithium compounds)
are also classified as “novel anticonvulsants” (or antiseizure drugs, or antiepileptic
drugs [AEDs]), which as a group were developed, beginning in the 1990s. Several
other novel anticonvulsants are used off-label for treatment of bipolar disorder, with
reported results comparable to those seen in comparable FDA-approved medica-
tions for that indication (e.g., carbamazepine [Tegretol®] and oxcarbazepine
[Trileptal®]).
Table 3.6 lists these “Antimanic Agents” and their legal status (FDA-approved or
off-label).
Table 3.6 Approved and off-label antimanic agents

Legal status Agent
FDA- Not useful for psychiatric
approved Off-label disorders Generic name (Brand name)
X Carbamazepine (Tegretol®)
X Lamotrigine (Lamictal®)
X Lithium carbonate preparations
(Eskaleth®; Lithobid®)
X Valproate (Depakene®; Depakote®)
X Gabapentin (Neurontin®)
X Oxcarbazepine (Trileptal®)
X X Topiramate (Topamax®)
X X Tiagabine (Gabitril®)
X X Zonisamide (Zonegran®)
Concerning lithium compounds—a staple in the psychopharmacotherapy of

mood instability—the undesirable (“side”) effects of these agents are generally
divided into mild and common (fine tremors, drowsiness and fatigue, memory prob-
lems, and excessive urination); moderate and less common (diarrhea, thirst, hypo-
thyroidism, and more severe symptomatology of the mild type); and severe and
unusual (cardiac electrical disturbances, hypothyroidism, and inappropriate antidi-
uretic hormone syndrome [IADH] and resulting fluid and electrolyte disturbances,
among other). Severe or unusual side effects are often associated with inadvertent
or deliberate overdose of lithium preparations.
Lithium levels typically are monitored via periodic lithium-level serum-blood-
level determinations, and additional studies including periodic electrocardiograms
(ECGs), complete blood counts (CBCs), thyroid function testing (TFTs), liver func-
tion testing (LFTs), urine studies, and others may also be done on an ongoing basis
while an individual is taking this medication. In that way, both a patient’s compli-
ance with medication and possible development of side effects and undesired com-
plications associated with chronic and ongoing lithium pharmacotherapy can be
detected, tracked, and treated.
Anticonvulsants, mentioned earlier, are used primarily for the treatment of indi-
viduals with different types of seizure disorders. However, beginning with carbam-
azepine (Tegretol®) and valproate (valproic acid; Depakote® and Depakene®) as
early as the 1960s, the mood-stabilizing effects of these drugs on individuals with
bipolar disorder were recognized, and clinical research and practice into the mecha-
nisms of action and usefulness of anticonvulsants in this area began and has contin-
ued. As is the case with any class of medications, the side effects of these
mood-stabilizing anticonvulsants are based on their pharmacologic properties and
may include dizziness, drowsiness, ataxia, somnolence, nausea, and vomiting, psy-
chomotor slowing and dullness, decreased concentration, nervousness, tremor, and
depression, among others.
Finally, in the context of other psychotropic medications used for bipolar disor-
der, other types of psychotropic medications, such as “atypical antipsychotics”
(included in the “Antipsychotic Agents” subclass of this Primer’s classification sys-
tem; see below) are FDA-approved for particular phases (e.g., acute mania; bipolar
depression; maintenance) of the bipolar disorder cycle;4 as adjunctive therapy for
“Antimanic Agents;” for monotherapy (single-medication) therapy; for a combina-
tion of the two; and/or for pediatric use. The reader is referred to comprehensive
references (above) and current internet sources for details of doses, treatment indi-
cations, FDA dose schedule, phases of cycle, prescribing practices, legal status, and
the like, for these psychotropic medications.
Referring back to and continuing the case of “XY” to illustrate the psychophar-
macotherapy of bipolar disorder, his story continued:
4
The reader is referred to the DSM-5 for further details and information about the classification,
course, natural history, and progression of bipolar disorder.
Antipsychotic Agents 37
After about four months on lithium psychopharmacotherapy and supportive psychotherapy/

counseling, XY experienced the insidious onset of periodic palpitations and skipped heart-
beats, erratic episodes of mild chest pain, weakness, and intermittent shortness of breath.
XY consulted his primary care physician, who examined him and did a battery of tests
(including an electrocardiogram or ECG). The ECG showed erratic irregular beats of no
specific pattern, and the doctor’s recommendation was for XY to taper and discontinue his
lithium medication. XY’s psychiatric PA agreed, prescribed lamotrigine (Lamictal®), and
tapered XY’s lithium. After a stressful transition period, XY’s new medication “kicked in”
(his physician assistant’s words), his cardiac symptoms stopped, and he remained stable
over the next several months, to the present.
Antipsychotic Agents
Antipsychotic agents are also known as neuroleptics (from the Latin, “neuro-lysis”
meaning “nerve-breaking”); “major tranquilizers” (an inaccurate term, based his-
torically in contrast with “minor tranquilizers,” or anxiolytics, as described above.
The term “major tranquilizer” suggests that the principal effect of these medications
is to sedate or “tranquilize” the patient/client taking them, in contrast to reducing or
eliminating psychotic symptomatology); or—more recently, using a designation
based on the presumed predominant biological mechanism of action of these
agents—“dopamine blockers.”
Antipsychotic agents are for the treatment of symptoms of thought disorders, or
psychosis, the hallmark of which is symptomatology out of contact with reality.
Such symptoms include so-called “positive symptoms” (e.g., delusions, defined as
fixed and false beliefs which cannot be altered by logic or persuasion; hallucina-
tions, defined as false de novo perceptions and sensations—in contrast to “illu-
sions,” which are perceptual distortions based on misinterpretations of actual
stimuli, i.e., based on something, agitation, paranoia, occupational deterioration,
and the like); and “negative symptoms” (apathy, withdrawal, depression, pessi-
mism, and the like). These “negative” symptoms are said to be more effectively
treated with the relatively recent type of antipsychotic medications called “atypical
antipsychotics,” or “second-generation” antipsychotics (SGAs) than with the older,
traditional, conventional or “first-generation” antipsychotics (FGAs). These
psychotic-level symptoms can also be associated with a wide range of underlying
conditions, psychiatric and other.
Concerning the notion of “out of contact with reality,” the concept of “neurotic”
and “psychotic” levels of functioning is useful. “Neurotic”—a term derived from
psychoanalytic theory, now considered outmoded by many, and not used in the
DSM-5—refers to a level of functioning in which the patient/client is troubled, for
example, tired, worried, anxious, tense, sad, and so forth, but functioning ade-
quately: “Neurotics build castles in the air” (i.e., neurotic-level functioning).
“Psychotic,” on the other hand, refers to a level of functioning because of psychotic
symptomatology which is not adequate: “Psychotics live in them” (i.e., psychotic-
level functioning).
Psychotic-level disorders are classified in the DSM-5 as “Schizophrenic Spectrum

and Other Psychotic Disorders” (the chapter in the DSM-5 which presents and dis-
cusses these disorders). The main disorders in this chapter are “Schizophrenia,”
“Schizoaffective Disorder,” “Schizophreniform Disorder,” “Delusional Disorder,”
and “Brief Psychotic Disorder,” with several others listed, and with diagnostic cri-
teria, details, associated features, and nuances given in the chapter. The reader is
referred to that chapter in the DSM-5 for that information and those details.
Concerning the psychopharmacotherapy of individuals with psychotic-level psy-
chiatric disorders, and given that the desired antipsychotic effect for all of these
agents is the same, the choice of a particular medication for a particular individual
is based on optimizing the desired effect and minimizing the undesired effect of that
medication. Since antipsychotic medications consist of a wide range of agents,
which may produce adverse effects involving many organ systems, a practical
approach to choosing and monitoring antipsychotic psychopharmacotherapy is
given in a series of bulleted points in Table 3.7 followed by a list of potentially vul-
nerable organ systems, in Table 3.8. These tables, in turn, are followed by a list of
antipsychotic medications currently in use, in Table 3.9. As with all of the “Anti”
agents presented and discussed in this Primer, the reader is referred to applicable
comprehensive textbooks and manuals, internet sources, and the like for details of
dosing, dosing schedules, side effects, and other such information.
Table 3.7 Rational use of antipsychotic agents

1. A high-potency conventional antipsychotic or one of the SGAs should be given as first-line
treatment.
SGAs are effective and well tolerated and have less potential to induce EPS.
2. Second-line drug choices include the other conventional antipsychotics.
3. A drug trial should last 4-6 weeks.
The trial should be extended when there is a partial response that has not plateaued and
shortened when no response occurs or side effects are intolerable or unmanageable.
Aripiprazole, ziprasidone, or lurasidone may be the better choice in patients at risk for weight
gain.
Quetiapine or aripiprazole may be favored when low EPS and low prolactin levels are desired.
4. All antipsychotics should be started at a low dosage and gradually increased to fall within a
therapeutic range.
Evidence suggests that blood levels can help guide dosage adjustments for haloperidol and
clozapine.
5. There is little reason to prescribe more than one antipsychotic agent. Using two or more such
drugs increases adverse effects and adds little clinical benefit.
6. Because of its risk of agranulocytosis and need for monitoring of the white blood cell count,
clozapine should be reserved for patients with treatment-refractory illness.
7. Many patients can benefit from chronic antipsychotic administration.
Patients should be carefully monitored for evidence of weight gain, glucose dyscontrol, and
lipid abnormalities (metabolic syndrome).
Adapted from Hales et al. (2014)
Table 3.8 Organ systems Neurological

potentially adversely affected by
Metabolic
antipsychotic agents
Hematologic
Genitourinary
Gastrointestinal
Cardiovascular
Endocrinologic
Table 3.9 Conventional (first-generation) and atypical (second-generation) antipsychotic agents

Category Drug name (Brand name)
Conventional
First-generation agents (FGAs)
Phenothiazines Chlorpromazine (Thorazine®)
Aliphatic Thioridazine (Mellar®)
Piperidines Mesoridazine (Serentil®)
Piperazines Fluphenazine (Prolixin®)
Fluphenazine decanoate
Perphenazine (Trilafon®)
Trifluoperazine (Stelazine®)
Thioxanthene Thiothixene (Navane®)
Butyrophenone Haloperidol (Haldol®)
Dihydroindolone Molindone (Moban®; withdrawn in 2010)
Atypical Aripiprazole (Abilify®)
Second-generation agents (SGAs) Asenapine (Saphris®)
Brexpiprazole (Rexulti®)
Cariprazine (Vraylar®)
Clozapine (Clozaril®)
Lumateperone (Caplyta®)
Lurasidone (Latuda®)
Iloperidone (Fanapt®)
Olanzapine (Zyprexa®)
Quetiapine (Seroquel®)
Paliperidone (Invega®)
Risperidone (Risperdal®)
Ziprasidone (Geodon®)
By way of illustration, the following case vignette includes such concerns in the
treatment of psychotic-level patients as choice of medication, monitoring clinical
progress, compliance/adherence, psychosocial issues, and others:
PR is a 57-year-old married, white female who works part-time as a librarian’s assistant in
her hometown of Everywhere and whose husband has worked in vehicle maintenance for
the local Department of Public Works for the past 22 years. The couple has three children,
ages 17, 23, and 25, of whom the youngest—a daughter—is still living at home. The family
has lived in the same three-bedroom rented apartment for ten years. PR has a 23-year his-
tory of schizophrenic disorder (diagnosed then as “schizoaffective schizophrenia”), ques-
tionably associated with the birth of her second child and has been hospitalized in psychiatric
facilities five times during those years.
Psychiatric treatment over the years has consisted of supportive psychotherapy—usu-
ally with a private psychiatrist—on an infrequent basis, neuroleptic medications, and sup-
port from her family.
The patient was hospitalized most recently the previous November for four weeks in a
private facility following a period of rapid decompensation associated to some extent with
losses in her life (specifically, her daughter’s plans to leave home to attend college and her
referral to a new psychiatrist after her previous psychiatrist of 10 years moved to California).
Her hospitalization was uneventful and she was discharged in stable condition; the only
possible problem during her hospitalization was the presence of mild rigidity, cog-wheeling
in her arms and a slightly stiff gait; she was discharged on 2 mg. of benztropine mesylate
(Cogentin®) by mouth, twice a day, which did not seem to be initially effective in manage-
ment of these signs of extrapyramidal syndrome (EPS).
On February 11, 2011, PR was taken to the emergency room at Everywhere General
Hospital at 11:00 p.m. by the Everytown Rescue Squad in a highly delusional and agitated
state, with the additional findings of delirium: Disorientation (in all four parameters), com-
plete memory loss, and a perception of “wiggly things crawling all over my body” (formi-
cation). Additional history was obtained from her husband regarding her
pharmacotherapeutic management: Her new psychiatrist, Dr. Best, had been “juggling
medications” for the past several months in an effort to arrive at the best combination for
her and the patient herself had probably been inadvertently overdosing herself for the past
several weeks. The patient had been increasingly forgetful and withdrawn over the past
three weeks; the patient’s current medication consists of 4 mg. of Risperdal®, by mouth,
three times a day, and 6 mg. of benztropine mesylate (Cogentin®), by mouth, twice a day—
increased over the months in an effort to control what Dr. Best felt was PR’s increasing
EPS. Dr. Best has been on vacation for one week.
This case vignette illustrates some of the complex interrelationships between

psychotherapy, pharmacotherapy, family support, compliance/adherence to treat-
ment plans, patient/client factors (here, specifically, the extent to which PR inadver-
tently or purposefully took too much medication [“overdosed”]), and other such
factors, in keeping with the Epidemiologic Triangle model discussed earlier in this
book. The case also illustrates the need to “think outside the box” in terms of com-
plicating and overlapping neurologic conditions, such as dystonia, EPS, delirium,
and withdrawal (apathy).
Finally, for present purposes, Table 3.10 summarizes advisable treatment prac-
tices to enhance treatment adherence/compliance to the extent possible. In the table,
“long-acting injectables” (LAIs) refers to parenteral preparations of certain antipsy-
chotic agents for depot injections which leech out over time into the patient’s/cli-
ent’s body from the intramuscular depot injection site. The duration of action of
different preparations is from weeks to months, as presented in Table 3.11.
Table 3.10 Treatment strategies to enhance patient/client adherence/compliance

Arrange for a convenient and uncomplicated dosing schedule
Provide patient/client education: discussion, patient package insert (PPI), etc.
Arrange for a convenient and uncomplicated dosing schedule
Minimize adverse effects, to the extent possible, taking into account medication factors
(pharmacodynamic; pharmacokinetic), patient/client factors, and environmental factors
(supportive home, denial of illness, etc.)
Follow-up and check for patient/client compliance/adherence (phone; pill counts)
Consider using long-acting injectable (LAI) preparations with appropriate patients/clients,
where indicated
Table 3.11 First- and second-generation long-acting injectable (LAI) antipsychotics

Maintenance dose
FDA-approved frequency
Medication indications (duration of action)
Conventional Bromperidol decanoate* Psychosis Variable
(First- Fluphenazine decanoate Psychosis 2–3 weeks
generation) (Prolixin®) Psychosis 1–4 weeks
Antipsychotics Flupenthixol decanoate Psychosis 3–4 weeks
(Fluanxol®) Psychosis Several days for
Haloperidol decanoate (Haldol induction for
decanoate*) antipsychotic action
Zuclopenthixol decanoate
(Clopixol®; generic
equivalent available in the
U.S.)
Atypical Aripiprazole LAI** (Abilify Schizophrenia: 4 weeks
(Second- Maintena®) Bipolar disorder 4 weeks
generation) Aripiprazole lauroxil Schizophrenia 2–4 weeks
Antipsychotics Olanzepine pamoate LAI Schizophrenia 2–4 weeks
(Zyprexa®) Schizophrenia 4 weeks
Paliperidone palmitate LAI Schizophrenia 12 weeks
(Invega Trinza®) Schizoaffective 4 weeks
Paliperidone palmitate (Invega disorder 4 weeks
Sustenna®) Schizophrenia
Paliperidone palmitate (3 mo. Schizophrenia:
injections) (Invega Bipolar disorder
Sustenna®) Schizophrenia
Risperidone LAI (Risperdal
Consta®)
Risperidone LAI for SQ
(Perseris®)
Adapted from Parmentier B. Curr Psychiatry. (2020)
a
Used in Belgium, Italy, Germany, and the Netherlands
b
LAI: “Long-acting injectable” medication formulation
selected references, but also to applicable textbooks, monographs, electronic data-
Selected References
diagnoses.)
International classification of diseases (ICD-10). 10th ed. World Health
of the field.)
• Hales RE, Yudofsky ST, Roberts LW, editors, et al. The American Psychiatric
ries, viz.
sional journal)
tronic and print)
include:
Chapter 4
The Sixteen “Minor Anti-s”
The term “minor” in the context of this Primer is not intended to be synonymous
with “trivial” or “unimportant.” For an individual afflicted with any of these condi-
tions, the associated symptomatology and distress can be serious, or “major.”
Rather, the term “minor” as used in this system of “Major,” “Minor,” “Anti” psycho-
pharmacotherapeutic is intended as a reflection of the prevalence of the conditions
treated by their various “Anti” agents, and the frequency of prescribing profession-
als treating these conditions. In that sense, the unifying factor of the “Anti” classifi-
cation scheme, or taxonomy does not pertain to common, or linked, pathophysiology
of the conditions treated by the “Anti” agents, nor to common, or linked, mecha-
nisms of action of the “Anti” agents themselves. Rather, as also discussed in Chap.
1, the unifying factor of the several “Anti” agents discussed in this Primer is the
manifestational symptomatology from the underlying diagnosis, reduced or elimi-
nated by the particular “Anti” agent.
The importance of an accurate diagnosis cannot be underestimated in this con-
text, especially in view of the considerable overlap of symptomatology among dif-
ferent psychiatric conditions (The “differential diagnosis” of psychotic-level
symptoms, for example, in schizophrenia and Parkinson’s disease—discussed in
upcoming sections of this Primer—illustrate this point.)
Anti-addiction Agents
The first of the “Anti-agents” to be discussed in this chapter are “Anti-addiction

Agents” including reference to “medication-assisted treatment” or “MAT” (also
discussed in Chap. 5).
As a treatment modality in health care, psychopharmacotherapeutic approaches
to the treatment and management of addiction, substance abuse, and chemical
dependency (which terms are used interchangeably here and are also discussed in

Switzerland AG 2022
https://doi.org/10.1007/978-3-030-82507-2_4
46 4 The Sixteen “Minor Anti-s”
Chap. 5) are relatively young, having begun with the use of disulfiram as an aversive
agent to the pharmacologic treatment of alcoholism in the 1950s. This was followed
by methadone in the 1960s and going forward, as a blocking agent to the euphori-
genic effects of heroin and other opioids (i.e., not as an analgesic—“Anti-pain”—
medication; see below in this chapter). Subsequent pharmacologic aversive,
antagonistic, or blocking agents were developed over the ensuing years, for a vari-
ety of addictions and dependencies, such as nicotine addiction, addiction to heroin
and other opioids, cocaine addiction, and alcoholism, in the 1980s, 1990s, and 2000s.
In addition to chemical dependencies (“Substance Use Disorders,” in DSM-5
parlance), the several fields of addiction treatment have come to recognize the so-
called “Behavioral (i.e., not chemical) Addictions” as involving the same types of
neurobiological mechanisms of action as chemical dependencies, and therefore a
legitimate focus of attention for the fields of addiction treatment. Table 4.1 gives
examples of the “Behavioral Addictions.”
Table 4.1 Examples of behavioral Computer-based addictions

addictions Internet gaming
Internet surfing
Internet pornography
Texting and emailing
Exercise
Food and eating disorders (see Chap. 4 of this
book)
Kleptomania
Love
Sex
Shopping
Tanning
Work
Cutting
Anti-addiction Agents 47
For present purposes—with the exception of some eating and feeding disor-
ders—the principal overall treatment approach for the “Behavioral Addictions” is
behavioral. This may include the various behavioral therapies (see Chaps. 7 and 8),
family therapy, and psychopharmacotherapy with anti-depressant medications (e.g.,
some SSRIs for bulimic disorders, both FDA-approved and off-label), especially in
situations where depression is present. Otherwise, since psychopharmacotherapy
beyond symptomatic relief is not generally a significant part of the treatment of
behavioral disorders, no further discussion of psychopharmacotherapy for behav-
ioral disorders will follow.
However, the notion of symptomatic relief of “target symptoms” associated with
the addictions and their often comorbid, or co-occurring, conditions, leads to the
classification of “Anti-addiction Agents” into two parts. They are (1) psychophar-
macotherapy to address, or counter, or block mechanisms of action of specific drugs
of abuse and (2) psychopharmacotherapy of “target symptoms” attributable to drugs
of abuse. The former approach is called medication-assisted treatment, or MAT, and
the latter approach includes the types of psychopharmacotherapy covered in
this Primer.
The rationale behind pharmacotherapy for the addictions involves the use of psy-
chotropic agents as a substitute (i.e., a pharmacologic competitor agonist) for the
addictive substance, with a more desirable main effect and side effect profile than
that of the substance of abuse. Substituting methadone for street heroin is one exam-
ple. Such drugs may also serve as a partial substitute (a partial agonist) for the
addictive substance, such as nicotine replacement polacrilex gum. They might also
serve as an antagonist, or blocking agent (to counter undesirable effects of the
addictive substance, induce withdrawal or a withdrawal-like state, initiate detoxifi-
cation, and produce an aversive experience for the user); examples are disulfiram
(Antabuse®), naloxone (Narcan®), or naltrexone (Revia®) for opioid use. These
drugs might also serve as anti-withdrawal agents (to reduce the discomfort and like-
lihood of convulsions, seizures, and delirium tremens); examples include benzodi-
azepines and anti-anxiety drugs and anti-convulsants to treat alcohol and other
sedative-hypnotic withdrawal. Another use of these types of drugs is as anti-craving
agents to reduce the drive and compulsion of an addict to seek the desired drug or
medication. Finally, these drugs might serve as psychotropic medications or drugs
to treat symptoms arising from comorbid, or co-occurring, psychiatric disorders in
the substance-abusing patient with such psychiatric disorders.
Table 4.2 displays the above points in terms of the pharmacologic properties and
mechanisms of action, along with examples of these medications. Table 4.3 presents
specific anti-addiction agents in terms of their roles and indications in current con-
cepts of medication-assisted treatment (MAT).
Table 4.2 Anti-addiction agents and properties

Drug of
addiction Pharmacologic property Examples of medication
Alcohol Agonists (substitute) None
Partial agonists None
Antagonists Disulfiram (Antabuse®)
Anti-withdrawal Benzodiazepines; anti-convulsants
(detoxification) agents
Anti-craving agents Naltrexone (Revia®; Vivitrol® LAI*)
Concomitant treatment Acamprosate (Campral®)
agents
Cocaine Agonists (substitute) None
Antagonists None
Anti-withdrawal None (not a major clinical problem)
Anti-craving agents None
Concomitant treatment Varies
agents
Nicotine Agonists (substitute) Nicotine substitution, polacrilex gum, patch,
aerosol
Antagonists Mecamylamine
Anti-withdrawal Bupropion (Zyban®)
Anti-craving agents Nicotine substitution, bupropion
Concomitant treatment Varies
agents
Opiates/ Agonists (substitute) Methadone, LAAM
opioids Partial agonists Buprenorphine and congeners
Antagonists Naltrexone (Revia®; Vivitrol® LAI*); Naloxone
(Narcan®); Methadone
Anti-withdrawal Clonidine (Catapres®; Lofexidine);
(detoxification) agents Buprenorphine
Adapted and updated from Kleber (1999), CME Symposium
*
LAI: “Long-acting injectable” medication formulation
Anti-addiction Agents 49
Table 4.3 Medication-assisted For opioid addiction (opioid use disorder or OUD)
treatment (MAT) Methadone
Naltrexone (IR and L-A [Vivitrol,® injectable])
Buprenorphine (Subutex®; Suboxone®
[buprenorphine + naloxone]; other short- and
long-acting preparations)
For alcohol addiction (alcohol use disorder or AUD)
Disulfiram (Antabuse®)
Acamprosate (Campral®)
Naltrexone (Revia®)
For smoking (tobacco products)
Nicotine replacement therapy (patches, polacrilex
gum, others) and vaping replacement therapy
Varenicycline (Chantix®)
Bupropion (Zyban® for smoking, specifically)
In therapeutic work with addicts and alcoholics, several practical points ought to
be made:
• The heterogeneous agents and medications that comprise this class vary widely
in their own pharmacologic actions and properties and may initially be associ-
ated with any side effect that can affect the central nervous system (CNS). The
healthcare practitioner should know if the patient/client is taking or has taken any
of these medications in order to assess whether symptoms attributed to other
experiences may in fact be due to medication effects.
• A patient/client taking these medications for treatment of addiction may or may
not be adherent/compliant with the treatment regimen. Depending on the extent
of such adherence/compliance, nonspecific CNS symptomatology (such as dis-
comfort, depression, agitation, excitement, irritability, and so forth) may be the
result of complete or partial nonadherence/noncompliance and may erroneously
be attributed to other experiences. It behooves the healthcare practitioner not
only to inquire about whether the patient/client is taking prescribed anti-addiction
medications but also about the extent to which the patient/client is taking the
medication as prescribed.
• Finally, given the chronic and relapsing nature of the addictions and the nonspe-
cific psychological/psychiatric symptomatology associated with relapses, such
symptomatology in those situations may be erroneously attributed by the p atient/
client to life events and experiences, to prescribed medications, or to a combina-
tion of both, rather than to the true cause of such symptomatology—namely a
relapse into active addiction and its accompanying symptoms.
A number of the points made in this “Anti-addiction Agents” section of this

chapter will be revisited in Chap. 5, as mentioned above.
Anti-aggression Agents
As a practical matter, most aggression and violence associated with psychiatric dis-
orders, however broadly interpreted, are not amenable to psychopharmacotherapeu-
tic intervention. Aggression and violence are not psychiatric/neuropsychiatric
“diseases” or “disorders” per se, but in certain cases, they may be signs/symptoms
of underlying psychiatric disorders themselves. In those disorders in which aggres-
sive and violent intentions, tendencies, or behaviors are, or may be, manifestations
of the psychiatric conditions themselves, then psychopharmacotherapeutic inter-
vention may be indicated. For that reason, proper diagnosis of a potential underly-
ing psychiatric condition—as is always the case in clinical practice of any type—is
paramount. Table 4.4 presents psychiatric disorders and conditions in which aggres-
sion and violence may be part of the clinical picture.
Table 4.4 Psychiatric, Autism spectrum disorders (ASD)

neuropsychiatric, and medical/
Neurocognitive disorders
neurologic conditions and disorders
with associated aggressive and violent Conduct disorders
symptomatology Disruptive mood regulation disorders
Intermittent explosive disorder (IED)
Medical/neurologic conditions
Oppositional defiant disorder (ODD)
Personality disorders
Schizophrenia and other psychotic disorders
Anti-aggression Agents 51
A variety of psychotropic medications from a variety of “Anti-agents” may be

used for aggressive and violent symptoms as a manifestation of an underlying psy-
chiatric disorder. These agents include anti-psychotic medications (aripiprazole
[Abilify®] and risperidone [Risperdal®]) and anti-ADHD agents (methylphenidate
[Ritalin®] and atomoxetine [Strattera®]). Under some circumstances, some SSRIs
for anxiety and the driven repetitive behavior (e.g., rocking) seen in autism may also
be useful. Behavioral interventions based on principles of operant conditioning are
generally the most effective treatment modality and are the starting point for treat-
ment and management of individuals with autism spectrum disorder (ASD).
The constellation in DSM-5 of “disruptive impulse control and conduct disor-
ders” includes a wide variety of conditions in which, as the designation implies, a
number of “DSM-5 Disorders” is represented. These include, in turn, neurodevelop-
mental disorders (ADHD), bipolar disorders, obsessive-compulsive disorder (OCD)
and related conditions, substance use disorders (SUDs), and others. In situations in
which aggressive/violent and related symptomatology arises as “target symptoms”
from the underlying psychiatric disorder, or condition, applicable psychopharmaco-
therapy may be used, as clinically indicated for given cases.
Disruptive mood regulation disorder (DMRD), a new formal diagnostic designa-
tion in the DSM-5, like conduct disorder and others in this constellation, has aggres-
sion and out-of-control behaviors as a core sign/symptom. Specific
psychopharmacotherapy for this condition has not been identified at this point,
although in cases in which such symptoms as withdrawal, lethargy, and apathy pre-
dominate, then “activating” (non-sedating) anti-depressant agents may be indicated.
Conversely, in cases in which agitation, aggression, irritability, and the like, pre-
dominate, then calming and sedating anti-depressant agents may be indicated.
Given the current state-of-the-art-and-science—in psychiatry and neuropsychia-
try generally—that target symptom relief is the goal, then the goal for psychophar-
macotherapy is first to identify “target symptoms” for this and any other psychiatric
disorder condition (except, perhaps, some neurocognitive disorders) and to identify
a psychopharmacologic agent with the ability to ameliorate the symptomatology.
Similarly, schizophrenia and other psychotic disorders may present out-of-control
aggressive, violent, and actively psychotic “target” signs and symptoms often amenable
to psychopharmacotherapy, with the “positive symptoms” (see Chap. 3) being consid-
ered generally amenable to conventional (“first-generation”) and atypical (“second-gen-
eration”) anti-psychotic medications, and “negative symptoms” (see Chap. 3) being
considered generally amenable to atypical (“second-generation”) anti-psychotic agents.
Finally, for present purposes, as a diagnostic category, or entity, “Personality
Disorders” are perhaps the most “manifestational” in symptomatology and the least
“causal” (see Chap. 2) in terms of causation, etiology, or pathogenesis of all psychiatric/
neuropsychiatric conditions. The psychopharmacotherapeutic approach to these condi-
tions, therefore, relies on identifying those personality disorders with the greatest overt
“target” symptomatology potentially amenable to dulling, or amelioration. Examples
include psychotic-level symptomatology in schizotypal disorder (amenable to “Anti-
psychotic Agents”) and florid irritability, tension, and aggression in borderline personal-
ity disorder (amenable to “Anti-psychotic Agents” and to “Antianxiety Agents”). Even
so, beneficial treatment effects of psychopharmacotherapy for individuals with border-
line personality disorder are considered moderate, at best. Table 4.5 illustrates that point.
Table 4.5 Effectiveness of psychopharmacotherapy for personality disorders

Personality disorder Effectiveness of psychopharmacotherapy
Cluster A (odd or eccentric)
Paranoid Uncertain
Schizoid Not helpful
Schizotypal Moderate (for treating associated “target symptoms”)
Cluster B (dramatic, emotional or erratic)
Antisocial Not helpful
Borderline Moderate (for treating associated “target symptoms”)
Histrionic Not helpful
Narcissistic Not helpful
Cluster C (anxious or fearful)
Avoidant Uncertain
Dependent Not helpful
Obsessive-compulsive Not helpful
Anti-appetite Agents
Since the publication of an earlier version of this section of this chapter in 2009, the
fields of clinical nutrition, primary care medicine, and mental health care have
evolved considerably to include diet and exercise, weight control, appetite suppres-
sion, treatment of obesity and eating disorders, holistic medical care, complemen-
tary and alternative medicine (CAM; see Chap. 6 of the Primer), and other
related topics.
A full discussion of these areas is well beyond the scope of this section of the
chapter. In this section, however, I will focus on currently used medications for
appetite management, in the context of a comprehensive and holistic approach to
weight management. In the words of a prominent holistic dental practitioner, “If
you diet, exercise, floss your teeth regularly, and don’t smoke, you’ll live forever!”
Appetite suppressants, “anorectics” or “Anti-appetite Agents” for present pur-
poses, are the sixth of the 20 “Anti-s” in this classification system. As the name
suggests, these medications are intended for use in weight loss and weight manage-
ment. Within the “Anti” class are essentially two subtypes, (1) stimulants/psycho-
stimulants (e.g., amphetamines and related compounds) and (2) metabolic agents
(e.g., orlistat [Xenical®]). Table 4.6 presents these two subtypes and prescription
and OCT medications currently available.
Anti-appetite Agents 53
Table 4.6 Stimulant and non-stimulant appetite suppressants

Drug class Medication Mode of action
Stimulant/ Amphetamine (Biphetamine®; Adderall®*) CNS appetite
psychostimulant suppression
Fenfluramine (Pondimin®; removed from the market CNS appetite
in 1998, in combination with Phentermine as suppression
Fen-Phen®)
Mazindol (removed from the market in 2008) CNS appetite
suppression
Methamphetamine (Desoxyn®) CNS appetite
suppression
Phendimetrazine (various preparations) CNS appetite
suppression
Phentermine (Adipex-P®) CNS appetite
suppression
Sibutramine (Meridia®; removed from the market in CNS appetite
2010) suppression
Other mechanisms Glucomannan (OTC) Inhibit digestion
Guar gum (OTC) Inhibit digestion
Liraglutide (Saxenda®) Mimic satiety
Lorecaserin (Belviq®; removed from the market in Mimic satiety
2020)
Naltrexone/bupropion (Contrave®) Anti-craving
Phentermine/topiramate (Qsymia®) CNS appetite
suppression
Rimonabant (Acomplia®; removed from the market Cannabinoid
in 2008) receptor antagonism
*
Adderall®, or mixed amphetamine salts (MAS), is an amphetamine compound not indicated for
appetite suppression. Its use is as an “Anti-ADHD Agents,” discussed later in this chapter
The use of these medications for weight management and control has been con-
troversial over the years, in large part due to the potentially addictive properties of
psychostimulants and their legal status as Controlled Dangerous Substances (CDS)
for most of them, with abuse and diversion potential. Nevertheless, to the extent that
such psychopharmacotherapeutic agents are indicated and used for weight manage-
ment, current professional acceptance in healthcare dictates that these medications
be used on a short-term basis as part of a comprehensive, balanced clinical program
of diet, exercise, good sleep, hygiene, good dental care, and other such healthy prac-
tices. The non-stimulant appetite suppressants—Qsymia® (phentermine and topira-
mate), Saxenda® (liraglutide), Contrave® (naltrexone/bupropion), and the OTC and
other such preparations—are considered appropriate for long-term use.
Since a common feature of the stimulant/psychostimulant medications is their
stimulating (speeding) quality, patients/clients should be educated about that pre-
dominant effect when these medications are prescribed and followed over time.
In the sections of this chapter on “Anti-ADHD Agents” and in Chap. 5 stimu-
lants/psychostimulants will be discussed further.
Anti-attention Deficit Hyperactivity Disorder (ADHD) Agents
In his iconoclastic Saving Normal: An Insider’s Revolt Against Out-of-Control

Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary
Life (2015), Allen Frances, M.D., former Professor and Chairperson of the
Department of Psychiatry and Behavioral Medicine at Duke University School of
Medicine, and Chairperson of the DSM-IV (the predecessor Diagnostic and
Statistical Manual of Mental Disorders to the present DSM-5) Task Force, wrote
about himself and his own possible ADHD diagnosis.
In the chapter entitled “Attention Deficit Disorder Runs Wild,” of Saving
Normal.1 Dr. Frances described on one occasion having left his car at an airport
while on a business trip, and not remembering its location when he returned. He had
initially not paid attention to where he had left the car. The story ends happily, but
Dr. Frances raises the question of whether his behavior warranted a formal diagno-
sis of ADHD: “My wife…unemphatically claims my lack of attention to the needs
and errands of everyday life reflect willful avoidance rather than diagnosable mental
disorder…”
But in this vein, Dr. Frances then questions the reportedly rapid recent increase
in the prevalence of the formal ADHD diagnosis (“…an amazing 10 percent of kids
now qualify…”). He offers a number of possible explanations for this prevalence,
concluding that “…there is no reason to think the kids have changed, it is just the
labels have…”
Without taking a position on this controversial condition, this present section of
“Anti-ADHD Agents,” in this chapter about the “Minor Anti-s,” presents and dis-
cusses the basics of ADD (attention deficit disorder) and ADHD (attention deficit
hyperactivity disorder) and the principal psychopharmacotherapeutic agents cur-
rently used in treatment of these conditions. As with “Anti-appetite Agents,” most of
these medications are stimulants/psychostimulants by drug class, potentially posing
the same problems with abuse, dependence, and diversion (i.e., from prescribers’
practices) as when they are used for other conditions or indications (see Chap. 5).
The DSM-5, for practical purposes, distinguishes between two main diagnostic
features which give rise to the nomenclature and the term “attention deficit hyper-
activity disorder,” or ADHD. These features are inattention and hyperactivity (the
DSM-5 also discusses impulsivity, but that feature is not incorporated into the
ADHD nomenclature). In terms of the life cycle, hyperactivity generally precedes
inattention, starting in childhood, and in some cases, proceeding into the adult
years. Population surveys indicate that the prevalence of ADHD in the general pop-
ulation is about 5% in children and about 2.5% in adults.
1
For an even more iconoclastic and vehement treatment of these topics, see Watters E. Crazy like
us: the globalization of the American psyche. Free Press; 2010.
Anti-attention Deficit Hyperactivity Disorder (ADHD) Agents 55
For practical purposes, anti-ADHD agents may be classified into three subcate-
gories, viz., (1) Methylphenidate and congeners; (2) Dexmethylphenidate (the dex-
tro-isomer of methylphenidate); (3) Mixed amphetamine salts (MAS); and (4)
Non-stimulant medications. The paradoxical effects of the stimulants/psychostimu-
lants on children and adults with ADHD—the calming and organizing effects on the
aggressive, irritable, distracted, and disorganized features, whether the inattentive,
hyperactive, or combined types of ADHD—are counterintuitive, and are the basis
for the positive results often seen in ADHD psychopharmacotherapy. Table 4.7 lists
medications commonly used for ADHD psychopharmacotherapy, according to the
three subcategories just noted.
Table 4.7 Anti-ADHD agents

1a. Methylphenidate 2. Dextroamphetamine formulations
formulations DestroStat (IR) (3–5 hours)
Generic (IR) (3–4 hours) Dexedrine (IR) (3–5 hours)
Methylin (IR) (3–4 hours) Generic (IR) (3–5 hours)
Methylin ER (6–8 hours) LiquADD (3–5 hours) (dextroamphetamine sulfate)
Ritalin (IR) (3–4 hours) Dexedrine Spansule (6–8 hours)
Ritalin SR (6–8 hours) Dextroamphetamine ER (6–8 hours)
Generic SR (6–8 hours) Vyvanse (12–14 hours) (lisdexamfetamine dimesylate)
Metadate ER (6–8 hours)
Ritalin LA (8–10 hours)
Metadate CD (6–8 hours)
Concerta (12 hours)
Daytrana (transdermal)
1b. Dexmethylphenidate
formulations
Focalin (3–4 hours)
Ceneric (3–4 hours)
Focalin XR (10–12 hours)
3. Mixed amphetamine salts 4. Non-stimulants
(MAS) Atomexetine (Strattera®; NRI)
Adderall (IR) (3–5 hours) Bupropion (Wellbutrin®; off-label for ADHD)
Generic (IR) (3–5 hours) Clonidine XR (Kapvay®)
Adderall XR capsule Guanfacine ER (Intuniv®; α-agonist [alpha-adrenoceptor
(10–12 hours) agonist])
Generic (XR) Guanfacine IR (Tenex®; α-agonist [alpha-adrenoceptor
(10–12 hours) agonist]; not approved for children)
Modafinil (Provigil®; not approved for children)
Key: ER extended release, IR immediate release, NRI norepinephrine reuptake inhibitor
As a practical matter, the predominant current use of anti-convulsant agents (or

antiepileptic drugs [AEDs], or anti-seizure drugs) in psychiatric practice is for bipo-
lar disorder (see section “Antimanic Agents,” Chap. 3), either alone or in combina-
tion with other psychotropic agents (such as atypical anti-psychotic agents) to
address various phases of the disorder, although other conditions (such as anxiety
disorders and substance use disorders) have been treated with good results by anti-
convulsant agents, as well. Table 4.8 delineates these phases in bipolar disorder in
which anti-convulsant psychopharmacotherapy has a role.
Although more likely used in neurology practice for treating patients with sei-
zure disorders of a variety of types, lithium and two anti-convulsants (valproic acid
[Depakote®] and carbamazepine [Tegretol®]) have been used in the treatment of
bipolar disorder (or manic-depressive disorder, as the condition was known then)
since as long ago as the 1960s, and beginning in the 1990s, several novel anti-
convulsants have been developed and used in various aspects of psychiatric prac-
tice. Table 4.9 gives a summary of these agents and their other (i.e., other than for
treating seizures) clinical indications in psychiatric practice.
Table 4.8 Phases of bipolar disorder treated with anti-convulsants and other agents
Phase of illness Psychopharmacotherapeutic approach
Manic episodes Anti-psychotic agents, enhanced with mood stabilizers (e.g., risperidone
[Risperdal®] with lithium, and lorazepam [Ativan®] as needed)
Bipolar Symbyax® (fluoxetine [Prozac®] and olanzapine [Zyprexa®]), quetiapine
depression [Seroquel®], lurasidone [Latuda®], and cariprazine [Vraylar®], (FDA-
approved); lithium compounds, lamotrigine [Lamictal®], and aripiprazole
[Abilify®], with augmentation with bupropion [Wellbutrin®], probably least
likely to cause a manic switch (off-label use)
Bipolar Lithium, lamotrigine [Lamictal®], valproic acid [Depakote®], carbamazepine
treatment [Tegretol®]
maintenance
Table 4.9 Anti-convulsant agents

Indications Agents
Anti-convulsants used in psychiatry: older Carbamazepine (Tegretol®; othersa)
agents Oxcarbazepine (Trileptal®; others)
Valproic acid (Depakote®; Depakene®; others)
Anti-convulsants used in psychiatry: novel Gabapentin (Neurontin®; others)
anti-convulsants Pregabalin (Lyrica®, CDS-V; off-label for
neuropathic pain and anxiety)
Tiagabine (Gabitril®; off-label for anxiety and pain)
Topiramate (Topamax®; others)
Novel anti-convulsants not used in Levetiracetam (Keppra®; others)
psychiatry Vigabatrin (Sabril®; others)
Zonisamide (Zonegran®; others)
a
As also described earlier in this book, several brands with different brand or trade names by dif-
ferent manufacturers are available for many medications of all types, once the compound’s patent
life has expired. “Others” in this Table indicates that alternative brand names are available for the
basic compound, also known as the “generic equivalent.” At the time of this writing, pregabalin
(Lyrica®) was under patent protection
Anti-dementia Agents 57
As noted above, other psychiatric conditions in which the novel anti-convulsants

may have a role in treatment include anxiety disorders (see Chap. 3) and substance
use disorders (see Chap. 5). Examples of these medications and their indicated con-
ditions are pregabalin (Lyrica®), which seems useful as a cross-reactive agent in
tapering and discontinuing benzodiazepines, and in reducing neuropathic (e.g.,
peripheral diabetic neuropathy) pain; topiramate (Topamax®) as an adjunct for alco-
hol dependence and weight loss (in virtually any condition); and gabapentin
(Neurontin®) for alcohol dependence and anxiety.
Concerning side effects of the novel anti-convulsants, while they are in general
less toxic than older anti-convulsants, these medications as a class carry a “black
box” (FDA drug class) warning for increased risk of suicidal thoughts and behaviors
and have to be monitored carefully in patients for that reason. In addition, prescrip-
tions for both pregabalin (Lyrica®) and gabapentin (Neurontin®) are frequently
diverted from clinical practices and abused, prompting some states to mandate
reporting of them (like “Controlled Dangerous Substances,” or CDS; see Chap. 5)
to some states instituting Prescription Drug Monitoring Programs (PDMPs)—as in
New Jersey—to control their misuse and spread.
Anti-dementia Agents
Known also as “cognition enhancers,” these agents are intended to slow the progres-
sion of dementing diseases, such as Alzheimer’s disease, especially in the elderly
population. Generally, such slowing will last 6–12 months, after which the decline
in memory and progression of other secondary signs and symptoms (such as agita-
tion, restlessness, wandering [“sundowning”], irritability, hostility, dysphonia,
mood swings, and depression) will resume. At that point, the efficacy of using
another anti-dementia to re-establish a plateau in memory loss in unclear. If the
course of treatment is interrupted, cognitive decline will be accelerated and not
likely to regain the previous level of cognitive functioning if resumed.
Recognizing the prevalence and difficulty of both the primary memory decline
and the secondary signs and symptoms of dementing diseases, Table 4.10 presents
the principal classes of medications useful in ameliorating these signs and symp-
toms, along with their mechanisms of action and clinical indications. Some of these
classes and medications have already been discussed, and others will be discussed
later in this Primer.
Table 4.11 presents a list of miscellaneous agents of a variety of types potentially
useful in a myriad of ways for treating patients with dementias.
Table 4.10 Anti-dementia agents useful for primary and secondary signs and symptoms of
dementia
Class of medication Examples Clinical indications
1. Primary signs and symptoms (memory loss)
Cholinesterase inhibitors Donepezil (Aricept®) Mild, moderate, severe Alzheimer’s
(and some with other dementia (dose-dependent)
cholinergic actions) Galantamine (Razadyne®) Mild to moderate Alzheimer’s
dementia
Rivastigmine (Exelon®) Mild to moderate Alzheimer’s and
Parkinsonian dementia
Rivastigmine (Exelon Mild to moderate Alzheimer’s and
Patch®) Parkinsonian dementia
N-Methyl-D-aspartate Memantine (Namenda®) Moderate to severe Alzheimer’s
(NMDA) receptor dementia
antagonists Memantine ER (Namenda Moderate to severe Alzheimer’s
XR®) dementia
Memantine ER/donepezil Moderate to severe Alzheimer’s
(Namzaric®) dementia (for individuals on both
medications, a combination single-
dose agent)
(2) Secondary signs and symptoms
Selective serotonin Escitalopram (Lexapro®) Agitation, hostility, irritability,
reuptake inhibitors Sertraline (Zoloft®) restlessness
(SSRIs) Agitation, hostility, irritability,
restlessnessS
Serotonin-norephedrine Mirtazapine (Remeron®) Insomnia, depression
agonists
Benzodiazepines (see Lorazepam (Ativan®) and Use on a short-term basis; associated
“Antianxiety Agents”) other short-acting agents with excess sedation, memory loss;
low doses
Anti-psychotics (see Risperidone (Risperdal®): Low-dose; be aware of the FDA
“Anti-psychotic Agents”) not in Parkinson’s patients “black box” warning (2005) against
use of anti-psychotics in the elderly
because of increased risk of stroke
(CVA)
Quetiapine (Seroquel®), Only for treating psychotic symptoms;
clozapine (Clozaril®), or monitor carefully
pimavanserin (Nuplazid®)
for Parkinson’s patients
Serotonin-norephedrine Gabapentin (Neurontin®) Manicky symptomatology;
agonists Lamotrigine (Lamictal®) stabilization and calming; monitor
Oxcarbazepine (Trileptal®) carefully for lithium and other toxicity
Valproic acid (Depakote®)
Lithium preparation
Adapted from Puzantian and Carlat (2020)
Anti-dementia Agents 59
Table 4.11 Other agents of use in dementia

Acetaminophen (Tylenol®) for pain, often underdiagnosed in dementia patients. Opioids (low
dose) can also be useful, recognizing confusion and potential for falls; monitor carefully.
Trazodone (Desyrel®), for agitation and insomnia, at low doses.
Prazosin (Minipress®, others). Originally an antihypertensive medication, used in dementia
patients for agitation, nightmares, and related PTSD symptomatology (see section “Anti-trauma
Agents”). Monitor blood pressure and sensorial carefully.
Clonidine patch (Catapres®, others). Another antihypertensive agent, originally used in dementia
patients for agitation and anxiety, and useful ensuing adherence/compliance (transdermal
delivery system). Monitor blood pressure and sensorium carefully.
Dronabinol (Marinol®), a cannabinoid preparation for diminishing weight loss in AIDS and
nausea from chemotherapy, off-label use in agitation with dementia patients.
Last—but probably most important for these frail demented individuals, consid-
ering the potential adverse (“side”) effects of the wide range of “anti-dementia”
medications—the treating professional should practice nonpharmacologic interven-
tions first, such as individual and group counseling/psychotherapy (especially for
depressed individuals with dementia), art and music therapy, recreation therapy,
habilitation therapy, and others.
The following case vignette illustrates several principles of psychopharmaco-
therapy with individuals with dementia, discussed below.
LG is an 88-year-old widowed primary care physician, a resident in an upscale nursing
home, in reasonably good health for his age. Over a period of weeks, LG developed confu-
sion, uncertainty, and depression. One evening, he “sundowned” into another male resi-
dent’s room, whom he did not know well and with whom he did not have a previous
relationship. He told the nurse who retrieved him from the other resident’s room that he had
been “distracted, that’s why I went into Joe’s room that night.” LG had been on donepezil
(Aricept®) for about three months, with stabilization of his prior forgetfulness. He was
referred to the house physician assistant (PA).
The history that the PA obtained from LG and his daughter included several depressive
episodes on LG’s part in the 30 years since his wife’s death, some treated with tricyclic
anti-depressants, some not, and all associated, directly or indirectly, with grief and sadness
for the loss of his wife. His daughter’s impression was that LG generally responded well to
anti-depressant psychopharmacotherapy. The PA started LG on a clinical trial of mirtazap-
ine (Remeron®). Over the next several weeks, LG’s mood cleared as did his periods of
confusion and forgetfulness. In formal counseling sessions with a staff nurse (“…who
reminds me of my daughter…”) also helped LG maintain his mood and daily functioning.
He attributed his clinical improvement, in part, to his “…sleeping better with the Remeron®.
Thank you, doctor…”
This case vignette illustrates (1) The need to make one change at a time when
multiple psychotropic agents are used. In this case, LG’s donepezil (Aricept®) was
maintained with the mirtazapine (Remeron®), leading to the impression that LG’s
clinical improvement was due, at least in part, to his sedating anti-depressant (i.e.,
mirtazapine; Remeron®). This further leads to the impression that (2) LG’s forget-
fulness was actually a symptom of pseudodementia (depressive symptoms
presenting as dementia, especially in the elderly) and not the worsening of a dement-
ing process. The vignette also illustrates (3) The need to take a full history. LG
himself was not cognitively capable of giving the history to the house PA that his
daughter could. That history, in turn, prompted the PA to think of pseudodementia
in the differential diagnosis of LG’s condition, and to prescribe mirtazapine
(Remeron®). The diagnosis turned out to be correct, and the psychopharmacother-
apy to be helpful.
Anti-feeding/eating Agents
As the “flip side” of “Anti-appetite Agents,” this present class of psychopharmaco-

therapeutic agents serves as an adjunct to the primary modality of psychotherapy/
counseling and behavioral approaches, with which individuals with eating/feeding
disorders are treated. The DSM-5 currently recognizes several types of feeding and
eating disorders, as presented in Table 4.12.
As a practical matter, as presently practiced, psychopharmacotherapy has a lim-
ited role in the treatment of these disorders. As of this writing, fluoxetine (Prozac®)
has FDA approval for treatment of bulimia nervosa, and lisdexamfetamine
(Vyvanse®) for the treatment of binge eating disorder (BED). Other classes of anti-
depressants, such as other SSRIs, MAOIs, and tricyclic anti-depressants have been
used off-label, especially when depression is a “target” symptom. Olanzepine
(Zyprexa®) and other atypical anti-psychotic medications appear beneficial for
weight gain in anorexia nervosa, again through off-label use.
Considering the numerous organ systems adversely affected by eating disorders,
especially anorexia nervosa, careful attention must be paid to assessing and treating
the consequences of these disorders. This attention may be in conjunction with the
primary non-medical treating professional (e.g., psychologist, social worker, coun-
selor) if that is the treatment model, or alone, if the medical professional is the pri-
mary treating professional.
Table 4.12 Feeding and eating Pica

disorders per DSM-5
Rumination disorder
Avoidant/restrictive food intake disorder
Anorexia nervosa
Bulimia nervosa
Binge-eating disorder (BED)
Other specified feeding or eating disorder
Unspecified feeding or eating disorder
Anti-impotence Agents 61
Anti-impotence Agents
For this subclass of “Anti-agents” in this Primer, it is useful to divide “impotence,”

or sexual dysfunctions, broadly speaking, into (1) Primary erectile dysfunction or
hypofunction in men and low sexual drive (or, when meeting DSM-5 Diagnostic
Criteria, hypoactive sexual desire disorder, or HSDD) in women, not resulting from
other causes, such as medication (including many psychotropic agents), medical
conditions, and the like; (2) Secondary, resulting from other causes (as in “second-
ary to…”); and (3) Combined or mixed causes. Table 4.13 lists some secondary
causes of sexual dysfunction.
Table 4.13 Secondary causes of sexual dysfunction

Type of cause Examples
Psychiatric disorders Anxiety disorders
Dementia
Depressive disorders
Schizophrenia and other psychotic disorders
Psychotropic medications Anti-cholinergic agents (see Chap. 2)
Anti-depressant agents
Anti-psychotic agents
Barbiturates
Non-psychotropic medications Anti-androgens (e.g., for cancer chemotherapy)
Anti-hypertensive agents (especially centrally acting ones)
Finasteride (Proscar®; others)
Drugs of abuse Alcohol (licit, but abusable; see Chap. 5)
Marijuana
Opioids
Stimulants/psychostimulants
Medical conditions Acromegaly
Addison’s disease
Diabetes
Hyperthyroidism
Hypothyroidism
Klinefelter’s syndrome (XXY genotype)
Multiple sclerosis
Parkinson’s disease
Pelvic surgery
Pelvic irradiation
Peripheral vascular disease (PVD)
Spinal cord injury (SCI)
Syphilis (Ives)
Temporal lobe epilepsy (TLE)
Until the 1990s, the mainstay of treatment for sexual dysfunction was counsel-
ing/psychotherapy of a variety of types including cognitive behavior therapy (or
CBT; see Chaps. 7 and 8) and the behaviorally oriented Masters and Johnson cou-
ples approach (using exercises such as “sensate focus” to heighten couple’s sexual
awareness); as well as counseling/psychotherapy, from the 1960s and 1970s.
In 1998, however, a vasodilator (PGE inhibitor) named sildenafil (Viagra®)
received FDA approval for treating erectile dysfunction, and a new era of pharma-
cotherapy for sexual dysfunction began. Over the years, a raft of new agents for
sexual dysfunction in men appeared and gained popularity. As recently as 2015,
flibanserin (Addyi®) was FDA-approved for hypoactive sexual desire disorder
(HSDD, per DSM-5) in premenopausal women. Table 4.14 presents these “anti-
impotence” agents and their current clinical indications.
Table 4.14 Anti-impotence agents

Gender Agent Indications
Men Alprostadil (Caverject®; others) Erectile dysfunction
Cyproheptadine (Periactin®; discontinued, No FDA indication; anorgasmia
generic only available)
Sildenafil (Viagra®) Erectile dysfunction
Tadalafil (Cialis®) Erectile dysfunction
Testosterone (various preparations) Hypogonadism
Vardenafil (Levitra®) Erectile dysfunction
Vardenafil ODT (Staxyn®) Erectile dysfunction
Women Bremelanotide (Vyleesi®) Hypoactive sexual desire disorder in
premenopausal women
Flibanserin (Addyi®) Hypoactive sexual desire disorder in
premenopausal women
Anti-impotence Agents 63
Two additional agents, testosterone and cannabidiol (CBD), are worth mention-
ing. The former agent, testosterone, is available by prescription when clinically
indicated, in a variety of types, preparations, and routes of administration. Clinical
indications are hypogonadism and low serum testosterone; studies do not suggest
clinical benefit in the presence of normal testosterone levels, notwithstanding media
and other hype to the contrary.
Cannabidiol (CBD), available over-the-counter and in a variety of facilities, is a
non-euphorigenic compound in marijuana, recently touted to be useful in pain man-
agement, anxiety and depression, sexual dysfunction, and a number of other condi-
tions (see Chap. 5). Mechanisms proposed for the purported effectiveness of CBD
in sexual dysfunction include a general relaxing and disinhibiting effect of sexual
tension and performance anxiety, and a vasodilation effect in genital areas, not
unlike the vasodilation of sildenafil (Viagra®) and other such medications. As of this
writing, however, effectiveness of CBD in sexual dysfunction has not been demon-
strated, to my knowledge, in formal studies (which, as a practical matter, are not
required by the FDA for off-label use of medications and non-regulated products).
The jury is still out on this question!
Last, for present purposes and focusing on medications and drugs (psychotropic,
medical, and illicit) as potential causes of sexual dysfunction, the prescribing
healthcare professional should approach individuals with sexual dysfunction as they
would use a common-sense clinical approach: Take a careful and detailed history
and drug history; include these several types of agents, when applicable, in a dif-
ferential diagnosis of the basis, or cause, of the sexual dysfunction; and develop an
investigation and treatment plan based, at least in part, on these data.
Anti-insomnia Agents
Even though sleep disorders are at least as prevalent in the community as anxiety,
depression, bipolar disorder, and schizophrenia, their designation as a “Minor”
Anti-agent in this particular book is simply because most pharmacologic interven-
tion for insomnia, specifically, is not made by psychiatrists or other prescribing
mental health professionals but rather by primary care practitioners.
Other sleep-wake disorders (i.e., in addition to insomnia) exist, which are classi-
fied in the DSM-5 as what may be called “primary” sleep disorders (insomnia disor-
der, hypersomnolence disorder, excessive daytime sleepiness [EDS], and
narcolepsy), i.e., sleep disorders per se; breathing-related sleep disorders (obstruc-
tive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation);
circadian rhythm sleep-wake disorders; and parasomnias (characterized by abnor-
mal behavior, physiological events, or odd experiences in association with sleep,
sleep-wake transitions, or sleep architecture stages: “parasomnia,” from the Greek,
translates as the “opposite” of “sleep”). In this vein, sleep medicine is an enormous
field, with pulmonologists, neurologists, and sleep medicine specialists. (Sleep
medicine is a specific specialty recognized and monitored by the American Board
of Medical Specialties, or ABMS.) Specialists are taking the lead in the care, treat-
ment, and research of these disorders, with diagnostic sleep centers/laboratories
widely available for polysomnographic sleep studies. Pharmacotherapeutic inter-
ventions are available for most of these sleep disorders and conditions.
For present purposes, this chapter focuses on pharmacotherapy of insomnia, the
most prevalent (whether as a formal DSM-5 disorder or a treatment symptom) of
these sleep disorders, with “anti-insomnia agents,” or “hypnotics.”2 For information,
details, and pharmacotherapeutic recommendations concerning these other sleep
disorders, the reader is referred to works cited in the Selected References in Chap.
1 of this Primer.
In recognizing the potential cause of insomnia for any given individual with that
prevalent condition, the “primary” and “secondary” distinctions are a useful
approach to treatment, psychopharmacotherapeutic or not.
First, if an individual’s insomnia is not caused by a specific diagnosable sleep disorder with
a specific pharmacotherapeutic intervention, then “sleep hygiene” should be the start of any
treatment plan. That term involves such practices as avoiding the use of stimulating sub-
stances such as tea, caffeinated coffee, spicy food, nicotine, alcohol (which can produce a
stimulating withdrawal 6–8 hours after ingestion), exercise, and others, at bedtime; restrict-
ing bedtime to sleep (and sex) only, not to include extensive reading, computer work, stren-
uous exercise, and the like; regular exercise (but not strenuous exercise at bedtime), good
diet and weight control; low light, comfortable sheets, and other such amenities to enhance
the sleep environment; and relaxation exercises and behavioral interventions (such as CBT
for insomnia, or CBT-I) before sleep.
2
“Hypnotics,” as opposed to “sedatives,” the latter for inducing calmness during the day (see Chap.
3, section “Antianxiety Agents”).
Anti-insomnia Agents 65
Second, if treatment of insomnia does call for psychopharmacotherapy, a wide variety of

medications is available, with different pharmacologic properties (onset and duration of
action, drug–drug and drug–food interactions, undesirable effects, and the like) from which
to choose for individual patients/clients. These medications include some which have been
discussed previously in this Primer and which are clinically indicated for other conditions,
such as anxiety (i.e., the benzodiazepines: “Antianxiety Agents”). With the benzodiaze-
pines, in particular, attention must be paid to abuse potential, as also discussed in Chap. 5.
Other potential side effects of concern with hypnotics—especially with the

elderly—include development of tolerance with long-term use; withdrawal signs
and symptoms with abrupt discontinuation; paradoxical (aggression, irritability)
reactions to the agents; respiratory depression (especially for the elderly with the
benzodiazepines); and benzodiazepines combined with opioids. With this last com-
bination, a recent FDA “black box” warning concerned the serious and potentially
fatal effects of that combination); anterograde amnesia (especially with the “z-drugs”
and the benzodiazepines, and especially in the elderly); CNS depression; complex
sleep-related behaviors (such as eating, driving, texting, and having sex, especially
in combination with alcohol—a “black box” FDA warning about these behaviors
with these agents was listed in 2019); and daytime sedation, hangovers, and
grogginess.
Table 4.15 summarizes several medications and their classifications used as
sedatives-hypnotics. (See also Chap. 3, section “Antianxiety Agents,” for further
information and details.)
Table 4.15 Anti-insomnia agents

Medication class Examples Comments
Anti-depressants Doxepin (Silenor®; Off-label for insomnia, except Silenor®
(see Chap. 3, tricyclic Off-label for insomnia; discontinued, available as
“Antidepressant anti-depressant) generic
Agents”) Trazodone (Desyrel®;
Oleptro®)
Mirtazapine
(Remeron®;
serotonin
norepinephrine
agonist)
Anti-psychotic Quetiapine (Seroquel®; Off-label for insomnia
(see Chap. 3, in low doses)
“Antipsychotic
Agents”)
Antihistamines Diphenhydramin Can cause confusion, especially in the elderly
(Benadryl®; others) Doxylamine (Unisom®; others)
Benzodiazepines Clonazepam Benzodiazepines as a group differ among one
(Klonopin®; brand another in terms of pharmacologic properties
discontinued, such as rapidity of onset, half-life, duration of
available as action, and the like. Some are FDA-approved
generic) for daytime use (sedative) and some are for
Flurazepam nighttime use for sleep induction (“hypnotic”)
(Dalmane®; brand
discontinued,
available as
generic)
Lorazepam (Ativan®;
FDA-approved for
GAD; off-label for
insomnia)
Temazepam (Restoril®;
for short-term use)
Triazolam (Halcion®;
for short-term use)
Melatonin agonist Ramelteon (Rozerem®)
Dual orexin Suvorexant
receptor antagonist (Belsomra®)
“Z-drugs” Eszopiclone (Lunesta®) GABAergic action, like benzodiazepines, but
Zaleplon (Sonata®) lower sedation and addiction potential,
Zolpidem (Ambien®; reportedly
others)
Zolpidem low dose
(Intermezzo®)
Anti-obsessive-compulsive Agents 67
Anti-obsessive-compulsive Agents
Like a number of other psychiatric disorders for which psychopharmacotherapy

may be indicated, no specific medication for this condition presently exists because
the condition itself is not considered a discrete entity with a known neurobiological
cause for which a specific and discrete psychopharmacologic agent would provide
the “key” to the “lock” of the condition. As discussed early on in this Primer, this
disorder’s pathophysiologic mechanism of action (“cause”) does not “carve nature
at her joints.”
In that context, the new chapter in the DSM-5 entitled “Obsessive-Compulsive
and Related Disorders” discusses obsessive-compulsive disorder (OCD) and other
such conditions as being within an obsessive-compulsive spectrum. Table 4.16 lists
these disorders as presented in the DSM-5.
Obsessive-compulsive disorders and its related conditions can be devastating in
their effects on affected individuals. Treatment often consists of a behavioral psy-
chotherapeutic approach (e.g., systematic desensitization, flooding; see Chaps. 7
and 8) in combination with a pharmacologic agent. For the latter, clomipramine
(Anafranil®, an older tricyclic anti-depressant agent) and several SSRIs—all anti-
depressant agents—have FDA approval for treatment of OCD. Other SSRIs are
periodically used off-label for this indication. Table 4.17 summarizes these points.
Table 4.16 Obsessive- Obsessive-compulsive disorder (OCD)

compulsive and related
Body dysmorphic disorder (BDD)
disorders per DSM-5
Hoarding disorder
Trichotillomania (hair-pulling disorder)
Excoriation (skin-picking) disorder
Substance/medication-induced obsessive-compulsive and
related disorder
Obsessive-compulsive and related disorder due to another
medical condition
Other specified obsessive-compulsive and related disorder
Unspecified obsessive-compulsive and related disorder
Table 4.17 Anti-obsessive-compulsive disorder (OCD) agents

Medication class Examples Comments
Anti-depressants: tricyclic Clomipramine (Anafranil®) FDA indication for OCD
antidepressant
Anti-depressants: selective serotonin Fluoxetine (Prozac®; others) FDA indication for OCD
receptor inhibitors (SSRIs) Fluvoxamine (Luvox®) FDA indication for OCD
Fluvoxamine ER (Luvox FDA indication for OCD
CR®)
Paroxetine (Paxil®; others) FDA indication for OCD
Paroxetine CR (Paxil CR®) FDA indication for OCD
Sertraline (Zoloft®; others) Off-label for OCD
Anti-depressants: serotonin Desvenlafaxine (Pristiq®) Off-label for OCD
norepinephrine reuptake inhibitors Venlafaxine (Effexor®) Off-label for OCD
(SNRIs)
The following case vignette illustrates “classic” OCD in an individual whose life
trajectory was characteristic of this disorder, and whose treatment was unremark-
able, and—fortunately—helpful.
JZ is a 28-year-old former accounting student, living for the past two years with his girl-
friend, working as a bookkeeper with a small manufacturing company, and an individual
who had always taken pride in his meticulous and careful work. Over about a six-month
period, he became increasingly careful and rigid in his personal and professional life,
engaging in taking long showers and washing his hands as often as he could, and in fre-
quently checking and rechecking light switches, faucets, moving furniture to right-angle
positions, and in other such compulsive behaviors. These compulsions reached the point at
which JZ’s girlfriend at first suggested, and then insisted, that he consult a healthcare pro-
fessional for help.
JZ consulted a psychiatric APN (advanced practice nurse), who referred him to a local
psychologist, who in turn treated him with a CBT-desensitization program. This program
seemed to help for a few weeks. However, after that, JZ’s symptoms and signs increased to
the point that he felt paralyzed at work, and unable to do much at home except for shower,
wash his hands, and check light switches. He re-consulted the APN, who prescribed fluox-
etine (Prozac®), initially 20 mg. in the morning. Over several months, the APN increased
his dose to 80 mg. and continued to follow him as an outpatient. JZ’s signs/symptoms
remitted gradually over several months, and he was able to return to a reasonable approxi-
mation of his earlier life.
Over the years, JZ remained stable and productive with his combined therapy, maintain-
ing his fluoxetine (Prozac®) on an ongoing basis, with periodic “refreshers” of his CBT-
desensitization therapy with the psychologist. Periodically, JZ and his APN attempted to
reduce his dose of Prozac®, invariably resulting in a return or exacerbation of his OCD
symptomatology.
Eventually, JZ accepted that he would be on Prozac® “for a long time,” and no longer
questioned his treatment plan. By then, he and his girlfriend had married and had a child.
JZ managed the additional stresses of these major life changes well, without an exacerba-
tion of his OCD symptomatology.
This vignette illustrates several features of the ongoing treatment of OCD includ-
ing the need to rule out possible underlying medical causes or influences on JZ’s
OCD condition, the effectiveness of combined modalities of therapy with his condi-
tion, the need to maintain both modalities of treatment in this chronic condition, the
need to maintain high doses of fluoxetine (Prozac®), and the need for communica-
tion and coordination among treating professionals.
Anti-pain Agents 69
Anti-pain Agents
Also known as “analgesics,” this group of medications is extensive, covering a wide

variety of types and classes of medications, and a focus of clinical attention in a
burgeoning clinical specialty called “pain management,” or “pain medicine.”
Along with anxiety, depression, and insomnia, pain is one of the most reported
and most treated symptoms in clinical practice.
The definition of pain per the IASP (International Association for the Study of
Pain) Task Force on Taxonomy is “An unpleasant sensory and emotional experience
associated with actual or potential tissue damage, or described in terms of such
damage” (Merskey H, Bogduk N, editors. Part III: Pain terms. A current list with
definitions and notes on usage. In: Classification of chronic pain. 2nd ed. IASP
Press; 1994. p. 209–214.)
And in his writings of 1914, Dr. Albert Schweitzer vividly described pain in
these words: “Pain is a more terrible lord of mankind than even death itself”
(Schweitzer A. On the edge of the primeval forest. The Macmillan Company; 1931).
A full review of pain management is well beyond the scope of this present sec-
tion, and the reader is referred to any number of books, articles, electronic databases
and directories, internet sources, and the like for information and details about this
vast topic.
For present purposes, it is useful to categorize pain condition and pain psycho-
pharmacotherapy in several discrete ways, as presented in Table 4.18. Each of these
categories will be discussed, in turn, in the rest of this chapter.
“Acute” vs. “chronic” pain refers to pain that lasts for fewer than 30 days or more
than 30 days, respectively. Conceptually, acute pain syndromes are generally easier
for healthcare practitioners to understand, empathize with, and treat, since analge-
sia, by definition, is achieved relatively quickly. Difficult and elaborating behav-
ioral/psychiatric symptomatology is generally not present or minimally present
with these patients/clients. “Chronic” pain, on the other hand, refers to pain syn-
dromes that last more than 30 days, are often difficult for the healthcare practitioner
to understand, empathize with, and treat, and generally include significant behav-
ioral/psychiatric overlay. A variety of chronic pain syndromes has been identified
and characterized in the pain management field, depending on the origin and patho-
physiology (e.g., ischemic cardiovascular and peripheral neurologic pathology, and
others), the cause (e.g., neoplasm), location, and other such parameters.
In this vein, chronic malignant pain (CMP, resulting from on underlying neoplas-
tic process) vs. chronic benign pain (CBP, not resulting from an underlying neoplas-
tic process) is a useful contrast, in that an important approach to both of these types
of patients/clients is to diagnose and treat the underlying causative condition, what-
ever it might be, to the extent possible. The longstanding controversy in this area
about the advisability of prescribing long-term opioid medications for chronic
benign pain has gone through cycles and phases, in this writer’s experience, over the
years. In the 1980s, chronic opioid use was considered ill-advised because of con-
cerns about tolerance, overdose, the therapeutic index, and potential danger of
opioids especially when taken with other agents, and death, either inadvertently or
on purpose. As with hallucinogens (psychedelics), healthcare professionals pre-
scribed these agents conservatively and sparingly (see also, Chap. 4 concerning
hallucinogens/psychedelic agents).
However, in the 1990s and the early 2000s, with the advent of “pain as the fifth
vital sign” (an approach and campaign which has since been discontinued), the
more liberal use of opioid psychopharmacotherapy was seen as a swing of the pre-
scribing pendulum, and the prescribing of opioids for benign chronic pain syn-
dromes became more acceptable in the healthcare community.
Then, with the onset and worsening of what has been referred to variously as the
current “opioid epidemic,” or “opioid crisis” in the early 2010s, the pendulum of
opioid prescribing practices has swung back to conservative approaches, and more
careful scheduling and tracking of opioids and related compounds (e.g., Federal and
State “Prescription Drug Monitoring Programs,” or PDMPs). A number of different
factors has been considered responsible for the uptick of licit and illicit opioids and
related drugs and drug-related deaths during this time frame, including the far-
reaching effects of the “pain as a fifth vital sign” movement, the ready availability
of potent opioids (such as Fentanyl® and Carfentanyl®), the sense in the general
population that licit and illicit drugs can resolve problems in living, and so forth.
These points will be discussed further in Chap. 5.
“Central” vs. “peripheral” pain refers to the cause and pathophysiology of differ-
ent pain syndromes. “Central” pain syndromes refer to those that arise in the CNS
itself (recognizing that any pain sensation can be modulated, elaborated, or modi-
fied by higher centers of the brain, since pain is, at its core, a neurologic phenome-
non) or are modified by CNS influences. “Peripheral” pain syndromes, in contrast,
refer to those that originate in somatic tissue damage and are medicated through
afferent nervous pathways to central brain areas. The concept of using psychotropic
agents (in contrast to strictly analgesic agents), such as anti-convulsants (see above),
to influence and modify pain perception is based on this distinction. The following
two tables (Tables 4.18, and 4.19) further illustrate these points.
Finally, for present purposes, the dichotomous distinctions in pain syndromes
presented in Table 4.18 are actually the same, the first (“real” vs. “imagined” pain)
couched in the common-sense terminology often perceived by individuals who
work with real-world patients/clients in pain, and the second couched in more tech-
nical terminology. As a practical matter, whether pain is “real” or “not real” is a
Table 4.18 Categories of pain Acute (nociceptive) vs. chronic pain

conditions for purposes of
Chronic benign pain (CBP) vs. chronic malignant
this Primer
pain (CMP)
Central vs. peripheral pain
“Real” vs. “imagined” pain
Pain without significant psychiatric contribution
vs. pain with significant psychiatric contribution
(somatic symptom disorder)
Anti-pain Agents 71
Table 4.19 Variants and terms for chronic pain

Nociceptive (somatic) pain Neuropathic pain
Syrinx formation (central cavitation) Chronic nerve syndrome
Causalgia Central dysesthesia syndrome
Central pain Allodynia
Phantom limb pain Hyperpathia
Dysesthesia Neural injury pain
Adapted from Velez D. CME program (2008)
meaningless distinction, since as a subjective symptom, “pain”—whether plausible

to the onlooker or not—is “real” to the person in pain, and in the healthcare context,
needs to be addressed in some way by the evaluating and/or treating healthcare
professional.
From a psychiatric viewpoint and, from the diagnostic perspective, pain syn-
dromes which are more elaborated and less straightforward than short-term acute
situations (which would be less likely to require psychiatric/psychological/counsel-
ing intervention than more complex symptomatology) are specifically embodied in
the DSM-5 as “Somatic Symptom and Related Disorders,” depicted in Table 4.20.
Although the current edition of the DSM no longer endorses what may be termed
“elaborated” pain disorder, this broad category of disorders includes pain syn-
dromes, emphasizing an individual’s response to pain and/or other symptoms rather
than to the pain symptoms themselves.
Focusing on psychopharmacotherapeutic agents, the following “World Health
Organization Analgesic Ladder” outlines four steps in terms of increasing potency
of medications and interventions involved in the evaluation and treatment of differ-
ent pain syndromes.
Table 4.20 Somatic symptom and Somatic symptom disorder

related disorders, per DSM-5
Illness anxiety disorder
Conversion disorder
Psychological factors affecting other medical
conditions
Factitious disorder imposed on self and imposed
on another
Other specified somatic symptom and related
disorder
Unspecified somatic symptom and related
disorder
For examples of analgesic medications, their doses and dosing schedules, and
other such information about the various non-steroid anti-inflammatory drugs
(NSAIDs), opioids, non-opioids, and other agents in this table, the reader is referred
to applicable textbooks, monographs, internet services, electronic databases, and
the like.
For purposes of this chapter, several specific psychotropic medications for two
specific syndromes, peripheral neuropathic pain syndromes and fibromyalgia—
both with significant psychiatric components—will be reviewed next.
First, concerning peripheral neuropathic pain syndromes, two psychotropic
medications of two different classes—duloxetine (Cymbalta®), an anti-depressant,
and pregabalin (Lyrica®), a novel anti-convulsant—have FDA-indications and off-
label uses in these areas. Duloxetine (Cymbalta®) is approved for diabetic periph-
eral neuropathic pain, fibromyalgia, and other chronic musculoskeletal pain
syndromes (and other off-label chronic pain disorders). Pregabalin (Lyrica®) is
approved for diabetic peripheral neuropathic pain, neuropathic pain associated with
spinal cord injury, postherpetic neuralgia, and fibromyalgia (and other non-pain
indications, including partial complex seizures, generalized anxiety disorder, and
withdrawal from benzodiazepines and alcohol; these last three are off-label uses).
Second, fibromyalgia as a chronic pain condition is characterized by widespread
and chronic pain, fatigue, and cognitive impairment (“fibro fog”). For proper diag-
nosis, the presence of some of the 18 “tender points” designated by the American
College of Rheumatology, first in the 1990s, is no longer required. A number of
Anti-pain Agents 73
co-morbid or co-occurring conditions may be seen with fibromyalgia, including

irritable bowel syndrome, migraine and other types of headaches, interstitial cystitis
or painful bowel syndrome, temporomandibular joint (TMJ) disorder/dysfunction,
and others. These frequent comorbidities confer a strong psychiatric component to
this condition. The psychopharmacotherapy of fibromyalgia rests on three princi-
ples: (1) Use of non-opioid analgesic agents as depicted in the “World Health
Organization Analgesic Ladder” (Table 4.21) for amelioration and relief of pain not
complicated by psychiatric symptomatology or overlay; (2) Use of an FDA-
approved agent specifically for fibromyalgia, once the diagnosis is made and con-
firmed, namely duloxetine (Cymbalta®), pregabalin (Lyrica®), or milnacipran
(Savella®, a serotonin-norepinephrine reuptake inhibitor, or SNRI), or other such
off-label agent with which the prescriber is familiar and experienced; and (3) Use of
other psychopharmacotherapeutic agents to address the fibromyalgia patient’s psy-
chiatric “target symptoms.”
No discussion of “Anti-pain Agents” would be complete without some mention
of headaches and headache pain. Without going into the details and nuances of the
types, classifications, diagnostic approaches, treatment, and the like about head-
aches and headache pain, and without underestimating the prevalence and
Table 4.21 World Health Organization Step 4: Invasive and minimally invasive
analgesic ladder treatments
Step 3: Opioids from moderate to severe
pain ± non-opioid agents ± adjuvants
Step 2: Opioids from mild to moderate pain
+ non-opioid agents ± adjuvants
Step 1: Non-opioids ± adjuvants
Adapted from Anekar A, Castella M. WHO
analgesic ladder (2020)
significance of headaches as a public health concern, the rest of this section will
focus on the psychopharmacotherapy of migraine and cluster headaches. As a prac-
tical matter, a variety of analgesic and psychotropic medications have been used for
migraine prophylaxis (prevention) and for aborting migraine attacks. Table 4.22
lists such medications, non-psychotropic and psychotropic. As with other sections
of this chapter, for further information and details about migraine and other head-
ache pathophysiology, diagnosis, treatment, doses and dose scheduling, and the
like, the reader is referred to applicable textbooks, monographs, articles, internet
sources, electronic databases, and the like.
Although this section has focused on psychopharmacotherapy of different types
and syndromes of pain conditions, the beneficial role of psychotherapy/counseling,
behavioral intervention, weight control, exercise, and other such
Table 4.22 Medications for migraine prevention and treatment

Examples
(P) = prophylaxis
Class (A) = abort attacks Indications
Non-psychotropic Non-steroidal anti-inflammatory Acetaminophen (Tylenol®; others)
agents drugs (NSAIDs) (A) Naproxen (Aleve®; others)
Aspirin
Ibuprofen (Advil®; others)
Stimulants (A) Caffeine/ergotamine (Migergot®;
others)
Triptans (A) Sumatriptan (Imitrex®; others)
Antihistamines (A) Diphenhydramine (Benadryl®; others)
Beta-blockers (P) Metoprolol (ToprolXL®; others)
Calcium channel blockers (P) Verapamil (Isoptin®; others)
ACE inhibitors (P) Lisinopril (Prinivil®; others)
Psychotropic Tricyclic anti-depressants (P) Amitriptyline (Elavil®; others)
agents Novel anti-convulsants (P) Topiramate (Topamax®; others);
Gabapentin (Neurontin®)
Anti-convulsants (P) Valproic acid (Depakote®; others)
Selective serotonin reuptake Fluoxetine (Prozac®; others)
inhibitors (SSRIs) (P)
Anti-pain Agents 75
non-pharmacologic interventions should not be underestimated for these condi-

tions. Such interventions are discussed in Chaps. 6, 7, and 8 in this book.
Last, to illustrate some of the dilemmas encountered in frequent clinical scenario-
treating chronic benign pain syndromes with opioid pharmacotherapy on a long-
term basis, the following case vignettes present examples, respectively, of a “good”
candidate and a “bad” candidate for long-term opioid pain management therapy.
These vignettes incorporate a number of biopsychosocial features in their evalua-
tions. Both individuals were seen for consultation/evaluation in an acute general
community hospital by the hospital’s Consultation-Liaison Psychiatry Service.
WO, a 43-year-old married female insurance executive from the suburbs, wife of an attor-
ney and mother of two older teenage children, was involved in a motor vehicle accident in
which she sustained a T10 fracture dislocation. This injury rendered WO paraplegic with an
inconsistent sensory level between T8 and T10. WO had been a happy and productive wife,
mother, and professional, who had exercised and played tennis regularly throughout the
year, and who has no past personal or family history of psychiatric disorder or sub-
stance abuse.
Seriously depressed and angered initially by her accident and her paraplegia, WO grad-
ually came to accept her condition to some extent after several months of inpatient and day
hospital rehabilitation, physical therapy and psychotherapy/counseling alone and with her
husband. She did not require potent analgesic medication during that time.
However, after several weeks, WO developed the rapid onset of dysesthesia, burning,
and occasionally lancinating low-back pain. This pain increased and persisted over several
weeks. WO’s initial pharmacologic treatment consisted of increasing non-narcotic analge-
sic medication (prescribed on a maintenance basis), with the addition of Elavil (25 mg. at
hour of sleep) to this regimen. WO’s response to these changes in her treatment plan was
inconsistent. Psychiatric consultation was requested to evaluate WO for a trial of chronic
long-term opioid therapy.
CK is a 20-year-old male, who at age 10, while playing across the street from his house,
sustained a gunshot wound to his back. This injury left CK paraplegic, wheelchair- and
bed-bound, with an inconsistent sensory level between T8 and T0, where T10 was the site
of impact of the bullet in CK’s gunshot wound.
CK was electively admitted to the hospital for surgical correction of a back ulcer. CK
had a known and long history—both before and after his back trauma—of polysubstance
abuse and addiction. For this reason and to assist in CK’s medical management, the
Consultation-Liaison Psychiatry Service was consulted by CK’s treatment team.
At the age of 16, CK required the placement of surgical rods in his back in order to cor-
rect a progressive kyphosis. These rods were removed approximately 2½ years later, and an
abscess formed in the area of removal several months after that. CK developed a full-blown
decubitus which had not healed by the time of his elective admission, and which became
very large as a result of multiple infections. These infections required hospitalizations for
antibiotic therapy and debridement, and CK was noted during those hospitalization to have
been a management problem and demanding of analgesic medications (primarily opioids).
CK had been inactive at home for a number of years, despite a large and supportive fam-
ily. He had been treated with multiple pain medications at home, and he also acknowledged
using four to five Percodan® tablets every three hours, as well as two 5 mg. Valium® every
four to six hours, above and beyond the non-narcotic analgesic medications prescribed for
him by his family physician on a maintenance basis. In addition to his prescription drug
supplementation with Percodan®, CK also supplemented his medication regimen with alco-
hol, marijuana, and illicit acetaminophen (Tylenol®) with codeine.
CK underwent myocutaneous and paraspinal flap closure of the decubitus during this
elective hospitalization. At the time that the Psychiatry Service was consulted for CK, his
prescribed medication regimen was Percocet® (two tablets every three hours as needed) and
Valium (5 mg. every six hours as needed) with Clinitron® therapy. CK’s nurses noted his
difficult and demanding behaviors, especially around his analgesic regimen. CK com-
plained that the prescribed medications (i.e., Percocet® and Valium®) were not holding him
for the full three hours for which they were prescribed.
Therefore, Consultation-Liaison Psychiatry was consulted for advice in managing and
medicating (pain medication) CK, particularly with regard to the evaluation of CK for a
trial of long-term (maintenance) opioid therapy.
Anti-panic Agents
Of anxiety disorders, broadly speaking, ongoing manifest panicky symptoms, in

general, may be considered as bursts of intense anxiety, tension, and other symp-
toms on an unpredictable or random basis (“panic attacks”) or in a recurrent pattern
over time (“panic disorder”). In that vein, the DSM-5 distinguishes between those
two conditions, emphasizing the multi-organ system symptomatology (e.g., the
“DSM-5 Panic Attack Specifier” gives a number of such symptoms, including pal-
pitations, diaphoresis, tremulousness, chest pain, choking sensation, dizziness,
numbness and tingling, nausea and abdominal distress, and others) of panic attacks
and panic disorder.
As with the anxiety disorders in general and many other psychiatric disorders,
the optimal approach to the treatment of panic disorder is multidisciplinary, includ-
ing psychotherapy/counseling, psychopharmacotherapy, combination approaches
(especially cognitive behavior therapy [CBT] and psychopharmacotherapy), life
style modification, diet and weight control, exercise, avoidance of stimulants/psy-
chostimulants, and the like. Focusing on psychopharmacotherapy, for present pur-
poses, the mainstay psychopharmacotherapeutic agents for panic disorder are the
benzodiazepines (specifically alprazolam [Xanax®; others], clonazepam [Klonopin®;
others], with others used off-label) and anti-depressants (SSRIs: fluoxetine [Prozac®;
others], paroxetine [Paxil®; others], and sertraline [Zoloft®; others], with others
used off-label). Venlafaxine ER (Effexor XR®) is also FDA-approved for panic dis-
order, and desvenlafaxine (Pristiq®; others) is used off-label for the same indication.
As an off-label use for what may be considered a forme fruste of a panic attack,
propranolol (Inderal®; others) is given for performance anxiety (“stage fright”) and
akathisia (motor restlessness; see Chap. 3, section “Antipsychotic Agents”), espe-
cially for individuals with marked somatic symptomatology as part of their anxiety
or panic. These uses are in addition to the FDA-approved indications of propranolol
(Inderal®; others) for hypertension, atrial fibrillation, migraine prophylaxis, post-
myocardial infarction cardioprotection, and essential tremor.
Antiparkinsonian Agents 77
The reader is cross-referenced to those sections of “Antianxiety Agents” and

“Antidepressant Agents” concerning benzodiazepines and SSRIs/SNRIs for further
information and details about these psychopharmacotherapeutic agents. The second
case vignette (AB) for “Antianxiety Agents,” for example, illustrates an individual
with panic disorder.
Antiparkinsonian Agents
As discussed in the Preface of this volume, psychiatry as a medical specialty and a

relative newcomer into medicine was almost interchangeable during the latter half
of the nineteenth century: Neurologists took care of chronic patients in “insane
asylums” (what are now called state or county mental hospitals); psychiatrists in
office practices evaluated and treated patients with such neurologic conditions as
conversion disorders, or paralyses (“hysterical neurosis”); and vice-versa, with
interchange among these physicians. As both fields evolved over the years, they
diverged, with neurologists taking care of individuals with cerebrovascular acci-
dents (CVAs or “strokes”), degenerative disorders, neoplastic disorders, seizures,
and the other panoply of conditions which are now called neurologic disorders.
Psychiatry diverged toward psychological constructs and inferences about which
are now called psychiatric disorders.3 In about the 1960s, however, as medical tech-
nology and psychopharmacology grew and became more sophisticated, the
evidenced-based foundations of both fields began to drive them back together, giv-
ing definition to areas of training and practice such as neuropsychiatry and behav-
ioral neurology.
One area of practice and research which is a good example of this convergence
of the disciplines of neurology and psychiatry is Parkinson’s disorder. This degen-
erative multisymptomatic disorder was identified in 1817 by the English neurolo-
gist, Dr. James Parkinson, after whom the disorder was named, and who himself
called the condition “paralysis agitans.” Dr. Parkinson’s original description of the
condition, and his subsequent study and treatment over many years, focused on the
motoric aspects of the condition, namely the “Parkinsonian tremor, bradykinesia,
poverty of motion, mask-like facies,” and so forth.
More recently, however, the interest and focus of neurology and psychiatry in
Parkinson’s disease have been on three major areas of symptomatology often mani-
fested by Parkinsonian patients, viz., (1) motoric, (2) behavioral, and (3) neuropsy-
chiatric/cognitive. All of the foregoing is to say that the treatment of individuals
with Parkinson’s disease is of increasing interest and practice to psychiatrists, espe-
cially concerning behavioral and neuropsychiatric symptomatology associated with
the disease.
3
For an engaging account of these two branches of medicine during the American “Gilded Age,”
with a forensic bent, see Rosenberg CE. The trial of the assassin Guiteau: psychiatry and the law
in the gilded age. University of Chicago Press; 1968.
In addition to Parkinson’s disease as a focus of psychiatric interest, also of inter-

est are the terms “Parkinsonian” and “Parkinsonism,” descriptors for the types of
dystonias (movement disorders) seen as a side effect in a number of psychotropic
medications (especially first-generation anti-psychotic agents of the high-potency,
low-dose type). This section will focus on both of these areas of interest.
In this area of Parkinson’s disease—the neuropsychiatric/cognitive area—clini-
cal depression (in as many as half of Parkinson’s patients) and psychosis (with delu-
sions and hallucinations) are not uncommon. For psychopharmacotherapy of the
former (depression), a wide range and variety of anti-depressants are available to
treat these co-occurring “target symptoms,” although care must be taken not to use
agents significantly affecting dopaminergic neurotransmitter systems. Dopamine
agonist medications which directly address the dopamine deficiency of Parkinson’s
disease must necessarily be in careful balance with other agents affecting the dopa-
mine system. For psychopharmacotherapy of the latter (psychosis), the prescriber
also has to be careful about the balance between dopamine-blocking properties of
most anti-psychotic agents (see “Anti-psychotic Agents” in this chapter) and dopa-
mine depletion in Parkinson’s disease. As of this writing, only one anti-psychotic
agent, pimavanserin (Nuplazid®)—the only non-dopamine blocking atypical anti-
psychotic currently available—has FDA approval specifically for psychosis in
Parkinson’s disease, although the recency and expense of this agent are of concern.
In this context, as a practical matter, quetiapine (Seroquel®) has been used fre-
quently for Parkinson’s disease, as well as for treating insomnia, both as off-
label use.
Parkinsonism, also known as extra-pyramidal syndrome, or EPS, refers to sev-
eral medication-induced movement disorders, or dystonias, caused by a variety of
medications—both psychopharmacologic and non-psychopharmacologic—primar-
ily, for present purposes, the conventional/traditional (“first-generation”) high-
potency, low-dose anti-psychotic agents, such as haloperidol (Haldol®) and
fluphenazine (Prolixin®). These dystonias consist of a Parkinsonian tremor at rest,
rigidity, akathisia, akinesia, (late-onset) tardive dyskinesia (TD), cogwheeling, bra-
dykinesia, and mask-like facies. Pharmacologic treatment of EPS focuses on anti-
cholinergic agents (see Chap. 2, section “Three Additional Classes”), with others
and cardiac drugs also useful. Table 4.23 presents these agents.
Antiparkinsonian Agents 79
Table 4.23 Antiparkinsonian agents

Drug class Examples Comments
Anti-cholinergic/ Benztropine (Cogentin®; Antihistamine with anti-cholinergic
antimuscarinic others) preparations
compounds Biperiden (Akineton®; others)
Diphenhydramine (Benadryl®;
others)
Ethopropazine (Parsidol®; Phenothiazine derivative with anti-
others) cholinergic preparations
Orphenadrine (Norflex®; Muscle relaxant (CNS)
others)
Pramipexole (Mirapex®; Also indicated for restless leg syndrome
others)
Procyclidine (Kemedrin®;
others)
Trihexyphenidyl (Artane®;
others)
Dopamine Amantadine (Symmetrel®; Used as adjunct in Parkinson’s disease
facilitators others)
Entacapone (Comtan®; others)
Beta-blockers Beta-propranolol (Inderal®; Antihypertensive agent; monitor BP
others) carefully
Alpha-agonists Clonidine (Catapres®; others) Antihypertensive agent; monitor BP
carefully. (See also section “Anti-addiction
Agents” in this chapter and Chap. 5)
Recognizing tardive dyskinesia as a Parkinsonian movement disorder, until rela-

tively recently, no specific pharmacologic agent was available for this condition.
Treatment involved dosage scheduling of the causative medications (usually anti-
psychotic agents), changing the anti-psychotic medications, drug holidays, and the
like. However, three specific medications have recently become available to treat
tardive dyskinesia (and in the case of tetrabenazine [Xenazine®] to treat the chorei-
form dystonias of Huntington’s disease), viz., valbenazine (Ingrezza®), deutetra-
benazine (Austedo®), and tetrabenazine (Xenazine®). Other agents used secondarily
for the treatment of tardive dyskinesia include amantadine (Symmetrel®), benzodi-
azepines, and the OTC and health food agents gingko biloba extract and vitamin
E. Tardive dyskinesia, again, is a common side effect of high-potency, low-dose
conventional/traditional, “first-generation” anti-psychotic agents, but can also result
from long-term and chronic use of dopamine-blocking agents for other indications,
such as the antiemetic metoclopramide (Reglan®) and prochlorperazine
(Compazine®). Adventitious movements characteristic of tardive dyskinesia include
chewing, grimacing, tongue protrusion, lip smacking, and other repetitive, writhing,
oro-bucco-lingual facial movements.
Anti-pseudobulbar Affect Agents
The extreme mood swings and uncontrollable affect known as “pseudobulbar

affect” is another example (see section “Antiparkinsonian Agents” in this chapter)
of the convergence of psychiatry and neurology as disciplines over the past
40–50 years. This neuropsychiatric condition is part of the symptom complex in
“pseudobulbar palsy,” an upper motor neuron lesion caused by bilateral distur-
bances of the corticobulbar track resulting from vascular, degenerative, neoplastic,
and other such etiologies involving cranial nerves IX, X, and XII. This condition is
characterized by motor signs, such as impairment in, or inability to control, facial
and related movements (such as speaking, dysphagia, smiling, chewing, grimacing,
and others) and emotional signs and symptoms of labile affect, and uncontrollable
fits of laughter and crying (the portrayal of the main character, Arthur Fleck, in the
2019 movie, Joker, is a good illustration of this condition). Bulbar palsy is a lower
motor neuron lesion involving the same cranial nerves with the same motor deficits,
but without the marked affective lability and symptomatology of pseudobulbar palsy.
Although pseudobulbar palsy was first identified and characterized in the 1800s,
specific pharmacotherapy for this condition did not come into being until 2010, with
FDA-approval of a combined preparation of dextromethorphan and quinidine called
Nuedexta®. As of this writing, Nuedexta® is the only FDA-approved drug for that
particular indication, although it has also been used off-label for individuals with
Parkinson’s disease and dementia. Conversely, off-label use of a variety of anti-
depressant agents, and cognitive therapy, has also been approaches to the treatment
of pseudobulbar affect.
Anti-sex Agents
Conceptually, the opposite of “Anti-impotence Agents” are “Anti-sex Agents,”

intended to influence, control, and reduce what may be called “hyper-sexed” behav-
iors of such individuals as paraphilics, pedophiles, and sex offenders. Like many of
the other “Anti” categories of medications presented and discussed in this Primer,
this “Anti” category is not a distinct category per se but rather consists of other psy-
chotropic agents, especially SSRI anti-depressants.
The field of paraphilic (from the Greek: “para” meaning “opposite,” and “philia”
meaning “love”) disorder has a long and notorious history, including historical fig-
ures such as the Marquis de Sade (the term “sadism” derives from his name),
Richard F. von Krafft-Ebbing (who, in 1886, wrote Psychopathia Sexualis), Henry
Havelock Ellis (who co-authored Sexual Inversion, originally published in 1896),
and others, and covers a variety of anomalous sexual activity preferences and devi-
ant patterns of sexual arousal, behaviors, interests, and activities. Paraphilia (abnor-
mal and deviant sexual interests and behaviors) and paraphilic disorders (patterns of
abnormal and deviant sexual interests, behaviors, and thoughts leading to a formal
Anti-sex Agents 81
diagnosis) are given in Table 4.24; a full discussion of these topics is well beyond
the scope of this Primer.
For present purposes, the general approach to treatment of individuals with para-
philias includes behavioral/counseling/psychotherapeutic (especially cognitive
behavior therapy or CBT, with specialized approaches in sex-offender-specific
treatment or SOST, for example), with psychopharmacotherapy. The latter includes
two broad pharmacotherapeutic classes of agents, viz., hormonal agents (for more
severely symptomatic individuals, generally) and psychotropic agents (for less
severely symptomatic individuals, generally). Each of these two categories may be
further divided into two sub-categories, as displayed in Table 4.25.
Table 4.24 Paraphilic disorders per DSM-5 Voyeuristic disorder

Exhibitionistic disorder
Frotteuristic disorder
Sexual masochism disorder
Sexual sadism disorder
Pedophile disorder
Fetishistic disorder
Transvestic disorder
Other specified paraphilic disorder
Unspecified paraphilic disorder
Table 4.25 Anti-sex agents

I. Hormonal agents (antiandrogenic effects)
A. Indirect-acting mechanisms of action
1. Progestin analogue (feminizing hormone)
Medroxyprogesterone (Depo-Provera®; others)
2. Gonadotrophin hormone-releasing hormone (GrRH) agonists/Luteinizing hormone-
releasing (LHRH) agonists
Leuprolide acetate (Lupron®; others), depot preparations
Leuprorelin (Lucrin®; others)
Goserelin acetate (Zoladex®; others)
Triptorelin (Triptodur®; Trelstar Depot®; others)
B. Direct-acting mechanisms of action (androgen receptor blockade)
1. Cyproterone acetate
2. Flutamide (Eulexin® Oral; others)
3. Finasteride (Propecia®; others)
II. Psychotropic agents
A. Agents for treatment of male aggressive hypersexuality (mainstay: SSRI anti-depressant
agents)
B. Agents for treatment of co-occurring (comorbid) psychiatric symptoms (target symptoms)
and conditions
C. Specific off-label applications
Naltrexone (Revia®; others)
Methylphenidate (Ritalin®; others)
Adapted from Greenfield D. Journal of Psychiatry Law (2006)
Currently, even though surgical intervention is not a prevalent current treatment

modality, for completeness’ sake, mention will be made of this modality. Essentially,
two surgical approaches to hypersexuality have been practiced, the first for many
years. These approaches are (1) surgical castration (orchiectomy, a practice going
back at least to the Middle Ages, if not earlier) and (2) stereotactic brain surgery
(not used in the United States). While studies indicate that these approaches are
effective in reducing sex drive and sex offending recidivism, the irreversibility of
the procedures and the medico-legal and ethical concerns have made these
approaches little used in current practice. The following case vignette illustrates
some of these concerns and issues:
EH is a 37-year-old male patient/client in maintenance SOST (sex offender specific treat-
ment), court-ordered, with a serious sex offense history in his late teenage years. He has
been on court-ordered community supervision as a “Megan’s Registrant” since his release
from incarceration ten years ago for his earlier sex offenses.
Until about a year ago, EH had been doing well clinically—without recurrent sexual
acting out—on two sequential SSRI anti-depressant agents, regular individual and group
SOST. EH has a well-paying and steady job, a casual relationship with a male friend “from
when I was a kid,” and an active-enough social life with friends and family.
After a difficult spell at work about a year ago, EH began to feel strong and uncomfort-
able sexual urges and cravings. Psychological intervention and support from his SOST
staff, and several different psychopharmacotherapeutic changes, including a course of anti-
androgenic medications, still left him feeling desperate and worried about his status as a
registrant with his “Megan’s” community notification program.
Finally, he spoke with both his SOST psychologist and his prescribing Physician
Assistant, requesting referral to an urologist “who would be willing to castrate me.” Initial
inquiries were unsuccessful.
As mentioned above, a full discussion of even only the psychopharmacotherapy

of this fascinating and troubling field of “hyper-sexed” individuals, paraphilics, and
sex offenders is well beyond the scope of this chapter. The field is replete with psy-
chiatric, neuropsychiatric, medical, biochemical, pharmacologic, legal, ethical,
criminological, and societal controversies, as well as other such issues and con-
cerns, some raised by the case vignette just presented. For further discussion about
these disorders and their treatment, the reader is referred to the DSM-5 and to other
applicable books, monographs, electronic databases, articles, internet sources, and
the like.
Anti-trauma Agents
The last of the sixteen “Minor Anti-agents” in this classification system are those
used to treat symptomatology of trauma, especially of post-traumatic stress disorder
(PTSD) and acute stress disorder (ASD), as articulated in the DSM-5. Like many of
the disorders and syndromes discussed in Chaps. 3 and 4, specific traumatic mani-
festational symptomatology corresponding exactly to traumatic stimuli, or stressors
do not exist in nature. For that reason, and in view of the protean manifestations of
traumatic symptomatology, several psychopharmacotherapeutic “Anti-agents” have

been shown to be useful in ameliorating traumatic symptomatology, and several
have FDA-approval for treating symptoms of PTSD. Specifically, several SSRIs—
paroxetine (Paxil®; others), sertraline (Zoloft®; others), and fluvoxamine
(LuvoxCR®)—have FDA-approval for PTSD; two SNRIs—venlafaxine (Effexor®)
and desvenlafaxine (Pristiq®; others)—are used off-label for PTSD; and as a practi-
cal matter, other SSRIs are probably indicated for PTSD as well, depending on
patient/client characteristics (e.g., fluoxetine [Prozac®] for patients/clients without
prominent sleep disturbances). However, considering the affect storm in PTSD and
the “black box” FDA warning about suicidality with anti-depressants, these agents
should be used conservatively and carefully monitored.
In addition, prazosin (Minipress®, an anti-depressant agent) is often used to treat
PTSD victims with nightmares, as an off-label indication.
Several benzodiazepines (e.g., clonazepam [Klonopin®; others] and diazepam
[Valium®; others]) are used off-label to reduce PTSD-associated anxiety but should
be restricted to short-term use, owing to abuse potential, especially in individuals
with histories of chemical dependency.
In the final analysis, as recognized by the U.S. Department of Veterans Affairs,
among others, the first-line treatment for PTSD ought to be psychological (counsel-
ing; psychotherapy). Cognitive-behavioral therapy (CBT), eye movement desensiti-
zation and refocusing (EMDR), and controlled exposure desensitization, are among
the effective behaviorally oriented therapy modalities (see Chaps. 7 and 8) for these
conditions, and individual supportive counseling/psychotherapy, family, and group
psychotherapy are among such effective non-behavioral therapy modalities.
Historically, the concept of what the DSMs (since DSM-III, in 1980) have called
post-traumatic stress disorder, or PTSD, has gone back hundreds, perhaps thou-
sands, of years. “DaCosta’s syndrome” and “soldier’s heart,” (both terms from the
American Civil War era), “shell shock” (World War I era), “battle fatigue” (World
War II era), “post-traumatic neurosis” (in earlier DSMs), and other terms have been
used to describe this prevalent and serious condition.
A full review of this vast and complex condition is well beyond the scope of this
section of this Primer, which has focused on an overview of a secondary approach
to the treatment of this condition, namely psychopharmacotherapy. For further
information and details about PTSD and other traumatic conditions, the reader is
referred to applicable textbooks, the DSM-5, monographs, electronic databases,
internet sources, and other such sources, including those given in the Selected
References for this volume.
selected references, but also to applicable textbooks, monographs, electronic data-
Selected References
diagnoses.)
of the field.)
ries, viz.
sional journal)
tronic and print)
include:

Chapter 5
Illicit Substances and Drugs
The field of substance abuse, chemical dependency, drug and alcohol abuse, and
other such designations—all to be used interchangeably in this Primer—is a vast
one, for which a full and comprehensive review is well beyond the scope of this
volume. For that, the reader is referred to the Selected References at the end of the
Preface of this Primer and, as before, to applicable electronic databases, internet
sources, and the like.
Referring to Chap. 2 (“Basic Principles of Pharmacology, Psychopharmacology,
and Psychopharmacotherapy”) in this Primer and for purposes of this chapter, psy-
chotropic agents may be categorized in several ways:
1. One such way is in terms of the various psychiatric disorders, conditions, and
symptoms for which the agent is used in treatment. The four “Major Anti-s” and
the sixteen “Minor Anti-s” are examples of this system of categorizing
these agents.
2. Another way is in terms of whether use of the agents is licit (legal) or illicit
(illegal). These categories recognize considerable overlap among agents, in that
virtually any legitimate psychotropic agent—or any non-psychotropic agent, for
that matter—may be misused or abused. Conversely, some usually illicit drugs
may have licit indications, depending on their legal status (medical marijuana is
a good recent example of this).
3. “Lumpers” and “Splitters.” Lumpers: In terms of taxonomies, these individuals
seek to create broad categories or taxons of things, collecting multiple character-
istics and examples into few taxons. Splitters: In contrast, these individuals seek
to create narrow categories, or taxons of things, collecting narrow and few char-
acteristics and examples into many taxons. In the chemical dependency context,
Lumpers generally distinguish in terms of the broad psychoactive effects of
these drugs, for example: among stimulants, or psychostimulants; depressants;
and hallucinogens, or psychotomimetics. Examples are presented in Table 5.1.

Switzerland AG 2022
https://doi.org/10.1007/978-3-030-82507-2_5
88 5 Illicit Substances and Drugs
4. From an applied clinical perspective, a fourth way of categorizing the addictions

generally—i.e., not only those involving drugs and alcohol—is in terms of
chemical and behavioral addictions. Table 5.2 lists some of both.
5. With respect to addiction medicine, a youthful distinction is made between
medications which treat the chemical addictions per se (known as “medication-
assisted treatment,” or MAT) and those that treat symptomatology (“target
symptoms”) of addicts and alcoholics. Table 5.3 summarizes these points.
In this chapter, the distinction between “licit” and “illicit” substances, between
chemical and behavioral addictions, and between MAT and psychopharmacothera-
peutic treatment of symptoms of various addictive conditions will be presented and
discussed. DSM-5 treatment of what are termed in the DSM-5 as “Substance Use
Disorders” (SUDs) will also be covered.
The conclusion of this chapter will review non-pharmacologic approaches to the
treatment of addicts and alcoholics, emphasizing the strong need for multidisci-
plinary and “continuum of care” treatment of these often difficult and challenging
patients/clients.
Table 5.1 “Lumper” and “splitter” taxonomies of drugs

Drug class Examples (L = Licit; I = Illicit)
Lumpers Stimulants/psychostimulants (see Cocaine (L & I)
also “anti-ADHD agents;” and Amphetamines/methamphetamines (L & I)
“anti-appetite agents”) Caffeine (L)
Depressants (see also Methylphenidate compounds (L & I)
“antidepressants”) Many others
Hallucinogens (psychotomimetic) Alcohol (L)
Opioids (L & I)
Barbiturates (L)
Benzodiazepines (L & I) and “Z-drugs” (L)
Many others
Lysergic acid diethylamide (LSD) (I)
Phencyclidine (PCP) (I)
Cannabis sativa (marijuana) (L & I)
Psilocybin (I)
Ayahuasca (L & I)
Synthetic marijuana (I)
Khat (I)
Ketamine (“special K;” Spravato®) (L & I)
Splitters Alcohol, caffeine, cannabis (including synthetic marijuana), “designer drugs,”
hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants, others
or unknown
5 Illicit Substances and Drugs 89
Table 5.2 Chemical and Nature of addiction Examples

behavioral addictions
Chemical addictions Alcohol
Caffeine
Cannabis (marijuana)
Hallucinogens/psychotomimetic
Inhalants
Opioids
Sedative – hypnotics
Stimulants/psychostimulants
Tobacco
Behavioral Exercise
addictions Food (obesity)
Gambling (listed in the DSM-5)
Internet gaming
Internet surfing
Kleptomania
Love
Sex
Shopping
Tanning
Texting/emailing
Work (“workaholism”)
Table 5.3 Medication-assisted treatment (MAT) and symptomatic treatment of addicts and
alcoholics
I. Agents That Treat Chemical Addictions Per Se
Medication-assisted treatments (MATs):
For opioid addiction (OUD)
Methadone
Naltrexone (IR and L-A [Vivitrol®, Injectable])
Buprenorphine (Subutex®; Suboxone® [buprenorphine]) and other preparations
Naloxone (for emergency opioid overdose)
Clonidine (Catapres®)
Lofexidine (Lucemyra®)
For alcohol addiction (AUD)
Disulfiram (Antabuse®)
Acamposate (Campral®)
Naltrexone (Revia®)
For smoking (tobacco products) addiction
Nicotine replacement therapy (patches, polacrilex gum, others); “vaping” replacement
therapy
Varenicicline (Chantix®)
Bupropion (Zyban®, for smoking specifically)
II. Agents That Treat Symptomatology of Addicts and Alcoholics
(See Table 2.5 in Chap. 2, “The Twenty Licit Anti-Agents”)
Controlled Dangerous Substances (CDS)
In 1970, the Controlled Substance Act (CSA) of the FDA created a series of five
categories of “dangerous drugs” on a sliding scale of five “Schedules” (I–V) from
those considered the most dangerous (Schedule I) to those considered the least dan-
gerous in terms of safety and abuse potential. These prescriptions were monitored
by the (then) Bureau of Narcotics and Dangerous Drugs (BNDDs), later called the
Drug Enforcement Administration (DEA) of the Department of Justice of the United
States government. Review of the agents in these several categories in Table 5.4
indicates that while some agents are strictly “illicit” (i.e., CDS Schedule I) with “no
accepted medical use,” most—and most of the medications and agents discussed in
this Primer—can be both, depending on the circumstances under which they are
prescribed, whether prescribers follow acceptable federal and state guidelines (this
can be especially problematic in the case of medical marijuana, in which in a num-
ber of states this prescribing is legal under proper conditions, but in which the fed-
eral jurisdiction, marijuana1 remains illicit), and other such circumstances. For these
reasons, it behooves the health professional registered and authorized to prescribe
CDSs, “Scheduled Drugs,” or “Controlled Substances” (the terms are used inter-
changeably here) to know and to stay abreast of (1) the CDS law and regulations in
the state or other jurisdiction in which they practice and (2) the procedures and
processes of the Prescription Drug Monitoring Program (PDMP), which provides
electronic searchable databases for tracking licit CDS patients and their prescrip-
tions, in the state or other jurisdiction in which they practice. The former can be
searched in the annual update of Title 21 Code of Federal Regulations (www.fda.
gov/medical-devices/medical-device-databases/code-federal-regulations-title-21-
food-and-drugs) and the latter in the website for the PDMP Training and Technical
Assistance Center (www.pdmpassist.org).
1
A word about “CBD” (cannabidiol) is pertinent here. Cannabidiol is a phytocannabinoid plant
product related to cannabis sativa, the psychoactive and psychotomimetic compound in marijuana
and hashish. Cannabidiol is one of many such related compounds and does not itself have
psychoactive effects on consumers; is not a prescription-only medication or a Controlled Dangerous
Substance; and is widely available in pharmacies, health food stores, and through the internet. It is
touted as beneficial for a multitude of health conditions, including pain syndromes, tension and
anxiety, general malaise, anorexia, and bulimia, and others, reportedly without dependency
potential or deleterious psychiatric symptomatology. This Primer does not take a position on the
usefulness (or not) of CBD, but it does note the widespread and burgeoning popularity of this
cannabinoid and recommends further searching and researching on the part of the interested reader.
Controlled Dangerous Substances (CDS) 91
Table 5.4 The controlled dangerous substances (CDS) schedules

CDS
schedule Characterization Prescribing patterns Examples
I No accepted medical May not be prescribed at all (with Heroin, LSD, ecstasy,
use, high potential the exception of medical and others
for abuse, illegal to marijuana in some states) Marijuana (though
possess or use legalized in some
states, it is still illegal
at the federal level)
II High potential for May be prescribed only 1 month All psychostimulants,
abuse, but legal for at a time, cannot be refilled, may such as amphetamine
medical use not be called in, and patient must and methylphenidate
give the pharmacy a paper script Opiates that are
(unless using an e-prescribing especially potent, such
program that is DEA-certified, as oxycodone,
and that allows prescribing of fentanyl, and others
controlled substances) Vicodin® (hydrocodone
and acetaminophen)
was recently
rescheduled from
Schedule III to
Schedule II
III Lower potential for May be refilled up to 5 times (no Suboxone®
abuse than Schedule I more than 6 months); may be (buprenorphine/
or II, but still quite called in naloxone)
abusable Ketamine
Xyrem® (sodium
oxybate)
Anabolic steroids
Barbiturates
Dronabinol (Marinol®)
IV Lower potential for May be refilled up to 5 times (no All benzodiazepines
abuse than Schedule more than 6 months); may be (e.g., clonazepam,
III called in lorazepam, etc.)
Various hypnotics, such
as zolpidem, zaleplon,
and suvorexant
(Belsomra®)
Wake-promoting agents,
like modafinil and
armodafinil
Tramadol (Ultram®)
Carisoprodol (Soma®)
Lorcaserin (Belviq®), an
anti-obesity drug
V Lowest potential for May be refilled as many times as Pregabalin (Lyrica®)
abuse prescriber chooses (e.g., for 1 year Cough preparations with
or more); may be called in small amounts of
codeine such as
Robitussin AC®
Antidiarrheal (Lomotil®;
diphenoxylate/
atropine)
DSM-5 Considerations
Concerning DSM-5 and other characterizations of the licit and illicit chemical
dependencies, Table 5.5 presents the core clinical features of the category of psychi-
atric disorders which the DSM-5 calls “Substance Use Disorders,” or SUDs. Going
beyond the features and diagnostic criteria for SUDs in the DSM-5, Table 5.6 gives
factors affecting an individual’s response to a given drug. These factors recognize
that such responses are determined by more than the drug, or agent itself: In effect,
these factors are an application of the Epidemiologic Triangle model discussed in
Chap. 1.
Table 5.5 DSM-5 features of substance use disorders (SUDs)

“A problematic pattern of substance use leading to clinically significant impairment or distress,
as manifested by at least TWO symptoms occurring within a 12-MONTH PERIOD…”
Social impairment
Impaired control
Risky use
Neuroadaptive/withdrawal
Mild, moderate, severe (symptoms); course specific (duration)
Table 5.6 Factors affecting an individual’s responses to a drug
Pharmacology of the drug

Mental set of the drug user
Setting of the drug use
Biological vulnerability of the user
Route of administration of the drug (PO; IM; IV; IN; SC; etc.)
Co-occurring (comorbid) conditions and symptomatology of the user
Adapted from NIDA (1980s)
Medication-assisted Treatment (MAT) 93
Chemical and Behavioral Addictions
Another area of addiction medicine, or addictionology, is in the relatively recent

recognition of the non-chemical addictions, or behavioral addictions. Table 5.2
gives examples of such addictions or dependencies. In this broadened view of addic-
tions, it is significant that the only non-chemical dependency listed in the DSM-5 is
“Gambling Disorder.” Without doubt, other behavioral disorders will be given in
further iterations of the DSM. From a psychologic perspective, a common mecha-
nism of the various addictions is in the strong actions of the dopaminergic reward
system in addicts, which increases the repetitive and reinforced nature of their neu-
rologic activity along with a reduction in what translates clinically as good judg-
ment and an increase in what translates clinically as denial: “I can stop/quit any
time” and “The other guy’ll get hooked, not me.” This neurobiological commonality
between the chemical and behavioral addictions is a basis, in part, for the next topic
in this chapter, viz., Medication-assisted treatment (MAT).
Medication-assisted Treatment (MAT)
While psychopharmacotherapy is not the only approach to the treatment of addicts

and alcoholics, in one type of addiction—opioid addiction—in particular,
“medication-assisted treatment” or MAT (Table 5.3) has been shown during the
recent and ongoing opioid crisis2 to be a real life saver! Data and studies from the
federal agencies, Centers for Disease Control and Prevention (CDC) and the
National Institute on Drug Abuse (NIDA), demonstrate the effectiveness of MAT in
preventing deaths from opioid overdose and in clinically helping to stabilize
addicted individuals. As Table 5.3 shows, however, MAT can also be used in other
chemical dependencies. The actual agents used in MAT derive from several “Anti-
Agents” already discussed, including Anti-pain Agents (opioid antagonists, “block-
ers”), antihypertensives, and Antidepressant Agents. Since addicts and alcoholics
often present with myriad physical and psychiatric symptoms, and with co-occurring
(comorbid) psychiatric disorders, they will often request and/or need psychotropic
medications drawn from such “Anti-Agent” classes as antidepressants, antianxiety
agents (especially benzodiazepines), anti-manic agents, anti-insomnia agents, and
others. And since the genesis of many of addicts’ and alcoholics’ problems and
symptoms is generally from the agents that they request in those circumstances, the
free and willy-nilly prescribing of such psychotropic agents for those patients/
2
While a detailed discussion of what has been called the current “Great Opioid Crisis” is well
beyond the scope of this book, the excessive prescribing, diversion, and use of both licit and illicit
opioids, resulting in dramatic overdose mortality from 2014 to the present, has been identified as
one of most serious social and public health crises in the 2000s, on a par with the COVID-19
pandemic.
clients is not indicated. These are individuals who have to learn to cope with life’s
stressors without chemicals (i.e., psychopharmacotherapeutic agents), for the most
part, not with them. Striking a balance between MAT and other psychopharmaco-
therapy comprises both the art and science of treating addicts and alcoholics.
Treatment Settings for the Addictions: A Continuum of Care
This last point brings up the issue of the treatment setting for addicts and alcoholics.
Such settings range from outpatient counseling with a non-mental health profes-
sional (e.g., teacher, friend, priest, etc.) to medical inpatient services, with interme-
diate settings between those two poles, along with what is called a “continuum of
care” model. The ASAM (American Society of Addiction Medicine) Criteria pres-
ents a good conceptual model of this continuum. (See Table 5.7, as adapted from the
ASAM Criteria.)
A full discussion of treatment settings for the addictions, like other topics in this
book, is well beyond its scope. A particularly good reference for this topic, and
many others in this field, is the multi-authored (2018) ASAM Principles of Addiction
Medicine, Sixth Edition to which the reader is referred, along with electronic data-
bases, other books and articles, and internet sources, for further information and
details.
Table 5.7 Continuum Stage of

of care in addiction intervention Type of intervention/treatment
treatment
1 (least intense) None
2 Early intervention
3 Outpatient treatment (counseling,
psychotherapy)
4 Intensive outpatient program (IOP)
Partial hospital program (PHP)
5 Residential/inpatient programs
Low-intensity residential
High-intensity residential
6 (most intense) Medically managed intensive inpatient
program, including detoxification services
Adapted from the ASAM Criteria (2015)
Psychedelics 95
Psychedelics
Spurred on to some extent by best-selling author Michael Pollan’s How to Change

Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness,
Dying, Addiction, Depression and Transcendence (Pollan 2018) and after having
lain dormant from the 1960s until the early 2000s, clinical research and treatment
with psychedelic (classified for present purposes as “hallucinogens”) agents has
become a hot new topic in psychiatry, addiction medicine, psychology and counsel-
ing, and other areas of health care.
The history of these compounds goes back to prehistoric times, when such
psychedelic agents as psilocybin, peyote, and ayahuasca were used in rituals and
shamanistic practices by many pretechnological societies. Systematic scientific
interest and study of these agents may be traced to “Bicycle Day” (April 19, 1938),
when Dr. Albert Hoffman, a Swiss industrial chemist, ingested microdoses of
lysergic acid diethylamide (LSD) in his research laboratory, rode his bicycle, and
experienced the first documented psychedelic “trip” (it was a vivid and good one!).
Research and scientific, clinical, and sociologic interest in hallucinogens and psy-
chedelics grew over the next decades, accelerated in part by a seminal Life magazine
article in 1957 called “Seeking the Magic Mushroom” until the 1960s.
During the turbulent 1960s, counterculture “bad trips,” the ill-fated Harvard
Psilocybin Project of Dr. Timothy Leary and Dr. Richard Alpert, and the 1970
Controlled Substances Act (which placed LSD, PCP, marijuana, psilocybin, and
other hallucinogens and psychedelics into CDS Schedule I—which is still the case;
see Table 5.4—effectively making them illegal) all soured society and the scientific
community on psychedelics and led to a dearth of study, research, and optimism
about the possible role of these compounds for human well-being. An abbreviated
history of these events and others is presented in Table 5.8.
In 2006, a banner year for psychedelic research into clinical application, several
significant events occurred, marking the modern renaissance of psychedelic
research. These events are presented in Table 5.9.
As a result of these and later events and trends, scientific, societal, and clinical
interest has grown dramatically in these and other related compounds over the past
two decades, with no end in sight. Perhaps the advent of, at first, legalized medical
marijuana in many states, and legalized recreational marijuana in fewer but a grow-
ing number of states, are manifestations of this interest and trend. Psilocybin, in
particular, is the core of clinical research at two major medical centers in the United
States: Johns Hopkins Center for Psychedelic & Consciousness Research and NYU
Langone Health, among others. Studies are underway in the application of psyche-
delics (“mind-dissolving” agents also known as “entheogens,” or “generating the
divine within”)—purportedly without the abuse potential of illicit agents, if used
properly—for applications in the study and treatment of anxiety, trauma, depression,
addiction, consciousness, and the mental and emotional stresses of death and dying.
Psychedelics are back!
Table 5.8 Events in the history of psychedelics

Era: Events:
Pre-historic Psychedelic agents known to be used by pre-historic humans:
Psilocybin
Peyote
Ayahuasca
Others: Rituals; shamanic practices
1938 LSD discovered by Dr. Albert Hoffman on April 19, 1938 (henceforth known
and celebrated as “Bicycle Day”)
1950s Brain science:
“Soup v. Sparks”
Neurotransmitters, clinical applications
LSD (lysergic acid dimethylamine)
Psilocybin (“teonanacatl” or “flesh of the gods” by the Aztecs)
Psychedelics were “good.”
1957 Article appears in Life magazine: “Seeking the Magic Mushroom,” by
R. Gordon Wasson, May 13, 1957
1960s Counterculture “acid trips”
Leary and Alpert
“Turn on, tune in, drop out.”
Harvard Psilocybin Project
Psychedelics were “bad.”
1970s & Controlled Substance Act, 1970
1980s
1990s & Renaissance of:
2000s Neuroscience
Psychotherapy
“Psychonauts”
Treatment of:
Anxiety – trauma
Depression – dying
Addiction – consciousness
Organized studies:
NYU Langone Health
Johns Hopkins CPCR
Others
Psychedelics are “back.”
Table 5.9 Three significant events for psychedelics

100th anniversary, in 2018, of the birth of Albert Hoffman, Ph.D., discoverer of LSD. (“Bicycle
Day,” April 19, is celebrated annually.)
Under the Religious Freedom Restoration Act of 1993, U.S. Supreme Court allowed the
importing of ayahuasca, with DMT (CDS Schedule I) for sacramental purposes, by União do
Vegetal (UDV), a Native American religious sect.
Seminal scientific paper “Psilocybin Can Occasion Mystical-Type Experiences Having
Substantial and Sustained Personal Meaning and Spiritual Significance,” by R. Griffiths et al.
(2006). In Psychopharmacology. Springer Nature.
Evaluating and Treating Addicts and Alcoholics 97
Evaluating and Treating Addicts and Alcoholics
No essay on illicit substances and drugs would be complete without some discussion
of the “host” (in the Epidemiologic Triangle model)—the patient/client—in this
context. In that vein, rather than presenting a case as such, Table 5.10 presents
salient features and hallmarks of a paradigmatic drug-seeking patient/client. The
interviewing/examining clinician needs to be aware of these potential “con-men/
women” and able to deal with them in a calm, compassionate, but firm manner. It is
not per se illegal to be duped, but it is illegal for a prescriber to continue prescribing
to the scammer.
Table 5.10 Simulated interview: behaviors and hallmarks of the drug-seeking patient/client
1. New patient, new physician (new practice)
2. From a long distance away
3. Very well dressed
4. Late (in the day) visit, without a scheduled appointment
5. Immediately before a holiday weekend
6. Young (22–50 years old)
7. Requests specific analgesics only
8. Describes “classic” pain syndrome
9. Gives “textbook description” of a known disease
10. Behavior is quiet when nobody is looking
11. Behavior is agitated and painful when somebody is looking (the “Pain Show”)
12. Lacks involuntary autonomic features associated with pain
13. Factitious (“faked”) vital signs where possible
14. Referral patterns are vague and evasive (doesn’t name the referring physician or give
plausible reasons for the referral)
15. Ingratiating, unctuous approach to the physician (“I heard you really cared about patients
with pain.”)
16. Paranoid, guilt-provoking attitude toward the physician (“If you don’t help me, you’ll force
me to get what I need on the street.”)
17. Occupational history is vague and evasive
18. History of doctor-shopping and multiple hospitalizations (when history is obtainable)
19. Knows psychopharmacology, and CDS in particular, very well
20. Offers payment in cash for visit
21. Blaming and “conning” the physician
22. Insists on “drug of choice”
23. Refuses to submit blood or urine samples for toxicology screen (TDS)
Rather than burdening the reader with excessive and detailed references and citations
in this Primer, given below are particularly useful selected references. In addition,
other specific references and citations will be given in parentheses throughout the
Primer. For further information and details about any topics presented and discussed
in this book, the interested reader is referred not only to the following list of selected
references but also to applicable textbooks, monographs, electronic databases, print
articles and materials, internet sources, and other applicable resources.
Selected References
diagnoses.)
University Press: 2019. (A scholarly, detailed, and lengthy overview of
psychopharmacology, also covering social practice and research/methodologic
aspects of the field.)
ries, viz.
1. Refereed (“peer-reviewed;” “juried”) scientific, technical, and professional
journals, newsletters, and the like, including e-journals, e-newsletters, and other
• Journal of Clinical Psychopharmacology (peer-reviewed independent
professional journal)
• National Institute of Mental Health (NIMH) website, affiliated institutes,
programs, centers, websites, and publications (electronic and print)
• National Institute on Alcoholism and Alcohol Abuse (NIAAA) website,
affiliated institutes, programs and centers, and websites and publications
(electronic and print)
• National Institute on Drug Abuse (NIDA) website, affiliated institutes,
centers, programs and websites, and publications (electronic and print)
• Canadian Centre on Substance Abuse (CCSA), affiliated programs and
publications (electronic and print)
(NCASACU), programs, and publications (electronic and print)

include:
As a practical matter, in researching particular topics electronically in
psychopharmacology/ psychopharmacotherapy, the logical rule—as with everything
else—is to search for topic(s), keyword(s), and the like on a search engine, then to
narrow the search with entries given by the search engine. An important factor to
keep in mind here is the reliability, accuracy, and quality of the source: Sources
from (1) and (2)—above—are considered more reliable than those in (3), generally.
Those in (3), in turn, are generally considered more reliable than personal blogs,
newsletters, product websites, company websites, and the like.
Chapter 6
Botanicals, Herbals, Nutraceuticals,
and (Dietary) Supplements (“Natural
Products”)
This heterogeneous grouping of non-prescription agents called “Botanicals, Herbals,

Nutraceuticals, and (Dietary) Supplements,” or BHNSs, for present purposes does
not “fit” easily into biochemically and pharmacologically based categories: Their
commonality, for purposes of this Primer, is that they are widely available (pharma-
cies, supermarkets, health food stores, and others); have a broad range of therapeu-
tic and adverse effects; are very popular; are part of current prevalent trends in
holistic and personal healthcare lifestyles, and education (complementary and alter-
native medicine, or CAM; diet and exercise1; and the like); are almost all available
over-the-counter (OTC; see Chap. 2); are often a source of patients’/clients’ ques-
tions for their healthcare providers; and are of increasing interest to mental health
professionals and other healthcare providers for psychopharmacotherapeutic rea-
sons. These compounds are generally not regulated by the FDA, leaving the con-
sumer faced with uncertain claims by the manufacturers, and the categories of these
compounds and products overlap considerably, leaving some confusion about what
they are and what they do.
For all of these reasons, it behooves the prescribing professional to have at least
a rudimentary understanding of the nature, scope, and applications of these agents.
The purpose and intent of this chapter are to provide such an understanding.
Table 6.1 gives a broad overview of the areas of treatment in the field of
Complementary and Alternative Medicine (CAM), including more than botanicals,
herbals, nutraceuticals, and supplements. CAM is also a vast topic well beyond the
scope of this Primer; the reader is referred, in particular to: Micozzi M, editor.
Fundamentals of complementary, alternative, and integrative medicine. 6th ed.
Elsevier, Inc.; 2019 for both broad overviews and encyclopedic in-depth coverage
of this field, as well as to other texts and monographs, electronic databases, internet
sources, and the like.
1
My dentist, a very holistic and preventive practitioner herself, has told me for years that with
“…diet, exercise, tooth flossing, and not smoking, you’ll live forever…”.

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102 6 Botanicals, Herbals, Nutraceuticals, and (Dietary) Supplements (“Natural Products”)
Table 6.1 Topics in holistic health and complementary and alternative medicine (CAM)
Aromatherapy Manual therapies and bodywork
Chiropractic Massage
Diet and weight control Meditation and mindfulness practices
Essential oil therapy Naturopathy and naturopathic medicine
Exercise (for depression and cognitive decline) Clinical nutrition
Herbal medicines Osteopathic manipulative techniques
Hydration (OMT)
Light therapy (for seasonal affective disorder, or Yoga and other forms of mind/bodywork
SAD; see Chaps. 3 and 9)
Since many products in the fields of holistic health and CAM are not regulated
by the FDA or other health-related oversight agencies, questions may arise of dose
equivalents, bioavailability of active ingredients, standardization among brands,
adulterants among products, and other such concerns in what may be termed “qual-
ity control” of these very varied products. So, as a practical matter—as with making
choices among a wide variety of psychotropic agents for the same clinical indica-
tion—the most sensible practice, in my view, is for patients/clients and their con-
sulting healthcare professionals to become familiar with a narrow group of specific
non-regulated agents and then stay with that particular agent and brand (e.g., St.
John’s wort, for depression).
Focusing on the four entities presented in this chapter, Table 6.2 gives defini-
tions, examples, and uses of these entities.
6 Botanicals, Herbals, Nutraceuticals, and (Dietary) Supplements (“Natural Products”) 103
Table 6.2 Botanicals, herbals, nutraceuticals, and (dietary) supplements, including overlapping
products and applications
Topic Definition Examples Applications
Botanicals Plant products used as Gin (juniper berry), Spices, flavor
additives anise, arugula enhancement, cooking
extract, orris root,
lemon peel, baobab,
saffron
Herbals Plant products used for Evening primrose Multiple uses as
(medicinal) prevention and/or treatment oil, St. John’s wort, antioxidants, nutritional
of disease, and for Asian ginseng, supplements, vitamins,
monitoring health; also chamomile, minerals, trace elements,
called “phytomedicines” echinacea, gingko, and many others
green tea, valerian,
yohimbe, and many
others
Nutraceuticals A food or fortified food Vitamins, minerals, Nutritional
(Bioceuticals) product milk, fortified dairy supplementation and
products, cereals, disease prevention
herbals, and many
others
Supplements A manufactured product for Glucosamine Cartilage and bone health,
(dietary) adding to the diet; to correct (cartilage and bone collagen health, dietary
deficiencies and maintain health), vitamin D, deficiency states, muscle
health, either from food calcium (bone loss, bodybuilding, and
sources or synthetic health), probiotics, others (Note: FDA rules
manufacture; in pill, fish oils, and many prohibit claims for
capsule, tablet, or liquid others actually treating these
form conditions)
Concerning products of these four types of current interest to mental health prac-
titioners and providers, specifically including products which have been shown to
be effective through randomized controlled trials (RCTs, the “gold standard” for
studies of safety and efficacy)—but rarely in terms of FDA approvals. Table 6.3
gives the clinical indication of some RCT-approved products, the category of the
product, and examples of the product.
Table 6.3 Selected natural products proven effective through RCT testing
Clinical indication of the Category of the
product product Examples of the product
Depression (off-label) Vitamin (dietary L-methyl folate (Deplin®), a
supplement) “medical food” by prescription; folic
acid preparations (OTC)
Depression, PMDD, smoking Essential amino acid L-tryptophan; OTC preparations
cessation (all off-label) (dietary supplement)
Depression (unipolar, bipolar; Fatty acid (dietary Omega-3 fatty acids (fish oil); various
off-label); hypertriglyceridemia supplement) OTC preparations; Lavazza® for
(FDA-approved) hypertriglyceridemia
Depression, osteoarthritis Essential amino acid S-adenosyl-L-methionine (SAME);
cirrhosis, fatty liver disease (all (dietary supplement) various OTC preparations
off-label)
Depression, mild-to-moderate Botanical St. John’s wort; various OTC
(off-label) preparations
Depression for low vitamin D Nutraceutical (vitamin; Vitamin D; various OTC preparations
levels (off-label) dietary supplement)
Insomnia and jetlag symptoms Pineal gland hormone Pineal gland hormone, present in
(off-label) (dietary supplement) many foods; various OTC
preparations
Trichotillomania, nail biting, Semi-essential amino N-acetylcysteine (NAC); various
skin picking, OCD (all acid congener (dietary OTC preparations. Adjunctive to
off-label) supplement) SSRIs in OCD and related conditions.
A “cook’s tour” of the vast and parallel (to psychopharmacotherapy) world of

natural products can only touch on salient features of that world; that has been the
purpose of this chapter. “Take-away” messages for the reader of this Primer are:
• Do not underestimate the popularity, prevalence, and potential good that these
varied products can do for patients/clients requiring mental health professional
care and treatment,
but
• Do be aware of the largely unregulated nature and scope of these varied products
and the potential harm they can cause patients/clients from adverse and unde-
sired (“side”) effects,
and
• In that vein, do be aware that by relying on natural products to the exclusion of
psychopharmacotherapeutic agents, when indicated, some patients/clients may
not receive the benefit they need from their natural products,
and
• Do be aware, again, of the enormous popularity of these natural products and of
CAM: Patients/clients are also aware of this popularity. They will often ask their
treating mental health professionals about BHNSs, and make suggestions to
those professionals about their using these products. In other words, be fore-
warned and be prepared!
Selected References
diagnoses.)
of the field.)
ries, viz.
sional journal)
tronic and print)

include:
Part II
Therapies That May Involve
Psychopharmacology/
Chapter 7
A Selective Overview of Therapies
in Mental Health Care
Current therapies or treatment approaches and modalities in mental health care may
be broadly divided into two categories, viz., (1) “Psychotherapies” and (2) “Somatic
Therapies.” For present purposes, these modalities may be summarized as follows:
• Psychotherapies focus on verbal, psychological, and cognitive interactions and
discussion, conscious and unconscious (i.e., of which the patient/client is and is
not overtly aware, respectively), between the treating professional and the
patient/client. Theoretically, these psychotherapeutic techniques bring about
symptom relief and personal change through that interactive process, whether
didactic (i.e., counseling, and giving advice), through insight on the patient’s/
client’s part, or through behavioral techniques (i.e., using specific techniques
based on learning theory to produce specific changes in undesired and dysfunc-
tional behaviors, thereby alleviating problematic symptoms). This therapeutic
approach relies heavily on the respective roles and expectations of the treated
(“patient/client”) and the treater (“therapist”): Those roles and expectations, in
turn, are described in technical terms as “transference” on the part of the treated
and “countertransference” on the part of the treater.
• Somatic therapies, on the other hand, follow the biomedical orientation of doing
something to or putting something (e.g., psychotropic medications) into a cli-
ent’s/patient’s body (“soma,” from the Latin) in order to bring about a desired
change in that individual’s mood state, cognition, emotion or affect, mental state,
and so forth, through manipulation of the patient’s/client’s physiology. Although
a patient’s/client’s attitude and emotional condition do influence their response
to the administration of such “somatic” interventions to some extent, the primary
effect in the patient/client is intended to be the physiologic change brought about
by the somatic intervention itself and not by the transference/countertransference
effects and interactions of the patient/client and treating professional.
As a practical matter, a myriad of psychotherapies and somatic therapies exists,
some frequently and infrequently practiced. A compendium of such treatments from

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112 7 A Selective Overview of Therapies in Mental Health Care
as long ago as 1980 identified over 250 different types of psychotherapies (Herink
R. The psychotherapy handbook: the A to Z guide to more than 250 different thera-
pies used today. New American Library; 1980) and a more recent text identified 12
such therapies in general use (Corsini RJ, Wedding D, editors. Current psychothera-
pies. 6th ed. Brooks Cole; 2000).
The purpose of this volume is not to provide a detailed or comprehensive review
of all types of psychotherapies and somatic therapies. However, for present pur-
poses, the reader should be aware of the place of psychopharmacology or—in treat-
ment terminology—“pharmacotherapy/psychopharmacotherapy” in the universe of
psychiatric and psychological treatments, given the focus of this book on one par-
ticular type of somatic treatment, namely “psychopharmacology.” (See Tables 7.1
and 7.2).
Table 7.1 An overview of Non-behavioral therapies

psychotherapies
Adlerian psychotherapy
Asian psychotherapies
Couples therapy
Existential psychotherapy
Gestalt therapy
Insight-oriented/exploratory psychotherapy
Interpersonal therapy
Marital and family therapy
Multimodal therapy
Person-centered therapy
“Primal scream” therapy
Psychoanalysis
Self-help recovery group therapy such as
alcoholics anonymous (AA) and narcotics
anonymous (NA)
Supportive/relationship psychotherapy
Others
Behavioral therapies
Behavior modification
Cognitive behavioral therapy (CBT)
Dialectical behavioral therapy (DBT)
Hypnosis/hypnotherapy
Rational emotive behavior therapy
Mindfulness and meditation
Others
Table 7.2 An overview of Psychopharmacotherapy

somatic therapies
Brain stimulation therapies (electroshock
therapies)
Electroconvulsive therapy (ECT)/electroshock
therapy (EST)
Deep brain stimulation (DBS)
Transcranial magnetic stimulation (TMS)
Vagus nerve stimulation (VNS)
Magnetic seizure therapy (MST): experimental
Phototherapy/light therapy
For seasonal affective disorder syndrome (SADS):
DSM-5 specifier
Psychosurgery (brain surgery)
Coma therapies (historic)
Insulin coma therapy (ICT)/insulin shock
therapy (IST): no longer used
Analeptic (seizure inducing) therapy/Metrazol
therapy: no longer used
Selected References
diagnoses.)
114 7 A Selective Overview of Therapies in Mental Health Care

of the field.)
ries, viz.
sional journal)

tronic and print)
include:
pharmacology/ psychopharmacotherapy the logical rule—as with everything else—
Chapter 8
Psychotherapies and Counseling
In an insightful essay in The New York Times entitled “About That Mean Streak of
Yours: Psychiatry Can Only Do So Much (When Nastiness Is A Personality Trait,
Not A Sign of Mental Illness),” psychiatrist Richard A. Friedman offered the com-
ment that “It’s not fashionable in our therapy-friendly nation, where people who
behave obnoxiously are assumed to have a treatable psychiatric problem until
proven otherwise. Nothing in the human experience is beyond the power of psychia-
try to diagnose or fix, it seems.” He continues the essay by presenting several case
examples of people—patients, actually—who should be considered “bad,” not
“mad,” and concludes that “To put it another way, some medically ill patients can be
mean or bad just like anyone else, and this is not a problem for psychiatry to fix”
(Friedman R. “About That Mean Streak of Yours.” The New York Times, February
6, 2007).
For those legions of other troubled people, many different types of what current
parlance calls “mental health providers” are available to see to their needs, and
many different ways for those “providers” to accomplish that goal. Historically, one
of the earliest of those ways—after prehistoric neurosurgical techniques—was what
has variously been called “therapy,” “psychotherapy,” “talk therapy,” and “counsel-
ing.” Those types of mental health treatments are the subject of this chapter.
As described in Chap. 7 (“An Overview of Therapies in Mental Health Care”),
many different types of therapy are available to the disturbed public, far too many to
be treated in detail in this chapter. Therefore, distinguishing broadly, between “non-
behavioral” and “behavioral” (see Table 7.1) and between “individual” and “group”
psychotherapies, this chapter will present an overview of these therapies, focusing
on those used most prevalently in current mental health practice.

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118 8 Psychotherapies and Counseling
In current mental health practice, shaped and directed by such practical factors
as insurance reimbursement limitations, time limitations, non-availability in person
(due to the coronavirus social distancing as of this writing) and financial restric-
tions, many of these therapies are combined with others (such as pharmacotherapy),
in the interest of better and greater treatment outcomes and greater cost efficiency.
These so-called “combination approaches” have been mentioned in Chap. 3 and 4
and will be revisited in Chap. 13.
Non-behavioral Psychotherapies
Table 8.1 depicts a continuum going from those non-behavioral individual therapies
considered the least structured and didactic to those considered the most structured
and didactic, with examples of psychotherapies of intermediate levels of structure in
between. The following section elaborates on these individual non-behavioral
psychotherapies.
Table 8.1 Continuum Level of structure Type of psychotherapy

of non-behavioral
Least structured Psychoanalysis
individual
psychotherapies Psychodynamic (exploratory; insight-
(least structured to oriented) psychotherapy
most structured) Supportive (rational) psychotherapy
Brief short-term dynamic psychotherapy
Interpersonal psychotherapy (IPT)
Multimodal therapy
Most structured Individual counseling
Non-behavioral Psychotherapies 119
A limiting case on the unstructured end of the above continuum is classical

Freudian “psychoanalysis.” This treatment modality is derived from the discoveries
and theories of the nineteenth century intuitively regarded by most individuals as the
caricature of mental health treatment. While “rules” and “techniques” do exist in
psychoanalytic practice, the role of the psychoanalyst or analyst is much less engaged
in interactions with the patient than is the case with other psychotherapies. The psy-
choanalytic technique of “free association” (the patient/client speaks about whatever
is on their mind in as uncensored and free-flowing way as possible, with minimal
disturbance “on the couch” to the patient as possible) is the paradigmatic way in
which psychoanalysis is conducted. Through the slow and painstaking insight gained
independently by the patient/client, with periodic interpretation but little guidance by
the psychoanalyst, progress and understanding come to the patient/client—often
through frequent therapy sessions and a lengthy (years, not months) course of treat-
ment—in dealing with such psychoanalytically labeled impediments as conflicts,
resistances, and blocks. This is a slow, often difficult, expensive, and infrequently
used treatment modality, historically important as a basis, or formulation for a num-
ber of schools and practices of psychotherapy (especially non-behavioral approaches)
but not extensively used in current cost-conscious mental healthcare practices.
Variants of Freudian psychoanalysis are also practiced, such as Adlerian psycho-
therapy, Jungian analysis, Reichian analysis, and others. They all derive from the
same era (late nineteenth and early twentieth century), and all represent “schools of
thought” developed and promoted by their founders.
Somewhat more structured than psychoanalysis is “psychodynamic psychother-
apy,” also known as “exploratory psychotherapy” and “insight-oriented psychother-
apy.” Unlike the “schools” of psychoanalysis just described, psychodynamic
psychotherapy is not associated with any particular founder or author, and as a practi-
cal matter, uses many of the same principles as psychoanalysis, albeit in an adulterated
way. The use of such concepts as “transference” (the sum total of feelings and attitudes
of patients toward the therapist in the context of the therapist–patient relationship,
whether realistic or symbolic of psychological issues in the patient’s life), “counter-
transference” (the converse of transference), “resistance” (unclear and/or unconscious
reasons for a patient’s lack of progress in treatment), the “therapeutic alliance” (a posi-
tive and productive treatment relationship between the patient and the therapist which,
if not present, needs to be explored in therapy), and others derived from psychoana-
lytic principles characterizes “psychoanalytic psychotherapy.” Like psychoanalysis,
psychoanalytic psychotherapy tends to be of long term and not rigidly structured.
Next on the continuum of non-behavioral psychotherapies (Table 8.1) is “sup-
portive (relational) psychotherapy.” This approach is less intense and more struc-
tured than the two psychoanalytic approaches just discussed and involves more
direct engagement by the therapist than do the psychoanalytic and psychodynamic
approaches. The involvement of the therapist in the therapist–patient/client relation-
ship includes giving the patient/client active encouragement, counseling, and
advice, and—as the name indicates—active support and endorsement of the
patient’s/client’s needs and plans, when appropriate. (This is a very different
approach from that of the “technical neutrality” of the psychoanalyst, who serves as
an interpreter of thoughts and ideas which originate with the patient and which are
neither encouraged nor discouraged by the psychoanalyst. In that respect, another

school of non-behavioral psychotherapy entitled “person-centered therapy,” founded
and promoted by the psychologist Carl Rogers, Ph.D., also focuses almost exclu-
sively on the patient as the source of ideas and content for the therapy.)
Maintenance of appropriate boundaries and roles is important in this type of
therapy, in that, for example, if the patient/client comes to rely excessively on the
support and advice of the therapist, the patient’s/client’s autonomy could be under-
mined, and the positive effects of the therapy similarly diminished. An extreme
example of what has been called “boundary erosion” could lead to inappropriate
intimacy, and even sexual relations between the patient/client and the therapist,
originating from either party, or consensually.
Brief dynamic psychotherapy, or short-term dynamic psychotherapy, is the next
type of non-behavioral psychotherapy depicted in the continuum of Table 8.1. This
type of therapy uses the principles of psychoanalysis and dynamic psychotherapy in
a more concentrated and shorter time course than the other two approaches.
Practically speaking, a specific number (usually fewer than 25) of treatment ses-
sions is allotted, and specific treatment goals (such as overcoming a work inhibi-
tion) are articulated, with specific milestones identified to be accomplished during
the course of treatment. The focus of treatment is on more circumscribed goals than
in longer term treatment approaches. Intervention and feedback from the therapist
are more frequent, direct, and didactic than in the longer term treatment approaches.
Historically, an impetus for the development of this approach to treatment has been
economic. As a practical matter, circumscribed and time-limited psychotherapeutic
approaches have been shown to be cost-effective and efficient as measured and
determined in a variety of ways, especially in many instances, when combined with
psychopharmacotherapy (see Chap. 13 in this Primer).
Following brief dynamic psychotherapy on the continuum of Table 8.1 is interper-
sonal psychotherapy (IPT). IPT was developed in the 1990s as a practical and focused
approach at first directed toward the treatment of non-psychotic depression. IPT
addresses current psychological signs and symptoms of patient/client by linking such
symptoms to one (or more) of several aspects of depression considered important to
treatment (these are grief, role dispute, role transition, and interpersonal defects). In
directed psychotherapy sessions on a short-term basis, applicable aspects of the
patient’s/client’s depression are addressed, identified, and understood in a concrete and
straightforward way in order to enable them to cope effectively with their troublesome
symptomatology. In focusing on signs and symptoms in a “here and now” way; in not
focusing on psychodynamic and historical potential “causes” of depressive symptom-
atology; and in using a structured and time-limited approach, IPT is similar to the
focused approach which characterizes the behavioral psychotherapies, described below.
Multimodal therapy is a broad-based, systematic, and structured approach to psy-
chotherapy which uses a wide variety of techniques and methods, to address both the
multiple problems and problem areas of a given patient with multiple modalities
(hence, the term multimodal). The acronym BASIC ID (which stands for Behavior,
Affect, Sensation, Imagery, Cognitive, Interpersonal Relationships, and Drugs/Biology,
including nutrition, hygiene, and exercise) conveys the broad range of assessment and
intervention in multimodal therapy. As the next position in the continuum of Table 8.1,
Non-behavioral Psychotherapies 121
multimodal therapy is both highly structured and short-term. It is intended to address

the many symptoms and problem areas found in many mental health patients, regard-
less of the patient’s/client’s specific underlying psychiatric diagnosis.
Finally, the most structured and didactic type of psychotherapy presented in
Table 8.1 is called “individual counseling.” Although that particular term may be
used in a variety of ways in the various mental health professions, its use here is
intended to convey the notion that “counseling” involves the didactic giving of
advice (“counsel”) from the informed and experienced mental health professional to
the uninformed (or less informed) and inexperienced (or less experienced) patient/
client. This process necessarily has less interactive give and take between counselor
and patient than do other psychotherapies, even though a therapist–patient/client
relationship exists, and such phenomena as role, role expectation, transference, and
countertransference also exist in this type of non-behavioral psychotherapy.
In this discussion of non-behavioral therapies, so far, I have dealt only with indi-
vidual psychotherapies. To complete this part of this chapter without going into
unnecessary detail, I will conclude this section of this chapter with a discussion of
therapies involving more than one individual at a time, specifically couples therapy,
group therapy, and marriage and family therapy.
Starting with couples therapy, this modality and that of marriage and family ther-
apy should be of considerable interest to the family or primary care-oriented practi-
tioner. This is so because referrals of patients/clients for that type of treatment as
well as evaluations by mental health professionals in those disciplines often consti-
tute a significant focus of attention for those practitioners. Couples therapy—which
may be defined as “…a format of intervention involving both members of a dyad, in
which the focus of intervention is the problematic irrational patterns of the cou-
ple…” (Retvo et al. Couples and family therapy. In Hales RE, editor. The APP
textbook of psychiatry. 5th ed. APP, Inc.; 2008)—is generally short-term, focused
on dysfunctional aspects of the relationship between the couple (such as poor com-
munication), and practical, in the sense of attempting to help the troubled couple
deal with concrete problems. It is worth noting that with changing cultural mores,
the term “couple” no longer necessarily refers to a paired relationship between a
man and a woman of about the same age and of the same sociocultural and ethnic
background. In this age of easing sociocultural and ethnic constraints, and incredi-
bly rapid and broad electronic communication (instant messaging, texting, emailing,
social networking, relationship websites, computer dating, and so forth), “coupling”
can occur in an incredible variety of ways, with a potentially wide array of problems.
Conceptually, family therapy and couples therapy are similar endeavors, with
individuals beyond the basic dyad—parents, children, and members of the dyad’s
extended family—included in therapy, to the extent that they contribute to family
problems or to what is known in the field as “family pathology.” Similar issues of
poor communication, poor support, and connections among families and couples,
dysfunctional problem-solving, sexual problems, different approaches to family and
couples conflicts, and the like, are addressed in this type of psychotherapy.
Group therapy in concept is similar to couples therapy and marriage and family
therapy, in that the focus is on more than one person. In the case of group therapy, the
members of the therapeutic group go beyond intimates (couples therapy) and family
members (marriage and family therapy) to include individuals who start out as strang-
ers and whose initial common bond is membership in the group. Group settings in
non-therapeutic settings—work, school, clubs, professional societies, and so forth—
are ubiquitous, and although not always the case, membership in a cohesive and sup-
portive group can be very invigorating and enhancing for its members. Therapeutic
groups, or “support groups” in medical contexts, take advantage of this closeness and
have been shown over the years to help their members succeed and do well in life, even
in such non-psychological, medical, and somatic areas as increased breast cancer sur-
vival, increased malignant melanoma survival, and other types of cancer survival. A
variety of therapeutic groups is found in inpatient, outpatient, partial hospital, and other
treatment settings, involving patients (i.e., group members) with a wide array of psychi-
atric diagnoses and the full range of levels of impairment, or symptomatology (i.e.,
from fully functional—the “worried well”—to the overly and fully psychotic and dys-
functional). The core approaches to group psychotherapy in all of these types of groups
involve support and positive regard for the group and its members, attitudes of accep-
tance toward group members, cohesiveness of the group, encouragement by members
for other members to participate in the group process, and willingness of the members
to change as a result of that learning, among many other such features.
In this vein, although I will not discuss the effectiveness of a wide range and
variety of non-professionally led or supervised therapeutic groups—known as “self-
help” groups, or “recovery” groups, such as Alcoholics Anonymous (AA), Gamblers
Anonymous (GA), Narcotics Anonymous (NA), Sexaholics Anonymous (SA),
Parents Without Partners, Compassionate Friends, Overeaters Anonymous (OA),
and many others—I emphasize and endorse their widespread availability, low or
non-existent cost, and widespread community acceptance, especially in the addic-
tive orders (see Chap. 5 in this Primer). The group therapy principles of cohesive-
ness, a common goal, acceptance of the group, willingness to learn from the group,
and many other such features also apply to these self-help groups.
I reiterate—a point made in Table 7.1 of Chap. 7 in this book—that schools and
modalities of psychotherapeutic treatment, non-behavioral and behavioral alike, are
numerous and that a detailed discussion of them is well beyond the scope and scale
of this book. For further information and details, the interested reader is referred to
applicable articles, electronic databases, internet references, textbooks, mono-
graphs, and the like in these areas.
Behavioral Psychotherapies
As is the case with non-behavioral psychotherapies, the behavioral therapies come

in a wide variety and range of types. In this section, I will focus on a selected set of
behavioral therapies, as listed in Table 8.2. As with the non-behavioral psychothera-
pies, a full discussion of behavioral psychotherapies is well beyond the nature and
scope of this book. To research this topic further, the interested reader is also referred
to applicable articles, electronic databases, internet references, textbooks, mono-
graphs, and the like in these areas.
Behavioral Therapy (Generally) 123
Table 8.2 Behavioral Behavior (modification) therapy

therapies Rational emotive behavior therapy (REBT)
Cognitive behavioral therapy (CBT)
Dialectical behavioral therapy (DBT)
Hypnosis/hypnotherapy
Eye movement desensitization and reprocessing (EMDR)
Mindfulness and meditation
Metacognitive therapy
Many others
Behavioral Therapy (Generally)
The common thread of behavioral therapies is the root of their treatment techniques
in psychological learning theory, including the “classical conditioning” paradigm of
the nineteenth century Russian physiologist, Ivan Pavlov and the twentieth-century
“operant conditioning” paradigm of the American psychologist, Burroughs F. (B.F.)
Skinner, and other approaches containing features of both. In these paradigms, the
effect of stimulating the organism (the patient/client or person, or “black box,” for
present purposes) is paramount, without the need for a detailed (or psychodynamic,
for present purposes) understanding of what happens in the “black box.” The
“organism” somehow processes stimuli, receiving them and turning them into pre-
dictable, measurable, and productive responses and behaviors. The behavior is
“modified” without the strong need to “understand” it on a psychological or neuro-
biological level.
According to both classical and operant conditioning paradigms, specific changes
in the initial stimulation subsequent “reinforcers” (reinforcing stimuli), whether
introduced from outside the organism or from within the organism, can shape sub-
sequent behaviors in the organism in desirable ways, if properly done.
An example of classical, or Pavlovian, conditioning is the temporal pairing of an
unconditioned stimulus (meat powder, which will cause a dog to salivate reflexively,
without any previous training) with a conditioning stimulus (the ring of a bell,
which will not cause a dog to salivate, but is the stimulus which is to become an
unconditioned stimulus in this experimental model): Given the right timing and
intensity (of the two stimuli) factors, the conditioning stimulus will link with the
unconditioned stimulus, cause the dog to salivate, become interchangeable with the
unconditional stimulus, and eventually replace the unconditioned stimulus
altogether.
An example of operant, or Skinnerian conditioning of clinical mental health
significance, is the organism’s substitution through therapy and training of posi-
tively reinforcing internal stimuli for negative such stimuli, with resulting positive
effect, clinical improvement, and reduction of negative psychological signs and
symptoms. In a clinical application, Dr. Martin Seligman’s concept of “learned
helplessness” which “…postulates that past experiences of real helplessness imbue
the individual with the connection that future unpleasant situations will also be
uncontrollable, and therefore, such situations are responded to by passivity, resig-

nation, and depressive acceptance…” (Corsini RJ, Wedding D, editors. Current
psychotherapies. 6th ed. Brooks Cole; 2000) is a good example of both classical
and operant behavioral models. The substitution of positive—not helpless—per-
cepts for these “…past experiences of real helplessness…” in a conscious, aware,
and behavioral way enables the patient/client or person, to “unlearn” these negative
percepts, and in conditioning parlance, to lessen the strength between the associa-
tions connecting the stimuli with responses. The depression, anxiety, fear (or other
such impairing symptomatology) is lessened or even eliminated, and the patient/
client feels better. In an applied clinical setting, treatment approaches using this
model are broadly called behavioral therapy. Three specific historical schools of
thoughts in these approaches (now subsumed under the broader school of “cogni-
tive behavior therapy,” or CBT, as discussed next) were called “applied behavior
analysis,” “neo-behaviorist meditational stimulus-response model,” and “social-
cognitive theory.”
Rational-Emotive Behavior Therapy (REBT)
Historically, an important school of personality theory and behavioral psychother-

apy is called rational-emotive behavior therapy, or REBT, developed by clinical
psychologist, Albert Ellis, Ph.D., in the 1950s. Now subsumed by more current
approaches in behavioral psychotherapies (especially CBT), the contribution
brought to behavioral psychotherapy by REBT uses the assertion that (1) an indi-
vidual’s underlying belief system—rational or not—is an important determinant to
their behavioral reaction, or response to a stimulus, on the one hand, and conversely
that (2) this belief system is an important determinant to how that individual permits
themselves to handle therapy. In Ellis’ words:
…when a highly charged emotion consequence follows a significant activity event (A),
event A may seem to, but actually does not, cause C. Instead, emotional consequences are
largely created by B—the individual’s belief system. When an undesirable emotional con-
sequence occurs, such as severe anxiety, this usually involves the person’s irrational
beliefs, and when these beliefs are effectively disputed (at point D), by challenging them
rationally and behaviorally, the disturbed consequences are reduced. (Ellis A. Rational
emotive therapy. In Corsini RJ, Wedding D, editors. Current psychotherapies. 6th ed.
Brooks Cole; 2000)
Practically speaking, REBT is an eclectic type of behavioral therapy, using

counseling, role-playing, desensitization, support, suggestion, assertiveness train-
ing, and other such techniques in a therapy described as similar to cognitive behav-
ior therapy.
Cognitive Behavior Therapy 125
Cognitive Behavior Therapy
Currently, cognitive behavior therapy (CBT) is probably the most widely practiced
form of all behavioral psychotherapies. CBT derives from the work of psychiatrist
Aaron Beck, M.D. and his colleagues at the University of Pennsylvania, beginning
in the 1960s. As described by Beck and his colleagues, this “…cognitive model for
psychotherapy is grounded on the theory that there are characteristic errors in infor-
mation processing in psychiatric disorders, and that these alterations in thought pro-
cesses are closely linked to emotional reactions and dysfunctional behavior
patterns…” (Wright JH, et al. Cognitive therapy. In Hales RE, et al., editors. The
American Psychiatric Publishing textbook of psychiatry. APP, Inc.; 2008). Originally
formulated as treatment for depression, CBT has been extended over the years to
treat anxiety and panic disorders, phobias, psychoses, personality disorders, sub-
stance abuse disorders, eating disorders, bipolar disorders, and psychiatric symp-
tomatology (such as anxiety and depression) secondary to a wide variety of medical
conditions. A course of CBT starts with an interactive and problem-solving collabo-
ration between the patient and the therapist, in which negative percepts, stimulus
blocks to the patient’s well-being and self-image, interpersonal conflicts, and other
such problems and problem areas are identified (such “automatic thoughts” like “I
always freeze in a new social situation,” or “I can never please my partner”); made
explicit (through concrete and explicit assignments, such as keeping a log or com-
pleting a workbook); and systematically altered through various (cognitive) exer-
cises, active intervention and assistance by the therapist, and what has been called
“collaborative empiricism” in the therapist–patient relationship. CBT is usually a
short-term type of treatment, with concrete and specific goals identified, and behav-
ioral treatment approaches applied, and with follow-up and “booster” courses of
treatment as necessary, especially for patients with longstanding chronic conditions.
As with a number of other types of therapy, CBT is “manual-based,” with protocols,
algorithms, instructions, and other such structured devices included in print and
electronic instruction manuals for this therapy.
As a paradigm of behavioral approaches focusing on the “black box” of the
patient and on practical goals and results of treatment, CBT has become popular and
prevalent in a variety of mental health professions; has been extensively researched
over the years and shown to be effective for many patients/clients; and is widely
taught and practiced in many different mental health settings, both explicitly and as
a treatment model for eclectic approaches to mental health treatment, often in com-
bination with psychopharmacotherapy (see Chap. 13).
A variant of CBT which addresses a major public health problem—insomnia
(see Chap. 4: “Anti-insomnia Agents”)—is called cognitive behavior therapy for
insomnia, or CBT-I. Using the principles of CBT (e.g., cognitive restructuring and
psychoeducation) to start, this approach is considered a multicomponent type of
treatment, in that in addition to CBT, it uses such additional sleep-inducing and
sleep-maintaining techniques as stimulus (light, noise, ambient room temperature)
control; sleep hygiene; sleep restricting and structuring (e.g., fixed bedtimes and
wake-up times); relaxation training (e.g., breathing exercises); progressive muscle

relaxation; autogenic training; biofeedback; hypnosis (see below, this chapter),
meditation (see below, this chapter), and homework (e.g., using a sleep diary, for
feedback).
For present purposes and for the reader of this book, CTB-I is generally a short-
term (6-8 treatment sessions) and effective treatment modality not requiring “Anti-
insomnia Agents” (Chap. 4) for primary insomnia (i.e., not a symptom of an
underlying psychotic disorder such as anxiety or PTSD, sometimes requiring its
own psychopharmacotherapy), which often can be administered by primary care
professionals, without the need for referral to sleep medicine specialists.
Dialectical Behavior Therapy
Also classified as a brief psychotherapy, dialectical behavior therapy, or DBT, was

developed by psychologist Marsha Linehan, Ph.D. in the early 1990s as a short-
term, focused, and intense way to treat seriously troubled and difficult patients/cli-
ents (among others). Such patients/clients may include those with borderline
personality disorder (see Chap. 2), suicidal patients/clients, patients/clients with
addictions, impulsive patients/clients, and others. This approach uses short-term
(brief), sequential interventions in an accepting therapeutic environment, in which
the therapist, as a practical matter, endorses positive and productive behaviors, atti-
tudes and beliefs, but discourages negative ones in a didactic and instructive way, as
well as in an interactive (“dialectical”) way. In the second edition of What Works for
Whom? (Roth A, Fonagy P. Guilford Press; 2006) the authors report that DBT is
more effective in modifying dysfunctional behaviors than in changing more global
aspects of functioning, such as interpersonal relationships. This finding is expect-
able in a behaviorally-oriented, goal-directed, and short-term-focused behavioral
therapy geared toward modifying, or changing, specific identified behaviors.
Hypnosis and Hypnotherapy
Hypnosis and hypnotherapy probably have the most colorful and intriguing history
of any school or type of psychotherapy, embodying both pre-scientific study and
applications (such as “animal magnetism,” Mesmerism, and parlor tricks—which
still find spellbound crowds of observers at parties and other such events) and scien-
tific applications. The mid-nineteenth century interest in states of split conscious-
ness led to the systematic study of sleep and somnambulism (Zilboorg G, Henry
G. A history of medical psychology. W.W. Norton and Company; 1941) by such
iconic clinicians as Jean-Martin Charcot, Pierre Janet, Hippolyte Bernheim, and
Sigmund Freud. These individuals used hypnosis as a means of studying these
Eye Movement Desensitization and Reprocessing (EMDR) 127
conditions, which later evolved to one of the two broad present-day applications of
hypnosis, viz., diagnostic interviewing.
Currently, the two major areas of use of hypnosis/hypnotherapy in mental health
are in diagnosis and therapy. In the latter applications, hypnosis/hypnotherapy may
be considered the most structured and directed of the behavioral therapies in the list
of Behavioral Psychotherapies in Table 8.2 (above). However, from the legal per-
spective (see Part III of this book), as a subset of the former diagnostic application
of hypnosis—specifically in the forensic application of the hypnotic interview in
detecting truth—the interest of the legal profession requires some knowledge of this
intriguing subject.
Going back to 1896—the year of the first admission of hypnotic testimony as
evidence in a court proceeding (Gravitz MA. First Admission (1846) of Hypnotic
Testimony in Court. In American Journal of Clinical Hypnosis. American Society of
Clinical Hypnosis; 2002)—hypnosis in the court room has fascinated onlookers,
even though, generally, courts have been uniformly unwilling to admit the testi-
mony of a person hypnotized while testifying. Requirements vary among venues
about the circumstances and conditions under which information obtained under
hypnosis may be admitted as evidence and how that information may be used in
court proceedings: It behooves the legal practitioner to be familiar with these
requirements in the venue in which such information might be used. However, from
the clinical perspective, recent guidelines (Maldonado J, Spiegel D. Dissociative
disorders. In Hales RE, et al., editors. The American Psychiatric Publishing text-
book of psychiatry. APP, Inc.; 2008) suggest that a series of 17 detailed steps be
followed by clinicians doing forensic hypnotic evaluations to be certain that proper
clinical, ethical, and legal practices are observed. These requirements include
obtaining the evaluee’s informed consent, maintaining neutrality (not advocacy)
during the evaluation, measuring the prospective subject’s hypnotizability objec-
tively, video recording all hypnotically-involved interactions, clarifying with eval-
uees the nature and scope of their expectations from hypnosis and others.
Advocacy and other such forensic/legal topics of interest to the mental health
professional and the legal professional are discussed in Part III.
Eye Movement Desensitization and Reprocessing (EMDR)
Eye Movement Desensitization and Reprocessing (EMDR) is a behaviorally-

oriented type of psychotherapy first developed by Francine Shapiro, Ph.D., a psy-
chologist, in 1987, especially intended for and endorsed for the treatment of
symptoms of post-traumatic stress disorder (PTSD: see Chaps. 1 and 2, and the
DSM-5), along with other such exposure-based modalities as exposure therapy,
trauma-focused cognitive behavior therapy, and others. The traumatic symptom-
atology to be treated by PTSD include anxiety (in this context, in earlier iterations
of the DSM, PTSD was categorized as a subtype of anxiety disorder, not as a cate-
gory of its own: “Trauma and stressor-related disorders;” see Chap. 1), depression,
hypervigilance, avoidance (of the traumatic stressor environment), recurring night-

mares of the traumatic event, flashbacks of the traumatic event, psychic numbing,
feelings of detachment from others, generalized lack of interest, hypervigilance,
dyssomnia, difficulty concentrating, irritability, guilt or shame, and others.
The technique of EMDR involves multiple structured treatment sessions with a
trained EMDR therapist in which the patient/client focuses on the traumatic stimu-
lus memory while simultaneously being exposed to a mental stimulus (eye move-
ments, with EMDR) while through an unknown mechanism is associated with a
dulling of the emotional impact and symptomatology of the memory of the trau-
matic stimulus. This treatment modality and its apparently adaptive “reprocessing”
of negative and emotionally destructive traumatic memories is widely used in work
with trauma victims, along with other similar modalities, including psychopharma-
cotherapy (currently, SSRIs and minipres [Prazosin®]: Sertraline [Zoloft®] and
paroxetine [Paxil®] are FDA-approved for use with PTSD, and other SSRIs are also
used, all to treat the target depression-related symptoms of PTSD; minipres
[Prazosin®], an antihypertensive, is used off-label for nightmares in PTSD; see
Chap. 4, “Anti-trauma Agents”), and combination therapies.
Mindfulness and Meditation
No discussion of psychotherapies would be complete without mindfulness and

meditation. These techniques, known and practiced for hundreds of years if not
longer, have become extremely popular in about the past 30 to 40 years, along with
public enthusiasm about self-help, holistic health care, “patients/clients as consum-
ers,” patient/client autonomy, and other such trends (see Chap. 6). “Mindfulness,”
defined by one of its main spokespersons and proponents, Jon Kabat-Zinn, Ph.D., as
“…paying attention in a particular way: on purpose, in the present moment and non-
judgmentally…” (Williams ME. Why every mind needs mindfulness. In TIME
Special Edition: Mindfulness, The New Science of Health and Happiness. Time,
Inc.; April 2017) describes a state of mind, attitude, and approach to life’s problems.
“Meditation” is a technique—or more correctly, a number of techniques—which
helps the meditator to achieve a state of mindfulness. An important work in the “his-
tory” of Western meditation is Dr. Herbert Benson’s (1974) The Relaxation
Response, First Edition: As an academic cardiologist adept in applying meditation
techniques to his practice, the popularity of Dr. Benson’s book lent credibility to
meditation and mindfulness in medical circles and established the effectiveness of
these techniques in medical care for a wide range of conditions.
From the patient’s/client’s perspective, these techniques are without adverse
(“side”) effects, inexpensive, readily available, and even enjoyable. A full review of
the types and techniques of mindfulness and meditations is beyond the scope of this
brief review, and the interested reader is referred to myriad textbooks, articles, elec-
tronic databases, internet sources, and the like for further information and details
about these prevalent, useful, and healthy practice.
Psychotherapy and Counseling During the COVID Pandemic 129
Metacognitive Therapy
In the early 1990s, a type of behavioral therapy called “metacognitive therapy”

(from the Greek: “meta,” or “beyond;” and the Latin: “cognoscere,” or “to think”)
was developed, focusing on how individuals think in contrast to what they feel. In
that sense, this approach to psychological treatment was analogous to Seligman’s
“learned helplessness model of depression,” in which the pattern or mechanism of
depressed individual’s thinking (i.e., “how they got there”) took precedence over the
depression symptomatology itself and lent itself to behavior intervention.
Similarly, the process of “catastrophizing” (i.e., “making a mountain out of a
molehill,” or “anticipating the worst”) also applies to metacognitive therapy as the
way for an affected individual to develop secondary concerns and defenses. In the
case of anxiety, for example, such an individual may be worried that their worry will
spin out of control and that they will “worry about worrying” to the point of psycho-
logical paralysis.
Enter metacognitive therapy: By offering patients/clients structured, task-
oriented, practical, and concrete (i.e., behavioral) activities, such individuals are, in
effect, distracted from their symptomatology (e.g., anxiety or depression) and
diverted to focus on the activity, or task of their metacognitive therapy. Then, in
theory, over time, the goal-directed and practical thinking (and its assorted lack of
serious symptomatology) prevails, and takes over the affected individual’s psyche,
going forward.
While the above gives a very brief summary of metacognitive therapy, it is no
substitute for a careful review of the literature, print sources, internet resources,
consultation with practitioners, and the like, for the interested reader.
Psychotherapy and Counseling During the COVID Pandemic
The New York Times Sunday Review on October 25, 2020—during the early onset of
the second wave of the pandemic in the United States—carried the following excerpt
from an editorial by columnist Nicholas Kristof covering the mental health impact
of the SARS-CoV-2 (or COVID-19) pandemic:
...More than 40% of adults reported in June [2020] that they were struggling with mental
health, and 13% have begun or increased substance abuse, a CDC study found. More than
one-quarter of young adults said they have seriously contemplated suicide.... (Kristof
N. America and the Virus: ‘A Colossal Failure of Leadership.’ In The New York Times.
2020, October 22. https://www.nytimes.com/2020/10/22/opinion/sunday/coronavirus-
united-states.html).
Without taking a deeper dive into the epidemiologic and clinical aspects of what
is likely the most overwhelming biopsychosocial event in all our lifetimes, these
data underscore that healthcare providers of all types are being and will continue to
be called upon to minister to the needs of many of those currently impacted by the
pandemic. This necessity will likely continue for many months to come, virtually
(i.e., via telemedicine and teletherapy) and/or live, and with psychopharmacother-
apy and/or counseling/psychotherapy.
Concerning pandemic-related psychotherapy and counseling, Osna Haller,
Ph.D., a clinical psychologist and psychoanalyst (see section “Non-behavioral
Psychotherapies”) articulated three approaches to this public health issue in a recent
guest lecture on October 22, 2020 given to physician assistant students attending the
author’s psychiatry course at Seton Hall University:
• Recognize and accept the varied and far-reaching effects of the COVID pan-
demic on the mental health of the entire population of the world.
• In psychotherapy and counseling, recognize and accept the resiliency of people
in coping with stressors of the pandemic and incorporate that resiliency into
treatment.
• As in any clinical situation, evaluate the patient’s/client’s therapeutic needs and
conduct treatment accordingly, with (for example) modalities described in this
chapter, and/or with clinically indicated psychopharmacotherapy. (Haller,
O. Psychotherapy and Counseling during the COVID Pandemic. Unpublished
lecture. October 22, 2020).
In a phrase often seen and heard since the pandemic began, “We’re all in this
together.” The mental and physical damage which the pandemic has and will con-
tinue to wreak on all of us will continue to require the creative and hard work of
healthcare professionals of all types for many individuals for a long time into
the future.
Selected References

diagnoses.)
of the field.)
ries, viz.

sional journal)
tronic and print)
include:
Chapter 9
Somatic Therapies (Somatotherapies)
As described in the introductory chapter (Chap. 7, “An Overview of Therapies in

Mental Health Care”) to this part of this Primer, the common thread of somatic
therapies is the notion of doing something (necessarily non-pharmacologic) to a
patient’s/client’s body (“soma”), usually the brain, to bring about a lessening or
amelioration of undesirable symptomatology (for present purposes, to “anti” unde-
sired signs and symptoms), through manipulation of the patient’s/client’s physiol-
ogy. In that sense, psychopharmacology/psychopharmacotherapy is considered one
type of somatic therapy. Current terms used to describe these therapies include neu-
romodulation, brain stimulation techniques and recently electroceutical therapies,
and neuropharmacologic somatic treatments.
Going back many years, other types of somatic therapies have been used. These
include outmoded and outdated approaches (such as analeptic/seizure-inducing, or
Metrazol® therapy; insulin shock therapy; dental and general surgical extraction;
hemodialysis; and others).
Current such somatotherapies include the longstanding effective modality of sei-
zure induction through electrical stimulation of the brain (electroconvulsive/electro-
shock therapy or ECT/EST); more recent variants of electrical and magnetic
stimulation techniques (transcranial magnetic stimulation, or TMS, and repetitive
TMS, or rTMS; vagal nerve stimulation, or VNS; and deep brain stimulation, or
DBS); and even more recent experimental variants of these approaches (for exam-
ples: magnetic seizure therapy, or MST; transcutaneous electrical nerve stimulation
(TENS), light therapy (phototherapy); and focal electrically administered seizure
therapy, or FEAST). Table 9.1 summarizes these different therapies and their clini-
cal indications.

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134 9 Somatic Therapies (Somatotherapies)
Table 9.1 Summary of somatic therapies (other than psychopharmacotherapy)

Therapy Clinical indication(s)
Electroconvulsive/electroshock therapy (ECT/EST) Depression, mania, catatonia
Transcranial magnetic stimulation (TMS); repetitive Depression
transcranial magnetic stimulation (rTMS)
Vagus nerve stimulation (VNS) Treatment-resistant depression
Deep brain stimulation (DBS) Treatment-resistant depression,
Parkinson’s disease, PTSD
Magnetic seizure therapy (MST) Depression (experimental)
Focal electrically administered seizure therapy (FEAST) Depression (experimental)
Transcranial direct current stimulation (tDCS) Depression; substance abuse
(experimental)
Transcutaneous electrical nerve stimulation (TENS) Peripheral nerve pain relief
Without reiterating details of clinical indications, methodology and techniques,

treatment outcome measures, and the like for these various somatic therapy modali-
ties, several common features apply to all of them:
1. They recognize that the brain (and the central nervous system or CNS) is an
electro-chemical body organ, that electrical impulse conduction is the core basis
and function of the CNS, and that it operates by influencing this conduction.
2. The concomitant growth and development of neuroimaging techniques (e.g.,
neurosurgical placement of DBS electrodes) have contributed to a better scien-
tific understanding of the mechanism of action of the therapies.
3. These therapies are usually used in conjunction with other therapies (e.g., psy-
chopharmacotherapy in treating treatment-resistant depression) as supplemen-
tary treatments and not alone, sometimes providing synergistic interactive effects
and dramatic patient/client clinical improvement.
Since this present Primer is not intended to be a comprehensive or detailed com-
pendium of its subject matter, the reader is referred to works given in the Selected
References for this chapter, as well as applicable monographs, books, articles, elec-
tronic databases, and current internet sources, for further information and details
about somatic therapies.
Selected References
diagnoses.)
of the field.)
136 9 Somatic Therapies (Somatotherapies)
ries, viz.
sional journal)
tronic and print)
include:

Part III
Forensic and Legal Applications of
Psychopharmacology/
Chapter 10
Overview
For practicing attorneys, law professors, paralegals, and other legal professionals—
regardless of their work and specialties—properties and effects of “licit” (legiti-
mately prescribed by medical providers) and “street” (illicit substances or prescribed
medications diverted from their intended use) psychotropic agents may be relevant
to clients with psychiatric backgrounds and histories, to an understanding of clients’
mental states at different periods of time, and to clients’ ability to work with counsel
in a variety of ways. Table 10.1 presents a broad overview of these potential applica-
tions of psychopharmacology to the law.
To be more specific and to flesh out the extent to which psychopharmacology
figures in the law, a computer-based LexisNexis® Academic search, restricted to
10 years (1999–2009), of approximately 31,000 reported appellate cases in federal
and state jurisdictions1 of those cases, revealed a large number—about 6200, or
approximately 20% of the 31,000—in which psychopharmacologic drugs and med-
ications (as discussed in this Primer) are mentioned. Further research then revealed
that of those approximately 6200 cases, 670—or about 11%—involved psychophar-
macologic issues and concerns as important and significant elements of the case.
Using these data and this information, Table 10.2 gives a frequency distribution
for these reported cases of psychopharmacologic mentions according to the area of
the law in which they occur.
1
The bulk of the material in this chapter is drawn from an unpublished survey on “Applications of
Psychopharmacology in the Law.” Thanks go to Jeffrey Harris, Esquire, who conducted a good
deal of the research for this survey.

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142 10 Overview
Table 10.1 Applications of psychopharmacology to the law: an overview of reported cases by

area of law
Area of the law Applications and examples
Civil law
Professional liability Misrepresenting psychotropic medications
Personal injury Psychiatric/neuropsychiatric damages (treatment aspects)
Product liability (medications) Celebrex®; Fen-Fen® litigation
Employment law Psychiatric/neuropsychiatric damages (treatment aspects)
Toxic torts Psychiatric/neuropsychiatric damages (treatment aspects)
Mental health law Psychiatric/neuropsychiatric damages (treatment aspects)
Regulatory law Civil commitment (psychiatric patients and sexually violent
predators/sexually dangerous persons); treatment issues
Testamentary/estate law Competency to participate in bankruptcy preparation and
proceedings
Other Will contests (caveat proceedings)
Criminal law
Psychiatric defenses Legal insanity; diminished capacity (e.g., “Prozac® Defense”);
intoxication; irresistible impulse; passion-provocation
(mitigation)
Competency to proceed to Effects of psychotropic medications (e.g., “chemical sanity”)
trial; “Miranda” competency
Others
Family law Effects of illicit drugs or psychotropic medications on children,
adolescents, and adults
10 Overview 143
Table 10.2 Frequency distribution of reported cases by area of law

Anti- Illicit Botanical, herbal, nutraceutical, and
Area of law agent substance (dietary) supplement agent
Bankruptcy 1 0 1
Civil competency 5 0 0
Consumer fraud 1 0 8
Constitutional law/civil 20 11 6
rights
Contract law (including 13 1 1
health coverage)
Copyright/intellectual 27 4 5
property/patent law
Criminal law 43 88 5
Defamation 0 2 0
Disability law (including 73 8 1
Social Security)
Education law 5 1 0
False advertising 26 2 2
Family law 0 0 5
Mental health law 33 10 1
Negligence law 11 0 0
Personal injury 13 0 1
Product liability 9 4 6
Professional liability 57 0 8
Professional liability: 53 4 1
malpractice
Regulation/administration 11 7 0
Unfair competition 0 0 3
Will contest (caveat 11 0 3
proceeding)
Workers compensation 0 3 0
Conversely, Tables 10.3, 10.4, and 10.5 give frequency distributions for these
reported cases of areas of the law according to the three broad categories of psycho-
pharmacologic medications or drugs in which they occur:
• The “anti” class of medications (Table 10.3);
• Illicit drugs (Table 10.4); and.
• Botanical, herbal, nutraceutical, and (dietary) supplements agents (Table 10.5).
144 10 Overview
Table 10.3 Frequency distribution of Anti-addiction 89

reported cases by “anti” class of
Anti-anxiety 67
medication, high to low order
Anti-depressant 67
Anti-psychotic 67
Anti-ADHD 36
Anti-pain (including fibromyalgia) 25
Anti-insomnia 22
Anti-appetite 19
Antiparkinsonian 17
Anti-convulsant 12
Anti-dementia 11
Anti-obsessive 9
Anti-sex 9
Anti-impotence 8
Anti-manic 8
Anti-pain 5
Anti-aggression 0
From a survey of “Anti-agents” using an ear-
lier classification system
Table 10.4 Frequency Stimulants

distribution of reported cases
Cocaine 14
by type of illicit drug
Amphetamines/methamphetamines 21
Depressants
Heroin 14
Opioids 16
Hallucinogens
Marijuana/hashish 25
LSD 10
Mescaline 17
MDMA 13
PCP/ketamine 32
Ecstasy 12
Table 10.5 Frequency distribution of reported cases by type of botanical, herbal, nutraceutical, or
(dietary) supplement agent, high to low order
Green tea 7 Kava kava 2
Aloe vera 5 Psyllium 2
Capsicum 5 Stevia 2
Ephedra (ma huang) 5 Arnica 1
Lycopene 5 Black cohosh 1
Magnesium 5 CoQ10 1
St. John’s wort 5 Echinacea 1
Chamomile 4 Evening primrose 1
Lecithin 3 5-methylfolate 1
Milk thistle 3 Garlic 1
Fatty acid 3 Gotu kola 1
Selenium 3 Lemon balm 1
Siberian ginseng 3 Passion flower 1
Cranberry 2 Senna 1
Dong quai 2 Valerian root 1
Ginseng 2
Given the wide range and number of reported legal cases significantly involving
psychopharmacology in only this 10-year period, and recognizing that these
reported cases represent only the “tip of the iceberg” of legal cases in which psycho-
pharmacology plays a role, it behooves the legal professional to have at least a pass-
ing understanding of psychopharmacology. That is the purpose and goal of this part
of this book: To present the busy legal professional with an easy-to-read, broad, not
overly technical, user-friendly, concise, and convenient Primer of psychopharma-
cology to give the professional a practical passing understanding of this potentially
daunting subject.
In addition, Chaps. 11 and 12 (“Selection and Use of Experts: Five Questions”
and “Evaluating Versus Treating Doctor/Therapist: A Word to the Wise”) present
and discuss these two important topics in litigation, in the context of psychopharma-
cologic issues and concerns. “Forewarned is forearmed!”
146 10 Overview
Selected References
diagnoses.)
of the field.)

ries, viz.
sional journal)
tronic and print)
include:
Chapter 11
Selection and Use of Experts:
Five Questions
In “Alice’s Adventures in Wonderland” (In Carroll L. Lewis Carroll: The Complete

Illustrated Works. Gramercy Books; 1982), the Queen’s response to the King’s
instructions to “Let the jury consider their verdict...” was “No, no! Sentence first,
verdict afterwards.”
Analogously, the prospective expert witness’s response to counsel’s (and some-
times to the court’s) request for “a report addressing such-and-such” should be
“Don’t you want to know my opinion before you get my report?” This unsubtle
response by the expert demonstrates the fundamental difference in advocacy
between attorneys and their experts:
• Attorneys are zealous advocates for their clients, whereas.
• The attorneys’/courts’ experts are zealous advocates for their opinions about the
attorneys’/courts’ questions about the clients.
With this basic and important distinction in mind, this chapter will next present
and discuss “Selection and Use of Experts: Five Questions.”
The logical first question for the reader of this chapter is “Do I need an expert?”
The second question is “What type of expert do I need for my case, for whatever
reason I might need that expert?” The second question, convoluted though it may
seem, suggests several underlying sub-questions. The sub-questions are:
1. Do I actually need an expert? Why?
2. If yes, what type of expert do I need?
3. In the area of psychopharmacology, what type of experts are available?
4. As an extension of Question 3: Do I need an expert who can, and actually has,
prescribed these psychotropic drugs or medications? And if yes, how do I go
about selecting that expert?
5. Can or should my expert do more (or less) than evaluate, offer an opinion, and
testify in a case?

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150 11 Selection and Use of Experts: Five Questions
This chapter will address each of these questions in turn, in a practical and com-
mon sense way. The chapter will also address questions and concerns from the
expert’s perspective about the litigation process.
Question 1. Do I actually need an expert? Why?
General legal requirements for use of experts are discussed in relation to Table 11.1.
Without reiterating the formal statutory or legal/evidentiary requirements for the
use of experts in the law, and skipping first to the broader perspective of practicality,
we are aware that in our increasingly complex and technical world, knowledge is
vital and expertise is crucial. When properly used, evidence offered by a qualified
expert in a forensic setting—hearing, trial, deposition—as a negotiating tool, in a
practical context, or in any other such way, may be a key to an attorney’s successful
representation of their client (see Table 11.2).
Table 11.1 Ways of using experts in legal/forensic matters

Educating retaining counsel in the area of the expert’s expertise.
Advising counsel about strengths and weaknesses of the case from the expert’s perspective.
Providing counsel with information and opinions about opposing expert(s), when applicable
and when possible.
Reviewing available records and materials about a case and consulting with retaining counsel
before issuing a written report.
Consulting and discussing all aspects of a case with retaining counsel throughout the litigation
process.
Working with retaining counsel in any other appropriate and acceptable way.
Table 11.2 Criminal and civil issues in which mental health experts may be used
Traditional criminal responsibility- Future dangerousness
reducing psychiatric defenses Miranda (constitutional rights) waiver
Legal insanity Mitigation of penalty (federal sentencing
Diminished capacity guidelines)
Intoxication Suicide
Irresistible impulse Transfer (waiver; referral issues for juveniles)
Sex offenses Employment law (sexual harassment;
Sex offenses discrimination; others)
Sexually violent predators (SVPs) and Personal injury (including sexual abuse)
sexually dangerous persons (SDPs) Professional liability (malpractice)
Community notification (Megan’s Law Mental health law (civil commitment, including
registrants) sexually violent predators (SVPs) and sexually
Domestic violence deviant predators (SDPs)
Malingering Toxic exposure
Arson Professional regulation
Competency to stand (proceed to) trial Will contests
Mitigation issues (death penalty) Dram-shop liability
Embezzlement Competency (civil)
Battered woman (spouse) syndrome Divorce
(syndrome evidence cases) Custody and visitation
Elder abuse
Adapted from Greenfield and Gottschalk (2009)
11 Selection and Use of Experts: Five Questions 151
A series of cases beginning in 1923 (see Table 11.3) broadened the acceptability
of scientific forensic experts considerably, making way for many different types of
forensic “experts.” In the legal context, a stricter interpretation of the words “expert
evidence,” “opinion evidence,” and “forensic expert” suggests that any type of
expert input can assist the court in a resolution of a question or issue.1 The legal
system has become increasingly dependent on experts providing their factual and
opinion evidence in fields ranging throughout the alphabet from “Accounting” to
“Zoology.”
Table 11.3 Summary of salient evidentiary features for expert testimony

Frye v. United States Daubert v. Merrell Dow Kumho Tire Co. v. Carmichael
293 F. 1013 509 U.S. 579, L.S. 4805 526 U.S. 137
(D.C. Circuit, 1923) 113 S. Ct. 2786 (1993) 119 S. Ct. 1167 (1999)
The “general Expert testimony not based only
Is it testable, and has it been tested?
acceptance” rule on “scientific” knowledge may be
Has it been subjected to peer review accepted as evidence in court
and publication?
In the case of a particular scientific
technique, what is the known or
potential rate of error?
What (if any) are the standards that
control the techniques operation?
To what extent is the theory
accepted in the scientific community
(the “general acceptance” rule)?
1
The legal community has come a long way since the first recorded use, in 1783, of forensic evi-
dence and expert opinion.
In addition to the traditional ways in which experts are used in litigation, several
less discussed but equally important uses of experts ought to be kept in mind by
attorneys. These include educating counsel in the area of the expert’s field; advising
counsel about strengths and weaknesses of the case from the expert’s perspective;
providing counsel with information and opinions about the opposing expert(s) when
possible and applicable; reviewing available records and materials about a case
(including the opposing expert’s written report, if available) and consulting with
counsel before issuing a written report; consulting with counsel and discussing with
counsel all applicable aspects of a case throughout the litigation process; and work-
ing with counsel in any other appropriate and acceptable way that counsel sees fit.
Of course, the opposite is true of the need for counsel to work closely with the
expert they have hired, including providing, in a timely manner, all essential materi-
als and documents for the expert to review; making time and being available to
discuss all applicable aspects of the case with the expert; and otherwise aiding the
expert in any other appropriate ways.
In the real world, such factors pertaining to prospective experts as expense, avail-
ability, quality and reputation, cooperativeness, and so forth will influence the attor-
ney’s decision about whether to retain an expert.
However, as a practical matter, the applicability of a variant of the well-known
attorney’s “smell test” (“If it doesn’t smell right, it probably isn’t.”) will likely be
useful for deciding whether to retain an expert for any given case: “If it smells like
I need an expert for this case, I probably do.” And merely because the expert does
not, in the end, testify in the case does not mean that the expert was not needed on
the case.
Question 2. If yes, what type of expert do I need?

Having made the decision that an expert is needed for a case, for whatever reason,
this second question must be addressed: What type of expert do I need?
Dividing the predominant areas of the law for present purposes into criminal law,
civil law, and family law, one can list the types of experts most frequently used
within each area, as noted below.
• In criminal matters, frequently encountered forensic expertise will come through
medical, mental health, dental, accident reconstruction, fingerprint, DNA, bal-
listics, computer science, and other related such experts, to address such ques-
tions as the cause and timing of death or injury, identification of victims,
and others.
• In civil matters, because of the wide variety of substantive aspects of cases, a
great variety of questions to be addressed by experts will be encountered. This
variety may include virtually any question brought out in a civil matter: Accident
specialists, forensic accountants, engineers, and many other types of traditional
and non-traditional experts may be relevant. As an example of the wide range of
types of cases in which one particular forensic expert—the mental health
expert—might be used, Table 11.2, adapted from Writing Forensic Reports
(Greenfield DP, Gottschalk J. Writing Forensic Reports: A Guide for Mental
Health Professionals. Springer; 2009), gives examples of the types of cases in

which mental health experts may be utilized.
• In family law, in this author’s experience, mental health experts are the most
widely used, to assist the court in resolving such concerns as child custody (and
the best interest of the child); fair treatment of a spouse or partner with mental
illness of some sort (and often on psychotropic medications); and other such
examples.
As every law student knows, for purposes of using an expert in litigation, it is not
sufficient simply to have an “expert” carry on in court only with the idea of some-
how “educating the jury,” or about expressing an opinion about this or that pet the-
ory: “Junk science in the courtroom” is not allowed, and court standards for the
admissibility of expert evidence must be met. The standards most often applied, in
this writer’s experience, are the Frye standard from 1923 and the more recent
Daubert/Kumho Tire Co.1999 decision, and their progeny, beginning in 1993.
Table 11.3 outlines the salient features of these two standards. The Frye and Daubert
standards generally refer to the admissibility of expert evidence of any type—
including written expert reports—and apply in both state and federal jurisdictions.
However, some states use the Frye standard, some use the Daubert and progeny
standard, and some use both (such as New Jersey, as of this writing, criminal cases
require the Frye standard for experts, and civil cases require the Daubert standard).
It behooves counsel to advise the expert which standard applies for any given
case, and it behooves the expert to know or to find out that applicable standard.
Question 3. In the area of psychopharmacology, what types of experts are

available?
Having made the decision that an expert is needed for a particular case and that the
case involves drugs, medications, toxicologic agents, botanicals/herbals-
nutraceuticals/(dietary) supplements—in other words, any of the substances dis-
cussed in Part 1, “Psychopharmacology,” of this book—how do I decide what
specific type of expert I need? and what types of experts in these areas are avail-
able? These issues will be discussed next.
To begin, retaining counsel has to find, select, and retain an expert.
Finding an expert, first of all, implies that the attorney knows the type of expert
needed. In psychopharmacologic and related cases, this usually boils down to physi-
cians, toxicologists, clinical pharmacologists, nurse practitioners, physician assis-
tants, and other professionals whose main area of expertise involves study, teaching,
research, and/or prescribing psychotropic agents, or combinations of these activi-
ties. Two additional principles apply here:
1. In cases in which opposing counsel has already retained an expert, especially in
situations involving clinical practice issues, an expert of at least the same or a
comparable discipline ought to be selected, especially in potential jury trial situ-
ations. This principle of “like begets like” generally applies to selection of
experts by counsel, in my experience. For example, a practicing psychologist
licensed to prescribe in New Mexico (see Chap. 3) pitted against another such
psychologist would create an “even playing field,” all other factors being equal.
However, such a psychologist pitted against an academic practicing physician/
clinical psychopharmacologist would likely be perceived, especially by a jury, as
“outclassed,” regardless of the quality of the psychologist’s expertise and ability
to testify persuasively and compellingly.
Other considerations exist, such as whether to select a local or out-of-town
expert; whether to select an experienced forensic expert—a “litigation consul-
tant”—or an experienced clinical or academic expert without considerable liti-
gation experience; and other such factors. These must necessarily be decided on
a case-by-case basis.
2. In addition to the “like begets like” principle (above) of expert selection, counsel
needs to know what types of experts are potentially available with expertise in
psychopharmacology and related areas. As a practical matter, such an expert will
often be found in the mental health profession, as well as in the scientific disci-
plines of pharmacology and toxicology and their forensic subdivisions. The
interested reader is referred to applicable books, monographs, electronic
databases, internet sources, and the like, recognizing that not all types of mental
health professionals discussed in this volume prescribe medications or deal
extensively with psychopharmacology.
Next comes selecting an expert, once the type of expert has been identified.
While an extensive discussion of all of the factors which might enter into selection
criteria for an expert is well beyond the scope of this book, some basic and practical
points should be considered. Among such factors are whether to select an expert
experienced in litigation or an experienced academic practitioner with little court-
room presence (to name one such dichotomy); whether to select an out-of-town
expert without ties to the professional and/or legal community in which the litiga-
tion takes place or a local expert (presumably with those ties); whether to select the
treating professional of a litigant (which I strongly do not recommend: See Chap.
12); whether to select a highly reputed “superstar” expert whom counsel does not
know; and other relevant common sense considerations.
To begin the search process for an expert, counsel is well advised to consult with
colleagues in the legal community for referrals. In that way, prospective experts will
have already been vetted to some extent. Failing in that approach or wanting to
expand the search, counsel could consult with any number of professional societies
(e.g., medical and medical specialty societies) whose members provide forensic
expert consultation services. Access to these sources can be either through the inter-
net or through print resources. Directories and forensic consulting services specifi-
cally designed to provide expert referrals for attorneys may be consulted, such as
those listed in a number of publications like the state-based Lawyers’ Diary directo-
ries, some of which are affiliated with state and national bar associations and legal
specialty societies.
The final step in the process of counsel’s selecting an expert witness is the reten-
tion of the expert. This step assumes that the proposed expert meets all of the neces-
sary professional qualifications and that from the interpersonal perspective, retaining
counsel and the proposed expert can work together. The litigation process tends to
strain both nerves and relationships. Prior to actual retention, counsel should inter-
view their prospective expert both to discuss substantive aspects of the case at hand
and to screen the expert for psychological compatibility and ease of interpersonal
communication. Once the decision to retain is made, a formal written contractual
agreement should be entered into with the expert, which specifies terms, conditions,
scheduling issues, financial arrangements, and other such aspects of the attorney–
expert relationship. Sometimes attorneys will promulgate such a document; some-
times experts use their own; and sometimes expert consultation services use
contracts involving all three entities (i.e., the retaining attorney, the expert, and the
service). In any event, before the actual work by the expert begins, the terms, condi-
tions, and requirements of the expert’s consultation should be as clear as possible to
all concerned, to facilitate the working relationship between counsel and the expert.
In private sector cases, the expert is ultimately paid by the attorney’s client, albeit
indirectly. Since the expert forensic services provided are not clinical consultation,
evaluation, or treatment in nature but rather are consultative services to the client’s
attorney about the attorney’s client, payment to the expert should be made by the
attorney, through the attorney’s client trust or escrow account (this type of account
has a variety of names), directly to the expert, from monies paid to the attorney by
the attorney’s client with funds earmarked for costs associated with litigation. With
that practice, no question of a doctor–patient, psychologist–client, social worker/
counselor–client relationship or other such therapist–client treatment relationship
would arise. In public sector cases, the expert is usually paid directly by the retain-
ing agency. However, that agency may have arrangements with its clients in which
the clients pay some or all of the costs of representation and litigation (such as the
Office of the Public Defender in New Jersey, which charges non-indigent clients an
initial administrative fee and a subsequent hourly rate for attorneys’ and related
services). Experts are generally not paid by attorneys’ clients in the public sector
(such as Public Defender and Attorney General cases) or quasi-public agencies
(such as legal aid organizations).
Volumes2 could be written about the relationship between counsel and expert
once the expert’s consultation has begun. Without belaboring the obvious and
acknowledging that this relationship can be difficult for both, especially during trial
(or hearing, or deposition), four salient features deserve emphasis:
• The first is communication. Counsel and their experts should ascertain their
preferred mode of communication (i.e., telephone, email, fax, texting, or a com-
bination of these) and should maintain frequent communication with each
other—virtually constant during trial (or hearing, or deposition)—through that
mode. As any frustrated attorney or expert will confirm, violation of this rule will
2
For a not-too-serious treatment of these issues, see: Greenfield DP. A Practical Guide to Forensic
Mental Health Consultation Through Aphorisms and Caveats. Cognella Academic Publishing;
In Press.
be at least troublesome and even infuriating for either counsel, the expert, or
both, and at worst, may jeopardize the outcome of the case.
• The second is preparation. As in any phase of the litigation process, the impor-
tance of thorough mutual preparation (by telephone, electronic contact, or in
person, although the last is usually preferable) by counsel and expert cannot be
underestimated.
• The third is consistency. The ups and downs of litigation can be very trying for
both counsel and their experts, and both may be pressed to depart from previ-
ously agreed upon parameters and elements of the arrangements between them.
This is not advisable, in my experience, no matter what the exigencies of the liti-
gation process may be.
• The fourth is flexibility. This is especially illustrated by the situation presented
by the current COVID-19 pandemic, in which virtual communication is neces-
sitated by social distancing requirements, whether or not the attorneys, experts,
and/or parties to litigation like that practice.
Question 4. Do I need an expert who can, and actually has, prescribed
psychotropic drugs or medications? And if yes, how do I go about selecting
that expert?
A response to this question clearly should be based on the nature of the case for
which the expert is sought and may be considered an extension of the “like begets
like” principle articulated earlier in this chapter. For example, in civil malpractice
matters involving psychotropic drugs or medications, an expert—such as a practic-
ing physician—who can opine about prescribing from personal, professional expe-
rience would generally be preferable to one who has not.
On the other hand, in a product liability case involving complex statistical and
technical analysis, such consultation might be beyond the ability of a professional
who is predominantly a clinical practitioner. In that example, an academic or
industry-based expert would likely be preferable. Decisions of this type need to be
made on a case-by-case basis, with retaining counsel aware of the professional
capabilities, licensing authority, and experience of potential expert witnesses.
Locating such experts follows the same principles discussed earlier in this chapter:
Word-of-mouth recommendations, directories, previous experience and contact
with the proposed expert, professional societies, academic institutions, industry set-
tings, the internet, and other such referral sources.
Question 5. Can or should my expert do more (or less) than evaluate, offer an
opinion, and testify in a case?
Although any forensic expert’s advocacy position—to develop and offer an expert
opinion about someone of concern being evaluated, and to be an advocate for that
opinion, not for the person or the concern evaluated—in a case is different from the
retaining attorney’s position (to be an advocate for their client, who is evaluated by
the forensic expert), the expert may legitimately be called upon to do more in any
given case than simply evaluate an attorney’s client, develop, and write an opinion
about the forensic issues in the case at hand and testify about that opinion (when
testimony occurs). Table 11.1 alludes to this expanded view of the role of a forensic
expert, especially in terms of the last two bullet points (“…consulting with counsel
and discussing with counsel all applicable aspects of a case throughout the litigation
process; and working with counsel in any other appropriate and acceptable way that
counsel sees fit…”).
As a practical matter, in my view, no expert should agree to consult on a case
without being willing to testify at trial, deposition, and/or hearing about their opin-
ion in that case. Conversely, no attorney should expect that their retained expert will
only consult and assist in a case short of (and not including) testifying in this case.
While most cases in litigation do not go to trial, the retaining attorney and retained
expert generally ought to assume that any given case will go to trial (and/or hearing,
and/or deposition), and should prepare accordingly, intensively or thoroughly: “It
comes with the territory.” Once a trial (and/or deposition, and/or hearing) is sched-
uled and likely to proceed, preparation begins. This process is described from the
expert’s perspective earlier in this chapter, and its importance cannot be overstated.
One particular point in this context which should be emphasized is the usefulness of
the expert’s written report as a guide, or “trial notebook” for their testimony. This is
a point discussed in detail in Writing Forensic Reports: A Guide for Mental Health
Professionals (p. 179 of that book).
In addition to thorough preparation and knowledge of the expert’s report, both
personal and professional characteristics are necessary to present persuasive and
convincing testimony in court, at a hearing, or at a deposition. It goes without saying
that the testifying expert should dress carefully and conservatively, but not over-
dress. The expert should speak slowly and deliberately, making “bullet points” on
direct examination which have been previously discussed and agreed upon by
retaining counsel and making them in such a way as not to be an advocate for retain-
ing counsel’s client: Again, the advocacy position of representing counsel is for
their client, whereas the advocacy position of the retained expert mental profes-
sional is about the retaining attorney’s client.
In testifying, the expert should use clear, understandable, and straightforward
language; present a friendly and informal—and not arrogant or distantly profes-
sional—demeanor; speak directly to the jury (in jury trials); present testimony in a
conversational and story-telling style in easily understood words and terms; and not
“speak down” to the court or the jury, no matter how technical or complicated the
testimony content may be. All of these points should be made to or known by the
expert during preparation for direct examination testimony, and the mental health
expert in their expanded role, as described above, should point out strengths and
weaknesses in their opinion and testimony, as relevant to the case.
All of the above are points relating to strategy which the mental health expert in
this expanded role should discuss with retaining counsel. Conversely, these are also
strategic points which retaining counsel should expect from their retained expert in
that expert’s expanded role.
Professional literature abounds with discussions and advice about the use of
mental health expert witnesses, but space limitations do not permit a comprehensive
review of this broad topic. The foregoing points, in broad strokes, have been particu-
larly practical and helpful to this author over the years of his forensic psychiatric
practice.
Liability of Experts
This next section shifts from the lawyer’s perspective to the expert’s perspective.
Aside from feeling the stresses and strains of deadlines, testimony, and the myriad
of other potential problems generated for the forensic expert consultant in litigation,
two questions at the back of any expert’s mind are: (1) “Can I get into trouble from
performing this expert witness work?” and (2) “If I do, what kind of trouble will that
be?” In my experience, this is especially the case with mental health and other clini-
cians—licensed and regulated practitioners, generally, of any mental health or other
medical or related professional who treats patients/clients, in a formal doctor–
patient, or therapist–client relationship—who are not acting in that capacity in per-
forming forensic evaluations. Whether those clinicians are private practitioners,
full- or part-time academics, hospital or other institutional employees, or in any
other occupational or professional setting does not matter for these concerns. The
specter of being sued, whether for clinical treatment or forensic consultation, is
disturbing for any clinician or practitioner.
The response to the first question (“Can I get into trouble from performing this
expert witness work?”) is simple and straightforward: “Yes. Anything is possible.”
Without belaboring the obvious to a legal audience, in tort law, virtually any person
can be sued at any time for any reason at all. The more important question is whether
a potential civil suit against a forensic expert witness has standing and merit and
whether its basis is sound and likely to succeed against the expert.
The answer to the first question leads inexorably to the second: “What kind of
trouble will that be?” In other words, what are the potential sources of liability for
the forensic expert witness? While commentators agree that the traditional doctor–
patient treatment relationship does not apply for the evaluating/consulting forensic
expert, some requirements in the forensic expert–evaluee relationship do apply. In
“Liability of the Forensic Psychiatrist,” for example, Willick et al., describe the fol-
lowing conceptual framework (Table 11.4) for identifying sources of liability of
forensic experts, then present a series of examples which illustrate the framework,
specifically for forensic psychiatric experts. (Willick D, et al. Liability of the foren-
sic psychiatrist. In: Rosner R, editor. Principles and Practice of Forensic Psychiatry.
2nd ed. Taylor & Francis Group; 2009).
Table 11.4 Forensic consultation 1. Who is the forensic client?

2. What task is being performed?
3. Is the task being performed with legal
protections such as pursuant to a court order?
Adapted from Willick et al. (2009)
Liability of Experts 159
Some examples of forensic liability, given by Willick et al., are based on claims
of negligence, intentional torts, and federal civil rights actions.
As a practical matter, in the medical context, even though forensic third party
evaluations are not the same as consultations/evaluations in the treatment of patients,
“…The law considers both third-party evaluations and evaluations conducted for
treatment purposes to constitute the practice of medicine… case law does not dif-
ferentiate between them…” and a limited physician–patient relationship has been
articulated concerning duties of physicians (experts) toward third-party evaluees.
(Gold L, Davidson J. Do you understand your risk? Liability and third-party evalu-
ations in civil litigations. The Journal of the American Academy of Psychiatry and
the Law. AAPL. 2007).
A final area of potential liability and risk for forensic experts lies in alleged vio-
lations of applicable practice (e.g., medical, for physician) law and regulations, ethi-
cal codes, and practice guidelines. Actions in these areas may not directly or
inexorably lead to civil lawsuits, but they may lead to disciplinary actions or censure
by the expert’s legal licensing, registration, and regulatory agencies; professional
societies; specialty certification boards; or other such actions. One particular area of
concern in this regard pertains to healthcare professionals who engage in forensic
activities in jurisdictions in which they are not licensed in their health profession.
In addition to the customary protections for any forensic expert practitioner—
such as having adequate professional liability insurance, having a clear and written
understanding with retaining counsel about the parameters and requirements of the
forensic consultations (as also discussed above), having the forensic work done
pursuant to court order (with resulting quasi-judicial immunity) when possible, and
having a written confidentiality disclosure consent statement for each evaluation—a
practical rule-of-thumb defining professional malpractice (professional liability) for
the forensic expert consultant may be seen as a modification of the “Four Ds” in tort
law (“Duty” to treat; “Dereliction” in the “Duty,” resulting in; “Damages” to the
client, proximately or; “Directly” caused by the “Dereliction”) which constitutes
clinical malpractice: The forensic expert has a:
• “Duty” to apply the best scientific bases to their evaluation of the third-party
evaluee;
but
• If “Derelict” in that “Duty,” resulting in
• “Damages” to counsel’s case, there must be a proximate,
or
• “Direct” relationship between the “Duty” and the “Damages.”
In this vein, for forensic medical experts, some protection from potential legal
liability for consultations in which opinions are ultimately determined to be errone-
ous or inadmissible is found in endorsement of the concept that experts not be held
liable for such opinions as long as the opinions were based on a proper, sound, and
scientific evaluation.
In this chapter, and as described in the Author’s Disclaimer Note (located near
the beginning of this book), the information given in the three forensic/legal chap-
ters of this Primer should not be construed or taken as legal advice, which as a non-
lawyer or legal professional, the author is not competent to give, and which can be
given only by an attorney or qualified legal professional.
Selected References
diagnoses.)
of the field.)
ries, viz.
1. Referreed (“peer-reviewed;” “juried”) scientific, technical, and professional
sional journal)
tronic and print)

include:
Chapter 12
Evaluating Versus Treating
Doctor/Therapist:
A Word to the Wise
The reader of this Primer of primarily psychopharmacology/psychopharmacother-

apy might well ask why this chapter is included in this book. One response to that
question, as stated in the Preface, is that part of the intended audience for this book
is the legal professional who interacts with psychopharmacology/psychopharmaco-
therapy in various ways, including litigation. But the other response, more geared to
the overall readership of this book, is that prescribers—regardless of discipline,
orientation, or professional qualifications—may be called upon, sometimes invol-
untarily, or at least unwillingly, to testify about their patients/clients as an expert
witness, as a fact, or material witness (i.e., the “treating professional”), or as both, a
hybrid of the treating professional with “expertise in the field” (as a trial attorney
told me a number of years ago). This chapter will provide basic and practical infor-
mation about this question.
But what is the bottom line answer to the conundrum posed by the title of this
chapter? This writer’s response—my word to the wise—in that regard, is a resound-
ing “no,” to employing the forensic services of a treating doctor/therapist for rea-
sons to be presented and discussed below.
In the litigation context, prescribers of all disciplines and professions can serve
as witnesses concerning patients/clients in two ways, viz., (1) as fact, or material
witnesses, providing clinical information and testimony about their treatment of
their own patients/clients and (2) as expert, or opinion witnesses, providing evi-
dence and testimony about others evaluated by them for litigation purposes, who are
not their own patients/clients.
That treating (prescribing, for present purposes) healthcare professionals ought
to and do have a duty to provide the first service (i.e., as a fact, or material/treating
witness) is mandated by legal (case law) precedents and by codes of ethics and pro-
fessional conduct in a number of professional organizations (such as the APA and
the AMA), in this writer’s experience.

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164 12 Evaluating Versus Treating Doctor/Therapist: A Word to the Wise
However, conflict in this area between legal/forensic practices (such as litigation

and testimony) and clinical guidelines and sensibilities (such as c onfidentiality/pri-
vacy/privilege) necessarily arises in situations in which the boundary is blurred
between the prescribing healthcare professional as treatment provider for a patient/
client in litigation and that same professional as an opinion evidence “provider”
(i.e., expert witness) for that same patient/client. Although the advisability of a cli-
nician’s serving as their patient’s/client’s expert witness remains controversial for
some practitioners (legal and clinical), in this author’s experience, that role on the
part of the clinician presents a difficult role conflict for the clinician. That conflict is
the bedrock contraindication to a clinician’s serving as their patient’s/client’s expert
witness. Concisely put, the treating clinician cannot objectively and with neutrality
give opinion evidence about their patient/client (for whom the clinician is an advo-
cate), especially if such opinion evidence disadvantages (i.e., does not advocate for)
their client.
The following tables respectively give further reasons for (Table 12.1 “Pros”)
and against (Table 12.2 “Cons”) treating clinicians’ serving as experts for their
patients/clients.
Table 12.1 “Pros:” reasons for the treating clinician to serve as expert witness
The treating clinician has had longer and more extensive contact with the patient/client/litigant
and “knows” the patient/client better than an evaluating forensic clinician
The treating clinician would be less expensive to employ as forensic expert than would be an
independent outside evaluating clinician
The treating clinician would be more invested as an advocate in the patient’s/client’s/litigant’s
legal matter than would be a neutral objective evaluating clinician
The practicing treating clinician might have more clinical experience—and therefore more
credibility—than an outside evaluating clinician
Table 12.2 “Cons:” reasons for the treating clinician not to serve as expert witness (but for the
evaluating clinician to serve as expert)
The outside evaluating clinician is not an advocate for the patient/client/litigant and can be
unbiased and objective in their evaluation and opinion
The outside evaluating clinician does not have an ongoing relationship and/or financial interest
in the outcome of the patient’s/client’s/litigant’s legal matter
The outside evaluating clinician will more likely have greater experience and credibility in
forensic evaluations than the treating clinician
Additional reasons and justifications both for and against treating clinicians’
serving as expert witnesses for their patients/clients can be marshaled, including
arguments pertaining to patient/client advocacy; psychodynamic and psychothera-
peutic conflicts; financial considerations and interests in the outcome of a legal mat-
ter; and treating clinician bias (i.e., advocacy).
In the final analysis, this writer is not aware of any formal or informal prohibition
against treating clinicians serving as forensic expert witnesses for their patients/
clients. However, in view of the “pro” and “con” points and other such arguments
presented and discussed in this chapter about that practice, the bottom line, or bal-
ance, requires that treating mental health professionals must be advocates for their
patients/clients, as attorneys must be for their clients. To ask such clinicians to do
otherwise by serving as a patient’s/client’s expert witness as well as that patient’s/
client’s therapist is fraught with potential biases and conflicts, and thus should be
avoided. A cautionary tale is raised by common sense and professional guidelines in
this practice: “A word to the wise.”
Selected References
diagnoses.)
166 12 Evaluating Versus Treating Doctor/Therapist: A Word to the Wise

of the field.)
ries, viz.
sional journal)

tronic and print)
include:
pharmacology/ psychopharmacotherapy, the logical rule—as with everything
Part IV
Synthesis and Conclusions
Chapter 13
Synthesis and Conclusions
To reiterate (from the first section of Chap. 3, “Antianxiety Agents”):

A 38-year-old woman from the suburbs consulted her primary care physician assistant (PA)
with complaints of severe tension and anxiety, insomnia, overeating, stage fright, and a
pervasive sense of dread and foreboding. After interviewing and examining the patient, the
PA determined that there was no obvious pathophysiologic basis for the patient’s anxiety
and prescribed a sedating (hypnotic) benzodiazepine, estazolam (Prosom®) for her. He
instructed her to keep a daily mood diary, to call the practice before the next scheduled
appointment and to return for a follow-up visit in two weeks.
The patient returned as scheduled, appearing calmer, well-rested, energetic, and with a
five-pound weight loss. She told the PA “Ever since I started giving the medication to my
husband, I’ve felt 1000% better. Thank you so much.”
Although intended as a fairly lame joke, this “case” actually illustrates a number
of important clinical points which have been emphasized from the beginning and
throughout this Primer. These points include:
• Proper diagnosis (Anxiety, in this case.)
• Clinically indicated medication (Benzodiazepine, in this case.)
• Use of other treatment modalities (Giving the medication to the patient’s hus-
band, in this case, “couples therapy,” in a sense. Not a conventional approach!)
• Awareness of compliance/adherence factors (Concerning the husband in
this case!)
• Awareness of the need for follow-up and proper interpretation of manifestational
criteria—Epidemiologic Triangle model—symptoms (“…calmer, well-rested,
energetic,” in this case)
• Follow-up is obviously essential, especially for expected changes in patients’/
clients’ conditions (This is unlike the situation in which a stable chronic condi-
tion—e.g., schizophrenia; hypertension—can be monitored “from a distance,” to
coin the phrase, every 2–3 months.)
These points bring to mind other technical points and caveats which are sum-
marized in Table 13.1.

Switzerland AG 2022
https://doi.org/10.1007/978-3-030-82507-2_13
172 13 Synthesis and Conclusions
Table 13.1 Important points in clinical psychopharmacotherapy

The use of psychopharmacological agents for given psychiatric disorders should be based on
the best available clinical evidence.
Psychopharmacology should be combined, when appropriate, with evidence-based psychosocial
and psychotherapeutic modalities in order to enhance medication adherence, reduce symptom
burden and relapse, and increase function.
The choice of psychopharmacological agent is based on multiple factors, including evidence for
efficacy, side effects, desirable secondary pharmacodynamics effects, routes of administration,
drug–drug interactions, medical and psychiatric comorbidities, and personal and family history
of medication response.
There is tremendous inter- and intra-individual variation in response to psychotropic
medications.
If a patient does not respond to one drug in a given class, it does not mean that they will not
respond to another drug from the same class.
In general, drugs that are approved for specific disorders are equally efficacious and differ
primarily in terms of pharmacokinetics, adverse-effect profiles, and drug–drug interactions.
The most notable exception to this rule is clozapine, which has unique efficacy for treatment-
refractory schizophrenia.
When possible, minimize polypharmacy, which increases the risk for medication toxicity and
drug-drug interactions.
Concerning drug–drug interactions (CYP-450 cytochrome enzyme oxidase systems),
decreasing or increasing the doses of the necessary psychotropic medications should always be
taken into account where potentially interactive drugs of any doses are administered which
could increase or decrease the effective dose level of other drugs the patient/client is taking.
Charts, tables, patient package insert (PPI) data, electronic databases, and other sources are
readily available for this information.
All of the foregoing assumes that the prescriber is actually going to prescribe an
“Anti-Agent” (psychotropic) of some sort, often with recommendations for accom-
panying psychotherapy/counseling of some sort, based at least in part on the pre-
senting patient’s/client’s “chief complaint,” symptomatology, and history. In fact,
why bother to be able to prescribe—to undergo the time, effort, expense, and the
like to become qualified to prescribe these “Anti-Agents” and other medications—if
not intending and expecting to do just that? The answer to this logical question is
central to this last part of this book.
In the words of Dr. Allen Frances, “The easiest and most mindless part of psy-
chiatry is prescribing meds: be good at it, but not limited by it” (Psychiatric Times,
October 2019). That prescribing of psychotropic medications has skyrocketed in the
past 40-plus years is axiomatic, in part because, as the English writer and philoso-
pher, Aldous Huxley, put it: “Medical science has made such tremendous progress
that there is hardly a healthy human left;” in part because of the dramatic increase
in practitioners with prescribing authority; in part because of what Dr. Frances calls
“diagnostic inflation” through the DSM-III, DSM-III-R, DSM-IV, DSM-IV-TR, and
currently DSM-5, and what Ethan Watters, in the title of his book Crazy Like Us,
calls “The Globalization of the American Psyche”; in part because of the strong
13 Synthesis and Conclusions 173
paradigm shift in medicine, in general, and psychiatry, in particular, toward evi-

dence-based medicine in medicine and toward psychopharmacology and what is
called “medication management” of symptoms in psychiatric practice and research;
in part because of the dearth of prescribing mental health professionals in society
who could treat patients/clients with modalities other than or in addition to psycho-
pharmacotherapy; in part because of the convenience and rapidity (i.e., the per-
ceived “quick fix”) of psychopharmacotherapy and the public’s demand for “quick
fixes” to many of life’s troubles (“Big Pharma” and the burgeoning created and
existing consumer demand for relief from those troubles); and in part because of
interactions among all of these various factors and trends.
But this Primer is, after all, a guide to psychopharmacology and not a wholesale
detractor from that field. So, on balance, what beneficial observations and practices
can be extracted from this book, both in summarizing the book (not as a “cookbook”
for prescribing) and in encouraging sensible psychopharmacotherapeutic practice
among the different types of prescribers who might use this book? In addition to the
points made in Table 13.1 of this chapter, the following additional points and pre-
scribing recommendations come to mind:
• Trends change. As described in the Preface of this book, the pendulum of what
has been called “overprescribing” of psychotropic medications, or “polyphar-
macy,” appears to be swinging away from that practice. “Deprescribing”—
defined by the Bruyère Research Institute as “the planned and supervised process
of dose reduction or stopping of medication that might be causing harm, or no
longer be of benefit.”— began recently in geriatric medicine and is moving into
other areas and specialties in medicine, including psychiatry and psychopharma-
cotherapy. (Bruyère Deprescribing Research Team. What is deprescribing. In:
deprescribing.org. 2020, June. https://deprescribing.org/what-is-deprescribing/)
• Combination approaches are generally recognized in the mental health profes-
sions—including those with prescribing authority—as producing better out-
comes than either modality alone. In the case of psychopharmacotherapy plus
something else, the role of that “something else” will likely become more appre-
ciated by the prescribing professionals and the public as psychopharmacotherapy
comes increasingly under the scrutiny of the “deprescribing” movement.
• As described early in Chap. 3 (“Antianxiety Agents”), the research approach to
psychiatric diagnoses has changed dramatically in this country over about the
past 10 years. If the “roots,” or “causes” (in an epidemiologic sense) are deter-
mined in coming years, and psychopharmacotherapeutic intervention becomes
specifically suited to those causes, then the role of medications will result in bet-
ter treatment of symptomatology resulting from these causes, and better side
effect profiles, presumably.
• Depending on the study, “off-label prescribing”—prescribing currently avail-
able medications for a clinical indication for which it has not received formal
FDA approval—is common, conservatively estimated at 10 to 20% of all
prescriptions; the practice is not considered per se illegal (Furey K, Wilkins
K. Prescribing ‘Off-label:’ what should a physician disclose? AMA Journal of

Ethics. AMA; 2016). As frequently noted in this Primer, off-label prescribing of
psychotropic medications permits greater flexibility and wider use of potentially
useful agents for patients/clients.
So, in summary, this Primer is intended as a concise and practical guide to the
nature, scope, and applications of psychopharmacotherapy, focusing on a classifica-
tion system (i.e., the “Twenty Anti-s”) based on manifestational criteria and symp-
tomatology of patients/clients. The Primer is intended for a broad range of potential
readers interested in the topic, as described in the Preface of the book.
This Primer is not intended as an encyclopedic, scholarly, or detailed “cook-
book” of conventional psychopharmacology, as also first described in the Preface of
the book. The fields of psychiatry, psychopharmacology, cognitive science, neuro-
science, and related areas are awash with books, articles, reports, internet sources
and information, symposium and meeting proceedings, electronic databases, and
myriad other such sources. As mentioned in several places in this volume, the reader
is referred to those sources for more detailed information about the vast topic of
psychopharmacology.
The reader is also referred to the Selected References given at the end of the
Preface of this Primer and to other references in various places in this book, for
details of materials discussed in the various chapters. Some of these references pro-
vide such practical information as the available preparations of different agents,
their doses and recommended dosing schedules, adverse (“side”) effects, specific
clinical indications, and the like.
Finally, I reiterate a point made early in this book: The success or failure of this
Primer will depend on its usefulness to its readers. For that reason, I welcome feed-
back and suggestions to make this book as practical and useful as possible.
Please contact me with feedback and suggestions at dpgreenfieldmdpsychiatry@
msn.com.
tions in this Primer, given below are particularly useful selected references. In
addition, other specific references and citations will be given in parentheses
throughout the Primer. For further information and details about any topics pre-
sented and discussed in this book, the interested reader is referred not only to the
following list of selected references but also to applicable textbooks, monographs,
electronic databases, print articles and materials, internet sources, and other appli-
cable resources.
Selected References
diagnoses.)
of the field.)

ries, viz.
sional journal)
tronic and print)
include:
pharmacology/ psychopharmacotherapy, the logical rule—as with everything
Index
A Anti-Parkinsonian agents, 77–79

Addictionology, 93 Anti-Pseudobulbar affect agents, 80
Addictive substance, 47 Antipsychotic agents, 37, 38, 40
Addicts, 89, 97–98 atypical (second-generation), 39
Adverse drug reactions (ADR), 11 conventional (first-generation), 39
Alcoholics, 89, 97–98 organ systems, 39
Analgesics, 69 rational use, 38
Anorectics, 52 Antipsychotic medications, 51
Anti-addiction agents, 45, 47–50 Anti-psychotropic agent, 172
Anti-ADHD agents, 51, 55 Anti-sex agents, 80–82
Anti-aggression agents, 50, 51 Anti-trauma agents, 82–83
Antianxiety agents, 34 Anxiolytic/sedative (daytime)-hypnotic
local academic psychiatric APN, 30 (nighttime) agents, 29
matrix of neuroscientific structures, 28 Anxiolytics, 28
Antianxiety drugs, 28, 47 Appetite suppressants, 52
Anti-appetite agents, 52, 53 Atypical antipsychotics, 36
Anti-attention deficit hyperactivity disorder Augmentation strategies, 31
(ADHD) agents, 54–57 Autonomic nervous system (ANS), 17, 18
Anticholinergic drugs and medications, 17, 18
Anticholinergic syndrome for legitimately
prescribed drugs and B
medications, 18 Behavior, Affect, Sensation, Imagery,
Anticonvulsant agents, 56 Cognitive, Interpersonal
Anticonvulsants, 36, 57 Relationships (BASIC ID), 120
Anti-dementia agents, 57–60 Behavioral addictions, 46, 47
Antidepressant agents, 30, 32–34 Behavioral interventions, 51
Anti-feeding/eating agents, 60–61 Behavioral therapies, 123
Anti-impotence agents, 61–63 Benzodiazepines, 47, 83
Anti-insomnia agents, 64–67, 126 Binge eating disorder (BED), 60
Antimanic agents, 35–37 Bipolar disorder treated with
Anti-obsessive-compulsive agents, 67–68 anticonvulsants, 56
Anti-obsessive-compulsive disorder (OCD) Borderline personality disorder, 51
agents, 68 Botanicals, herbals, nutraceuticals, and
Anti-pain agents, 69–76 (dietary) supplements,” (BHNSs),
Anti-panic agents, 76–77 19, 20, 101–104, 143
© The Editor(s) (if applicable) and The Author(s), under exclusive license to 177
Springer Nature Switzerland AG 2021
D. P. Greenfield, Psychopharmacology for Non-Psychiatrists,
https://doi.org/10.1007/978-3-030-82507-2
178 Index
Boundary erosion, 120 Dose-response relationship, 10

Brief dynamic psychotherapy, 120 Drug/medication tolerance, 10
Drug-seeking patient/client, 97
DSM-5 diagnostic criteria, 3
C DSM-5 features of substance use disorders
Cannabidiol (CBD), 63 (SUDs), 92
Cardiac electrical disturbances, 36 DSM-5 Major Diagnostic Categories, 4
Centers for Disease Control and Prevention DSM-5 of disruptive impulse control and
(CDC), 93 conduct disorders, 51
Central nervous system (CNS), 17, 18
“Central” vs. “peripheral” pain, 70
Chemical and behavioral addictions, 89, 93 E
Chronic pain, variants and terms, 71 Electroconvulsive/electroshock therapy (ECT/
Civil matters, experts, 152 EST), 33, 133
Clinical psychopharmacotherapy, 172 Epidemiologic Triangle Model, 1
Cognition enhancers, 57, 59, 60 agent, 1
Cognitive behavior therapy (CBT), 30, 62, 83, causal criteria, 2
125, 126 environment, 1
Combination approaches, 173 host, 1
Complementary and alternative medicine manifestational criteria, 2
(CAM), 102 Expert testimony, evidentiary features, 151
Compliance/adherence, 20 Expert witness, 164
Consultation-Liaison Psychiatry, 76 Expert witness, psychopharmacology,
Continuum of care in addiction treatment, 94 153–155
Continuum of care model, 94 Exploratory psychotherapy, 119
Controlled dangerous substances (CDS), Eye movement desensitization and refocusing
53, 90–92 (EMDR), 83
Controlled Substance Act (CSA) of Eye movement desensitization and
the FDA, 90 reprocessing (EMDR), 127, 128
Couples therapy, 121
COVID-19 pandemic, 1, 22, 130
Criminal and civil issues, mental health F
experts, 150 Family law, 153
Criminal matters, frequently encountered Family pathology, 121
forensic experts, 152 Family therapy, 121
CTB-I, 126 FDA dose schedule, 36
Feeding and eating disorders, 60
Fibromyalgia, 72
D First- and second-generation long-acting
DaCosta’s syndrome, 83 injectable (LAI) antipsychotics, 41
Dementia Forensic and legal applications, 141, 145
agents of use, 59 applications of psychopharmacology to the
anti-dementia agents, 58 law, 142
Depressants, 14 frequency distribution of reported cases by
Desired and undesired (“side”) effects, 11 “Anti“ class of medication, high to
Dexmethylphenidate, 55 low order, 144
Dialectical behavior therapy (DBT), 126 frequency distribution of reported cases by
Diazepam, 83 area of law, 143
Disruptive mood regulation disorder frequency distribution of reported cases by
(DMRD), 51 type of botanical, herbal,
Doctor/therapist, evaluation vs. treatment, nutraceutical or (dietary)
164, 165 supplement agent, high to low
Dopamine agonist medications, 78 order, 145
Index 179
frequency distribution of reported cases by M

type of illicit drug, 144 Medication-assisted treatment (MAT), 47, 49,
Forensic consultation, 158 88, 89, 93–94
Forensic expert practitioner, 159 Meditation, 128
Forensic expert, role of, 156, 157 Mental health care, therapies, 111–113
Forensic medical experts, 159 Mental health experts, criminal and civil
Freudian psychoanalysis, 119 issues, 150
Metabolic agents, 52
Metacognitive therapy, 129
G Methylphenidate and congeners, 55
Gambling disorder, 93 Migraine prevention and treatment,
Group therapy, 121 medications, 74
Mindfulness, 128
Minor tranquilizers, 28
H Mixed amphetamine salts (MAS), 55
Hallucinogens, 14 Multimodal therapy, 120
Holistic health and complementary and
alternative medicine (CAM), 102
Hypnosis/hypnotherapy, 126, 127 N
Hypnotics, 65 National Institute on Drug Abuse (NIDA), 93
Hypoactive sexual desire disorder (HSDD) in Neuroleptics, 37–40
women, 61 Neurotransmitter reuptake inhibitors, 31
Nocebos in psychiatry and psycho-
pharmacotherapy, 21
I Non-behavioral individual
Illicit agents, 15 psychotherapies, 118
Illicit drugs and medications, 14, 15, 143 Non-behavioral individual therapies, 118
Illicit psychotropic agents, 14 Non-behavioral psychotherapies, 118–122
Inappropriate antidiuretic hormone syndrome Non-psychotropic medications, 12, 13
(IADH), 36 Non-stimulant appetite suppressants, 53
International Association for the Study of Pain Non-stimulant medications, 55
(IASP) Task Force, 69 Nuedexta®, 80
Interpersonal psychotherapy (IPT), 120
O
L Obsessive-compulsive and related disorders
Legal requirements for use of experts, per DSM-5, 67
150, 152 Obsessive-compulsive disorders, 67
Legal/forensic matters, experts in, 150 Off-label prescribing, 173
Legal system, 151 Opioid crisis, 70
Liability of experts, 158–160 Opioid epidemic, 70
“Licit” agents, 15 Over-the-Counter (OTC) drugs and
Licit and illicit psychotropic agents, 14 medications, 17
Licit drugs and medications, 14
Licit psychotropic agents, 16
Lithium compounds, 36 P
Lithium levels, 36 Pain conditions, categories, 70
Lithium psychopharmacotherapy, 37 Paraphilic disorders per DSM-5, 81
Long-acting injectable (LAI) Parkinsonian movement disorder, 79
antipsychotics, 41 Parkinsonism, 78
“Lumper” And “Splitter” Taxonomies of Patient/client adherence/compliance, 41
Drugs, 88 Peripheral neuropathic pain syndromes, 72
Lumpers, 87 Personality disorders, 51, 52
180 Index
Pharmacologic interactions, 12 Respiratory depression, 65

Physician’s Desk Reference (PDR), 11
Placebo methodology in pharmacologic study
design, 21 S
Placebos in psychiatry and psycho- SARS-CoV-2 pandemic, 129
pharmacotherapy, 21 Schizophrenia, 51
Post-traumatic neurosis, 83 Sedative-hypnotics, 28
Prazosin, 83 Sedative-hypnotic withdrawal, 47
Prescribed psychotropic drugs or Seizure induction through electrical
medications, 156 stimulation of the brain, 133
Prescription Drug Monitoring Programs Sexual dysfunction, secondary causes, 61
(PDMPs), 70 Short-term dynamic psychotherapy, 120
Product liability case, statistical and technical Skinnerian conditioning of clinical mental
analysis, 156 health significance, 123
Pseudobulbar affect, 80 Sleep medicine, 64
Pseudobulbar palsy, 80 Social distancing, 1
Psychedelics, 95, 96 Sociocultural and ethnic constraints, 121
Psychiatric diagnosis, 2 Somatic anticholinergic side effects, 18
Psychiatric, neuropsychiatric, and medical/ Somatic symptom and related disorders, 72
neurologic conditions and Somatic therapies (Somatotherapies), 111,
disorders, 50 113, 133, 134
Psychoactive effects, 15 Splitters, 87
Psychoanalytic approaches, 119 Stereotactic brain surgery, 82
Psychoanalytic technique of “free Stimulant and non-stimulant appetite
association”, 119 suppressants, 53
Psychodynamic psychotherapy, 119 Stimulants/psychostimulants, 14, 52, 53
Psychotherapies, 111, 112 Substance use disorders (SUDs), 88
Psychotic-level disorders, 38 Supervised therapeutic groups, 122
Psychotropic agents, 15 Surgical castration, 82
Psychotropic medications, 14
T
Q Telemedicine, 22
Quarantining, 1 Theoretical dose-response curves, 11
R V
Randomized controlled trials (RCTs), Voluntary nervous system, 17
103, 104
Rational-emotive behavior therapy
(REBT), 124 W
Research approach to psychiatric Weight management and control, 53
diagnosis, 173 World Health Organization analgesic
Research domain criteria, 28 ladder, 73

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Daniel P.

Greenfield, MD, MPH, MS, FASAM

ISBN 978-3-030-82506-5 ISBN 978-3-030-82507-2 (eBook)

After years of teaching in a physician assistant (PA) program, I am gradually com-

June, 2020 Christopher J. Hanifin

This latest work by Dr. Daniel Greenfield on psychopharmacology is a must read

into the possible impact on a court case by psychopharmacological, psychopharma-

June, 2020 Kevin G. Callahan

This book’s cover is a stylized version of an ancient

In addition, the COVID-19 experience has been extremely anxiety-producing

Table P.1 Historical trends in psychiatry, ca. 1850-present

Table P.2 The intended audience for this Primer

Selected Internet References

As a practical matter, in researching particular topics electronically in psychophar-

Short Hills, NJ, USA Daniel P. Greenfield

I am particularly grateful to Joann Codella, my dedicated assistant and typist, who

1 Introduction: Epidemiologic Triangle Model, Diagnosis,

Part I Essentials of Psychopharmacology and Psychopharmacotherapy

Anti-dementia Agents������������������������������������������������������������������������������ 57

Part II Therapies That May Involve Psychopharmacology/

Cognitive Behavior Therapy�������������������������������������������������������������������� 125

Part III Forensic and Legal Applications of Psychopharmacology/

Part IV Synthesis and Conclusions

Daniel P. Greenfield, MD, MPH, MS, FASAM is

In a thought-provoking essay entitled “How Prozac Slew Freud,” Edward Shorter,

© The Author(s), under exclusive license to Springer Nature 1

1. Manifestational criteria, in which ill persons are grouped according to similar-

Table 1.1 DSM-5 major Neurodevelopmental disorders

• Ghaemi SN. Clinical psychopharmacology: principles and practice. Oxford

Selected Internet References

2. Government and academic/research institutions, publications and e-­publications,

© The Author(s), under exclusive license to Springer Nature 9

importance. These are (1) dose–response relationships; (2) desired or undesired

2. Desired and Undesired (“Side”) Effects

Fig. 2.1 Theoretical 1

employment litigation, 2nd

Classes of Pharmacologic and Psychopharmacologic Agents

Table 2.1 Selected Organ system Agent (medication)

Table 2.2 Selected examples of non-psychotropic medications classified by diseases treated

Psychotropic Medications, for purposes of the “anti” classification system pre-

Table 2.3 Licit and illicit psychotropic agents

1. Classification according to Lawfulness of Use (Licit and Illicit

3. Classification according to Predominant Clinical Indication Or Reason for

Table 2.5 Licit psychotropic agents: the “twenty anti-s”

Three Additional Classes

(“slowing down” involuntary bodily functions, such as salivation, digestion, and

Two Additional Concepts (For All Pharmacologic Agents)

These concepts—compliance/adherence and placebo/nocebo, respectively—to

As with considerations of compliance/adherence, a detailed discussion of place-

 OVID-19, Telemedicine, Telepsychiatry,

Since the varied, changing, and complex nature of telemedicine, telepsychiatry,

Selected Internet References

In Part I of this book—the core of this Primer—the substance of psychopharmaco-

Psychiatric disorders “Anti” psychopharmacotherapeutic agents

© The Author(s), under exclusive license to Springer Nature 27

Table 3.2 Anxiolytic/sedative (daytime)-hypnotic (nighttime) agents

Without reiterating details of types and subtypes of DSM-5 classifications of

Table 3.3 Types of neurotransmitter reuptake inhibitors (mostly antidepressant agents)

Generally, antidepressant psychopharmacotherapy is effective in about two-­

June, 2020 Christopher J. Hanifin

June, 2020 Kevin G. Callahan

Selected Internet References

Short Hills, NJ, USA Daniel P. Greenfield

1 Introduction: Epidemiologic Triangle Model, Diagnosis,

Part I Essentials of Psychopharmacology and Psychopharmacotherapy

Anti-dementia Agents�� 57

Part II Therapies That May Involve Psychopharmacology/

Cognitive Behavior Therapy�� 125

Part III Forensic and Legal Applications of Psychopharmacology/

Part IV Synthesis and Conclusions

Selected Internet References

2. Government and academic/research institutions, publications and e-publications,

Classes of Pharmacologic and Psychopharmacologic Agents

Three Additional Classes

Two Additional Concepts (For All Pharmacologic Agents)

OVID-19, Telemedicine, Telepsychiatry,

Selected Internet References

Generally, antidepressant psychopharmacotherapy is effective in about two-

Selected Internet References

Anti-attention Deficit Hyperactivity Disorder (ADHD) Agents

Anti-pseudobulbar Affect Agents

Selected Internet References

Controlled Dangerous Substances (CDS)