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For more information about cultural syndromes, see "Glossary of Cultural Concepts of Distress" in the Appendix to this manual. Diagnostic Markers Physiological recordings of naturally occurring panic attacks in individuals with panic disorder indicate abrupt surges of arousal, usually of heart rate, that reach a peak within minutes and subside within minutes, and for a proportion of these individuals the panic attack may be preceded by cardiorespiratory instabilities. Functional Consequences of Panic Attaclcs In the context of^co-occurring mental disorders, including anxiety disorders, depressive disorders, bipolar disorder, substance use disorders, psychotic disorders, and personality disorders, panic attacks are associated with increased symptom severity, higher rates of comorbidity and suicidality, and poorer treatment response. A detailed history should be taken to determine if the individual had panic attacks prior to excessive substance use. Features such as onset after age 45 years or the presence of atypical symptoms during a panic attack. Repeated unexpected panic attacks are required but are not sufficient for the diagnosis of panic disorder. Panic attacks are associated with increased likelihood of later developing anxiety disorders, depressive disorders, bipolar disorders, and possibly other disorders. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context. Diagnostic Features the essential feature of agoraphobia is marked, or intense, fear or anxiety triggered by the real or anticipated exposure to a wide range of situations (Criterion A).

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Like bipolar disoronly rarely cause mania, and before attributing any given der, it is characterized by episodes of mood disturbance case to one of them, one would want to be able to demonbut these are much milder in intensity and indeed may not strate not only a fairly close temporal relationship between bring the patient to clinical attention. For each of these medications, mania them with psychotic symptoms (such as delusions and haloccurs, not during treatment, but rather within days to a lucinations) in the intervals between mood disturbances, week after discontinuation of long-term treatment; here clearly distinguishes this illness from bipolar disorder, which the mania occurs as a withdrawal phenomenon. Importantly, these patients are symptomatology, with euphoria and gregariousness (Murphy well at other times, and although they may have recurrent et al. Uremia may rarely present with mania: in one post-partum psychoses after subsequent deliveries (Hadley case (El-Mallakh et al. Prednisone, cally accompany these manic changes (Haskett 1985) and in doses of 80 mg or more per day, may produce mania in serve to suggest the correct diagnosis. In some cases, the mania is Appropriately situated infarctions, tumors, or plaques of so appealing that patients may abuse levodopa in order to multiple sclerosis may all cause mania and, as noted below, p06. In the case of midbrain infarction not only has mania all been associated with mania. As an aside, it is worth notbeen seen, but also, remarkably, in these cases there were ing the remarkable ability of hypothalamic disturbances to recurrent episodes of mania and of depression: this has been cause mania. In one case (Alpers 1940), the patient was noted after an infarction secondary to a subarachnoid hemundergoing surgery for the removal of a craniopharynorrhage (Blackwell 1991) and after an ischemic lesion of the gioma; when the surgeon produced traction on the hyporight mesencephalopontine area (Kulisevsky et al. She subsequently developed symptomatology; indeed, Cottrell and Wilson (1926), noted a severe depression accompanied by left hemiparkinsonism, euphoria in 63 percent of their 100 patients. Subsequent case both of which persisted, only to spontaneously remit after 19 series have reported a lower rate, varying from 42 percent months. Eventually she was successfully treated with admission of patients with multiple sclerosis to a psychiatric lithium. Importantly, in patients anesthesia and slight hemiparesis, and Bogousslavsky et al. A review of the cases of mania secondary to infarctions (1993) reported a case of mania accompanied by chorea and and tumors allows for some speculation regarding both the ballismus occurring secondary to an infarction of the ventral localizing and the lateralizing value of this syndrome. Bilateral thalamic infarction caused localizing value of mania does not appear to be high, as it has mania in two cases.

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Phonological paraphasias in this type of aphasia are mostly due to phoneme omission and phoneme substitution. As a matter of fact, patients can have significant difficulties in producing certain phonemes. Writing is difficult to test because of the right hemiparesis and usually the patient has to use his/her non-preferred hand to write, representing an additional burden; writing with the left hand is usually clumsy due to the lack of practice. Interestingly, agrammatism in writing may be more severe than in spoken agrammatism, because written language requires a more precise use of the grammar; in general, spoken language is more flexible than written language. A large part of the fronto-parieto-temporal cortex has been observed to be involved with syntacticmorphological functions (Bhatnagar et al. Apraxia of speech has been specifically associated with damage in the left precentral gyrus of the insula (Dronkers, 1996; but see Hillis et al. If both impairments (apraxia of speech and agrammatism) are simultaneously observed, it simply means they are just two different manifestations of a single underlying defect. It has been observed that indeed language networks supporting grammar and fluency are overlapped (Borovsky et al.

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